NCLEX practice #1

1. The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?

A) Heart rate

B) Muscle tone

C) Cry

D) Color

The correct answer is D: Color

Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal adaptation in the newborn.

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.

2. A mother telephones the clinic and says “I am worried because my breast-fed 1 month-old infant has soft, yellow stools after each feeding.” The nurse's best response would be which of these?

A) "This type of stool is normal for breast fed infants. Keep doing as you have."

B) "The stool should have turned to light brown by now. We need to test the stool."

C) "Formula supplements might need to be added to increase the bulk of the stools."

D) "Water should be offered several times each day in addition to the breast feeding."

The correct answer is A: "This type of stool is normal for breast fed infants. Keep doing as you have."

In breast-fed infants, stools are frequent and yellow to golden, and vary from soft to thick liquid in consistency. No change in feedings is indicated.

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

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

3. A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse?

A) Suggest isometric exercises

B) Maintain the client on bed rest

C) Ambulate for several minutes

D) Apply ice to the extremity

The correct answer is B: Maintain the client on bed rest

The finding suggests deep vein thrombosis. The client must be maintained on bed rest and the provider notified immediately.

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.

4. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?

A) Separation anxiety

B) Fear of pain

C) Loss of control

D) Bodily injury

The correct answer is A: Separation anxiety

While a toddler will experience all of the stresses, separation from parents is the major stressor.

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. The nurse is speaking to a group of parents and elementary school teachers about care for children with rheumatic fever. It is a priority to emphasize that

A) home schooling is preferred to classroom instruction

B) children may remain strep carriers for years

C) most play activities will be restricted indefinitely

D) clumsiness and behavior changes should be reported

The correct answer is D: clumsiness and behavior changes should be reported

A major manifestation of rheumatic fever that reflects central nervous system involvement is chorea. Early symptoms of chorea include behavior changes and clumsiness. Chorea is characterized by sudden, aimless, irregular movements of the extremities, involuntary facial grimaces, speech disturbances, emotional lability, and muscle weakness. Chorea is transitory and all manifestations eventually disappear.

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.

6. In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?

A) Cardizem SR tablet (diltiazem)

B) Lanoxin liquid

C) Os-cal tablet (calcium carbonate)

D) Tylenol liquid (acetaminophen)

The correct answer is A: Cardizem SR tablet (diltiazem)

Cardizem SR is a "sustained-release" drug form. Sustained release (controlled-release; long-acting) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The provider must substitute another medication.

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.

7. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is

A) avoiding alcohol use during this time

B) observing the client for hypotension

C) abrupt discontinuation of the drug

D) assessing for mild physical symptoms

The correct answer is A: avoiding alcohol use during this time

Central nervous system depressants interact with alcohol. The client will gradually reduce the dosage, under the health care provider''s direction. During this time, alcohol must be avoided.

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.

8. A client with considerable pain asks, “What is your opinion regarding acupuncture as a drug-free method for alleviating pain?” The nurse responds, "I'd forget about it as those weird non-Western treatments can be scary." The nurse's response is an example of

A) prejudice

B) discrimination

C) ethnocentrism

D) cultural insensitivity

The correct answer is C: ethnocentrism

Ethnocentrism, the universal tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways, can be a major barrier to providing culturally conscious care. Ethnocentrism perpetuates an attitude that beliefs that differ greatly from one''s own are strange, bizarre, or unenlightened, and therefore wrong. Ethnocentrism refers to the unconscious tendency to look at others through the lens of one''s own cultural norms and customs and to take for granted that one''s own values are the only objective reality. At a more complex level, the ethnocentrist regards others as inferior or immoral and believes his or her own ideas are intrinsically good, right, necessary, and desirable, while remaining unaware of his or her own value judgments.

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.

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

9. To obtain data for the nursing assessment, the nurse should:

A) observe carefully the client’s nonverbal behaviors

B) adhere to pre-planned interview goals and structure

C) allow clients to talk about whatever they want

D) elicit clients' description of their experiences, thoughts and behaviors

The correct answer is D: elicit clients'' description of their experiences, thoughts and behaviors

The nurse’s understanding of the client rests on the comprehensiveness of assessment data obtained by listening to the client’s self revelation.

