Answer A is incorrect because it does not best meet the

1. The nurse is caring for a client with systemic lupus client’s needs. Answer B is incorrect because it is not the
erythematosis (SLE). The major complication associated with best means of preventing bleeding. Answer C is incorrect
systemic lupus erythematosis is: because the medications should not be given with milk or
A.Nephritis antacids.
B.Cardiomegaly
C.Desquamation 8. A client with an inguinal hernia asks the nurse why he should
D.Meningitis have surgery when he has had a hernia for years. The nurse
understands that surgery is recommended to:
2. A client with benign prostatic hypertrophy has been started on
Proscar (finasteride). The nurse’s discharge teaching should A.Prevent strangulation of the bowel
include: B.Prevent malabsorptive disorders
A.Telling the client’s wife not to touch the tablets C.Decrease secretion of bile salts
B.Explaining that the medication should be taken with meals D.Increase intestinal motility
C.Telling the client that symptoms will improve in 1–2 weeks
D.Instructing the client to take the medication at bedtime, to Answer A is correct.
prevent nocturia Surgical repair of an inguinal hernia is recommended to
prevent strangulation of the bowel, which could result in
3. A 5-year-old child is hospitalized for correction of congenital hip intestinal obstruction and necrosis. Answer B does not relate
dysplasia. During the assessment of the child, the nurse can to an inguinal hernia; therefore, it is incorrect. Bile salts,
expect to find the presence of: which are important to the digestion of fats, are produced by
A.Scarf sign the liver, not the intestines; therefore, answer C is incorrect.
B.Harlequin sign Repair of the inguinal hernia will prevent swelling and
C.Cullen’s sign obstruction associated with strangulation, but it will not
D.Trendelenburg sign increase intestinal motility; therefore, answer D is incorrect.

4. Which diet is associated with an increased risk of colorectal 9. The nurse is providing dietary instructions for a client with iron-
cancer? deficiency anemia. Which food is a poor source of iron?
A.Low protein, complex carbohydrates
B.High protein, simple carbohydrates A.Tomatoes
C.High fat, refined carbohydrates B.Legumes
D.Low carbohydrates, complex proteins C.Dried fruits
D.Nuts
5. The nurse is caring for an infant following a cleft lip repair.
While comforting the infant, the nurse should avoid: Answer A is correct.
A.Holding the infant Tomatoes are a poor source of iron, although they are an
B.Offering a pacifier excellent source of vitamin C, which increases iron
C.Providing a mobile absorption. Answers B, C, and D are good sources of iron;
D.Offering sterile water therefore, they are incorrect.

6. The physician has diagnosed a client with cirrhosis 10. A client is admitted with suspected acute pancreatitis. Which
characterized by asterixis. If the nurse assesses the client with lab finding confirms the diagnosis?
asterixis, he can expect to find:
A.Irregular movement of the wrist A.Blood glucose of 260mg/dL
B.Enlargement of the breasts B.White cell count of 21,000cu/mm
C.Dilated veins around the umbilicus C.Platelet count of 250,000cu/mm
D.Redness of the palmar surfaces D.Serum amylase level of 600 units/dL

Answer A is correct. Answer D is correct.

The client with asterixis or “flapping tremors” will have Serum amylase levels greater than 200 units/dL help confirm
irregular flexion and extension of the wrists when the arms the diagnosis of acute pancreatitis. Elevations of blood
are extended and the wrist is hyperextended with the fingers glucose occur with conditions other than acute pancreatitis;
separated. Asterixis is associated with hepatic therefore, answer A is incorrect. Elevations in WBC are
encephalopathy. Answers B, C, and D do not relate to associated with infection and are not specific to acute
asterixis; therefore, they are incorrect. pancreatitis; therefore, answer B is incorrect. Answer C is
within the normal range; therefore, it is incorrect.
7. The physician has ordered Amoxil (amoxicillin) 500mg
capsules for a client with esophageal varices. The nurse can best 11. The nurse is teaching a client with Parkinson’s disease ways
care for the client’s needs by: to prevent curvatures of the spine associated with the disease. To
A.Giving the medication as ordered prevent spinal flexion, the nurse should tell the client to:
B.Providing extra water with the medication
C.Giving the medication with an antacid A.Periodically lie prone without a neck pillow
D.Requesting an alternate form of the medication B.Sleep only in dorsal recumbent position
C.Rest in supine position with his head elevated
Answer D is correct. D.Sleep on either side, but keep his back straight
The client with esophageal varices might develop
spontaneous bleeding from the mechanical irritation caused Answer A is correct.
by taking capsules; therefore, the nurse should request the Periodically lying in a prone position without a pillow will
medication in an alternative form such as a suspension. help prevent the flexion of the spine that occurs with
Parkinson’s disease. Answers B and C flex the spine; hot bath morning and evening would make her condition
therefore, they are incorrect. Answer D is not realistic worse.
because position changes during sleep; therefore, it is
incorrect. 16. The nurse caring for a client with a closed head injury obtains
an intracranial pressure (ICP) reading of 17mmHg. The nurse
12. The physician has ordered Dilantin (phenytoin) 100mg recognizes that:
intravenously for a client with generalized tonic clonic seizures.
The nurse should administer the medication: A.The ICP is elevated and the doctor should be notified.
B.The ICP is normal; therefore, no further action is needed.
A.Rapidly with an IV push C.The ICP is low and the client needs additional IV fluids.
B.With IV dextrose D.The ICP reading is not as reliable as the Glascow coma scale.
C.Slowly over 2–3 minutes
D.Through a small vein Answer A is correct.
An ICP of 17mmHg should be reported to the doctor because
Answer C is correct. it is elevated. (The ICP normally ranges from 4mmHg to
The medication should be administered slowly (no more than 10mmHg, with upper limits of 15mmHg.) Answer B is
50mg per minute); otherwise, cardiac arrhythmias can occur. incorrect because the pressure is not normal. Answer C is
Answer A is incorrect because the medication must be given incorrect because the pressure is not low. Answer D is
slowly. Dextrose solutions cause the medication to incorrect because the ICP reading provides a more reliable
crystallize in the line and the medication should be given measurement than the Glascow coma scale.
through a large vein to prevent “purple glove” syndrome;
therefore, answers B and D are incorrect.

