MED SURG 206 Comprehensive Foundation NCLEX Questions And Answers( All Answers Are Correct)

Comprehensive Foundation NCLEX Question 1 100 / 100 pts The client with cellulitis of the lower leg has had cultures done on the affected area. The nurse reviewing the results of the culture repor t interprets that which of the following organisms is not part of the normal flora of the skin? Staphylococcus epidermidis Correct! Escherichia coli Candida albicans Staphylococcus aureus Rationale: E. coli is normally found in the intestines and is a common source of infection of wounds and the urinary system. C. albicans, S. aureus, and S. epidermis are part of the normal flora of the skin. Test-Taking Strategy: To answer this question correctly, you must be familiar with the normal microorganisms that inhabit the skin. Note that the question asks for the organism that is not part of normal flora. Remember that E. coli is normally found in the intestines. Review basic skin structures if you had difficulty with this question. Question 2 100 / 100 pts The client has been diagnosed with paronychia. The nurse understands that this is a disorder of the: Pilosebaceous glands Correct! Nails Hair follicles Epithelial layer of skin Rationale: Paronychia is a fungal infection that is most often caused by Candida albicans. This results in inflammation of the nail fold, with separation of the fold from the nail plate. The area is generally tender to touch, with purulent drainage. Disorders of the hair follicles include folliculitis, furuncles, and carbuncles. Disorders of the pilosebaceous glands include acne vulgaris and seborrheic dermatitis. There are a variety of disorders involving the epithelial skin. Test-Taking Strategy: To answer this question accurately, you must be familiar with a variety of skin disorders and their causes. Remember that paronychia is a nail disorder. If this question was difficult, review the characteristics of paronychia. Question 3 100 / 100 pts The nurse is assigned to the care of a client scheduled for surgery for a right colon tumor. Which of the following is the most characteristic manifestation of cancer at this site? Correct! Dull abdominal pain exacerbated by walking Flat, ribbon-like stools Crampy gas pains Frequent diarrhea Rationale: Characteristic symptoms of right colon tumors include vague, dull, abdominal pain exacerbated by walking, and dark red- or mahogany-colored blood mixed in the stool. The symptoms described in the other options are associated with left colon tumors. Test-Taking Strategy: Knowledge regarding the signs of right and left colon tumors is required to answer this question. Note, however, that “crampy gas pains” and “dull abdominal pain exacerbated by walking” describe different patterns of pain. This may suggest to you that one of the two is correct. If you are not familiar with the differences between right and left colon tumors, review this content. Question 4 100 / 100 pts The client with an endocrine disorder complains of weight loss and diarrhea, and says that he can “feel his heart beating in his chest.” The nurse interprets that which of the following glands is most likely responsible for these symptoms? Parathyroid Pituitary Correct! Thyroid Adrenal cortex Rationale: The thyroid gland is responsible for a number of metabolic functions in the body, including metabolism of nutrients (such as fats and carbohydrates). Increased metabolic function places a demand on the cardiovascular system for a higher cardiac output. Thus, a client with increased activity of the thyroid gland exhibits weight loss from higher metabolic rate and increased pulse rate. Test-Taking Strategy: Use knowledge of the function of the thyroid gland to answer this question. Remember that the thyroid gland is responsible for metabolic function. This will assist in directing you to “thyroid.” If you had difficulty answering this question, review the function of the thyroid gland. Question 5 100 / 100 pts The client with diabetes mellitus is being tested to determine long-term diabetic control. Which of the following results would the nurse expect to see if the client’s long-term control is within acceptable limits? Fasting blood glucose level of 150 mg/dL Correct! Glycosylated hemoglobin of 6% Presence of albumin in the urine Presence of ketones in the urine Rationale: This measurement of glycosylated hemoglobin (Hb A1c) detects glucose binding on the red blood cell (RBC) membrane and is expressed as a percentage. It measures glucose for the life of the RBC, which is 120 days. The fasting blood glucose level should be lower than 130 mg/dL. The urine should be free of both ketones and urine. Test-Taking Strategy: Specific knowledge of the effects of an increased blood glucose level in the body is necessary to answer this question. Noting the words “long-term” will direct you to “glycosylated hemoglobin of 6%.” Review the alterations in normal physiology that occur with diabetes mellitus if you had difficulty with this question. Question 6 100 / 100 pts Discharge teaching for a client recovering from an attack of chronic pancreatitis should include which of the following instructions? Diet should be high in carbohydrates, fats, and proteins. Frothy fatty stools indicate that enzyme replacement is working. Alcohol should be consumed in moderation. Correct! Avoid caffeine, because it may aggravate symptoms. Rationale: Knowing that caffeinated beverages, such as coffee, tea, and soda, will worsen symptoms, such as pain, will direct you to select “Avoid caffeine, because it may aggravate symptoms.” Alcohol can precipitate an attack of chronic pancreatitis and needs to be avoided. The recommended diet is moderate carbohydrates, low fat, and high protein. Frothy fatty stools indicate that the replacement enzyme dose needs to be increased. Test-Taking Strategy: “Alcohol should be consumed in moderation” can be immediately eliminated because alcohol can precipitate another attack and needs to be avoided. “Diet should be high in carbohydrates, fats, and proteins” can be eliminated because the recommended diet is moderate carbohydrates, low fat, and high protein. Finally, frothy fatty stools indicate that the enzyme dose needs to be increased, so “frothy fatty stools indicate that enzyme replacement is working” can be eliminated. Review home care instructions for the client with chronic pancreatitis if you had difficulty answering this question. Question 7 100 / 100 pts A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which of the following reflects appropriate intervention by the nurse? Correct! Withhold oral fluids until the client’s gag reflex has returned. Tell the client to report a sore throat immediately, because it is a serious complication. Allow the client unassisted bathroom privileges. Keep the client lying flat in bed in the supine position. Rationale: In preparation for the passage of the endoscope, an anesthetic is sprayed to inactivate the gag reflex and thus facilitate passage of the tube. It may take 1 to 2 hours for the anesthetic spray to wear off and for the gag reflex to return. “Allow the client unassisted bathroom privileges,” “keep the client lying flat in bed in the supine position,” and “tell the client to report a sore throat immediately, because it is a serious complication” are incorrect. Test-Taking Strategy: Apply knowledge of endoscopic procedures of the upper gastrointestinal tract to assist you with selecting the correct option. Because the client will receive conscious sedation for the procedure and anesthetic spray to the throat, postprocedure safety precautions must be maintained. This includes assistance to the bathroom and head of the bed elevation to prevent aspiration