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.

10. During the two-month well-baby visit, the mother complains that formula seems to stick to her baby's mouth and tongue. Which of the following would provide the most valuable data for nursing assessment?

A) Inspect the baby's mouth and throat

B) Obtain cultures of the mucous membranes

C) Flush both sides of the mouth with normal saline

D) Use a soft cloth to attempt to remove the patches

The correct answer is D: Use a soft cloth to attempt to remove the patches

Candidiasis can be distinguished from coagulated milk when attempts to remove the patches with a soft cloth are unsuccessful.

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.

11. A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to

A) promote verbal and nonverbal communication with both the client and the interpreter

B) speak only a few sentences at a time and then pause for a few moments

C) plan that the encounter will take more time than if the client spoke English

D) ask the client to speak slowly and to look at the person spoken to

The correct answer is A: promote verbal and nonverbal communication with both the client and the interpreter

The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues.

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.

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

12. A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are not receptive to the plan. As a change agent, the nurse manager should first

A) support the planning committee and post the new schedule

B) explore how the planning committee evaluated barriers to the plan

C) design a different approach to deliver care with fewer staff

D) retain the previous staffing pattern for another 6 months

The correct answer is B: explore how the planning committee evaluated barriers to the plan

The manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the right to approve or disapprove the change. Planned change involves exploring barriers and restraining forces before implementing change. To smooth acceptance of the change, restraining factors need to be evaluated. The manager wants to build the staff''s skills at implementing change. Helping the committee evaluate its decision-making is a useful step before rejecting or implementing the change. When possible all affected by the change should be involved in the planning. The question is whether staff input has been thoroughly taken into consideration.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

13. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?

A) Skin irritation

B) Drug tolerance

C) Severe headaches

D) Postural hypotension

The correct answer is B: Drug tolerance

Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.

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

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

14. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?

A) Allow the infant to drink the liquid from a medicine cup

B) Administer the medication with a syringe next to the tongue

C) Mix the medication with the infant's formula in the bottle

D) Hold the child upright and administer the medicine by spoon

The correct answer is B: Administer the medication with a syringe next to the tongue

Using a needle-less syringe to give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced.

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.

15. A mother calls the clinic, concerned that her 5 week-old infant is "sleeping more than her brother did." What is the best initial response?

A) "Do you remember his sleep patterns?"

B) "How old is your other child?"

C) "Why do you think this a concern?"

D) "Does the baby sleep after feeding?"

The correct answer is C: "Why do you think this a concern?"

Open ended questions encourage further discussion and conversation, thereby eliciting further information.

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.

16. Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin damage?

A) Ninety-ninety

B) Buck's

C) Bryant

D) Russell

The correct answer is A: Ninety-ninety

Ninety degree-ninety degree traction is used for fractures of the femur or tibia. A skeletal pin or wire is surgically placed through the distal part of the femur, while the lower part of the extremity is in a boot cast. Traction ropes and pulleys are applied.

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.

17. What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?

A) Acceptance of the pregnancy

B) Acceptance of the termination of the pregnancy

C) Acceptance of the fetus as a separate and unique being

D) Satisfactory resolution of fears related to giving birth

The correct answer is A: Acceptance of the pregnancy

During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts.

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.

18. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?

A) Temperature of 102 degrees Fahrenheit

B) Pulse rate of 98 beats per minute

C) Respiratory rate of 32

D) Blood pressure of 90/50

The correct answer is C: Respiratory rate of 32

Clients with deep vein thrombosis are at risk for the development of pulmonary embolism (PE). The most common symptoms of PE are tachypnea, dyspnea, and chest pain.

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.

19. The nurse is caring for a client with COPD who becomes dyspneic. The nurse should

A) instruct the client to breathe into a paper bag

B) place the client in a high Fowler's position

C) assist the client with pursed lip breathing

D) administer oxygen at 6L/minute via nasal cannula

The correct answer is C: assist the client with pursed lip breathing

Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.

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.

20. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?