13. The nurse is planning dietary changes for a client following an

episode of acute pancreatitis. Which diet is suitable for the client?
17. A client has been hospitalized with a diagnosis of lar yngeal
A.Low calorie, low carbohydrate cancer. Which factor is most significant in the development of lar
B.High calorie, low fat yngeal cancer?
C.High protein, high fat
D.Low protein, high carbohydrate A.A family history of laryngeal cancer
B.Chronic inhalation of noxious fumes
Answer B is correct. C.Frequent straining of the vocal cords
The client recovering from acute pancreatitis needs a diet D.A history of frequent alcohol and tobacco use
that is high in calories and low in fat. Answers A, C, and D
are incorrect because they can increase the client’s Answer D is correct.
discomfort. A history of frequent alcohol and tobacco use is the most
significant factor in the development of cancer of the larynx.
14. A client is admitted with a diagnosis of polycythemia vera. Answers A, B, and C are also factors in the development of
The nurse should closely monitor the client for: laryngeal cancer but they are not the most significant;
therefore, they are incorrect.
A.Increased blood pressure
B.Decreased respirations 18. The nurse is completing an assessment history of a client with
C.Increased urinary output pernicious anemia. Which complaint differentiates pernicious
D.Decreased oxygen saturation anemia from other types of anemia?

Answer A is correct. A.Difficulty in breathing after exertion

The client with polycythemia vera has an abnormal increase B.Numbness and tingling in the extremities
in the number of circulating red blood cells that results in C.A faster than usual heart rate
increased viscosity of the blood. Increases in blood pressure D.Feelings of lightheadedness
further tax the overworked heart. Answers B, C, and D do not
directly relate to the condition; therefore, they are incorrect. Answer B is correct.
Numbness and tingling in the extremities is common in the
15. A client with hypothyroidism frequently complains of feeling client with pernicious anemia, but not those with other types
cold. The nurse should tell the client that she will be more of anemia. Answers A, C, and D are incorrect because they
comfortable if she: are symptoms of all types of anemia.

A.Uses an electric blanket at night 19. A client with rheumatoid arthritis is beginning to develop
B.Dresses in extra layers of clothing flexion contractures of the knees. The nurse should tell the client
C.Applies a heating pad to her feet to:
D.Takes a hot bath morning and evening
A.Lie prone and let her feet hang over the mattress edge
Answer B is correct. B.Lie supine, with her feet rotated inward
Dressing in extra layers of clothing will help decrease the C.Lie on her right side and point her toes downward
feeling of being cold that is experienced by the client with D.Lie on her left side and allow her feet to remain in a neutral
hypothyroidism. Decreased sensation and decreased position
alertness are common in the client with hypothyroidism. The
use of electric blankets and heating pads can result in burns, Answer A is correct.
making answers A and C incorrect. Answer D is incorrect Lying prone and allowing the feet to hang over the end of the
because the client with hypothyroidism has dry skin, and a mattress will help prevent flexion contractures. The client
should be told to do this several times a day. Answers B, C,
and D do not help prevent flexion contractures; therefore,
they are incorrect.

20. The chart of a client with schizophrenia states that the client 24. The nurse notes that a post-operative client’s respirations
has echolalia. The nurse can expect the client to: have dropped from 14 to 6 breaths per minute. The nurse
administers Narcan (naloxone) per standing order. Following
A.Speak using words that rhyme administration of the medication, the nurse should assess the
B.Repeat words or phrases used by others client for:
C.Include irrelevant details in conversation
D.Make up new words with new meanings A.Pupillary changes
B.Projectile vomiting
Answer B is correct. C.Wheezing respirations
The client with echolalia will repeat words or phrases used D.Sudden, intense pain
by others. Answer A is incorrect because it refers to clang
association. Answer C is incorrect because it refers to Answer D is correct.
circumstantiality. Answer D is incorrect because it refers to Narcan is a narcotic antagonist that blocks the effects of the
neologisms. client’s pain medication; therefore, the client will experience
sudden, intense pain. Answers A, B, and C do not relate to
21. The mother of a 1-year-old with sickle cell anemia wants to the client’s condition and the administration of Narcan;
know why the condition didn’t show up in the nursery. The nurse’s therefore, they are incorrect.
response is based on the knowledge that:
25. A newborn weighed 7 pounds at birth. At 6 months of age, the
A.There is no test to measure abnormal hemoglobin in newborns. infant could be expected to weigh:
B.Infants do not have insensible fluid loss before a year of age.
C.Infants rarely have infections that would cause them to have a A.14 pounds
sickling crises. B.18 pounds
D.The presence of fetal hemoglobin protects the infant. C.25 pounds
D.30 pounds
Answer D is correct.
The presence of fetal hemoglobin until about 6 months of Answer A is correct.
age protects affected infants from episodes of sickling. The infant’s birth weight should double by 6 months of age.
Answer A is incorrect because it is an untrue statement. Answers B, C, and D are incorrect because they are greater
Answer B is incorrect because infants do have insensible than the expected weight gain by 6 months of age.
fluid loss. Answer C is incorrect because respiratory
infections such as bronchiolitis and otitis media can cause 26. A client with nontropical sprue has an exacerbation of
fever and dehydration, which cause sickle cell crisis. symptoms. Which meal selection is responsible for the recurrence
of the client’s symptoms?
22. Which early morning activity helps to reduce the symptoms
associated with rheumatoid arthritis? A.Tossed salad with oil and vinegar dressing
B.Baked potato with sour cream and chives
A.Brushing the teeth C.Cream of tomato soup and crackers
B.Drinking a glass of juice D.Mixed fruit and yogurt
C.Holding a cup of coffee
D.Brushing the hair Answer C is correct.
The symptoms of nontropical sprue as well as those of celiac
Answer C is correct. are caused by the ingestion of gluten, found in wheat, oats,
The warmth from holding a cup of coffee or hot chocolate barley, and rye. Creamed soup and crackers as well as some
helps to relieve the pain and stiffness in the hands of the cold cuts contain gluten. Answers A, B, and D do not contain
client with rheumatoid arthritis. Answers A, B, and D do not gluten; therefore, they are incorrect.
relieve the symptoms of rheumatoid arthritis; therefore, they
are incorrect. 27. A client with congestive heart failure has been receiving
digoxin (Lanoxin). Which finding indicates that the medication is
23. A client with B negative blood requires a blood transfusion having a desired effect?
during surgery. If no B negative blood is available, the client
should be transfused with: A.Increased urinary output
B.Stabilized weight
A.A positive blood C.Improved appetite
B.B positive blood D.Increased pedal edema
C.O negative blood
D.AB negative blood Answer A is correct.
Lanoxin slows and strengthens the contraction of the heart.
Answer C is correct. An increase in urinary output shows that the medication is
If the client’s own blood type and Rh are not available, the having a desired effect by eliminating excess fluid from the
safest transfusion is O negative blood. Answers A, B, and D body. Answer B is incorrect because the weight would
are incorrect because they can cause reactions that can decrease. Answer C is not related to the medication;
prove fatal to the client. therefore, it is incorrect. Answer D is incorrect because pedal
edema would decrease, not increase.
28. Which play activity is best suited to the gross motor skills of
the toddler? Answer A is correct.
The client with nephotic syndrome will be treated with
A.Coloring book and crayons immunosuppressive drugs. Limiting visitors will decrease
B.Ball the chance of infection. Answer B is incorrect because the
C.Building cubes client needs additional protein. Answer C is incorrect
D.Swing set because dialysis is not indicated for the client with nephrotic
syndrome. Answer D is incorrect because additional fluids
Answer B is correct. are not needed until the client begins diuresis.
The toddler has gross motor skills suited to playing with a
ball, which can be kicked forward or thrown overhand. 33. A client is admitted with acute adrenal crisis. During the intake
Answers A and C are incorrect because they require fine assessment, the nurse can expect to find that the client has:
motor skills. Answer D is incorrect because the toddler lacks
gross motor skills for play on the swing set. A.Low blood pressure
B.A slow, regular pulse
29. A client in labor admits to using alcohol throughout the C.Warm, flushed skin
pregnancy. The most recent use was the day before. Based on D.Increased urination
the client’s history, the nurse should give priority to assessing the
newborn for: Answer A is correct.
The client with acute adrenal crisis has symptoms of
A.Respiratory depression hypovolemia and shock; therefore, the blood pressure would
B.Wide-set eyes be low. Answer B is incorrect because the pulse would be
C.Jitteriness rapid and irregular. Answer C is incorrect because the skin
D.Low-set ears would be cool and pale. Answer D is incorrect because the
urinary output would be decreased.
Answer C is correct.
Jitteriness and irritability are signs of alcohol withdrawal in 34. A 5-month-old infant is admitted to the ER with a temperature
the newborn. Answer A is incorrect because it would be of 103.6°F and irritability. The mother states that the child has
associated with use more recent than 1 day ago. Answers B been listless for the past several hours and that he had a seizure
and D are characteristics of a newborn with fetal alcohol on the way to the hospital. A lumbar puncture confirms a
syndrome, but they are not a priority at this time; therefore, diagnosis of bacterial meningitis. The nurse should assess the
they are incorrect. infant for:

