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100 Item Comprehensive Nursing Exam With Answers

Nursing (Bukidnon State University)

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100 item Nursing Comprehensive Exam with Answers

1. The nurse enters the room as a 3 year-old is having a generalized seizure.

Which intervention should the nurse do first?
A) Clear the area of any hazards
B) Place the child on the side
C) Restrain the child
D) Give the prescribed anticonvulsant

The correct answer is B: Place the child on the side

Protecting the airway is the top priority in a seizure. If a child is actively
convulsing, a patent airway and oxygenation must be assured.

2. A client has just returned to the medical-surgical unit following a segmental

lung resection. After assessing the client, the first nursing action would be to
A) Administer pain medication
B) Suction excessive tracheobronchial secretions
C) Assist client to turn, deep breath and cough
D) Monitor oxygen saturation

The correct answer is B: Suction excessive tracheobronchial secretions

Suctioning the copious tracheobronchial secretions present in post-thoracic
surgery clients maintains an open airway which is always the priority nursing
intervention.

3. A nurse from the surgical department is reassigned to the pediatric unit. The
charge nurse should recognize that the child at highest risk for cardiac arrest
and is the least likely to be assigned to this nurse is which child?
A) Congenital cardiac defects
B) An acute febrile illness
C) Prolonged hypoxemia
D) Severe multiple trauma

The correct answer is C: Prolonged hypoxemia

Most often, the cause of cardiac arrest in the pediatric population is prolonged
hypoxemia. Children usually have both cardiac and respiratory arrest.

4. Which of the following would be the best strategy for the nurse to use when
teaching insulin injection techniques to a newly diagnosed client with diabetes?
A) Give written pre and posttests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration

The correct answer is D: Observe a return demonstration

Since this is a psychomotor skill, this is the best way to know if the client has
learned the proper technique.

5. The nurse is assessing a 2-year-old client with a possible diagnosis of

congenital heart disease. Which of these is most likely to be seen with this
diagnosis?
A) Several otitis media episodes in the last year
B) Weight and height in 10th percentile since birth
C) Takes frequent rest periods while playing
D) Changing food preferences and dislikes

The correct answer is C: Takes frequent rest periods while playing

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Children with heart disease tend to have exercise intolerance. The child self-
limits activity, which is consistent with manifestations of congenital heart
disease in children.

6. The nurse is reassigned to work at the Poison Control Center telephone

hotline. In which of these cases of childhood poisoning would the nurse suggest
that parents have the child drink orange juice?
A) An 18 month-old who ate an undetermined amount of crystal drain
cleaner
B) A 14 month-old who chewed 2 leaves of a philodendron plant
C) A 20 month-old who is found sitting on the bathroom floor beside an empty
bottle of diazepam (Valium)
D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid

The correct answer is A: An 18 month-old who ate an undetermined amount of

crystal drain cleaner. Drain cleaner is very alkaline. The orange juice is acidic
and will help to neutralize this substance.

7. A 23-year-old single client is in the 33rd week of her first pregnancy. She tells
the nurse that she has everything ready for the baby and has made plans for
the first weeks together at home. Which normal emotional reaction does the
nurse recognize?
A) Acceptance of the pregnancy
B) Focus on fetal development
C) Anticipation of the birth
D) Ambivalence about pregnancy

The correct answer is C: Anticipation of the birth

Directing activities toward preparation for the newborn’s needs and personal
adjustment are indicators of appropriate emotional response in the third
trimester.

8. Upon examining the mouth of a 3-year-old child, the nurse discovers that the
teeth have chalky white-to-yellowish staining with pitting of the enamel. Which
of the following conditions would most likely explain these findings?
A) Ingestion of tetracycline
B) Excessive fluoride intake
C) Oral iron therapy
D) Poor dental hygiene

The correct answer is B: Excessive fluoride intake

The described findings are indicative of fluorosis, a condition characterized by
an increase in the extent and degree of the enamel''s porosity. This problem can
be associated with repeated swallowing of toothpaste with fluoride or drinking
water with high levels of fluoride.

9. Which of the following should the nurse teach the client to avoid when taking
chlorpromazine HCL (Thorazine)?
A) Direct sunlight
B) Foods containing tyramine
C) Foods fermented with yeast
D) Canned citrus fruit drinks

The correct answer is A: Avoid direct sunlight

Phenothiazine increases sensitivity to the sun, making clients especially
susceptible to sunburn.

10. The nurse is discussing dietary intake with an adolescent who has acne. The

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most appropriate statement for the nurse is

A) "Eat a balanced diet for your age."
B) "Increase your intake of protein and Vitamin A."
C) "Decrease fatty foods from your diet."
D) "Do not use caffeine in any form, including chocolate."

The correct answer is A: "Eat a balanced diet for your age."

A diet for a teenager with acne should be a well-balanced diet for their age.
There are no recommended additions and subtractions from the diet.

11. The nurse is caring for a child who has just returned from surgery following
a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
A) Offer ice cream every 2 hours
B) Place the child in a supine position
C) Allow the child to drink through a straw
D) Observe swallowing patterns

The correct answer is D: Observe swallowing patterns

The nurse should observe for increased swallowing frequency to check for
hemorrhage.

12. The nurse is caring for a client with acute pancreatitis. After pain
management, which intervention should be included in the plan of care?
A) Cough and deep breathe every 2 hours
B) Place the client in contact isolation
C) Provide a diet high in protein
D) Institute seizure precautions

The correct answer is A: Cough and deep breathe every 2 hours

Respiratory infections are common because of fluid in the retro peritoneum
pushing up against the diaphragm causing shallow respirations. Encouraging
the client to cough and deep breathe every 2 hours will diminish the occurrence
of this complication.

13. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux).
To assist the client with nutrition needs, the nurse should
A) Offer small meals of high calorie soft food
B) Assist the client to sit in a chair for meals
C) Provide additional servings of fruits and raw vegetables
D) Encourage the client to eat fish, liver and chicken

The correct answer is A: Offer small meals of high calorie soft food
If the client is losing weight because of poor appetite due to the pain, assist in
selecting foods that are high in calories and nutrients, to provide more
nourishment with less chewing. Suggest that frequent, small meals be eaten
instead of three large ones. To minimize jaw movements when eating, suggest
that foods be pureed.

