Escuela

Nstra. SUPERVISED
Sra.
de La
Salette
DE
LAde
SALLE
Tapuac
District,
Dagupan
City
FINAL EXAM IN CA II
COMPETENCY APPRAISAL II

I. Write the correct answer in your test booklet. (Write your answer in capital
letters only and NO ERASURES.)
1.

An 8-year-old child is sent home by the school nurse with pediculosis. The child's father speaks with the nurse and is obviously
upset and embarrassed. Which of the following statements by the mother would indicate to the nurse that he understands how his
child got pediculosis?
A.
B.
C.
D.

"I brush her hair twice a day."

"Could this result from sharing batting helmets at T-ball practice?"
"I make sure she shampoos her hair daily."
"We always use a dandruff-control shampoo."
353.
2
2: Pediculosis, or head lice, is commonly spread by the sharing of headwear, combs, and brushes. The adult lice can also
travel from one person to another if contact is close. The adult lice lay eggs, or nits. These nits are "glued" to the hair and
cannot be removed unless treated with special shampoo formulated for just this purpose. The hair is then combed with a finetoothed comb to remove the nits. Because head lice spread so easily, a child is usually kept out of school until he or she is
treated and found to be free of nits. 1: Hairbrushing will not prevent pediculosis. 3: Cleanliness does not prevent the
acquisition of pediculosis. 4: Dandruff shampoos will not protect the child from head lice. (SR 2978)

2.

The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of
performing the examination is to discover:
A.
B.
C.
D.

cancerous lumps.
areas of thickness or fullness.
changes from previous self-examinations.
fibrocystic masses.
354.
3
Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can
diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are
fibrocystic as opposed to malignant. (SR 4622)

3.

A client has had a cerebrovascular accident (CVA). Because the CVA affected the left side of the client's brain, the nurse should
anticipate that the client would most likely experience:
A.
B.
C.
D.

Expressive aphasia.
Dyslexia.
Apraxia.
Agnosia.
356.
1
1: Broca's area, which controls expressive speech, is located on the left side of the brain. Therefore, a client with a
cerebrovascular accident in this area is likely to exhibit expressive or motor aphasia. 2: Dyslexia, the inability of a person with
normal vision to interpret written language, is thought to be due to a central nervous system defect in the ability to organize
graphic symbols. 3: Apraxia is the inability to perform purposeful movements in the absence or loss of motor power, sensation,
or coordination. 4: Agnosia is the loss of comprehension of auditory, visual, or other sensations despite an intact sensory
sphere. (SR 3206)

4.

The nurse inspects a client's back and notices small hemorrhagic spots. The nurse documents that the client has:
A.
B.
C.
D.

extravasation.
osteomalacia.
petechiae.
uremia.
357.
3
Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the
softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood. (SR 3952)

5.

Which of the following reasons, given by a mother who permits her preschool-aged child to sleep in the same bed (co-sleeping) as
the parents, requires further investigation by the nurse?
A.
B.
C.

"I am too tired to get up at night to check on the baby in the other room."
"This promotes bonding between us and our child."
"I slept with my parents when I was a small child."

D.

"I can be certain my husband is not being inappropriate."

358.
4
(4) This statement by the patient may indicate that she suspects her husband of child abuse and does not trust him to be alone
with the child. The statement requires further exploration. (1)(2)and (3). Co-sleeping, in which the parents allow the child to
sleep with them, is a relatively common and accepted practice, especially among Black, Hispanic and Asian families. Other
groups that are adopting co-sleeping include single parents, whose need for company may encourage the practice; working
parents, who desire the closeness at night that was lost during the day and parents who have had an issue about sleep or
separation in their past. (SR 5458)

6. A school-age child is admitted to the hospital with a diagnosis of acute lymphoblastic

leukemia. The nurse formulates a nursing diagnosis of Risk for infection. Which of the
following is the most effective way for the nurse to reduce the child's risk of infection?
A. Implementing reverse isolation
B. Maintaining standard precautions
C. Requiring staff and visitors to wear masks
D. Practicing thorough hand washing
ANSWER:
D
Acute lymphoblastic leukemia and its treatment cause immunosuppression.
Thorough hand washing is the single most effective way to prevent infection in an
immunosuppressed client. Reverse isolation doesn't significantly reduce the
incidence of infection in immunosuppressed clients; furthermore, isolation may
cause psychological stress. Standard precautions are intended mainly to protect
caregivers from contact with infectious matter, not to reduce the client's risk of
infection. Staff and others need not wear masks when visiting because most
infections are transmitted by direct contact. Instead of relying on masks and other
barrier methods, the nurse should keep persons with known infections out of the
client's room.
7. Upon admission of a four-year-old child to rule out leukemia, the parents ask the nurse
when they will know the diagnosis. The nurse's response is based on the knowledge
that the results of which of the following confirms leukemia?
A. Bone marrow aspiration
B. Complete blood count (CBC)
C. Lumbar puncture
D. Peripheral blood smear
ANSWER:
A
A bone marrow aspiration or biopsy confirms the diagnosis and type of leukemia
based on an examination of the actual cells.
B: Although a CBC may suggest leukemia (such as normal, elevated, or decreased
WBC count with immature cells, decreased RBC, and decreased platelet count), it
does not confirm the diagnosis.
C: A lumbar puncture is performed to rule out spread of leukemia cells to the
central nervous system once the diagnosis has been established.
D: Even though the peripheral blood smear is used to note immature blood cells, it
is not the definitive diagnostic test.
8. The nurse analyzes the laboratory values of a child with leukemia who is receiving
chemotherapy. The nurse notes that the platelet count is 20,000 cells/l. Based on
this laboratory result, which intervention will the nurse document in the plan of care?
A. Initiate protective isolation precautions.
B. Monitor the temperature every 4 hours.
C. Monitor closely for signs of infection.
D. Use a soft small toothbrush for mouth care.
ANSWER:
D
If a child is severely thrombocytopenic and has a platelet count less than 20,000
cells/l, precautions need to be taken because of the increased risk of bleeding.
The precautions include limiting activity that could result in head injury, using soft
toothbrushes or Toothettes, checking urine and stools for blood, and administering
stool softeners to prevent straining with constipation. In addition, suppositories and
rectal temperatures are avoided. Options A, B, and C are related to the prevention
of infection rather than bleeding.
2

9. A child with leukemia is to be sent home on a protocol that includes several

antineoplastics after an intrathecal administration of methotrexate. Before discharge
the nurse instructs the child's parents to:
A. Limit contact with peers because they tend to have communicable diseases
B. Return weekly for bone marrow aspiration to monitor effectiveness of therapy
C. Schedule routine laboratory screening to evaluate response to the medication
D. Withhold medications when nausea occurs to prevent additional episodes of
vomiting
ANSWER:
C
Blood tests indicate response to therapy; if the WBC count drops severely, therapy
may be temporarily halted.
A: These children receive therapy for extended periods, and prolonged isolation
from their peers may lead to destructive social isolation.
B: This is a very painful procedure and is not done weekly.
D: Nausea commonly occurs with this therapy; although antiemetic measures are
instituted, the drug is not withdrawn.
10. In addition to systemic chemotherapy, the nurse is aware that cranial radiation is
done on children with leukemia to:
A. Improve the quality of the child's life
B. Reduce the risk of systemic infection
C. Avoid metastasis to the lymphatic system
D. Prevent central nervous system involvement
ANSWER:
D
Cranial radiation destroys leukemic cells in the brain because chemotherapeutic
agents are poorly absorbed through the blood-brain barrier.
A: This is not the primary reason for the treatment; it is a curative measure.
B:This is not the reason for cranial radiation.
C:This is inaccurate; leukemia is an abnormality of the bone marrow and lymphatic
system.
11. A child with leukemia is complaining of nausea. A nurse suspects that the nausea
is related to the chemotherapy. The nurse, concerned about the child's nutritional
status, most appropriately would offer which of the following during this episode of
nausea?
A. The child's favorite foods
B. Cool, clear liquids
C. Low-protein foods
D. Low-calorie foods
ANSWER:
B
When the child is nauseated, offering cool, clear liquids is best because they are
soothing and better tolerated. One should not offer favorite foods when the child is
nauseated because foods eaten during times of nausea will be associated with
being sick. Supportive nutritional measures also should include oral supplements
with high-protein and high- calorie foods.
12.
A.
B.
C.
D.