30. The physician has ordered Basalgel (aluminum carbonate A.Periorbital edema
gel) for a client with recurrent indigestion. The nurse should teach B.Tenseness of the anterior fontanel
the client common side effects of the medication, which include: C.Positive Babinski reflex
D.Negative scarf sign
A.Constipation
B.Urinary retention Answer B is correct.
C.Diarrhea Tenseness of the anterior fontanel indicates an increase in
D.Confusion intracranial pressure. Answer A is incorrect because
periorbital edema is not associated with meningitis. Answer
Answer A is correct. C is incorrect because a positive Babinski reflex is normal in
Antacids containing aluminum tend to cause constipation. the infant. Answer D is incorrect because it relates to the
Answers B, C, and D are not common side effects of the preterm infant, not the infant with meningitis.
medication.
35. A client with AIDS is admitted with a diagnosis of
31. A client is admitted with suspected abdominal aortic aneur pneumocystis carinii pneumonia. Shortly after his admission, he
ysm (AAA). A common complaint of the client with an abdominal becomes confused and disoriented. He attempts to pull out his IV
aortic aneurysm is: and refuses to wear an O2 mask. Based upon his mental status,
A.Loss of sensation in the lower extremities the priority nursing diagnosis is:
B.Back pain that lessens when standing
C.Decreased urinary output A.Social isolation
D.Pulsations in the periumbilical area B.Risk for injury
Answer D is correct. C.Ineffective coping
The client with an abdominal aortic aneurysm frequently D.Anxiety
complains of pulsations or feeling the heart beat in the
abdomen. Answers A and C are incorrect because they are Answer B is correct.
not associated with abdominal aortic aneurysm. Answer B is The client’s priority nursing diagnosis is based on his risk
incorrect because back pain is not affected by changes in for self-injury. Answers A, C, and D focus on the client’s
position. psychosocial needs, which do not take priority over
physiological needs; therefore, they are incorrect.
32. The nurse is caring for a client hospitalized with nephotic
syndrome. Based on the client’s treatment, the nurse should: 36. The doctor has ordered Ampicillin 100mg every 6 hours IV
push for an infant weighing 7kg. The suggested dose for infants is
A.Limit the number of visitors 25–50mg/kg/day in equally divided doses. The nurse should:
B.Provide a low-protein diet
C.Discuss the possibility of dialysis A.Give the medication as ordered
D.Offer the client additional fluids B.Give half the amount ordered
C.Give the ordered amount q 12 hrs. A.Irregular movements of the extremities and facial grimacing
D.Check the order with the doctor B.Painless swellings over the extensor surfaces of the joints
C.Faint areas of red demarcation over the back and abdomen
Answer D is correct. D.Swelling, inflammation, and effusion of the joints
The recommended dose ranges from 175mg to 350mg per
day based on the infant’s weight. The order as written calls Answer A is correct.
for 400mg per day for an infant weighing 7kg; therefore, the The child with Sydenham’s chorea will exhibit irregular
nurse should check the order with the doctor before giving movements of the extremities, facial grimacing, and labile
the medication. Answer A is incorrect because the dosage moods. Answer B is incorrect because it describes
exceeds the recommended amount. Answers B and C are subcutaneous nodules. Answer C is incorrect because it
incorrect choices because they involve changing the describes erythema marginatum. Answer D is incorrect
doctor’s order. because it describes polymigratory arthritis.

37. An elderly client is hospitalized for a transurethral 41. A child with croup is placed in a cool, high-humidity tent
prostatectomy. Which finding should be reported to the doctor connected to room air. The primary purpose of the tent is to:
immediately?
A.Prevent insensible water loss
A.Hourly urinary output of 40–50cc B.Provide a moist environment with oxygen at 30%
B.Bright red urine with many clots C.Prevent dehydration and reduce fever
C.Dark red urine with few clots D.Liquefy secretions and relieve laryngeal spasm
D.Requests for pain med q 4 hrs.
Answer D is correct.
Answer B is correct. The primary reason for placing a child with croup under a
Bright red bleeding with many clots indicates arterial mist tent is to liquefy secretions and relieve laryngeal
bleeding that requires surgical intervention. Answer A is spasms. Answers A, B, and C are inaccurate statements;
within normal limits, answer C indicates venous bleeding, therefore, they are incorrect.
which can be managed by nursing intervention, and answer
D does not indicate excessive need for pain management 42. The nurse is suctioning the tracheostomy of an adult client.
that requires the doctor’s attention; therefore, they are The recommended pressure setting for performing tracheostomy
incorrect. suctioning on the adult client is:

