NCLEX practice #15

1. After 4 electroconvulsive treatments over 2 weeks, a client is very upset and states “I am so confused. I lose my money. I just can’t remember telephone numbers.” The most therapeutic response for the nurse to make is

A) "You were seriously ill and needed the treatments."

B) "Don't get upset. The confusion will clear up in a day or two."

C) "It is to be expected since most clients have the same results."

D) "I can hear your concern and that your confusion is upsetting to you."

The correct answer is D: "I can hear your concern and that your confusion is upsetting to you."

Communicating caring and empathy with the acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short term effects would be discussed.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

2. The visiting nurse makes a postpartum visit to a married female client. Upon arrival, the nurse observes that the client has a black eye and numerous bruises on her arms and legs. The initial nursing intervention would be to

A) call the police to report indications of domestic violence

B) confront the husband about abusing his wife

C) leave the home because of the unsafe environment

D) interview the client alone to determine the origin of the injuries

The correct answer is D: interview the client alone to determine the origin of the injuries

It would be wrong to assume domestic violence without further assessment. Separate the suspected victim from the partner until battering has been ruled out.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

3. A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client?

A) Fresh juice, carrots, vanilla pudding

B) Apple juice, ham salad, fresh pineapple

C) Hamburger, fries, strawberry shake

D) Red wine, fava beans, aged cheese

The correct answer is D: Red wine, fava beans, aged cheese

Red wine and cheese contain tyramine (as do chicken liver and ripe bananas) and so are contraindicated when taking MAOIs. Fava beans contain other vasopressors that can interact with MAOIs also causing malignant hypertension.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

4. The client asks the nurse how the health care provider could tell she was pregnant “just by looking inside.” What is the best explanation by the nurse?

A) Bluish coloration of the cervix and vaginal walls

B) Pronounced softening of the cervix

C) Clot of very thick mucous that obstructs the cervical canal

D) Slight rotation of the uterus to the right

The correct answer is A: Bluish coloration of the cervix and vaginal walls

Chadwick''s sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4 weeks of pregnancy, that is caused by vasocongestion.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

5.A client is discharged on warfarin sulfate (Coumadin). Which statement by the client indicated a need for further teaching?

A) "I know I must avoid crowds."

B) "I will keep all laboratory appointments."

C) "I plan to use an electric razor for shaving."

D) "I will report any bruises for bleeding."

The correct answer is A: "I know I must avoid crowds."

There are no specific reasons for the client on Coumadin to avoid crowds. General instructions for any cardiac surgical client include limiting exposure to infection.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

6. A male client is preparing for discharge following an acute myocardial infarction. He asks the nurse about his sexual activity once he is home. What would be the nurse's initial response?

A) Give him written material from the American Heart Association about sexual activity with heart disease

B) Answer his questions accurately in a private environment

C) Schedule a private, uninterrupted teaching session with both the client and his wife

D) Assess the client's knowledge about his health problems

The correct answer is D: Assess the client''s knowledge about his health problems

The nursing process is continuous and cyclical in nature. When a client expresses a specific concern, the nurse performs a focused assessment to gather additional data prior to planning and implementing nursing interventions.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

7. The nurse is assessing a client with chronic obstructive pulmonary disease receiving oxygen for low PaO2 levels. Which assessment is a nursing priority?

A) Evaluating SaO2 levels frequently

B) Observing skin color changes

C) Assessing for clubbing fingers

D) Identifying tactile fremitus

The correct answer is A: Evaluating SaO2 levels frequently

The best method to evaluate a client''s oxygenation is to evaluate the SaO2. This is just as effective as an arterial blood gas reading to evaluate oxygenation status, and is less traumatic and expensive.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

8. The nurse is teaching a group of college students about breast self-examination. A woman asks for the best time to perform the monthly exam. What is the best reply by the nurse?

A) "The first of every month, because it is easiest to remember"

B) "Right after the period, when your breasts are less tender"

C) "Do the exam at the same time every month"

D) "Ovulation, or mid-cycle is the best time to detect changes"

The correct answer is B: "Right after the period, when your breasts are less tender"

The best time for a breast self exam (BSE) is a week after a menstrual cycle, when the breasts are no longer swollen and tender due to hormone elevation.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition). Philadelphia, PA: Lippincott Williams & Wilkins.

9. The nurse is teaching a client about the difference between tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). Which statement is true with regards to tardive dyskinesia?

