NR 322 passpoint review NCLEX latest(QUESTIONS AND ANSWERS)

Question 1 See full question What is the nurse’s most important intervention for a client having a tonic-clonic seizure? You Selected:  Protect the client from further injury Correct response:  Protect the client from further injury Explanation: The priority during and after a seizure is to protect the person from injury by keeping them from falling to the floor. Furniture or other objects that be a source of injury during the seizure should be moved out of the client’s way. Timing the seizure, and noting the origin of the seizure are important, but are not the priority. Nothing should be placed in the client’s mouth during a seizure because teeth may be dislodged or the tongue pushed back, further obstructing the airway. Remediation:  Seizure management Question 2 See full question The nurse is caring for a neonate weighing 4,536 g (10 lb) who was born via cesarean section 1 hour ago to a mother with insulin-dependent diabetes. She asks the nurse, “Why is my baby in the neonatal intensive care unit?” The nurse bases a response on the understanding that neonates of mothers with diabetes commonly develop which condition? You Selected:  hypoglycemia Correct response:  hypoglycemia Explanation: Hypoglycemia is caused by the rapid depletion of glucose stores. In addition, neonates born to class women with insulin dependent diabetes are about seven times more likely to suffer from respiratory distress syndrome than neonates born to nondiabetic women. This neonate should be closely monitored for symptoms of hypoglycemia and respiratory distress. Neonates of diabetic mothers commonly have polycythemia, not anemia. Anemia and hemolytic disease are associated with erythroblastosis fetalis. Persistent pulmonary hypertension is associated with meconium aspiration syndrome. Remediation:  Glucose management, neonatal Question 3 See full questionAfter knee replacement surgery, a client is being discharged with acetaminophen with codeine 30 mg tablets for pain. During discharge preparation, the nurse should include which instruction? You Selected:  "Avoid driving a car while taking this medication." Correct response:  "Avoid driving a car while taking this medication." Explanation: Clients taking codeine should avoid driving because the medication can impair mental alertness. Fluid restriction isn't indicated, especially after surgery. To prevent adverse GI effects such as nausea, vomiting, anorexia, and constipation, the client shouldn't take codeine on an empty stomach. Codeine may cause dizziness, drowsiness, and seizures but doesn't cause fine motor tremors. Remediation:  Codeine phosphate–acetaminophen Question 4 See full question The nurse manager has noticed a sharp increase in medication errors associated with IV antibiotic administration over the past 2 months. The nurse manager should discuss the situation with each nurse involved and then: You Selected:  ask them to attend in-service training for administration of IV medications. Correct response:  ask them to attend in-service training for administration of IV medications. Explanation: Identification of causes of medication errors requires in-service education to inform the staff of strategies to decrease these errors. Errors are frequently the result of systemic problems that can be identified and rectified through problem-solving techniques and changes in procedures. Documenting or reporting the situation would not directly assist the nurses in eliminating errors. Reporting the incidents to the hospital attorney is unnecessary. Remediation:  Safe medication administration practices Question 5 See full questionClients receiving a monoamine oxidase inhibitor must avoid tyramine, a compound found in which foods? You Selected:  Aged cheese and Chianti wine Correct response:  Aged cheese and Chianti wine Explanation: Aged cheese and Chianti wine contain high concentrations of tyramine. Green, leafy or yellow vegetables, figs, cream cheese, and fruit are low in tyramine. Remediation:  Tranylcypromine Question 6 See full question A client with a diagnosis of schizophrenia and who is paranoid asks the nurse, "How do I know what is really in those pills?" The best response is to: You Selected:  allow the client to open the individual medication wrappers. Correct response:  allow the client to open the individual medication wrappers. Explanation: Allowing a paranoid client to open his medication can help reduce his suspiciousness. Telling the client that he should know the pills are his medicine is incorrect because the client doesn't know this information for sure; he's obviously suspicious that it isn't. Telling the client not to worry or ignoring his comment isn't supportive and doesn't reassure him. Remediation:  Oral drug administration, psychiatric patient Question 7 See full question When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which problem? You Selected:  cataracts from beta-hemolytic streptococcus Correct response: blindness secondary to gonorrhea Explanation: The instillation of erythromycin into the neonate’s eyes provides prophylaxis for ophthalmia neonatorum, or neonatal blindness caused by gonorrhea in the mother. Erythromycin is also effective in the prevention of infection and conjunctivitis from Chlamydia trachomatis. The medication may result in redness of the neonate’s eyes, but this redness will eventually disappear. Erythromycin ointment is not effective in treating neonatal chorioretinitis from cytomegalovirus. No effective treatment is available for a mother with cytomegalovirus. Erythromycin ointment is not effective in preventing cataracts. Additionally, neonatal infection with beta-hemolytic streptococcus results in pneumonia, bacterial meningitis, or death. Cataracts in the neonate may be congenital or may result from maternal exposure to rubella. Erythromycin ointment is also not effective for preventing and treating strabismus (crossed eyes). Infants may exhibit intermittent strabismus until 6 months of age. Remediation:  Neonatal eye prophylaxis Question 8 See full question For the client who has difficulty falling asleep at night because of withdrawal symptoms from alcohol, which are abating, which nursing intervention is likely to be most effective? You Selected:  teaching the client relaxation exercises to use before bedtime Correct response:  teaching the client relaxation exercises to use before bedtime Explanation: The best action by the nurse to help a client who has difficulty falling asleep