14. A client treated for depression tells the nurse at the mental health clinic
that he recently purchased a handgun because he is thinking about suicide. The
first nursing action should be to
A) Notify the health care provider immediately
B) Suggest in-patient psychiatric care
C) Respect the client's confidential disclosure
D) Phone the family to warn them of the risk

The correct answer is A: Notify the health care provider immediately

The health care provider must be contacted immediately as the client is a

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danger to self and others. Hospitalization is indicated.

15. The initial response by the nurse to a delusional client who refuses to eat
because of a belief that the food is poisoned is
A) "You think that someone wants to poison you?"
B) "Why do you think the food is poisoned?"
C) "These feelings are a symptom of your illness."
D) "You’re safe here. I won’t let anyone poison you."

The correct answer is A: "You think that someone wants to poison you?"
This response acknowledges perception through a reflective question which
presents opportunity for discussion, clarification of meaning, and expressing
doubt.

16. A client has just been admitted with portal hypertension. Which nursing
diagnosis would be a priority in planning care?
A) Altered nutrition: less than body requirements
B) Potential complication hemorrhage
C) Ineffective individual coping
D) Fluid volume excess

The correct answer is B: Potential complication hemorrhage

Esophageal varices are dilated and tortuous vessels of the esophagus that are
at high risk for rupture if portal circulation pressures rise.

17. The nurse in a well-child clinic examines many children on a daily basis.
Which of the following toddlers requires further follow up?
A) A 13 month-old unable to walk
B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination
D) A 30 month-old only drinking from a sippy cup

The correct answer is D: A 30 month-old only drinking from a sippy cup

A 30 month-old should be able to drink from a cup without a cover.

18. Which of the following conditions assessed by the nurse would

contraindicate the use of benztropine (Cogentin)?
A) Neuromalignant syndrome
B) Acute extrapyramidal syndrome
C) Glaucoma, prostatic hypertrophy
D) Parkinson's disease, atypical tremors

The correct answer is C: Glaucoma, prostatic hypertrophy

Glaucoma and prostatic hypertrophy are contraindications to the use of
benztropine (Cogentin) as the drug is an anticholinergic agent.

19. A 15 year-old client with a lengthy confining illness is at risk for altered
growth and development of which task?
A) Loss of control
B) Insecurity
C) Dependence
D) Lack of trust

The correct answer is C: Dependence

The client role fosters dependency. Adolescents may react to dependency with
rejection, uncooperativeness, or withdrawal.

20. The nurse is caring for a client with cirrhosis of the liver with ascites. When

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instructing nursing assistants in the care of the client, the nurse should
emphasize that
A) The client should remain on bed rest in a semi-Fowler's position
B) The client should alternate ambulation with bed rest with legs
elevated
C) The client may ambulate and sit in chair as tolerated
D) The client may ambulate as tolerated and remain in semi-Fowlers position in
bed

The correct answer is B: The client should alternate ambulation with bed rest
with legs elevated. Encourage alternating periods ambulation and bed rest with
legs elevated to mobilize edema and ascites. Encourage and assist the client
with gradually increasing periods of ambulation.

21. In providing care to a 14 year-old adolescent with scoliosis, which of the

following will be most difficult for this client?
A) Compliance with treatment regimens
B) Looking different from their peers
C) Lacking independence in activities
D) Reliance on family for their social support

The correct answer is B: Looking different from their peers

Conformity to peer influences peaks at around age 14. Since many persons
view any disability as deviant, the client will need help in learning how to deal
with reactions of others. Treatment of scoliosis is long-term and involves bracing
and/or surgery.

22. The nurse is preparing to perform a physical examination on an 8 month-old

who is sitting contentedly on his mother's lap. Which of the following should the
nurse do first?
A) Elicit reflexes
B) Measure height and weight
C) Auscultate heart and lungs
D) Examine the ears

The correct answer is C: Auscultate heart and lungs

The nurse should auscultate the heart and lungs during the first quiet moment
with the infant so as to be able to hear sounds clearly. Other assessments may
follow in any order.

23. Which of these principles should the nurse apply when performing a
nutritional assessment on a 2 year-old client?
A) An accurate measurement of intake is not reliable
B) The food pyramid is not used in this age group
C) A serving size at this age is about 2 tablespoons
D) Total intake varies greatly each day

The correct answer is C: A serving size at this age is about 2 tablespoons

In children, a general guide to serving sizes is 1 tablespoon of solid food per
year of age. Understanding this, the nurse can assess adequacy of intake.

24. The nurse is assessing a client with delayed wound healing. Which of the
following risk factors is most important in this situation?
A) Glucose level of 120
B) History of myocardial infarction
C) Long term steroid usage
D) Diet high in carbohydrates

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The correct answer is C: Long term steroid usage

Steroid dependency tends to delay wound healing. If the client also smokes, the
risk is increased.

25. Which of the following nursing assessments indicate immediate

discontinuance of an antipsychotic medication?
A) Involuntary rhythmic stereotypic movements and tongue protrusion
B) Cheek puffing, involuntary movements of extremities and trunk
C) Agitation, constant state of motion
D) Hyperpyrexia, severe muscle rigidity, malignant hypertension

The correct answer is D: Hyperpyrexia, severe muscle rigidity, malignant

hypertension, hyperpyrexia, sever muscle rigidity, and malignant hypertension
are assessment signs indicative of NMS (neuroleptic malignant syndrome).

26. A client with HIV infection has a secondary herpes simplex type 1 (HSV-1)
infection. The nurse knows that the most likely cause of the HSV-1 infection in
this client is
A) Immunosuppression
B) Emotional stress
C) Unprotected sexual activities
D) Contact with saliva

The correct answer is A: Immunosuppression

The decreased immunity leads to frequent secondary infections. Herpes
simplex virus type 1 is an opportunistic infection. The other options may result
in HSV-1. However they are not the most likely cause in clients with HIV.

