Pre-Board Nursing Exam for June 2013 NLE

ANSWER: Nausea, vomiting, and anorexia ; RATIONALE: Acute cholecystitis is an acute inflammation of the gallbladder commonly manifested by the following: anorexia, nausea, and vomiting; biliary colic; tenderness and rigidity the right upper quadrant (RUQ) elicited on palpation (e.g., Murphy’s sign); fever; fat intolerance; and signs and symptoms of jaundice. Ecchymosis, petechiae, and coffee-ground emesis are clinical manifestations of esophageal bleeding. The coffee-ground appearance indicates old bleeding. Jaundice, dark urine, and steatorrhea are clinical manifestations of the icteric phase of hepatitis.

ANSWER: The client’s parents are skilled stained-glass artists. ; RATIONALE: Plumbism is lead poisoning. One factor associated with the consumption of lead is eating from pottery made in Central America or Mexico that is unfired. The child lives in a house built after 1976 (this is when lead was taken out of paint), and the parents make stained glass as a hobby. Stained glass is put together with lead, which can drop on the work area, where the child can consume the lead beads. Answer A is incorrect because simply traveling out of the country does not increase the risk. In answer C, the house was built after the lead was removed with the paint. Answer D is unrelated to the stem.

ANSWER: Assessing the client’s neurologic status every 2 hours ; Evaluating the client’s serum ammonia level ; Monitoring the client’s handwriting daily; RATIONALE: Hepatic encephalopathy results from an increased ammonia level due to the liver’s inability to covert ammonia to urea, which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the client’s neurologic status, serum ammonia level, and handwriting. Monitoring the client’s hemoglobin and hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping fingernails short address jaundice.

ANSWER: Client complaints of chest pain, dyspnea, or abdominal pain ; RATIONALE: Client complaints about chest pain, dyspnea, or abdominal pain are considered part of the review of body systems. This potion of the assessment elicits subjective information on the client’s perceptions of major body system functions, including cardiac, respiratory, and abdominal. The client’s name, address, age, and phone number are biographical data. A brief statement about what brought the client to the health care provider is the chief complaint. Information about the client’s sexual performance and preference addresses past health status.

ANSWER: Wash her hands for 2 minutes before care ; RATIONALE: The best way to prevent post-operative wound infection is hand washing. Use of prescribed antibiotics will treat infection, not prevent infections, making answer A incorrect. Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections; therefore, answers C and D are incorrect.

ANSWER: High-seat commode ; RATIONALE: The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. The recliner is good because it prevents 90° flexion but not daily activities. A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management and an abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis; therefore, answers B, C, and D are incorrect.

ANSWER: Keeping the client’s fingernails short and smooth ; RATIONALE: The client with pruritus experiences itching, which may lead to skin breakdown and possibly infection from scratching. Keeping his fingernails short and smooth helps prevent skin breakdown and infection from scratching. Applying pressure when giving I.M. injections and administering vitamin K subcutaneously are important if the client develops bleeding problems. Decreasing the client’s dietary intake is appropriate if the client’s ammonia levels are increased.

ANSWER: Using good sanitation with dishes and shared bathrooms ; RATIONALE: Hepatitis A is transmitted through the fecal oral route or from contaminated water or food. Measures to protect the family include good handwashing, personal hygiene and sanitation, and use of standard precautions. Complete isolation is not required. Avoiding contact with blood-soiled clothing or dressings or avoiding the sharing of needles or syringes are precautions needed to prevent transmission of hepatitis B.

ANSWER: Assessing the client’s bowel sounds ; Taking the client’s blood pressure and apical pulse ; Determining the last time the client received pain medication ; RATIONALE: The nurse must rule out complications prior to administering pain medication, so her interventions would include assessing to make sure the client has bowel sounds and determining if the client is hemorrhaging by checking the client’s blood pressure and pulse. The nurse must also make sure the pain medication is due according to the health care provider’s orders. Obtaining a pulse oximeter reading and turning, coughing, and deep breathing will not help the client’s pain. There is no need to notify the health care provider in this situation.

