NURSING 216 Nclex Practice with Answers Graded A+

NURSING 216 Nclex Practice with Answers 1. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child? Review Information: The correct answer is D: "I have the four year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." The infant seat is to be placed on the rear seat. Small children and infants are not to be left unsupervised. Infants are to be placed on their "back when they go back" to sleep or are lying in a crib. A 4 year-old could assist with the care of an infant with proper supervision. This enhances bonding with the infant and the developmental needs of the preschooler to "help" and not feel left out. 2. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? Review Information: The correct answer is B: Give information about advance directives For each admission, nurses should request a copy of the current advance directive. If there is none, the nurse must offer information about what an advance directive implies. It is then the client’s choice to sign it. In option 1 just recording the information is not sufficient. In option 3 the nurse should not assume that the client has been informed of choices for emergency care. In option 4 this represents an inappropriate delegation approach. 3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to Review Information: The correct answer is D: Call the provider for clarification Relying on anyone else''s interpretation is very risky. When in doubt, check it out with the person who wrote the illegible order. Order entry systems help to minimize this problem. 7. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: Review Information: The correct answer is D: open the client''s airway According to the ABCs of CPR the first step in rescuing an unresponsive victim after checking responsiveness and calling for help is to open the victims airway. The airway must be opened appropriately before the need for rescue breaths can be determined. The pulse is assessed, after breathing is evaluated. The need for abdominal thrusts is determined by inability to achieve chest rise when ventilation is attempted. 8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? Review Information: The correct answer is D: Ausculate the lungs All of the options would be part of the evaluation for the effects of the large amount of fluid in a short period of time. However the worst result is heart failure with lung congestion so the auscultation of the lungs is the priority action. The sequence of actions would be 4 1 3 2. 9. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? Review Information: The correct answer is B: Administer epinephrine 1:1000 as ordered .All the answers are correct given the circumstances. The correct sequence of care is to administer the epinephrine, then maintain airway. In the early stages of anaphylaxis, when the patient has not lost consciousness and is normatensive, administering the epinephrine and then applying the oxygen, watching for hypotension and shock are later responses. The prevention of a severe crisis is maintained by using diphenhydramine. 4. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? Review Information: The correct answer is C: 72 year-old recovering from surgery after a hip replacement 2 hours ago Look for the client who is in the least stable condition. The client who returned from surgery 2 hours ago is at risk for hemorrhage and should be seen first. The 16 year-old should be seen next because it is still the first post-op day. The 75 year-old in skin traction should be seen next. The client who can safely be seen last is the 20 year-old who is 2 weeks post-injury. 10. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? Review Information: The correct answer is B: A toddler with severe deep abrasions over 98% of the body .This child has the least chance of survival. Severe deep abrasions are to be thought of as second and third degree burns. The child has great risk of shock and infection combined. 5. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse’s best action is to Review Information: The correct answer is C: notify the admissions office and wait to apply the bracelet The Admissions Office has the responsibility to verify the client’s identity and keep all the records in the system consistent. Making the changes puts the client at risk for misidentification. Using an incorrect identification bracelet is unsafe. Making a new bracelet on the unit is not appropriate. 6. The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? Review Information: The correct answer is B: That was done correctly. Did you have any problems with the insertion? Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. After a short time it will not hurt the client to turn in any manner. The suppository should be somewhat melted after 10 to 15 minutes. The other responses are incorrect since no data is in the stem to support such comments. 11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? Review Information: The correct answer is C: contact precautions The resistant bacteria remain alive for up to 3 days post death. Therefore, contact precautions must still be implemented. Also label the body so that the funeral home staff can protect themselves as well. Gown and gloves are required. 12. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? Review Information: The correct answer is B: clean the meatus, begin voiding, then catch urine stream A clean catch urine is difficult to obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins voiding it''s best to just slip the container into the stream. Other responses are not correct technique. 13. The provider orders Lanoxin (digoxin) 0.125 mg po and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? Review Information: The correct answer is B: watermelon Watermelon is high in potassium and will replace any potassium lost by the diuretic. The other foods are not high in potassium. 14. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? An elderly client who had a myocardial infarction a week ago - UAP Review Information: The correct answer is A: An admission at the change of shifts with atrial fibrillation and heart failure - PN The care for a new admissions should be performed by an RN. Since the client was admitted at the change of shifts, the stability of the client would not have been established. The charge nurse should take this client. The PN could monitor the IV fluids in option C. Tasks that do not require independent judgment should be delegated. The nurse may delegate the care for a stable client to a UAP. 19. A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? Review Information: The correct answer is B: Restlessness and increased mucus production This infant could be experiencing gastroesophageal reflux, or could be allergic to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present. Soy based formula is often recommended. 20. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? Review Information: The correct answer is C: Immediately wash the hands with vigor The immediate action of vigorously washing will help remove possible contamination. Then the sequence would then be options 4, 1, 2. 15. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? Review Information: The correct answer is C: "Clothes are becoming tighter across her abdomen." One of the most common signs of neuroblastoma is increased abdominal girth. The parents'' report that clothing is tight is significant, and should be followed by additional assessments. 21. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? Review Information: The correct answer is D: Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream. Option 4 protects the client and is the most professional. 16. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? Review Information: The correct answer is D: Proceed with the triage process in the same manner as any adult client Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this client, who is married, has the legal capacity of an adult. 22. A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? Review Information: The correct answer is B: Glascow Coma Scale 8, respirations regular The Glascow Coma Scale provides a standard reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a neurological impairment. Using the term comatose provides too much room for interpretation and is not very precise. 17. A client enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the direction of care for this client? Review Information: The correct answer is B: 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. Because the RN is responsible for all care-related decisions, only implementation tasks should be assigned because they do not require independent judgment. 23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? Review Information: The correct answer is C: A notarized original of advance directives brought in by the partner This document specifies the client''s wishes. 18. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? Review Information: The correct answer is B: Strep throat went through all the children at the day care last month. Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2 to 6 weeks). Therefore, the history of playmates recovering from strep throat would indicate that the child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an infection has no clinical symptoms. 24. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to 30. Which statement best describes time management strategies applied to the role of a nurse manager? Review Information: The correct answer is A: Discuss the feeling of reluctance with an objective peer or supervisor The nurse who experiences stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse- client relationship. 25. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action Review Information: The correct answer is C: Set daily goals with a prioritization of the work Time management strategies include setting goals and prioritization . This is similar to time management of direct care for clients 31. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? Review Information: The correct answer is A: May result in charges of unlawful seclusion and restraint Seclusion should only be used when there is an immediate threat of violence or threatening behavior to the staff, the other clients, or the client upon himself. 26. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? Review Information: The correct answer is D: Abdominal mass and weakness Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability. 32. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? Review Information: The correct answer is A: 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 stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands. 27. The provisions of the law for the Americans with Disabilities Act require nurse managers to Review Information: The correct answer is A: "I will only have to wear this for 6 months." The brace must be worn long-term, during periods of growth, usually for 1 to 2 years. It is used to correct curvature of the spine. 33. The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self- scheduling knowing that this method will Review Information: The correct answer is B: 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 perform the job and not discriminate on the basis of a disability. Employers also must make "reasonable accommodations." 28. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? Review Information: The correct answer is C: "I have diminished sexual function." Inderal, beta-blocking agent used in hypertension, prohibits the release of epinephrine into the cells; this may result in hypotension which results in decreased libido and impotence. 29. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? Review Information: The correct answer is D: "I think I remember that standing cannot be done until after 72 hours." Applying ice is a safe method of relieving the itching. Synthetic casts will typically set up in 30 minutes and dry in a few hours. Thus, standing can be done within the initial 24 hours. With plaster casts the set up and drying time, especially in a long leg cast which is thicker than an arm cast, can take up to 72 hours to dry. Both types of cast give off a lot of heat when drying and it is preferred to keep the cast uncovered in the initial 24 hours. Clients may complain of chilling from the wet cast and therefore can simply be covered lightly with a sheet or blanket. Review Information: The correct answer is D: Improve team morale Nurses are more satisfied when opportunites exist for autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision- maker of the schedule when self-scheduling exists. 34. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? Review Information: The correct answer is A: Diffuse expiratory wheezing In asthma, the airways are narrowed - creating difficulty getting air in and a wheezing sound. 35. The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to Review Information: The correct answer is D: Request an immediate private meeting with the health care provider and staff nurse Assertive communication respects the 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. 36. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states “I demand to be released now!” The appropriate action is for the nurse to Review Information: The correct answer is C: Let’s discuss your decision to leave and then we can prepare you for discharge. Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision initially allows an opportunity for other interventions. 37. A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Options c and d are corrrect answers but not the best answer since they are too general. 43. Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform? Review Information: The correct answer is B: Heart murmur Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the 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. 38. A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to Review Information: The correct answer is B: Maintain alveolar surface tension Respiratory distress syndrome is primarily a disease related to the developmental delay in lung maturation. Although many factors may lead to the development of the problem, the central factor is the lack of a normally functioning surfactant system in the alveolar sac from immaturity in lung development since the infant is premature. 39. An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be Review Information: The correct answer is C: Check the blood pressure of a 2 hours post operative client UAPs must be assigned tasks that require no nursing judgment or decision making situations. Vital signs on stable clients are commonly assigned to unlicensed staff. 44. A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is Review Information: The correct answer is C: Assess the child and the extent of the injury When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis). 45. When interviewing the parents of a child with asthma, it is most important to gather what information about the child's environment? Review Information: The correct answer is A: Household pets Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust. 46. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider? Review Information: The correct answer is C: Respiratory function Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problems identified, respiratory assessment is a priority. 40. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? Review Information: The correct answer is A: Slurred speech Changes in speech patterns and level of conscious can be indicators of continued intercranial bleeding or extension of the stroke. Further diagnostic testing may be indicated. 47. A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem? Review Information: The correct answer is A: 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 when the 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. 41. The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance? Review Information: The correct answer is D: Pinworms Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span. Scabies is an itchy skin condition caused by a tiny, eight-legged burrowing mite called Sarcoptes scabiei . The presence of the mite leads to intense itching in the area of its burrows. 48. A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse? Review Information: The correct answer is A: Assume a decision- making role Authoritarian leadership assumes that decision-making is the role of the leader with little input by subordinates. This style is best used in emergency situations or as a triage nurse. 42. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance? Review Information: The correct answer is C: Assessing the client''s ability to participate in self care and/or the reliability of a caregiver The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option. 49. The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse? Review Information: The correct answer is B: Metabolic alkalosis Review Information: The correct answer is A: "Folic acid should be taken before and after conception." 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. 50. A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse? Review Information: The correct answer is D: Suggest communication strategies Alzheimer''s disease, a progressive chronic illness greatly challenges caregivers. During the initial visit the nurse can be of greatest assistance in helping family to use communication strategies to enable identification of language changes in the client. By use of select verbal and nonverbal communication strategies the client’s aberrant behavior may be minimized. 57. The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to Review Information: The correct answer is B: Moist sterile nonadherent dressing Before surgical closure the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist. 51. A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? Review Information: The correct answer is C: 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 in sealing water pipes. Letting tap water run for several minutes will diminish the lead contamination. 