27. The nurse measures the head and chest circumferences of a 20 month-old
infant. After comparing the measurements, the nurse finds that they are
approximately the same. What action should the nurse take?
A) Notify the health care provider
B) Palpate the anterior fontanel
C) Feel the posterior fontanel
D) Record these normal findings

The correct answer is D: Record these normal findings

The question is D. The rate of increase in head circumference slows by the end
of infancy, and the head circumference is usually equal to chest circumference
at 1 to 2 years of age.

28. At a routine clinic visit, parents express concern that their 4 year-old is
wetting the bed several times a month. What is the nurse's best response?
A) "This is normal at this time of day."
B) "How long has this been occurring?"
C) "Do you offer fluids at night?"
D) "Have you tried waking her to urinate?"

The correct answer is B: "How long has this been occurring?"

Nighttime control should be present by this age, but may not occur until age 5.
Involuntary voiding may occur due to infectious, anatomical and/or
physiological reasons.

29. A client was admitted to the psychiatric unit after refusing to get out of bed.
In the hospital the client talks to unseen people and voids on the floor. The
nurse could best handle the problem of voiding on the floor by
A) Requiring the client to mop the floor
B) Restricting the client’s fluids throughout the day

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C) Withholding privileges each time the voiding occurs

D) Toileting the client more frequently with supervision

The correct answer is D: Toileting the client more frequently with supervision
With altered thought processes the most appropriate nursing approach to alter
the behavior is by attending to the physical need.

30. The nurse is caring for a client with a sigmoid colostomy who requests
assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which
is the correct intervention?
A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus
B) Opening the bottom of the pouch, allowing the flatus to be expelled
C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to
escape
D) Assisting the client to ambulate to reduce the flatus in the pouch

The correct answer is B: Opening the bottom of the pouch, allowing the flatus to
be expelled. The only correct way to vent the flatus from a 1 piece drainable
ostomy pouch is to instruct the client to obtain privacy (the release of the flatus
will cause odor), and to open the bottom of the pouch, release the flatus and
dose the bottom of the pouch.

31. The nurse is teaching parents of an infant about introduction of solid food to
their baby. What is the first food they can add to the diet?
A) Vegetables
B) Cereal
C) Fruit
D) Meats

The correct answer is B: Cereal

Cereal is usually introduced first because it is well tolerated, easy to digest, and
contains iron.

32. When counseling parents of a child who has recently been diagnosed with
hemophilia, what must the nurse know about the offspring of a normal father
and a carrier mother?
A) It is likely that all sons are affected
B) There is a 50% probability that sons will have the disease
C) Every daughter is likely to be a carrier
D) There is a 25% chance a daughter will be a carrier

The correct answer is D: There is a 25% chance a daughter will be a carrier

Hemophilia A is a sex-linked recessive trait seen almost exclusively in males.
With a normal father and carrier mother, affected individuals are male. There is
a 25% chance of having an affected male, 25% chance of having a carrier
female, 25% chance of having a normal female and 25% chance of having a
normal male.

33. When teaching a client with chronic obstructive pulmonary disease about
oxygen by cannula, the nurse should also instruct the client's family to
A) Avoid smoking near the client
B) Turn off oxygen during meals
C) Adjust the liter flow to 10 as needed
D) Remind the client to keep mouth closed

The correct answer is A: Avoid smoking near the client

Since oxygen supports combustion, there is a risk of fire if anyone smokes near
the oxygen equipment.

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34. The nurse is caring for a post-op colostomy client. The client begins to cry
saying, "I'll never be attractive again with this ugly red thing." What should be
the first action by the nurse?
A) Arrange a consultation with a sex therapist
B) Suggest sexual positions that hide the colostomy
C) Invite the partner to participate in colostomy care
D) Determine the client's understanding of her colostomy

The correct answer is D: Determine the client’s understanding of her colostomy.

One of the greatest fears of colostomy clients is the fear that sexual intimacy is
no longer possible. However, the specific concern of the client needs to be
assessed before specific suggestions for dealing with the sexual concerns are
given.

35. A schizophrenic client talks animatedly but the staff are unable to
understand what the client is communicating. The client is observed mumbling
to herself and speaking to the radio. A desirable outcome for this client’s care
will be
A) Expresses feelings appropriately through verbal interactions
B) Accurately interprets events and behaviors of others
C) Demonstrates improved social relationships
D) Engages in meaningful and understandable verbal communication

The correct answer is D: Engages in meaningful and understandable verbal

communication. Data support impaired verbal communication deficit. The
outcome must be related to the diagnosis and supporting data. No data is
presented related to feelings or to thinking processes.

36. A 7 year-old child is hospitalized following a major burn to the lower

extremities. A diet high in protein and carbohydrates is recommended. The
nurse informs the child and family that the most important reason for this diet
is to
A) Promote healing and strengthen the immune system
B) Provide a well-balanced nutritional intake
C) Stimulate increased peristalsis absorption
D) Spare protein catabolism to meet metabolic needs

The correct answer is D: Spare protein catabolism to meet metabolic needs

Because of the burn injury, the child has increased metabolism and catabolism.
By providing a high carbohydrate diet, the breakdown of protein for energy is
avoided. Proteins are then used to restore tissue.

37. The parents of a 7 year-old tell the nurse their child has started to "tattle"
on siblings. In interpreting this new behavior, how should the nurse explain the
child's actions to the parents?
A) The ethical sense and feelings of justice are developing
B) Attempts to control the family use new coping styles
C) Insecurity and attention getting are common motives
D) Complex thought processes help to resolve conflicts

The correct answer is A: The ethical sense and feelings of justice are
developing. The child is developing a sense of justice and a desire to do what is
right. At seven, the child is increasingly aware of family roles and
responsibilities. They also do what is right because of parental direction or to
avoid punishment.