ANSWER: The client distracts himself during pain episodes. ; RATIONALE: Distraction is an appropriate method of reducing pain. Denying the existence of any pain is inappropriate and not indicative of coping. Exclusion of family members and other sources of support represents a maladaptive response. Range-of-motion exercises and at least mild activity, not decreased activity, can help reduce pain and are important to prevent complications of immobility.

ANSWER: “It will be alright for your friends to autograph the cast.” ; RATIONALE: There is no reason that the client’s friends should not be allowed to autograph the cast; it will not harm the cast in any way, so answers B, C, and D are incorrect.

ANSWER: Have narcan (naloxone) available ; RATIONALE: Narcan is the antidote for narcotic overdose. If hypoxia occurs, the client should have oxygen administered by mask, not cannula. There is no data to support the administration of blood products or cardiac resuscitation, so answers A, C, and D are incorrect.

ANSWER: increased oxidative enzyme levels. ; RATIONALE: Oxidative enzyme levels decrease in the elderly, which affects the disposition of medication and can alter the therapeutic effects of medication. Alcohol has a smaller water distribution level in the elderly, resulting in higher blood alcohol levels. Alcohol also interacts with various drugs to either potentate or interfere with their effects. Magnesium is contained in a lot of medications elder clients routinely obtain over the counter. Magnesium toxicity is a real concern. Albumin is the major drug-binding protein. Decreased levels of serum albumin mean that higher levels of the drug remain free and that there are less therapeutic effects and increased drug interactions.

ANSWER: “I must flush the tube with water after feedings and clamp the tube.” ; RATIONALE: The client’s family member should be taught to flush the tube after each feeding and clamp the tube. The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client, so answers B and C are incorrect. Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing; therefore, answer D is incorrect.

ANSWER: Applying pressure to injection sites ; RATIONALE: The client with cirrhosis who has altered clotting is at high risk for hemorrhage. Prolonged application of pressure to injection or bleeding sites is important. Complete independence may increase the client’s potential for injury, because an unsupervised client may injure himself and bleed excessively. Antibiotics and good nutrition are important to promote liver regeneration. However, they are not most important for a client at high risk for hemorrhage.

ANSWER: wide-spaced eyes, smooth philtrum, flattened nose ; RATIONALE: The nurse should anticipate that the infant may have fetal alcohol syndrome and should assess for signs and symptoms of it. These include the characteristics listed in choice A.

ANSWER: Malpractice ; RATIONALE: The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. Answers A, B, and C are incorrect because they apply to other wrongful acts. Negligence is failing to perform care for the client; a tort is a wrongful act committed on the client or their belongings; and assault is a violent physical or verbal attack.

ANSWER: “Jaundice produces pruritus due to impaired bile acid excretion.” ; RATIONALE: Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid excretion is impaired, increasing the bile acids in the skin and causing pruritus. Jaundice is not associated with pressure ulcer formation. However, edema and hypoalbuminemia are. Jaundice itself does not impair urea production or lead to decreased tissue perfusion.

ANSWER: Resonance ; RATIONALE: Normally, when percussing a client’s chest, percussion over the lungs reveals resonance, a hollow or loud, low-pitched sound of long duration. Tympany is typically heard on percussion over such areas as a gastric air bubble or the intestine. Dullness is typically heard on percussion of solid organs, such as the liver or areas of consolidation. Hyperresonance would be evidenced by percussion over areas of overinflation such as an emphysematous lungs.

ANSWER: Ask the parent/guardian to room-in with the child. ; RATIONALE: The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Allowing the child to have items that are familiar to him is allowed and encouraged; therefore, answers A and B are incorrect. Answer D is not part of the nurse’s responsibilities.

ANSWER: High fever ; RATIONALE: If the child has bacterial pneumonia, a high fever is usually present. Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough, making answer B incorrect. Rhinitis is often seen with viral pneumonia, and vomiting and diarrhea are usually not seen with pneumonia, so answers C and D are incorrect.

ANSWER: “Avoid taking other medications within 2 hours of this one.” ; RATIONALE: Antacids neutralize gastric acid and decrease the absorption of other medications. The client should be instructed to avoid taking other medications within 2 hours of the antacid. Water, which dilutes the antacid, should not be taken with antacid. A histamine receptor antagonist should be taken even when pain subsides. Daily weights are indicated if the client is taking a diuretic, not an antacid.