52. A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The most appropriate intervention for this client is Review Information: The correct answer is A: Position client in upright position while eating An upright position facilitates proper chewing and swallowing. 53. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from… Review Information: The correct answer is C: my thigh." Autografts are done with tissue transplanted from the client''s own skin. 54. The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? Review Information: The correct answer is B: Ineffective airway clearance The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula at or near the bifurcation. Thus, a priority is maintaining an open airway, preventing aspiration. Other nursing diagnoses are then addressed. 55. A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to Review Information: The correct answer is D: Improve venous return Elevating the leg both improves venous return and reduces swelling. 56. During the initial home visit a nurse is discussing the care of a newly diagnosed client with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time? Review Information: The correct answer is D: Keep a regular schedule of meals and snacks Currently, calorie-controlled diets with strict meal plans 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. 58. The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated to the findings in the infant? Review Information: The correct answer is A: DTaP The majority of reactions occur with the administration of the DTaP vaccination. Contradictions to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within 7 days of the immunization. 59. The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? Review Information: The correct answer is C: Unprotected sex Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risk for infection. 60. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the unlicensed assistive presonnel (UAP)? A client with Review Information: The correct answer is B: an order of enemas until clear prior to colonoscopy The UAP can be assigned routine tasks which have predictable outcomes. 61. A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: ”My child seems to have problems in learning to count and recognizing basic colors.” Based on this data, the nurse suspects that the child is most likely showing the effects of which problem? Review Information: The correct answer is C: Fetal alcohol syndrome Major features of fetal alcohol syndrome consist of facial and associated physical features, such as small head circumference and brain size (microcephaly), small eyelid openings, a sunken nasal bridge, an exceptionally thin upper lip, a short, upturned nose and a smooth skin surface between the nose and upper lip. Vision difficulties include nearsightedness (myopia). Other findings are mental retardation, delayed development, abnormal behavior such as short attention span, hyperactivity, poor impulse control, extreme nervousness and anxiety. Many behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome. 62. The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately? D) Appearance of the use of abdominal muscles for breathing Review Information: The correct answer is B: Expiratory wheezes that are suddenly absent in one lobe Acute asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest. However, sudden cessation of wheezing is an omnious or bad sign that indicates an emergency in that the small airways are now collasped. 63. The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best? Review Information: The correct answer is B: Ground beef patty, lima beans, wheat roll, raisins, milk Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice, high in iron and is appropriate for a toddler. 64. A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to Review Information: The correct answer is C: Plan nursing care around lengthy rest periods The initial priority for this client is rest due to the inability of red blood cells to carry oxygen. 65. The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a priority? Review Information: The correct answer is B: Client controlled analgesia Management of a crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum comfort. 66. As the nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate? Vital sign changes include pulse that is variable, i.e., rapid, slow and bounding, or feeble. Respirations are more often slow, deep, and irregular. 69. The nurse is performing a physical assessment on a toddler. Which of the following should be the first action? Review Information: The correct answer is B: Use minimal physical contact The nurse should approach the toddler slowly and use minimal physical contact initially so as to gain the toddler''s cooperation. Be flexible in the sequence of the exam, and give only brief simple explanations just prior to the action. 70. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? Review Information: The correct answer is C: The appearance of eyeballs that appear to "pop" out of the client''s eye sockets Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves'' Disease. It can result in corneal abrasions with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be needed. 71. Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required? Review Information: The correct answer is C: HCT of 60 This high HCT is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis. Without sufficient hydration all systems of the body are at risk for hypoxia from a lack of or sluggish circulation. In the absence of insulin, which facilitates the transport of glucose into the 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), which would be the second concern for this client. The potassium and PaO2 are near normal. 72. The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate? Review Information: The correct answer is D: The measles, mumps and rubella vaccine should be delayed Discharge instructions for a child with Kawasaki Disease should include immunoglobulin therapy may interfere with the body''s ability to form appropriate amounts of antibodies and live immunizations should be delayed. 