The most common symptom associated with bladder cancer is:

Painless hematuria.
Decreasing urine output.
Burning on urination.
Frequent infections.
ANSWER:
A
Painless hematuria is the most common symptom associated with bladder cancer.
Bleeding from the lesions occurs fairly early in the disease process, but bladder
cancer is basically asymptomatic in early stages.
B: Bladder cancer is not related to renal function.
C: Burning on urination is associated with urinary tract infections.
D: Bladder cancer is not related to infection.

13. A client with carcinoma of the tonsils and enlarged lymph glands in the neck is
receiving chemotherapy following surgery. The nurse, recognizing the effects of
therapy, should check the client's laboratory reports, especially the:
A. Platelet count
B. Red blood cell count
C. White blood cell count
D. Hematocrit and hemoglobin
ANSWER:
C
Antineoplastic drugs depress bone marrow, which causes leukopenia; the client
must be protected from infection, which could cause death.
A: These may decrease as rapidly but complications can be limited with infusions
of platelets.
B: RBCs diminish slowly and can be easily replaced with a transfusion of packed
cells.
D: RBCs diminish slowly and can be easily replaced with a transfusion of packed
cells.
14. A client who is to receive radiation therapy for cancer says to the nurse, "My family
said I will get a radiation burn." The best response by the nurse would be:
A. "It will be no worse than a sunburn."
B. "A localized skin reaction usually occurs."
C. "Have they had experience with this type of radiation?"
D. "Daily application of an emollient will prevent the burn."
ANSWER:
B
Radiodermatitis occurs 3 to 6 weeks after the start of treatment.
A: The word burn should be avoided because it may increase anxiety.
C: This response does not address the client's concern.
D: Emollients are contraindicated; they may alter the calculated x-ray route and
injure normal tissue.
15. After a mastectomy for breast cancer, the nurse teaches the client how to avoid
the development of lymphedema. Which of the following instructions would be
included?
A. Applying an elastic bandage to the affected extremity.
B. Limiting range-of-motion exercises in the shoulder and elbow.
C. Elevating the affected arm on a pillow.
D. Taking diuretics as necessary to decrease swelling.
ANSWER:
C
The client should be taught to elevate the affected arm on a pillow to promote
venous return and lymphatic drainage of the area.
A: Applying an elastic bandage is inappropriate because constriction of the
extremity should be avoided.
B: Range-of-motion exercising is not limited. Rather, it is encouraged.
D: Diuretics are not used to control lymphedema.
16. The nurse is caring for a client who spontaneously aborted an 8-week-old fetus. The client is sobbing and moaning after the
expulsion of the fetus. A priority goal for this client is that she'll:
A.
B.
C.
D.

verbalize her feelings related to the pregnancy loss.

express decreased pain and increased comfort.
discuss the causes of the spontaneous abortion.
avoid sexual intercourse for at least 2 days.
16.
1
A pregnancy loss can precipitate the grieving process. Verbalizing her feelings about the pregnancy loss is important for the
client so that she may recover from the grief process. Expressing decreased pain and increased comfort is important but not a
priority at this time. Discussing the causes of the spontaneous abortion isn't helpful at this time. The client should avoid
inserting anything into the vagina for at least 2 weeks. (SR 4429)

17. Which of the following nursing diagnoses should the nurse use to best address the suicidal patient's feelings of despair?
A.
B.
C.
D.

Ineffective coping
Spiritual distress
Anxiety
Dysfunctional grieving

17.
2
(2)The nursing diagnosis of spiritual distress is appropriate for the suicidal client who is experiencing a lack of hope for the
future and a feeling of despair. (1)Ineffective coping may describe the individual's lack of problem-solving skills that led to the
suicidal ideation or intent, but is not related to feelings of despair. (3)Anxiety may be appropriate to describe the suicidal
client's concerns regarding the future. It may also be a response to a situational crisis. However, it does not best describe the
feelings of despair. (4)Dysfunctional grieving resulting from a loss may contribute to the person feeling isolated and confused
and lead to the suicidal feelings. However, spiritual distress better describes the individual's feeling of despair (SR 5499)
18. Which of the following statements best explains the common observation that health care personnel avoid terminally ill people?
A.
B.
C.
D.

The family members who are present can provide essential care.
Health care personnel do not understand their own feelings about death and dying.
The dying person requires minimal physical care to be comfortable.
To protect a person's right to die with dignity, it is best to avoid interrupting the client.
18.
2
2: Health care personnel may avoid the terminally ill client because they are uncomfortable about death and do not understand
their own feelings about dying. 1: Family members should not be expected to assume responsibility for the client's care, but
they should be involved in the client's care to the extent they desire. 3: Skilled and knowledgeable nursing care is required to
make a dying person comfortable. 4: Interrupting the client does not necessarily interfere with the right to die with dignity. (SR
3087)

19. The nurse is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:
A.
B.
C.
D.

sedation.
diarrhea.
vertigo.
urticaria.
19.
2
Diarrhea is a common physiological response to stress and anxiety. The other choices could also be related to stress and
anxiety but they don't occur as commonly as diarrhea. (SR 4238)

20. A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the
hospital in a daze without any outward display of emotions. The client is being admitted to the stress unit with the diagnosis of
Acute Stress Disorder. The client tells the nurse in a matter-of-fact manner that her husband is paraplegic, "but that's better than
total paralysis." Which protective mechanism is the client exhibiting?
A.
B.
C.
D.

Suppression.
Rationalization.
Denial.
Intellectualization.
20.
4
4: The client is exhibiting intellectualization, which is using logical explanations without feelings or an affective component. 1:
Suppression is the voluntary exclusion from awareness of feelings, ideas, or situations that are anxiety provoking. 2:
Rationalization is an attempt to make or prove that one's feelings or behaviors are justifiable. 3: Denial is an unconscious
refusal to admit an unacceptable idea or behavior. (SR 2892)

21. Which of the following would be an effective relaxation strategy for a school-age child to use during a painful procedure?
A.
B.
C.
D.

Having the child keep his eyes shut at all times

Having the child hold his breath and not allowing him to yell
Having the child take a deep breath and then blow it out until told to stop
Being honest with the child and telling him the procedure will hurt a lot
21.
3
Having the child take a deep breath and then blow it out is a form of distraction and will help the child cope better with the
procedure. A child may prefer to keep his eyes open during a procedure so he can see what is going on and can anticipate
what is going to happen. Holding the breath isn't beneficial and could have adverse effects (such as dizziness or faintness).
Allowing the child to yell during a procedure is another form of distraction. The nurse should prepare a child for a procedure by
using nonpain descriptors and not suggesting pain. For example, the nurse might say, "Sometimes this feels like pushing or
sticking, and sometimes it doesn't bother children at all." (SR 4145)

22. A single, pregnant client, attending a crisis intervention group, has decided to go through with the pregnancy and keep the baby.
Now the crisis intervention nurse's primary responsibility is to:
A.
B.
C.
D.

