NCLEX Select All That Apply Questions

NCLEX has increasing quantity of alternative format questions, but the one that is challenging for most candidates is the dreaded: “Select All That Apply” format of questions.  The main frustration is that the test candidate does not get credit for the entire question if not all the possible right answers are selected, or adding an option that is not accurate.  So here are some NCLEX Select All That Apply Questions for your practice.

NCLEX Select All That Apply Questions

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Question 1
Patient X is scheduled to undergo cataract extraction with intraocular implant. Which home care measures will the nurse include in planning for care of the patient? Select all that apply
A
To avoid activities that require bending over
B
To place an eye shield on the surgical eye at bedtime
C
To take acetaminophen (Tylenol) for minor eye discomfort
D
To contact the surgeon if a decrease in visual acuity occurs
Question 1 Explanation: 
ANSWER: To avoid activities that require bending over ; To place an eye shield on the surgical eye at bedtime ; To contact the surgeon if a decrease in visual acuity occurs ; To take acetaminophen (Tylenol) for minor eye discomfort ; RATIONALE: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.
Question 2
Kiko is studying to learn how to interpret ECG. When interpreting an ECG, which should he keep in mind about the P wave? Select all that apply.
A
Indicated electrical impulse beginning at the AV node
B
Has duration of normally 0.11 seconds or less
C
Reflects electrical impulse beginning at the SA node
D
Reflects atrial muscle depolarization
Question 2 Explanation: 
ANSWER: Reflects electrical impulse beginning at the SA node ; Reflects atrial muscle depolarization ; Has duration of normally 0.11 seconds or less ; RATIONALE: In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.
Question 3
Mrs Antonio, a patient who has diabetes mellitus is receiving acarbose (Precose). Which of the following should Nurse Gemma instruct? Select all that apply.
A
"Report symptoms such as shortness of breath or tiredness."
B
"Take some form of glucose if hypoglycemia occurs."
C
“Take the medication with each meal."
D
"Side effects include abdominal bloating and flatus."
Question 3 Explanation: 
ANSWER: “Take the medication with each meal." ; "Side effects include abdominal bloating and flatus." ; "Take some form of glucose if hypoglycemia occurs." ; "Report symptoms such as shortness of breath or tiredness." RATIONALE: The mechanism of action of acarbose is a delay in absorption of dietary carbohydrates, thereby reducing the rise in blood glucose after a meal. To accomplish this, the medication must be taken with each meal. Because of its bacterial fermentation of unabsorbed carbohydrates in the colon, side effects such as borborygmus, cramps, abdominal distention, and flatulence can occur. The medication also can affect absorption of iron, leading to symptoms (shortness of breath, tiredness) of anemia.
Question 4
Nurse Fibii is aware the cause of primary cause/s of insomnia is/are. Select all that apply:
A
Chronic stress
B
Severe anxiety
C
Environmental noise
D
Excessive caffeine
Question 4 Explanation: 
ANSWER: Chronic stress ; Excessive caffeine ; Environmental noise ; RATIONALE: Acute or primary insomnia is caused by emotional or physical discomfort not caused by the direct physiologic effects of a substance or a medical condition. Excessive caffeine intake is an example of disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and/or emotional and therefore is related to primary insomnia.
Question 5
Which actions should the nurse take when monitoring a client who is receiving peritoneal dialysis with noted outflow of less than the inflow?
A
Check the peritoneal dialysis system for kinks
B
Reposition the client to his or her side.
C
Check the level of the drainage bag
D
Place the client in good body alignment
Question 5 Explanation: 
ANSWER: Place the client in good body alignment ; Check the level of the drainage bag ; Check the peritoneal dialysis system for kinks ; Reposition the client to his or her side. ; RATIONALE: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.
Question 6
Which of the following clients is/are at risk for fluid volume deficit?
A
The client with cirrhosis
B
The client with decreased kidney function
C
The client with a colostomy
D
The client with congestive heart failure (CHF)
Question 6 Explanation: 
ANSWER: The client with a colostomy ; RATIONALE: Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy. A client with cirrhosis, CHF, or decreased kidney function is at risk for fluid volume excess.
Question 7
Nurse Abby is busy making a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list. Select all that apply.
A
Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.
B
Contact the health care provider if the child complains of numbness or tingling in the extremity.
C
Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold.
D
Keep small toys and sharp objects away from the cast.
Question 7 Explanation: 
ANSWER: Keep small toys and sharp objects away from the cast. ; Contact the health care provider if the child complains of numbness or tingling in the extremity. ; Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. ; RATIONALE: While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside of the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop.
Question 8
Warning signs of cancer should be taught to the client for early diagnosis and prompt diagnosis and treatment. Which of the following are warning signals of cancer? Select all that apply.
A
Sore that healed for 2 weeks
B
Change in wart or mole
C
Lump in breast or elsewhere
D
Fever that lasts for 2 weeks
E
Nagging cough or hoarseness
F
Heavy bleeding during menses
G
Constipation
Question 8 Explanation: 
ANSWER: Change in wart or mole ; Nagging cough or hoarseness ; Lump in breast or elsewhere ; RATIONALE: Warning signs of cancer: • Change in bowel or bladder habits • Sore that doesn’t heal • Lump in breast or elsewhere • Unusual bleeding or discharge • Indigestion or dysphagia • Change in wart or mole • Nagging cough or hoarseness
Question 9
In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?  Select all that apply.
A
Decrease in stool frequency and liquidity
B
Firm skin turgor
C
Absence of erythema in perianal skin and mucous membranes
D
Urine output of at least 30 ml/hour
E
Moist mucous membranes
F
Formed stools at regular intervals
Question 9 Explanation: 
ANSWER: Firm skin turgor ; Moist mucous membranes ; Urine output of at least 30 ml/hour ; RATIONALE: Because of the criteria in the question, FLUID RESUSCITATION, the diagnosis for diarrhea in this case is narrowed to Deficient Fluid Volume related to excessive fluid loss in stool. Thus, fluid resuscitation is needed and expected outcomes of successful intervention include:  Firm skin turgor  Moist mucous membranes  Urine output of at least 30 ml/hr The client also has a nursing diagnosis of diarrhea with the following expected outcomes:  Passage of formed stools at regular intervals  Decrease in stool frequency and liquidity
Question 10
Nurse Via is assigned at the Emergency room and is currently admitting a client with a possible diagnosis of chronic bronchitis. She collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply.
A
Purulent mucus production
B
Mild episodes of dyspnea
C
Early onset cough
D
Marked weight loss
Question 10 Explanation: 
ANSWER: Early onset cough ; Purulent mucus production ; Mild episodes of dyspnea ; RATIONALE: Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea.
Question 11
An infant with a diagnosis of tetralogy of Fallot suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.
A
Prepare to administer morphine sulfate.
B
Prepare to administer 100% oxygen by face mask
C
Notify the registered nurse.