38. Which statement by the parent of a child with sickle cell A.40–60mmHg
anemia indicates an understanding of the disease? B.60–80mmHg
C.80–120mmHg
A.“The pain he has is due to the presence of too many red blood D.120–140mmHg
cells.”
B.“He will be able to go snow-skiing with his friends as long as he Answer C is correct.
stays warm.” The recommended setting for performing tracheostomy
C.“He will need extra fluids in summer to prevent dehydration.” suctioning on the adult client is 80–120mmHg. Answers A
D.“There is very little chance that his brother will have sickle cell.” and B are incorrect because the amount of suction is too
low. Answer D is incorrect because the amount of suction is
Answer C is correct. excessive.
The child will need additional fluids in summer to prevent
dehydration that could lead to a sickle cell crises. Answer A 43. A client is admitted with a diagnosis of myxedema. An initial
is not a true statement; therefore, it is incorrect. Answer B is assessment of the client would reveal the symptoms of:
incorrect because the activity will create a greater oxygen
demand and precipitate sickle cell crises. Answer D is not a A.Slow pulse rate, weight loss, diarrhea, and cardiac failure
true statement; therefore, it is incorrect. B.Weight gain, lethargy, slowed speech, and decreased
respiratory rate
39. A toddler with otitis media has just completed antibiotic C.Rapid pulse, constipation, and bulging eyes
therapy. A recheck appointment should be made to: D.Decreased body temperature, weight loss, and increased
respirations
A.Determine whether the ear infection has affected her hearing
B.Make sure that she has taken all the antibiotic Answer B is correct.
C.Document that the infection has completely cleared Symptoms of myxedema include weight gain, lethargy, slow
D.Obtain a new prescription, in case the infection recurs speech, and decreased respirations. Answers A and D do not
describe symptoms associated with myxedema; therefore,
Answer C is correct. they are incorrect. Answer C describes symptoms
The client should be assessed following completion of associated with Graves’s disease.
antibiotic therapy to determine whether the infection has
cleared. Answer A would be done if there are repeated 44. Which statement describes the contagious stage of varicella?
instances of otitis media, answer B is incorrect because it
will not determine whether the child has completed the A.The contagious stage is 1 day before the onset of the rash until
medication, and answer D is incorrect because the purpose the appearance of vesicles.
of the recheck is to determine whether the infection is gone. B.The contagious stage lasts during the vesicular and crusting
stages of the lesions.
40. A 9-year-old is admitted with suspected rheumatic fever. C.The contagious stage is from the onset of the rash until the
Which finding is suggestive of Sydenham’s chorea? rash disappears.
D.The contagious stage is 1 day before the onset of the rash until D.Overwhelming anxiety
all the lesions are crusted.
Answer C is correct.
Delusions of grandeur are associated with feelings of low
Answer D is correct. self-esteem. Answer A is incorrect because reaction
The contagious stage of varicella begins 24 hours before the formation, a defense mechanism, is characterized by
onset of the rash and lasts until all the lesions are crusted. outward emotions that are the opposite of internal feelings.
Answers A, B, and C are inaccurate regarding the time of Answers B and D can cause an increase in the client’s
contagion. delusions but do not explain their purpose; therefore, they
are incorrect.
45.The nurse is reviewing the results of a sweat test taken from a
child with cystic fibrosis. Which finding supports the client’s 49. Which of the following statements reflects Kohlberg’s theory
diagnosis? of the moral development of the preschool-age child?

A.A sweat potassium concentration less than 40mEq/L A.Obeying adults is seen as correct behavior.
B.A sweat chloride concentration greater than 60mEq/L B.Showing respect for parents is seen as important.
C.A sweat potassium concentration greater than 40mEq/L C.Pleasing others is viewed as good behavior.
D.A sweat chloride concentration less than 40mEq/L D.Behavior is determined by consequences.

Answer B is correct. Answer D is correct.

The child with cystic fibrosis has sweat concentrations of According to Kohlberg, in the preconventional stage of
chloride greater than 60mEq/L. Answers A and C are development, the behavior of the preschool child is
incorrect because they refer to potassium concentrations determined by the consequences of the behavior. Answers
that are not used in making a diagnosis of cystic fibrosis. A, B, and C describe other stages of moral development;
Answer D is incorrect because the sweat concentration of therefore, they are incorrect.
chloride is too low to be diagnostic.
50. The nurse is caring for an 8-year-old following a routine
46. A client in labor has an order for Demerol (meperidine) 75 mg. tonsillectomy. Which finding should be reported immediately?
IM to be administered 10 minutes before delivery. The nurse
should: A.Reluctance to swallow
B.Drooling of blood-tinged saliva
A.Wait until the client is placed on the delivery table and C.An axillary temperature of 99°F
administer the medication D.Respiratory stridor
B.Question the order
C.Give the medication IM during the delivery to prevent pain from Answer D is correct.
the episiotomy Respiratory stridor is a symptom of partial airway
D.Give the medication as ordered obstruction. Answers A, B, and C are expected with a
tonsillectomy; therefore, they are incorrect.
Answer B is correct.
The nurse should question the order because administering 51. The nurse is admitting a client with a suspected duodenal
a narcotic so close to the time of delivery can result in ulcer. The client will most likely report that his abdominal
respiratory depression in the newborn. Answers A, C, and D discomfort decreases when he:
are incorrect because giving the medication prior to or
during delivery can cause respiratory depression in the A.Avoids eating
newborn. B.Rests in a recumbent position
C.Eats a meal or snack
47. Which of the following statements describes Piaget’s stage of D.Sits upright after eating
concrete operations?
Answer C is correct.
A.Reflex activity proceeds to imitative behavior. Pain associated with duodenal ulcers is lessened if the client
B.The ability to see another’s point of view increases. eats a meal or snack. Answer A is incorrect because it makes
C.Thought processes become more logical and coherent. the pain worse. Answer B lessens the discomfort of dumping
D.The ability to think abstractly leads to logical conclusion. syndrome; therefore, it is incorrect. Answer D lessens the
discomfort of gastroesophageal reflux; therefore, it is
Answer C is correct. incorrect.
During concrete operations, the child’s thought processes
become more logical and coherent. Answers A, B, and D are 52. The nurse is assessing a newborn in the well-baby nursery.
incorrect because they describe other types of development: Which finding should alert the nurse to the possibility of a cardiac
sensorimotor, intuitive, and formal. anomaly?

