1.
A client with a history of emboli is receiving Lovenox (enoxaparin). Which drug is given to counteract the effects of enoxaparin?
Correct Answer
D. Protamine sulfate
Explanation
Protamine sulfate is given to counteract the effects of enoxaprin as well as heparin. Calcium gluconate is given to counteract the effects of magnesium sulfate. Aquamephyton is given to counteract the effects of sodium warfarin. Methargine is given to increase uterine contractions following delivery.
2.
The nurse is formulating a plan of care for a client with a cognitive disorder. Which activity is most appropriate for the client with confusion and short attention span?
Correct Answer
A. Taking part in a reality-orientation group
Explanation
Participating in reality orientation is the most appropriate activity for the client who is confused. Other answer choices are incorrect because they are not suitable activities for a client who is confused.
3.
The mother of a child with hemophilia asks the nurse which over-the-counter medication is suitable for her child’s joint discomfort. The nurse should tell the mother to purchase:
Correct Answer
B. Tylenol (acetaminopHen)
Explanation
The nurse should recommend acetaminophen for the child’s joint discomfort because it will have no effect on the bleeding time. Other answer choices are all nonsteroidal anti-inflammatory medications that can prolong bleeding time; therefore, they are not suitable for the child with hemophilia.
4.
Which home remedy is suitable to relieve the itching associated with varicella?
Correct Answer
D. Applying a paste of baking soda and water
Explanation
Applying a paste of baking soda and water soothes the itching and helps to dry the vesicles. The use of baby powder is not recommended for either children. Hydrogen peroxide and saline will not relieve the itching and will prevent the vesicles from crusting.
5.
A newborn male has been diagnosed with hypospadias with chordee. The nurse understands that the infant will have altered patterns of urination because:
Correct Answer
A. The urinary meatus is on the dorsum of the penis.
Explanation
The infant with hypospadias has altered patterns of urinary elimination caused by the location of the urinary meatus on the dorsum, or underside, of the penis. The ureters will reflux urine into the kidneys is incorrect because it refers to ureteral reflux.The urinary meatus is on the top of the penis is incorrect because it refers to epispadias. The bladder lies outside the abdominal cavity is incorrect because it refers to exstrophy of the bladder.
6.
The recommended time for administering Zantac (ranitidine) is:
Correct Answer
D. At bedtime
Explanation
Zantac (ranitidine) should be administered in one dose at bedtime or with meals. Other answer choices have incorrect times for dosing.
7.
Which statement best describes the difference between the pain of angina and the pain of myocardial infarction?
Correct Answer
A. Pain associated with angina is relieved by rest.
Explanation
Pain associated with angina is relieved by rest. Pain associated with angina can be referred to the jaw, the left arm, and the back. Pain from a myocardial infarction can be referred to areas other than the left arm.
8.
The nurse is developing a bowel-retraining plan for a client with multiple sclerosis. Which measure is likely to be least helpful to the client:
Correct Answer
A. Limiting fluid intake to 1000mL per day
Explanation
It would not be helpful to limit the fluid intake of a client during bowel retraining.
9.
The nurse is providing dietary teaching for a client with Meniere’s disease. Which statement indicates that the client understands the role of diet in triggering her symptoms?
Correct Answer
B. "I need to limit foods that taste salty or that contain a lot of sodium."
Explanation
The client with Meniere’s disease should limit the intake of foods that contain sodium. Other answer choices have no relationship to the symptoms of Meniere’s disease; therefore, they are incorrect.
10.
The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-induced hypertension and preeclampsia. The nurse should give priority to assessing the client for:
Correct Answer
A. Facial swelling
Explanation
The nurse should pay close attention to swelling in the client with preeclampsia. Facial swelling indicates that the client’s condition is worsening and blood pressure will be increased. Pulse deficits is not related to the question; therefore, it is incorrect. Ankle edema is incorrect because ankle edema is expected in pregnancy. Diminished reflexes are associated with the use of magnesium sulfate, which is the treatment of preeclampsia; therefore, diminished reflexes is incorrect.
11.
An adolescent with borderline personality is hospitalized with suicidal ideation and self-mutilation. Which goal is both therapeutic and realistic for this client?
Correct Answer
D. The client will seek out a staff member to verbalize feelings of anger and sadness.
Explanation
Verbalizing feelings of anger and sadness to a staff member is an appropriate therapeutic goal for the client with a risk of self-directed violence. Answers "The client will remain in her room when feeling overwhelmed by sadness" and " The client will leave group activities to pace when feeling anxious" place the client in an isolated situation to deal with her feelings alone; therefore, they are incorrect. Answer "The client will request medication when feeling loss of emotional control" is incorrect because it does not allow the client to ventilate her feelings.
12.
A client with angina has an order for nitroglycerin ointment. Before applying the medication, the nurse should:
Correct Answer
C. Remove the previously applied ointment
Explanation
The nurse should remove any remaining ointment before applying the medication again. Applying the ointment to the previous application is incorrect because it interferes with absorption. Obtaining both a radial and an apical pulse does not apply to the question of how to administer the medication; therefore, it is incorrect. Telling the client he will experience pain relief in 15 minutes is incorrect because the medication’s action is more immediate.