would be to teach the client relaxation exercises to use before bedtime to reduce anxiety and promote relaxation. This activity will also be useful for the client when out of the hospital. Inviting the client to play a board game is inappropriate because this activity can be competitive and thus stimulate the client. Allowing the client to sit in the community room until she feels sleepy is inappropriate because it does nothing to help the client relax. Taking frequent naps can worsen the ability to fall asleep at night. Remediation:  Relaxation and stress management techniques  Alcoholism Question 9 See full question An 18-year-old is highly dependent on her parents and fears leaving home to attend college. Shortly before the fall semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admitsthe woman to the psychiatric unit, where she is diagnosed with functional neurologic symptom disorder. She asks the nurse, "Why has this happened to me?" What is the nurse's best response? You Selected:  "Your problem is real but, there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened." Correct response:  "Your problem is real but, there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened." Explanation: The nurse must be honest by telling the client that her paralysis has no physiologic cause while also conveying empathy and acknowledging that her symptoms are real. The client will benefit from psychiatric treatment, which will help her understand the underlying cause of her symptoms. After her psychological conflict is resolved, her symptoms will disappear. Telling the client that being unable to move her legs must be awful wouldn't answer the client's question; knowing that the cause is psychological rather than physical wouldn't necessarily make her feel better. Telling the client that she has developed paralysis to avoid leaving her parents or that her personality caused her disorder wouldn't help her understand and resolve the underlying conflict. Remediation:  Conversion disorder patient care  Psychiatric nursing assessment Question 10 See full question A client periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, the client may experience: You Selected:  a decreased perceptual field. Correct response:  a decreased perceptual field. Explanation: Panic is the most severe level of anxiety. During a panic attack, a client's perceptual field, narrows. He becomes more focused on himself, less aware of surroundings, and unable to process information from his environment. His decreased perceptual field impairs his attention and ability to concentrate. During an acute panic attack, the client may experience an increase, not a decrease, in heart and respiratory rates, resulting from stimulation of the sympathetic nervous system. Remediation: Panic disorder Question 11 See full question A nurse obtained a client’s fasting blood sugar (FBS) at 0700, which was 144 mg/dL (8 mmol/L). The client has an order for regular insulin 8 units every morning. What should the nurse do next? You Selected:  Administer the insulin as ordered. Correct response:  Administer the insulin as ordered. Explanation: The nurse should know that a normal fasting blood sugar is between 72 and 108 mg/dL (4 and 6 mmol/L). The result of 144 mg/dL indicates that the client requires insulin to lower the blood glucose level. The other options are incorrect because they do not reflect the nurse's understanding of diabetes and its treatment. Remediation:  Blood glucose monitoring  Insulins (short-acting)  Hormonal Control of Blood Glucose Question 12 See full question A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching? You Selected:  "I can eat whatever I want as long as it's low in fat." Correct response:  "I can eat whatever I want as long as it's low in fat." Explanation: The client requires additional teaching if he states that he can eat whatever he wants. Immunosuppressed clients should avoid raw fruit and vegetables because they may contain bacteria that could increase the risk of infection; foods must be thoroughly cooked. Avoiding people who are sick, products containing alcohol, and people who have just received vaccines are appropriate actions for an immunosuppressed client. Remediation:  Neutropenia Question 13 See full question The client with acute renal failure is recovering and asks the nurse, "Will my kidneys ever function normally again?" The nurse's response is based on knowledge that the client's renal status will most likely: You Selected:  continue to improve over a period of weeks. Correct response:  continue to improve over a period of weeks. Explanation: The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months. The client should be taught how to recognize the signs and symptoms of decreasing renal function and to notify the health care provider (HCP) if such problems occur. In a client who is recovering from acute renal failure, there is no need for renal transplantation or permanent hemodialysis. Chronic renal failure develops before end-stage renal failure. Remediation:  Renal failure, acute  Urinary: Renal Function Question 14 See full question Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization? You Selected:  Observe the puncture site for swelling and bleeding. Correct response:  Observe the puncture site for swelling and bleeding. Explanation: Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required. Remediation:  Cardiac catheterization Question 15 See full questionThe nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first: You Selected:  stay with the client during the first 15 minutes of infusion. Correct response:  stay with the client during the first 15 minutes of infusion. Explanation: The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 ml of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution. Remediation:  Blood product transfusion management  Blood product transfusion Question 16 See full question A nurse is performing a sterile dressing change. Which action contaminates the sterile field? You Selected:  Pouring solution onto a sterile field cloth Correct response:  Pouring solution onto a sterile field cloth Explanation: Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. Holding sterile objects above the waist, leaving a 1″ edge around the sterile field, and opening the outermost flap of a sterile package away from the body maintain the sterile field. Remediation:  Sterile field management, OR  Cleaning a Wound and Applying a Sterile Dressing Question 17 See full question The nurse