Support the client for making a wise decision

Explore other problems the client may be experiencing
Make an appointment for the client to see a physician for prenatal care
Provide information about other health resources where the client may receive additional assistance
22.
4
D","This is part of the general interaction with the client; it is not a specific primary responsibility. ","This is not part of the
immediate goal during the crisis; the client may be encouraged to seek help later for other problems. ","This is one of many
instructions for which the client must take primary responsibility. ","The crisis center nurse's main responsibility is to assist the
client in using the problem-solving process; the client will be helped in exploring alternative solutions to a situation and will be
given information regarding other agencies, facilities, and services. " (SR 2192)

23. A 45-year-old woman is brought to the mental health center by her family. She is experiencing severe headaches, insomnia, and a
poor appetite. Each time a question is asked, the patient provides a lengthy, detailed description of events. Which of the following
actions, if taken by the nurse, would be MOST appropriate?
A.
B.
C.
D.

Remind her of the time.

Tell her not to worry.
Sit and listen to her.
Ask her to be brief.
23.
3
QUESTION: What should you do in this situation? STRATEGY: Remember, the NCLEX is asking you to implement "ivory
tower nursing." The answers are found in nursing textbooks and journals. They may not be what is done in the clinical area
with shortages in time, personnel, and/or equipment. CORRECT ANSWER: (3) assess first to meet pt's needs (1)
nontherapeutic (2) false reassurance (4) nontherapeutic (SR 1082)

24. In closed or locked units, the nurse judges the milieu as therapeutic because priorities are given to:
A.
B.
C.
D.

Socialization and self-understanding.

Education and vocation counseling.
Safety, structure, and support.
Developing communication, social, and leisure skills.
24.
3
3: Clients on a closed or locked inpatient psychiatric unit are typically acutely ill. Providing safety, structure, and support are
immediate priorities in the therapeutic milieu for clients with cognitive impairment and inability to handle stress. 1: For clients
who are less acutely ill, socialization and self-understanding are the priorities of treatment and the milieu. 2: Education and
vocational counseling will be addressed when the client is discharged from inpatient status and referrals are made along the
continuum of care. 4: Developing leisure, social, and communication skills is important. As clients improve, they become better
organized in their thinking and more capable of tolerating stress. They would then be more apt to benefit from such groups and
therapies at that time. These activities are part of the therapeutic milieu. (SR 2862)

25. The most accurate definition of "depression," as used in psychiatry, is a:

A.
B.
C.
D.

Difficulty in decision making and functioning

Total loss of control over emotional impulses
Disturbance in mood as a reaction to the loss of a love object
Disturbance in mood as a result of frustrated instinctual strivings
25.
3
C","The degree of depression will determine the extent to which a person can function. ","There is not a total loss of control,
and the loss of control may be only part of the clinical picture. ","Depression is a disturbance in the mood or affect (classified
as a mood disorder) that usually develops when the person suffers a real or imagined loss. ","This may also be true, but it is
not the most accurate description. " (SR 2016)

26. A client's nursing diagnosis is Chronic Low Self-Esteem related to self-doubt as evidenced by self-deprecatory statements. Which
of the following expected outcomes specifically relates to this diagnosis? The client will:
A.
B.
C.
D.

Identify positive aspects of self.

Demonstrate reality-based thinking.
Use relaxation exercises.
Set attainable goals.
1.
1
1: The expected outcome that the client identify positive aspects of self specifically relates to the nursing diagnosis of Chronic
Low Self-esteem related to self-doubt as evidenced by self-deprecatory comments. An expression of positive self comments
indicates a realistic view of the client's self-concept. 2: Demonstrating reality-based thinking relates to altered thought
processes. 3: Using relaxation exercises relates more to decreasing anxiety. 4: Setting attainable goals relates to
hopelessness. (SR 3005)

27. The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and
can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:
A.
B.
C.
D.

barbiturates.
amphetamines.
methadone.
benzodiazepines.
2.
3
Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system
but doesn't have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Barbiturates,
amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment. (SR 4357)

28. The client with dual diagnoses of major depression and alcohol abuse states, "I only drink when I can't sleep." An initial outcome
for this client is that the client will:
A.
B.
C.
D.

Describe adaptive methods of coping to induce sleep.

Verbalize negative effects of alcohol on the body.
Describe dangerous effects when combining alcohol and antidepressant medication.
Verbalize the desire to stop drinking alcohol.

3.
4
4: Verbalizing the desire to stop drinking alcohol is an initial outcome that acknowledges alcohol consumption as a problem
behavior and leads to further participation in treatment. 1: Describing adaptive methods to use instead of drinking alcohol to
induce sleep is an outcome to be reached later in the clients course of treatment. 2: Verbalizing the negative effects of
alcohol on the body is a therapeutic behavior but is not specific to helping the client sleep. 3: Describing the dangerous effects
of using alcohol with antidepressant medication is a therapeutic behavior but is not specific to helping the client sleep. (SR
2919)
29. The nurse is working in a community mental health center. A client with an Axis I diagnosis of Anxiolytic Withdrawal is prescribed
prazepam (Centrax) in daily decreasing doses for 3 weeks. She has been taking Centrax for 3 days. The client had been
dependent on diazepam (Valium), which she had been taking daily for the past 8 months at a dose of 60 mg. The client states she
feels shaky, is having problems sleeping, and does not want to continue with Centrax. She asks the nurse if she can stop taking
the Centrax now. The nurse's best response is:
A.
B.
C.
D.

"You need to continue the Centrax as prescribed to ensure a slow and safe withdrawal."
"Because your symptoms of withdrawal are minimal, you can take the Centrax when you feel you need it."
"You can discontinue the Centrax because the worse symptoms of withdrawal are over."
"I recommend one dose of Centrax at bedtime to help you sleep."
4.
1
1: The nurse instructs the client to continue taking prazepam (Centrax) as prescribed to ensure a safe, slow tapering
withdrawal from diazepam (Valium). 2: This reflects poor nursing judgment as the client needs to follow the tapering schedule
to ensure a safe withdrawal from benzodiazepine dependence. 3: This reflects poor nursing judgment as the client needs to
follow the tapering schedule to ensure a safe withdrawal from benzodiazepine dependence. 4: This reflects poor nursing
judgment as the client needs to follow the tapering schedule to ensure a safe withdrawal from benzodiazepine dependence.
(SR 2882)

30. The nurse is teaching a client about the disease concept of alcoholism. Which of the following client statements indicates that the
client understands the nurse's teaching?
A.
B.
C.
D.

"Now that I know I have this disease, it's up to me to decide if I'm going to take that drink."
"I can't help it if I drink. I have an illness."
"All of my relatives have problems with alcohol, but I' m not as bad as they are."
"My children won't be affected by my drinking because I've quit."
5.
1
1: The development of alcoholism is influenced by biologic, sociocultural, and environmental factors. The biologic theories of
alcoholism clearly identify genetic factors as a major influence on the development of alcoholism in some people. The disease
concept of alcoholism permits the individual with the disease to not feel guilty about causing the illness. However, the
responsibility of using alcohol is still up to the individual, who alone decides whether or not to take that drink of alcohol. 2: This
statement reflects using the disease of alcoholism as an excuse to drink and as a way to avoid responsibility for taking that
drink. 3: This statement reflects ongoing denial about alcoholism. 4: Children of alcoholic parents are more likely to become
alcoholics than are the children of nonalcoholic parents, even if raised in an alcohol-free environment. (SR 2869)

31. In teaching a client about Alcoholics Anonymous, the nurse states that Alcoholics Anonymous has helped in the rehabilitation of
many alcoholics, probably because many people find it easier to change their behavior when they:
A.
B.
C.
D.

Have the support of rehabilitated alcoholics.