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38. A school nurse is advising a class of unwed pregnant high school students.
What is the most important action they can perform to deliver a healthy child?
A) Maintain good nutrition
B) Stay in school
C) Keep in contact with the child's father
D) Get adequate sleep

The correct answer is A: Maintaining good nutrition

Nurses can serve a pivotal role in providing nutritional education and case
management interventions. Weight gain during pregnancy is one of the
strongest predictors of infant birth weight. Specifically, teens need to increase
their intake of protein, vitamins, and minerals including iron. Pregnant teens
who gain between 26 and 35 pounds have the lowest incidence of low-birth-
weight babies.

39. A client continually repeats phrases that others have just said. The nurse
recognizes this behavior as
A) Autistic
B) Ecopraxic
C) Echolalic
D) Catatonic

The correct answer is C: Echolalic

Echolalic - repeating words heard.

40. A client is admitted for hemodialysis. Which abnormal lab value would the
nurse anticipate not being improved by hemodialysis?
A) Low hemoglobin
B) Hypernatremia
C) High serum creatinine
D) Hyperkalemia

The correct answer is A: Low hemoglobin

Although hemodialysis improves or corrects electrolyte imbalances it has not
effect on improving anemia.

41. The nurse is caring for a 7 year-old child who is being discharged following a
tonsillectomy. Which of the following instructions is appropriate for the nurse to
teach the parents?
A) Report a persistent cough to the health care provider
B) The child can return to school in 4 days
C) Administer chewable aspirin for pain
D) The child may gargle with saline as necessary for discomfort

The correct answer is A: Report a persistent cough to the health care provider.
Persistent coughing should be reported to the health care provider as this may
indicate bleeding.

42. The nurse is caring for a 14 month-old just diagnosed with Cystic Fibrosis.
The parents state this is the first child in either family with this disease, and ask
about the risk to future children. What is the best response by the nurse?
A) 1in 4 chance for each child to carry that trait
B) 1in 4 risk for each child to have the disease
C) 1in 2 chance of avoiding the trait and disease
D) 1in 2 chance that each child will have the disease

The correct answer is B: 1 in 4 risk for each child to have the disease
Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation,

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both parents must be carriers of the trait for the disease since neither one of
them has the disease. Therefore, for each pregnancy, there is a 25% chance of
the child having the disease, 50% chance of carrying the trait and a 25%
chance of having neither the trait or the disease.

43. The nurse is performing an assessment on a client with pneumococcal

pneumonia. Which finding would the nurse anticipate?
A) Bronchial breath sounds in outer lung fields
B) Decreased tactile fremitus
C) Hacking, nonproductive cough
D) Hyper resonance of areas of consolidation

The correct answer is A: Bronchial breath sounds in outer lung fields

Pneumonia causes a marked increase in interstitial and alveolar fluid.
Consolidated lung tissue transmits bronchial breath sounds to outer lung fields.

44. During seizure activity which observation is the priority to enhance further
direction of treatment?
A) Observe the sequence or types of movement
B) Note the time from beginning to end
C) Identify the pattern of breathing
D) Determine if loss of bowel or bladder control occurs

The correct answer is A: Protect the client from injury

It is a priority to note, and then record, what movements are seen during a
seizure because the diagnosis and subsequent treatment often rests solely on
the seizure description.

45. Which of the following statements describes what the nurse must know in
order to provide anticipatory guidance to parents of a toddler about readiness
for toilet training?
A) The child learns voluntary sphincter control through repetition
B) Myelination of the spinal cord is completed by this age
C) Neuronal impulses are interrupted at the base of the ganglia
D) The toddler can understand cause and effect

The correct answer is B: Myelination of the spinal cord is completed by this age.
Voluntary control of the sphincter muscles can be gradually achieved due to the
complete myelination of the spinal cord, sometime between the ages of 18 to
24 months of age.

46. A client complaining of severe shortness of breath is diagnosed with

congestive heart failure. The nurse observes a falling pulse oximetry. The
client's color changes to gray and she expectorates large amounts of pink
frothy sputum. The first action of the nurse would be which of the following?
A) Call the health care provider
B) Check vital signs
C) Position in high Fowler's
D) Administer oxygen

The correct answer is D: Administer oxygen

When dealing with a medical emergency, the rule is airway first, then
breathing, and then circulation. Starting oxygen is a priority.

47. 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

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C) Frequent urination
D) Urine is dark and concentrated

The correct answer is C: Frequent urination

Clients with Benign Prostatic Hypertrophy have overflow incontinence with
frequent urination in small amounts day and night.

48. An anxious parent of a 4 year-old consults the nurse for guidance in how to
answer the child's question, "Where do babies come from?" What is the nurse's
best response to the parent?
A) "When a child asks a question, give a simple answer."
B) "Children ask many questions, but are not looking for answers."
C) "This question indicates interest in sex beyond this age."
D) "Full and detailed answers should be given to all questions."

The correct answer is A: "When a child asks a question, give a simple answer."
During discussions related to sexuality, honesty is very important. However,
honesty does not mean imparting every fact of life associated with the
question. When children ask 1 question, they are looking for 1 answer. When
they are ready, they will ask about the other pieces.

49. A 3 year-old child is treated in the emergency department after ingestion of

1ounce of a liquid narcotic. What action should the nurse do first?
A) Provide the ordered humidified oxygen via mask
B) Suction the mouth and the nose
C) Check the mouth and radial pulse
D) Start the ordered intravenous fluids

The correct answer is C: Check the mouth and radial pulse

The first step in treatment of a toxic exposure or ingestion is to assess the
airway, breathing and circulation; then stabilize the client. The other nursing
actions will follow.

50. The charge nurse on the eating disorder unit instructs a new staff member
to weigh each client in his or her hospital gown only. What is the rationale for
this nursing intervention?
A) To reduce the risk of the client feeling cold due to decreased fat and
subcutaneous tissue
B) To cover the bony prominence and areas where there is skin breakdown
C) So the client knows what type of clothing to wear when weighed
D) To reduce the tendency of the client to hide objects under his or her
clothing

The correct answer is D: To reduce the tendency of the client to hide objects
under his or her clothing. The client may conceal weights on their body to
increase weight gain.