D
Prepare to administer intravenous fluids.
Question 11 Explanation: 
ANSWER: Notify the registered nurse. ; Prepare to administer morphine sulfate. ; Prepare to administer intravenous fluids. ; Prepare to administer 100% oxygen by face mask ; RATIONALE: The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.
Question 12
Nurse Anton is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection?
A
Respiratory
B
Neurological
C
Psychosocial
D
Cardiovascular
Question 12 Explanation: 
ANSWER: Psychosocial ; RATIONALE: The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that would be the priority.
Question 13
Patient X admitted at cubicle has a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation? Select all that apply
A
Metabolic acidosis
B
Respiratory acidosis
C
Respiratory alkalosis
D
Metabolic alkalosis
Question 13 Explanation: 
ANSWER: Metabolic alkalosis ; RATIONALE: The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis.
Question 14
Brent has just underwent surgery for retinal detachment. Which nursing interventions are appropriate for Brent as he recovers? Select all that apply.
A
Administer eye medications.
B
Assist with activities of daily living.
C
Maintain the eye patch or shield.
D
Educate regarding symptoms of retinal detachment.
E
Encourage coughing and deep breathing.
F
Monitor for hemorrhage.
Question 14 Explanation: 
ANSWER: Monitor for hemorrhage. ; Administer eye medications. ; Maintain the eye patch or shield. ; Assist with activities of daily living. ; Educate regarding symptoms of retinal detachment. ; RATIONALE: An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse’s assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.
Question 15
Nurse Isabelle is assigned to care for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. Which of the following protective items will be required to perform colostomy care for this client?
A
Gloves, a gown, and shoe protectors
B
Gloves and goggles
C
Gloves, a gown, and goggles
D
Gloves and a gown
Question 15 Explanation: 
ANSWER: Gloves, a gown, and goggles ; RATIONALE: Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.
Question 16
Nurse Vicky is planning care for a client with ulcerative colitis who is experiencing symptoms. Which of the following client care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply.
A
Evaluating the client’s response to antidiarrheal medications
B
Maintaining intake and output records
C
Obtaining the client’s weight.
D
Providing skin care following bowel movements
Question 16 Explanation: 
ANSWER: Providing skin care following bowel movements ; Maintaining intake and output records ; Obtaining the client’s weight. ; RATIONALE: The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s response to medication are registered nurse activities that cannot be delegated.
Question 17
Patient X is suspected to have hypoglycemia. Identify the signs and symptoms the nurse should expect. Select all that apply.
A
Slurred speech
B
Palpitations
C
Diaphoresis
D
Thirst
Question 17 Explanation: 
ANSWER: Palpitations ; Diaphoresis ; Slurred speech ; RATIONALE: Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed.
Question 18
In the assessment of a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply.
A
The client functions well in other areas of his life.
B
The violent behavior is most often justified by the stressor.
C
The client has a history of parental alcoholism and chaotic, abusive family life
D
The degree of aggressiveness is out of proportion to the stressor.
Question 18 Explanation: 
ANSWER: The client functions well in other areas of his life. ; The degree of aggressiveness is out of proportion to the stressor. ; The client has a history of parental alcoholism and chaotic, abusive family life ; RATIONALE: A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.
Question 19
The doctor has made rounds to a patient who has just undergone thyroidectomy. After the rounds, Nurse Jonathan checks the chart and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to:
A
Prevent cardiac irritability.
B
Treat thyroid storm.
C
Treat hypocalcemic tetany.
D
Stimulate the release of parathyroid hormone.
Question 19 Explanation: 
ANSWER: Treat hypocalcemic tetany.
Question 20
In a ward, which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.
A
A 101-year-old man
B
A client with diabetes mellitus
C
A client on renal dialysis
D
A premature infant
Question 20 Explanation: 
ANSWER: A premature infant ; A 101-year-old man ; A client on renal dialysis ; RATIONALE: Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients
Question 21
When caring for a 3-year-old child, which of the following toys should be provided to the child?
A
A wagon
B
A farm set
C
A puzzle
D
A golf set
Question 21 Explanation: 
ANSWER: A wagon ; RATIONALE: Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. A puzzle with large pieces only may be appropriate. A farm set and a golf set may contain items that the child could swallow.
Question 22
A female patient with a terminal illness is in denial. Indicators of denial include:
A
Shock
B
Preparatory grief
C
Numbness
D
dismay
Question 22 Explanation: 
ANSWER: Shock ; dismay ; RATIONALE: Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.
Question 23
Albie is reading all about internal radiation implant. Which of the following should be included in the plan of care of a patient who has one? Select all that apply.
A
Keeping all linens in the room until the implant is removed
B
Placing the client in a semiprivate room at the end of the hallway
C
Wearing a film (dosimeter) badge when in the client’s room
D
Wearing gloves when emptying the client’s bedpan
E
Wearing a lead apron when providing direct care to the client
Question 23 Explanation: 
ANSWER: Wearing gloves when emptying the client’s bedpan ; Keeping all linens in the room until the implant is removed ; Wearing a film (dosimeter) badge when in the client’s room ; Wearing a lead apron when providing direct care to the client ; RATIONALE: A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device.
Question 24
Which medications should Nurse Ella expect in the treatment of the client with heart failure? Select all that apply.
A
Phosphodiesterase (PDE) inhibitors
B
Angiotensin-converting enzyme (ACE) inhibitors
C
Cardiac glycosides
D
Anticholinergics
Question 24 Explanation: 
ANSWER: Cardiac glycosides ; Phosphodiesterase (PDE) inhibitors ; Angiotensin-converting enzyme (ACE) inhibitors ; RATIONALE: Medications recommended for treatment of heart failure include diuretics, cardiac glycosides such as digoxin (Lanoxin), PDE inhibitors, and ACE inhibitors. Clients in heart failure do not need anticoagulants or anticholinergics.
Question 25
Nurse Vivien is assigned to monitor a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. Which of the following are specific signs of Preeclampsia (select all that apply)?
A
Elevated blood pressure
B
Negative urinary protein
C
Facial edema
D
Increased respirations
Question 25 Explanation: 
ANSWER: Elevated blood pressure ; Facial edema ; RATIONALE: The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia.
Question 26
When preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant, which home care measures will the nurse include in the plan? Select all that apply.
A
To place an eye shield on the surgical eye at bedtime
B
That episodes of sudden severe pain in the eye is expected
C
To contact the surgeon if eye scratchiness occurs
D
To take acetaminophen (Tylenol) for minor eye discomfort
E
To contact the surgeon if a decrease in visual acuity occurs
F
To avoid activities that require bending over
Question 26 Explanation: 
ANSWER: To avoid activities that require bending over ; To place an eye shield on the surgical eye at bedtime ; To contact the surgeon if a decrease in visual acuity occurs ; To take acetaminophen (Tylenol) for minor eye discomfort ; RATIONALE: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.
