Nursing Pre-Board Exam for June 2012 NLE

ANSWER: Place the client in Trendelenburg position ; RATIONALE: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the 105 hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and the others staff members should call the physician and notify the delivery room.

ANSWER: Two fingers can be slid comfortably under the holder ; RATIONALE: There should be enough room for two fingers to slide comfortably under the tracheostomy holder. This ensures that the holder is tight enough to present tracheostomy dislocation, while preventing excessive constriction around the neck.

ANSWER: Shock ; RATIONALE: A client in shock is placed in a modified Trendelenburg position that includes elevating the legs, leaving the trunk flat and elevated head and shoulders. This position promotes increase venous return from the lower extremities without compressing the abdominal organ against the diaphragm

ANSWER: A sputum culture positive for Mycobacterium Tuberculosis ; RATIONALE: The most accurate means of confirming the diagnosis of Tuberculosis is by sputum culture.

ANSWER: More accurate ; RATIONALE: A blood glucose testing is a one direct accurate measure.

ANSWER: Notify the physician of the client’s request ; RATIONALE: External Cardiac Massage is a life-saving treatment that a client can refuse. The most appropriate initial nursing action is to notify the physician, because written do not Resuscitate (DNR) order from the physician is needed. The DNR order must be reviewed or renewed on a regular basis per agency policy.

ANSWER: Use a night light and turn off the television ; RATIONALE: Provision of a consistent daily routine and a low stimulating environment is important when the client is oriented Noise, including radio and television, may add to the confusion and disorientation.

ANSWER: A form of behavior modification therapy ; RATIONALE: Systematic desensitization is a form of therapy used when the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Gradually exposure is increased until the anxiety about or fear of the objects or situation has ceased.

ANSWER: Desmopressin ( DDAVP, Stimate) ; RATIONALE: A complication of head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic hormone storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9L per day generally requires treatment with Desmopressin.

ANSWER: “This is NOT an emergency; I will speak to the physician and call you right back” ; RATIONALE: The size and appearance of the tympanostomy tube should be described to the parents after surgery. They should be reassured that if the tube fall out, it is not an emergency, but the physician should be notified

ANSWER: Administration of syrup of ipecac ; RATIONALE: Initial treatment of salicylate overdose includes inducing vomiting with syrup of ipecac.

ANSWER: Keep the client talking and signal another staff member to trace the call so that appropriate help can be sent. ; RATIONALE: In a crisis the nurse must take an authoritative, active role to promote the client’s safety. A bottle of poisonous substance that will be used to kill her is the “crisis”. The client’s safety is the prime concern. Keeping the client on the phone and getting help to the client is the best intervention.

ANSWER: All the nursing supervisor ; RATIONALE: Nurse Practice acts require reporting impaired nurses. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and authorities.

ANSWER: Assess for hypovolemia and notify the healthcare provider ; RATIONALE: Symptoms of hypovolemia include cool clammy pale skin, sensation of anxiety or impending doom, restlessness and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the healthcare provider.

ANSWER: A client with tracheostomy and is on mechanical ventilator, client scheduled for a cardiac catheterization followed by the client with diabetes mellitus scheduled for discharged. ; RATIONALE: Airway is always a high priority and the nurse would assess the client who has a tracheostomy and is on a mechanical ventilator first. The nurse next step of care would assess the client scheduled for cardiac catheterization, followed by the client scheduled for discharge.

ANSWER: “I’m glad I don’t have to lie still for this procedure” ; RATIONALE: The client doest not have to lie still for ERCP, which takes about an hour to perform.

ANSWER: “How much do you use and what effect does it have on you” ; RATIONALE: Whenever the nurse employs an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being judgmental and direct.

ANSWER: Most frequently occurs from 2-4 months of life ; RATIONALE: Sudden infant death syndrome usually occurs during sleep and during the winter months and most frequently occurs between the second and the forth month of life. The syndrome is more common in boys.

ANSWER: Is easily stimulated by the environment ; RATIONALE: These individuals readily respond to environmental cues; increased stimulation increases activity; decreased stimulation decreases activity.

ANSWER: Initiate confinement measures ; RATIONALE: During the escalation period, the client’s behavior is moving toward loss of control. Nursing actions include taking control, maintaining safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is not appropriate.

ANSWER: Quietly approach the client and assist her in getting dressed ; RATIONALE: A person who is experiencing mania lacks insight and judgment, has poor impulse control and is highly excitable. The nurse must take control without creating increased stress or anxiety to the client.