51. In teaching parents to associate prevention with the lifestyle of their child
with sickle cell disease, the nurse should emphasize that a priority for their
child is to
A) Avoid overheating during physical activities
B) Maintain normal activity with some restrictions
C) Be cautious of others with viruses or temperatures
D) Maintain routine immunizations

The correct answer is A: Avoid overheating

Fluid loss caused by overheating and dehydration can trigger a crisis.

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52. The nurse understands that during the "tension building" phase of a violent
relationship, when the batterer makes unreasonable demands, the battered
victim may experience feelings of
A) Anger
B) Helplessness
C) Calm
D) Explosive

The correct answer is B: Helplessness

The battered individual internalizes appropriate anger at the batterer’s
unfairness and instead feels depressed with a sense of helplessness, when the
partner explodes in spite of best efforts to please the batterer.

53. A parent has numerous questions regarding normal growth and

development of a 10 month-old infant. Which of the following parameters is of
most concern to the nurse?
A) 50% increase in birth weight
B) Head circumference greater than chest
C) Crying when the parents leave
D) Able to stand up briefly in play pen

The correct answer is A: 50% increase in birth weight

Birth weight should be doubled at 6 months of age, tripled at 1 year, and
quadrupled by 18 months.

54. 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

The correct answer is C: Tension pneumothorax with slight tracheal deviation to

the right. Tracheal deviation indicates a significant volume of air being trapped
in the chest cavity with a mediastinal shift. In tension pneumothorax the
tracheal deviation is away from the affected side. The affected side is the side
where the air leak is in the lung. This situation also results in sudden air hunger,
agitation, hypotension, pain in the affected side, and cyanosis with a high risk
of cardiac tamponade and cardiac arrest.

55. The nurse is assessing a 4 year-old for possible developmental dysplasia of

the right hip. Which finding would the nurse expect?
A) Pelvic tip downward
B) Right leg lengthening
C) Ortolani sign
D) Characteristic limp

The correct answer is D: Characteristic limp

Developmental dysplasia produces a characteristic limp in children who are
walking.

56. A 2 year-old child has recently been diagnosed with cystic fibrosis. The
nurse is teaching the parents about home care for the child. Which of the
following information is appropriate for the nurse to include?
A) Allow the child to continue normal activities
B) Schedule frequent rest periods
C) Limit exposure to other children
D) Restrict activities to inside the house

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The correct answer is A: Allow the child to continue their normal activities
Physical activity is important in a two year-old who is developing autonomy.
Physical activity is a valuable adjunct to chest physical therapy. Exercise tends
to stimulate mucous secretion and help develop normal breathing patterns.

57. The nurses on a unit are planning for stoma care for clients who have a
stoma for fecal diversion. Which stomal diversion poses the highest risk for skin
breakdown
A) Ileostomy
B) Transverse colostomy
C) Ileal conduit
D) Sigmoid colostomy

The correct answer is A: Ileostomy

Ileostomy output contains gastric and enzymatic agents that when present on
skin can denuded skin in several hours. Because of the caustic nature of this
stoma output adequate peristomal skin protection must be delivered to prevent
skin breakdown.

58. A client is unconscious following a tonic-clonic seizure. What should the

nurse do first?
A) Check the pulse
B) Administer Valium
C) Place the client in a side-lying position
D) Place a tongue blade in the mouth

The correct answer is C: Place the client in a side-lying position

Place the client in a side-lying position to maintain an open airway, drain
secretions, and prevent aspiration if vomiting occurs.

59. The nurse is teaching a client who has a hip prostheses following total hip
replacement. Which of the following should be included in the instructions for
home care?
A) Avoid climbing stairs for 3 months
B) Ambulate using crutches only
C) Sleep only on your back
D) Do not cross legs

The correct answer is D: Do not cross legs

Hip flexion should not exceed 60 degrees.

60. A nurse who travels with an agency is uncertain about what tasks can be
performed when working in a different state. It would be best for the nurse to
check which resource?
A) The state nurse practice act in which the assignment is made
B) With a nurse colleague who has worked in that state 2 years ago
D) The Nursing Social Policy Statement within the United States
C) The policies and procedures of the assigned agency in that state

The correct answer is A: The state nurse practice act in which the assignment is
made. The state nurse practice act is the governing document of what can be
done in the assigned state.

61. Parents of a 7 year-old child call the clinic nurse because their daughter was
sent home from school because of a rash. The child had been seen the day
before by the health care provider and diagnosed with Fifth Disease (erythema
infectiosum). What is the most appropriate action by the nurse?

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A) Tell the parents to bring the child to the clinic for further evaluation
B) Refer the school officials to printed materials about this viral illness
C) Inform the teacher that the child is receiving antibiotics for the rash
D) Explain that this rash is not contagious and does not require
isolation

The correct answer is D: Explain that this rash is not contagious and does not
require isolation. Fifth Disease is a viral illness with an uncertain period of
communicability (perhaps 1 week prior to and 1 week after onset). Isolation of
the child with Fifth Disease is not necessary except in cases of hospitalized
children who are immunosuppressed or having aplastic crises. The parents may
need written confirmation of this from the health care provider.

62. What principle of HIV disease should the nurse keep in mind when planning
care for a newborn who was infected in utero?
A) The disease will incubate longer and progress more slowly in this infant
B) The infant is very susceptible to infections
C) Growth and development patterns will proceed at a normal rate
D) Careful monitoring of renal function is indicated

The correct answer is B: The infant is very susceptible to infections

HIV infected children are susceptible to opportunistic infections due to a
compromised immune system.

63. While teaching a client about their medications, the client asks how long it
will take before the effects of lithium take place. What is the best response of
the nurse?
A) Immediately
B) Several days
C) 2 weeks
D) 1 month

The correct answer is C: 2 weeks

Lithium is started immediately to treat bipolar disorder because it is quite
effective in controlling mania. Lithium takes approximately 2 weeks to effect
change in a client’s symptoms.

64. The nurse is caring for a 12 year-old with an acute illness. Which of the
following indicates the nurse understands common sibling reactions to
hospitalization?
A) Younger siblings adapt very well
B) Visitation is helpful for both
C) The siblings may enjoy privacy
D) Those cared for at home cope better

The correct answer is B: Visitation is helpful for both

Contact with the ill child helps siblings understand the reasons for
hospitalization and maintains the relationship.