67. The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken Review Information: The correct answer is D: The affected child''s age and weight All of the above information is important. However, once the substance is stated the age and weight is a priority. This gives the appropriate healthcare providers an opportunity to calculate the needed dosage for an antidote while the child is being transported to the emergency department. After this information, the time of the accidental poisoning is next in importance to report. 73. A 2 year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement? Review Information: The correct answer is C: 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. 68. The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit? Review Information: The correct answer is B: Continue with the regular diet and include oral rehydration fluids Current recommendations for mild to moderate diarrhea are to maintain a normal diet with rehydration fluids. 74. The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication? Review Information: The correct answer is B: Irritability Signs of IICP (increased intracranial pressure) in infants include bulging fontanel, instability, high-pitched cry, and cries when held. Review Information: The correct answer is B: Adding a spacer device to the MDI canister If the client is not using the MDI properly, the medication can get trapped in the upper airway, resulting in dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth. It is especially useful in the elderly because it allows more time to inhale and requires less eye-hand coordination. 75. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? Review Information: The correct answer is D: Whitish oval specks sticking to the hair Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment includes shampoo application, such as lindane for children over 2 years of age, and meticulous combing and removal of all nits. 76. When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the nurse would suggest for the parents to give sips of which substance? Review Information: The correct answer is D: I had a blood transfusion 15 years ago. The client who was transfused prior to blood screening for hepatitis C may show findings many years later. Options b and c are associated with risk of hepatitis B. 82. A client is recovering from a thyroidectomy. While monitoring the client's initial post operative condition, which of the following should the nurse report immediately? Review Information: The correct answer is A: Tetany and paresthesia Because the parathyroid gland may be damaged in this surgery, secondary hypocalcemia may occur. Findings of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures. 83. A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The most appropriate action by the nurse to protect the self would be which of these? Review Information: The correct answer is B: Water Small amounts of water will dilute the corrosive substance prior to gastric lavage. 77. A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client’s history indicate a potential hazard for this test? Review Information: The correct answer is C: Particulate respirator mask Tight fitting, high-efficiency masks are required when caring for clients who have suspected communicable disease of the airborne variety. 84. A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? Review Information: The correct answer is B: Allergic to shellfish It is important to know if the client has an allergy to iodine or shellfish. If the client does, they may have an allergic reaction to the IVP contrast dye injected during the procedure. 78. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? Review Information: The correct answer is C: 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 be the urine output. 85. The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied Review Information: The correct answer is A: Solid foods are introduced 1 at a time beginning with cereal Solid foods should be added 1 at a time between 4-6 months. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food. 79. The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? Review Information: The correct answer is C: Limit the infusion time of each of the unit to a maximum of four hours Infuse the specified amount of blood within 4 hours. If the infusion will exceed this time, the blood should be divided into appropriately sized quantities. 80. A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on this data, what is the first nursing action? Review Information: The correct answer is C: Administer oxygen The client has a low PCO2 due to increased respiratory rate from the hypoxemia and signs of respiratory alkalosis. Immediate intervention is indicated. 81. A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important? A) I got back from Central America a few weeks ago. Review Information: The correct answer is A: When it is 1/3 to 1/2 full If the pouch becomes more than half full it may separate from the flange. 86. Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? Review Information: The correct answer is C: A decrease in lethargy Lactulose produces and acid environment in the bowel and traps ammonia in the gut; the laxative effect then aids in removing the ammonia from the body. This decreases the effects of hepatic encephalopathy, including lethargy and confusion. 87. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? Review Information: The correct answer is B: Whole milk is difficult for a young infant to digest Cow''s milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. Also it contains little iron and creates a high renal solute load. 88. The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period? Review Information: The correct answer is A: Estrogen replacement therapy Estrogen increases the hypercoagualability of the blood and increased the risk for development of thrombophlebitis. 