1.
A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client’s:
Correct Answer
B. Gag reflex
Explanation
The client’s gag reflex is depressed before having an EGD. The nurse should give priority to checking for the return of the gag reflex before offering the client oral fluids. Level of consciousness is incorrect because conscious sedation is used. Urinary output and movement of extremities are not affected by the procedure; therefore, they are incorrect.
2.
Which instruction should be included in the discharge teaching for the client with cataract surgery?
Correct Answer
B. The eye shield should be worn at night.
Explanation
The eye shield should be worn at night or when napping, to prevent accidental trauma to the operative eye. Prescription eyedrops, not over-the-counter eyedrops, are ordered for the client. The client might or might not require glasses following cataract surgery. Cataract surgery is pain free.
3.
An 8-year-old is admitted with drooling, muffled phonation, and a temperature of 102°F. The nurse should immediately notify the doctor because the child’s symptoms are suggestive of:
Correct Answer
B. Epiglottitis
Explanation
The child’s symptoms are consistent with those of epiglottitis, an infection of the upper airway that can result in total airway obstruction. Symptoms of strep throat, laryngotracheobronchitis, and bronchiolitis are different than those presented by the client.
4.
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
Correct Answer
A. Offer the baby sterile water between feedings of formula
Explanation
Providing additional fluids will help the newborn eliminate excess bilirubin in the stool and urine. Oils and lotions should not be used with phototherapy. Physiologic jaundice is not associated with infection; therefore, wearing a gown, gloves, and a mask and placing the baby on enteric isolation are incorrect.
5.
A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client’s plan of care?
Correct Answer
B. Having a staff member remain with her for 1 hour after she eats
Explanation
Having a staff member remain with the client for 1 hour after meals will help prevent self-induced vomiting. Weighing the client after she eats is incorrect because the client will weigh more after meals, which can undermine treatment. Placing high-protein foods in the center of the client’s plate is incorrect because the client will need a balanced diet and excess protein might not be well tolerated at first. Providing the client with child-size utensils is incorrect because it treats the client as a child rather than as an adult.
6.
According to Erickson’s stage of growth and development, the developmental task associated with middle childhood is:
Correct Answer
D. Industry
Explanation
According to Erikson’s Psychosocial Developmental Theory, the developmental task of middle childhood is industry versus inferiority. Trust is incorrect because it is the developmental task of infancy. Initiative is incorrect because it is the developmental task of the school-age child. Independence is incorrect because it is not one of Erikson’s developmental stages.
7.
The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
Correct Answer
B. Nausea
Explanation
A side effect of bronchodilators is nausea. Tinnitus and ataxia are not associated with bronchodilators; therefore, they are incorrect. Hypotension is incorrect because hypotension is a sign of toxicity, not a side effect.
8.
The 5-minute Apgar of a baby delivered by C-section is recorded as 9. The most likely reason for this score is:
Correct Answer
C. Cyanosis of the hands and feet
Explanation
Although cyanosis of the hands and feet is common in the newborn, it accounts for an Apgar score of less than 10. The mottled appearance of the trunk suggests cooling, which is not scored by the Apgar. The presence of conjunctival hemorrhages is incorrect because conjunctival hemorrhages are not associated with the Apgar. Respiratory rate of 20–28 per minute is incorrect because it is within normal range as measured by the Apgar.
9.
A 5-month-old infant is admitted to the ER with a temperature of 6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
Correct Answer
B. Tenseness of the anterior fontanel
Explanation
Tenseness of the anterior fontanel indicates an increase in intracranial pressure. Periorbital edema is incorrect because periorbital edema is not associated with meningitis. Positive Babinski reflex is incorrect because a positive Babinski reflex is normal in the infant. Negative scarf sign is incorrect because it relates to the preterm infant, not the infant with meningitis.
10.
A client with a bowel resection and anastamosis returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suction is working properly?
Correct Answer
A. The client’s abdomen is soft.
Explanation
Nasogastric suction decompresses the stomach and leaves the abdomen soft and nondistended. The client is able to swallow is incorrect because it does not relate to the effectiveness of the NG suction. The client has active bowel sounds is incorrect because it relates to peristalsis, not the effectiveness of the NG suction. The client’s abdominal dressing is dry and intact is incorrect because it relates to wound healing, not the effectiveness of the NG suction.
11.
The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia?
Correct Answer
A. Tremulousness
Explanation
Tremulousness is an early sign of hypoglycemia. Other answer choices are incorrect because they are symptoms of hyperglycemia.
12.
Which of the following symptoms is associated with exacerbation of multiple sclerosis?
Correct Answer
C. Diplopia
Explanation
The most common sign associated with exacerbation of multiple sclerosis is double vision. Other answer choices are not associated with a diagnosis of multiple sclerosis; therefore, they are incorrect.