A.Diminished femoral pulses

B.Harlequin’s sign
48. A client admitted to the psychiatric unit claims to be the Pope C.Circumoral pallor
and insists that he will not be kept away from his subjects. The D.Acrocyanosis
most likely explanation for the client’s delusion is:
Answer A is correct.
A.A reaction formation Diminished femoral pulses are a sign of coarctation of the
B.A stressful event aorta. Answers B, C, and D are found in normal newborns
C.Low self-esteem and are not associated with cardiac anomaly.
 A.The client complains of blurred vision.
53. A 2-year-old is hospitalized with a diagnosis of Kawasaki’s B.The client complains of increased thirst and increased urination.
disease. A severe complication of Kawasaki’s disease is: C.The client complains of increased weight gain over the past
year.
A.The development of Brushfield spots D.The client complains of rhinorrhea.
B.The eruption of Hutchinson’s teeth
C.The development of coxa plana Answer B is correct.
D.The creation of a giant aneurysm Increased thirst and increased urination are signs of lithium
toxicity. Answers A and D are not associated with the use of
Answer D is correct. lithium; therefore, they are incorrect. Answer C is an
A severe complication associated with Kawasaki’s disease is expected side effect of the medication; therefore, it is
the development of a giant aneurysm. Answers A, B, and C incorrect.
are incorrect because they have no relationship to
Kawasaki’s disease. 58. The physician has ordered intravenous fluid with potassium
for a client admitted with gastroenteritis and dehydration. Before
54. The charge nurse is formulating a discharge teaching plan for adding potassium to the intravenous fluid, the nurse should:
a client with mild preeclampsia. The nurse should give priority to:
A.Assess the urinary output
A.Teaching the client to report a nosebleed B.Obtain arterial blood gases
B.Instructing the client to maintain strict bed rest C.Perform a dextrostick
C.Telling the client to notify the doctor of pedal edema D.Obtain a stool culture
D.Advising the client to avoid sodium sources in the diet
Answer A is correct.
Answer A is correct. During dehydration, the kidneys compensate for electrolyte
A nosebleed in the client with mild preeclampsia may imbalance by retaining potassium. The nurse should check
indicate that the client’s blood pressure is elevated. Answers for urinary output before adding potassium to the IV fluid.
B, C, and D are incorrect because the client will not need Answer B is incorrect because it measures respiratory
strict bed rest, pedal edema is common in the client with compensation caused by dehydration. Answers C and D do
preeclampsia, and the client does not need to avoid sodium, not apply to the use of intravenous fluid with potassium;
although the client should limit or avoid high-sodium foods. therefore, they are incorrect.

55. The nurse is preparing to discharge a client who is taking an 59. A 2-month-old infant has just received her first Tetramune
MAOI. The nurse should instruct the client to: injection. The nurse should tell the mother that the immunization:

A.Wear protective clothing and sunglasses when outside A.Will need to be repeated when the child is 4 years of age
B.Avoid over-the-counter cold and hayfever preparations B.Is given to determine whether the child is susceptible to
C.Drink at least eight glasses of water a day pertussis
D.Increase his intake of high-quality protein C.Is one of a series of injections that protects against diphtheria,
pertussis, tetanus and H.influenza b
D.Is a one-time injection that protects against measles, mumps,
rubella and varicella
Answer B is correct.
The client taking an MAO inhibitor should avoid over-the- Answer C is correct.
counter medications for colds and hayfever because many The immunization protects the child against diphtheria,
contain pseudoephedrine. Combining an MAO inhibitor with pertussis, tetanus, and H. influenza b. Answer A is incorrect
pseudoephedrine can result in extreme elevations in blood because a second injection is given before 4 years of age.
pressure. Answer A is incorrect because it refers to the client Answer B is not a true statement and answer D is not a one-
taking an antipsychotic medication such as Thorazine. time injection, nor does it protect against measles, mumps,
Answer C is not specific to the client taking an MAO inhibitor rubella, or varicella.
and answer D does not apply to the question.
60. A client with Addison’s disease has been receiving
56. Which of the following meal selections is appropriate for the glucocorticoid therapy. Which finding indicates a need for dosage
client with celiac disease? adjustment?

A.Toast, jam, and apple juice A.Dryness of the skin and mucus membranes
B.Peanut butter cookies and milk B.Dizziness when rising to a standing position
C.Rice Krispies bar and milk C.A weight gain of 6 pounds in the past week
D.Cheese pizza and Kool-Aid D.Difficulty in remaining asleep

Answer C is correct. Answer C is correct.

Foods containing rice or millet are permitted in the diet of the A weight gain of 6 pounds in a week in the client taking
client with celiac disease. Answers A, B, and D are not glucocorticoids indicates that the dosage should be
permitted because they contain gluten, which exacerbates modified. Answers A and B are not specific to the question;
the symptoms of celiac disease; therefore, they are incorrect. therefore, they are incorrect. Answer D is an expected side
effect of the medication; therefore, it is incorrect.
57. A client with hyperthyroidism is taking lithium carbonate to
inhibit thyroid hormone release. Which complaint by the client 61. The nurse is caring for an obstetrical client in early labor. After
should alert the nurse to a problem with the client’s medication? the rupture of membranes, the nurse should give priority to:
A.Applying an internal monitor affect because the maximal effects of tricyclic antidepressant
B.Assessing fetal heart tones medication do not occur for:
C.Assisting with epidural anesthesia A.48–72 hours
D.Inserting a Foley catheter B.5–7 days
C.2–4 weeks
Answer B is correct. D.3–6 months
Assessing fetal heart tones reveals whether fetal distress Answer D is correct.
occurred with rupture of the membranes. Answers A, C, and The maximal effects from tricyclic antidepressants might not
D are later interventions; therefore, they are incorrect. be achieved for up to 6 months after the medication is
started. Answers A and B are incorrect because the time for
62. The physician has prescribed Synthroid (levothyroxine) for a maximal effects is too brief. Answer C is incorrect because it
client with myxedema. Which statement indicates that the client refers to the initial symptomatic relief rather than maximal
understands the nurse’s teaching regarding the medication? effects.

A.“I will take the medication each morning after breakfast.” 66. An elderly client with glaucoma has been prescribed Timoptic
B.“I will check my heart rate before taking the medication.” eyedrops. Timoptic should be used with caution in clients with a
C.“I will report visual disturbances to my doctor.” history of:
D.“I will stop the medication if I develop gastric upset.”
A.Diabetes
Answer B is correct. B.Gastric ulcers
Synthroid (levothyroxine) increases metabolic rate and C.Emphysema
cardiac output. Adverse reactions include tachycardia and D.Pancreatitis
dysrhythmias; therefore, the client should be taught to check
her heart rate before taking the medication. Answer A is Answer C is correct.
incorrect because the client does not have to take the Beta blockers such as timolol (Timoptic) can cause
medication after breakfast. Answer C does not relate to the bronchospasms in the client with chronic obstructive lung
medication; therefore, it is incorrect. The medication should disease. Timoptic is not contraindicated for use in the client
not be stopped because of gastric upset; therefore, Answer with diabetes, gastric ulcers, or pancreatitis; therefore,
D is incorrect. answers A, B, and D are incorrect.