administers a tap water enema to a client. While the solution is being infused, the client has abdominal cramping. What should the nurse do first?You Selected:  Temporarily stop the infusion, and have the client take deep breaths. Correct response:  Temporarily stop the infusion, and have the client take deep breaths. Explanation: If the client begins to experience abdominal cramping during administration of the enema fluid, the nurse’s first action is to temporarily stop the infusion and have the client take a few deep breaths. After the cramping subsides, the nurse can continue with the enema solution. If the cramping does not subside, the nurse should clamp the tubing and remove it. Raising the height of the container will increase the flow of fluid and cause the cramping to increase. Rubbing the abdomen while infusing the enema fluid will not stop the cramping. Remediation:  Enema administration Question 18 See full question The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the nurse best communicate with the client? You Selected:  Ask the client's child to describe the client's pain to the best of the client's ability. Correct response:  Enlist the help of a hospital interpreter; ask the son to translate if none is readily available. Explanation: Whenever possible, interpreters should be used to communicate with clients who do not speak English. If none is available, however, it may be necessary to have a family member translate. It would be unsafe to put off an emergency assessment pending the arrival of an interpreter. Remediation:  Cultural assessment Question 19 See full question A client with a diagnosis of schizophrenia is admitted to the inpatient unit of the mental health center. He's shouting that the government of France is trying to assassinate him. Which response is most appropriate? You Selected:  "A foreign government is trying to kill you? Please tell me more about it." Correct response:  "I don't see evidence that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." Explanation: Responses should focus on reality while acknowledging the client's feelings. It isn't therapeutic for the nurse to argue with the client or deny his belief. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the client's psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions. Remediation:  Delusions, care of patient Question 20 See full question The nurse administers fat emulsion solution during TPN as prescribed based on the understanding that this type of solution: You Selected:  provides essential fatty acids. Correct response:  provides essential fatty acids. Explanation: The administration of fat emulsion solution provides additional calories and essential fatty acids to meet the body’s energy needs. Fatty acids are lipids, not carbohydrates. Fatty acids do not aid in the metabolism of glucose. Although they are necessary for meeting the complete nutritional needs of the client, fatty acids do not necessarily help a client maintain normal body weight. Remediation:  Parenteral nutrition administration  Fat emulsions Question 21 See full question A nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings? You Selected:  Breast sensitivity Correct response:  Breast sensitivity Explanation: Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea, not the presence of menses, is expected during this time. Uterine enlargement and fetal heart tones don't occur until after the first 4 weeks of pregnancy. Remediation:  Breast care for non-nursing mothers Question 22 See full question The nurse is teaching a client with stomatitis about mouth care. Which instruction is most appropriate? You Selected:  Eat a soft, bland diet. Correct response:  Eat a soft, bland diet. Explanation: Clients with stomatitis (inflammation of the mouth) have significant discomfort, which impacts their ability to eat and drink. They will be most comfortable eating soft, bland foods, and avoiding temperature extremes in their food and liquids. Gargling with an antiseptic mouthwash will be irritating to the mucosa. Mouth care should include gentle brushing with a soft toothbrush and flossing. Remediation:  Mouth lesions  Stomatitis Question 23 See full question A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement? You Selected:  Related to impaired balance Correct response:  Related to impaired balance Explanation: A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal lobe dysfunction. Remediation:  Brain tumor, malignant Question 24 See full question The nursing team on an oncology unit consists of a registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and one unlicensed assistive personnel (UAP). Which client should be assigned to the RN? You Selected:  a 28-year-old client being evaluated for a bone marrow transplant Correct response:  a 52-year-old client with lung cancer admitted for acute dyspnea Explanation: Ongoing assessment by the RN is required to evaluate the client with dyspnea to monitor for potential deterioration of the respiratory status. If the RN is the care provider, the RN will have greater interaction with the individual client. The RN is responsible for assessment of all the clients. The other clients would not be considered unstable, and maintaining a patent airway is always the priority in providing care. Care for the other clients could be assigned safely, according to the abilities of the LPN/VN and UAP. Remediation:  Lung cancer Question 25 See full question A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do? You Selected:  Use constant, gentle touch. Correct response:  Use constant, gentle touch. Explanation: Neonates that are sick do not have the physical resources or energy to respond to all elements of the environment. The use of a constant touch provides comfort and only requires one response to a stimulus. To comfort a sick neonate, the care provider applies gentle, constant physical support or touch. Toys for distraction are not developmentally appropriate for a neonate. Sick neonates react to any stimulus; in responding, the sick neonate may have increased energy demands and increased oxygen requirements. A musical mobile may be too much audio stimulation and thus increases energy and oxygen demands. Repetitive touching with a hand going off and on the neonate, as with stroking or patting, requires the neonate to respond to every touch, thus increasing energy and oxygen demands. Remediation:  Therapeutic touch, neonatal Question 26 See full question A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6- month-old