89. The nurse is planning discharge for a 90 year-old client with musculo-skeletal weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls? Review Information: The correct answer is A: Place nightlights in the bedroom Because more falls occur in the bedroom than any other location, begin there. However, work in partnership with the 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. 90. An 8 year-old client is admitted to the hospital for surgery. The child’s parent reports the following allergies. Of these allergies which one should all health care personnel be aware of? Review Information: The correct answer is C: Balloons Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non- latex gloves. 91. The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action? Review Information: The correct answer is C: Continue to monitor the client to see if the bubbling increases Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required. 92. The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? Review Information: The correct answer is C: Rash, blood dyscrasias, severe depression Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication to the use of neuroleptics. 96. The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan? Review Information: The correct answer is C: Assess movement and sensation of extremities Following corrective surgery for scoliosis, neurological status requires special attention and assessment, especially that of the extremities. 97. A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack? Review Information: The correct answer is C: 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. 98. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first? Review Information: The correct answer is B: Administer the prn dose of Albuterol Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client''s baseline reading is a medical alert condition and a short-acting beta- agonist must be taken immediately. 99. What finding signifies that children have attained the stage of concrete operations (Piaget)? Review Information: The correct answer is B: Begin treatment with acyclovir at the onset of symptoms of recurrence When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. Medications for herpes simples do not cure the disease; they simply decrease the level of symptoms. 93. An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice? Review Information: The correct answer is C: Makes the moral judgment that "stealing is wrong" The stage of concrete operations is depicted by logical thinking and moral judgments. 100. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? Review Information: The correct answer is C: Chicken strips, corn on the cob, milk This menu is lowest in sodium. Ideally, low fat milk would be available. 94. The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized? Review Information: The correct answer is D: Liver enzymes (AST and ALT) Because acetaminophen is toxic to the liver and causes hepatic cellular necrosis, liver enzymes are released into the blood stream and serum levels of those enzymes rise. Other lab values are reviewed as well. 101. 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 Review Information: The correct answer is B: Empty the child''s mouth in any case of possible poisoning Emptying the mouth of poison interferes with further ingestion and should be done first to limit contact with the substance. Note that all of the actions are correct. However option B is the priority to emphasize. 95. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? Review Information: The correct answer is A: Formula or breast milk The usual diet for a young infant should be followed. 102. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. What is the physiological basis for this instruction? Review Information: The correct answer is B: Stimulates hydrochloric acid production Decadron increases the production of hydrochloric acid, which may cause gastrointestinal ulcers. 103. The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to 109. During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse? Review Information: The correct answer is A: 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. 104. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? Review Information: The correct answer is C: "Keep in mind that for the age this is a normal response to being in the hospital." The protest phase of separation anxiety is a normal response for a child this age. In toddlers, ages 1 to 3, separation anxiety is at its peak 105. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic reponse to the drug? Review Information: The correct answer is C: Prothrombin time Coumadin is ordered daily, based on the client''s prothrombin time (PT). This test evaluates the adequacy of the extrinsic system and common pathway in the clotting cascade; Coumadin affects the Vitamin K dependent clotting factors. 106. The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately? Review Information: The correct answer is D: Increased restlessness Restlessness and increased respiratory and heart rates are often early signs of hemorrhage. 107. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? Review Information: The correct answer is B: "In some instances the result is a retarded bone growth." An epiphyseal (growth) plate fracture in a 7 year-old often results in retarded bone growth. The leg often will be different in length. 108. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessement finding as what? Review Information: The correct answer is C: Telangiectatic nevi are normal and will disappear as the baby grows Telangiectatic nevi, salmon patch or stork bite birthmarks are a normal variation and the facial nevi will generally disappear by ages 1 to 2 years. 110. A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate? Review Information: The correct answer is C: Monitor vital signs The potential complication of this procedure is internal hemorrhage. Monitoring vital signs is critical to detect early indications of bleeding. 