63. The nurse is caring for a client with a radium implant for the 67. A 2-year-old is hospitalized with suspected intussusception.
treatment of cervical cancer. While caring for the client with a Which finding is associated with intussusception?
radioactive implant, the nurse should:
A.“Currant jelly” stools
A.Provide emotional support by spending additional time with the B.Projectile vomiting
client C.“Ribbonlike” stools
B.Stand at the foot of the bed when talking to the client D.Palpable mass over the flank
C.Avoid handling items used by the client
D.Wear a badge to monitor the amount of time spent in the Answer A is correct.
client’s room The child with intussusception has stools that contain blood
and mucus, which are described as “currant jelly” stools.
Answer D is correct. Answer B is a symptom of pyloric stenosis; therefore, it is
The nurse should wear a special badge when taking care of incorrect. Answer C is a symptom of Hirschsprungs;
the client with a radioactive implant, to measure the amount therefore, it is incorrect. Answer D is a symptom of Wilms
of time spent in the room. The nurse should limit the time of tumor; therefore, it is incorrect.
radiation exposure; therefore, answer A is incorrect.
Standing at the foot of the bed of a client with a radioactive 68. Which of the following findings would be expected in the infant
cer vical implant increases the nurse’s exposure to radiation; with biliary atresia?
therefore, answer B is incorrect. The nurse does not have to
avoid handling items used by the client; therefore, answer C A.Rapid weight gain and hepatomegaly
is incorrect. B.Dark stools and poor weight gain
C.Abdominal distention and poor weight gain
64. The nurse is caring for a client hospitalized with bipolar D.Abdominal distention and rapid weight gain
disorder, manic phase who is taking lithium. Which of the
following snacks would be best for the client with mania? Answer C is correct.
The infant with biliary atresia has abdominal distention, poor
A.Potato chips weight gain, and clay-colored stools. Answers A, B, and D do
B.Diet cola describe the symptoms associated with biliary atresia;
C.Apple therefore, they are incorrect.
D.Milkshake
69. A client is being treated for cancer with linear acceleration
Answer D is correct. radiation. The physician has marked the radiation site with a blue
The milkshake will provide needed calories and nutrients for marking pen. The nurse should:
the client with mania. Answers A, B, and C are incorrect A.Remove the unsightly markings with acetone or alcohol
choices because they do not provide as many calories or B.Cover the radiation site with loose gauze dressing
nutrients as the milkshake. C.Sprinkle baby powder over the radiated area
D.Refrain from using soap or lotion on the marked area
65.The physician has prescribed imipramine (ToFranil) for a client
with depression. The nurse should continue to monitor the client’s Answer D is correct.
The nurse should not use water, soap, or lotion on the area interfere with oxygenation of the skin; therefore, answers A,
marked for radiation therapy. Answer A is incorrect because C, and D are incorrect.
it would remove the marking. Answers B and C are not
necessary for the client receiving radiation; therefore, they 74. The physician has ordered DDAVP (desmopressin acetate)
are incorrect. for a client with diabetes insipidus. Which finding indicates that
the medication is having its intended effect?
70. The blood alcohol concentration of a client admitted following
a motor vehicle accident is 460mg/dL. The nurse should give A.The client’s appetite has improved.
priority to monitoring the client for: B.The client’s morning blood sugar was 120mg/dL.
C.The client’s urinary output has decreased.
A.Loss of coordination D.The client’s activity level has increased.
B.Respiratory depression
C.Visual hallucinations Answer C is correct.
D.Tachycardia Diabetes insipidus is characterized by excessive production
of dilute urine. A decline in urinary output shows that the
Answer B is correct. medication is having its intended effect. Answers A and D do
Blood alcohol concentrations of 400–600mg/dL are not relate to the question; therefore, they are incorrect.
associated with respiratory depression, coma, and death. Answer B refers to diabetes mellitus; therefore, it is
Answer A occurs with blood alcohol concentrations of incorrect.
50mg/dL, which affects coordination and speech but does
not cause respiratory depression; therefore, it is incorrect. 75. A client with pregnancy-induced hypertension is scheduled for
Answers C and D are associated with alcohol withdrawal, not a C-section. Before surgery, the nurse should keep the client:
overdose; therefore, they are incorrect.
A.On her right side
71. The nurse is caring for a client with acromegaly. Following a B.Supine with a small pillow
transphenoidal hypophysectomy, the nurse should: C.On her left side
D.In knee chest position
A.Monitor the client’s blood sugar
B.Suction the mouth and pharynx every hour Answer C is correct.
C.Place the client in low Trendelenburg position Positioning the client on her left side will take pressure off
D.Encourage the client to cough the vena cava and allow better oxygenation of the fetus.
Answers A and B do not relieve pressure on the vena cava;
Answer A is correct. therefore, they are incorrect. Answer D is the preferred
Following a hypophysectomy, the nurse should check the position for the client with a prolapsed cord; therefore, it is
client’s blood sugar because insulin levels may rise rapidly incorrect for this situation.
resulting in hypoglycemia. Answer B is incorrect because
suctioning should be avoided. Answer C is incorrect 76. The physician has prescribed Coumadin (sodium war farin)
because the client’s head should be elevated to reduce for a client having transient ischemic attacks. Which laboratory
pressure on the operative site. Answer D is incorrect test measures the therapeutic level of Coumadin?
because coughing increases pressure on the operative site
that can lead to a leak of cerebral spinal fluid. A.Prothrombin time
B.Clot retraction time
72. A client newly diagnosed with diabetes is started on Precose C.Partial thromboplastin time
(acarbose). The nurse should tell the client that the medication D.Bleeding time
should be taken:
Answer A is correct.
A.1 hour before meals Prothrombin time measures the therapeutic level of
B.30 minutes after meals Coumadin. Answer B is incorrect because it measures the
C.With the first bite of a meal quantity of each specific clotting factor. Answer C is
D.Daily at bedtime incorrect because it measures the therapeutic level of
heparin. Answer D is incorrect because it evaluates the
Answer C is correct. vascular and platelet factors associated with hemostasis.
Acarbose is to be taken with the first bite of a meal. Answers
A, B, and D are incorrect because they specify the wrong 77. An adolescent client with cystic acne has a prescription for
schedule for taking the medica tion. Accutane (isotretinoin). Which lab work is needed before
beginning the medication?
73. A client with a deep decubitus ulcer is receiving therapy in the
hyperbaric oxygen chamber. Before therapy, the nurse should: A.Complete blood count
B.Clean-catch urinalysis
A.Apply a lanolin-based lotion to the skin C.Liver profile
B.Wash the skin with water and pat dry D.Thyroid function test
C.Cover the area with a petroleum gauze
D.Apply an occlusive dressing to the site Answer C is correct.
Accutane is made from concentrated vitamin A, a fat-soluble
Answer B is correct. vitamin. Fat-soluble vitamins have the potential of being
The client going for therapy in the hyperbaric oxygen hepatotoxic, so a liver panel is needed. Answers A, B, and D
chamber requires no special skin care; therefore, washing do not relate to therapy with Accutane; therefore, they are
the skin with water and patting it dry are suitable. Lotions, incorrect.
petroleum products, per fumes, and occlusive dressings
78. Twenty-four hours after an uncomplicated labor and delivery, Answer B is not specific to the question; therefore, it is
a client’s WBC is 12,000cu/mm. The elevation in the client’s WBC incorrect. Answer C is incorrect because it does not relate to
is most likely an indication of: cor pulmonale.