65. Following a cocaine high, the user commonly experiences an extremely

unpleasant feeling called
A) Craving
B) Crashing
C) Outward bound
D) Nodding out

The correct answer is B: Crashing

Following cocaine use, the intense pleasure is replaced by an equally

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unpleasant feeling referred to as crashing.

66. One reason that domestic violence remains extensively undetected is

A) Few battered victims seek medical care
B) There is typically a series of minor, vague complaints
C) Expenses due to police and court costs are prohibitive
D) Very little knowledge is currently known about batterers and battering
relationships

The correct answer is B: There is typically a series of minor, vague complaints.

Signs of abuse may not be clearly manifested and a series a minor complaints
such as headache, abdominal pain, insomnia, back pain, and dizziness may be
covert indications of abuse undetected. Complaints may be vague.

67. When making a home visit to a client with chronic pyelonephritis, which
nursing action has the highest priority?
A) Follow-up on lab values before the visit
B) Observe client findings for the effectiveness of antibiotics
C) Ask for a log of urinary output
D) As for the log of the oral intake

The correct answer is C: Ask for a log of urinary output

The nurse must monitor the urine output as a priority because it is the best
indictor of renal function. The other options would be done after an evaluation
of the urine output.

68. When a client is having a general tonic clonic seizure, the nurse should
A) Hold the client's arms at their side
B) Place the client on their side
C) Insert a padded tongue blade in client's mouth
D) Elevate the head of the bed

The correct answer is B: Place the client on their side

This position keeps the airway patent and prevents aspiration.

69. The nurse is teaching a client with dysrhythmia about the electrical pathway
of an impulse as it travels through the heart. Which of these demonstrates the
normal pathway?
A) AV node, SA node, Bundle of His, Purkinje fibers
B) Purkinje fibers, SA node, AV node, Bundle of His
C) Bundle of His, Purkinje fibers, SA node , AV node
D) SA node, AV node, Bundle of His, Purkinje fibers

The correct answer is D: SA node, AV node, Bundle of His, Purkinje fibers

The pathway of a normal electrical impulse through the heart is: SA node, AV
node, Bundle of His, Purkinje fibers.

70. Clients with mitral stenosis would likely manifest findings associated with
congestion in the
A) Pulmonary circulation
B) Descending aorta
C) Superior vena cava
D) Bundle of His

The correct answer is A: Pulmonary circulation

Congestion occurs in the pulmonary circulation due to the inefficient emptying
of the left ventricle and the lack of a competent valve to prevent back flow into
the pulmonary vein.

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71. In assessing the healing of a client's wound during a home visit, which of
the following is the best indicator of good healing?
A) White patches
B) Green drainage
C) Reddened tissue
D) Eschar development

The correct answer is C: Reddened tissue

As the wound granulates, redness indicates healing.

72. The nursing intervention that best describes treatment to deal with the
behaviors of clients with personality disorders include
A) Pointing out inconsistencies in speech patterns to correct thought disorders
B) Accepting client and the client's behavior unconditionally
C) Encouraging dependency in order to develop ego controls
D) Consistent limit-setting enforced 24 hours per day

The correct answer is D: Consistent limit-setting enforced 24 hours per day

Treatment approaches that include restructuring the personality, assisting the
person with developmental level and setting limits for maladaptive behavior
such as acting out.

73. A client has received her first dose of fluphenazine (Prolix in) 2 hours ago.
She suddenly experiences torticollis and involuntary spastic muscle movement.
In addition to administering the ordered anticholinergic drug, what other
measure should the nurse implement?
A) Have respiratory support equipment available
B) Immediately place her in the seclusion room
C) Assess the client for anxiety and agitation
D) Administer prn dose of IM antipsychotic medication

The correct answer is A: Have respiratory support equipment available

Persons receiving neuroleptic medication experiencing torticollis and
involuntary muscle movement are demonstrating side effects that could lead to
respiratory failure.

74. The nurse asks a client with a history of alcoholism about the client’s
drinking behavior. The client states "I didn’t hurt anyone. I just like to have a
good time, and drinking helps me to relax." The client is using which defense
mechanism?
A) Denial
B) Projection
C) Intellectualization
D) Rationalization

The correct answer is D: Rationalization

Rationalization is justifying illogical or unreasonable ideas, actions, or feelings
by developing acceptable explanations that satisfies the teller as well as the
listener.

75. The nurse is teaching a smoking cessation class and notices there are 2
pregnant women in the group. Which information is a priority for these women?
A) Low tar cigarettes are less harmful during pregnancy
B) There is a relationship between smoking and low birth weight
C) The placenta serves as a barrier to nicotine
D) Moderate smoking is effective in weight control

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The correct answer is B: There is a relationship between smoking and low birth
weight. Nicotine reduces placental blood flow, and may contribute to fetal
hypoxia or placenta previa, decreasing the growth potential of the fetus.

76. 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

The correct answer is C: Palpate for a thrill over the fistula

To assess for patency in a fistula or graft, the nurse auscultates for a bruit and
palpates for a thrill. Other options are not related to evaluation for patency.

77. Which therapeutic communication skill is most likely to encourage a

depressed client to vent feelings?
A) Direct confrontation
B) Reality orientation
C) Projective identification
D) Active listening

The correct answer is D: Active listening

Use of therapeutic communication skills such as silence and active listening
encourages verbalization of feelings.

78. The nurse walks into a client's room and finds the client lying still and silent
on the floor. The nurse should first
A) Assess the client's airway
B) Call for help
C) Establish that the client is unresponsive
D) See if anyone saw the client fall

The correct answer is C: Establish that the client is unresponsive

The first step in CPR is to establish unresponsiveness. Second is to call for help.
Third is opening the airway.

