NCSBN question bank NCLEX-2022

NCLEX NUR 101 NCSBN question bank NCSBN question bank -2022 NCSBN question bank NCLEX NUR 101 written by solutions | Pretest Question 1 A c. What document should be in guiding the care of this client? A) Client Self Determination Act B) Physician's treatment orders C) Advance Directives. D) Clinical Pathway protocols Review Information:the correct answer is: C) Advance Directives. This document specifies the client's wishes Question 2 You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant , a nursing student and yourself. To whom is it appropriate to assign complete care for A) Yourself B)the nursing student C)the licensed vocational nurse D)the nursing assistant Review Information:the correct answer is:) Yourself. While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for a new admission. Only tasks that do not require independent judgment should be delegated. 3Question 3 A mother brings her the clinic, complaining that the child seems to be the nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Rash and restlessness C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor Review Information:the correct answer is:) Rash and restlessness. S - The Marketplace to Buy and Sell your Study Material | S - The Marketplace to Buy and Sell your Study Material Question 4 Asthe nurse takes a history of a 3 year-old with neuroblastoma, what comments bythe parents require follow-up and are consistent withthe diagnosis? A) "The child has been listless and has lost weight." B) "Her urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D+) "We notice muscle weakness and some unsteadiness." Review Information:the correct answer is:) "Clothes are becoming tighter across her abdomen.". One ofthe most common signs of neuroblastoma is increasing abdominal parents'' report that clothing is tight is significant, and should be followed by additional assessments. Question 5 A 16 year-old presents tothe emergency triage nurse finds that this teenager is legally married and signedthe consent form for treatment. What would bethe appropriate INITIAL action bythe nurse? A) Refuse to seethe client until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained fromthe spouse C) Referthe client to a community pediatric hospital emergency room D) Assess and treat inthe same manner as any adult client Review Information:the correct answer is:) Assess and treat inthe same manner as any adult client. Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service inthe military. Therefore, this client, who is married, hasthe legal capacity of an adult. Question 6 A newly admitted elderly client is severely dehydrated. When planning care for this client, which one ofthe following is an appropriate task for an Unlicensed Assistive Personnel (UAP)? A) Obtain a history of fluid loss | S - The Marketplace to Buy and Sell your Study Material B) Report output of less than 30 ml/hr C) Monitor response to IV fluids D) Check skin turgor every four hours Review Information:the correct answer is:) Report output of less than 30 ml/hr. When directing a UAP,the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Becausethe RN is responsible for all care-related decisions,only implementation tasks should be assigned because they do not require independent judgment. Question 7 The nurse is assessing a 4 year-old for possible rheumatic fever. Which ofthe following wouldthe nurse suspect is related to this diagnosis? A) Diagnosis of chickenpox six months ago B) Exposure to strep throat in daycare last month C) Treatment for ear infection two months ago D) Episode of fungal skin infection last week Review Information:the correct answer is:) Exposure to strep throat in daycare last month. Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2-6 weeks). Therefore,the history of playmates recovering from strep throat would indicate thatthe child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an infection has no clinical symptoms. Question 8 Whenthe nurse becomes aware of feeling reluctant to interact with a manipulative client,the BEST action bythe nurse is to A) Discussthe feeling of reluctance with an objective peer or supervisor B) Limit contacts withthe client to avoid reinforcingthe manipulative behavior C) Confrontthe client regardingthe negative effects of his/her behavior on others D) Develop a behavior modification plan that will promote more functional behavior Review Information:the correct answer is:) Discussthe feeling of reluctance with an objective peer or supervisor. The nurse who is experiencing stress inthe therapeutic relationship can gain objectivity through nurse must attempt to discover attitudes and feelings inthe self that influencethe nurseclient relationship. | S - The Marketplace to Buy and Sell your Study Material Question 9 A client is being treated for paranoid schizophrenia. Whenthe client became loud and boisterous,the nurse immediately placed him in seclusion as a precautionary client willingly nurse's action A) May result in charges of unlawful seclusion and restraint B) Leavesthe nurse vulnerable for charges of assault and battery C) Was appropriate in view ofthe client's history of violence D) Was necessary to maintainthe therapeutic milieu ofthe unit Review Information:the correct answer is:) May result in charges of unlawful seclusion and restraint. Seclusion should only be used when there is an immediate threat of violence or threatening behavior. Question 10 A client has been admitted tothe Coronary Care Unit with a Myocardial Infarction. Which ofthe following nursing diagnosis should have PRIORITY? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety Review Information:the correct answer is:) Pain related to ischemia. Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulatesthe sympathetic nervous system and increased preload, further increasing myocardial demands. Question 11 The nurse manager who is responsible for hiring professional nursing staff is required to comply withthe Americans with Disabilities A provisions ofthe law requirethe nurse manager to A) Maintain an environment free from hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals D) Consider only physical disabilities in making employment decisions | S - The Marketplace to Buy and Sell your Study Material Review Information:the correct answer is:) Provide reasonable accommodations for disabled individuals. The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to performthe job and not discriminate onthe basis of a disability. Employers also must make "reasonable accommodations. Question 12 The mother of a school-aged child in a long leg cast asksthe nurse how to relieve itching insidethe cast. Which ofthe following is appropriate forthe nurse to suggest as a remedy? A) Scratchingthe outside ofthe cast vigorously, applying pressure overthe area B) Blowing a hair dryer or heat lamp onthe cast overthe area that is itching C) Using a long, smooth piece of wood to gently scratchthe affected area D) Applying an ice pack overthe area ofthe cast that is affected Review Information:the correct answer is:) Applying an ice pack overthe area ofthe cast that is affected. Applying ice is a safe method of relievingthe itching. Question 13 Which ofthe following BEST describesthe application of time management strategies inthe role ofthe nurse manager? A) Scheduling staff efficiently to cover client needs B) Assuming a fair share ofthe client care as a role model C) Setting daily goals to prioritize work D) Delegating tasks to reduce work load Review Information:the correct