infant. The nurse should select which tubing to safely administer the solution? You Selected:  I.V. tubing with a volume-control chamber Correct response:  I.V. tubing with a volume-control chamber Explanation: Because infants have a small circulating blood volume, inadvertent administration of extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing with a volume-control chamber should always be used for infants and children to closely regulate the amount of fluid infused. The volume-control chamber should be filled only with enough I.V. fluid for the next two 2 hours. A microdrip chamber that allows for 60 drops/ml (as opposed to a macrodrip chamber, which allows for 10 to 20 drops/ml, depending on the manufacturer) should be used to infuse the smaller amounts of I.V. fluids an infant needs. A filter is typically used only for the administration of total parenteral nutrition and certain blood products. Standard I.V. tubing for adults should be avoided for infants because of the inability to closely regulate the amount of fluid infused. Question 27 See full question A client is hospitalized for severe preeclampsia and complete placenta previa. The husband tells the nurse that he is frustrated to have been waiting for 3 hours for the physician to discuss his wife’s condition and plan of care with them. What is the nurse’s most appropriate action? You Selected:  Notify the physician that the husband has been waiting to discuss his wife’s condition. Correct response:  Notify the physician that the husband has been waiting to discuss his wife’s condition. Explanation: Because of the client’s severe and deteriorating condition, the nurse is obligated to advocate for the family and to notify the physician of the husband’s request for a meeting and information. It is not appropriate to tell a client or family not to worry or that the physician is too busy to come. While it may be appropriate to inquire about family supports, in this context it is crucial that the nurse respond to the client and husband’s concerns. The nurse should ensure his/her practice aligns with the American Nurses Association (Canadian Nurses' Association) Code of Ethics, ensuring that the nurse is advocating for the family and promoting and respecting informed decision making. Remediation:  Labor, care during Question 28 See full question A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed? You Selected:  Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. Correct response:  Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. Explanation: Because it's important to get more information about the client with a decreased pulse oximetry level, the nurse should ask the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delaying treatment to the client who is already in her care. The nurse can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The nurse doesn't need to immediately attend to the client with a decreased pulse oximetry level; she may wait until she completes the assessment of the newly admitted client. The physician doesn't need to be notified at this time because an order for oxygen administration is already on record. Question 29 See full question The nurse is instructing a competent client in his legal rights regarding ECT (electroconvulsive therapy). Which statement by the client suggests further explanation is needed? You Selected:  "I do not need a legal guardian to assist me in this process." Correct response:  "Since I was an Emergency Involuntary Commitment, I will be unable to sign the ECT form myself." Explanation:There are some instances where a client may not sign for treatments as in a ECT treatment. If the client had been judged incompetent in a court of law, then a legal guardian will sign the form. Otherwise, the client must sign an informed consent. Options a, b, and d are incorrect as the family cannot sign as they are not guardians or health care power of attorney. Also, the client doesn't need a guardian as the client is competent. Option c is correct. Regardless of the manner in which the client has been admitted, voluntary or involuntary, as the client understands the risks and benefits of the ECT treatment and there has been no coercion in the process, the client may sign the consent form. Remediation:  Electroconvulsive therapy Question 30 See full question A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond? You Selected:  "Ketones will tell us if your body is using other tissues for energy." Correct response:  "Ketones will tell us if your body is using other tissues for energy." Explanation: The nurse should tell the client that ketones are a byproduct of fat metabolism and that ketone testing can determine whether the body is breaking down fat to use for energy. The spleen doesn't release ketones when the body can't use glucose. Although ketones can damage the eyes and kidneys and help the physician evaluate the severity of a client's diabetes, these responses by the nurse are incomplete. Remediation:  Ketone tests  Ketones, urine  Diabetes Question 31 See full question For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? You Selected:  Imbalanced nutrition: Less than body requirements Correct response:  Deficient fluid volumeExplanation: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema. Remediation:  Intake and output assessment  Fluid and Electrolytes Question 32 See full question The mother of a client who has a radium implant asks why so many nurses are involved in her daughter’s care. She states, “The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to 30 minutes.” The nurse explains that this variation is based on the fact that nurses: You Selected:  work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. Correct response:  work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. Explanation: The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years. Remediation:  Radiation safety, oncology  Radiation implant therapy Question 33 See full question A nurse is caring for a client with bruises on her face and arms. Her husband refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate? You Selected:  Collaborate with the physician to make a referral to social services. Correct response: Collaborate with the physician to make a referral to social services. Explanation: Collaborating with the physician to make a referral to social services helps the client by creating a plan and providing support. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the police, and follow up with a written report. Although confrontation can be used therapeutically, this action will most likely provoke anger in the suspected abuser. Questioning the client in front of her spouse does not allow her the privacy required to address this issue and may place her in greater danger. If the woman is not in imminent danger, there is no need to call hospital security. Remediation:  Cultural needs assessment during pregnancy  Suspected domestic abuse assessment  Risk for ineffective childbearing process Question 34 See full question When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing? You Selected:  SOAP charting. Correct response:  SOAP charting. Explanation: The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation. Remediation:  Documentation Question 35 See full questionA nurse is providing dietary instructions to a client with a history of pancreatitis. Which of the following instructions would be most appropriate? You Selected:  Maintain a high-carbohydrate, low-fat diet. Correct response:  Maintain a high-carbohydrate, low-fat diet. Explanation: A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake is not necessary because chronic pancreatitis is not associated with hyponatremia or fluid loss. Remediation:  Pancreatitis Question 36 See full question A nurse works with a client diagnosed with bulimia. What is the most appropriate long-term client goal for this client? You Selected:  Manage stresses in life without binging or purging. Correct response:  Manage stresses in life without binging or purging. Explanation: A successful outcome for a bulimic client is to avoid using the eating disorder as a coping measure when dealing with stress. Being able to attend college, eat at home, and eat out without binging and purging are important goals, but they do not address the primary problem of stress management and its connection to eating. Remediation:  Bulimia nervosa Question 37 See full question A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: You Selected: turning the client's head suddenly while holding the eyelids open. Correct response:  turning the client's head suddenly while holding the eyelids open. Explanation: To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the client's eyes deviate to the side of ice water introduction. The nurse touches the client's cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the client's pupil helps evaluate brain stem and cranial nerve III function; normally, the client's pupil responds by constricting. Remediation:  Doll Question 38 See full question Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate? You Selected:  urine output greater than 30 ml/hour Correct response:  urine output greater than 30 ml/hour Explanation: Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 35 mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock. Remediation:  Shock, hypovolemic Question 39 See full question When developing the postoperative plan of care for an adolescent who has undergone an appendectomy for a ruptured appendix, in which position should the nurse expect to place the client during the early postoperative period? You Selected: semi-Fowler's position Correct response:  semi-Fowler's position Explanation: After an appendectomy for a ruptured appendix, assuming the semi-Fowler’s or a right side-lying position helps localize the infection. These positions promote drainage from the peritoneal cavity and decrease the incidence of subdiaphragmatic abscess. Remediation:  Appendicitis  Appendectomy Question 40 See full question A child with suspected rheumatic fever is admitted to the pediatric unit. When obtaining the child's history, the nurse considers which information to be most important? You Selected:  A recent episode of pharyngitis Correct response:  A recent episode of pharyngitis Explanation: A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the child may have a history of fever or vomiting or lack interest in food, these findings aren't specific to rheumatic fever. Remediation:  Acute rheumatic fever, pediatric  Pharyngitis Question 41 See full question A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid–base balance? You Selected:  Returning bicarbonate to the body's circulation Correct response: Returning bicarbonate to the body's circulation Explanation: The kidney performs two major functions to assist in acid–base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions. Question 42 See full question A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella? You Selected:  "I told my husband to give my son aspirin for his fever." Correct response:  "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son." Explanation: By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur during the first trimester of pregnancy if the pregnant woman contracts rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Acetaminophen should be used instead of aspirin. Rubella immunization isn't recommended for children until ages 12 to 15 months. Having the measles (rubeola) won't provide immunity for rubella. Remediation:  Rubella vaccine administration  Rubella, pediatric Question 43 See full question The nurse is developing a teaching plan for a client with stress incontinence. Which instruction should be included? You Selected:  Avoid activities that are stressful and upsetting. Correct response:  Avoid caffeine and alcohol. Explanation:Clients with stress incontinence are encouraged to avoid substances that are bladder irritants, such as caffeine and alcohol. Emotional stressors do not cause stress incontinence. It is most commonly caused by relaxed pelvic musculature. Wearing girdles is not contraindicated. Although clients may want to limit physical exertion to avoid incontinence episodes, they should be encouraged to seek treatment instead of limiting their activities. Remediation:  Stress urinary incontinence Question 44 See full question A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? You Selected:  Continue to monitor the client as ordered. Correct response:  Continue to monitor the client as ordered. Explanation: Normal CVP ranges from 3 to 7 mm Hg. The nurse doesn't need to take any action other than to monitor the client. It isn't necessary to rezero the equipment. Calling a physician and obtaining an order for a fluid bolus would be an appropriate intervention if the client has a CVP less than 3 mm Hg. Administering a diuretic would be appropriate if the client had excess fluid, as demonstrated by a CVP greater than 7 mm Hg. Remediation:  Central