A) Pack the nose and ears with sterile gauze

B) Apply pressure to the injury site

C) Apply bulky, loose dressing to nose and ears

D) Apply an ice pack to the back of the neck

The correct answer is C: Apply bulky, loose dressing to nose and ears

Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference for the amount of drainage.

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

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

21. A nurse is caring for a client with peripheral arterial insufficiency of the lower extremities. Which intervention should be included in the plan of care to reduce leg pain?

A) elevate the legs above the heart

B) increase ingestion of caffeine products

C) apply cold compresses

D) lower the legs to a dependent position

The correct answer is D: lower the legs to a dependent position

Ischemic pain is relieved by placing feet in a dependent position. This position improves peripheral perfusion.

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.

22. A diabetic client asks the nurse why the provider ordered a glycosylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:

A) Provides a more precise blood glucose value than self-monitoring

B) Is performed to detect complications of diabetes

C) Measures circulating levels of insulin

D) Reflects an average blood sugar for several months

The correct answer is D: Reflects an average blood sugar for several months

Glycosylated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 2-3 months and can be used to monitor client adherence to the therapeutic regimen.

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

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

23. Which statement describes factors that help build personal power in an organization?

A) Longevity in an organization, social ties to people in power, and a history as someone who does not back down in conflict ends with success

B) Goals are met with the use of networking, mentoring, and coalition building

C) High visibility and formal power are maintained with a confrontational style

D) Credibility to one's position is enhanced when professional dress and demeanor are employed

The correct answer is B: Goals are met with the use of networking, mentoring, and coalition building

Networking, mentoring, and coalition building are positive uses of personal power to meet goals.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

24. A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have

A) scrotal discoloration

B) sustained painful erection

C) inability to achieve erection

D) heaviness in the affected testicle

The correct answer is D: heaviness in the affected testicle

The feeling of heaviness in the scrotum is related to testicular cancer and not epididymitis. Sexual performance and related issues are not affected at this time.

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.

25. Which statement describes the advantage of using a decision grid for decision making?

A) It is both a visual and a quantitative method of decision making

B) It is the fastest way for group decision making

C) It allows the data to be graphed for easy interpretation

D) It is the only truly objective way to make a decision in a group

The correct answer is A: It is both a visual and a quantitative method of decision making

A decision grid allows the group to visually examine alternatives and evaluate them quantitatively with weighting.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

26. The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an understanding of the diet by stating

A) "I will increase sodium and fluids and restrict potassium."

B) "I will increase potassium and sodium and restrict fluids."

C) "I will increase sodium, potassium and fluids."

D) "I will increase fluids and restrict sodium and potassium."

The correct answer is A: "I will increase sodium and fluids and restrict potassium."

The manifestations of Addison''s disease due to mineralocorticoid deficiency, resulting from renal sodium wasting and potassium retention, include dehydration, hypotension, hyponatremia, hyperkalemia and acidosis.

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

Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company

27. A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?

A) Report the behavior to the charge nurse

B) Talk with the client to find out about the preferred herbal preparation

C) Contact the client's primary care provider

D) Explain the importance of the medication to the client

The correct answer is B: Talk with the client to find out about the preferred herbal preparation

Respect for differences is demonstrated by incorporating traditional cultural practices for staying healthy into professional prescriptions and interventions. The challenge for the health care provider is to understand the client''s perspective. "Culture care preservation or maintenance refers to those assistive, supporting, facilitative or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values to that they can maintain their well-being, recover from illness or face handicaps and/or death."

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.

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

28. During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client's knees. The best action for the nurse to take is to

A) Ask the client for more information about the nature of the bruises

B) Ask the client and then the family about the findings

C) Report the bruising to social services to follow-up

D) Document the findings on the admission sheet

The correct answer is A: Ask the client for more information about the nature of the bruises

"Cupping" is practiced by Vietnamese. The principle is to create a vacuum inside a special cup by igniting alcohol-soaked cotton inside the cup. When the flame extinguishes, the cup is immediately applied to the skin of the painful site. The belief: the suction exudes the noxious element. The greater the bruise, the greater the seriousness of the illness. There is typically no need to ask an adult’s family members.