Know that rehabilitated alcoholics will sympathize with them.
Can depend on rehabilitated alcoholics to help them identify personal problems related to alcoholism.
Realize that rehabilitated alcoholics will help them develop mechanisms to cope with their alcoholism.
6.
1
1: Membership in Alcoholics Anonymous is voluntary. Its rehabilitated members are available to support alcoholics, and the
understanding and influence of these rehabilitated members often helps alcoholics change their behavior. 2: The role of
rehabilitated members does not include sympathizing with others abusing alcohol. 3: The role of rehabilitated members does
not include helping others abusing alcohol to identify personal problems. 4: The role of rehabilitated members does not include
helping others abusing alcohol to develop defense mechanisms to cope with alcoholism. (SR 2929)

32. The client in an outpatient alcohol treatment program states to the nurse, "Why do we need to talk about relapse? I know I'll never
drink again." Which of the following responses by the nurse is best?
A. "Anyone can slip. Relapse commonly occurs during the first few months after a treatment program."
B. "Relapse prevention is important in follow-up care."
C. "It's important to talk about relapse prevention because your recovery has only begun."
D. "If you don't continue with follow-up care, you won't hear about relapse prevention."
7.
1
1: The client's statement "I know I'll never drink again" reflects overconfidence, one of the symptoms of relapse. The nurse
reminds the client that anyone can slip, that anyone is vulnerable to start drinking again, and that relapse often occurs during
the first few months after treatment. 2: This statement is true but is not complete information to give to the client. 3: This
statement is true but does not provide any useful rationale for understanding relapse. 4: This statement is not helpful because
it does not provide the client with any information about relapse. (SR 2872)
33. The nursing care coordinator in the surgical intensive care unit notes that a number of clients do not seem to be responding to
meperidine (Demerol) that has been administered for pain. Later that evening the coordinator finds a staff nurse in the nurses'
lounge dozing. On being awakened the staff nurse appears somewhat uncoordinated and drugged with slurred speech. The
coordinator should:
A. Ask the other staff members whether they have noticed anything unusual
B. Tell the staff nurse that everyone now knows who has been stealing the Demerol
C. Call the nursing director and have the director present before confronting the staff nurse

D.

Arrange to secretly observe the staff nurse the next time the staff nurse administers Demerol
8.
3
C","This is unnecessary; as a professional the nurse has enough information to confront the other nurse. ","This is an
assumption that may result in an altercation; a witness should be present. ","This is a serious charge, and confrontation should
occur in the presence of the supervisor. ","This is not a professional approach; the nurse has a legal responsibility to intervene.
" (SR 2131)

34. To give clients with long histories of alcohol abuse greater responsibility for self-control, the nurse should initially plan to:
A. Tell them about detoxification programs
B. Confront them with their substance abuse
C. Assist them to identify and adopt more healthful coping patterns
D. Administer their medications according to the prescribed schedule
9.
3
C","This would tell the client what to expect but would not instill responsibility for change. ","This will increase guilt and place
the client on the defensive; it usually does not foster the development of a trusting relationship. ","The client must learn to
develop and use more healthful coping mechanisms if drinking is to be stopped; the responsibility is with the client because
the client must do the changing. ","Medications do not provide the motivation for change; this must come from within the client.
" (SR 2132)
35. A client is admitted to the psychiatric unit with complaints of sleep disturbance, fatigue, feelings of uselessness, and inability to
concentrate. The client was let go from her place of employment last month owing to her inability to keep up with the demands of
her position. On the day after an interview during which the client talked at length and tearfully about feeling useless and old, she
failed to keep an appointment with the nurse. Which action would be best for the nurse to take?
A. Assume that the client had a good reason for not coming and let her make the next move.
B. Confront the client with her behavior and ask her to explain the reason for her absence.
C. Seek out the client at the end of the scheduled interview time and tell her she was missed today.
D. Arrange for another session with the client later the same day and say nothing about her absence.
10.
3
3: The responsibility for maintaining a relationship with a client rests with the nurse. If a client misses a scheduled interview,
the nurse is assuming responsibility for the relationship by seeking her out at the end of the scheduled interview time and
telling her she was missed. 1: Without knowing the facts, the nurse makes an assumption by thinking that the client has good
reason for not keeping her appointment. The nurse is not assuming responsibility by waiting for the client to make the next
move in this situation. 2: To confront the client with her absence and ask her to explain it is threatening and not therapeutic. 4:
To arrange another session with the client and to say nothing about the missed appointment does not keep to the terms of the
nurseclient contract and offers little help to the client. (SR 2778)

36. Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have:
A. Multiple stimuli
B. Routine Activities
C. Minimal decision making
D. Varied Activities
37. To further assess a clients suicidal potential. Nurse Katrina should be especially alert to the client
expression of:
A. Frustration & fear of death
B. Anger & resentment
C. Anxiety & loneliness
D. Helplessness & hopelessness
38. A nursing care plan for a male client with bipolar I disorder should include:
A. Providing a structured environment
B. Designing activities that will require the client to maintain contact with reality
C. Engaging the client in conversing about current affairs
D. Touching the client provide assurance
39. When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual:
A. Helps the client focus on the inability to deal with reality
B. Helps the client control the anxiety
C. Is under the clients conscious control
D. Is used by the client primarily for secondary gains
40. A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work
and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a
diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:
A. Low self esteem
B. Concrete thinking
C. Effective self boundaries
D. Weak ego
8

41. A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse Yes, its march,
March is little woman. Thats literal you know. These statement illustrate:
A. Neologisms
B. Echolalia
C. Flight of ideas
D. Loosening of association
42. A long term goal for a paranoid male client who has unjustifiably accused his wife of having many
extramarital affairs would be to help the client develop:
A. Insight into his behavior
B. Better self control
C. Feeling of self worth
D. Faith in his wife
43. A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental
health unit. The nurse uses which communication technique to encourage the client to eat dinner?
A. Focusing on self-disclosure of own food preference
B. Using open ended question and silence
C. Offering opinion about the need to eat
D. Verbalizing reasons that the client may not choose to eat
44. Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the
clients room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should?
A. Ask the client direct questions to encourage talking
B. Rake the client into the dayroom to be with other clients
C. Sit beside the client in silence and occasionally ask open-ended question
D. Leave the client alone and continue with providing care to the other clients
45. Nurse Tina is caring for a client with delirium and states that look at the spiders on the wall. What should
the nurse respond to the client?
A. Youre having hallucination, there are no spiders in this room at all
B. I can see the spiders on the wall, but they are not going to hurt you
C. Would you like me to kill the spiders
D. I know you are frightened, but I do not see spiders on the wall
46. Nurse Jonel is providing information to a community group about violence in the family. Which statement
by a group member would indicate a need to provide additional information?
A. Abuse occurs more in low-income families
B. Abuser Are often jealous or self-centered
C. Abuser use fear and intimidation
D. Abuser usually have poor self-esteem
47. During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure
ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary
because?
A. Anesthesia is administered during the procedure
B. Decrease oxygen to the brain increases confusion and disorientation
C. Grand mal seizure activity depresses respirations
D. Muscle relaxations given to prevent injury during seizure activity depress respirations.
48. When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the
discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care
requiring evaluation?
A. The client eliminates all anxiety from daily situations
B. The client ignores feelings of anxiety
C. The client identifies anxiety producing situations
D. The client maintains contact with a crisis counselor
9

49. Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The
nurse anticipates that what treatment procedure may be prescribed?
A. Neuroleptic medication
B. Short term seclusion
C. Psychosurgery
D. Electroconvulsive therapy
50. Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed
antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is
the:
A. Length of time on the med.
B. Name of the ingested medication & the amount ingested
C. Reason for the suicide attempt
D. Name of the nearest relative & their phone number

36. B. Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and
least anxiety producing.
37. D. The expression of these feeling may indicate that this client is unable to continue the struggle of life.
38. A. Structure tends to decrease agitation and anxiety and to increase the clients feeling of security.
39. B. The rituals used by a client with obsessive compulsive disorder help control the anxiety level by
maintaining a set pattern of action.
40. C. A person with this disorder would not have adequate self-boundaries.
41. D. Loose associations are thoughts that are presented without the logical connections usually necessary
for the listening to interpret the message.
42. C. Helping the client to develop feeling of self worth would reduce the clients need to use pathologic
defenses.
43. B. Open ended questions and silence are strategies used to encourage clients to discuss their problem in
descriptive manner.
44. C. Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions.
Communication with withdrawn clients requires much patience from the nurse. The nurse facilitates
communication with the client by sitting in silence, asking open-ended question and pausing to provide
opportunities for the client to respond.
45. D. When hallucination is present, the nurse should reinforce reality with the client.
46. A. Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and
jealousy.
47. D. A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this
procedure to prevent injuries during seizure.
48. C. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid
specific stimulus.
49. D. Electroconvulsive therapy is an effective treatment for depression that has not responded to
medication.