ANSWER: 15ml ; RATIONALE: Desire Available x ml = 30mEq/ 40mEq x 20ml = 15ml

ANSWER: Discontinue the prescribed antihistamine 5days before the test. ; RATIONALE: Client preparation for a scratch skin test includes informing the client to discontinue the administration of systemic corticosteroids or antihistamines for at least 5days before the test. This medication must be discontinues to prevent suppression of the inflammatory response to the allergen.

ANSWER: Ventricular tachycardia ; RATIONALE: At least ½ of all deaths occur from the life-threatening dysrhythmias of ventricular tachycardia.

ANSWER: Informs the client that he is being secluded to help regain self-control ; RATIONALE: The client is removed to a nonstimulating environment as a result of behavior. It is best to inform the client the purpose of the seclusion.

ANSWER: That this is an expected side effect of the medication ; RATIONALE: Chlorpromazine is an antipsychotic medication. A side effect of this medication is that the color of the urine may darken. The client should be aware that this effect is harmless.

ANSWER: Performing a procedure without consent of the client ; RATIONALE: Performing a procedure without consent of the client is a form of battery. Threatening the client to give medication is an example of assault. Threatening the client cannot leave the hospital constitute false imprisonment and sharing the client’s data is a form of invasion of privacy.

ANSWER: Administering Narcotic Analgesic intramuscularly. ; RATIONALE: After biopsy the client usually requires mild analgesic.

ANSWER: 12 months ; RATIONALE: For children with human immunodeficiency virus infection, a minimum of 12 months of treatment with isoniazid is recommended.

ANSWER: Every 15minutes for the first hour, every 30minutes for the second hour, every hour for 4 hours and then every four hour as needed. ; RATIONALE: When the post operative client arrives from the post anesthesia care unit, the nurse performs an initial assessment. Common time frames for continuing postoperative assessment activities are every 15 minutes for the first hour, every 30 minutes for the second hour, and then every hour for four hours and every four hour as needed.

ANSWER: Immobilization of the affected leg ; RATIONALE: Autograft placed over joints or on the lower extremities often are elevated and immobilized following surgery for 3-7 days. This period immobilization allows the autograft time to adhere and attach to the wound bed.

ANSWER: Emphysema ; RATIONALE: The client with emphysema has hyper inflation of the alveoli and flattening of the diaphragm. This lead to increased anteropoasterior diameter referred to as barrel chest.

ANSWER: An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum. ; RATIONALE: Option c describes the procedure for a pyloroplasty.

ANSWER: Nail bed pressure ; RATIONALE: Motor testing of the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

ANSWER: A single registered nurse is responsible for planning and providing individualized nursing care ; RATIONALE: Primary nursing is concerned with keeping the nurse at the bedside actively involved in direct care while planning goal-directed, individualized client care.

ANSWER: Blow or trauma to the bladder or abdomen ; RATIONALE: Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria.

ANSWER: Document the findings and tell the mother that the monitor indicates fetal well-being. ; RATIONALE: Acceleration are transient increase in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well being and adequate oxygen reserve.

ANSWER: The most serious complication of this infection is sterility. ; RATIONALE: The most serious complication of the chlamydial infection is sterility. The infection can be prevented by the use of latex condoms.

ANSWER: Ability to get to work on time each day ; RATIONALE: Amitriptyline is a tricyclic antidepressant. Depressed individuals sleep for extended periods, have a change in appetite, unable to go to work, and have difficulty concentrating. They also may experience increased fatigue, feeling of guilt, worthlessness, loss of interest in activities and possible suicidal tendencies.

ANSWER: Activated partial thromboplastin time ; RATIONALE: Anticoagulation therapy maybe used to prevent the extension of thrombus by delaying the clotting time of the blood. Activated partial thromboplastin time should be monitored, and the heparin dose should be adjusted to maintain a therapeutic level of 1.5 – 2.5 times the control. The prothrombin time and the international normalized ratio are used to monitor coagulation time when warfarin (coumadin) is used. The platelet count cannot be used to determine an adequate dosage for the heparin infusion.

ANSWER: Discomfort my occur with needle insertion and there is minimal exposure to radiation ; RATIONALE: Pulmonary angiography involves minimal exposure to radiation. The procedure is painless although the client may feel discomfort with insertion of the needle for the catheter that is used for dye injection.