answer is:) Setting daily goals to prioritize work. Time management strategies must include setting priorities and meeting goals. Question 14 The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptomsthe nurse observes that suggest this problem include A) Lymphedema and nerve palsy B) Hearing loss and ataxia | S - The Marketplace to Buy and Sell your Study Material C) Headaches and vomiting D) Abdominal mass and weakness Review Information:the correct answer is:) Abdominal mass and weakness. Clinical manifestations of neuroblastoma include an irregular abdominal mass that crossesthe midline, weakness, pallor, anorexia, weight loss and irritability. Question 15 A fifteen year-old client has been placed in a Milwaukee Brace. Which one ofthe following statements fromthe client indicatesthe need for additional teaching? A) "I will only have to wear this for six months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower." Review Information:the correct answer is:) "I will only have to wear this for six months.". The brace must be worn long-term, usually for 1-2 years. Question 16 The nurse manager has been using a decentralized block scheduling plan to staffthe nursing unit. However, staff have asked for many changes and exceptions tothe schedule overthe past few manager considers self-scheduling knowing that A) Quality of care will improve B) Staff turnover should decrease C) Flexible scheduling will occur D) Team morale will improve Review Information:the correct answer is:) Team morale will improve. Nurses are more satisfied with autonomy and nurse manager becomesthe facilitator of scheduling rather thanthe decision-maker ofthe schedule. Question 17 A client is admitted tothe emergency room following an acute asthma attack. Which ofthe following assessments would be expected bythe nurse? A) Diffuse expiratory wheezing B) Loose, productive cough | S - The Marketplace to Buy and Sell your Study Material C) No relief from inhalant D) Fever and chills Review Information:the correct answer is:) Diffuse expiratory wheezing. In asthma,the airways are narrowed - creating difficulty getting air in and a wheezing sound. Question 18 The nurse manager hears a physician loudly criticizing one of the staff nurses in the hearing of others. the employee does not respond to the physician's complaints. the nurse manager's FIRST action should be A) Walk up to the physician and quietly ask that this unacceptable behavior stop B) Allow the staff nurse to handle this situation without interference C) Notify the Nursing Director and Medical Staff Chief of a breech of professional conduct D) Request an immediate private meeting physician and staff nurse Review Information:the correct answer is:) Request an immediate private meeting withthe physician and staff nurse. Assertive communication respectsthe needs of all parties to express themselves, but not at the expense of others. the nurse manager needs first to protect clients and other staff from this display and come to the assistance of the nurse employee. Question 19 A client voluntarily admits herself tothe hospital due to suicidal client has been onthe unit for two days and is now demanding to be MOST appropriate action is forthe nurse to A) Tellthe client that she cannot be released because she is still suicidal B) Informthe client that she can be released only if she signs a no suicide contract C) Discuss withthe clientthe decision to leave and prepare for her discharge D) Instruct her regarding her right to sign out upon receipt ofthe physician's discharge order Review Information:the correct answer is:) Discuss with the client the decision to leave and prepare for her discharge. Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision allows opportunity for other interventions. Question 20 | S - The Marketplace to Buy and Sell your Study Material A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? A) Dyspnea B) Heart murmur C) Macular rash D) Hemorrhage Review Information:the correct answer is:) Heart murmur. Large, soft, rapidly developing vegetations attach tothe heart valves. They have a tendency to break off, causing emboli and leaving ulcerations onthe valve leaflets. These emboli produce symptoms of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore,the vegetations may travel to various organs such as spleen, kidney, coronary artery, brain and lungs and obstruct blood flow. Question 21 A nurseadmits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based onthe fact thatthe MOST likely cause of this problem stems fromthe infant's inability to A) Stabilize thermoregulation B) Maintain alveolar surface tension C) Begin normal pulmonary blood flow D) Regulate intracardiac pressure Review Information:the correct answer is:) Maintain alveolar surface tension. Respiratory distress syndrome is primarily a disease related to developmental delay in lung maturation. Although many factors lead tothe development ofthe problem,the central factor relates tothe lack of a normally functioning surfactant system due to immaturity in lung development. Question 22 An 18 year-old client is admitted to intensive care fromthe emergency room following a diving injury is suspected to be atthe level ofthe 2nd cervical nurse's PRIORITY assessment should be A) Response to stimuli B) Bladder control C) Respiratory function D) Muscle weakness | S - The Marketplace to Buy and Sell your Study Material Review Information:the correct answer is: C) Respiratory function. Spinal injury atthe C-2 level results in quadriplegia. Whilethe client will experience all ofthe problems identified, respiratory assessment is a priority. Question 23 The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which ofthe following assessments is CRITICAL forthe nurse to include inthe plan of care? A) Hourly urine output B) White blood count C) Blood glucose every four hours D) Temperature every two hours Review Information:the correct answer is:) Hourly urine output. Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs whenthe effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition. Question 24 The nurse admitting a 5 month-old who vomited nine times inthe past six hours should observe for signs of A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis Review Information:the correct answer is:) Metabolic alkalosis. Vomiting causes loss of acid fromthe stomach. Prolonged vomiting can result in excess loss and lead to metabolic alkalosis. Question 25 A child is injured onthe school playground and appears to have a fractured FIRST actionthe school nurse should take is | S - The Marketplace to Buy and Sell your Study Material A) Call for emergency transport tothe hospital B) Immobilizethe limb and joints above and belowthe injury C) Assessthe child andthe extent ofthe injury D) Apply cold compresses tothe injured area Review Information:the correct answer is:) Assessthe child andthe extent ofthe injury. When applyingthe nursing process, assessment isthe first step in providing 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis). Question 26 Asthe nurse interviewsthe parents of a child with asthma, it is a PRIORITY to ask about A) Household pets B) New furniture C) Lead based paint D) Plants such as cactus Review Information:the correct answer is:) Household pets. Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust. Question 27 An 80 year-old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressure has ranged from 180/110 to 160/100. Overthe past several hours,the nurse noted increasing lethargy. Which ofthe following assessments shouldthe nurse report IMMEDIATELY tothe physician? A) Slurred speech B) Incontinence C) Muscle weakness D) Rapid pulse Review Information:the correct answer is:) Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued intercranial bleeding. Treatment options may change based on further diagnostic tests. | S - The Marketplace to Buy and Sell your Study Material Question 28 A 3 year-old child is brought tothe clinic by his grandmother to be seen for "scratching his bottom and wettingthe bed at night." Based on these complaints,the nurse would INITIALLY assess for A) Allergies B) Hyperactivity C) Regression D) Pinworms Review Information:the correct answer is:) Pinworms. Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span. Question 29 A 72 year-old client with osteomyelitis requires a six week course of intravenous antibiotics. In planning for home care,the MOST important action bythe nurse is A) Investigatingthe client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities inthe home C) Assessingthe client's ability to participate in self care and/orthe reliability of a caregiver D) Selectingthe appropriate venous access device Review Information:the correct answer is:) Assessingthe client''s ability to participate in self care and/orthe reliability of a caregiver. The cognitive ability ofthe client as well asthe availability and reliability of a caregiver must be assessed to determine if home care is a feasible option. Question 30 The mother of a child with a neural tube defect asksthe nurse what she can do to decreasethe chances of having another baby with a neural tube BEST response bythe nurse is A) "Folic acid should be taken before and after conception." B) "Multivitamin supplements are recommended during pregnancy." C) "A well balanced diet promotes normal fetal development." D) "Increased dietary iron improvesthe health of mother and fetus." Review Information:the correct answer is:) "Folic acid should be taken before and after conception.". | S - The Marketplace to Buy and Sell your Study Material The American Academy of Pediatrics recommends that all childbearing women increase folic acid from dietary sources and/or supplements. There is evidence that increased amounts of folic acid prevents neural tube defects. Question 31 The nurse is caring for a newborn with a neural tube BEST covering forthe lesion is A) Telfa dressing with antibiotic ointment B) Moist sterile nonadherent dressing C) Dry sterile dressing D) Sterile occlusive pressure dressing Review Information:the correct answer is:) Moist sterile nonadherent dressing. Before surgical closurethe sac is prevented from drying bythe application of a sterile, moist, nonadherent dressing overthe defect. Dressings are changed frequently to keep them moist. Question 32 A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which ofthe following is most important to prevent lead poisoning? A) Use ready-to-feed commercial infant formula B) Boilthe tap water for 10 minutes prior to preparingthe formula C) Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled "lead free" to mixthe formula Review Information:the correct answer is:) Let tap water run for 2 minutes before adding to concentrate. Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or lead solder used insealing water pipes. Letting tap water run for several minutes will diminishthe lead contamination. Question 33 A client is admitted tothe rehabilitation unit following a CVA and mild MOST appropriate intervention for this client is A) Position client in upright position while eating B) Place client on a clear liquid diet | S - The Marketplace to Buy and Sell your Study Material C) Tilt head back to facilitate swallowing reflex D) Offer finger foods such as crackers or pretzels Review Information:the correct answer is:) Position client in upright position while eating. An upright position facilitates proper chewing and swallowing. Question 34 The nurse explains an autograft to a client scheduled for excision of a skin nurse knowsthe client understandsthe procedure whenthe client says, "I will receive tissue from A) a tissue bank." B) a pig." C) my thigh." D) synthetic skin." Review Information:the correct answer is:) my thigh.". Autografts are done with tissue transplanted fromthe client''s own skin. Question 35 The nurse is caring for a newborn with tracheoesophageal fistula. Which ofthe following nursing diagnoses is a PRIORITY? A) Risk for dehydration B) Ineffective airway clearance C) Altered nutrition D) Risk for injury Review Information:the correct answer is:) Ineffective airway clearance. The most common form of TEF is one in whichthe proximal esophageal segment terminates in a blind pouch andthe distal segment is connected tothe trachea or primary bronchus by a short fistula at or nearthe bifurcation. Thus, a priority is maintaining an open airway, preventing aspiration. Other nursing diagnoses are then addressed. Question 36 A client has been hospitalized after an automobile accident. A full leg cast was applied inthe emergency MOST important reason forthe nurse to elevatethe casted leg is to | S - The Marketplace to Buy and Sell your Study Material A) Promotethe client's comfort B) Reducethe drying time C) Decrease irritation tothe skin D) Improve venous return Review Information:the correct answer is:) Improve venous return. Elevatingthe leg both improves venous return and reduces swelling. Question 37 A nurse is working with family members of a newly diagnosed client with Alzheimer's disease. Which ofthe following interventions is MOST helpful? A) Teaching relaxation techniques B) Implementing a daily exercise routine C) Improving daily nutritional intake D) Suggesting communication strategies Review Information:the correct answer is:) Suggesting communication strategies. Since Alzheimer''s disease is a progressive chronic illness that greatly challenges caregivers,the nurse can be of greatest assistance in helping family to identify language changes, and select verbal and nonverbal communication strategies to minimize aberrant behavior. Question 38 The nurse is teaching a client with non-insulin dependent diabetes mellitus aboutthe prescribed nurse should teachthe client to A) Maintain previous calorie intake B) Keep a candy bar available at all times C) Reduce carbohydrates intake to 25% of total calories D) Keep a regular schedule of meals and snacks Review Information:the correct answer is:) Keep a regular schedule of meals and snacks. Currently, calorie-controlled diets with strict mealplans are rarely suggested for clients who have diabetes. Try to incorporate schedule or food changes into clients'' existing dietary patterns. Help clients learn to read labels and identify specific canned foods, frozen entrees, or other foods which are acceptable and those which should be avoided. Question 39 | S - The Marketplace to Buy and Sell your Study Material The mother of a two month-old baby callsthe nurse at a well-baby clinic two days afterthe first DTaP immunization. She reports thatthe baby feels very warm, has cried inconsolably for as long as three hours, and has had several shaking response ofthe nurse should be to A) instructthe mother to call 911 for an ambulance to transportthe infant B) suggest that these are expected reactions and to begin every 4 hour antipyretics C) tellthe mother to takethe infant immediately tothe nearest emergency room D) give instructions to bringthe infant tothe clinic now Review Information:the correct answer is:)instructthe mother to call 911 for an ambulance to transportthe infant The exhibited findings ofthe infant indicate a severe reaction tothe immunizations. Immediate attention is needed & an ambulance with trained staff needs to transport because ofthe risk of grand mal seizures from potential encephalopathy which is a critical mother would need to be instructed after this acute reaction to informthe provider of this reaction tothe first dose of DTaP. Based onthe need and risk involved tothe infant,the health care provider may decide that further DTaP immunizations are contraindicated for clinic nurse would need to document inthe notes for this infant:the instructions given, findings reported bythe mother and specific follow-up needs forthe next clinic visit in relation to teaching and evaluation ofthe outcome of this event. Question 40 The nurse is teaching a class on HIV prevention. Which ofthe following should be emphasized as increasing risk? A) Donating blood B) Using public bathrooms C) Unprotected sex D) Touching a person with AIDS Review Information:the correct answer is:) Unprotected sex. Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remainthe highest risk for infection. Question 41 A 6 year-old child is seen forthe first time inthe clinic. Upon assessment,the nurse finds thatthe child has short palpebral fissures, thinned upper lip, and hypoplastic philtrum ofthe upper mother states thatthe child seems to have problems in learning to count and recognizing basic colors. Based on this data,the nurse suspects thatthe child is MOST likely showingthe effects of A) Congenital abnormalities B) Chronic toxoplasmosis C) Fetal alcohol syndrome D) Lead poisoning | S - The Marketplace to Buy and Sell your Study Material Review Information:the correct answer is:) Fetal alcohol syndrome. Major features of fetal alcohol syndrome consist of facial and associated physical features, such as short palpebral fissure, hypoplastic philtrum, thinned upper lip, short, upturned nose. Behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome. Question 42 The nurse is performingthe admission assessment of a client with an acute episode of asthma. Which ofthe following assessments wouldthe nurse anticipate finding? A) Prolonged inspiration B) Expiratory wheezes C) Expectorating large amounts of purulent mucous D) Lethargy Review Information:the correct answer is:) Expiratory wheezes. Asthma is characterized by expiratory wheezes caused by obstruction ofthe airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes withthe feeling of tightness inthe chest. Question 43 The nurse is planning a meal plan that would providethe most iron for a child with anemia. Which ofthe following dinner menus would be BEST? A) Fish sticks, french fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) Peanut butter and jelly sandwich, apple slices, milk Review Information:the correct answer is:) Ground beef patty, lima beans, wheat roll, raisins, milk. Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, dried fruits such as raisins. This dinner isthe best choice, high in iron and is appropriate for a toddler. Question 44 A ten year-old client is recovering from a splenectomy following a traumatic clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 BEST approach forthe nurse to use is to | S - The Marketplace to Buy and Sell your Study Material A) Limit milk and milk products B) Encourage bed activities and games C) Plan nursing care around lengthy rest periods D) Promote a diet rich in iron Review Information:the correct answer is:) Plan nursing care around lengthy rest periods. The initial priority for this client is rest due tothe inability of red blood cells to carry oxygen. Question 45 The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis ofthe elbow should include which one ofthe following as a PRIORITY? A) Limit fluids B) Client controlled analgesia C) Cold compresses to elbow D) Passive range of motion exercise Review Information:the correct answer is:) Client controlled analgesia. Management of a crisis is directed towards supportive and symptomatic priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum comfort. Question 46 Asthe nurse provides discharge teaching tothe parents of a 15 month-old child with Kawasaki Disease who has received immunoglobulin therapy, which one ofthe following instructions would be MOST appropriate? A) High doses of aspirin will be continued for some time B) Complete recovery is expected within several days C) Active range of motion exercises should be done frequently D) the measles, mumps and rubella vaccine should be delayed Review Information:the correct answer is:)the measles, mumps and rubella vaccine should be delayed. Discharge instructions for a child with Kawasaki Disease should include immunoglobulin therapy may interfere withthe body''s ability to form appropriate amounts of antibodies and live immunizations should be delayed. | S - The Marketplace to Buy and Sell your Study Material Question 47 The nurse is giving instructions tothe parents of a child with Cystic F nurse would emphasize that pancreatic enzymes should be taken A) Once each day B) Three times daily after meals C) With each meal or snack D) Each time carbohydrates are eaten Review Information:the correct answer is:) With each meal or snack. Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of all foods that are eaten. Question 48 The nurse is assessing an eight month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one ofthe following manifestations wouldthe infant be MOST likely to exhibit? A) Lethargy B) Irritability C) Negative Moro D) Depressed fontanel Review Information:the correct answer is:) Irritability. Signs of IICP (increased intracranial pressure) in infants include bulging fontanel, instability, high-pitched cry, and cries when held. Vital sign changes include pulse that is variable, i.e., rapid, slow and bounding, or feeble. Respirations are more often slow, deep, and irregular. Question 49 The nurse is performing a physical assessment on a toddler. Which ofthe following should bethe FIRST action? A) Perform traumatic procedures B) Use minimal physical contact C) Proceed from head to toe D) Explainthe exam in detail Review Information:the correct answer is:) Use minimal physical contact. | S - The Marketplace to Buy and Sell your Study Material The nurse should approachthe toddler slowly and use minimal physical contact initially so as to gainthe toddler''s cooperation. Be flexible inthe sequence ofthe exam, and give only brief simple explanations just prior tothe action. Question 50 A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which ofthe following symptoms noted onthe initial nursing assessment is expected? A) Recent weight gain B) Physical growth delay C) Protruding eyeballs D) Sudden onset of irritability Review Information:the correct answer is:) Protruding eyeballs. Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves'' Disease. Question 51 When assessing a client admitted tothe hospital for diabetic acidosis, which ofthe following clinical manifestations wouldthe nurse expect? A) A blood pH level above 7.5 B) Arterial blood PCO2 above 40 C) Blood pH level below 7.3 D) Arterial blood PCO2 below 10 Review Information:the correct answer is:) Blood pH level below 7.3. Inthe absence of insulin, which facilitatesthe transport of glucose intothe cell,the body breaks down fats and proteins to supply energy ketones, a by-product of fat metabolism. These accumulate causing metabolic acidosis (pH 7.3). Question 52 The nurse is explainingthe proper use of syrup of ipecac to a group of parents. For which ofthe following accidental poisonings isthe treatment appropriate? A) Oven cleaner B) Drain cleaner C) Kerosene D) Chewable vitamins | S - The Marketplace to Buy and Sell your Study Material Review Information:the correct answer is:) Chewable vitamins. Ofthe above choices, poisoning with vitamins isthe only case in which it is safe to induce vomiting with syrup of ipecac. Question 53 A two year-old child is brought tothe pediatrician's office with a chief complaint of mild diarrhea for two days. Nutritional counseling bythe nurse should include which one ofthe following statements? A) Placethe child on clear liquids and gelatin for 24 hours B) Continue withthe regular diet and include oral rehydration fluids C) Give bananas, apples, rice and toast as tolerated D) Place NPO for 24 hours, then rehydrate with milk and water Review Information:the correct answer is:) Continue withthe regular diet and include oral rehydration fluids. Current recommendations for mild to moderate diarrhea are to maintain a normal diet with rehydration fluids. Question 54 The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers).the nurse is concerned thatthe client is unable to coordinatethe release ofthe medication withthe inhalation nurse's BEST recommendation forthe client is A) Nebulized treatments for home care B) Adding a spacer device tothe MDI canister C) Asking a family member to assistthe client withthe MDI D) Request a visiting nurse to followthe client at home Review Information:the correct answer is:) Adding a spacer device tothe MDI canister. The majority of pulmonary medications for COPD are delivered by inhalation.This is often preferred over oral administration because a lower drug dose is needed and systemic side effects are reduced. In addition,the onset of action of bronchodilator medication given via inhalation is faster. Question 55 Which ofthe following manifestations observed bythe school nurse confirmsthe presence of pediculosis capitis in students? A) Scratchingthe head more than usual | S - The Marketplace to Buy and Sell your Study Material B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking tothe hair Review Information:the correct answer is:) Whitish oval specks sticking tothe hair. Diagnosis of pediculosis capitis is made by observation ofthe white eggs (nits) firmly attached tothe hair shafts. Treatment includes shampoo application, such as lindane for children over 2 years of age, and meticulous combing and removal of all nits. Question 56 When parents callthe emergency room to report that a toddler has swallowed drain cleaner,the nurse instructs them to call for emergency transport tothe hospital. While waiting for an ambulance,the BEST actionthe nurse would suggest tothe parents is A) Administer syrup of ipecac B) Offer small amounts of water C) Havethe child drink milk D) Give ginger ale or cola Review Information:the correct answer is:) Offer small amounts of water. Small amounts of water will dilutethe corrosive substance prior to gastric lavage. Question 57 A client is scheduled for an IVP (Intravenous Pyelogram). Which ofthe following data fromthe client's history indicate a potential hazard for this test? A) Reflex incontinence B) Allergic to shellfish C) Claustrophobia D) Hypertension Review Information:the correct answer is:) Allergic to shellfish. It is important to know ifthe client has an allergy to iodine or shellfish. Ifthe client does, they may have an allergic reaction tothe IVP contrast dye injected duringthe procedure. Question 58 | S - The Marketplace to Buy and Sell your Study Material A high school nurse is advising a class of unwed pregnant students thatthe MOST important action they can perform to deliver a healthy child is A) Maintaining good nutrition B) Staying in school C) Keeping in contact withthe child's father D) Getting adequate sleep Review Information:the correct answer is:) Maintaining good nutrition. Nurses can serve a pivotal role in providing nutritional education and case management interventions. Weight gain during pregnancy is one ofthe 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 havethe lowest incidence of low-birth-weight babies. Question 59 The nurse is preparing a handout on infant feeding to be distributed to families visitingthe clinic. Which ofthe following should be included inthe teaching materials? A) Solid foods are introduced one at a time beginning with cereal B) Finely ground meat should be started early to provide iron C) Egg white is added early to increase protein intake D) Solid foods should be mixed with formula in a bottle Review Information:the correct answer is:) Solid foods are introduced one at a time beginning with cereal. Solid foods should be added one at a time between 4-6 months. Ifthe infant is able to toleratethe food, another may be added in a week. Iron fortified cereal isthe recommended first food. Question 60 The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which ofthe following is an appropriate action forthe nurse when administeringthe infusion? A) Storingthe packed red cells inthe medicine refrigerator while starting IV B) Slowthe rate of infusion ifthe client develops fever or chills C) Limitthe infusion time of each ofthe unit to a maximum of four hours D) Assess vital signs every 15 minutes throughoutthe entire infusion Review Information:the correct answer is:) Limitthe infusion time of each ofthe unit to a maximum of four hours. | S - The Marketplace to Buy and Sell your Study Material Infusethe specified amount of blood within 4 hours. Ifthe infusion will exceed this time,the blood should be divided into appropriately sized quantities. Question 61 A client with a documented pulmonary embolism hasthe following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on thisdata, what isthe FIRST nursing action? A) Review other lab data B) Notifythe physician C) Administer oxygen D) Calmthe client Review Information:the correct answer is:) Administer oxygen. The client has a low PCO2 due to increased respiratory rate fromthe hypoxemia and signs of respiratory alkalosis. Immediate intervention is indicated. Question 62 A client diagnosed with hepatitis C discusses his health history withthe admitting nurse should recognize which ofthe following asthe MOST important data? A) Recent travel to Central America B) Ingestion of raw shellfish last week C) Multiple sex partners D) Blood transfusion 15 years ago Review Information:the correct answer is:) Blood transfusion 15 years ago. The client who was transfused prior to blood screening for hepatitis C may show symptoms many years later. Question 63 A client is recovering from a thyroidectomy. While monitoringthe client's initial post operative condition, which ofthe following shouldthe nurse report immediately? A) Tetany and paresthesia B) Mild stridor and hoarseness | S - The Marketplace to Buy and Sell your Study Material C) Irritability and insomnia D) Headache and nausea Review Information:the correct answer is: A) Tetany and paresthesia. Becausethe parathyroid gland may be damaged in this surgery, secondary hypocalcemia may occur. Symptoms of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures. Question 64 A client is admitted with a right upper lobe infiltrate, and also to rule out isolation precautionsthe nurse would institute include A) Positive pressure ventilation B) Gown and gloves C) Particulate respirator mask D) Barrier precautions Review Information:the correct answer is:) Particulate respirator mask. Tight fitting, high-efficiency masks are required when caring for clients who have suspected communicable disease