of oral secretions. A sore throat is common postprocedure and may persist for a few days but is not a cause for alarm. Review these postprocedural instructions if you had difficulty with this question. Question 8 100 / 100 pts A client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which of the following is the priority action taken by the nurse? Perform a complete abdominal assessment. Obtain a thorough history of the recent health status. Prepare to insert a nasogastric tube and test pH and occult blood. Correct! Take the client’s vital signs. Rationale: The nurse should take the client’s vital signs first to determine whether the client is hypovolemic or in shock from blood loss; this also provides a baseline blood pressure and pulse by which to gauge the effectiveness of treatment. Signs and symptoms of shock include low blood pressure, rapid weak pulse, increased thirst, cold clammy skin, and restlessness. Test-Taking Strategy: The strategic word in the question is “priority.” This tells you that more than one or all of the options may be partially or totally correct. Although all the options may be applicable to the care of this client, use principles of priority setting to answer the question. A client with an acute upper gastrointestinal (GI) bleed is at risk for shock. From the options provided, taking the client’s vital signs is the nursing action that will provide information about the status of the client’s circulating volume status. Review care to the client with a GI bleed if you had difficulty with this question. Question 9 100 / 100 pts The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope: In the fifth intercostal space Near the lateral 12th rib Posteriorly, under the left-sided scapula Correct! Just under the left-sided clavicle Rationale: For the client with a left apical pneumothorax, the nurse would place the stethoscope just under the left clavicle. The apex of the lung is the rounded uppermost part of the lung. All the other options are incorrect. Test-Taking Strategy: Knowledge of anatomical landmarks is needed to answer this basic question. Noting the client’s diagnosis and the strategic words “left apical” will direct you to “just under the left-sided clavicle.” If needed, review assessment of the client with a left apical pneumothorax. Question 10 100 / 100 pts A client’s total cholesterol level is 344 mg/dL, low-density lipoprotein cholesterol (LDL-C) level is 164 mg/dL, and high-density lipoprotein cholesterol (HDL-C) level is 30 mg/dL. Based on analysis of the data, how should the nurse direct client teaching? Correct! The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors should be taught. The client should maintain the current dietary regimen but increase activity levels. Results are inconclusive unless the triglyceride level is also screened, so teaching is not indicated at this time. The client is at low risk for cardiovascular disease, so the client should be encouraged to continue to follow the current regimen. Rationale: In the absence of documented cardiovascular disease, the desired goal is to have the total cholesterol level lower than 200 mg/dL. A desired LDL-C level for all individuals is lower than 100 mg/dL, and a desirable HDL-C level is higher than 40 mg/dL. Because the client’s levels are outside the range for all three values to a significant degree, the client is at high risk for developing cardiovascular disease and requires teaching on risk factor reduction. Test-Taking Strategy: Use knowledge of normal values for serum cholesterol and lipoprotein levels to answer this question. The question does not indicate that the client has documented heart disease, so the standard recommended values apply. Knowing that the total cholesterol should be lower than 200 mg/dL helps you choose your answer correctly. Review the risk factors for cardiovascular disease if you had difficulty answering this question. Question 11 100 / 100 pts The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client’s laboratory results and determines that which of the following results would be consistent with the observation? Serum chloride level of 95 mEq/L Correct! Serum potassium level of 2.8 mEq/L Serum sodium level of 150 mEq/L Serum calcium level of 11.5 mg/dL Rationale: The nurse assesses the client’s serum laboratory study results for hypokalemia. The client may experience PVCs in the presence of hypokalemia, because this electrolyte imbalance increases the electrical instability of the heart. The electrolyte imbalances mentioned in the other options do not have this effect. Test-Taking Strategy: Focus on the data in the question. Recalling that a low potassium level causes cardiac irritability will direct you to “serum potassium level of 2.8 mEq/L.” If this question was difficult, review the effects of electrolyte imbalances on the cardiac system. Question 12 0 / 100 pts The client is admitted to the hospital with a tentative diagnosis of bladder cancer. The nurse expects the client history to reveal which of the following earliest manifestations of the disease? Pyuria and palpable abdominal mass You Answered Painful urination and hematuria Proteinuria and dysuria Correct Answer Hematuria with no pain Rationale: The earliest signs and symptoms of bladder cancer are hematuria that is not accompanied by pain. The hematuria is intermittent at first. Later symptoms include hematuria with dysuria and frequency because of bladder irritation. Pyuria and proteinuria are not part of the clinical picture. A mass is usually not palpable. Test-Taking Strategy: The strategic word in the question is “earliest.” Begin to answer this question by eliminating “pyuria and palpable abdominal mass” first, because pyuria would be caused by infection. Knowing that pain and discomfort are later signs helps you eliminate “proteinuria and dysuria” and “painful urination and hematuria” next. This leaves “hematuria with no pain” as correct. The client usually presents with intermittent painless hematuria. Review the early manifestations of bladder cancer if you had difficulty with this question. Question 13 100 / 100 pts The nurse is attempting to inspect the lacrimal apparatus of the client’s eye. Because of its anatomical location, the nurse should do which of the following? Retract the lower eyelid, and ask the client to look up. Correct! Retract the upper eyelid, and ask the client to look down. Retract the upper eyelid, and ask the client to look up. Retract the lower eyelid, and ask the client to look down. Rationale: The lacrimal apparatus consists of the lacrimal gland (in the upper lid over the outer canthus) and the secretory ducts, which direct tears to the lacrimal sac in the inner canthus. The nurse examines part of this apparatus by retracting the upper eyelid and asking the client to look down. Abnormal findings would include edema and tenderness. The other statements are incorrect. Test-Taking Strategy: Recall the normal anatomy of the eye and visualize the procedure for checking the lacrimal apparatus. This will direct you to “retract the upper eyelid, and ask the client to look down.” If this question was difficult, review this assessment procedure. Question 14 100 / 100 pts The nurse who is assessing the client’s eyes notes that the pupil gets larger when looking at an object in the distance and gets smaller when looking at a near object. The nurse documents this finding as: Correct! Accommodation Myopia Hyperopia Photophobia Rationale: Accommodation is the expected change in pupil size when changing gaze from a near object to a far one, and back again. The pupils dilate when looking at the far object and constrict when looking at the near one. Photophobia is an abnormal sensitivity