ANSWER: Increased calcium level ; RATIONALE: Findings indicates of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the released of calcium from the deteriorating bone tissue and an elevated blood urea nitrogen level.

ANSWER: A normal response that indicates the presence of phantom limb sensation ; RATIONALE: Phantom limb sensation are felt in the area of the amputated limb. These sensations can include itching, warmth and cold. The sensations are due to intact peripheral nerves in the area amputated.

ANSWER: Inform the client to return in 4-6 weeks to be tested because testing before this time is not reliable ; RATIONALE: A blood test is available to detect Lyme disease however the test is not reliable if performed before 4-6 weeks following the tick bite.

ANSWER: Numbness and tingling in the fingers ; RATIONALE: The earliest symptoms of compartment syndrome is paresthesia (numbness and tingling)

ANSWER: Bedrest for 6-8 hours, with the head of the bed elevated 15-30 degrees ; RATIONALE: Following a myelogram, the client is placed on bedrest for 6-8 hours after the procedure. When a water based contrast medium is used, the client is position with the head of bed elevated 15-30 degrees.

ANSWER: Interrupt the client and offer to take her for a walk. ; RATIONALE: Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits to rigorous activities.

ANSWER: Assisting the client to exercise in bed ; RATIONALE: Inactivity causes venous stasis hyper coagulability, and arterial pressure against the vein, all of which lead to thrombus formation, early ambulation in exercise of the lower extremities reduce the occurrence of this phenomenon

ANSWER: Senna accumulates water and increases peristalsis ; RATIONALE: Senna works by changing the transport of water in the large intestine which causes accumulation of water in the mass of stool and increase peristalsis.

ANSWER: Adrenal cortex ; RATIONALE: An Aldosteronoma is an aldosterone secreting adrenal cortex

ANSWER: Indicates the presence of infection ; RATIONALE: Lochia, the discharge present after birth, is not for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia indicates infection and these findings are not normal.

ANSWER: “ I need to stop breast feeding until this condition resolves” ; RATIONALE: In most cases, the mother can continue to breast-feed with both breast. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 – 48 hours. Additional supporting measures include ice packs, breast supports, and analgesics.

ANSWER: 15 minutes ; RATIONALE: The nurse must remain with the client for the first 15 minutes of transfusion which is the most frequent period of danger of transfusion reaction. This enables the nurse to detect reactions and intervene quickly.

ANSWER: Immune globulin ; RATIONALE: Immune globulin is administered intravenously to the child with Kawasaki Disease to decrease the incidence of coronary artery lesions and aneurysms and to decrease fever and inflammation.

ANSWER: Choking with feedings ; RATIONALE: Any child who exhibits the 3 C – coughing and choking with feedings and unexplained cyanosis- should be suspected of tracheoesopahgeal fistula.

ANSWER: A client with a fever who is diaphoretic and restless ; RATIONALE: A nurse would plan to care first a client who had a fever and restless because the client’s needs are the priority. Waiting for pain medication to take effect before providing care to the post operative client is best.

ANSWER: Disturbed Thought Processes ; RATIONALE: Major depression, recurrent, with psychotic features alerts the nurse that in addition to the criteria that designates the diagnosis of major depression, one also must deal with the client’s psychosis. Psychosis is defined as a state in which a person’s mental capacity to recognize reality and to communicate and relate to others is impaired, thus interfering with the person’s capacity to deal with the demand of life.

ANSWER: 1.8 mEq/L ; RATIONALE: The therapeutic serum level of lithium is 0.6 to 1.2 mEq/L. A serum lithium level of 1.8 mEq/L indicates moderate toxicity. Serum lithium concentration of 1.5 – 2.5 mEq/L may produce vomiting, diarrhea, ataxia, incoordination, muscle twitching,and slurred speech.

ANSWER: The presence of loose teeth ; RATIONALE: In the preoperative period, the child should be observed for the presence of loose teeth to decrease the risk of aspiration during surgery.

ANSWER: Urinary output of 30ml per hour ; RATIONALE: A rate of 30ml/hr is considered adequate perfusion of the kidney, heart and brain.

ANSWER: Moves the cane when the right leg is moved ; RATIONALE: The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support and move forward with the affected leg.

ANSWER: Maintaining the supine position for a minimum of 4 hours. ; RATIONALE: The supine position prevents hip flexion limiting injury and promoting healing of the catheter insertion site; if the head of the bed is elevated, it should not exceed 20 degrees.