Question 27
Human cancers are majorly related to environmental carcinogens. Physical environmental carcinogens include which of the following. Select all that apply.
A
Cigarette smoking
B
X-rays
C
Alkylating agents
D
Ultraviolet rays
E
Trauma
Question 27 Explanation: 
ANSWER: Trauma ; Ultraviolet rays ; X-rays ; RATIONALE: Majority (over 80%) of human cancers related to environmental carcinogens. The types of environmental carcinogens are: Physical • Radiation: x-rays, radium, nuclear explosion or waste, UV • Trauma or chronic irritation Chemical • Nitrites and food additives, alkylating agents • Drugs: arsenicals, stilbesterol • Cigarrete smoke • Hormones
Question 28
Albert is on his 2nd day of duty as a student nurse in the ICU. Today, he is assigned to a patient with nasogastric tube that is attached to low suction. The client should be closely monitored for which acid-base disorder that is most likely to occur in this situation?
A
Respiratory alkalosis
B
Metabolic acidosis
C
Metabolic alkalosis
D
Respiratory acidosis
Question 28 Explanation: 
ANSWER: Metabolic alkalosis ; RATIONALE: The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis
Question 29
Nurse Venice is reviewing the report of a client’s routine urinalysis. Which value are normal findings?
A
Specific gravity of 1.03
B
Urine pH of 3.0
C
Absence of glucose
D
Absence of protein
Question 29 Explanation: 
ANSWER: Specific gravity of 1.03 ; Absence of protein ; Absence of glucose ; RATIONALE: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this client’s value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, its color ranging from pale yellow to deep amber.
Question 30
Albert is a nurse lawyer and provides an education session to the nursing staff regarding client rights. A nurse asks the lawyer to describe an example that may relate to invasion of client privacy. A nursing action that indicates a violation of this right is:
A
Threatening to place a client in restraints
B
Taking photographs of the client without consent
C
Performing a surgical procedure without consent
D
Telling the client that he or she cannot leave the hospital
Question 30 Explanation: 
ANSWER: Taking photographs of the client without consent ; RATIONALE: Invasion of privacy takes place when an individual's private affairs are intruded on unreasonably. Threatening to place a client in restraints constitutes assault. Performing a surgical procedure without consent is an example of battery. Not allowing a client to leave the hospital constitutes false imprisonment.
Question 31
Four clients are assigned to Nurse Paul today. When planning client rounds, which client/s would the he prioritize and check first?
A
A client admitted on the previous shift who has a diagnosis of gastroenteritis
B
A client on a ventilator
C
A postoperative client preparing for discharge
D
A client in skeletal traction
Question 31 Explanation: 
ANSWER: A client on a ventilator ; RATIONALE: The airway is always a high priority, and the nurse first checks the client on a ventilator. The clients described in options 2, 3, and 4 have needs that would be identified as intermediate priorities.
Question 32
Nurse Vicky is reinforcing instructions to the mother of a child who has been hospitalized with croup. Which of the following statements, if made by the mother, would indicate the need for further instruction?
A
"During an attack, I will take my child to a cool location."
B
"I will be sure that my child drinks at least three to four glasses of fluids every day."
C
"I will give acetaminophen (Tylenol) if my child develops a fever."
D
"I will give my child cough syrup if a cough develops."
Question 32 Explanation: 
ANSWER: "I will give my child cough syrup if a cough develops." ; RATIONALE: Cough syrups and cold medicines are not to be given, because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions.
Question 33
Hillary, a student nurse, heard the staff nurse report that a client has a positive Chvostek's sign. What other data would the nurse expect to find on data collection? Select all that apply.
A
Diarrhea
B
Possible seizure activity
C
Hypoactive bowel sounds
D
Positive Trousseau's sign
Question 33 Explanation: 
ANSWER: Diarrhea ; Possible seizure activity ; Positive Trousseau's sign ; RATIONALE: A positive Chvostek's sign is indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, seizures, positive Trousseau's sign, diarrhea, hyperactive bowel sounds, and a prolonged QT interval.
Question 34
Which data indicates to the nurse that a client may be experiencing ineffective coping? Select all that apply
A
Visits her husband's grave once a month
B
Frequently looks at snapshots of her husband and family
C
Visits the senior citizens' center once a month
D
Constantly neglects personal grooming
Question 34 Explanation: 
ANSWER: Constantly neglects personal grooming ; RATIONALE: Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual, physically, psychologically, or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process. The remaining options identify effective coping behaviors.
Question 35
A client with a T5 complete spinal cord injury is admitted at the Private Pavilionand is being assessed by the Nurse on duty. The nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.
A
Elevate the HOB to 90 degrees
B
Loosen constrictive clothing
C
Use a fan to reduce diaphoresis
D
Assess for bladder distention and bowel impaction
Question 35 Explanation: 
ANSWER: Elevate the HOB to 90 degrees ; Loosen constrictive clothing ; Assess for bladder distention and bowel impaction ; RATIONALE: The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.
Question 36
As a nurse discharge planner preparing your patient for discharge from acute care, you assess that home care services are clinically indicated. Your assessment is based on all of the following indicators except:
A
your patient's family will be there to care for him 24 hours/day.
B
your patient is ordered to continue IV antibiotics 5 days post discharge.
C
your patient has a Foley catheter.
D
your patient has been admitted to the hospital three times in the last two months.
Question 36 Explanation: 
ANSWER: your patient's family will be there to care for him 24 hours/day. ; RATIONALE: c. 24-hour family availability to provide care and assistance is not an indicator for home care. In fact, the nurse might see some opportunity for family education in meeting the patient's needs so that less community support may be needed. This would need to be negotiated with the family. Frequent hospital readmissions imply that the patient has not been able to manage either due to condition instability or lack of care needs being met. This would be a red flag for home care services to be able to meet those needs and appropriately monitor the patient. A Foley catheter is an indication for home healthcare due to infection potential and care requirements. IV antibiotics involve home care due to maintaining line patency and assessment of the site.
Question 37
Tonight Earl is studying about Graves’ disease and the signs of thyrotoxicosis (thyroid storm). Which of the following signs and symptoms, if noted in a client diagnosed with such, will alert the nurse to the presence of this crisis? Select all that apply.
A
Bradycardia
B
Fever
C
Agitation
D
Sweating
E
Pallor
Question 37 Explanation: 
ANSWER: Fever ; Sweating ; Agitation ; RATIONALE: Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body’s tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.
Question 38
Nurse Bea is scanning through the charts and notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.
A
Maintaining a low-sodium diet
B
Monitoring extremities for edema
C
Maintaining a low-potassium diet
D
Monitoring intake and output
Question 38 Explanation: 
ANSWER: Monitoring intake and output ; Monitoring extremities for edema ; Maintaining a low-sodium diet ; RATIONALE: The client with Cushing's syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.