A.A normal response to the birth process 82. A client with a laryngectomy returns from surgery with a
B.An acute bacterial infection nasogastric tube in place. The primary reason for placement of
C.A sexually transmitted virus the nasogastric tube is to:
D.Dehydration from being NPO during labor
A.Prevent swelling and dysphagia
Answer A is correct. B.Decompress the stomach
The client’s WBC is only slightly elevated and is most likely C.Prevent contamination of the suture line
due to the birth process. Answer B is incorrect because the D.Promote healing of the oral mucosa
WBC would be more elevated if an acute bacterial infection
was present. Answer C is incorrect because viral infections Answer C is correct.
usually do not cause elevations in WBC. Answer D is The primary reason for the NG to is to allow for nourishment
incorrect because dehydration is not reflected by changes in without contamination of the suture line. Answer A is not a
the WBC. true statement; therefore, it is incorrect. Answer B is
incorrect because there is no mention of suction. Answer D
79. The home health nurse is visiting a client who plans to deliver is incorrect because the oral mucosa was not involved in the
her baby at home. Which statement by the client indicates an lar yngectomy.
understanding regarding screening for phenylketonuria (PKU)?
83. The physician orders the removal of an in-dwelling catheter
A.“I will need to take the baby to the clinic within 24 hours of the second postoperative day for a client with a prostatectomy.
delivery to have blood drawn.” The client complains of pain and dribbling of urine the first time he
B.“I will need to schedule a home visit for PKU screening when voids. The nurse should tell the client that:
the baby is 3 days old.”
C.“I will remind the midwife to save a specimen of cord blood for A.Using warm compresses over the bladder will lessen the
the PKU test.” discomfort.
D.“I will have the PKU test done when I take her for her first B.Perineal exercises will be started in a few days to help relieve
immunizations.” his symptoms.
C.If the symptoms don’t improve, the catheter will have to be
Answer B is correct. reinserted.
PKU screening is usually done on the third day of life. D.His complaints are common and will improve over the next few
Answer A is incorrect because the baby will not have had days.
sufficient time to ingest protein sources of phenylalanine.
Answer C is incorrect because blood is obtained from a heel Answer D is correct.
stick, not from cord blood. Answer D is incorrect because The client’s complaints are due to swelling associated with
the first immunizations are done at 6 weeks of age, and by surgery and catheter placement. Answer A is incorrect
that time, brain damage will already have occurred if the because it will not relieve the client’s symptoms of pain and
baby has PKU. dribbling. Answer B is incorrect because perineal exercises
will not help relieve the post-operative pain. Answer C is
80. The physician has ordered intubation and mechanical incorrect because the client’s complaints do not indicate the
ventilation for a client with periods of apnea following a closed need for catheter reinsertion.
head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28,
and HCO3 of 23. These findings indicate that the client has: 84. A client with a right lobectomy is being transported from the
intensive care unit to a medical unit. The nurse understands that
A.Respiratory acidosis the client’s chest drainage system:
B.Respiratory alkalosis
C.Metabolic acidosis A.Can be disconnected from suction if the chest tube is clamped
D.Metabolic alkalosis B.Can be disconnected from suction, but the chest tube should
remain unclamped
Answer B is correct. C.Must remain connected by means of a portable suction
The client’s blood gases indicate respiratory alkalosis. D.Must be kept even with the client’s shoulders during the
Answers A, C, and D are not reflected by the client’s blood transport
gases or present condition; there- fore, they are incorrect.
Answer B is correct.
81. A client is diagnosed with emphysema and cor pulmonale. The chest-drainage system can be disconnected from
Which findings are characteristic of cor pulmonale? suction, but the chest tube should remain unclamped to
prevent a tension pneumothorax. Answer A is incorrect
A.Hypoxia, shortness of breath, and exertional fatigue because it could result in a tension pneumothorax. Answer C
B.Weight loss, increased RBC, and fever is not a true statement; therefore, it is not correct. Answer D
C.Rales, edema, and enlarged spleen is incorrect because the chest-drainage system should be
D.Edema of the lower extremities and distended neck veins kept lower than the client’s chest and shoulders.

Answer D is correct. 85. A nurse is caring for a client with a myocardial infarction. The
Cor pulmonale, or right-sided heart failure, is characterized nurse recognizes that the most common complication in the client
by edema of the legs and feet, enlarged liver, and distended following a myocardial infarction is:
neck veins. Answer A is incorrect because the symptoms are
those of left-sided heart failure and pulmonary edema. A.Right ventricular hypertrophy
B.Cardiac dysrhythmia D.Tell the client she will need joint immobilization for 2–3 weeks
C.Left ventricular hypertrophy
D.Hyperkalemia Answer C is correct.
The client with rheumatoid arthritis needs to continue
Answer B is correct. moving affected joints within the limits of pain. Answer A
Cardiac dysrhythmias are the most common complication for and D are incorrect because they will increase stiffness and
the client with a myocardial infarction. Answers A and C do joint disuse. Answer B is incorrect because, if done
not relate to myocardial infarction; therefore, they are correctly, passive range-of-motion exercises will improve the
incorrect. Answer D is incorrect because it is not the most use of affected joints.
common complication following a myocardial infarction.
90. The nurse is assessing a trauma client in the emergency
86. A client develops a temperature of 102°F following coronary room when she notes a penetrating abdominal wound with
artery bypass surgery. The nurse should notify the physician exposed viscera. The nurse should:
immediately because elevations in temperature:
A.Apply a clean dressing to protect the wound
A.Increase cardiac output B.Cover the exposed visera with a sterile saline gauze
B.Indicate cardiac tamponade C.Gently replace the abdominal contents
C.Decrease cardiac output D.Cover the area with a petroleum gauze
D.Indicate graft rejection
Answer B is correct.
Answer A is correct. Exposed abdominal visera should be covered with a sterile
Elevations in temperature increase the cardiac output. saline-soaked gauze, and the doctor should be notified
Answer B is incorrect because temperature elevations are immediately. Answer A is incorrect because the dressing
not associated with cardiac tamponade. Answer C is should be sterile, not clean. Answer C is incorrect because
incorrect because temperature elevation does not decrease attempting to replace abdominal contents can cause greater
cardiac output. Answer D is incorrect because elevations in injur y and should be done only surgically. Answer D is
temperature in the client with a coronary artery bypass graft incorrect because the area is kept moist only with sterile
indicate inflammation, not necessarily graft rejection normal saline.