79. What is the best way for the nurse to accomplish a health history on a 14
year-old client?
A) Have the mother present to verify information
B) Allow an opportunity for the teen to express feelings
C) Use the same type of language as the adolescent
D) Focus the discussion of risk factors in the peer group

The correct answer is B: Allow an opportunity for the teen to express feelings
Adolescents need to express their feelings. Generally, they talk freely when
given an opportunity and some privacy to do so.

80. A new nurse on the unit notes that the nurse manager seems to be highly
respected by the nursing staff. The new nurse is surprised when one of the
nurses states: "The manager makes all decisions and rarely asks for our input."
The best description of the nurse manager's management style is
A) Participative or democratic
B) Ultraliberal or communicative
C) Autocratic or authoritarian
D) Laissez faire or permissive

The correct answer is C: Autocratic or authoritarian

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Autocratic leadership style is suggested in this situation. It is appropriate for

groups with little education and experience and who need strong direction,
while participative or democratic style is usually more successful on nursing
units.

81. A 2 year-old child is being treated with Amoxicillin suspension, 200

milligrams per dose, for acute otitis media. The child weighs 30 lb. (15 kg) and
the daily dose range is 20-40 mg/kg of body weight, in three divided doses
every 8 hours. Using principles of safe drug administration, what should the
nurse do next?
A) Give the medication as ordered
B) Call the health care provider to clarify the dose
C) Recognize that antibiotics are over-prescribed
D) Hold the medication as the dosage is too low

The correct answer is A: Give the medication as ordered

Amoxicillin continues to be the drug of choice in the treatment of acute otitis
media. The dose range is 20-40 mg/kg/day divided every 8 hours. 15kg x 40mg
= 600mg, divided by 3 = 200 mg per dose. The prescribed dose is correct and
should be given as ordered.

82. The nurse is performing a developmental assessment on an 8 month-old.

Which finding should be reported to the health care provider?
A) Lifts head from the prone position
B) Rolls from abdomen to back
C) Responds to parents' voices
D) Falls forward when sitting

The correct answer is D: Falls forward when sitting

Sitting without support is expected at this age.

83. The nurse is participating in a community health fair. As part of the

assessments, the nurse should conduct a mental status examination when
A) An individual displays restlessness
B) There are obvious signs of depression
C) Conducting any health assessment
D) The resident reports memory lapses

The correct answer is C: Conducting any health assessment

A mental status assessment is a critical part of baseline information, and should
be a part of every examination.

84. The nurse caring for a 14 year-old boy with severe Hemophilia A, who was
admitted after a fall while playing basketball. In understanding his behavior and
in planning care for this client, what must the nurse understand about
adolescents with hemophilia?
A) Must have structured activities
B) Often take part in active sports
C) Explain limitations to peer groups
D) Avoid risks after bleeding episodes

The correct answer is B: Often take part in active sports

Establish an age-appropriate safe environment. Adolescent hemophiliacs should
be aware that contact sports may trigger bleeding. However, developmental
characteristics of this age group such as impulsivity, inexperience and peer
pressure, place adolescents in unsafe environments.

85. When assessing a client who has just undergone a cardioversion, the nurse

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finds the respirations are 12. Which action should the nurse take first?
A) Try to vigorously stimulate normal breathing
B) Ask the RN to assess the vital signs
C) Measure the pulse oximetry
D) Continue to monitor respirations

The correct answer is D: 4. Continue to monitor respirations

12 respirations per minute is tolerated post-operatively. A range from 8 to 10
gives cause for concern. At that point pulse oximetry is taken, as that rate could
be tolerated. Vigorous stimulation is not indicated beyond deep breathing and
coughing. It is not necessary to ask the RN to check findings.

86. In order to enhance a client's response to medication for chest pain from
acute angina, the nurse should emphasize
A) Learning relaxation techniques
B) Limiting alcohol use
C) Eating smaller meals
D) Avoiding passive smoke

The correct answer is A: Learning relaxation techniques

The only factor that can enhance the client’s response to pain medication for
angina is reducing anxiety through relaxation methods. Anxiety can be great
enough to make the pain medication totally ineffective.

87. The primary nursing diagnosis for a client with congestive heart failure with
pulmonary edema is
A) Pain
B) Impaired gas exchange
C) Cardiac output altered: decreased
D) Fluid volume excess

The correct answer is C: Cardiac output altered: decreased

All nursing interventions should be focused on improving cardiac output.
Increasing cardiac output is the primary goal of therapy. Comfort will improve as
the client improves and the respiratory status will improve as cardiac output
increases.

88. After talking with her partner, a client voluntarily admitted herself to the
substance abuse unit. After the second day on the unit the client states to the
nurse, "My husband told me to get treatment or he would divorce me. I don’t
believe I really need treatment but I don’t want my husband to leave me."
Which response by the nurse would assist the client?
A) "In early recovery, it's quite common to have mixed feelings, but
unmotivated people can’t get well."
B) "In early recovery, it’s quite common to have mixed feelings, but I didn’t
know you had been pressured to come."
C) "In early recovery it’s quite common to have mixed feelings, perhaps it would
be best to seek treatment on an out client bases."
D) "In early recovery, it’s quite common to have mixed feelings. Let’s
discuss the benefits of sobriety for you."

The correct answer is D: "In early recovery, it’s quite common to have mixed
feelings. Let’s discuss the benefits of sobriety for you." This response gives the
client the opportunity to decrease ambivalent feelings by focusing on the
benefits of sobriety. Dependence issues are great for the client fostering
ambivalence.

89. Clients taking which of the following drugs are at risk for depression?

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A) Steroids
B) Diuretics
C) Folic acid
D) Aspirin

The correct answer is A: Steroids

Adverse medication effects can cause a syndrome that may or may not remit
when the medication is discontinued. Examples include: phenothiazines,
steroids, and reserpine.

90. The nurse is assessing a client on admission to a community mental health

center. The client discloses that she has been thinking about ending her life.
The nurse's best response would be
A) "Do you want to discuss this with your pastor?"
B) "We will help you deal with those thoughts."
C) "Is your life so terrible that you want to end it?"
D) "Have you thought about how you would do it?"

The correct answer is D: "Have you thought about how you would do it?"
This response provides an opening to discuss intent and means of committing
suicide.