venous pressure measurement, water manometer  Central venous pressure monitoring, transducer Question 45 See full question What is the nurse expected to do when filing a report about an incident of finding an elderly client with mild dementia on the floor? You Selected:  The nurse must file an incident or adverse event report. Correct response:  The nurse must file an incident or adverse event report. Explanation: Nurses who witnessed the event are responsible for entering the information. Adverse reporting is a mechanism to find persistent problems; it is confidential and nonpunitive.Question 46 See full question A client is admitted for an exacerbation of irritable bowel syndrome who insists on being allowed to keep a head covering on at all times. The best response by the nurse is: You Selected:  “Tell me why is this so important to you.” Correct response:  “Please help me to understand this practice.” Explanation: The nurse should demonstrate respect for the client’s request. Asking the client to explain the need for this practice in the hospital will lead to a discussion where a reasonable solution can be determined. Demanding the client tell you why this is so important is antagonistic and disrespectful. Resorting to standard responses such as hospital policy or infection control presumes prejudgment and no room for discussion. These responses are also disrespectful. Remediation:  Irritable bowel syndrome Question 47 See full question A homeless client comes to the clinic coughing up blood and is diagnosed with active tuberculosis (TB). Which of the following interventions by the nurse will be most effective in ensuring adherence with the pharmacological treatment regimen? You Selected:  Arrange for the client to come to a community center each day to receive a meal and medication Correct response:  Arrange for the client to come to a community center each day to receive a meal and medication Explanation: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen for tuberculosis. Providing the client with a daily meal will help ensure the client will come to receive the medication. It is not cost effective to keep the client hospitalized, TB medication regime may last one or more years. A homeless client probably will not have the financial resources to pick up the medication at a pharmacy so a prescription and/or written instructions will not be an effective way to ensure adherence. Question 48 See full question A client with schizophrenia who receives fluphenazine develops pseudoparkinsonism and akinesia. What drug should the nurse administer as ordered to minimize this client's extrapyramidal symptoms?You Selected:  Benztropine Correct response:  Benztropine Explanation: Benztropine is an anticholinergic administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Dantrolene, a hydantoin that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Clonazepam, a benzodiazepine that depresses the CNS, is administered to control seizure activity. Diazepam, a benzodiazepine, is administered to reduce anxiety. Remediation:  Dantrolene sodium  Clonazepam  Fluphenazine decanoate  Benztropine mesylate Question 49 See full question Following an eclamptic seizure, the nurse should assess the client for which complication? You Selected:  polyuria Correct response:  uterine contractions Explanation: After an eclamptic seizure, the client commonly falls into a deep sleep or coma. The nurse must continually monitor the client for signs of impending labor because the client will not be able to verbalize that contractions are occurring. Oliguria is more common than polyuria after an eclamptic seizure. Facial flushing is not common unless it is caused by a reaction to a medication. Typically, the client remains hypertensive unless medications such as magnesium sulfate are administered. Remediation:  Uterine contraction palpation Question 50 See full questionAfter administering a prescribed medication to a client who becomes restless at night and has difficulty falling asleep, which nursing action is most appropriate? You Selected:  sitting quietly with the client at the bedside until the medication takes effect Correct response:  sitting quietly with the client at the bedside until the medication takes effect Explanation: To promote adequate rest (6 to 8 hours per night) and to eliminate hyposomnia, the nurse should sit with the client at the bedside until the medication takes effect. The presence of a caring nurse provides the client with comfort and security and helps to decrease the client’s anxiety. Engaging the client in interaction until the client falls asleep, reading to the client, or encouraging the client to watch television may be too stimulating for the client, consequently increasing rather than decreasing the client’s restlessness. Remediation:  Insomnia Question 51 See full question A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? You Selected:  "Infuse I.V. fluids at 83 ml/hour." Correct response:  "Infuse I.V. fluids at 83 ml/hour." Explanation: Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client. Remediation:  Shock, hypovolemic Question 52 See full questionA client is receiving chemotherapy for the diagnosis of brain cancer. When teaching the client about contamination from excretion of the chemotherapy drugs within 48 hours, the nurse should instruct the client that: You Selected:  any contaminated linens should be washed separately and then washed a second time, if necessary. Correct response:  any contaminated linens should be washed separately and then washed a second time, if necessary. Explanation: The client may excrete the chemotherapeutic agent for 48 hours or more after administration. Blood, emesis, and excretions may be considered contaminated during this time, and the client should not share a bathroom with children or pregnant women. Any contaminated linens or clothing should be washed separately and then washed a second time, if necessary. All contaminated disposable items should be sealed in plastic bags and disposed of as hazardous waste. Remediation:  Chemotherapeutic drugs Question 53 See full question A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which of the following best describes why the nurse is asking questions about the family’s birth plan? You Selected:  Recognizing the family as active participants in their care Correct response:  Recognizing the family as active participants in their care Explanation: The nurse recognizes the family as active participants in their care by discussing and