Question 39
A primary excess of carbonic acid in the extracellular fluid leading to decreased in pH, elevated pCO2 and bicarbonate (if renal compensation is present) is caused by which of the following. Select all that apply.
A
Diarrhea
B
COPD
C
Guillain-Barre syndrome
D
Weakness of respiratory muscles
E
Hyperventilation
F
Mechanical overventilation
G
Barbiturate or sedative overdose
Question 39 Explanation: 
ANSWER: COPD ; Guillain-Barre syndrome ; Barbiturate or sedative overdose ; Weakness of respiratory muscles ; RATIONALE: Respiratory Acidosis, a primary excess of carbonic acid in the extracellular fluid leading to decreased in pH, elevated pCO2 and bicarbonate (if renal compensation is present), may be caused by: • COPD • Barbiturate or sedative overdose • Acute airway obstruction • Weakness of respiratory muscles • Guillain-Barre syndrome
Question 40
Patient X who has leukemia has been noted to have poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?
A
Dry mucous membranes
B
Postural blood pressure changes
C
Slow bounding pulse
D
Intense thirst
Question 40 Explanation: 
ANSWER: Postural blood pressure changes ; RATIONALE: Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.
Question 41
Nurse Ava is assigned to collect data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply.
A
Increased incidence of awakening after sleep onset
B
Decline in visual acuity
C
Increased susceptibility to urinary tract infections
D
Decreased respiratory rate
Question 41 Explanation: 
ANSWER: Decline in visual acuity ; Increased susceptibility to urinary tract infections ; Increased incidence of awakening after sleep onset ; RATIONALE: Anatomical changes to the eye affect the individual's visual ability, which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases, and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Changes in sleep patterns are consistent, age-related changes. Older persons experience an increased incidence of awakening after sleep onset.
Question 42
The Health Insurance Portability and Accountability Act (HIPAA) protects the
A
patient’s need to have liability insurance
B
patient’s right to refuse treatment
C
patient from third-party payers
D
patient’s medical and health information
Question 42 Explanation: 
ANSWER: patient’s medical and health information ; RATIONALE: a. The Act is a federal privacy standard that protects the patient’s medical records and other identifiable health information. The Act requires confidentiality and ensures the privacy of patients.
Question 43
Nurse Gina is about to receive a patient who has just undergone a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.
A
With extreme hip flexion
B
In a semi-Fowler's position
C
Supine on the left side
D
With the head in a midline position
Question 43 Explanation: 
ANSWER: In a semi-Fowler's position ; With the head in a midline position ; RATIONALE: Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.
Question 44
Norie is tasked by the Clinical instructor to assist the staff nurse assigned to patient X who has sustained an injury from a house fire. According to his folks, the client attempted to save a neighbor involved in the fire but, in spite of the client’s efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?
A
Identifying the client’s potential for self-harm
B
Inquiring about the client’s feelings that may affect coping
C
Identifying the client’s ability to function
D
Inquiring about the client’s perception of the cause of the neighbor’s death
Question 44 Explanation: 
ANSWER: Inquiring about the client’s feelings that may affect coping ; RATIONALE: The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client’s feelings. Options 1, 2, and 4 do not directly address the client’s feelings.
Question 45
A patient who is due for discharge was given a prescription for nifedipine (Adalat) for blood pressure management. In the discharge teaching plan, which instructions should the nurse include? Select all that apply.
A
"Palpitations may occur early in therapy."
B
"Be careful when rising from sitting to standing."
C
"Take pulse rate each day."
D
"Weigh at the same time each day."
Question 45 Explanation: 
ANSWER: "Take pulse rate each day." ; "Weigh at the same time each day." ; "Palpitations may occur early in therapy." ; "Be careful when rising from sitting to standing." ; RATIONALE: Nifedipine is a calcium-channel blocker. Its therapeutic outcome is to decrease blood pressure. Its method of action is blockade of the calcium channels in vascular smooth muscle, promoting vasodilation. Side effects that can occur early in therapy include reflex tachycardia (palpitations) and first-dose hypotension, leading to orthostatic hypotension. Weight should be checked regularly to monitor for early signs of heart failure. Also the client is taught to take his or her own pulse. Nifedipine does not affect serum calcium levels. Increased water intake is not indicated in the client with cardiovascular disease.
Question 46
Nurse James is conducting health teaching to a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications?
A
A 60-year-old male client with rhinitis
B
A 24-year-old male client with a lower back injury
C
A 45-year-old female client with a history of migraine headaches
D
A 10-year-old female client with a urinary tract infection
Question 46 Explanation: 
ANSWER: A 10-year-old female client with a urinary tract infection ; RATIONALE: Children should not be given herbal therapies, especially in the home and without professional supervision. There are no general contraindications for the clients described in options 1, 2, and 4.
Question 47
All of the following support the nurse as a patient advocate except:
A
ANA Code of Ethics for Nurses.
B
institutional review boards for the protection of human subjects engaged in research.
C
federal nurse practice acts.
D
JCAHO.
Question 47 Explanation: 
ANSWER: federal nurse practice acts. ; RATIONALE: c. Nurse practice acts are based in state law, not federal law, as mandated for the advocacy of nurses; JCAHO, ANA, and institutional review boards all support nurse advocacy.
Question 48
In collecting data on a client with severe preeclampsia, which findings should be noted? Select all that apply.
A
Muscle cramps
B
Proteinuria 3+
C
Contractions
D
Oliguria
Question 48 Explanation: 
ANSWER: Oliguria ; Proteinuria 3+ ; Muscle cramps ; RATIONALE: Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.
Question 49
Which of the following nursing actions should be implemented in the plan of care for chemotherapy administration in a client with a central venous line? Select all that apply.
A
Inspect the insertion site for swelling, erythema, or drainage
B
If unable to aspirate blood, reposition the client and encourage the client to cough.
C
Verify patency of the line by the presence of a blood return at regular intervals.
D
Contact the health care provider about verifying placement if the status is questionable.
Question 49 Explanation: 
ANSWER: Verify patency of the line by the presence of a blood return at regular intervals. ; Inspect the insertion site for swelling, erythema, or drainage ; If unable to aspirate blood, reposition the client and encourage the client to cough. ; Contact the health care provider about verifying placement if the status is questionable. ; RATIONALE: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.
Question 50
Nurse Rachelle is on duty at the medical ward and is assigned to care for a client with a peripheral IV infusion. When providing hygiene care to the client, which should she avoid while changing the client's hospital gown?
A
Using a hospital gown with snaps at the sleeves
B
Putting the bag and tubing through the sleeve, followed by the client's arm
C
Checking the IV flow rate immediately after changing the hospital gown
D
Disconnecting the IV tubing from the catheter in the vein
Question 50 Explanation: 
ANSWER: Disconnecting the IV tubing from the catheter in the vein ; RATIONALE: The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection. Options 1 and 4 are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change.