10

50. B. In an emergency, lives saving facts are obtained first. The name and the amount of medication
ingested are of outmost important in treating this potentially life threatening situation.
51. A female client who has had a myocardial infarction asks the nurse why she should not bear down or
strain to ensure having a bowel movement. The nurse incorporates in a response that this would trigger
A.
B.
C.
D.

Vagus nerve stimulation, causing a decrease in heart rate and cardiac contractility.
Vagus nerve stimulation, causing an increase in heart rate and cardiac contractility.
Sympathetic nerve stimulation, causing an increase in heart rate and cardiac contractility.
Sympathetic nerve stimulation, causing a decrease in heart rate and cardiac contractility.

51.
1
Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the
vagus nerve causes a decrease in heart rate and cardiac contractility. The sympathetic nervous system
stimulation has the opposite effect. These two branches of the autonomic nervous system oppose each
other to maintain homeostasis. (SR 6688)
52. A nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. When performing chest
compressions, the nurse understands that correct hand placement is located over the
A.
B.
C.
D.

Lower third of the sternum.

Upper half of the sternum.
Upper third of the sternum.
Lower half of the sternum.

52.
4
Determine proper hand placement for chest compressions by locating the notch where the rib margin
meets the sternum and placing the middle finger on this notch and the index finger next to it. Then place
the heel of the opposite hand on the lower half of the sternum close to the index finger. Remove the first
hand and place it on top of the hand on the sternum, and begin chest compressions. This location is the
lower half of the sternum. (SR 6737)
53. A client with cardiogenic shock has a catheter multilumen pulmonary artery catheter placed. The nurse
would interpret that the client is most unstable if which of the following cardiac output (CO) and
pulmonary capillary wedge pressure (PCWP) readings were obtained?
A.
B.
C.
D.

CO 5 L/min, PCWP low

CO 4 L/min, PCWP high
CO 3 L/min, PCWP high
CO 2 L/min, PCWP low

53.
3
The normal cardiac output is 4 to 8 L/min. With cardiogenic shock the cardiac output falls below normal
because of failure of the heart as a pump. The pulmonary capillary wedge pressure, however, rises
because it is a reflection of the left ventricular end-diastolic pressure, which rises with pump failure. (SR
6751)
54. A nurse is preparing to defibrillate a client in ventricular fibrillation. The nurse places that paddles on
the clients chest and before defibrillating the client assesses that
A.
B.
C.
D.

The client has received lidocaine hydrochloride (Xylocaine)

The rhythm is actually ventricular fibrillation.
The machine has been set to the synchronize mode.
The client has been intubated.

54.
2
Until the defibrillator is attached and charged, the client is resuscitated by using cardiovascular
resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that
the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any
loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated
to be defibrillated. Lidocaine may be given subsequently but is not set to the synchronous mode because
there is no underlying rhythm with which to synchronize. (SR 6767)
11

55. A client is admitted to the hospital with a suspected diagnosis of myocardial infarction. The nurse is
reviewing the laboratory results performed on the client. Which of the following laboratory results most
specifically would indicate the presence of a myocardial infarction?
A.
B.
C.
D.

Increased creatinine kinase MB.

Increased creatinine kinase MM
Increased blood urea nitrogen.
Decreased white blood cell count.

55.
1
The creatinine kinase MB is specific in determining the presence of a myocardial infarction. The
creatinine kinase MM reflects injury to skeletal muscle. The white blood cell count will most likely
would be elevated in the client with a myocardial infarction. The blood urea nitrogen is unrelated to this
disorder. (SR 6608)
56. A female client is at risk for developing disseminated intravascular coagulation. The nurse is reviewing
the laboratory results and determines that the fibrinogen level is normal if which of the following is
noted on the laboratory report?
A.
B.
C.
D.

180 mg/dL
400 mg/dL
480 mg/dL
500 mg/dL

56.
2
The normal fibrinogen level is 180 to 340 mg/dL for males and 190 to 420 mg/dL for females. A critical
value is one that is less than 100 mg/dL. With disseminated intravascular coagulation the fibrinogen
level drops because fibrinogen is used up in the clotting process. Option 2 is the only option that
identifies a normal level for a female client. (SR 6723)
57. A client with myocardial infarction has been transferred from a coronary care unit to a general medical
unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client
activities?
A.
B.
C.
D.

Strict bed rest for 24 hours after transfer

Bathroom privileges and self-care activities
Unsupervised hallway ambulation with distance under 200 feet
Ad lib activities because the client is monitored

57.
2
On transfer from the coronary care unit, the client is allowed self-care activities and bathroom
privileges. Supervised ambulation in the hall for brief distances gradually increased (50, 100, 200 feet).
(SR 6743)
58. A client recovering from pulmonary edema is preparing for discharge. The nurse plans to teach the client
to do which of the following to manage or prevent recurrent symptoms after discharge?
A.
B.
C.
D.

Take a double dose of the diuretic if peripheral edema is noted.

Hold the digoxin (Lanoxin) if slight respiratory distress occurs.
Weigh self daily.
Sleep with the head of the bed flat.

58.
3
The client can best determine fluid status at home by weighing daily. The client should report to the
physician increases of 2 to 3 lb in a short time. The client should sleep with the head of the bed elevated.
During recumbent sleep, fluid (which has seeped into the interstitium by day with the assistance of the
effects of gravity) is reabsorbed rapidly into the systemic circulation. Sleeping with the head of bed flat
is therefore avoided. The client does not modify medication dosages without consulting the physician.
(SR 6624)

12

59. A client receiving total parenteral nutrition has a history of congestive heart failure. The physician has
ordered furosemide (Lasix) 40 mg PO daily to prevent fluid overload. The nurse monitors which
laboratory value to identify adverse effects from this medication?
A.
B.
C.
D.

Glucose
Sodium
Potassium
Magnesium

59.
3
Furosemide is a non-potassium-sparing diuretic, and insufficient replacement of potassium may lead to
hypokalemia. Although the glucose, sodium, and magnesium levels may be monitored, these laboratory
values are not specific to administering furosemide. (SR 6629)
60. A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6
mEq/L. For this client, the nurse's priority would be to assess her:
A.
B.
C.
D.

neuromuscular function.
bowel sounds.
respiratory rate.
electrocardiogram (ECG) results.

60.
4
Although changes in all these findings are seen in hyperkalemia, ECG changes can indicate potentially
lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's
neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia. (SR 4594)
61. A client admitted to the hospital with coronary artery disease complains of
dyspnea at rest. A nurse caring for the client uses which of the following items as the
best means to monitor respiratory status on an ongoing basis?
A.
B.
C.
D.