13.
The nurse is caring for a client who is unconscious following a fall. Which comment by the nurse will help the client become reoriented when he regains consciousness?
Correct Answer
D. "You were in an accident that hurt your head. You are in the hospital."
Explanation
Telling the client what happened and where he is helps with reorientation. The statement "I am your nurse and I will be taking care of you today." does not explain what happened to the client; therefore, it is incorrect. The statement "Can you tell me your name and where you are?" is not helpful because the client regaining consciousness will not know where he is; therefore, the answer is incorrect. The nurse should not offer false reassurances, such as "everything will be alright"; therefore, it is incorrect.
14.
Following a generalized seizure, the nurse can expect the client to:
Correct Answer
B. Be drowsy and prone to sleep
Explanation
Following a generalized seizure, the client frequently experiences drowsiness and postictal sleep. The client is able to move the extremities.The client can remember events before the seizure and the blood pressure is elevated.
15.
A client with oxylate renal calculi should be taught to avoid eating:
Correct Answer
A. Strawberries
Explanation
The client with oxylate renal calculi should avoid sources of oxylate, which include strawberries, rhubarb, and spinach. Other answer choices are incorrect because they are not sources of oxylate.
16.
A 6-year-old is diagnosed with Legg-Calve Perthes disease of the right femur. An important part of the child’s care includes instructing the parents:
Correct Answer
D. To prevent weight bearing on the affected leg
Explanation
The child with Legg-Calve Perthes disease should be prevented from bearing weight on the affected extremity until revascularization has occurred.Increasing the amount of dietary protein is incorrect because it does not relate to the condition. Instructing about exercises to strengthen affected muscles and relaxation exercises to minimize pain in the joints are incorrect choices because the condition does not involve the muscles or the joints.
17.
The nurse is assessing an infant with Hirschsprung’s disease. The nurse can expect the infant to:
Correct Answer
B. Have a scapHoid-shaped abdomen
Explanation
The child with Hirschsprung’s disease will have a scaphoid or hollowed abdomen. Other answer choices do not apply to the condition; therefore, they are incorrect.
18.
The physician has prescribed supplemental iron for a prenatal client. The nurse should tell the client to take the medication with:
Correct Answer
B. Tomato juice, to increase absorption
Explanation
Iron supplements should be taken with a source of vitamin C to promote absorption. Iron should not be taken with milk. High-fiber sources such as oatmeal prevent the absorption of iron. Water, to increase serum iron levels is an inaccurate statement; therefore, it is incorrect.
19.
The nurse is teaching a client with a history of obesity and hypertension regarding dietary requirements during pregnancy. Which statement indicates that the client needs further teaching?
Correct Answer
A. "I need to reduce my daily intake to 1,200 calories a day."
Explanation
The client does not need to drastically reduce her caloric intake during pregnancy. Doing so would not provide adequate nourishment for proper development of the fetus. Other answer choices indicate that the client understands the nurse’s dietary teaching regarding obesity and hypertension; therefore, they are incorrect.
20.
An elderly client is admitted to the psychiatric unit from the nursing home. Transfer information indicates that the client has become confused and disoriented, with behavioral problems. The client will also likely show a loss of ability in:
Correct Answer
B. Judgment
Explanation
Confusion, disorientation, behavioral changes, and alterations in judgment are early signs of dementia. Other answer choices do not relate to the question; therefore, they are incorrect.
21.
The physician has ordered an external monitor for a laboring client. If the fetus is in the left occipital posterior (LOP) position, the nurse knows that the ultrasound transducer will be located:
Correct Answer
C. Over the fetal back
Explanation
In the left occipital posterior position, the heart sounds will be heard loudest through the fetal back. Other answer choices are incorrect locations.
22.
A client develops tremors while withdrawing from alcohol. Which medication is routinely administered to lessen physiological effects of alcohol withdrawal?
Correct Answer
B. Klonopin (clonazepam)
Explanation
Benzodiazepines such as clonazepam and lorazepam are given to the client withdrawing from alcohol. Methodone is given to the client withdrawing from opiates.Naloxone is an antidote for narcotic overdose. Disufiram is used in aversive therapy for alcohol addiction.
23.
A client with Type II diabetes has an order for regular insulin 10 units SC each morning. The client’s breakfast should be served within:
Correct Answer
C. 30 minutes
Explanation
The client’s breakfast should be served within 30 minutes to coincide with the onset of the client’s regular insulin.
24.
A 10-year-old has an order for Demerol (meperidine) 35mg IM for pain. The medication is available as Demerol 50mg per ml. How much should the nurse administer?
Correct Answer
C. .7mL
Explanation
The nurse should administer .7mL of the medication. Other answer choices are incorrect because the dosage is incorrect.
25.
Which antibiotic is contraindicated for the treatment of infections in infants and young children?
Correct Answer
A. Tetracyn (tetracycline)
Explanation
Tetracycline is contraindicated for use in infants and young children because it stains the teeth and arrests bone development. Other answer choices are incorrect because they can be used to treat infections in infants and children.