1.
A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty:
Correct Answer
D. Expressing anger toward others
Explanation
The suicidal client has difficulty expressing anger toward others. The depressed suicidal client frequently expresses feelings of low self-worth, feelings of remorse and guilt, and a dependence on others.
2.
A client receiving hydrochlorothiazide is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:
Correct Answer
D. Banana
Explanation
Other answer choices are incorrect because they contain lower amounts of potassium. (Note that the banana contains 450mg K+, the orange contains 235mg K+, the pear contains 208mg K+, and the apple contains 165mg K+.)
3.
The nurse is caring for a client following removal of the thyroid. Immediately post-op, the nurse should:
Correct Answer
A. Maintain the client in a semi-Fowler’s position with the head and neck supported by pillows
Explanation
Following a thyroidectomy, the client should be placed in semi-Fowler’s position to decrease swelling that would place pressure on the airway. Other answer choices are incorrect because they would increase the chances of post-operative complications that include bleeding, swelling, and airway obstruction.
4.
A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer?
Correct Answer
D. Luncheon meats
Explanation
Luncheon meats contain preservatives such as nitrites that have been linked to gastric cancer. Other answer choices have not been found to increase the risk of gastric cancer; therefore, they are incorrect.
5.
A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client’s record, the nurse could expect to find:
Correct Answer
C. A history of cruelty to animals
Explanation
A history of cruelty to people and animals, truancy, setting fires, and lack of guilt or remorse are associated with a diagnosis of conduct disorder in children, which becomes a diagnosis of antisocial personality disorder in adults. The client with antisocial personality disorder does not hold consistent employment, IQ is usually higher than average and lack of guilt or remorse for wrong-doing.
6.
The licensed vocational nurse may not assume the primary care for a client:
Correct Answer
C. With a venous access device
Explanation
The licensed vocational nurse may not assume primary care of the client with a central venous access device. The licensed vocational nurse may care for the client in labor, the client post-operative client, and the client with bipolar disorder.
7.
The physician has ordered dressings with Sulfamylon cream for a client with full-thickness burns of the hands and arms. Before dressing changes, the nurse should give priority to:
Correct Answer
A. Administering pain medication
Explanation
Sulfamylon produces a painful sensation when applied to the burn wound; therefore, the client should receive pain medication before dressing changes. Other answer choices do not pertain to dressing changes for the client with burns, so they are incorrect.
8.
The nurse is teaching a group of parents about gross motor development of the toddler. Which behavior is an example of the normal gross motor skill of a toddler?
Correct Answer
A. She can pull a toy behind her.
Explanation
According to the Denver Developmental Screening Test, the child can pull a toy behind her by age 2 years. Other answer choices are not accomplished until ages 4–5 years; therefore, they are incorrect.
9.
A client hospitalized with a fractured mandible is to be discharged.
Which piece of equipment should be kept on the client with a fractured
mandible?
Correct Answer
A. Wire cutters
Explanation
The client with a fractured mandible should keep a pair of wire cutters with him at all times to release the device in case of choking or aspiration. Answer B is incorrect because the wires would prevent insertion of an oral airway. Answer C is incorrect because it would be of no use in releasing the wires. Answer D is incorrect because it would be used only as a last resort in case of airway obstruction.
10.
The nurse is to administer digoxin elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of The nurse should:
Correct Answer
B. Record the heart rate and administer the medication
Explanation
The infant’s apical heart rate is within the accepted range for administering the medication. Other answer choices are incorrect because the apical heart rate is suitable for giving the medication.
11.
A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse’s explanation is based on the knowledge that lead poisoning is treated with:
Correct Answer
B. Chelating agents
Explanation
Chelating agents are used to treat the client with poisonings from heavy metals such as lead and iron. Gastric lavage and activated charcoal are used to remove noncorrosive poisons; therefore, they are incorrect. Antiemetics prevents vomiting; therefore, it is an incorrect response.
12.
An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are:
Correct Answer
A. Elbow restraints
Explanation
The least restrictive restraint for the infant with cleft lip and cleft palate repair is elbow restraints. Other answer choices are more restrictive and unnecessary; therefore, they are incorrect.
13.
A client with glaucoma has been prescribed Timoptic (timolol) eyedrops. Timoptic should be used with caution in the client with a history of:
Correct Answer
C. EmpHysema
Explanation
Beta blockers such as timolol (Timoptic) can cause bronchospasms in the client with chronic obstructive lung disease. Timoptic is not contraindicated for use in clients with diabetes, gastric ulcers, or pancreatitis.
14.