to light. Myopia (nearsightedness) and hyperopia (farsightedness) are disturbances in visual acuity. Test-Taking Strategy: Focus on the data in the question, and note the relationship between the data and the definition of accommodation. If this question was difficult, review the definition of accommodation. Question 15 100 / 100 pts The nurse suspects the client may be experiencing dysfunction in the area of the semicircular canals of the ear if the client experiences: Conduction hearing loss Sensorineural hearing loss Tinnitus Correct! Disturbance in balance Rationale: The semicircular canals function to aid the client’s sense of balance. These canals do not relate to hearing function or the presence of tinnitus. Test-Taking Strategy: Eliminate “conduction hearing loss” and “sensorineural hearing loss” first because they are comparable or alike. For the remaining options, it is necessary to know that the semicircular canals function to aid the client’s sense of balance. Review the function of the semicircular canals if you had difficulty with this question. Question 16 100 / 100 pts The nurse is caring for a client who is scheduled to have electroencephalography. The nurse determines that the client is ready for the procedure after noting which of the following? The morning dose of an anticonvulsant has been administered. Correct! The client’s hair has been shampooed. The client has had two cups of coffee with breakfast. The client has not had any breakfast. Rationale: Preprocedure care for electroencephalography involves client teaching about the procedure, shampooing the client’s hair, and providing a light meal and fluids to prevent hypoglycemia (which could alter electroencephalographic results). Medications, such as antidepressants, tranquilizers, and anticonvulsants, are withheld for 24 to 48 hours before the procedure, as determined by the physician. Stimulants, such as coffee, tea, cola, alcohol, and cigarettes, are also withheld for 12 hours prior to the test. Test-Taking Strategy: Focus on the name of the test and think about the procedure involved in performing this test. This will direct you to “the client’s hair has been shampooed.” Review this neurological test if you had difficulty with this question. Question 17 100 / 100 pts The nurse should ask the client to do which of the following when testing the function of the spinal accessory nerve (CN XI)? Open the mouth and say “ah.” Vocalize the sounds “la-la,” “mi-mi,” and “kuh-kuh.” Swallow a sip of water. Correct! Elevate the shoulders. Rationale: The spinal accessory nerve has only a motor component. This cranial nerve is assessed by asking the client to elevate the shoulders, which may be done with or without resistance. It can also be assessed by asking the client to turn the head from one side to the other, resist attempts to pull the chin toward midline, and push the head forward against resistance. The incorrect options are assessed as part of glossopharyngeal nerve (CN IX) and vagus nerve (CN X) testing, which are done together. Test-Taking Strategy: Focus on the subject, the spinal accessory nerve. Recalling the function of this nerve and that it has only a motor component will direct you to “elevate the shoulders.” Review the cranial nerves and neurological assessment if you had difficulty with this question. Question 18 100 / 100 pts The nurse is assisting in performing a physical assessment of a right-handed client’s musculoskeletal system. Which of the following would be an abnormal finding? Symmetrical movements bilaterally Correct! Presence of fasciculations Muscle strength of normal power Hypertrophy of right upper arm of 1 cm Rationale: Fasciculations are fine muscle twitches that are not normally present. Hypertrophy, or increased muscle size, on the client’s dominant side of up to 1 cm is considered normal. Muscle strength is graded from (paralysis) to (normal power). Symmetrical muscle movement is a normal finding. Test-Taking Strategy: “Muscle strength of normal power” and “symmetrical movements bilaterally” should be eliminated first because they are normal findings. To choose correctly between the remaining two options, you must know that slight hypertrophy is normal on the dominant side, whereas fasciculations are not. Review basic physical assessment findings of the musculoskeletal system if you had difficulty with this question. Question 19 0 / 100 pts Which of the following teaching points is the priority when the nurse is teaching the client about caring for a plaster cast? The cast gives off heat as it dries. You Answered A stockinette and soft padding are put over the leg area before casting. Correct Answer Immediately report any increase in drainage or interruption in cast integrity. The client can bear weight on the cast in 1 hour. Rationale: Increases in drainage or interruption in cast integrity will affect healing and could lead to osteomyelitis. To apply a cast, the skin is washed and dried well. A stockinette is placed smoothly and evenly over the area to be casted, followed by a roll of padding. The plaster is then rolled onto the padding, and the edges are trimmed or smoothed if needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight-bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast. Test-Taking Strategy: Note the strategic word “priority.” Recalling that drainage is a sign of infection will direct you to “immediately report any increase in drainage or interruption in cast integrity.” Review the principles of cast care and the client teaching points if you had difficulty with his question. Question 20 100 / 100 pts The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. The nurse understands that in cases in which the recipient rejects transplanted organs, the cells of the transplanted organs are seen by the body as a(n): T cell Correct! Foreign antigen B cell Antibody Rationale: In cases in which transplanted organs are rejected by the recipient, the transplanted organs are seen by the body as foreign antigens. Antibodies are produced to act against a specific antigen. B and T lymphocytes are responsible for cellular and humoral immunity. Test-Taking Strategy: Knowledge regarding the action and purpose of each of the items listed in the options is required to answer this question. Noting that the subject of the question is rejection of a transplanted organ will assist in directing you to “a foreign antigen.” If you had difficulty with this question, review the types of immune responses. Question 21 100 / 100 pts The nursing student understands that the primary purpose of neutrophils in the inflammatory response is to: Dilate the blood vessels. Correct! Phagocytize any potentially harmful agents. Produce permeability of the blood vessels. Increase fluids at the site of injury. Rationale: In the inflammatory response, neutrophils appear in the area of injury in 30 to 60 minutes. Their primary purpose is to phagocytize (ingest and destroy) any potentially harmful agents, such as microorganisms. “Dilate the blood vessels,” “increase fluids at the site of injury,” and “produce permeability of the blood vessels” are incorrect. Test-Taking Strategy: Knowledge regarding the inflammatory response and physiological process that occurs is required to answer this question. Remember that neutrophils phagocytize. If you are unfamiliar with the inflammatory response, review this content. Question 22 100 / 100 pts The nurse is receiving a client from the postanesthesia care unit following left aboveknee amputation. The priority nursing action at this time is which of the following? Correct! Elevate the foot of the bed. Put the bed in a reverse Trendelenburg’s position. Position the stump flat on the bed. Keep