Question 51
Nurse Kina is collecting data on a client with severe preeclampsia, which of the following findings would be noted in severe preeclampsia. Select all that apply.
A
Proteinuria 3+
B
Muscle cramps
C
Seizures
D
Oliguria
E
Blood pressure 168/116 mm Hg
F
Contractions
Question 51 Explanation: 
ANSWER: Oliguria ; Proteinuria 3+ ; Blood pressure 168/116 mm Hg ; RATIONALE: Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.
Question 52
Nurse Allan is currently on her 2nd duty for the week at the Emergency room and is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply.
A
Early onset cough
B
Marked weight loss
C
Scant mucus
D
Purulent mucus production
E
Mild episodes of dyspnea
Question 52 Explanation: 
ANSWER: Early onset cough ; Purulent mucus production ; Mild episodes of dyspnea ; RATIONALE: Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea.
Question 53
A patient who hasileal conduit has been ordered for discharge. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply
A
“I can usually keep my ostomy pouch on for 3 to 7 days before changing it.”
B
“I can place an aspirin tablet in my pouch to decrease odor.”
C
“I must use a skin barrier to protect my skin from urine.”
D
“I should empty my ostomy pouch of urine when it is full.”
Question 53 Explanation: 
ANSWER: “I can usually keep my ostomy pouch on for 3 to 7 days before changing it.” ; “I must use a skin barrier to protect my skin from urine.” ; RATIONALE: The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.
Question 54
In a group of clients for acid-base imbalances, which clients are at highest risk for metabolic acidosis? Select all that apply.
A
Malnourished client
B
Diabetic mellitus client
C
Asthma client
D
Renal failure client
Question 54 Explanation: 
ANSWER: Diabetic mellitus client ; Malnourished client ; Renal failure client ; RATIONALE: Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1, 2, and 5 are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis.
Question 55
When it comes to clients for acid-base imbalances, which clients are at highest risk for metabolic acidosis? Select all that apply.
A
Diabetic mellitus client
B
Malnourished client
C
Pneumonia client
D
Asthma client
E
Severely anxious client
F
Renal failure client
Question 55 Explanation: 
ANSWER: Diabetic mellitus client ; Malnourished client ; Renal failure client ; RATIONALE: Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1, 2, and 5 are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis.
Question 56
In assistingan adult client to sleep better, Nurse Giorecommends which of the following? (Select all that apply.)
A
Consuming a small glass of warm milk at bedtime
B
Drinking a glass of wine just before retiring to bed
C
Eating a large meal 1 hour before bedtime
D
Performing mild exercises 30 minutes before going to bed
Question 56 Explanation: 
ANSWER: Consuming a small glass of warm milk at bedtime ; RATIONALE: A small glass of milk relaxes the body and promotes sleep.
Question 57
Mrs. Johnson who has been diagnosed with acute renal failure is undergoing dialysis for the first time. The nurse in charge monitors the client closely for dialysis equilibrium syndrome, a complication that is most common during the first few dialysis sessions. Typically, dialysis equilibrium syndrome causes:
A
confusion, , and.
B
headache
C
seizures
D
acute bone pain
Question 57 Explanation: 
ANSWER: confusion, , and. ; headache. ; seizures ; RATIONALE ; Dialysis equilibrium syndrome causes confusion, a decreasing level of consciousness, headache, and seizures. These findings, which may last several days, probably result from a relative excess of interstitial or intracellular solutes caused by rapid solute removal from the blood. The resultant organ swelling interferes with normal physiologic functions. To prevent this syndrome, many dialysis centers keep first-time sessions short and use a reduced blood flow rate. Acute bone pain and confusion are associated with aluminum intoxication, another potential complication of dialysis. Weakness, tingling, and cardiac arrhythmias suggest hyperkalemia, which is associated with renal failure. Hypotension, tachycardia, and tachypnea signal hemorrhage, another dialysis complication
Question 58
Which of the following nursing interventions are written correctly? (Select all that apply.)
A
Perform neurovascular checks.
B
Elevate head of bed 30 degrees before meals.
C
Change dressing once a shift
D
Apply continuous passive motion machine during day.
Question 58 Explanation: 
ANSWER: Elevate head of bed 30 degrees before meals. ; RATIONALE: It is specific in what to do and when.
Question 59
A client has been suspected with air embolism. Which clinical manifestations are expected of this client? Select all that apply.
A
Rise in venous pressure
B
Swelling at the site
C
Cyanosis
D
Edema
E
Tachycardia
F
Coldness at the site
G
Unconsciousness
H
Hypertension
Question 59 Explanation: 
ANSWER: Cyanosis ; Tachycardia; Unconsciousness ; Rise in venous pressure ; RATIONALE: In air embolism the expected clinical manifestations are cyanosis, hypotension, tachycardia, rise in venous pressure and unconsciousness.
Question 60
Nurse Mia is caring for a 6-year-old child with leukemia who is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply.
A
Encourage the consumption of fresh fruits and vegetables.
B
Change dressings using sterile technique.
C
Perform meticulous hand washing before caring for the child
D
Place the child on a low-bacteria diet.
Question 60 Explanation: 
ANSWER: Place the child on a low-bacteria diet. ; Change dressings using sterile technique. ; Perform meticulous hand washing before caring for the child ; RATIONALE: For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed with sterile technique. Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child’s room. Meticulous hand washing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy).
Question 61
Clary is observing as the staff nursecares for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.
A
On the left side
B
With the neck flexed
C
Supine on the left side
D
In a semi-Fowler’s position
E
With the head in a midline position
F
With extreme hip flexion
Question 61 Explanation: 
ANSWER: In a semi-Fowler’s position ; With the head in a midline position ; RATIONALE: Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.
Question 62
Nurse Olive is performing assessment to a patient who has pneumonia. Which of the following would be priority assessment data to gather? Select all that apply.
A
Auscultation of breath sounds
B
Presence of peripheral edema
C
Color of nail beds
D
Presence of chest pain.
Question 62 Explanation: 
ANSWER: Presence of chest pain. ; Color of nail beds ; Auscultation of breath sounds ; RATIONALE: A respiratory assessment, which includes auscultation of breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultate bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.
Question 63
When providing hygiene care to a client with a peripheral IV infusion, which of the following should the nurse avoid while changing the client’s hospital gown?
A
Using a hospital gown with snaps at the sleeves
B
Putting the bag and tubing through the sleeve, followed by the client’s arm
C
Checking the IV flow rate immediately after changing the hospital gown
D
Disconnecting the IV tubing from the catheter in the vein
Question 63 Explanation: 
ANSWER: Disconnecting the IV tubing from the catheter in the vein ; RATIONALE: The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection. Options 1 and 4 are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change.
Question 64
The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client’s teaching plan? Select all that apply.