91. The nurse is caring for a client 2 hours after a right lower lobectomy. During
the evaluation of the water-seal chest drainage system, it is noted that the fluid
level bubbles constantly in the water seal chamber. On inspection of the chest
dressing and tubing, the nurse does not find any air leaks in the system. The
next best action for the nurse is to
A) Check for subcutaneous emphysema in the upper torso
B) Reposition the client to a position of comfort
C) Call the health care provider as soon as possible
D) Check for any increase in the amount of thoracic drainage

The correct answer is A: Check for subcutaneous emphysema in the upper

torso. Continuous bubbling in the water seal chamber is an abnormal finding 2
hours after a lobectomy. Further assessment of appropriate factors was done by
the nurse to rule out an air leak in the sytem. Thus the conclusion is that the
problem is one of an air leak in the lung. This client may need to be returned to
surgery to deal with the sustained air leak. Action by the health care provider is
required to prevent further complications.

92. The nurse is caring for a newborn who has just been diagnosed with
hypospadias. After discussing the defect with the parents, the nurse should
expect that
A) Circumcision can be performed at any time
B) Initial repair is delayed until ages 6-8
C) Post-operative appearance will be normal
D) Surgery will be performed in stages

The correct answer is D: Surgery will be performed in stages

Hypospadias, a condition in which the urethral opening is located on the ventral
surface or below the penis, is corrected in stages as soon as the infant can
tolerate surgery.

93. A client has been receiving lithium (Lithane) for the past two weeks for the
treatment of bipolar illness. When planning client teaching, what is most
important to emphasize to the client?
A) Maintain a low sodium diet
B) Take a diuretic with lithium

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C) Come in for evaluation of serum lithium levels every 1-3 months

D) Have blood lithium levels drawn during the summer months

The correct answer is D: Have blood lithium levels drawn during the summer
months. Clients taking lithium therapy need to be aware that hot weather may
cause excessive perspiration, a loss of sodium and consequently an increase in
serum lithium concentration.

94. When an autistic client begins to eat with her hands, the nurse can best
handle the problem by
A) Placing the spoon in the client’s hand and stating, "Use the spoon
to eat your food."
B) Commenting "I believe you know better than to eat with your hand."
C) Jokingly stating, "Well I guess fingers sometimes work better than spoons."
D) Removing the food and stating "You can’t have anymore food until you use
the spoon."

The correct answer is A: Placing the spoon in the client’s hand and stating "Use
the spoon to eat your food." This response identifies adaptive behavior with
instruction and verbal expectation.

95. A client develops volume overload from an IV that has infused too rapidly.
What assessment would the nurse expect to find?
A) S3 heart sound
B) Thready pulse
C) Flattened neck veins
D) Hypoventilation

The correct answer is A: Auscultation of an S3 heart sound

Auscultation of an S3 heart sound. This is an early sign of volume overload (or
CHF) because during the first phase of diastole, when blood enters the
ventricles, an extra sound is produced due to the presence of fluid left in the
ventricles.

96. A neonate born 12 hours ago to a methadone maintained woman is

exhibiting a hyperactive MORO reflex and slight tremors. The newborn passed
one loose, watery stool. Which of these is a nursing priority?
A) Hold the infant at frequent intervals.
B) Assess for neonatal withdrawl syndrome
C) Offer fluids to prevent dehydration
D) Administer paregoric to stop diarrhea

The correct answer is B: Assess for neonatal withdrawl syndrome

Neonatal withdrawl syndrome is a cluster of findings that signal the withdrawal
of the infant from the opiates. The findings seen in methadone withdrawal are
often more severe than for other substances. Initial signs are central nervous
system hyper irritability and gastro-intestinal symptoms. If withdrawal signs are
severe, there is an increased mortality risk. Scoring the infant ensures proper
treatment during the period of withdrawal.

97. While planning care for a preschool aged child, the nurse understands
developmental needs. Which of the following would be of the most concern to
the nurse?
A) Playing imaginatively
B) Expressing shame
C) Identifying with family
D) Exploring the playroom

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The correct answer is B: Expressing shame

Erikson describes the stage of the preschool child as being the time when there
is normally an increase in initiative. The child should have resolved the sense of
shame and doubt in the toddler stage.

98. A depressed client who has recently been acting suicidal is now more social
and energetic than usual. Smilingly he tells the nurse "I’ve made some
decisions about my life." What should be the nurse’s initial response?
A) "You’ve made some decisions."
B) "Are you thinking about killing yourself?"
C) "I’m so glad to hear that you’ve made some decisions."
D) "You need to discuss your decisions with your therapist."

The correct answer is B: "Are you thinking about killing yourself?"

Sudden mood elevation and energy may signal increased risk of suicide. The
nurse must validate suicide ideation as a beginning step in evaluating
seriousness of risk.

99. The nurse is caring for 2 children who have had surgical repair of congenital
heart defects. For which defect is it a priority to assess for findings of heart
conduction disturbance?
A) Artrial septal defect
B) Patent ductus arteriosus
C) Aortic stenosis
D) Ventricular septal defect

The correct answer is D: Ventricular septal defect

While assessments for conduction disturbance should be included following
repair of any defect, it is a priority for this condition. A ventricular septal defect
is an abnormal opening between the right and left ventricles. The
atrioventricular bundle (bundle of His), a part of the electrical conduction
system of the heart, extends from the atrioventricular node along each side of
the interventricular septum and then divides into right and left bundle
branches. Surgical repair of a ventricular septal defect consists of a purse-string
approach or a patch sewn over the opening. Either method involves
manipulation of the ventricular septum, thereby increasing risk of interrupting
the conduction pathway. Consequently, postoperative complications include
conduction disturbances.

100. The nurse is caring for a post myocardial infarction client in an intensive
care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to
30 ml per hour. This change is most likely due to
A) Dehydration
B) Diminished blood volume
C) Decreased cardiac output
D) Renal failure

The correct answer is C: Decreased cardiac output

Cardiac output and urinary output are directly correlated. The nurse should
suspect a drop in cardiac output if the urinary output drops.

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