ANSWER: Active ; RATIONALE: The active phase of labor occurs when the client is dilated 4–7cm. The latent or early phase of labor is from 1cm to 3cm in dilation, so answers B and D are incorrect. The transition phase of labor is 8–10cm in dilation, making answer C incorrect.

ANSWER: Obtaining cooperation and reducing fear ; RATIONALE: An esophageal tamponade tube would be inserted in critical situations. Typically, the client is fearful and highly anxious. The nurse therefore explains about the placement to help obtain the client’s cooperation and reduce his fear. This type of tube is used only short term and is not indicated for home use. The tube is large and uncomfortable. The client would not be helping to insert the tube. A client’s anxiety should be decreased, not maintained, and depending on the degree of hemorrhage, the client may not be alert.

ANSWER: Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction ; RATIONALE: With acute pancreatitis, the client is kept on nothing-by-mouth status to inhibit pancreatic stimulation and secretion of pancreatic enzymes. NG intubation with low intermittent suction is used to relieve nausea and vomiting, decrease painful abdominal distention, and remove hydrochloric acid. Vasopressin would be appropriate for a client diagnosed with bleeding esophageal varices. Paracentesis and diuretics would be appropriate for a client diagnosed with portal hypertension and ascites. A low-fat diet and increased fluid intake would further aggravate the pancreatitis.

ANSWER: Hyperkalemia ; RATIONALE: This is a potassium-sparing diuretic so clients should be monitored closely for hyperkalemia. Diarrhea, dizziness, and headaches are other more common side effects. Tachycardia, jaundice, and constipation are not expected side effects of spironolactone (Aldactone).

ANSWER: Serum collection (Davol) drain ; RATIONALE: Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. The client’s pain should be assessed, but this is not life-threatening. When the client is in less danger, the nutritional status should be assessed and an immobilizer is not used; thus, answers B, C, and D are incorrect.

ANSWER: The narcotic count has been incorrect on the unit for the past 3 days. ; RATIONALE: The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to care for the client with hepatitis might result in termination, but is not of interest to the Joint Commission.

ANSWER: Wrapping the newborn snugly in a blanket ; RATIONALE: The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Teaching the mother to provide tactile stimulation or provide for early infant stimulation are incorrect because he is irritable and needs quiet and little stimulation at this time, so answers A and D are incorrect. Placing the infant in an infant seat in answer C is incorrect because this will also cause movement that can increase muscle irritability.

ANSWER: A moderate amount of straw-colored fluid ; RATIONALE: An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. Fetal heart tones of 160 indicate tachycardia, and greenish fluid is indicative of meconium, so answers A and C are incorrect. If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord, so answer D is incorrect and would need to be reported immediately.

ANSWER: Hormonal disturbances ; RATIONALE: After menopause, women lack hormones necessary to absorb and utilize calcium. Doing weight-bearing exercises and taking calcium supplements can help to prevent osteoporosis but are not causes, so answers A and C are incorrect. Body types that frequently experience osteoporosis are thin Caucasian females, but they are not most likely related to osteoporosis, so answer D is incorrect.

ANSWER: Fever and chills ; RATIONALE: Septicemia is a common complication after a percutaneous transhepatic cholangiography. Evidence of fever and chills, possibly indicative of septicemia, is important. Hypotension, not hypertension, is associated with septicemia. Tachycardia, not bradycardia, is most likely to occur. Nausea and diarrhea may occur but are not classic signs of sepsis.

ANSWER: Fetal heart tones ; RATIONALE: When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort, making answers A, C, and D incorrect.

ANSWER: “That feeling of warmth is normal when the dye is injected.” ; RATIONALE: It is normal for the client to have a warm sensation when dye is injected. Answers A, C, and D indicate that the nurse believes that the hot feeling is abnormal, so they are incorrect.

ANSWER: Apply oxygen by mask ; RATIONALE: Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation, so answers A and D are incorrect. The normal oxygen saturation for a child is 92%–100%, making answer B incorrect.

ANSWER: These measures potentiate the effects of analgesics. ; RATIONALE: Noninvasive measures may result in release of endogenous molecular neuropeptides with analgesics properties. They potentiate the effect of analgesics. No evidence indicates that noninvasive and nonpharmacologic measures are more effective than analgesics in relieving pain. Decreased input over large fibers allows more pain impulses to reach the central nervous system. There is no connection between type C fiber impulses and noninvasive and nonpharmacologic pain-control measures.

