NCLEX practice #11

1. The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. The need to avoid which of these should be emphasized to the client?

A) Large indoor gatherings

B) Exposure to sunlight

C) Active physical exercise

D) Foods rich in vitamin K

The correct answer is D: Foods rich in vitamin K

Vitamin K acts as an antidote to the pharmacologic action of Coumadin therapy, decreasing Coumadin''s effectiveness. Foods high in vitamin K include dark greens, tomatoes, bananas, cheese, and fish.

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

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

2. An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for tracheoesophageal fistula. The mother asks: ”When can the tube can be used for feeding?” The nurse's best response would be which of these comments?

A) "Feedings can begin in 5 to 7 days."

B) "The feeding tube can be used immediately."

C) "The stomach contents and air must be drained first."

D) "Healing of the incision must be complete before feeding."

The correct answer is C: "The stomach contents and air must be drained first."

After surgery for gastrostomy tube placement, the catheter is left open and attached to gravity drainage for 24 hours or more.

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.

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

3. To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the

A) finger and toenail quicks

B) eyes

C) perianal area

D) external ear canals

The correct answer is B: eyes

Keratitis is a corneal ulcer or abrasion. Keratitis is caused by exposure and requires application of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch.

Estes, M.E.Z. (2002). Health Assessment and Physical Examination, (2nd Ed). Albany, NY: Delmar.

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

4. A woman who delivered 5 days ago and had been diagnosed with pregnancy induced hypertension (PIH) calls the hospital triage nurse hotline to ask for advice. She states, “I have had the worst headache for the past 2 days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps.” What should the nurse do next?

A) Advise the client that the swings in her hormones may have that effect. However, suggest for her to call her provider within the next day.

B) Advise the client to have someone bring her to the emergency room as soon as possible.

C) Ask the client to stay on the line, get the address and send an ambulance to the home.

D) Ask what the client has taken? How often? Ask about other specific complaints.

The correct answer is C: Ask the client to stay on the line, get the address and send an ambulance to the home.

The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital. For at risk clients, PIH (preeclampsia and eclampsia) may occur prior to, during or after delivery. After delivery, the window of time can be up to ten days.

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

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

5. The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is

A) "Drink 3000 to 4000 cc of fluid each day for one month."

B) "Limit fluid intake to 1000 cc each day for one month."

C) "Increase intake of citrus fruits to three servings per day."

D) "Restrict milk and dairy products for one month."

The correct answer is A: "Drink 3000 to 4000 cc of fluid each day for one month."

Drinking three to four quarts (3000 to 4000 cc) of fluid each day will aid passage of fragments and help prevent formation of new calculi.

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.

6. The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting." The nurse manager's leadership style is best described as

A) Laissez-faire

B) Autocratic

C) Participative

D) Group

The correct answer is C: Participative

A participative style of management involves staff in decision-making processes. Staff/manager interactions are open and trusting. Most work efforts are joint endeavors.

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

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

7. The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?

A) Weight reduction

B) Stress management

C) Physical exercise

D) Smoking cessation

The correct answer is D: Smoking cessation

Stopping smoking is the priority for clients at risk for cardiac disease, because of its effects of reducing oxygenation and constricting blood vessels.

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

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

8. The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is

A) advising client to restrict sodium intake

B) taking the blood pressure in the left arm

C) elevating her left arm above heart level

D) compressing the drainage device

The correct answer is B: taking the blood pressure in the left arm

Clients who have had a unilateral mastectomy should not have their blood pressure measured on the affected side. This helps avoid the possibility of lymphedema post-operatively and in the future.

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

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

9. The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated

A) "I can only wear cotton socks."

B) "I cannot go barefoot around my house."

C) "I will trim corns and calluses regularly."

D) "I should ask a family member to inspect my feet daily."

The correct answer is C: "I will trim corns and calluses regularly."