An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client’s confusion by:
Correct Answer
D. Leaving a nightlight on during the evening and night shifts
Explanation
Leaving a nightlight on during the evening and night shifts helps the client remain oriented to the environment and fosters independence. Assigning a nursing assistant to sit with him until he falls asleep and allowing the client to room with another elderly client will not decrease the client’s confusion. Administering a bedtime sedative will increase the likelihood of confusion in an elderly client.
15.
Which of the following is a common complaint of the client with end-stage renal failure?
Correct Answer
B. Itching
Explanation
Pruritis or itching is caused by the presence of uric acid crystals on the skin, which is common in the client with end-stage renal failure. Other answer choices are not associated with end-stage renal failure.
16.
Which of the following medication orders needs further clarification?
Correct Answer
C. Coumadin 10mg PO
Explanation
There is no specified time or frequency for the ordered medication. Other answer choices contain specified time and frequency.
17.
The best diet for the client with Meniere’s syndrome is one that is:
Correct Answer
B. Low in sodium
Explanation
A low-sodium diet is best for the client with Meniere’s syndrome. Other answer choices do not relate to the care of the client with Meniere’s syndrome; therefore, they are incorrect.
18.
Which of the following findings is associated with right-sided heart failure?
Correct Answer
B. Nocturnal polyuria
Explanation
Increased voiding at night is a symptom of right-sided heart failure. Shortness of breath and crackles in the lungs are incorrect because they are symptoms of left-sided heart failure. Daytime oliguria does not relate to the client’s diagnosis; therefore, it is incorrect.
19.
An 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should:
Correct Answer
D. Place the probe on the child’s finger
Explanation
The pulse oximeter should be placed on the child’s finger or earlobe because blood flow to these areas is most accessible for measuring oxygen concentration. Placing the probe on the child’s abdomen is incorrect because the probe cannot be secured to the abdomen. Recalibrating the oximeter at the beginning of each shift is incorrect because it should be recalibrated before application. Applying the probe and wait 15 minutes before obtaining a reading is incorrect because a reading is obtained within seconds, not minutes.
20.
An infant with Tetralogy of Fallot is discharged with a prescription for lanoxin elixir. The nurse should instruct the mother to:
Correct Answer
B. Administer the medication using the calibrated dropper in the bottle
Explanation
The medication should be administered using the calibrated dropper that comes with the medication. Administering the medication using a nipple and administering the medication using a plastic baby spoon are incorrect because part or all of the medication could be lost during administration. Administering the medication in a baby bottle with 1oz. of water is incorrect because part or all of the medication will be lost if the child does not finish the bottle.
21.
The client scheduled for electroconvulsive therapy tells the nurse, "I’m so afraid. What will happen to me during the treatment?" Which of the following statements is most therapeutic for the nurse to make?
Correct Answer
A. "You will be given medicine to relax you during the treatment."
Explanation
The client will receive medication that relaxes skeletal muscles and produces mild sedation. "The treatment will produce a controlled grand mal seizure." and "You can expect to be sleepy and confused for a time after the treatment." statements are incorrect because it increase the client’s anxiety level. Nausea and headache are not associated with ECT.
22.
Which of the following skin lesions is associated with Lyme’s disease?
Correct Answer
A. Bull’s eye rash
Explanation
Lyme’s disease produces a characteristic annular or circular rash sometimes described as a "bull’s eye" rash. Other answer choices are incorrect because they are not symptoms associated with Lyme’s disease.
23.
Which of the following snacks would be suitable for the child with gluten-induced enteropathy?
Correct Answer
B. Buttered popcorn
Explanation
The client with gluten-induced enteropathy experiences symptoms after ingesting foods containing wheat, oats, barley, or rye. Corn or millet are substituted in the diet. Other answer choices are incorrect because they contain foods that worsen the client’s condition.
24.
A client with schizophrenia is receiving chlorpromazine (Thorazine) 400mg twice a day. An adverse side effect of the medication is:
Correct Answer
B. Elevated temperature
Explanation
Neuroleptic malignant syndrome is an adverse reaction that is characterized by extreme elevations in temperature. Photosensitivity and weight gain are incorrect because they are expected side effects. Elevations in blood pressure are associated with reactions between foods containing tyramine and MAOI.
25.
Which information should be given to the client taking phenytoin (Dilantin)?
Correct Answer
C. More frequent dental appointments will be needed for special gum care.
Explanation
Gingival hyperplasia is a side effect of phenytoin. The client will need more frequent dental visits. Other answer choices do not apply to the medication; therefore, they are incorrect.