ANSWER: Breathe normally ; RATIONALE: Indirect laryngoscopy is done to assess the function of the vocal cords or to obtain tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror. The client is placed in an upright position to facilitate passage of the laryngeal mirror into the mouth and is instructed to breathe normally. The tongue cannot be moved back because it would occlude the airway. Swallowing can not be done with the mirror in place. The procedure takes longer that the time the client would be able to hold the breath, and this action is ineffective.

ANSWER: Ascertains the client’s safety, calmly asks the nursing assistant to join the nurse outside the room, and informs the nursing assistant that her voice was unusually loud. ; RATIONALE: The nurse must ascertain the client is safe, and then discuss the matter with the nursing assistant in an area away from the hearing of the client. If the client heard the conversation, the client may become more confused or agitated.

ANSWER: Check the client’s alignment in bed ; RATIONALE: The nurse realigns the client and if that is ineffective then calls the physician.

ANSWER: Do not allow pregnant women into the client’s room. ; RATIONALE: The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the client’s room. Children younger than 16 years of age and pregnant women are not allowed in the client’s room.

ANSWER: Monitoring the fetal heart rate ; RATIONALE: The priority is to monitor the fetal heart rate. Although providing comfort measures changing the client’s position frequently, and keeping the significant others informed of the progress of the labor are components of the plan of care, the fetal status would be the priority

ANSWER: The saphenous vein was used to bypass the coronary artery. ; RATIONALE: This response provide information and reduces anxiety. The nurse should understand that the greater saphenous vein in the leg is used to bypass the diseased coronary artery because the surgical team can obtain the vein while the other team perform the chest surgery, this shortens the surgical time and risk of surgery.

ANSWER: "I will begin abdominal exercises immediately.” ; RATIONALE: Abdominal exercises should not start immediately following abdominal surgery, and the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision.

ANSWER: Obtain a second nurse to also act as a witness and ask the client to sign the form with an X ; RATIONALE: Clients who cannot write may sign an informed consent with an X. This is witnessed by two nurses. Nurses serve as a witness to the client’s signature and not to the fact that the client is informed. It is the physician’s responsibility to inform the client about a procedure. The nurse clarifies facts presented by the physician. There is no useful reason to contact the physician at this time. A client is not send to a procedure without a signed informed consent

ANSWER: “You seem very upset. Let’s talk at the nurse’s station. I want to help you. It would be best if you agree to let you daughter stay here for now.” ; RATIONALE: When a suspected abused child is admitted to the hospital for further evaluation and protection, the physician will usually work with the parents so they will agree to the admission. If the parents refuse to agree to the admission, the hospital can request an immediate court order to retain the child for a specific length of time.

ANSWER: The client’s pain rating ; RATIONALE: The client’s self report is a critical component of pain assessment. The nurse should ask the client about the description of the pain and listen carefully to the client’s words used to describe the pain. The nurse’s impression of the client’s pain is not appropriate in determining the client’s level of pain. Nonverbal cues from the client are important but are not the most appropriate pain assessment measures.

ANSWER: Contact the physician ; RATIONALE: Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parents or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states requires that the client submit a written release notice to the facility staff, who reevaluates the client’s condition for possible conversion to involuntary status, according to criteria established by law.

ANSWER: Sore throat ; RATIONALE: Client’s taking Trimethoprim-sulfamethoxazole should be informed about early signs of blood disorder that can occur from this medication.

ANSWER: Dry hair and an intolerance to cold ; RATIONALE: Dry, sparse hair and cold intolerance are characteristics adaptations to low serum thyroxine.

ANSWER: An increase in the pulse rate from 88 to 102 beats per minute ; RATIONALE: During the fourth stage of labor, the maternal blood pressure, pulse and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes but a decreased in blood pressure would not be the earliest sign of hemorrhage.

ANSWER: Tachycardia ; RATIONALE: With shock the heart rate accelerates to increase blood flow and oxygen to body tissue

ANSWER: 1 week after menstruation begins ; RATIONALE: The breast self-examination should be performed monthly seven days after the menstruation period.

ANSWER: Contact the physician and verifies the order ; RATIONALE: If the nurse determines that a physician’s order is unclear, or if the nurse has a question about an order, the nurse should contact the physician, before implementing the order. Under no circumstances should the nurse carry out the order unless the physician has clarified the order.