Clients who are elderly, have diabetes, and/or have vascular disease often have decreased circulation and sensation in one or both feet. Their vision may also be impaired. Therefore, they need to be taught to examine their feet daily or have someone else do so. They should wear cotton socks which have not been mended, and always wear shoes when out of bed. They should not cut their nails, corns, and calluses, but should have them trimmed by their provider, nurse, or another provider who specializes in foot care.

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.

10. A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy?

A) Intraventricular hemorrhage

B) Retinopathy of prematurity

C) Bronchial pulmonary dysplasia

D) Necrotizing enterocolitis

The correct answer is B: Retinopathy of prematurity

While there are other causes for retinal damage in the premature infant, maintaining the oxygen concentration below 40% reduces this important risk factor.

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.

11. A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse’s contribution and begins to find objections to the suggestion. The nurse manager's best response is:

A) "Let’s move on to a new action that deals with the problem."

B) "I think you need to reserve judgment until after all suggestions are offered."

C) "Very well thought out. Your analytic skills and interest are incredible."

D) "Let’s move to the ‘what if…’ as related to these objections and explore spin off ideas."

The correct answer is D: "Let’s move to the ‘what if…’ as related to these objections and explore spin off ideas."

The goal of brainstorming is to gather as many ideas as possible without judgment that slows the creative process and may discourage innovative ideas. Exploration of the nurses objections would encourage the generation of new ideas.

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.

12. A client has been taking alprazolam (Xanax) for 3 days. Nursing assessment should reveal which expected effect of the drug?

A) Tranquilization, numbing of emotions

B) Sedation, analgesia

C) Relief of insomnia and phobias

D) Diminished tachycardia and tremors associated with anxiety

The correct answer is A: Tranquilization, numbing of emotions

The anti-anxiety drugs produce tranquilizing effects and may numb the emotions.

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.

13.A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The provider's diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first?

A) Cardiopulmonary resuscitation

B) Insertion of a chest tube

C) Oxygen therapy

D) Assisted ventilation

The correct answer is B: Insertion of a chest tube

Because a portion of the lung has collapsed, a chest tube will be inserted to restore negative pressure in the chest cavity.

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.

14. A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present

A) Temperature of 99.5 degrees Fahrenheit with painful urination

B) An open, reddened wound on the heel

C) Insomnia and daytime fatigue

D) Nausea with 2 episodes of vomiting

The correct answer is B: An open, reddened wound on the heel

When signs of trauma and/or infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.

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.

15. The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?

A) Expiratory wheezes

B) Blurred vision

C) Ascites

D) Dilated pupils

The correct answer is C: Ascites

Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites due to the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein metabolism suffers.

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

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle River, NJ: Prentice-Hall.

16. A 70 year-old post-operative client has elevated serum BUN, HCT, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is:

A) Impaired gas exchange

B) Metabolic acidosis

C) Renal insufficiency

D) Fluid volume deficit

The correct answer is D: Fluid volume deficit

In fluid volume deficit, serum BUN, Na+ and hematocrit may be elevated secondary to hemoconcentration.

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

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

17. The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered medications would most likely contribute to this change?

A) Anticoagulant

B) Liquid antacid

C) Antihistamine

D) Cardiac glycoside

The correct answer is C: Antihistamine

Elderly people are susceptible to the side effect of anticholinergic drugs, such as antihistamines. Antihistamines often cause confusion in the elderly, especially at high doses.

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.

18. A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse?

A) Avoid Alka-Seltzer because it contains aspirin

B) Take Alka-Seltzer at a different time of day than the warfarin

C) Select another antacid that does not inactivate warfarin

D) Use on-half the recommended dose of Alka-Seltzer

The correct answer is A: Avoid Alka-Seltzer because it contains aspirin

Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin, an antiplatelet drug, will potentiate the anticoagulant effect of warfarin, which may result in excess bleeding.

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.

19. The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to

A) begin cardiopulmonary resuscitation

B) prepare for immediate defibrillation

C) notify the "Code" team and provider

D) assess airway breathing and circulation

The correct answer is D: assess airway breathing and circulation

The nurse must first assess the client to determine the appropriate next step. In this case the first step the nurse must take is to evaluate the A, B, C''s.

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.