A
Headache
B
Visual disturbance
C
Orthopnea
D
Gout
Question 64 Explanation: 
ANSWER: Visual disturbance ; Headache ; Orthopnea ; Gout ; RATIONALE: Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.
Question 65
Genetic inheritance and environmental influence are two primary factors affecting growth and development. Genetic influences on a child’s pattern of growth and development includes which of the following? Select all that apply.
A
Ordinal position in the family
B
Temperament
C
Nutrition
D
Intelligence
E
Health
F
Gender
Question 65 Explanation: 
ANSWER: Gender. ; Health ; Temperament ; Intelligence ; RATIONALE: On average girls are born lighter and shorter than boys. A child who inherits a genetically transmitted disease may not grow as rapidly or develop fully as a healthy child, depending on the type of illness and the therapy or care available for the disease. Children with high intelligence do not generally grow faster than other children, but they do tend to advance faster in skills. Temperament is an inborn characteristic set at birth.
Question 66
Which of the following suggests that a client is experiencing insomnia (select all that apply)
A
Feeling tired after a night’s sleep
B
Difficulty staying asleep
C
Extended time to fall asleep
D
Falling asleep at inappropriate times
Question 66 Explanation: 
ANSWER: Extended time to fall asleep ; Difficulty staying asleep ; Feeling tired after a night’s sleep ; RATIONALE: These symptoms are often reported by clients with insomnia. Clients report nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia.
Question 67
Patient X is diagnosed with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus and is on contact precautions. As nurse Mike prepares to provide colostomy care to the client, which of the following protective items will be required to perform this procedure?
A
Gloves and a gown
B
Gloves, a gown, and goggles
C
Gloves and goggles
D
Gloves, a gown, and shoe protectors
Question 67 Explanation: 
ANSWER: Gloves, a gown, and goggles ; RATIONALE: Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.
Question 68
Nurse Lovely is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides to the client. Select all that apply.
A
Wash the stoma daily using a washcloth.
B
Soaps should be avoided near the stoma.
C
Protect the stoma from water.
D
Use diluted alcohol on the stoma to clean it.
Question 68 Explanation: 
ANSWER: Protect the stoma from water. ; Soaps should be avoided near the stoma. ; Wash the stoma daily using a washcloth. ; RATIONALE: The client with a stoma should be instructed to wash the stoma daily with a washcloth. Soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. The client should be instructed to avoid applying alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum jelly applied to the skin around the stoma helps prevent cracking. The client is instructed to protect the stoma from water.
Question 69
A nurse would use surgical asepsis at the client’s bedside in the following situations. (Select all that apply.)
A
Inserting a urinary catheter
B
Applying a sterile dressing
C
Suctioning the oropharynx and trachea
D
Inserting an IV
Question 69 Explanation: 
ANSWER: Inserting an IV ; Applying a sterile dressing ; Inserting a urinary catheter ; Suctioning the oropharynx and trachea ; RATIONALE: a. c, d. The cavities are considered sterile; sterile technique is required to not introduce microorganisms into the client’s body. b. The application of a sterile dressing requires a sterile field to not introduce microorganisms.
Question 70
Nurse Vina is assigned to care for a client recovering from surgery for retinal detachment. Which of the following interventions are appropriate Select all that apply.
A
Maintain the eye patch or shield.
B
Administer eye medications.
C
Assist with activities of daily living.
D
Monitor for hemorrhage.
Question 70 Explanation: 
ANSWER: Monitor for hemorrhage. ; Administer eye medications. ; Maintain the eye patch or shield. ; RATIONALE: An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse's assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.
Question 71
The intent of the Patient Self Determination Act (PSDA) of 1990 is to:
A
emphasize patient education.
B
enhance personal control over legal care decisions.
C
give one federal standard for living wills and durable powers of attorney.
D
encourage medical treatment decision making prior to need.
Question 71 Explanation: 
ANSWER: encourage medical treatment decision making prior to need. ; RATIONALE: b.The purpose of the PSDA is to promote decision making prior to need. The focus of the PSDA is healthcare decision making. A federal standard for advance directives does not exist. Each state has jurisdiction regarding these policies and protocols. The PSDA emphasizes the need for patient education in order to support an individual's treatment decisions.
Question 72
An advance directive is a legal document that allows an individual to express his/her wishes prior to the health care situation occurring. The two most common advance directives are:
A
living will and durable power of attorney
B
Nurse Practice Act and licensure
C
Patient’s Bill of Rights and standards of care
D
informed consent and confidentiality
Question 72 Explanation: 
ANSWER: living will and durable power of attorney ; RATIONALE: a. A living will provides for an individual’s preferences around end-of-life care; durable power of attorney designates a substitute decision maker for health care and medical decisions should the individual not be able to decide.
Question 73
Which of the following are advantages of the case management nursing care delivery system? (Select all that apply.)
A
is cost effective
B
is time consuming
C
increases quality of care
D
promotes multidisciplinary team collaboration
Question 73 Explanation: 
ANSWER: promotes multidisciplinary team collaboration ; is cost effective ; increases quality of care ; RATIONALE: a. An advantage of the case management model is that it promotes a collaborative process for quality cost-effective outcomes; it is a process of interactions within health care network, which enables a client to receive needed services. b. An advantage of the case management model is that outcomes result in more effective use of services and lessen costs. c. A principal advantage of the case management model is the client receives more services and has fewer unmet needs.
Question 74
The potential effectiveness of a decision depends on which of the following? (Select all that apply.)
A
personal value system of the decision maker
B
selling the decision
C
defensibility of the decision
D
kind of data used in making the decision
Question 74 Explanation: 
ANSWER: personal value system of the decision maker ; kind of data used in making the decision ; defensibility of the decision ; selling the decision ; RATIONALE: a. Many factors enter into the ability for problem identification; one factor that can influence problem identification is the decision maker’s personal value system. b. The generation of alternatives; if good alternatives are not generated, a good decision cannot be made. c. Can the decision maker support the outcome(s) and explain why the particular alternative was chosen if she/he had to support the decision to colleagues and nursing administration. d. Acceptance of the decision by those who will be affected by it is a key component to not having the decision fail.
Question 75
When caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate, which of the following interventions should be included in the care for the client.
A
Notify the physician if urinary output is less than 30 ml per hour.
B
Keep calcium gluconate on hand in case of a magnesium sulfate overdose
C
Monitor deep tendon reflexes hourly
D
Monitor renal function and cardiac function closely
Question 75 Explanation: 
ANSWER: Monitor renal function and cardiac function closely ; Keep calcium gluconate on hand in case of a magnesium sulfate overdose ; Monitor deep tendon reflexes hourly ; Notify the physician if urinary output is less than 30 ml per hour. ; RATIONALE: When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.
Question 76
Nurse Julius is assigned to care for a client with Graves' disease and is monitoring for signs of thyrotoxicosis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Select all that apply.