ANSWER: Exophthalmos ; RATIONALE: Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss; therefore, answers A, B, and D are incorrect.

ANSWER: Starting a blood transfusion ; RATIONALE: The licensed practical nurse should not be assigned to begin a blood transfusion. The licensed practical nurse can insert a Foley catheter, discontinue a nasogastric tube, and collect sputum specimen; therefore, answers A, B, and C are incorrect.

ANSWER: Central-control theory ; RATIONALE: No one theory explains all the factors underlying the pain experience, but the central-control theory discusses brain opiates with analgesic properties and how their release can be affected by actions initiated by the client and caregivers. The gate-control, specificity, and patter theories do not address pain control to the depth included in the central-control theory.

ANSWER: Risk for aspiration ; RATIONALE: Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Although answers B and D might be appropriate for this child, answer C should have the highest priority. Answer A does not apply for a child who has undergone a tonsillectomy.

ANSWER: “Tell me where you hurt.” ; RATIONALE: Four-year-olds are egocentric and interested in having the focus on themselves. They will not be interested in what it feels like to other children. Preschoolers are concrete thinkers and would literally interpret any analogies so they are not helpful in explaining procedures. Assurance of confidential communication is most appropriate for the adolescent. In addition, confidentiality is not maintained if the child plans to harm themselves, harm someone else, or discloses abuse.

ANSWER: Location of an advance directive ; RATIONALE: Biographic information may include name, address, gender, race, occupation, and location of a living will or a durable power of attorney for health care. The chief complaint, past health status, and history of immunizations are part of assessing the client’s health and illness patterns.

ANSWER: Contacting the physician ; RATIONALE: The vital signs are abnormal and should be reported immediately. Continuing to monitor the vital signs can result in deterioration of the client’s condition, making answer A incorrect. Asking the client how he feels in answer C will only provide subjective data, and the nurse in answer D is not the best nurse to assign because this client is unstable.

ANSWER: The entire family should be treated. ; RATIONALE: Enterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantelpamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answers A, C, and D are incorrect statements.

ANSWER: 12-year-old male with a fractured femur ; RATIONALE: The 6-year-old should have a roommate as close to the same age as possible, so the 12-year-old is the best match. The 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed, the 6-year-old with osteomyelitis is infected, and the client in answer A is too old and is female; therefore, answers A, C, and D are incorrect.

ANSWER: Referring the client for counseling and occupational therapy ; RATIONALE: Because it has been 6 months, the client needs professional help to get on with life and handle the limitations imposed by the current problems. Staying with the client, building trust, and providing method of pain relief, such as cutaneous stimulation, medications, distraction, and guided imagery interventions, would have been more appropriate in earlier stages of postburn injury, when physical pain was most severe and fewer psychologic factors needed to be addressed.

ANSWER: The tail of Spence area must be included in self-examination ; RATIONALE: The tail of Spence, an extension of the upper outer quadrant of breast tissue, can develop breast tumors. This area must also be included in breast self-examination. One half of all women who die of breast cancer are older than age 65. The correct position for breast self-examination is not limited to the supine position; the sitting position with hands at sides, above head, and on the hips is also recommended. A pad is placed under the ipsilateral (e.g., same side) scapula of the breast being palpated.

ANSWER: Utilizes a Steinman pin ; RATIONALE: Balanced skeletal traction uses pins and screws. A Steinman pin goes through large bones and is used to stabilize large bones such as the femur. Answer B is incorrect because only the affected leg is in traction. Kirschner wires are used to stabilize small bones such as fingers and toes, as in answer C. Answer D is incorrect because this type of traction is not used for fractured hips.

ANSWER: Cheese omelet ; RATIONALE: The child with celiac disease should be on a gluten-free diet. Answers A, B, and C all contain gluten, while answer D gives the only choice of foods that does not contain gluten.

ANSWER: Ask the client if the preference would be to remove the dentures in the operating room receiving area ; RATIONALE: Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client’s sense of self-esteem and self-concept.