A) TD develops within hours or years of continued antipsychotic drug use in people under 20 and over 30

B) It can occur in clients taking antipsychotic drugs longer than 2 years

C) Tardive dyskinesia occurs within minutes of the first dose of antipsychotic drugs and is reversible

D) TD can easily be treated with anticholinergic drugs

The correct answer is B: It can occur in clients taking antipsychotic drugs longer than 2 years

Tardive dyskinesia is a extrapyramidal side effect that appears after prolonged treatment with antipsychotic medication. Early symptoms of tardive dyskinesia are fasciculations of the tongue or constant smacking of the lips.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Tierney, L.M., McPhee, S.J., and Papadakis, M.A. (2004). Current medical Diagnosis and Treatment. (43rd edition). USA:McGraw-Hill.

10. A client is receiving lithium carbonate 600 mg T.I.D. to treat bipolar disorder. Which of these indicate early signs of toxicity?

A) Ataxia and course hand tremors

B) Vomiting, diarrhea and lethargy

C) Pruritus, rash and photosensitivity

D) Electrolyte imbalance and cardiac arrhythmias

The correct answer is B: Vomiting, diarrhea and lethargy

These are early signs of lithium toxicity.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

11. A woman in labor calls the nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on the bed linens. The nurse knows that fetal monitoring must now assess for what complication?

A) Early decelerations

B) Late accelerations

C) Variable decelerations

D) Periodic accelerations

The correct answer is C: Variable decelerations

When the membranes rupture, there is increased risk initially of cord prolapse. Fetal heart rate patterns may show variable decelerations, which require immediate nursing action to promote gas exchange.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

12. Initial postoperative nursing care for an infant who has had a pyloromyotomy would initially include

A) bland diet appropriate for age

B) intravenous fluids for 3-4 days

C) NPO then glucose and electrolyte solutions

D) formula or breast milk as tolerated

The correct answer is C: NPO then glucose and electrolyte solutions

Post-operatively, the initial feedings are clear liquids in small quantities to provide calories and electrolytes.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

13. Clients taking lithium must be particularly sure to maintain adequate intake of which of these elements?

A) Potassium

B) Sodium

C) Chloride

D) Calcium

The correct answer is B: Sodium

Clients taking lithium need to maintain an adequate intake of sodium. Serum lithium concentrations may increase in the presence of conditions that cause sodium loss.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

14. The spouse of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which of the following actions by the nurse should be a priority?

A) Link the caregiver with a support group

B) Ask friends to visit regularly

C) Schedule a home visit each week

D) Request anti-anxiety prescriptions

The correct answer is A: Link the caregiver with a support group

Assisting caregivers to locate and join support groups is most helpful. Families share feelings and learn about services such as respite care. Health education is also available through local and national Alzheimer''s chapters.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

15. A nurse is caring for a client who has just been admitted with an overdose of aspirin. The following lab data is available: PaO2 95, PaCO2 30, pH 7.5, K 3.2 mEq/l. Which should be the nurse's first action?

A) Monitor respiratory rate

B) Monitor intake and output every hour

C) Assist the client to breathe into a paper bag

D) Prepare to administer oxygen by mask

The correct answer is C: Assist the client to breathe into a paper bag

Side effects of aspirin toxicity include hyperventilation, which can result in respiratory alkalosis in the initial stages. Breathing into a paper bag will prevent further reduction in PaCO2.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

16. When teaching a client with a new prescription for lithium (Lithane) for treatment of a bi-polar disorder which of these should the nurse emphasize?

A) Maintaining a salt restricted diet

B) Reporting vomiting or diarrhea

C) Taking other medication as usual

D) Substituting generic form if desired

The correct answer is B: Reporting vomiting or diarrhea

If dehydration results from vomiting, diarrhea or excessive perspiration, tolerance to the drug may be altered and symptoms may return.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

17. What must be the priority consideration for nurses when communicating with children?

A) Present environment

B) Physical condition

C) Nonverbal cues

D) Developmental level

The correct answer is D: Developmental level

While each of the factors affect communication, the nurse recognizes that developmental differences have implications for processing and understanding information. Consequently, a child’s developmental level must be considered when selecting communication approaches.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

18. Which clinical finding would the nurse expect to assess first in a newborn with spastic cerebral palsy?

A) cognitive impairment

B) hypotonic muscular activity

C) seizures

D) criss-crossing leg movement

The correct answer is D: criss-crossing leg movement

Cerebral palsy is a neuromuscular impairment resulting in muscular and reflexive hypertonicity and the criss-crossing, or scissoring leg movements.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

19. The nurse is caring for a 2 month-old infant with a congenital heart defect. Which of the following is a priority nursing action?