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

Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New York: McGraw Hill/ Appleton and Long.

29. The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?

A) Massage legs frequently

B) Frequent turning

C) Moisten skin with lotions

D) Apply moist heat to reddened areas

The correct answer is B: Frequent turning

Frequent turning will prevent skin breakdown by relieving prolonged pressure on any one area.

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.

30. Dual diagnosis indicates that there is a substance abuse problem as well as a

A) cross addiction

B) mental disorder

C) disorder of any type

D) medical problem

The correct answer is B: mental disorder

Dual diagnosis is the concurrent presence of a major psychiatric disorder and chemical dependence.

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. After successful alcohol detoxification, a client remarked to a friend, "I’ve tried to stop drinking but I just can’t. I can’t even work without having a drink." The client’s belief that he needs alcohol indicates his dependence is primarily

A) psychological

B) physical

C) biological

D) social-cultural

The correct answer is A: psychological

With psychological dependence, it is the client’s thoughts and attitude toward alcohol that produce craving and compulsive use.

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.

32. A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action?

A) Report this immediately to the nurse manager

B) Confront the nurse about the suspected drug use

C) Sign the narcotic sheet and document the event in an incident report

D) Counsel the colleague about the risky behaviors

The correct answer is A: Report this immediately to the nurse manager

The incident must be reported to the appropriate supervisor, for both ethical and legal reasons. This is not an incident that a co-worker can resolve without referral to a manager.

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

Kozier, B., Erb, G., Berman, A. and Snyder, S. (2004). Fundamentals of Nursing. Upper Saddle River, N.J.: Pearson Prentice Hall.

33. A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. What would the nurse's best response to this request?

A) "That's a good choice, and I know it is your favorite. You can have it today."

B) "I'm sorry, that is not a good choice, but you could have pasta."

C) "I know that is your favorite, but let me help you pick another lunch."

D) "You cannot have the peanut butter until you are feeling better."

The correct answer is C: "I know that is your favorite, but let me help you pick another lunch."

Children with AGN who have edema, hypertension oliguria and azotemia may have dietary restrictions limiting sodium, fluids, protein and potassium. Giving the child a short explanation and offering to talk about an alternative is appropriate for this age.

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

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

34. The nurse is caring for a depressed client with a new prescription for a selective serotonin reuptake inhibitor (SSRI) antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?

A) History of obesity

B) Prescribed use of a monoamine oxidase (MAO) inhibitor

C) Diagnosis of vascular disease

D) Takes antacids frequently

The correct answer is B: Prescribed use of a monoamine oxidase (MAO) inhibitor

SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.

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.

35. A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?

A) "Touching the abdomen could cause cancer cells to spread."

B) "Examining the area would cause difficulty to the child."

C) "Pushing on the stomach might lead to the spread of infection."

D) "Placing any pressure on the abdomen may cause an abnormal experience."

The correct answer is A: "Touching the abdomen could cause cancer cells to spread."

Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully. The other options are similar but not the most specific.

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.

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

36. The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result in metabolic acidosis?

A) Severe diarrhea for 24 hours

B) Nausea with anorexia

C) Alternating constipation and diarrhea

D) Vomiting for over 48 hours

The correct answer is A: Severe diarrhea for 24 hours

Severe diarrhea is the only problem listed that can lead to metabolic acidosis if untreated.

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

Ball, J. & Bindler, R. (2003). Pediatric Nursing. Upper Saddle River, N.J.: Pearson Education.

37. Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy (ECT)?

A) Permission to videotape

B) Salivary pH

C) Mini-mental status exam

D) Pre-anesthesia work-up

The correct answer is D: Pre-anesthesia work-up

ECT is delivered under general anesthesia and the client should be prepared as for any procedure involving anesthesia.

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.

38. A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirin toxicity?

A) Serum potassium

B) Protein intake

C) Lactose tolerance

D) Serum albumin

The correct answer is D: Serum albumin

When highly protein-bound drugs are administered to patients with low serum albumin (protein) levels, excess free (unbound) drug can cause exaggerated and dangerous effects.

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.