ANSWER: 5 minutes ; RATIONALE: To completely determine that bowel sounds are absent, the nurse must auscultate each of the four quadrants for at least 5 minutes; 2, 3, or 4 minutes is too short a period to arrive at this conclusion.

ANSWER: Pain sensation is affected by a client’s anticipation of pain ; RATIONALE: Phases of pain experience include the anticipation of pain. Fear and anxiety affect a person’s response to sensation and typically intensify the pain. Intractable pain is moderate to severe pain that cannot be relieved by any known treatment. Pain is a subjective sensation that cannot be quantified by anyone except the person experiencing it. Psychological factors contribute to a client’s pain perception. In many cases, pain results from emotions, such as hostility, guilt, or depression.

ANSWER: The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter ; RATIONALE: The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is methicillin-resistant staphylococcus aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. The clients in answers A, B, and C are more stable and can be seen later.

ANSWER: Breaks down fat into fatty acids and glycerol ; RATIONALE: Lipase hydrolyses or breaks down fat into fatty acids and glycerol. Lipase is not involved with the transport of fatty acids into the brush border. Fat itself triggers cholecystokinin release. Protein breakdown into dipeptides and amino acids is the function of trypsin, not lipase.

ANSWER: Buccal cyanosis and capillary refill greater than 3 seconds ; RATIONALE: Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased oxygen to the tissues, which requires immediate intervention. Alert and oriented, clear breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and leukocyte count of 5,300/mm3 are normal data.

ANSWER: “When can I get my epidural?” ; RATIONALE: Dilation of 2 cm marks the end of the latent phase of labor. Answer A is a vague answer, answer B indicates the end of the first stage of labor, and answer C indicates the transition phase.

ANSWER: Control and distraction ; RATIONALE: The mothers actions are example of control and distraction. Involving the child in care and providing distraction took his mind off the pain. Pharmacologic agents for pain analgesics — were not used. The home environment was not changed, and cutaneous stimulation, such as massage, vibration, or pressure, was not used.

ANSWER: Store the hearing aid in a warm place. ; RATIONALE: The hearing aid should be stored in a warm, dry place. It should be cleaned daily but should not be moldy, so answer A is incorrect. A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aide, making answer C incorrect. Changing the batteries weekly, as in answer D, is not necessary.

ANSWER: The nurse wears gloves to take the client’s vital signs. ; RATIONALE: It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant staphylococcus aureus, gloves should be worn. The health care workers in answers A, B, and C indicate knowledge of infection control by their actions.

ANSWER: Promotive, preventive, and restorative health practices ; RATIONALE: The health-beliefs assessment includes expectations of health care; promotive, preventive, and restorative practices, such as breast self-examination, testicular examination, and seat-belt use; and how the client perceives illness. Use of medications provides information about the client’s personal habits. Educational level, financial status, and family role and relationship patterns represent information associated with role and relationship patterns.

ANSWER: The client receiving linear accelerator radiation therapy for lung cancer ; RATIONALE: The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department, so the client is not radioactive. The clients in answers B, C, and D pose a risk to the pregnant nurse. These clients are radioactive in very small doses, especially upon returning from the procedures. For approximately 72 hours, the clients should dispose of urine and feces in special containers and use plastic spoons and forks.

ANSWER: Left foot cold to touch; no palpable pedal pulse ; RATIONALE: A left foot cold to touch without palpable pedal pulse represents an abnormal finding on neurovascular assessment of the left leg. The client is most likely experiencing some complication from surgery, which requires immediate medical intervention. The nurse should notify the health care provider of these findings. A dry and intact hip dressing, blood pressure of 114/78 mm Hg, pulse rate of 82 beats per minute, and a left foot in functional anatomic position are all normal assessment findings that do not require medical intervention.

ANSWER: Hand tremors ; RATIONALE: Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to assess for signs of neurological involvement. Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common. These clients typically have ascites and edema so experience weight gain. Malaise and stomatitis are not related to neurological involvement.

ANSWER: Serum potassium level of 3.1 mEq/L ; RATIONALE: A normal potassium level is 3.5 to 5.5 mEq/L. A normal sodium level is 135 to 145 mEq/L, a normal nonfasting glucose level is 85 to 140 mg/dl, and a normal creatinine level is 0.2 to 0.8 mg/100 ml.