Oxygen flow meter

Oxygen saturation monitor
Telemetry cardiac monitor
Apnea monitor
218.
2
Dyspnea in the cardiac client often is accompanied by hypoxemia. Hypoxemia can
be detected by an oxygen saturation monitor, especially if used continuously. An
oxygen flow meter is part of the setup needed to deliver oxygen therapy. Cardiac
monitors detect dysrhythmias. An apnea monitor detects apnea episodes, such as
when the client has stopped breathing briefly. (SR 6626)

62. A client is admitted with pulmonary embolism and is to be treated with

streptokinase (Streptase). A nurse would report which of the following assessments to
the physician before initiating this therapy?
A.
B.
C.
D.

Adventitious breath sounds

Respiratory rate of 28 breaths per minute
Temperature of 99.4o F orally
Blood pressure of 198/110 mm Hg
219.
4
Thrombolytic therapy is contraindicated in a number of preexisting conditions in
which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant
therapy. Thrombolytic therapy also is contraindicated in sever uncontrolled
hypertension because of the risk of cerebral hemorrhage. Therefore the nurse
would report the results of the blood pressure to the physician before initiating
therapy. (SR 6784)

13

63. A client has developed atrial fibrillation with a ventricular rate of 150 beats per
minute. The nurse assesses the client for
A.
B.
C.
D.

Hypotension and dizziness.

Nausea and vomiting.
Hypertension and headache.
Flat neck veins.
220.
1
The client with uncontrolled atrial fibrillation and a ventricular rate of more than
100 beats per minute is at risk for low cardiac output because of loss of atrial kick.
The nurse assesses the client for palpitations, chest pain or discomfort,
hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of
breath, and distended neck veins. (SR 6697)

64. A clients electrocardiogram strip shows atrial and ventricular rates of 70

complexes per minute. The P-R interval is 0.16 second, the QRS complex measures
0.06 second, and the P-P interval is slightly irregular. The nurse interprets this rhythm
to be
A.
B.
C.
D.

Sinus bradycardia.
Normal sinus rhythm.
Sinus tachycardia
Sinus arrhythmia.
221.
4
Sinus arrhythmia has all the characteristics of normal sinus rhythm, except an
irregular P-P interval. This occurs because of phasic changes in the rate of firing of
the sinoatrial node, which may occur with vagal tone and with respiration. Cardiac
output is not affected. (SR 6655)

65. A nurse is assessing the blood pressure of a client diagnosed with primary
hypertension. The nurse ensures accurate measurement by avoiding which of the
following?
A.
B.
C.
D.

Seating the client with arm bared, supported and at heart level
Measuring the blood pressure after the client has been seated quietly for 5 minutes
Using a cuff with a rubber that encircles at least 80% of the limb
Taking the blood pressure within 15 minutes after nicotine or caffeine ingestion
222.
4
Blood pressure should be taken with the client seated with the arm bared,
positioned with support and at heart level. The client should sit with the legs on
the floor, feet uncrossed, and not speak during the recording. The client should not
have smoked tobacco or taken in caffeine in the 30 minutes preceding the
measurement. The client should rest quietly for 5 minutes before the reading is
taken. The cuff bladder should encircle at least 80% of the limb being measured.
Gauges other than a mercury sphygmomanometer should be calibrated every 6
months to ensure accuracy. Finally, two or more reading should be averaged. (SR
6779)

66. A new nursing graduate is caring for a client who is attached to a cardiac monitor.
While assisting the client with bathing, the nurse notes that the client suddenly
develops ventricular tachycardia but remains alert and oriented and has a pulse.
Select all interventions that the nurse would take?
A.
B.
C.
D.
E.

Defibrillate the client.

Assess airway, breathing, and circulation.
Administer a precordial thump.
Administer oxygen.
Obtain an electrocardiogram.
14

F. Contact the physician.

223.
2+4+5+6
For a stable client with ventricular tachycardia, the nurse assesses the client,
administers oxygen, and confirms the rhythm via a 12-lead electrocardiogram. The
nurse contacts the physician, who may prescribe an antidysrhythmic medication.
With pulseless ventricular tachycardia, the physician or specially trained nurse
must defibrillate the client immediately or initiate cardiopulmonary resuscitation
and defibrillate the client as soon as possible. (MR 6690)
67. The nurse is teaching the mother of an infant with tetralogy of Fallot. The mother
asks what to do when her infant becomes very blue and has trouble breathing after
crying. The nurse should tell the mother:
A.
B.
C.
D.

"Leave the infant alone until the crying stops."

"Put the infant in the knee-chest position."
"Offer the infant a bottle of formula."
"Take the infant for a ride in the car."
224.
2
The infant is having a "tet" or blue spell, which is an acute spell of hypoxia and
cyanosis. This occurs when the infant's oxygen requirements are greater than what
is supplied in the blood. Treatment involves placing the infant in the knee-chest
position to reduce venous return from the extremities because that blood is
desaturated. It also increases systemic vascular resistance, which causes more
blood to be shunted to the pulmonary artery. Leaving the infant alone until the
crying stops will cause an increase in cyanosis. An infant who is crying and having
trouble breathing shouldn't be offered a bottle because of the danger of aspiration.
A ride in the car may quiet some infants, but it would be inappropriate in this
situation. (SR 4029)

68. A client with myocardial infarction has been transferred from the coronary care unit
to the general medical unit. The nurse encourages the client to do which of the
following activities immediately after transfer?
A.
B.
C.
D.

Ad lib activities because the client will be discharged soon.

Unsupervised hallway ambulation with distances up to 200 feet
Bathroom privileges and self-care activities
Strict bedrest for 24 hours after transfer.
225.
3
On transfer from the coronary care unit (CCU) to an intermediate care or general
medical unit, the client is allowed self-care activities and bathroom privileges.
Limiting the client to bedrest is unnecessary and possibly harmful. The client
should ambulate with supervision in the hall for brief distances, with the distances
being increased gradually to 50, 100, and 200 feet. (SR 6638)

69. A client with myocardial infarction is experiencing new, multiform premature

ventricular contractions. Knowing that the client is allergic to lidocaine hydrochloride,
the nurse plans to have which of the following medications available for immediate
use?
A.
B.
C.
D.

Digoxin (Lanoxin)
Metoprolol (Lopressor)
Verapamil (Isoptin)
Procainamide (Pronestyl)
226.
4
Procainamide is an antidysrhythmic that may be used to treat ventricular
dysrhythmias in clients who are allergic to lidocaine. Digoxin is a cardiac glycoside;
15

metoprolol is a -adrenergic blocking agent; and verapamil is a calcium channel

blocking agent. (SR 6657)
70. A home health nurse is visiting a client who has had a prosthetic valve stenosis.
Which statement by the client reflects an understanding of specific postoperative care
following this surgery?
A.
B.
C.
D.

I
I
I
I

threw away my straight razor and bought an electronic razor.

have to go to the bathroom frequently because of my medication.
need to count my pulse everyday.
have to do deep breathing exercises every 2 hours.

227.
1
Prosthetic valves require long-term anticoagulation therapy to prevent clots from
forming on the foreign tissue implanted in the clients body. Anticoagulation
therapy requires clients to avoid any trauma or potential means of bleeding, such
as straight razors. Options B, C, and D are not related specifically to postoperative
care following prosthetic valve replacement. Option B relates to a client taking a
diuretic. Option C relates to a client with a pacemaker. Option D is necessary in the
immediate postoperative period. (SR 6666)
71. A nurse notes bilateral 2+ edema in the lower extremities of a client with
myocardial infarction who was admitted 2 days ago. The nurse would plan to do which
of the following next?
A.
B.
C.
D.