13.
Which of the following conditions is most likely related to the development of renal calculi?
Correct Answer
A. Gout
Explanation
Gout and renal calculi are the result of increased amounts of uric acid. Pancreatitis is incorrect because it does not contribute to renal calculi.Fractured femur and disc disease can result from decreased calcium levels. Renal calculi are the result of excess calcium.
14.
A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
Correct Answer
D. Providing small, frequent meals
Explanation
Providing small, frequent meals will improve the client’s appetite and help reduce nausea. Thoroughly cooking all foods is incorrect because it does not compensate for limited absorption. Foods and beverages containing live cultures are discouraged for the immune-compromised client; therefore, offering yogurt and buttermilk incorrect. Forcing fluids is incorrect because forcing fluids will not compensate for limited absorption of the intestine.
15.
The treatment protocol for a client with acute lymphatic leukemia includes prednisone, methotrexate, and cimetadine. The purpose of the cimetadine is to:
Correct Answer
D. Prevent a common side effect of prednisone
Explanation
A common side effect of prednisone is gastric ulcers. Cimetadine is given to help prevent the development of ulcers. Other answer choices do not relate to the use of cimetadine; therefore, they are incorrect.
16.
Which of the following meal choices is suitable for a 6-month-old infant?
Correct Answer
C. Rice cereal, apple juice, formula
Explanation
Rice cereal, apple juice, and formula are suitable foods for the 6-month-old infant. Whole milk, orange juice, and eggs are not suitable for the young infant.
17.
The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:
Correct Answer
B. Vastus lateralis muscle
Explanation
The nurse should administer the injection in the vastus lateralis muscle. Rectus femoris muscle and deltoid muscle are not as well developed in the newborn; therefore, they are incorrect. Answer dorsogluteal muscle is incorrect because the dorsogluteal muscle is not used for IM injections until the child is 3 years of age.
18.
The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephotic syndrome. The nurse should:
Correct Answer
A. Encourage the client to drink extra fluids
Explanation
The client taking Cytoxan should increase his fluid intake to prevent hemorrhagic cystitis. Other answer choices do not relate to the question; therefore, they are incorrect.
19.
The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?
Correct Answer
D. Ativan (lorazepam)
Explanation
Benzodiazepines are ordered for the client in alcohol withdrawal to prevent delirium tremens. Antabuse (disulfiram) is incorrect because it is a medication used in aversive therapy to maintain sobriety.Romazicon (flumazenil) is incorrect because it is used for the treatment of benzodiazepine overdose. Dolophine (methodone) is incorrect because it is the treatment for opiate withdrawal.
20.
A client with insulin-dependent diabetes takes 20 units of NpH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
Correct Answer
C. 3 p.m.
Explanation
The client taking NPH insulin should have a snack midafternoon to prevent hypoglycemia. 8 a.m. and 10 a.m. are incorrect because the times are too early for symptoms of hypoglycemia. 5 a.m. is incorrect because the time is too late and the client would be in severe hypoglycemia.
21.
The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?
Correct Answer
B. Alteration in mobility
Explanation
The client with a detached retina will have limitations in mobility before and after surgery. Alteration in comfort is incorrect because a detached retina produces no pain or discomfort. Alteration in skin integrity and alteration in O2 perfusion do not apply to the client with a detached retina; therefore, they are incorrect.
22.
The primary purpose for using a CPM machine for the client with a total knee repair is to help:
Correct Answer
B. Promote flexion of the artificial joint
Explanation
The primary purpose for the continuous passive-motion machine is to promote flexion of the artificial joint. The device should be placed at the foot of the client’s bed. Other answer choices do not describe the purpose of the CPM machine; therefore, they are incorrect.
23.
Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?
Correct Answer
D. Behavior is determined by consequences.
Explanation
According to Kohlberg, in the preconventional stage of development, the behavior of the preschool child is determined by the consequences of the behavior. Other answer choices describe other stages of moral development; therefore, they are incorrect.
24.
A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
Correct Answer
C. Document that the infection has completely cleared
Explanation
The client should be assessed following completion of antibiotic therapy to determine whether the infection has cleared. Determine whether the ear infection has affected her hearing would be done if there are repeated instances of otitis media; therefore, it is incorrect. Make sure that she has taken all the antibiotic is incorrect because it will not determine whether the child has completed the medication. Obtain a new prescription in case the infection recurs is incorrect because the purpose of the recheck is to determine whether the infection is gone.
25.
A factory worker is brought to the nurse’s office after a metal fragment enters his right eye. The nurse should:
Correct Answer
D. Cover both eyes and transport the client to the ER
Explanation
The nurse should cover both of the client’s eyes and transport him immediately to the ER or the doctor’s office. Other answer choices are incorrect because they increase the risk of further damage to the eye.