87. The chart indicates that a client has expressive aphasia 91.A client is admitted to the emergency room with multiple
following a stroke. The nurse understands that the client will have injuries. What is the proper sequence for managing the client?
difficulty with:
A.Assess for head injuries, control hemorrhage, establish an
A.Speaking and writing airway, prevent hypovolemic shock
B.Comprehending spoken words B.Control hemorrhage, prevent hypovolemic shock, establish an
C.Carrying out purposeful motor activity airway, assess for head injuries
D.Recognizing and using an object correctly C.Establish an airway, control hemorrhage, prevent hypovolemic
shock, assess for head injuries
Answer A is correct. D.Prevent hypovolemic shock, assess for head injuries, establish
The client with expressive aphasia has trouble forming an airway, control hemorrhage
words that are understandable. Answer B is incorrect
because it describes receptive aphasia. Answer C refers to Answer C is correct.
apraxia and answer D refers to agnosia, so they are Using the ABCD approach to the client with multiple trauma
incorrect. the nurse in the ER would: establish an airway, determine
whether the client is breathing, check circulation (control
88. A client receiving Parnate (tranylcypromine) is admitted in a hemorrhage), and check for deficits (head injuries). Answers
hypertensive crisis. Which food is most likely to produce a A, B, and D are incorrect because they are not in the
hypertensive crisis when taken with the medication? appropriate sequence for maintaining life.

A.Processed cheese 92. The nurse is teaching the mother of a child with attention
B.Cottage cheese deficit disorder regarding the use of Ritalin (methylphenidate).
C.Cream cheese The nurse recognizes that the mother understands her teaching
D.Cheddar cheese when she states the importance of:

Answer D is correct. A.Offering high-calorie snacks

The client taking MAOI, including Parnate, should avoid B.Watching for signs of infection
eating aged cheeses, such as cheddar cheese, because a C.Observing for signs of oversedation
hypertensive crisis can result. Answer A is incorrect because D.Using a sunscreen with an SPF of 30
processed cheese is less likely to produce a hypertensive
crisis. Answers B and C do not cause a hypertensive crisis in Answer A is correct.
the client taking an MAOI; therefore, they are incorrect. Stimulant medications such as Ritalin tend to cause anorexia
and weight loss in some children with ADHD. Providing high-
89. To prevent deformities of the knee joints in a client with an calorie snacks will help the child maintain an appropriate
exacerbation of rheumatoid arthritis, the nurse should: weight. Answer B is incorrect because the medication does
not mask infection. Answer C is incorrect because the
A.Tell the client to remain on bed rest until swelling subsides medication is a central nervous system stimulant, not a
B.Discourage passive range of motion because it will cause depressant. Answer D has no relationship to the medication;
further swelling therefore, it is incorrect.
C.Encourage motion of the joint within the limits of pain
93. A home health nurse has several elderly clients in her case
load. Which of the following clients is most likely to be A.A 28-year-old with a history of alcohol use during the pregnancy
a victim of elder abuse? B.A 24-year-old with a history of diabetes mellitus
C.A 30-year-old with a history of smoking during the pregnancy
A.A 76-year-old female with Alzheimer’s disease D.A 32-year-old with a history of pregnancy-induced hypertension
B.A 70-year-old male with diabetes mellitus
C.A 64-year-old female with a hip replacement Answer B is correct.
D.A 72-year-old male with Parkinson’s disease The client with a history of diabetes is most likely to deliver a
preterm large for gestational age newborn. These newborns
Answer A is correct. often lack sufficient surfactant levels to prevent respiratory
The most likely victim of elder abuse is the elderly female distress syndrome. Answers A, C, and D are less likely to
with a chronic, debilitating illness. Answers B, C, and D are have newborns with respiratory distress syndrome so they
less likely to be victims of elder abuse; therefore, they are are incorrect choices.
incorrect.
98. A client with a C4 spinal cord injury has been placed in
94. A camp nurse is applying sunscreen to a group of children traction with cervical tongs. Nursing care should include:
enrolled in swim classes. Chemical sunscreens are most effective
when applied: A.Releasing the traction for 5 minutes each shift
B.Loosening the pins if the client complains of headache
A.Just before sun exposure C.Elevating the head of the bed 90°
B.5 minutes before sun exposure D.Performing sterile pin care as ordered
C.15 minutes before sun exposure
D.30 minutes before sun exposure Answer D is correct.
Nursing care of the client with cervical tongs includes
Answer D is correct. performance of sterile pin care and assessment of the site.
Sunscreens of at least an SPF of 15 should be applied 20–30 Answers A, B, and C alter the traction and could result in
minutes before going into the sun. Answers A, B, and C are serious injury or death of the client; therefore, they are
incorrect because they do not allow sufficient time for sun incorrect.
protection.

95. The physician has made a diagnosis of “shaken child”

syndrome for a 13-month-old who was brought to the emergency
room after a reported fall from his highchair. Which finding
supports the diagnosis of “shaken child” syndrome? 99. The nurse is assessing a client following a coronar y artery
bypass graft (CABG). The nurse should give priority to reporting:
A.Fracture of the clavicle
B.Periorbital bruising A.Chest drainage of 150mL in the past hour
C.Retinal hemorrhages B.Confusion and restlessness
D.Fracture of the humerus C.Pallor and coolness of skin
D.Urinary output of 40mL per hour
Answer C is correct.
Retinal hemorrhages are characteristically found in the child Answer A is correct.
who has been violently shaken. Answers A, B, and D may Chest drainage greater than 100mL per hour is excessive,
result from trauma other than that related to abuse; and the doctor should be notified regarding possible
therefore, they are incorrect. hemorrhage. Confusion and restlessness could be in
response to pain, changes in oxygenation, or the emergence
from anesthesia; therefore, answer B is incorrect. Answer C
96. A post-operative client has an order for Demerol (meperidine) is incorrect because it is an expected finding in the client
75mg and Phenergan (promethazine) 25mg IM every 3–4 hours recently returning from a CABG. Answer D is within normal
as needed for pain. The combination of the two medications limits; therefore, it is incorrect.
produces a/an:
100. Before administering a client’s morning dose of Lanoxin
A.Agonist effect (digoxin), the nurse checks the apical pulse rate and finds a rate
B.Synergistic effect of 54. The appropriate nursing intervention is to:
C.Antagonist effect
D.Excitatory effect A.Record the pulse rate and administer the medication
B.Administer the medication and monitor the heart rate
Answer B is correct. C.Withhold the medication and notify the doctor
The combination of the two medications produces a D.Withhold the medication until the heart rate increases
synergistic effect (an effect greater than that of either drug
used alone). Agonist effects are similar to those produced by Answer C is correct.
chemicals normally present in the body; therefore, answer A The medication should be withheld and the doctor should be
is incorrect. Antagonist effects are those in which the notified. Answers A, B, and D are incorrect because they do
actions of the drugs oppose one another; therefore, answer not provide for the client’s safety.
C is incorrect. Answer D is incorrect because the drugs
would have a combined depressing, not excitator y effect. Note: This questionnaire is not really ours. It is just one of our materials when we
took the board exam and we’re sharing it to you guys to help you boost your
knowledge and get your license this 2018. Keep believing in yourself, RN!
97. Which obstetrical client is most likely to have an infant with -millennielnars
respiratory distress syndrome?