the stump flat, with the client lying on his or her operative side. Rationale: Edema of the stump is controlled by elevating the foot of the bed for the first 24 hours after surgery. After the first 24 hours, the stump is placed flat on the bed to reduce hip contracture. Edema is also controlled by stump wrapping techniques. Test-Taking Strategy: The subject of the question is correct positioning of the stump immediately following surgery. Use principles of gravity and edema control to answer this question. If you had difficulty with this question, review postoperative positioning following amputation. Question 23 100 / 100 pts The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which of the following positions? Dorsal recumbent position Supine position Correct! Semi-Fowler’s position Prone position Rationale: In supratentorial surgery (surgery above the brain’s tentorium), the client’s head is usually elevated 30 degrees to promote venous outflow through the jugular veins. The client’s head or the head of the bed is not lowered in the acute phase of care after supratentorial surgery. An exception to this position is the client who has undergone evacuation of a chronic subdural hematoma, but a physician’s prescription is required for positions other than those involving head elevation. Additionally, the physician’s prescription regarding positioning is always checked and agency procedures are always followed. Test-Taking Strategy: Knowledge regarding supratentorial surgery and craniotomy is required to answer this question. Remember that with supratentorial surgery the head should be kept up. If you had difficulty with this question, review positioning following craniotomy surgery. Question 24 0 / 100 pts The physician is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the physician asks the client to: Exhale immediately. Correct Answer Perform the Valsalva maneuver. You Answered Take a deep breath. Breathe in and out quickly. Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is then quickly withdrawn, and an airtight dressing is taped in place. The pleura seals itself off, and the wound heals in less than 1 week. Test-Taking Strategy: Knowledge of correct procedure for chest tube removal is required to answer this question. Visualize the procedure as you read each option. This will direct you to “perform the Valsalva maneuver.” If you had difficulty with this question, review the procedure for removing a chest tube. Question 25 100 / 100 pts A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to limit which of the following foods that are most likely to have this taste for the client? Potatoes Cantaloupe Correct! Pork Custard Rationale: Chemotherapy may cause distortion of taste. Frequently, beef and pork are reported to taste bitter or rancid. The nurse can promote client nutrition by helping the client choose alternative sources of protein in the diet, such as mild-tasting fish, cold chicken, turkey, eggs, or cheese. “Custard,” “potatoes,” and “cantaloupe” are not likely to cause distortion of taste. Test-Taking Strategy: The subject of the question is optimal management of a change in taste sensation. To answer this question accurately, you must be able to identify the most troublesome foods. Remember that meats can cause a distortion in taste. If you had difficulty with this question, review interventions related to nutrition in the client receiving chemotherapy. Question 26 100 / 100 pts The client has been diagnosed with gout. In developing a teaching plan for this client, the nurse should include a list that identifies which of the following foods to be avoided? Carrots Chocolate Correct! Chicken liver Tapioca Rationale: Liver and other organ meats should be omitted from the diet of a client who has gout because of their high purine content. Purines are a form of protein. The food items identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout. Test-Taking Strategy: Focus on the pathophysiology of the client’s diagnosis and the subject, foods high in purine. Remember that organ meats are high in purines. Review foods high in purine if you had difficulty with this question. Question 27 0 / 100 pts The nurse is caring for the client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which of the following? Correct Answer Pork Chicken Broccoli You Answered Milk Rationale: Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole grain and enriched cereals. Test-Taking Strategy: Note the strategic words “best understanding” in the question. This may indicate that more than one option may be a food that contains thiamine. Knowledge regarding food items high in thiamine is required to answer this question. If you are unfamiliar with these foods, review these food items. Question 28 100 / 100 pts The nurse reviews the plan of care for a child with Reye’s syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for: Correct! Signs of increased intracranial pressure The presence of protein in the urine Signs of hyperglycemia Signs of a bacterial infection Rationale: Intracranial pressure and encephalopathy are major symptoms of Reye’s syndrome. Protein is not present in the urine. Reye’s syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease. Test-Taking Strategy: This question asks you to select a priority nursing intervention for the child with Reye’s syndrome. Recalling that Reye’s syndrome is related to a history of viral infection and that hypoglycemia is associated with this syndrome will assist in eliminating “signs of hyperglycemia” and “signs of increased intracranial pressure.” Use prioritizing skills to select “signs of increased intracranial pressure” over “the presence of protein in the urine.” If you had difficulty with this question, review care of the child with Reye’s syndrome. Question 29 100 / 100 pts The pediatric nurse in the ambulatory surgery unit is caring for a child following a tonsillectomy. The child is complaining of a dry throat. Which of the following items would the nurse offer to the child? A glass of milk Cola with ice Correct! Green gelatin Cool cherry-flavored drink Rationale: Following tonsillectomy, cool clear liquids should be administered. Citrusflavored, carbonated, and extremely hot or cold liquids should be avoided because they may irritate the throat. Red liquids are avoided because they give the appearance of blood if the child vomits. Milk and milk products, including pudding, are avoided because they coat the throat and cause the child to clear his or her throat, thus increasing the risk of bleeding. Test-Taking Strategy: Knowledge of foods and fluids to avoid following tonsillectomy is required to answer this question. First, eliminate foods and fluids that may irritate or cause bleeding, which are “cola with ice” and “a glass of milk.” The strategic word “cherry” in “cool cherry-flavored drink” should be the clue that this is not an appropriate food item. Review dietary measures following tonsillectomy if you had difficulty with this question. Question 30 100 / 100 pts The ambulatory care nurse makes a follow-up telephone call to the mother of a child who underwent a myringotomy with insertion of tympanostomy tubes on the previous day. The mother of the child tells the nurse that the child is complaining of discomfort. The nurse would instruct the mother to: Call the local pharmacist regarding a stronger over-the-counter analgesic. Correct! Give the child acetaminophen (Tylenol) for the discomfort. Call the physician immediately. Give the child children’s aspirin, and call the physician if it does not help. Rationale: Following myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. It is not necessary to notify the physician, and additionally, this