Review the intake and output records for the laity 2 days.
Change the time of diuretic administration from morning to evening.
Request a sodium restriction of 1 g/day from the physician.
Order daily weights starting on the following morning.
228.
1
Edema, the accumulation of excess fluid in the interstitial spaces, can be measured
by intake greater than output and by a sudden increase in weight. Diuretics should
be given in the morning whenever possible to avoid nocturia. Strict sodium
restrictions are reserved for clients with severe symptoms. (SR 6744)

72. A child, age 4, is admitted with a tentative diagnosis of congenital heart disease.
When assessment reveals a bounding radial pulse coupled with a weak femoral pulse,
the nurse suspects that the child has:
A.
B.
C.
D.

patent ductus arteriosus.

coarctation of the aorta.
a ventricular septal defect.
truncus arteriosus.
229.
2
Coarctation of the aorta causes signs of peripheral hypoperfusion, such as a weak
femoral pulse and a bounding radial pulse. These signs are rare in patent ductus
arteriosus, ventricular septal defect, and truncus arteriosus. (SR 4112)

73. A client is at risk for pulmonary embolism and is on anticoagulant therapy with
warfarin sodium (Coumadin). The clients prothrombin time is 20 seconds, with a
control of 11 seconds. The nurse assesses that this result is
A.
B.
C.
D.

The same as the clients own baseline level.

Lower than the needed therapeutic level.
Within the therapeutic range.
Higher than the therapeutic range.
230.
3
The therapeutic range for prothrombin time is 1.5 to 2 times control for clients at
16

high risk for thrombus. Based on the clients control value, the therapeutic range
for this individual would be 16.5 to 22 seconds. Therefore the result is within the
therapeutic range. (SR 6781)
74. A client receiving total parenteral nutrition has a history of congestive heart failure.
The physician has ordered furosemide (Lasix) 40 mg PO daily to prevent fluid
overload. The nurse monitors which laboratory value to identify adverse effects from
this medication?
A.
B.
C.
D.

Glucose
Sodium
Potassium
Magnesium
231.
3
Furosemide is a non-potassium-sparing diuretic, and insufficient replacement of
potassium may lead to hypokalemia. Although the glucose, sodium, and
magnesium levels may be monitored, these laboratory values are not specific to
administering furosemide. (SR 6629)

75. When a client has a myocardial infarction, one of the major manifestations is a
decrease in the conductive energy provided to the heart. When assessing this client
the nurse understands that the existing action potential is in direct relationship to the:
A.
B.
C.
D.

Heart rate
Refractory period
Pulmonary pressure
Strength of contraction
232.
4
D","The heart rate is related to factors such as SA node function, partial pressures
of oxygen and carbon dioxide, and emotions. ","This is the period when the heart is
at rest, not when it is contracting. ","Pulmonary pressure does not influence action
potential; it becomes elevated in the presence of left ventricular failure. ","A direct
relationship exists between the strength of cardiac contractions and the electrical
conductions through the myocardium. " (SR 1473)

76) Adolescent poisonings are most likely to be caused by which factor?

A) improper storage of toxic household substances
B) inadequate supervision
C) recreational drugs
D) an overdose of a prescribed medication
Answer: C

77) Which statement by the parents of an infant indicates they understand safety measures for their
baby?
A) "I can prop the baby's bottle when I am busy with the two-year-old."
B) "A crib with wide spaces between the slats is safest."
C) "Large soft toys without little parts are best right now."
D) "The car seat can fit in the front passenger seat."
Answer: C

78) A 44-year-old client has sensory deficits from nerve damage. Which of the following nursing
interventions would be appropriate for this client?
A) Teach on the hazards of using a heating pad for muscle spasms.
17

B) Encourage the placement of grab bars in the bathroom.

C) Instruct on automobile safety.
D) Assess for home fire extinguisher and smoke alarm.
Answer: A

79) Which client is at risk for injury because of diminished ability to protect himself?
A) one who is deaf B) one who is bored with his marriage
C) one who did not finish high school D) one who works in a law firm
Answer: A

80) Which factor reduces the risk of electrical hazards?

A) two-pronged electrical plugs B) non-insulated wiring in the home
C) three-pronged electrical plugs D) using frayed cords cautiously
Answer: C

81) A 75-year-old client has been hospitalized because of a stroke. He has left-sided weakness but is
permitted to ambulate with a walker. To ensure the client's safety when he is out of bed, the nurse
should:
A) apply a Posey restraint when he is in the chair.
B) follow him with a wheelchair as he walks.
C) restrict his activity to use of a wheelchair.
D) see that he wears nonskid footwear.
Answer: D

82) The daughter of an elderly confused female client requests that her mother not be restrained.
What can the nurse do instead to ensure for this client's safety?
A) Put the restraint under the client's gown so the daughter won't see it.
B) Use a Geri chair.
C) Only restrain one limb.
D) Call the physician to get an order for restraints and show it to the daughter.
Answer: B

83) Which NANDA nursing diagnosis is specific to school-age children?

A) risk for poisoning B) risk for aspiration
C) risk for trauma D) risk for suffocation
Answer: C

84) Which type of restraint would allow the most movement by a client?
A) mummy restraint B) jacket restraint
C) wrist restraint D) mitt restraint
Answer: D

85) A 75-year-old client has been hospitalized because of a stroke. He has left-sided weakness but is
permitted to ambulate with a walker. Because the client is older, what other factor besides weakness
might increase his risk for physical injury?
A) decreased ability to learn B) decreased sensory acuity
C) inability to reason D) altered nutritional status
18

Answer: B
86. A nurse employed in an emergency department is assigned to triage clients arriving to the
emergency room for treatment on the evening shift. The nurse should assign highest priority to which
of the following
clients?
A. A client complaining of muscle aches, a headache, and malaise
B. A client who twisted her ankle when she fell while rollerblading
C. A client with a minor laceration on the index finger sustained while cutting an eggplant
D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
1. 4
Rationale: In an emergency department, triage involves brief client
assessment to classify clients according to their need for care and
includes establishing priorities of care. The type of illness or injury,
the severity of the problem, and the resources available govern the
process. Clients with trauma, chest pain, severe respiratory distress or
cardiac arrest, limb amputation, acute neurological deficits, and those
who have sustained chemical splashes to the eyes are classified as
emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma
without respiratory distress, fever,
hypertension, abdominal pain, or a renal stone have urgent needs and
are classified as number 2 priority. Clients with conditions such as a
minor laceration, sprain, or cold symptoms are classified as nonurgent
and are the number 3 priority.
87. A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just
ingested liquid furniture polish. The nurse would direct the mother immediately to:
A. Induce vomiting.
B. Call an ambulance.
C. Call the Poison Control Center.
C. Bring the child to the emergency department.
4. 3 Rationale: If a poisoning occurs, the Poison Control Center should
be contacted immediately. Vomiting should not be induced if the victim is unconscious or if the
substance ingested is a strong
corrosive or petroleum product. Bringing the child to the emergency
department or calling an ambulance would not be the initial action
because this would delay treatment. The Poison Control Center may
advise the mother to bring the child to the emergency department
and, if this is the case, the mother should call an ambulance.