ofthe airborne variety. Question 65 A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential forthe nurse to include atthe change of shift report? A) the client lost 2 pounds B) the client's potassium level is 4 mEq/liter. C) the client's urine output was 1500 cc in five hours D) the client is to receive another dose of Lasix at 10 PM Review Information:the correct answer is:)the client's urine output was 1500 cc in five hours. Although all of these may be correct information to include in report,the essential piece would bethe urine output. Question 66 | S - The Marketplace to Buy and Sell your Study Material The nurse is caring for a client with a colostomy. During a teaching session,the nurse recommends thatthe pouch be emptied A) When it is one third to one half full B) Prior to meals C) After each fecal elimination D) Atthe same time each day Review Information:the correct answer is:) When it is one third to one half full. Ifthe pouch becomes more than half full it may separate fromthe flange. Question 67 A couple asksthe nurse about risks of several birth control MOST appropriate response bythe nurse would be A) Norplant is safe and may be removed easily B) Oral contraceptives should not be used by smokers C) Depo-Provera is convenient with few side effects D) the IUD gives protection from pregnancy and infection Review Information:the correct answer is:) Oral contraceptives should not be used by smokers. The use of oral contraceptives in a pregnant woman who smokes increases her risk of cardiovascular problems. Question 68 Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which ofthe following assessments wouldthe nurse use to evaluatethe effectiveness of this treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice Review Information:the correct answer is:) A decrease in lethargy. Lactulose produces and acid environment inthe bowel and trapsammonia inthe gut;the laxative effect then aids in removingthe ammonia fromthe body. This decreasesthe effects of hepatic encephalopathy, including lethargy and confusion. | S - The Marketplace to Buy and Sell your Study Material Question 69 The mother of a 3 month-old infant tellsthe nurse that she wants to change from formula towhole milk and add cereal and meats tothe diet. What should be emphasized asthe nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months B) Whole milk is difficult for a young infant to digest C) Fluoridated tap water should be used to dilute milk D) Supplemental apple juice can be used between feedings Review Information:the correct answer is:) Whole milk is difficult for a young infant to digest. Cow''s milk is not given to infants younger than 1 year becausethe tough, hard curd is difficult to digest. Also it contains little iron and creates a high renal solute load. Question 70 The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which ofthe following information would indicate thatthe client is at risk for thrombusformation inthe post-operative period? A) Estrogen replacement therapy B) 10% less than ideal body weight C) Hypersensitivity to heparin D) History of hepatitis Review Information:the correct answer is:) Estrogen replacement therapy. Estrogen increasesthe hypercoagualability ofthe blood and increasedthe risk for development of thrombophlebitis. Question 71 The nurse is planning discharge for a 90 year-old client with musculo-skeletal weakness. Which ofthe following interventions would be MOST effective in preventing falls? A) Place nightlights in bedroom B) Wear eyeglasses at all times C) Install grab bars inthe bathroom D) Teach muscle strengthening exercises | S - The Marketplace to Buy and Sell your Study Material Review Information:the correct answer is:) Place nightlights in bedroom. Because more falls occur inthe bedroom than any other location, begin there. However, work in partnership withthe client and family so they are willing to move furniture, lamp cords, and storage areas; add lighting; remove throw rugs; and decrease other environmental hazards. Question 72 While obtainingthe history of a two week-old infant duringthe well-baby exam,the nurse finds thatthe neonatal screening for phenylketonuria (PKU) was done whenthe infant was less than 24 hours-old. It is a PRIORITY forthe nurse to A) Schedulethe infant for a repeat test in two weeks B) Obtain a repeat blood test at this point C) Contactthe hospital of birth forthe results D) Document thatthe test results are pending Review Information:the correct answer is:) Obtain a repeat blood test at this point. Testing for PKU is most reliable when protein has been ingested. A repeat blood specimen must be obtained bythe third week of life ifthe initial specimen was taken from an infant less than 24 hours-old. Question 73 Two hours afterthe normal spontaneous vaginal delivery of a woman who is gravida 4 para 4,the nurse notes thatthe fundus is boggy and displaced slightly above and tothe left ofthe appropriate INITIAL nursing action is to A) Assess lochia for color and amount B) Monitor pulse and blood pressure C) Callthe physician immediately D) Askthe woman to empty her bladder Review Information:the correct answer is:) Askthe woman to empty her bladder. A full bladder can displacethe uterus and prevent contraction. Afterthe woman emptiesthe bladder,the fundus should be assessed again. Question 74 An 8 year-old client is admitted tothe hospital for child's parent reports several allergies. Which ofthe following should all health care personnel be aware of? | S - The Marketplace to Buy and Sell your Study Material A) Shellfish B) Molds C) Balloons D) Perfumed soap Review Information:the correct answer is:) Balloons. Allergy to balloons indicates a latex allergy. All personnel in contact withthe child will need to be aware of this condition and use non-latex gloves. Question 75 The nurse is caring for a client who is post-op following a client has two chest tubes in place,connected to one chest nursing assessment reveals bubbling inthe water seal chamber whenthe client coughs. What isthe MOST appropriate nursing action? A) Clampthe chest tube B) Callthe surgeon immediately C) Continue to monitorthe client to see ifthe bubbling increases D) Instructthe client to try to avoid coughing Review Information:the correct answer is:) Continue to monitorthe client to see ifthe bubbling increases. Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escapethe pleural space when pressures insidethe chest increase with coughing. Monitoring isthe only nursing action required. Question 76 The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 nurse should instructthe client to A) Completethe entire course ofthe medication for an effective cure B) Begin treatment with acyclovir atthe onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birth defects D) Continue to take prophylactic doses for at least five years afterthe diagnosis Review Information:the correct answer is:) Begin treatment with acyclovir atthe onset of symptoms of recurrence. Whenthe client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. | S - The Marketplace to Buy and Sell your Study Material Question 77 An eight year-old child is hospitalized duringthe edema phase of minimal change nephrotic nurse is assisting in choosingthe lunch menu. Which one ofthe following isthe BEST choice? A) Bologna sandwich, pudding, milk B) Frankfurter, baked potato, milk C) Chicken strips, corn onthe cob, milk D) Grilled cheese sandwich, apple, milk Review Information:the correct answer is:) Chicken strips, corn onthe cob, milk. This menu is lowest in sodium. Ideally, low fat milk would be available. Question 78 The nurse is teaching parents about accidental poisoning in children. Which ofthe following should be emphasized? A) Start treatment before callingthe Poison Control Center B) Emptythe child's mouth in any case of possible poisoning C) Do not movethe child if a toxic substance was inhaled D) Induce vomiting ifthe poison is a hydrocarbon Review Information:the correct answer is:) Emptythe child''s mouth in any case of possible poisoning. Emptyingthe mouth of poison interferes with further ingestion and should be done first to limit contact withthe substance. Question 79 Which ofthe following symptoms contraindicatethe use of haloperidol (Haldol) and warrant withholdingthe dose? A) Drowsiness, lethargy, and inactivity B) Dry mouth, nasal congestion, and blurred vision C) Rash, blood dyscrasias, severe depression D) Hyperglycemia, weight gain, and edema Review Information:the correct answer is:) Rash, blood dyscrasias, severe depression. Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication tothe use of neuroleptics. | S - The Marketplace to Buy and Sell your Study Material Question 80 The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which ofthe following actions should receive PRIORITY inthe plan? A) Antibiotic therapy for 10 days B) Teach client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at bedside withinthe first 24 hours Review Information:the correct answer is:) Assess movement and sensation of extremities. Following corrective surgery for scoliosis, neurological status requires special attention and assessment, especially that ofthe extremities. Question 81 A three year-old child diagnosed as having celiac disease attends a day care center. Which ofthe following would be an appropriate snack? A) Cheese crackers B) Peanut butter sandwich C) Potato chips D) Vanilla cookies Review Information:the correct answer is:) Potato chips. Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible in persons with celiac disease. Question 82 The nurse is caring for a 14 month-old just diagnosed with Cystic F parents state this isthe first child in either family with this disease, and ask aboutthe risk to future BEST response bythe nurse is based onthe knowledge that there is a A) 1 in 4 chance for each child to carry that trait B) 1 in 4 risk for each child to havethe disease C) 1 in 2 chance of avoidingthe trait and disease D) 1 in 2 chance that each child will havethe disease Review Information:the correct answer is:) 1 in 4 risk for each child to havethe disease. | S - The Marketplace to Buy and Sell your Study Material Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation, both parents must be carriers ofthe trait forthe disease since neither one of them hasthe disease. Therefore, for each pregnancy, there is a 25% chance ofthe child havingthe disease, 50% chance of carryingthe trait and a 25% chance of having neitherthe trait orthe disease. Question 83 A client with moderate persistent asthma is admitted for a minor surgical procedure. On admissionthe peak flow meter is measured at 480 liters/minute. Post-operativelythe client is complaining of chest peak flow has dropped to 200 liters/minute. What shouldthe nurse do FIRST? A) Notifythe physician B) Administerthe prn dose of Albuterol C) Apply oxygen at 2 liters per nasal cannula D) Repeatthe peak flow reading in 30 minutes Review Information:the correct answer is: B) Administerthe prn dose of Albuterol. Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determinethe severity ofthe exacerbation and to guidethe treatment. A peak flow reading of less than 50% ofthe client''s baseline reading is a medical alert condition and a short-acting beta-agonist must be taken immediately. Question 84 What nursing observation signifies that a client has attainedthe stage of concrete operations (Piaget)? A) Explores his environment using sight and movement B) Can think in mental images or word pictures C) Makesthe moral judgment that "stealing is wrong" D) Reasons that homework is time-consuming but necessary Review Information:the correct answer is:) Makesthe moral judgment that "stealing is wrong". The stage of concrete operations is depicted by logical thinking and moral judgments. Question 85 The nurse is caring for a 17 month-old with acetaminophen poisoning. Which ofthe following lab reports shouldthe nurse review FIRST? A) Protime (PT) and partial thromboplastin time (PTT) | S - The Marketplace to Buy and Sell your Study Material B) Red blood cell and white blood cell counts C) Blood urea nitrogen and creatinine clearance D) Liver enzymes (AST and ALT) Review Information:the correct answer is:) Liver enzymes (AST and ALT). Because acetaminophen is toxic tothe liver and causes hepatic cellular necrosis, liver enzymes are released intothe blood stream and serum levels of those enzymes rise. Other lab values are reviewed as well. Question 86 The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids,the diet should include A) Formula or breast milk B) Broth and tea C) Rice cereal and apple juice D) Gelatin and ginger ale Review Information:the correct answer is:) Formula or breast milk. The usual diet for a young infant should be followed. Question 87 The nurse instructsthe client taking dexamethasone (Decadron) to take it with food or milk because this medication A) Retards pepsin production B) Stimulates hydrochloric acid production C) Slows stomach emptying time D） Decreases production of hydrochloric acid Review Information:the correct answer is:) Stimulates hydrochloric acid production. Decadron increasesthe production of hydrochloric acid, which may cause gastrointestinal ulcers. Question 88 The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for nurse needs to | S - The Marketplace to Buy and Sell your Study Material A) Assess for abdominal distention B) Maintain infant in an upright position C) Begin formula feedings when infant is alert D) Pumpthe shunt to assess for proper function Review Information:the correct answer is:) Assess for abdominal distention. The child is observed for abdominal distention because cerebrospinal fluid may cause peritonitis or a postoperative ileus as a complication of distal catheter placement. Question 89 The mother of a two year-old hospitalized child asksthe nurse's advice aboutthe child's screaming every timethe mother gets ready to leavethe hospital BEST response ofthe nurse would be to A) Requestthe mother to remain withthe child at all times B) Explain that this behavior will stop with in a few days C) Helpthe mother understand this is a normal response to hospitalization D) Suggest thatthe mother "sneak out" ofthe child's room when he sleep Review Information:the correct answer is:) Helpthe mother understand this is a normal response to hospitalization. The protest phase of separation anxiety is a normal response for a child this age. Question 90 When caring for a client receiving warfarin sodium (Coumadin),the nurse would monitorthe results ofthe client's A) Bleeding time B) Coagulation time C) Prothrombin time D) Partial thromboplastin time Review Information:the correct answer is:) Prothrombin time. Coumadin is ordered daily, based onthe client''s prothrombin time (PT). This test evaluatesthe adequacy ofthe extrinsicsystem and common pathway inthe clotting cascade; Coumadin affectsthe Vitamin K dependent clotting factors. | S - The Marketplace to Buy and Sell your Study Material Question 91 The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which ofthe following assessments must be reported