ANSWER: Progressive cervical dilation ; RATIONALE: The expected effect of Pitocin is cervical dilation. Pitocin causes more intense contractions, which can increase the pain, making answer A incorrect. Cervical effacement is caused by pressure on the presenting part, so answer B is incorrect. Answer C is opposite the action of Pitocin.

ANSWER: The client’s hematocrit is 26%. ; RATIONALE: The client with a total knee replacement should be assessed for anemia. A hematocrit of 26% is extremely low and might require a blood transfusion. Bleeding of 2cm on the dressing is not extreme. Circle and date and time the bleeding and monitor for changes in the client’s status. A low-grade temperature is not unusual after surgery. Ensure that the client is well hydrated, and recheck the temperature in 1 hour. If the temperature is above 101°F, report this finding to the doctor. Tylenol will probably be ordered. Voiding after surgery is also not uncommon and no need for concern; therefore answers A, B, and D are incorrect.

ANSWER: Documenting precise intake and output ; RATIONALE: For the client with ascites receiving diuretic therapy, careful intake and output measurement is essential for safe diuretic therapy. Diuretics lead to fluid losses, which if not monitored closely and documented, could place the client at risk for serious fluid and electrolyte imbalances. Hypokalemia, not hyperkalemia, commonly occurs with diuretic therapy. Because urine output increases, a client should be assessed for hypovolemia, not hypervolemia. Weights are also an accurate indicator of fluid balance. However, for this client, weights should be obtained daily, not weekly.

ANSWER: Disalignment ; RATIONALE: The client with a hip fracture will most likely have misalignment. Answers A, C, and D are incorrect because all fractures cause pain, and coolness of the extremities and absence of pulses are indicative of compartment syndrome or peripheral vascular disease.

ANSWER: The buttocks are 15° off the bed. ; RATIONALE: The infant’s hips should be off the bed approximately 15° in Bryant’s traction. Answer A is incorrect because this does not indicate that the traction is working correctly, nor does C. Answer D is incorrect because Bryant’s traction is a skin traction, not a skeletal traction.

ANSWER: Apply the fetal heart monitor ; RATIONALE: Applying a fetal heart monitor is the correct action at this time. There is no need to prepare for a Caesarean section or to place the client in Genupectoral position (knee-chest), so answers A and C are incorrect. Answer D is incorrect because there is no need for an ultrasound based on the finding.

ANSWER: Auscultation immediately after inspection and then percussion and palpation ; RATIONALE: With an abdominal assessment, auscultation always is performed before percussion and palpation because any abdominal manipulation, such as from palpation or percussion, can alter bowel sounds. Percussion should never precede inspection or auscultation, and any tender or painful areas should be palpated last.

ANSWER: Assisting the LPN with opening sterile packages and peroxide ; RATIONALE: The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. A licensed practical nurse can perform pin care, there is no need to clean the weights, and the nurse can help with opening the packages but it isn’t required; therefore, answers B, C, and D are incorrect.

ANSWER: Inserting the otoscope superiorly into the proximal two-thirds of the external canal ; RATIONALE: In the superior position, the speculum of the otoscope is nearest the tympanic membrane, and the most sensitive portion of the external canal is the proximal two-thirds. It is important to avoid these structures during the examination. Tipping the client’s head away from the examiner, pulling the ear up and back, inserting the otoscope inferiorly, and bracing the examiner’s hand against the client’s head are all appropriate techniques used during an otoscopic examination.

ANSWER: Turn and reposition every 2 hours ; Alternating air pressure mattress ; RATIONALE: Edematous tissue must receive meticulous care to prevent tissue breakdown. Range of motion exercises preserve joint function but do not prevent skin breakdown. Abdominal or foot massage will not prevent skin breakdown but must be cleansed carefully to prevent breaks in skin integrity. The feet should be kept at the level of heart or higher so Fowler’s position should be employed. An air pressure mattress, careful repositioning can prevent skin breakdown.

ANSWER: “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.” ; RATIONALE: Remember the ABCs (airway, breathing, circulation) when answering this question. Answer C because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. Answers A, B, and C are incorrect because white grape juice, a grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child.