response to the mother may alarm her. Aspirin should not be given to the child. Tylenol can be given to relieve the discomfort. “Call the local pharmacist regarding a stronger over-the-counter analgesic” is inappropriate. Test-Taking Strategy: “Call the physician immediately” and “call the local pharmacist regarding a stronger over-the-counter analgesic” can easily be eliminated. It is not necessary to call the physician immediately and it is inappropriate for the pharmacist to prescribe a stronger medication. It seems reasonable that the child may have some discomfort following this surgical procedure. Recalling that aspirin should not be given to a child will assist in eliminating “call the local pharmacist regarding a stronger overthe-counter analgesic.” If you had difficulty with this question, review postoperative care following myringotomy. Question 31 100 / 100 pts A nursing student is preparing a clinical conference. The topic of the discussion is caring for the child with cystic fibrosis (CF). Which of the following comments by the student would indicate that the student needs further review of information about cystic fibrosis? Correct! It is a disease that causes dilation of the passageways of many organs. It is a disease that causes mucus that is formed to be abnormally thick. It is transmitted as an autosomal recessive trait. It is a chronic multisystem disorder affecting the exocrine glands. Rationale: CF is a chronic multisystem disorder affecting the exocrine gland. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait. Test-Taking Strategy: Note the strategic words “needs further review” in the question. These words indicate a negative event query and the need to select the incorrect statement. Knowledge regarding the physiology associated with CF is required to answer this question. Recalling that obstruction of the small passageways of organs occurs, and careful reading of “it is a disease that causes dilation of the passageways of many organs,” will easily direct you to this option. If you are unfamiliar with the pathophysiology associated with CF, review this content. Question 32 100 / 100 pts A sweat test is performed on an infant with a suspected diagnosis of cystic fibrosis (CF). The nurse reviews the results of the test and notes that the chloride level is 40 mEq/L. The nurse interprets that this finding is indicative of: A negative test An unrelated finding A positive test Correct! Suggestive of CF and requires a repeat test Rationale: In a sweat test, sweating on the infant’s forearm is stimulated with pilocarpine, the sample is collected on absorbent material, and the amount of sweat chloride is measured. A chloride level higher than 60 mEq/L is considered to be a positive test result. A sweat chloride level lower than 40 mEq/L is considered normal. A sweat chloride level higher than or equal to 40 mEq/L is suggestive of CF and requires a repeat test. “A negative test,” “a positive test,” and “an unrelated finding” are incorrect interpretations of the test results. Test-Taking Strategy: Knowledge about diagnostic results related to the sweat test is required to answer this question. Remember a level of 40 mEq/L is suggestive of CF. If you had difficulty with this question or are unfamiliar with this test, review this content. Question 33 0 / 100 pts The nursing student is caring for an infant with a respiratory infection and is monitoring for signs of dehydration. The nursing instructor asks the student to identify the most reliable method of determining fluid loss. The instructor determines that the student understands this method when the student states that the plan is to: Obtain a temperature every 2 hours. Correct Answer Monitor body weight. You Answered Assess the mucous membranes. Monitor output. Rationale: Body weight is the most reliable method of measuring body fluid loss or gain. One kilogram of weight change represents 1 L of fluid loss or gain. “Monitor output,” “assess the mucous membranes,” and “obtain a temperature every 2 hours” are also appropriate measures to assess for dehydration, but the most reliable method is to monitor body weight. Test-Taking Strategy: Note the strategic words “most reliable” in the question to assist in eliminating “assess the mucous membranes” and “obtain a temperature every 2 hours” first. From the remaining options, recall that it would be very difficult to obtain an accurate measurement of output on an infant. This should direct you to “monitor body weight.” Review assessment techniques for determining dehydration if you had difficulty with this question. Question 34 100 / 100 pts The nurse is developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse includes to monitor the child for signs of: Failure to thrive Bleeding Decreased tolerance to stimulation Correct! Congestive heart failure (CHF) Rationale: Nursing care initially centers on observing for signs of CHF. The nurse monitors for increased respiratory rate, increased heart rate, dyspnea, crackles, and abdominal distention. “Bleeding,” “failure to thrive,” and “decreased tolerance to stimulation” are not findings directly associated with this disorder. Test-Taking Strategy: Knowledge that Kawasaki disease is a cause of acquired heart disease in children will assist in directing you to “congestive heart failure (CHF).” If you are unfamiliar with the characteristics of Kawasaki disease, review this content. Question 35 100 / 100 pts The nurse is reviewing the health record of an infant with a diagnosis of congenital heart disease. The nurse notes documentation in the record that the infant has clubbing of the fingers. The nurse understands that this finding is caused by: Correct! Poor oxygenation Poor sucking ability Consistent sucking on the fingers Chronic fatigue Rationale: The child with congenital heart disease may develop clubbing of the fingers. Clubbing of the fingers is thought to be caused by anoxia or poor oxygenation. “Chronic fatigue,” “poor sucking ability,” and “consistent sucking on the fingers” are unrelated to this occurrence. Test-Taking Strategy: Knowledge regarding the cause of clubbing of the fingers is required to answer this question. Focusing on the diagnosis identified in the question will assist in directing you to “poor oxygenation.” Review this clinical manifestation noted in congenital heart disease if you had difficulty with this question. Question 36 100 / 100 pts The nurse is caring for a child who was brought to the clinic complaining of severe abdominal pain and is suspected of having acute appendicitis. The child is lying on the examining table, with the knees pulled up toward the chest. The nurse assists the physician with further assessment of the progression of the child’s pain, knowing that the physician will palpate the abdomen: Correct! Midway between the right anterior superior iliac crest and the umbilicus Midway between the left iliac crest and the umbilicus Midway between the left inguinal area and the acetabulum Midway between the liver and the gallbladder Rationale: McBurney’s point is usually the location of greatest pain in the child with appendicitis. McBurney’s point is midway between the right anterior superior iliac crest and the umbilicus. “Midway between the liver and the gallbladder,” “midway between the left iliac crest and the umbilicus,” and “midway between the left inguinal area and the acetabulum” will not appropriately assess the progression of pain in the child with appendicitis. Test-Taking Strategy: Knowledge that the appendix is located in the right side of the abdomen will assist in eliminating “midway between the left iliac crest and the umbilicus” and “midway between the left inguinal area and the