A
Agitation
B
Sweating
C
Bradycardia
D
Fever
Question 76 Explanation: 
ANSWER: Fever ; Sweating ; Agitation ; RATIONALE: Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.
Question 77
It’s another busy day at the hospital and Nurse Jensen is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply
A
The hair should be washed the evening before the test.
B
Tea and coffee are restricted on the day of the test.
C
The test will take between 45 minutes and 2 hours.
D
All medications need to be withheld on the day of the test.
Question 77 Explanation: 
ANSWER: Tea and coffee are restricted on the day of the test. ; The test will take between 45 minutes and 2 hours. ; The hair should be washed the evening before the test. ; RATIONALE: Pre-procedure instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test, and gels, hairsprays, and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test.
Question 78
Which of the following signs and symptoms would the nurse expect the child with a brain tumor to demonstrate? Select all that apply.
A
Polydipsia
B
Head tilt
C
Lethargy
D
Vomiting
Question 78 Explanation: 
ANSWER: Head tilt ; Vomiting ; Lethargy ; RATIONALE: Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.
Question 79
Kobe is reading about internal radiation implant. In caring for a patient with this case, which of the following should be included in the plan of care? Select all that apply
A
Wearing a lead apron when providing direct care to the client
B
Wearing gloves when emptying the client's bedpan
C
Keeping all linens in the room until the implant is removed
D
Wearing a film (dosimeter) badge when in the client's room
Question 79 Explanation: 
ANSWER: Wearing gloves when emptying the client's bedpan ; Keeping all linens in the room until the implant is removed ; Wearing a film (dosimeter) badge when in the client's room ; Wearing a lead apron when providing direct care to the client ; RATIONALE: A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device.
Question 80
Which home care measures should Nurse Emma include in the teaching plan of a client who is undergoing cataract extraction with intraocular implant? Select all that apply.
A
To place an eye shield on the surgical eye at bedtime
B
To take acetaminophen (Tylenol) for minor eye discomfort
C
To contact the surgeon if a decrease in visual acuity occurs
D
That episodes of sudden severe pain in the eye is expected
Question 80 Explanation: 
ANSWER: To place an eye shield on the surgical eye at bedtime ; To contact the surgeon if a decrease in visual acuity occurs ; To take acetaminophen (Tylenol) for minor eye discomfort ; RATIONALE: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.
Question 81
A patient with diabetic ketoacidosis is admitted and the nurse assigned documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse most likely observe?
A
Respirations that are abnormally deep, regular, and increased in rate
B
Respirations that are labored and increased in depth and rate
C
Respirations that cease for several seconds
D
Respirations that are regular but abnormally slow
Question 81 Explanation: 
ANSWER: Respirations that are abnormally deep, regular, and increased in rate ; RATIONALE: Kussmaul’s respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.
Question 82
Nurse Jimmy is assigned to conduct health teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? Select all that apply.
A
Tuck pant legs into socks.
B
Wear closed shoes when hiking.
C
Apply insect repellent containing DEET.
D
Cover the ground with a blanket when sitting.
Question 82 Explanation: 
ANSWER: Tuck pant legs into socks. ; Wear closed shoes when hiking. ; Apply insect repellent containing DEET. ; Cover the ground with a blanket when sitting. ; RATIONALE: Measures to prevent tick bites focus on covering the body as completely as possible and spraying insect repellent containing DEET on the skin and clothing. Long sleeves and pants tucked into the socks along with closed shoes will offer some protection. Light-colored clothing should be worn so that ticks would be easily visible. Hikers should not sit directly on the ground and should cover the ground with an item such as a blanket. Ticks should be removed with tweezers.
Question 83
Nurse Israel is assigned to a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.
A
Impaired Gas Exchange
B
Activity Intolerance
C
Excess Fluid Volume
D
Imbalanced Nutrition; Less than Body Requirements
Question 83 Explanation: 
ANSWER: Excess Fluid Volume ; Imbalanced Nutrition; Less than Body Requirements ; Activity Intolerance ; RATIONALE: Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.
Question 84
Which home care measures should the nurse include in the teaching plan of a client who is undergoing cataract extraction with intraocular implant? Select all that apply.
A
To place an eye shield on the surgical eye at bedtime
B
To contact the surgeon if a decrease in visual acuity occurs
C
That episodes of sudden severe pain in the eye is expected
D
To contact the surgeon if eye scratchiness occurs
E
To take acetaminophen (Tylenol) for minor eye discomfort
F
To avoid activities that require bending over
Question 84 Explanation: 
ANSWER: To avoid activities that require bending over ; To place an eye shield on the surgical eye at bedtime ; To contact the surgeon if a decrease in visual acuity occurs ; To take acetaminophen (Tylenol) for minor eye discomfort ; RATIONALE: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.
Question 85
Carl is reading about SIDS tonight. According to what he has read, in order to prevent sudden infant death syndrome (SIDS) the best position to place the baby after nursing is (select all that apply):
A
Prone
B
Side-lying
C
Fowler’s
D
Supine
Question 85 Explanation: 
ANSWER: Side-lying ; Fowler’s ; RATIONALE: Research demonstrate that the occurrence of SIDS is reduced with these two positions.
Question 86
An African-American client is admitted to the ambulatory care unit and is being scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection?
A
Respiratory
B
Cardiovascular
C
Psychosocial
D
Neurological
Question 86 Explanation: 
ANSWER: Psychosocial ; RATIONALE: The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that would be the priority.
Question 87
Which of the following are uses of barbiturates in treating insomnia. Select all that apply:
A
When the barbiturates are discontinued, the REM sleep increases
B
When the barbiturates are discontinued, the NREM sleep increases
C
Barbiturates deprive people of REM sleep
D
Nightmares are often an adverse effect when discontinuing barbiturates
Question 87 Explanation: 
ANSWER: Barbiturates deprive people of REM sleep ; When the barbiturates are discontinued, the REM sleep increases ; Nightmares are often an adverse effect when discontinuing barbiturates ; RATIONALE: Barbiturates deprive people of REM sleep. When the barbiturate is stopped and REM sleep once again occurs, a rebound phenomenon occurs. During this phenomenon, the persons dream time constitutes a larger percentage of the total sleep pattern, and the dreams are often nightmares.
Question 88
Nurse Rene is caring for a patient who is suspected to have polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply:
A
Increased clotting time.
B
Hypertension.
C
Headaches
D
Weight loss.
Question 88 Explanation: 
ANSWER: Increased clotting time. ; Hypertension. ; Headaches ; RATIONALE: Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, and visual disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. Weight loss is not a manifestation of polycythemia vera.
Question 89
A female client is scheduled to undergo hemodialysis. Which of the following drugs can be allowed to be administered before this procedure?