inquiring about their birth plans, fostering a collaborative relationship with the family. After acknowledging the family as active participants, the nurse is then able to advocate for the family throughout the labor and birth experience. Considering principles of family-centered maternity and newborn care, nurses must advocate for clients to have autonomy in decision making and provide respect and informed choice to ensure that clients and their families are empowered to take responsibility to make decisions. It is the nurse’s role to guide and support choices rather than direct or correct. Question 54 See full questionA client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. Which nursing diagnosis takes priority with this client? You Selected:  Ineffective breathing pattern related to tissue trauma Correct response:  Ineffective breathing pattern related to tissue trauma Explanation: Although all of these nursing diagnoses are appropriate for this client, ineffective breathing pattern takes priority. According to Maslow's hierarchy of needs, air is essential to maintain life and is assigned the highest priority, along with the other physiologic needs, such as food, elimination, temperature control, sex, movement, rest, and comfort. Remediation:  Pulmonary embolism Question 55 See full question Which is a risk factor for cervical cancer? You Selected:  sedentary lifestyle Correct response:  adolescent pregnancy Explanation: Young age at first pregnancy is a risk factor for cervical cancer. Other risk factors include a family history of the disease, sexual experience with multiple partners, and a history of sexually transmitted disease (e.g., syphilis, human papillomavirus infection, gonorrhea). Cigarette smoking, promiscuous male partner, human immunodeficiency virus infection or other immunosuppression, and low socioeconomic status are other risk factors. Sexual relations with one partner, sedentary lifestyle, and obesity are not risk factors for cervical cancer. Remediation:  Cervical cancer Question 56 See full question The parents of a child with occasional generalized seizures want to send the child to summer camp. The parents contact the nurse for advice on planning for the camping experience. Which type of activity should the nurse and family decide the child should avoid? You Selected: hiking Correct response:  rock climbing Explanation: A child who has generalized seizures should not participate in activities that are potentially hazardous. Even if accompanied by a responsible adult, the child could be seriously injured if a seizure were to occur during rock climbing. Someone also should accompany the child during activities in the water. At summer camps, hiking and swimming would occur most commonly as group activities, so someone should be with the child. Tennis would be considered an appropriate, nonhazardous activity for a child with generalized seizures. Remediation:  Seizure management, pediatric  Seizure disorder, pediatric  Seizure disorder Question 57 See full question A client continues to improve after a left hemisphere cerebrovascular accident (CVA). The interprofessional team is planning a transfer to a rehabilitation unit for follow-up care. Which of the following is the priority nursing diagnosis? You Selected:  Decreased gastrointestinal motility Correct response:  Impaired swallowing Explanation: Impaired swallowing is the priority nursing diagnosis for this client because there is a risk for aspiration. The other choices are appropriate, but not the priority. Remediation:  Stroke Question 58 See full question A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside? You Selected:  Sphygmomanometer Correct response:  Suction machine with catheters Explanation: MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade is an appropriate seizure precaution, but should not be used in this client because its large size could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen delivery; this client requires a mechanical ventilator. Remediation:  Multiple sclerosis Question 59 See full question Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which problem should receive the highest priority during the acute phase? You Selected:  ineffective breathing pattern related to neuromuscular impairment Correct response:  ineffective breathing pattern related to neuromuscular impairment Explanation: An ineffective breathing pattern caused by the ascending paralysis of the disorder interferes with the child’s ability to maintain an adequate oxygen supply. Therefore, this nursing diagnosis takes precedence. Additionally, as the neurologic impairment progresses, it will probably have an effect on the child’s ability to maintain respirations. An increased risk for infection related to an altered immune system is not associated with Guillain-Barré syndrome. Although impaired swallowing and incontinence may occur with the ascending paralysis of this disorder, oxygenation is the priority. Remediation:  Guillain-Barré syndrome, pediatric  Guillain-Barré syndrome, pediatric, care planning  Respirations, shallow Question 60 See full question The nurse is making a postpartum visit at the home of a client who delivered 14 days earlier. After assessing the vital signs (temperature, 99° F [37.2° C]; pulse, 88 bpm; respiration rate, 20 breaths/min; and blood pressure, 112/60 mm Hg), the nurse records other findings in the chart above. Which finding indicates delayed involution?You Selected:  fundus Correct response:  fundus Explanation: The fundus descends at the rate of one to two cms per day and by 2 weeks is no longer a pelvic organ. The vital signs, breasts, heart, lungs, abdomen (with exception of fundus), lochia, perineum, and extremities are within normal limits. Question 61 See full question Which of the following assessment questions is most likely to yield clinically meaningful data about a female client’s sexual identity? You Selected:  "How do you feel about yourself as a woman?" Correct response:  "How do you feel about yourself as a woman?" Explanation: Sexual identity is a broad concept that includes, but supersedes, sexual functioning. However, it is more specific than simply asking about the quality of relationships. Asking an open-ended question about how the client feels about herself as a woman is likely to elicit important insights. Assessing the client’s history of STIs does not directly address her sexual identity. Remediation:  Health history interview and physical assessment Question 62 See full question