111. A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority? Review Information: The correct answer is B: Frequent neurovascular assessments of the affected leg The most important activity for the 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. 112. The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The best response is Review Information: The correct answer is A: Drop the canister in water to observe floating Dropping the canister into a bowl of water assesses the amount of medications remaining in a metered-dose inhaler. The client should obtain a refill when the inhaler rises to the surface and begins to tip over. Some of the newer canisters have counters. 113. While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions? Review Information: The correct answer is A: Maintain good oral hygiene and dental care Swollen and tender gums occur often with use of phenytoin. Oral hygiene and regular visits to the dentist should be emphasized. 114. A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate Review Information: The correct answer is B: Abdominal ultrasound The standard for diagnosis of placenta previa, which is suggested in the client''s history, is abdominal ultrasound. 115. The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? Review Information: The correct answer is D: Tardive dyskinesia Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue movements. Review Information: The correct answer is C: Decreased potassium In bulimia, loss of electrolytes can occur in addition to signs and symptoms of starvation and dehydration. 116. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first? Review Information: The correct answer is A: 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 especially if taking diuretics that enhance the loss of potassium while they are taking digitalis preparations. 117. The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time? Review Information: The correct answer is C: Ineffective breathing patterns related to central nervous system depression Respiratory depression is a life-threatening risk in this overdose. 118. The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's mother reports that the child "feels very warm" to touch. The first action by the nurse should be to Review Information: The correct answer is C: Reassess the child''s temperature A child''s temperature may have rapid fluctuations. The nurse should listen to and show respect for what parents say. 119. The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to Review Information: The correct answer is B: Measure forced expiratory volume The peak flow meter is used to measure peak expiratory flow volume. It provides useful information about the presence and/or severity of airway obstruction. 120. The nurse is performing a pre-kindergarten physical on a 5 year- old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? Review Information: The correct answer is C: Vastus lateralis Vastus lateralis, a large and well developed muscle, is the preferred site, since it is removed from major nerves and blood vessels. 121. A couple experienced the loss of a 7 month-old fetus. In planning for discharge, what should the nurse emphasize? Time is not completely understood by a 4 year-old. Preschoolers interpret time with their own frame of reference. Thus, it is best to explain time in relationship to a known, common event. 123. The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis? Review Information: The correct answer is B: Peak air flow volumes The peak airflow volume decreases about 24 hours before clinical manifestations. 124. Therapeutic nurse-client interaction occurs when the nurse Review Information: The correct answer is A: Assists the client to clarify the meaning of what the client has said Clarification is a facilitating/therapeutic communication strategy. Intrepretation or changing the focus/subject, giving approval, and advising are non- therapeutic/barriers to communication. 125. A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child? Review Information: The correct answer is D: Epistaxis A large dose of aspirin inhibits prothrombin formation and lowers platelet levels. With an overdose, clotting time is prolonged. 126. The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The first assessment the nurse should perform is Review Information: The correct answer is B: Pulse oximetry Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndrome followed by a very high temperature. The nurse needs to confirm hypoxia first. 127. Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills? Review Information: The correct answer is A: Offer the client frequent opportunities to interact with one person The withdrawn client is uncomfortable in social interaction. The nurse client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships. 128. The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? Review Information: The correct answer is A: To discuss feelings with each other and use support persons To communicate in a therapeutic manner, the nurse''s goal is to help the couple begin the grief process by suggesting they talk to each other, seek family 122. The parents of a 4 year-old hospitalized child tell the nurse, “We are leaving now and will be back at 6 PM.” A few hours later the child asks the nurse when the parents will come again. What is the best response by the nurse? Review Information: The correct answer is A: "They will be back right after supper." Review Information: The correct answer is D: Applying a hydrocolloid or foam dressing While the previously accepted treatment was a transparent cover, evidence now indicates that the foam (DuoDerm) dressings work best.. 129. A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." The nurse's best response would be which of these statements? Review Information: The correct answer is D: "Are you worried that the surgery will change you?" This is a general lead in type of response that encourages further discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem. 130. When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue 137. A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse? Review