acetabulum.” Additionally, recalling that the appendix is located in the lower abdominal area will assist in eliminating “midway between the liver and the gallbladder.” Review the location of McBurney’s point if you had difficulty with this question. Question 37 100 / 100 pts The nurse is developing a plan of care for an infant being admitted with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. In the preoperative period, the nurse suggests to document in the plan of care to position the child: Correct! Prone with the head of the bed elevated In an infant seat placed in the crib Supine with the head of the bed at a 30-degree angle Supine with the head at a 90-degree angle Rationale: In the preoperative period, the infant is positioned prone with the head of the bed elevated to reduce the risk of aspiration. “In an infant seat placed in the crib,” “supine with the head at a 90-degree angle,” and “supine with the head of the bed at a 30-degree angle” are inappropriate positions for preventing this risk. Test-Taking Strategy: Visualize each of the positions to select the correct option. Keeping in mind that aspiration is the concern will easily direct you to “prone with the head of the bed elevated.” Review preoperative care for pyloromyotomy if you had difficulty with this question. Question 38 100 / 100 pts A female adolescent with type 1 diabetes mellitus has been chosen for her school’s cheerleading squad. She visits the school nurse to obtain information regarding adjustments needed in her treatment plan for diabetes. The school nurse instructs the student to: Take the prescribed insulin 1 hour prior to practice or game time rather than in the morning. Correct! Eat six graham crackers or drink a cup of orange juice prior to practice or game time. Eat half the amount of food normally eaten. Take two times the amount of prescribed insulin on practice and game days. Rationale: An extra snack of 15 to 30 g of carbohydrate eaten before activities, such as cheerleader practice, will prevent hypoglycemia. Six graham crackers or a cup of orange juice will provide 15 to 30 g of carbohydrate. The adolescent should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be decreased. Test-Taking Strategy: “Take two times the amount of prescribed insulin on practice and game days” and “take the prescribed insulin 1 hour prior to practice or game time rather than in the morning” can be eliminated first, because insulin dosages and times should not be adjusted in this situation. From the remaining options, recalling the manifestations and treatment associated with hypoglycemia will direct you to “eat six graham crackers or drink a cup of orange juice prior to practice or game time.” Review treatment to prevent hypoglycemia if you had difficulty with this question. Question 39 0 / 100 pts The nurse has been caring for an adolescent newly diagnosed with type 1 diabetes mellitus. The nurse provides instructions to the adolescent regarding the administration of insulin. The nurse tells the adolescent to: You Answered Rotate each insulin injection site on a daily basis. Use the same site for injections for 1 month before rotating to another site. Use only the stomach and thighs for injections. Correct Answer Use one major site for the morning injection and another site for the evening injection for 2 to 3 weeks before changing major sites. Rationale: To help decrease variations in absorption from day to day, the child should use one location within a major site for the morning injection, rotating to another site for the evening injection, and a third site for the bedtime injection if needed. This pattern should be continued for a period of 2 to 3 weeks before changing major sites. “Use only the stomach and thighs for injections,” “rotate each insulin injection site on a daily basis,” and “use the same site for injections for 1 month before rotating to another site” are incorrect instructions to the adolescent. Test-Taking Strategy: Eliminate “use only the stomach and thighs for injections” first because of the close-ended word “only.” From the remaining options, knowledge of the physiology associated with absorption of insulin will easily direct you to “Use one major site for the morning injection and another site for the evening injection for 2 to 3 weeks before changing major sites.” If you had difficulty with this question, review insulin administration. Question 40 100 / 100 pts The nurse is talking to the parents of a child newly diagnosed with diabetes mellitus. The nurse determines that the parents have a proper understanding of preventing and managing hypoglycemia if the parents state that they will: Administer glucagon immediately if shakiness is felt. Correct! Carry a glucose source when leaving home in case a hypoglycemic reaction occurs. Give the child 8 oz of diet cola at the first sign of weakness. Report to the emergency department if the blood glucose level is 65 mg/dL. Rationale: The child or parents should carry a source of glucose so it is readily available in the event of a hypoglycemic reaction. LifeSavers or hard candies will provide a source of glucose. A diet carbonated beverage does not meet this need. If the blood glucose level is 65 mg/dL, a source of glucose may be needed, but it is unnecessary to report to the emergency department. Glucagon is used for an unconscious client or if a client experiencing a hypoglycemic reaction is unable to swallow. Test-Taking Strategy: Recalling the description and pathophysiology of hypoglycemia will assist in answering this question. Use the process of elimination and knowledge of hypoglycemia to assist in directing you to “carry a glucose source when leaving home in case a hypoglycemic reaction occurs.” Review the treatment for hypoglycemia if you had difficulty with this question. Question 41 100 / 100 pts A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. The student collects the specimen by: Catheterizing the infant using the smallest available Foley catheter Obtaining the specimen from the diaper by squeezing the diaper after the infant voids Noting the time of the next expected voiding and preparing to collect the specimen into a cup when the infant voids Correct! Attaching a urinary collection device to the infant’s perineum for collection Rationale: Although many methods have been used to collect urine from an infant, the most reliable method is the urine collection device. This device is a plastic bag that has an opening lined with adhesive so that it may be attached to the perineum. Urine for certain tests, such as specific gravity, may be obtained from a diaper by collection of the urine with a syringe. Urinary catheterization is not to be done unless specifically prescribed because of the risk of infection. It is not reasonable to try to identify the time of the next voiding to attempt to collect the specimen. Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate “noting the time of the next expected voiding and preparing to collect the specimen into a cup when the infant voids” because this is unrealistic. Eliminate “catheterizing the infant using the smallest available Foley catheter” because catheterization is not prescribed, and the risk of infection exists with this procedure. Eliminate “obtaining the specimen from the diaper by squeezing the diaper after the infant voids” because only certain tests can be done on the urine obtained from the diaper. If you had difficulty with this question, review the procedure for collecting urine specimens from an infant and an incontinent child. Question 42 0 / 100 pts A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which of the following will be prescribed initially? Application of an antimicrobial agent to the burns You Answered Insertion of a nasogastric tube Correct Answer Insertion of a Foley catheter Administration of an anesthetic agent for sedation Rationale: A Foley catheter is inserted into the child’s bladder so that urine output can be accurately measured on an hourly basis. Although pain medication may be required, the child would not receive an anesthetic agent and should not be sedated. The burn wounds would be cleansed after assessment, but this would not be the initial action. IV fluids are administered at a rate sufficient to keep the child’s urine output at 1 to 2 mL/kg of body weight per hour for children weighing less than 30 kg, thus reflecting adequate tissue perfusion. A nasogastric tube may or may not be required but would not be the priority intervention. Test-Taking Strategy: Note the strategic word “initially” in the question. “Administration of an anesthetic agent for sedation” can be eliminated first because the child should not be sedated and an anesthetic agent would not be administered. Eliminate “insertion of a nasogastric tube” next, knowing that a nasogastric tube may or may not be required. From the remaining options, knowledge that fluid resuscitation and determining the adequacy of the amounts of fluid are essential will direct you to “insertion of a Foley catheter.” Review the treatment of burns if you had difficulty with this question. Question 43 100 / 100 pts The nurse is implementing a teaching plan for a 4-month-old child who has been diagnosed with developmental dysplasia of the hip (DDH). The child will be placed in the Pavlik harness. Which of the following statements by the family would indicate that they understand the care of their child while placed in the Pavlik harness? “I realize that I will also need to put two diapers on my child so that the harness does not get soiled.” “I know that the harness must be worn continuously.” Correct! “I will watch for any redness or skin irritation where the straps are applied and call the doctor if there is any irritation.” “I will bring my child back to the orthopedic office in a month so the straps can be checked.” Rationale: If stabilization of the hip is required, a cast is initially applied. This is kept in place for 3 to 6 months until the hip is stabilized. After this is completed, and if further treatment is required, a Pavlik harness is the treatment of choice next. A Pavlik harness is a removable abduction brace. This is a procedure that requires the brace be checked every 1 to 2 weeks for adjustment of the straps. The use of double diapering is not recommended for DDH because of the possibility of hip extension. Because there are straps applied to the child’s skin, it is important to check the skin of the child frequently. Test-Taking Strategy: Knowledge regarding care of the child in a Pavlik harness is required to answer this question. Use of the process of elimination and knowing that the child must return to the orthopedic office in 1 to 2 weeks for strap adjustment will allow you to eliminate “I will bring my child back to the orthopedic office in a month so the straps can be checked.” Also, knowing that the Pavlik harness is removable will allow you to eliminate “I know that the harness must be worn continuously.” because this states that the harness should be worn continuously. It is also not recommended that double diapering be done with children who are diagnosed with DDH, so this will eliminate “I realize that I will also need to put two diapers on my child so that the harness does not get soiled.” This will lead you to the correct response, as stated in “I will watch for any redness or skin irritation where the straps are applied and call the doctor if there is any irritation.” If you had difficulty with this question, review teaching components for caregivers of children who are placed in a Pavlik harness. Question 44 100 / 100 pts The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by assessing for a(n): Correct! Elevated temperature Increase in the blood pressure Decrease in the urinary output Lack of appetite Rationale: The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used with the traction. Osteomyelitis may occur with any open fracture. Clinical manifestations include complaints of localized pain, swelling, warmth, tenderness, an unusual odor from the fracture site, and an elevated temperature. “A lack of appetite,” “a decrease in the urinary output,” and “an increase in the blood pressure” are not specifically associated with osteomyelitis. Test-Taking Strategy: Note that the question addresses skeletal traction. Recalling that skeletal traction involves an invasive procedure will direct you to “an elevated temperature.” Review the complications associated with skeletal traction if you had difficulty with this question. Question 45 100 / 100 pts A nursing student is assigned to care for a child with sickle cell disease (SCD). The nursing instructor asks the student to describe the causative factors related to this disease. Which of the following statements, if made by the student, indicates a need for further research? Correct! If each parent carries the trait, the children will inherit the trait. Children with the HbS (sickle cell hemoglobin) trait are not symptomatic. SCD is an autosomal recessive disease. If one parent has the HbS trait and the other parent is normal, there is a 50% chance that each offspring will inherit the trait. Rationale: SCD is an autosomal recessive disease. Children with the HbS trait are not symptomatic. If one parent has the HbS trait and the other parent is normal, there is a 50% chance that each offspring will inherit the trait. If each parent carries the trait, there is a 25% chance that their child will be normal, a 50% chance that the child will carry the trait, and a 25% chance that each child will have the disease. Test-Taking Strategy: Note the strategic words “need for further research.” These words indicate a negative event query and the need to select the incorrect option. Knowledge of the causative factors related to SCD is necessary to answer this question. If you had difficulty with this question, review this content. Question 46 100 / 100 pts The nurse has reviewed the physician’s prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse most appropriately prepares to: Correct! Collect a 24-hour urine sample. Send the child to the radiology department for a chest x-ray. Assist with a bone marrow aspiration. Perform a neurological assessment. Rationale: Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically, the tumor infringes on adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated vanillylmandelic acid (VMA) levels. A bone marrow aspiration will assist in determining marrow involvement. A neurological examination and a chest x-ray may be performed but will not confirm the diagnosis. Test-Taking Strategy: Use the process of elimination in answering this question. Focus on the strategic word “confirm” and the pathophysiology associated with this diagnosis. “Perform a neurological assessment” and “send the child to the radiology department for a chest x-ray” can be eliminated easily, because they will not confirm the diagnosis. Focusing on the origin of the tumor location will assist in eliminating “assist with a bone marrow aspiration.” If you are unfamiliar with this type of tumor, review this content. Question 47 100 / 100 pts The nurse is reviewing the record of a 10-year-old child suspected of having Hodgkin’s disease. The nurse anticipates noting which of the following characteristic manifestations documented in the assessment notes? Correct! Painless and movable lymph nodes in the cervical area Painful lymph nodes in the supraclavicular