20. The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care?

A) Risk for injury

B) Self care deficit

C) Alteration in comfort

D) Alteration in mobility

The correct answer is C: Alteration in comfort

Relieving pain is the number one objective of this client''s plan of care.

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.

21. While caring for a child with Reye's syndrome, the nurse should give which action the highest priority?

A) monitor intake and output

B) provide good skin care

C) assess level of consciousness

D) assist with range of motion

The correct answer is C: assess level of consciousness

An altered level of consciousness suggests increasing intracranial pressure related to cerebral edema.

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.

22. The nurse is caring for an acutely ill 10 year-old client. Which of the following assessment findings would require the nurses immediate attention?

A) Rapid bounding pulse

B) Temperature of 101.3 degrees Fahrenheit (38.5 degrees Celsius)

C) Profuse diaphoresis

D) Slow, irregular respirations

The correct answer is D: Slow, irregular respirations

A slow and irregular respiratory rate is a sign of fatigue in an acutely ill child. Fatigue can rapidly lead to respiratory arrest.

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

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

23. The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

A) Extreme fatigue

B) Increased appetite

C) Intense itching

D) Constipation

The correct answer is A: Extreme fatigue

Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be confirmed by a high blood serum level of digitalis.

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.

24. A client who is terminally ill has been receiving high doses of an opioid analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli, what orders would the nurse expect from the health care provider?

A) Decrease the analgesic dosage by half

B) Discontinue the analgesic

C) Continue the same analgesic dosage

D) Prescribe a less potent drug

The correct answer is C: Continue the same analgesic dosage

Dying patients who have been in chronic pain will probably continue to experience pain even though they cannot communicate their experience. Pain medication should be continued at the same dose, if effective.

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

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

25. A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client

A) "Be sure and eat a fat-free diet until the test."

B) "Do not eat or drink anything but water for 12 hours before the blood test."

C) "Have the blood drawn within 2 hours of eating breakfast."

D) "Stay at the laboratory so 2 blood samples can be drawn an hour apart."

The correct answer is B: "Do not eat or drink anything but water for 12 hours before the blood test."

Blood lipid levels should be measured on a fasting sample.

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

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

26. In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?

A) Uterine atony

B) Genital lacerations

C) Retained placenta

D) Clotting disorder

The correct answer is B: Genital lacerations

Continuous bleeding in the absence of a boggy fundus indicates undetected genital tract lacerations.

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.

27. The community health nurse has been caring for an adolescent with a history of morbid obesity, asthma, and hypertension, and is 22 weeks pregnant. Which of these lab reports need to be called to the teen’s provider within the next hour?

A) hemoglobin 11 g/L and calcium 6 mg/dl

B) magnesium 0.8 mEq/L and creatinine 3 mg/dl

C) blood urea nitrogen 28 and glucose 225 mg/dl

D) hematocrit 33% and platelets 200,000

The correct answer is B: magnesium 0.8 mEq/L and creatinine 3 mg/dl

The magnesium is low and the creatinine is high which indicates renal failure. With the history of hypertension, the findings exhibit the risk of preeclampsia. The client’s lab values are all abnormal except for the platelets. The client needs to be referred for immediate follow up with a provider.

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

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

28. A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include

A) The escalation of fees with a decreased reimbursement percentage

B) High costs of diagnostic and end-of-life treatment procedures

C) Increased numbers of elderly and of the chronically ill of all ages

D) A steep rise in provider fees and in insurance premiums

The correct answer is A: The escalation of fees with a decreased reimbursement percentage

The percentage of the gross national product representing health care costs rose dramatically with reimbursement based on fee for service. Reimbursement for Medicare and Medicaid recipients based on fee for service also escalates health care costs.