A
Antibiotics
B
Cardiac glycosides
C
Phosphate binders
D
Insulin
Question 89 Explanation: 
ANSWER: Phosphate binders ; Insulin ; Antibiotics ; RATIONALE: Phosphate binders and insulin can be administered because they aren’t removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis.Cardiac glycosides such as digoxin should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digitalis toxicity.
Question 90
Mr. Adams is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation? Select all that apply.
A
Prothrombin time
B
Partial thromboplastin time.
C
Platelet count
D
Complete Blood Count
Question 90 Explanation: 
ANSWER: Partial thromboplastin time. ; Platelet count ; Prothrombin time ; RATIONALE: Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation.
Question 91
Nurse Rio is assigned to care for a patient who has central venous line. Which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply
A
Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
B
If unable to aspirate blood, reposition the client and encourage the client to cough.
C
Verify patency of the line by the presence of a blood return at regular intervals.
D
Inspect the insertion site for swelling, erythema, or drainage.
Question 91 Explanation: 
ANSWER: Verify patency of the line by the presence of a blood return at regular intervals. ; Inspect the insertion site for swelling, erythema, or drainage. ; If unable to aspirate blood, reposition the client and encourage the client to cough. ; RATIONALE: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.
Question 92
You are working in the ER when an unconscious multiple trauma victim is admitted. You know that:
A
his girlfriend can give consent when his parents cannot be reached.
B
emergency surgery may be completed if deemed necessary by two attending physicians when a patient is unable to give consent and the next of kin cannot be reached.
C
consent must be obtained from the next of kin, so the patient must wait for surgery.
D
you must wake the patient and obtain consent for surgery.
Question 92 Explanation: 
ANSWER: emergency surgery may be completed if deemed necessary by two attending physicians when a patient is unable to give consent and the next of kin cannot be reached. ; RATIONALE: a. Standards of practice and many state laws support the initiation of emergency surgery if deemed necessary by two attending physicians when a patient is unable to give consent and the next of kin is unavailable to give consent.
Question 93
Nurse Cindy is caring for a patient with diabetic ketoacidosis. Which adaptations should the nurse caring for the client to exhibit? Select all that apply:
A
Retinopathy
B
Low PCO2
C
Acetone breath
D
Elevated serum bicarbonate
Question 93 Explanation: 
ANSWER: Low PCO2 ; Acetone breath ; RATIONALE: Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a lowered PCO2. A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis.
Question 94
Jona is studying for her exams the next day and comes about benzodiazepine overdose. Which of the following are appropriate actions for this case?
A
Gastric lavage
B
Hemodialysis
C
Activated charcoal and a saline cathartic
D
Administration of Flumazenil
Question 94 Explanation: 
ANSWER: Gastric lavage ; Activated charcoal and a saline cathartic ; Administration of Flumazenil ; RATIONALE: If ingestion is recent, decontamination of the GI system is indicated. The administration of syrup of ipecac is contraindicated because of aspiration risks related to sedation. Gastric lavage is generally the best and most effective means of gastric decontamination. Activated charcoal and a saline cathartic may be administered to remove any remaining drug. Hemodialysis is not useful in the treatment of benzodiazepine overdose. Flumazenil can be used to acutely reverse the sedative effects of benzodiazepines, though this is normally done only in cases of extreme overdose or sedation.
Question 95
Nurse Clary is assigned at the medical ward and is currently caring for four patients. When planning client rounds, which client would the nurse check first?
A
A client in skeletal traction
B
A client admitted on the previous shift who has a diagnosis of gastroenteritis
C
A client on a ventilator
D
A postoperative client preparing for discharge
Question 95 Explanation: 
ANSWER: A client on a ventilator ; RATIONALE: The airway is always a high priority, and the nurse first checks the client on a ventilator. The clients described in options 2, 3, and 4 have needs that would be identified as intermediate priorities.
Question 96
On her fifth day of duty at the NICU, Nurse Nina encounters an infant who is admitted with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.
A
Prepare to administer 100% oxygen by face mask.
B
Notify the registered nurse.
C
Prepare to administer morphine sulfate.
D
Place the infant in a prone position.
E
Call a code blue.
F
Prepare to administer intravenous fluids.
Question 96 Explanation: 
ANSWER: Notify the registered nurse. ; Prepare to administer morphine sulfate. ; Prepare to administer intravenous fluids. ; Prepare to administer 100% oxygen by face mask. ; RATIONALE: The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.
Question 97
Mr. Gonzales, in his attempt to save a neighbor involved in a fire, is admitted to the hospital after sustaining an injury from a house fire. However, despite his efforts, the neighbor still died. Which action would the nurse take to enable the client to work through the meaning of the crisis?
A
Inquiring about the client's feelings that may affect coping
B
Identifying the client's potential for self-harm
C
Identifying the client's ability to function
D
Inquiring about the client's perception of the cause of the neighbor's death
Question 97 Explanation: 
ANSWER: Inquiring about the client's feelings that may affect coping ; RATIONALE; The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not directly address the client's feelings.
Question 98
Mrs. T is an 80-year-old client admitted to your nursing unit with a diagnosis of weakness, status post fall. The admission face sheet indicates that she is widowed and lives alone. As you work through your nursing admission assessment, which of the following would be the least priority concern?
A
Ask Mrs. T about her ability to shop and cook for herself.
B
Does Mrs. T like to read?
C
What medications has she been taking?
D
Ask Mrs. T about the details of her fall.
Question 98 Explanation: 
ANSWER: Does Mrs. T like to read? ; RATIONALE: b. Mrs. T's reason for admission is weakness and a fall. Priority concerns in assessment would be to identify any intrinsic or extrinsic factors that lead to her fall. Her interest in reading, although it be important in determining possible activities to incorporate into her care plan while in the hospital, is a lesser priority.
Question 99
Nurse Jimmy is caring for a patient who has heart failure. Which of the following nursing diagnoses would be appropriate? Select all that apply.
A
Impaired gas exchange related to decreased sympathetic nervous system activity.
B
Decreased cardiac output related to structural and functional changes.
C
Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.
D
Activity intolerance related to increased cardiac output.
Question 99 Explanation: 
ANSWER: Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output. ; Decreased cardiac output related to structural and functional changes. ; RATIONALE: HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.
Question 100
A staff nurse has the responsibility for the care of five clients. She is working with a nursing assistant in the care of the clients. The staff nurse will assign specific care for clients to the nursing assistant. The nursing assistant will carry out the necessary care on the assigned clients and report back to the staff nurse. This is an example of how the nursing assistant does what? (Select all that apply.)
A
makes decisions
B
assumes responsibility
C
delegates to another individual
D
is accountable
Question 100 Explanation: 
ANSWER: assumes responsibility ; is accountable ; RATIONALE: a. The nursing assistant accepts the responsibility to carry out the necessary care on the assigned patients. b. By reporting back to the staff nurse the nursing assistant demonstrates accountability for her/his actions; the nursing assistant by accepting the assignment has an obligation to periodically report back to the delegator.
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