ANSWER: Assess the intravenous infusion site ; RATIONALE: Apmhotericin B is a toxic medication, which can produce symptoms during administration such as chills, fever, headache, vomiting, and impaired renal function. The medication is very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication monitors for these complications.

ANSWER: “If the child vomits after medication administration, I will repeat the dose.” ; RATIONALE: The parents need to be instructed that if the child vomits after the digoxin is administered they are not to repeat the dose.

ANSWER: Normal sodium intake ; RATIONALE: A high-complex carbohydrate and high protein diet will be prescribed for the client with Addison’s disease. To prevent excess fluid and sodium loss, the client will be taught to maintain a normal salt intake daily (3g) and to increase salt intake during hot weather, before strenuous exercise, and in response to fever, vomiting or diarrhea.

ANSWER: Gastrointestinal dysfunctions ; RATIONALE: The most common side effects related to the medication includes central nervous system and gastrointestinal system by causing nausea, vomiting, cramping and diarrhea.

ANSWER: Graham crackers and warm milk ; RATIONALE: The client with pheochromocytoma needs to be provided with a diet high in vitamins, minerals and calories. Beverages that contain caffeine, tea, cola, cocoa, are prohibited because they can precipitate hypertensive crisis.

ANSWER: Provide a simple explanation of the procedure and continue to reassure the client ; RATIONALE: The nurse should offer support and use clear, simple terms to allay the client’s anxiety.

ANSWER: Provides comforts by reducing muscles spasms and provide fracture immobilization ; RATIONALE: Traction reduces muscle spasms and helps to immobilize the fracture

ANSWER: Provide support and identify the underlying cause of the staff nurse’s problems ; RATIONALE: Option c empowers the charge nurse to assist the staff nurse while trying to identify and reduce the behaviors that make it difficult for the staff nurse to function.

ANSWER: Rice ; RATIONALE: Dietary management is the mainstay of treatment in celiac disease. All wheat, rye, barley, oats should be eliminated from the diet.

ANSWER: 300 units/L ; RATIONALE: The normal serum amylase is 25 to 151 IU/L. In client with chronic pancreatitis, the increase in serum amylase does not exceed 3 times the normal value.

ANSWER: Fracture ; RATIONALE: Typical sign and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling and ecchymosis.

ANSWER: Identifying anxiety-producing situations ; RATIONALE: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety producing situations, and this option does not encourage the development of internal strength. Ignoring feelings will not resolve anxiety.

ANSWER: “Did the child have a sore throat or an unexplained fever within the last 2 months?” ; RATIONALE: Rheumatic fever characteristically presents 2-6 weeks after an untreated or partially treated group A beta hemolytic streptococcal infections of the upper respiratory tract. Initially the nurse determines whether the child has a sore throat or an unexplained fever within the past 2 months.

ANSWER: Vitamin B12 ; RATIONALE: Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of the intrinsic factor is lost which results inability to absorb vitamin B12.

ANSWER: Blood Transfusion may be necessary ; RATIONALE: Blood products (packed RBC or platelet) are administered when warranted.

ANSWER: Inform the friend to directly contact the family and offer her assistance to them. ; RATIONALE: A nurse must uphold the client’s rights and does not give any information regarding a client’s care needs to anyone who is not directly involved in the client’s care. To request that the friend come for teaching is a direct violation of the client’s right to privacy. There is no information in the question to indicate that the family desires assistance form the friend. To refer the call to the nurse manager and social worker again assumes that the friend’s assistance and involvement is desired by the family. Informing the friend that the nurse is visiting daily is providing information that is considered confidential.

ANSWER: Hyperglycemia ; RATIONALE: When the head of the pancreas is removed, the client has a greatly reduced number of insulin-producing cells and hyperglycemia will occur. Immediate attention is necessary

ANSWER: Normal reaction to a devastating event ; RATIONALE: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction to an intensely difficult crisis event.

ANSWER: “I will ask the woman to extend the legs flat on the bed, and I will grasp the foot and sharply extend it backward.” ; RATIONALE: To elicit homan’s sign, the nurse asks the woman to extend her legs on the bed. The nurse grasps the foot and dorsiflexes it forward. If this cause any discomfort or resistance, the nurse should notify the physician or midwife that Homan’s sign is present.

ANSWER: Coffee, cola and chocolate ; RATIONALE: Oxtriphylline is a xanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine containing food when taking this medication.

ANSWER: Avoid getting the cast wet ; RATIONALE: A plaster cast must remain dry to keep its strength.