ANSWER: The client is oriented to time, place, and person. ; RATIONALE: Hepatic coma is the most advanced stage of hepatic encephalopathy. As hepatic coma resolves, improvement in the client’s level of consciousness occurs. The client should be able to express orientation to time, place, and person. Ecchymotic areas are related to decreased synthesis of clotting factors. Although oral intake may be related to level of consciousness, it is more closely related to anorexia. The serum albumin level reflects hepatic synthetic ability, not level of consciousness.

ANSWER: A tracheostomy set ; RATIONALE: For a child with epiglottitis and the possibility of complete obstruction of the airway, emergency tracheostomy equipment should always be kept at the bedside. Intravenous supplies, fluid, and oxygen will not treat an obstruction; therefore, answers A, C, and D are incorrect.

ANSWER: Mitral area ; RATIONALE: The mitral area (also known as the left ventricular area or the apical area), the fifth intercostal space (ICS) at the left midclavicular line, is the best area for auscultating the apical pulse. The aortic arch is the second ICS to the right of sternum. The pulmonic area is the second intercostal space to the left of the sternum. The tricuspid area is the fifth ICS to the left of the sternum.

ANSWER: Checking the client’s blood pressure; RATIONALE: Following epidural anesthesia, the client should be checked for hypotension and signs of shock every 5 minutes for 15 minutes. The client can be checked for cervical dilation later after she is stable. The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing. Fetal heart tones should be assessed after the blood pressure is checked. Therefore, answers A, B, and D are incorrect.

ANSWER: The client with Cushing’s disease ; RATIONALE: The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immunosuppressed. In answer B, the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hyperthyroidism or myxedema and poses no risk to others or himself.

ANSWER: decreased size of the nose and ears. ; RATIONALE: The nose and ears of the aging client actually become longer and broader. The chin line is also altered. Wrinkles on the face become more pronounced and tend to take on the general mood of the client over the years. For example laugh or frown wrinkles about the eyebrows, lips, cheeks, and outer edges of the eye orbit. The change in the androgen-estrogen ratio causes an increase in growth of facial hair in most older adults. The aging process shortens the platysma muscle, which contributes to neck wrinkles.

ANSWER: Palpating the pedal pulses ; RATIONALE: Palpating the client’s pedal pulses assists in determining if arterial blood supply to the lower extremities is sufficient. Assessing the medial malleoli for pitting edema is appropriate for assessing venous function of the lower extremity. Allen’s test is used to evaluate arterial blood flow before inserting an arterial line in an upper extremity or obtaining arterial blood gases. Homans’ sign is used to evaluate the possibility of deep vein thrombosis.

ANSWER: Passage of two or three soft stools daily ; RATIONALE: Lactulose reduces serum ammonia levels by inducing catharsis, subsequently decreasing colonic pH and inhibiting fecal flora from producing ammonia from urea. Ammonia is removed with the stool. Two or three soft stools daily indicate effectiveness of the drug. Watery diarrhea indicates overdose. Daily deterioration in the client’s handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy. Frothy, foul-smelling stools indicate steatorrhea, caused by impaired fat digestion.

ANSWER: Report chest pain. ; RATIONALE: Cox II inhibitors have been associated with heart attacks and strokes. Any changes in cardiac status or signs of a stroke should be reported immediately, along with any changes in bowel or bladder habits because bleeding has been linked to use of Cox II inhibitors. The client does not have to take the medication with milk, remain upright, or allow 6 weeks for optimal effect, so answers A, C, and D are incorrect.

ANSWER: Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep ; RATIONALE: Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrape the skin, collect a stool specimen, or bring a sample of hair, so answers B, C, and D are incorrect.

ANSWER: Standing close to provide support ; RATIONALE: During Romberg’s test, the client is asked to stand with feet together and eyes shut and still maintain balance with the minimum of sway. If the client loses his balance, the nurse standing close to provide support, such as having an arm close around his shoulder, can prevent a fall. Allowing the client to keep his eyes open, spread his feet apart, or hang on to a piece of furniture interferes with the proper execution of the test and yields invalid results.