88. An emergency department nurse receives a telephone call and is informed that a tornado has hit
a local residential area and that numerous casualties have occurred. The victims will be brought to
the emergency room. The initial nursing action is which of the following?
A. Prepare the triage rooms.
B. Activate the agency disaster plan.
C. Obtain additional supplies from the central supply department.
D. Obtain additional nursing staff to assist in treating the casualties.
5. 2 Rationale: In an external disaster, many victims may be brought to
the emergency department for treatment. Although options 1, 3, and
4 may be components of preparing for the casualties, the initial
nursing action must be to activate the disaster plan.
89. A nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately
assists the client out of the room. The next nursing action would be to:
A. Call for help.
B. Extinguish the fire.
19

C. Activate the fire alarm.

D. Confine the fire by closing the room door.
7. 3 Rationale: The order of priority in the event of a fire is to rescue the
clients who are in immediate danger. The next step is to activate the
fire alarm. The fire then is confined by closing all doors and, finally,
the fire is extinguished.
90. A nurse enters the nursing lounge and discovers that a chair is on fire. She activates the alarm,
closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin
on the fire extinguisher. The next appropriate action for the use of the fire extinguisher is to:
A. Aim at the base of the fire.
B. Squeeze the handle on the extinguisher.
C. Sweep the fire from side to side with the extinguisher.
D. Sweep the fire from top to bottom with the extinguisher.
8. 1 Rationale: A fire can be extinguished or by using a fire extinguisher.
To use the extinguisher, pull the pin first. The nurse then aims at the
base of the fire. The extinguisher is squeezed and the fire is
extinguished by sweeping from side to side to coat the area evenly.
91. A nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride
and plans to use an intravenous infusion pump. The nurse brings the pump to the bedside, prepares
to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. Which
of the following is the appropriate nursing action?
A. Initiate the intravenous line without the use of a pump.
B. Contact the electrical maintenance department for assistance.
C. Plug in the pump cord in the available plug above the room sink.
D. Use an extension cord from the nurses' lounge for the pump plug.
9. 2 Rationale: The nurse needs to use hospital resources for assistance.
A regular extension cord should not be used because it poses the risk
of fire. The use of electrical appliances near a sink also presents a
hazard. An intravenous line that contains a high dose of potassium
chloride should be administered by the use of a pump.
92. A nurse obtains an order from a physician to restrain a client by using a jacket restraint and
instructs a nursing assistant to apply the restraint to the client. Which observation by the nurse
indicates inappropriate application of the restraint by the nursing assistant?
A. A safety knot in the restraint straps
B. Restraint straps that are safely secured to the side rails
C. Jacket restraint straps that do not tighten when force is applied against them
D. Jacket restraint secured so that two fingers can slide easily between the restraint and the client's
skin
10. 2 Rationale: The restraint straps are secured to the bed frame and
never to the side rail to avoid accidental injury in the event that the
side rail is released. A half-bow or safety knot should be used for
applying a restraint because it does not tighten when force is applied
against it and it allows quick and easy removal of the restraint in case
of an emergency. The jacket restraint should be secure, and one to
two fingers should slide easily between the restraint and the client's
skin.
93. A client is to receive doxorubicin (Adriamycin) as part of a chemotherapy protocol. The major lifethreatening side effect of Adriamycin that the nurse should assess the client for is:
A. Cardiotoxicity
B. Pancytopenia
C. Pulmonary fibrosis
20

D. Ulcerative stomatitis
71.
1
1: Congestive heart failure and dysrhythmias are the only life-threatening toxic effects unique
to Adriamycin. 2: When bone marrow is depressed to precarious levels, the dose is altered
and/or blood components administered. 3: This is not a side effect of Adriamycin nor of any of
the other antineoplastic agents. 4: This is a very uncomfortable side effect but is not life
threatening. (SR 1307)
94. Following a left pneumonectomy, a critical nursing intervention in the recovery room when a client
regains consciousness would be to:
A.
B.
C.
D.

Remove the airway

Assess the client for pain
Encourage deep breathing
Place the client on the right side
135.
3
C: Keeps airway patent and prevents atelectasis by raising intrapleural pressure. A: The airway
should be removed only after the gag reflex returns. B: Although important, it is not life
threatening. D: Restricts right lung expansion; if sutured bronchus opens, fluid could drain from
operative area into good lung. (SR 1213)

95. The nursing diagnosis with the highest priority for a child with AIDS would be:
A.
B.
C.
D.

Risk for injury

Risk for infection
Alteration in growth and development
Alteration in nutrition: less than body requirements
28.
2
B","All children have a high risk for injury because of their curiosity, inexperience, and lack of
judgment. ","Children with AIDS have a dysfunction of the immune system (depressed or
ineffective T cells, B cells, and immunoglobulins) and are susceptible to opportunistic
infections. ","Although children with AIDS are most likely small for their ages, altered growth
and development are not as life threatening as an infection. ","Although this can occur in
children with AIDS, the prevention of infection is the priority. " (SR 1925)

96. A client arrives in the emergency room with a bloody nose. The initial nursing action is to
A.
B.
C.
D.

Place the client in supine position.

Apply an ice collar around the clients neck.
Assist the client to a sitting position with the head tilted forward.
Instruct the client to swallow the blood until the bleeding can be controlled.

169.
3
The initial action to treat the client with a bloody nose is to loosen clothing around the neck to prevent
pressure on the carotid artery. The nurse should assist the client to a sitting position with the head
tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the
septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are not
successful in controlling the bleeding, an ice collar may be applied along with topical vasoconstrictive
medication. The physician may also prescribe packing of the nostrils. The client should be provided
with an emesis basis and should be instructed not to swallow blood to reduce the risk of nausea and
vomiting.
97. An emergency room nurse is assessing a client who sustained a blunt injury to the chest wall.
Which of these signs would indicate the presence of a pneumothorax in this client?
A. A sucking sound at the site of injury.
B. Diminished breath sounds.
21

C. A low respiratory rate.

D. The presence of a barrel chest.
182.
2
This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax
are shortness of breath and chest pain. A larger pneumothorax are shortness of breath and chest
pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and
subcutaneous emphysema. Hyperressonce also may occur on the affected side.
98. A nurse in the emergency room is caring for a client who was in a motor vehicle accident and is
experiencing hypovolemic shock. A pneumatic antishock garment is applied to the client for the
treatment of the shock. The client will be transferred to the intensive care unit. While awaiting
client transfer to the intensive care unit, the emergency room nurse performs which critical
assessment?
A.
B.
C.
D.

Monitoring hemoglobin and hematocrit levels

Monitoring vascular status of the lower extremities
Assessing radial pulses
Assessing vascular status of the upper extremities

184.
2
The pneumatic antishock garment may be useful to treat hypovolemic shock associated with
traumatic injury to provide circulatory assistance. The device is used only as a temporary measure
until definitive treatment is given because it can compromise blood flow to the lower half of the body.
The critical nursing assessment includes monitoring the vascular status of the lower extremities.
Although options A, C, and D may be components of the nursing assessment, these actions are not
the critical assessment required in the client with a pneumatic antishock garment.
99. The client is brought into the emergency room in ventricular fibrillation. The advanced cardiac life
support nurse prepares to defibrillate by placing conductive gel pads on which part of the chest?
A.
B.
C.
D.

To the upper and lower half of the sternum

To the right of the sternum just below the clavicle and left of the precordium
To the right shoulder and in the back of the left shoulder
Parallel between the umbilicus and the right nipple

208.
2
The advanced cardiac life support nurse would place one gel pad to the right of the sternum just
below the clavicle and the other gel pad to the left of the precordium. The nurse then would place the
electrode paddles over the pads. Options A, C, and D identify incorrect positions.
100. A 10-year-old with history of bronchial asthma triggered by exposure to cold, smoke, and nuts
is brought to the hospital's emergency room by his mother. Appearing restless and anxious, the
child has a respiratory rate of 36 breaths/minute and pulse rate of 160 bpm. Which of the following
findings would be of greatest concern to the nurse?
A.
B.
C.
D.

Increased respiratory effort.

Moist, loose cough.
Absence of wheezing.
Prolonged expiratory phase.

84.
3
Increased respiratory effort would be suspected secondary to bronchospasm associated with asthma.
| During an asthma attack, the cough usually is dry and sounds tight due to mucus accumulation and
bronchoconstriction. | Knowing that this child is most likely experiencing an asthmatic attack, the
nurse would expect to hear wheezing and note some shortness of breath with a prolonged expiratory
phase. However, of greatest concern would be the absence of wheezing indicating that the child is
not moving air well through the lungs and is at risk for hypoxia and possible respiratory failure. |
22

Typically during an asthmatic attack, the client would demonstrate a prolonged expiratory phase
because of air trapping and the increased effort to move air through constricted bronchioles.

Prepared by:
Sir Lui

23