A) Provide small feedings every 3 hours

B) Maintain intravenous fluids

C) Add strained cereal to the diet

D) Change to reduced calorie formula

The correct answer is A: Provide small feedings every 3 hours

Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

20. The nurse is assessing a woman in early labor. While positioning for a vaginal exam, she complains of dizziness and nausea and appears pale. Her blood pressure has dropped slightly. What should be the initial nursing action?

A) Call the health care provider

B) Encourage deep breathing

C) Elevate the foot of the bed

D) Turn her to her left side

The correct answer is D: Turn her to her left side

The weight of the uterus can put pressure on the vena cava and aorta when a pregnant woman is flat on her back causing supine hypotension. Action is needed to relieve the pressure on the vena cava and aorta. Turning the woman to the side reduces this pressure and relieves postural hypotension.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

21. A client telephones the clinic to ask about a home pregnancy test she used this morning. The nurse understands that the presence of which hormone strongly suggests a woman is pregnant?

A) Estrogen

B) HCG

C) Alpha-fetoprotein

D) Progesterone

The correct answer is B: HCG

Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%, but the test does not conclusively confirm pregnancy.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

22. As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?

A) What and how much the client drinks, according to family and friends

B) The blood alcohol level of the client

C) The blood pressure level of the client

D) The blood glucose level of the client

The correct answer is B: The blood alcohol level of the client

Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

23. A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest

A) during the night shift when staffing is limited

B) when the client’s mood improves with an increase in energy level

C) at the time of the client's greatest despair

D) after a visit from the client's estranged partner

The correct answer is B: when the client’s mood improves with an increase in energy level

Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

24. In response to a call for assistance by a client in labor, the nurse notes that a loop on the umbilical cord protrudes from the vagina. What is the priority nursing action?

A) call the health care provider

B) check fetal heart beat

C) put the client in knee-chest position

D) turn the client to the side

The correct answer is C: put the client in knee-chest position

Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The Trendelenburg position accomplishes this. The exposed cord is covered with saline soaked gauze, not reinserted. The fetal heart rate also should be checked, and the provider called. A prolapsed umbilical cord is a medical emergency.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

25. A male client calls for a nurse because of chest pain. Which statement by the client would require the most immediate action by the nurse?

A) "When I take in a deep breath, it stabs like a knife."

B) "The pain came on after dinner. That soup seemed very spicy."

C) "When I turn in bed to reach the remote for the TV, my chest hurts."

D) "I feel pressure in the middle of my chest, like an elephant is sitting on my chest."

The correct answer is D: "I feel pressure in the middle of my chest, like an elephant is sitting on my chest."

This is a classic description of chest pain in men caused by myocardial ischemia. Women experience vague feelings of fatigue and back and jaw pain.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

26. Which medication is more helpful in treating bulimia than anorexia?

A) Amphetamines

B) Sedatives

C) Anticholinergics

D) Narcotics

The correct answer is C: Anticholinergics

In contrast to anorexics, individuals with bulimia are troubled by their behavioral characteristics and become depressed. The person feels compelled to binge, purge and fast. Feeling helpless to stop the behavior, feelings of self-disgust occur.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

27. A client is treated in the emergency room for diabetic ketoacidosis and a glucose level of 650mg.D/L. In assessing the client, the nurse's review of which of the following tests suggests an understanding of this health problem?

A) Serum calcium

B) Serum magnesium

C) Serum creatinine

D) Serum potassium

The correct answer is D: Serum potassium

Potassium is lost in diabetic ketoacidosis during rehydration and insulin administration. Review of this lab finding suggests the nurse has knowledge of this problem.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

28. A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is

A) bowel sounds

B) heart rate

C) peripheral pulses

D) lung sounds

The correct answer is D: lung sounds

Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

29. A client has been started on a long term corticosteroid therapy. Which of the following comments by the client indicate the need for further teaching?

A) "I will keep a weekly weight record."

B) "I will take medication with food."

C) "I will stop taking the medication for 1 week every month."

D) "I will eat foods high in potassium."

The correct answer is C: "I will stop taking the medication for 1 week every month."

Emphatically warn against discontinuing steroid dosage abruptly because that may produce a fatal adrenal crisis.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

30. The nurse can best ensure the safety of a client suffering from dementia who wanders from the room by which action?

A) Repeatedly remind the client of the time and location

B) Explain the risks of walking with no purpose

C) Use protective devices to keep the client in the bed or chair in the room

D) Attach a wander-guard sensor band to the client's wrist

The correct answer is D: Attach a wander-guard sensor band to the client''s wrist

This type of identification band easily tracks the client''s movements and ensures safety while the client wanders on the unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.

Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.

Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia: Saunders.

31. The nurse is assessing a client's home in preparation for discharge. Which of the following should be given priority consideration?

A) Family understanding of client needs

B) Financial status

C) Location of bathrooms

D) Proximity to emergency services

The correct answer is A: Family understanding of client needs

Functional communication patterns between family members are fundamental to meeting the needs of the client and family.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

32. When teaching a client about an oral hypoglycemic medication, the nurse should place primary emphasis on

A) recognizing findings of toxicity

B) taking the medication at specified times

C) increasing the dosage based on blood glucose

D) distinguishing hypoglycemia from hyperglycemia

The correct answer is B: taking the medication at specified times

A regular interval between doses should be maintained since oral hypoglycemics stimulate the islets of Langerhans to produce insulin.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

33. A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to

A) begin intravenous therapy

B) initiate continuous blood pressure monitoring

C) administer oxygen therapy

D) institute cardiac monitoring

The correct answer is C: administer oxygen therapy

Early findings of shock reveal hypoxia with rapid heart rate and rapid respirations, and oxygen is the most critical initial intervention. The other interventions are secondary to oxygen therapy.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

34. The nurse is caring for a post-operative client who develops a wound evisceration. The first nursing intervention should be to

A) medicate the client for pain

B) call the provider

C) cover the wound with sterile saline dressing

D) place the bed in a flat position

The correct answer is C: cover the wound with sterile saline dressing

When evisceration occurs, the wound should first be quickly covered by sterile dressings soaked in sterile saline. This prevents tissue damage until a repair can be effected.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

35. The nurse is caring for a client receiving intravenous nitroglycerin for acute angina. What is the most important assessment during treatment?

A) Heart rate

B) Neurologic status

C) Urine output

D) Blood pressure

The correct answer is D: Blood pressure

The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client''s blood pressure must be evaluated every 15 minutes until stable and then every 30 minutes to every hour.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

36. The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75 year-old client's

A) poor nutritional status

B) decreased gastrointestinal motility

C) increased splanchnic blood flow

D) altered peripheral resistance

The correct answer is B: decreased gastrointestinal motility

Together with shrinkage of the gastric mucosa, and changes in the levels of hydrochloric acid, this will decrease absorption of medications and interfere with their actions.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York: Delmar.

37. The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?

A) Central venous pressure reading of 11

B) Respiratory rate of 22

C) Pulse rate of 48 BPM

D) Blood pressure of 144/92

The correct answer is C: Pulse rate of 48 BPM

One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse and cardiac arrest (this drug should never be administered without continuous EKG monitoring).

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

38. A client diagnosed with chronic depression is maintained on tranylcypromine (Parnate). An important nursing intervention is to teach the client to avoid which of the following foods?

A) Wine, beer, cheese, liver and chocolate

B) Wine, citrus fruits, yogurt and broccoli

C) Beer, cheese, beef and carrots

D) Wine, apples, sour cream and beef steak

The correct answer is A: Wine, beer, cheese, liver and chocolate

These foods are tyramine rich and ingestion of these foods while taking monoamine oxidase inhibitors (MAOIs) can precipitate a life-threatening hypertensive crisis.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Wilson, B.A., Shannon, M.T., and Stang, C.L. (2004). Nurse’s drug guide. Upper Saddle River, New Jersey: Pearson Prentice Hall.

39. The nurse is working in a high risk antepartum clinic. A 40 year-old woman in the first trimester gives a thorough health history. Which information should receive priority attention by the nurse?

A) Her father and brother are insulin dependent diabetics

B) She has taken 800 mcg of folic acid daily for the past year

C) Her husband was treated for tuberculosis as a child

D) She reports recent use of over-the counter sinus remedies

The correct answer is D: She reports recent use of over-the counter sinus remedies

Over-the-counter drugs are a possible danger in early pregnancy. A report by the client that she has taken medications should be followed up immediately.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

40. After assessing a 70 year-old male client's laboratory results during a routine clinic visit, which one of the following findings would indicate an area in which teaching is needed:

A) Serum albumin 2.5 g/dl

B) LDL Cholesterol 140 mg/dl

C) Serum glucose 90 mg/dl

D) RBC 5.0 million/mm3

The correct answer is A: Serum albumin 2.5 g/dl

Serum albumin level is low (normal 3.0 – 5.0 g/dl in elders), indicating nutritional counseling to increase dietary protein is needed. Socioeconomic factors may need to be addressed to help the client comply with the recommendation.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.