ANSWER: Oral ; RATIONALE: Gloves should be worn any time there is a risk of exposure to the client’s blood or body fluids. Oral, rectal, and genital examinations require gloves because they involve contact with body fluids. Ophthalmic, breast, or integumentary examinations normally do not involve contact with the client’s body fluids and do not require the nurse to wear gloves for protection. However, if there are areas of skin breakdown or drainage, gloves should be used.

ANSWER: Turn the client to her left side ; RATIONALE: The normal fetal heart rate is 120–160 bpm; 100–110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Answer A is not indicated at this time. Answer C is not the best action for clients experiencing bradycardia. There is no data to indicate the need to move the client to the delivery room at this time.

ANSWER: The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops. ; RATIONALE: Before instilling eye drops, the nurse should cleanse the area with water. A 6-year-old child is not developmentally ready to instill his own eyedrops, so answer B is incorrect. Although the mother of the child can instill the eyedrops, the area must be cleansed before administration, making answer C incorrect. Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered, so answer D is incorrect.

ANSWER: The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm ; RATIONALE: The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. The clients in answers A, C, and D need to be placed in separate rooms due to the serious natures of their injuries.

ANSWER: File a formal reprimand ; RATIONALE: The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance. Therefore, Answers A, C, and D are incorrect.

ANSWER: Low-fat, high-carbohydrate meals ; RATIONALE: For the client with cholecystitis, fat intake should be reduced. The calories from fat should be substituted with carbohydrates. Reducing carbohydrate intake would be contraindicated. Any diet high in fat may lead to another attack of cholecystitis.

ANSWER: The RN with 3 years of experience in labor and delivery ; RATIONALE: The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. The nurse in answer A is a new nurse to the unit, and the nurses in answers C and D have no experience with the postpartum client.

ANSWER: “Is there anything else you would like to tell me?” ; RATIONALE: By asking the client if there is anything else, the nurse allows the client to end the interview by discussing feelings and concerns. Asking about what brought the client to the clinic is an ambiguous question to which the client may answer “my car” or any similarly disingenuous reply. Asking if the client describes his overall health as good is a leading question that puts words in his mouth. Asking if the client understands what is happening is a yes-or-no question that can elicit little information.

ANSWER: Adequate bed rest ; RATIONALE: Treatment of hepatitis consists of bed rest during the acute phase to reduce metabolic demands on the liver, thus increasing blood supply and cell regeneration. Forcing fluids, antibiotics, and bland diets are not part of the treatment plan for viral hepatitis.

ANSWER: Allows 24 hours before bearing weight ; RATIONALE: A plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24 hours. The cast should be handled with the palms, not the fingertips, so answer A is incorrect. Petaling a cast is covering the end of the cast with cast batting or a sock, to prevent skin irritation and flaking of the skin under the cast, making answer B incorrect. The client should be told not to dry the cast with a hair dryer because this causes hot spots and could burn the client. This also causes unequal drying; thus, answer C is incorrect.

ANSWER: The client has a grand mal seizure. ; RATIONALE: During ECT, the client will have a grand mal seize. This indicates completion of the electroconvulsive therapy. Answers A, B, and C do not indicate that the ECT has been effective, so are incorrect.

ANSWER: Counseling to stop alcohol consumption ; RATIONALE: Chronic pancreatitis typically results from repeated episodes of acute pancreatitis. More than half of chronic pancreatitis cases are associated with alcoholism. Counseling to stop alcohol consumption would be the most helpful for the client. Dietary protein modification is not necessary for chronic pancreatitis. Daily exercise and liberalizing fluid intake would be helpful but not the most beneficial intervention.

ANSWER: The client continues normal growth and development with intact support systems. ; RATIONALE: Even though the client may experience an aftermath phase, progress is still possible, as is effective rehabilitation. Aftermath reactions may occur but need not interfere with rehabilitation. Acute pain is not expected at this stage of recovery. Conditioning probably would produce less pain tolerance.

ANSWER: Referred pain ; RATIONALE: Referred pain is pain occurring at one site that is perceived in another site. Referred pain follows dermatome and nerve root patterns. Phantom pain refers to pain in a part of the body that is no longer there, such as in amputation. Intractable pain refers to moderate to severe pain that cannot be relieved by any known treatment. Aftermath of pain, a phase of the pain experience and the most neglected phase, addresses the client’s response to the pain experience.