IMMEDIATELY? A) Vomiting of dark emesis B) Complaints of throat pain C) Apical heart rate of 110 D) Increased restlessness Review Information:the correct answer is:) Increased restlessness. Restlessness and increased respiratory and heart rates are often early signs of hemorrhage. care of infants and children. Question 92 The nurse admits a 7 year-old tothe emergency room following a leg injury. X-rays show that there is a femur fracture nearthe nurse should be aware that at this age,the injury MOST likely will A) Heal quickly because of thin periosteum B) Result in retarded bone growth C) Stimulate bone growth inthe affected leg D) Show more rapid union than that of a younger child Review Information:the correct answer is: B) Result in retarded bone growth. An epiphyseal (growth) plate fracture in a 7 year-old often results in retarded bone growth. Limbs will be different in length. Question 93 A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visitthe nurse observesthe client smacking her lips alternately with grinding her nurse assesses this as A) Dystonia B) Akathesia C) Brady dysknesia D) Tardive dyskinesia | S - The Marketplace to Buy and Sell your Study Material Review Information:the correct answer is:) Tardive dyskinesia. Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue movements. Question 94 Whilethe nurse assesses a 2 month-old infant,the mother expresses concern because a flat pink birthmark onthe baby's forehead and eyelid has not gone nurse should tellthe parents that A) Mongolian spots are a normal finding in dark-skinned children B) Port wine stains are often associated with other malformations C) Telangiectatic nevi are normal and will disappear asthe baby grows D) the child is too young for surgical removal at this time Review Information:the correct answer is:) Telangiectatic nevi are normal and will disappear asthe baby grows. Telangiectatic nevi, salmon patch or stork bite birthmarks are a normal variation andthe facial nevi will generally disappear by ages 1-2 years. Question 95 A client has returned tothe unit following a renal biopsy. Which ofthe following nursing interventions is appropriate? A) Ambulatethe client 4 hours after procedure B) Maintain client on NPO status for 24 hours C) Monitor vital signs D) Change dressing every eight hours Review Information:the correct answer is:) Monitor vital signs. The potential complication of this procedure is internal hemorrhage. Monitoring vital signs is critical to detect early indications of bleeding. Question 96 The nurse assessing a newborn notices thatthe breasts are enlarged bilaterally with a white, thin INITIAL action ofthe nurse should be to A) Notifythe attending practitioner B) Ask about medications taken in pregnancy | S - The Marketplace to Buy and Sell your Study Material C) Recordthe findings as "normal" D) Obtain fluid to send for culture Review Information:the correct answer is:) Recordthe findings as "normal". Newborn infants of both sexes may have engorged breasts and may secrete milk duringthe first few days and weeks following birth. Question 97 A client has been admitted with a fractured femur and has been placed in skeletal traction. Which ofthe following nursing interventions should receive PRIORITY? A) Maintaining proper body alignment B) Frequent neurovascular assessments ofthe affected leg C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to assistthe client with movement in bed Review Information:the correct answer is:) Frequent neurovascular assessments ofthe affected leg. The most important activity forthe nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage. Question 98 The nurse is teaching a client newly diagnosed with asthma how to usethe metered-dose inhaler (MDI).the client asks when they will knowthe canister is BEST response is A) Dropthe canister in water to observe floating B) Estimate how many doses are usually inthe canister C) Countthe number of doses asthe inhaler is used D) Shakethe canister to detect any fluid movement Review Information:the correct answer is:) Dropthe canister in water to observe floating. Droppingthe canister into a bowl of water assessesthe amount of medications remaining in a metered-dose client should obtain a refill whenthe inhaler rises tothe surface and begins to tip over. Question 99 | S - The Marketplace to Buy and Sell your Study Material While teachingthe family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is MOST important forthe nurse to teach them to A) Maintain good oral hygiene and dental care B) Omit medication ifthe child is seizure free C) Administer acetaminophen to promote sleep D) Serve a diet that is high in iron Review Information:the correct answer is:) Maintain good oral hygiene and dental care. Swollen and tender gums occur often with use of phenytoin. Oral hygiene and regular visits tothe dentist should be emphasized. Question 100 A two year-old child has just been diagnosed with Cystic F child's father asksthe nurse "What arethe chances that another child of ours will have Cystic Fibrosis?" Which ofthe following isthe BEST response? A) "The probability of recurrence is unknown." B) "Cystic Fibrosis is more common in Asians." C) "Each of your children have a 25% chance of having Cystic Fibrosis." D) "The incidence of Cystic Fibrosis is approximately 1: 14,000 live births." Review Information:the correct answer is:) "Each of your children have a 25% chance of having Cystic Fibrosis.". Cystic Fibrosis is an autosomal recessive disease. There is a 25% chance of each pregnancy of these parents resulting in a child with Cystic Fibrosis. Question 101 A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several nurse should preparethe client for an immediate A) Non stress test B) Abdominal ultrasound C) Pelvic exam D) X-ray of abdomen Review Information:the correct answer is:) Abdominal ultrasound. | S - The Marketplace to Buy and Sell your Study Material The standard for diagnosis of placenta previa, which is suggested inthe client''s history, is abdominal ultrasound. Question 102 The nurse is assessing a 17 year-old female client with bulimia. Which ofthe following laboratory reports wouldthe nurse anticipate? A) Increased serum glucose B) Decreased albumin C) Decreased potassium D) Increased sodium retention Review Information:the correct answer is:) Decreased potassium. In bulimia, loss of electrolytes can occur in addition to signs and symptoms of starvation and dehydration. Question 103 An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which ofthe following laboratory results shouldthe nurse analyze FIRST? A) Potassium levels B) Blood pH C) Magnesium levels D) Blood urea nitrogen Review Information:the correct answer is:) Potassium levels. The most common cause of digitalis toxicity is a low potassium level. Clients must be taught that it is important to have adequate potassium intake while taking diuretics. Question 104 A mother telephonesthe clinic and tellsthe nurse she is concerned because her breastfed 1 month-old has soft, yellow stoolsafter each nurse's BEST response would be based onthe knowledge that A) This type of stool is normal for breast fed infants B) the stool should have turned to light brown by now C) Formula supplements will add bulk tothe stools | S - The Marketplace to Buy and Sell your Study Material D) Water should be offered several times each day Review Information:the correct answer is:) This type of stool is normal for breast fed infants. In breast-fed infants, stools are frequent and yellow to golden and vary from soft to thick liquid in consisten