A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? You Selected:  Head of the bed elevated 45 degrees Correct response:  Head of the bed elevated 45 degrees Explanation: After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an aircontrast study. Remediation:  Herniated intervertebral disk Question 63 See full question The nurse is assessing a client for heroin addiction. Which finding indicates the client has used heroin? You Selected:  pupils large and dilated Correct response:  pupils small and constricted Explanation: Heroin causes pinpoint pupils. Marijuana causes the eyes to appear red and bloodshot. Cocaine use causes pupils to dilate. Drooping of the eyelids is not typically associated with the use of any substance. Remediation:  Admission of a patient with a history of drug abuse Question 64 See full question The nurse is creating a medication list for a client and notes that he takes saw palmetto. What should the nurse assess next? You Selected:  “Tell me about your normal voiding patterns.” Correct response:  “Tell me about your normal voiding patterns.” Explanation: It would be important to assess about the client’s ability to void. Saw palmetto is used to relieve symptoms of benign prostatic hypertrophy. Joint pain would be important if the client was taking glucosamine. Niacin could be used to lower cholesterol, and melatonin would be appropriate for insomnia. Question 65 See full question When should a nurse introduce information about the end of the nurse-client relationship? You Selected: During the orientation phase Correct response:  During the orientation phase Explanation: Preparation for ending the nurse-client relationship should begin during the orientation phase, when realistic limits of the relationship are established. Termination should also be discussed as goals are achieved and the relationship nears an end. Although the nurse should remind the client when only one or two sessions remain, she must not wait until then to prepare the client for termination. The client's ability to tolerate the end of a relationship shouldn't dictate its timing. Because many clients have had negative experiences when ending relationships, the nurse may use termination of the nurse-client relationship to prepare the client for and work the client through positive termination experiences with others. Question 66 See full question The charge nurse in the newborn nursery has an unlicensed assistive personnel (UAP) with her for the shift. Under their care are 8 babies rooming in with their mothers, and 1 infant in the nursery for the night on tube feedings. There is a new client whose infant will be brought to the nursery in 15 minutes. Which tasks would the nurse assign to the UAP? Select all that apply. You Selected:  vital signs on all stable infants  document feedings of infants  record voids/stools Correct response:  vital signs on all stable infants  document feedings of infants  record voids/stools Explanation: The role of the UAP allows this member of the health care team to take vital signs on clients, record feedings, and voids and stools of infants according to hospital guidelines. The newborn assessment is completed by a licensed care provider as is the tube feeding. Bathing of the newborn is within the scope of practice for the UAP, but the initial assessment of patency of the gastrointestinal tract, which is initiated by the first feeding, is within the scope of licensed care providers. If there is a trachea esophageal fistula, this is the time when it may become evident. Question 67 See full questionA client is scheduled for a cardiac catheterization. The nurse should do which preprocedure tasks? Select all that apply. You Selected:  Verify that written consent has been obtained.  Withhold food and oral fluids before the procedure.  Check for iodine sensitivity. Correct response:  Check for iodine sensitivity.  Verify that written consent has been obtained.  Withhold food and oral fluids before the procedure. Explanation: For clients scheduled for a cardiac catheterization it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure. Remediation:  Cardiac catheterization  Preoperative Nursing Care on the Day of Surgery Question 68 See full question The nurse is assessing children at risk for phenylketonuria (PKU). Which child is at greatest risk? You Selected:  child with dark complexion who is overweight and has labile personalities Correct response:  blond, blue-eyed, fair-skinned child with eczema Explanation: Infants with PKU are usually blond, blue-eyed, and fair, and often have eczema. The other physical assessment findings are not typically found in children with PKU. Question 69 See full question A nurse hears a client state, “I have had it with this marriage. It would be so much easier to just hire someone to kill my husband!” What action should the nurse take? You Selected: The nurse must start the process to warn the client’s husband. Correct response:  The nurse must start the process to warn the client’s husband. Explanation: Confidentiality must be broken if there are credible threats made against another person’s safety. Confidentiality does not override the safety of other persons. Remediation:  Confidentiality, maintaining Question 70 See full question The nurse is caring for a client who has been diagnosed with pernicious anemia. Which statement by the client indicates an understanding of the treatment of pernicious anemia? You Selected:  "I will receive my first injection of vitamin B12 tomorrow, and I will return for a follow-up injection in 1 month." Correct response:  "I will need to take vitamin B12 replacements for the rest of my life." Explanation: Clients who have been diagnosed with pernicious anemia are lacking adequate amounts of the intrinsic factor (IF) that is secreted by the gastric mucosa. IF is necessary for the absorption of cobalamin (vitamin B12) in the distal ileum. Without the presence of IF, dietary intake of vitamin B12 is useless because it cannot be absorbed. Treatment of pernicious anemia includes IM injections of cobalamin, at first daily for 2 weeks, then weekly until the anemia is corrected. A maintenance schedule of monthly injections is then implemented. The injections will need to be continued for the rest of the client’s life. Remediation:  Anemia, pernicious Question 71 See full question What is an expected outcome for a client during the first 2 weeks who is recovering from an abdominalperineal resection with a colostomy? The client will: You Selected:  maintain