area Malaise Fever Rationale: Clinical manifestations specifically associated with Hodgkin’s disease include painless, firm, and movable adenopathy in the cervical and supraclavicular area. Hepatosplenomegaly is also noted. Although anorexia, weight loss, fever, and malaise are associated with Hodgkin’s disease, these manifestations are vague and can be seen in many disorders. Test-Taking Strategy: Note the strategic words “characteristic manifestations” in the question. Eliminate “fever” and “malaise” first because these symptoms are general and vague. Next, think about the pathophysiology associated with Hodgkin’s disease. Recalling that painless adenopathy is associated with Hodgkin’s disease will direct you to “painless and movable lymph nodes in the cervical area.” Review the clinical manifestations related to Hodgkin’s disease if you had difficulty with this question. Question 48 100 / 100 pts The nurse is providing instructions to the mother of a child with human immunodeficiency virus (HIV) infection regarding immunizations. Which of the following statements, if made by the mother, indicates an understanding of the immunization schedule? Correct! “Family members in the household need to receive the influenza vaccine.” “My child will receive all the vaccines like any other child.” “The hepatitis B vaccine is not to be given to my child.” “Blood tests need to be evaluated before any immunizations are given to my child.” Rationale: A child with HIV infection will receive the same immunizations as other children except for live vaccines. All household members receive the influenza vaccine. “Blood tests need to be evaluated before any immunizations are given to my child.” is not necessary and is inaccurate. Test-Taking Strategy: “Blood tests need to be evaluated before any immunizations are given to my child.” can be easily eliminated. From the remaining options, recalling that inactivated vaccines need to be administered to the child with HIV infection and siblings will assist in eliminating “My child will receive all the vaccines like any other child.” Careful reading of the remaining options will easily direct you to “Family members in the household need to receive the influenza vaccine.” Review immunizations for the immunodeficient child if you had difficulty with this question. Question 49 100 / 100 pts The nurse is preparing to administer an MMR (measles, mumps, and rubella) vaccine to a 15-month-old child. Prior to administering the vaccine, which of the following questions would the nurse ask the mother of the child? “Has the child had any sore throats?” Correct! “Is the child allergic to any antibiotics?” “Has the child been exposed to any infections?” “Has the child been eating properly?” Rationale: Prior to the administration of MMR vaccine, a thorough health history needs to be obtained. MMR is used with caution in a child with a history of an allergy to gelatin, eggs, or neomycin, because the live measles vaccine is produced by chick embryo cell culture and MMR also contains a small amount of the antibiotic neomycin. “Has the child had any sore throats?” “Has the child been eating properly?” and “Has the child been exposed to any infections?” are not contraindications to administering immunizations. Test-Taking Strategy: Knowledge regarding the contraindications related to administering the MMR vaccine is required to answer this question. When thinking about contraindications to this vaccine, think about allergic reactions. Remember that MMR is used with caution in a child with a history of an allergy to gelatin, eggs, or neomycin. If you had difficulty with this question, review the nursing implications related to the administration of MMR. Question 50 100 / 100 pts An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes that the adolescent has swollen lymph nodes. Laboratory test results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse informs the mother of the test results and provides instruction regarding care of the adolescent. Which of the following statements, if made by the mother, indicates an understanding of care measures? “I need to isolate my child so that the respiratory infection is not spread to others.” “I will call the physician if my child is still feeling tired in 1 week.” Correct! “I need to call the physician if my child complains of abdominal pain or left shoulder pain.” “I need to keep my child on bed rest for 3 weeks.” Rationale: The mother needs to be instructed to notify the physician if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs, because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until splenomegaly resolves. Bed rest is not necessary, and children usually self-limit their activity. No isolation precautions are required, although transmission can occur via saliva, close intimate contact, or contact with infected blood. The child may still feel tired in 1 week as a result of the virus. Test-Taking Strategy: Knowledge regarding the organs affected in mononucleosis will assist in answering this question. “I need to keep my child on bed rest for 3 weeks.” and “I need to isolate my child so that the respiratory infection is not spread to others.” can be eliminated first because they are unnecessary interventions in this disease. From the remaining two options, knowledge that splenic rupture is a concern will direct you to “I need to call the physician if my child complains of abdominal pain or left shoulder pain.” Review care to the child with this infection if you had difficulty with this question. Question 51 100 / 100 pts A child is seen in a health care clinic, and a diagnosis of chickenpox is confirmed. The mother expresses concern for two other children at home. She asks the nurse if the child is infectious to the other children. The most appropriate response by the nurse is: “The infectious period occurs after the lesions begin.” “The infectious period is not known, and it is possible that the children may develop the chickenpox.” Correct! “The infectious period begins 1 to 2 days before the onset of the rash to about 5 days after the onset of the lesions and crusting of the lesions.” “The infectious period begins when the lesions begin to crust.” Rationale: The infectious period of chickenpox is 1 to 2 days before the onset of the rash to about 5 days after the onset of the lesions and the crusting of the lesions. “The infectious period occurs after the lesions begin.” “The infectious period begins when the lesions begin to crust.” and “The infectious period is not known, and it is possible that the children may develop the chickenpox.” are inaccurate. Test-Taking Strategy: Knowledge about the infectious period associated with chickenpox is required to answer this question. Option “The infectious period is not known, and it is possible that the children may develop the chickenpox.” can easily be eliminated first because of the words “not known.” For the remaining options, select “The infectious period begins 1 to 2 days before the onset of the rash to about 5 days after the onset of the lesions and crusting of the lesions.” because it is the umbrella option. If you had difficulty with this question, review the infectious period associated with chickenpox. Question 52 100 / 100 pts A client who was receiving enteral feedings in the hospital has been started on a regular diet and is almost ready for discharge. The client will be self-administering supplemental tube feedings between meals for a short time after discharge. When the client expresses concern about his or her ability to perform this procedure at home, the nurse would best respond with which of the following? “Maybe a friend will do the feeding for you.” “Do you want to stay in t