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

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

29. A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in this client’s plan of care within the initial 24 hours?

A) Wear masks with shields if there is potential for fluid splash

B) Use disposable utensils and plates for meals

C) Wear gown and gloves during client contact

D) Provide soft easily digested food with frequent snacks

The correct answer is C: Wear gown and gloves during client contact

HAV is usually transmitted via the fecal-oral route, i.e., someone with the virus handles food without washing his or her hands after using the bathroom. The virus can also be contracted by drinking contaminated water, eating raw shellfish from water polluted with sewage or by being in close contact with a person who''s infected — even if that person has no signs and symptoms. In fact, the disease is most contagious before signs and symptoms ever appear. The nurse should recognize the importance of isolation precautions from the initial contact with the client on admission until the noncontagious convalescence period.

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.

30. The nurse is teaching a 27 year-old client with asthma about their therapeutic regime. Which statement would indicate the need for additional instruction?

A) "I should monitor my peak flow every day."

B) "I should contact the clinic if I am using my medication more often."

C) "I need to limit my exercise, especially activities such as walking and running."

D) "I should learn stress reduction and relaxation techniques."

The correct answer is C: "I need to limit my exercise, especially activities such as walking and running."

Limiting physical activity in an otherwise healthy, young client should not be necessary. If exercise intolerance exists, the asthma management plan should include specific medications to treat the problem such as using an inhaled beta-agonist 5 minutes before exercise. The goal is always to return to a normal lifestyle.

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

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

31. The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client?

A) Instruct the client to wear a high efficiency particulate air mask in public places.

B) Ask a family member to supervise daily compliance

C) Schedule weekly clinic visits for the client

D) Ask the health care provider to change the regimen to fewer medications

The correct answer is B: Ask a family member to supervise daily compliance

Direct-observed therapy (DOT) is a recognized method for ensuring client compliance to the drug regimen. A program can be set up to directly observe the client taking the medication in the clinic, home, workplace or other convenient location.

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

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

32. Which of these clients would the triage nurse request the provider examine immediately?

A) A 5 month-old infant who has audible wheezing and grunting

B) An adolescent who has soot over the face and shirt

C) A middle-aged man with second degree burns over the right hand

D) A toddler with singed ends of long hair that extends to the waist

The correct answer is A: A 5 month-old infant who has audible wheezing and grunting

The age and the findings suggest this client is at immediate risk for respiratory complications.

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

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

33. The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to

A) encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class

B) assist the parents to plan quiet play activities at home

C) stress to the parents that they will need relief care givers

D) instruct the parents to avoid contact with persons with infection

The correct answer is A: encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class

While all suggestions are appropriate, the education of the parents/caregivers should include techniques of cardiopulmonary resuscitation in order to provide for emergency care of their child.

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.

34. The nurse is caring for a 5 year-old child whose left leg is in skeletal traction. Which of the following activities would be an appropriate diversional activity?

A) Kicking balloons with right leg

B) Playing "Simon Says"

C) Playing hand held games

D) Throw bean bags

The correct answer is C: Playing hand held games

Immobilization with traction must be maintained until bone ends are in satisfactory alignment. Activities that increase mobility interfere with the goals of treatment.

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.

35. A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age?

A) Death is personified as the bogeyman or devil

B) Death is perceived as being irreversible

C) The child feels guilty for the grandmother's death

D) The child is worried that he, too, might die

The correct answer is A: Death is personified as the bogeyman or devil

Personification of death is typical of this developmental level.

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.

36. A confused client has been placed in physical restraints by order of the provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?

A) Assist the client with activities of daily living

B) Monitor the clients physical safety

C) Evaluate for basic comfort needs

D) Document mental status and muscle strength

The correct answer is A: Assist the client with activities of daily living

The person to whom the activity is delegated must be capable of performing it . The UAP is capable of assisting clients with basic needs.

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

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

37. A nurse who is a native English speaker admits an elderly Mexican-American migrant worker after an accident that occurred during work. To facilitate communication the nurse should initially

A) Request a Spanish interpreter

B) Speak through the family or co-workers

C) Use pictures, letter boards, or monitoring

D) Assess the client's ability to speak English

The correct answer is D: Assess the client''s ability to speak English

Despite the cultural heritage, the nurse cannot make assumptions. Stereotyping is to be avoided. The nurse should assess the client''s comfort and ability in speaking English.

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

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

38. A newborn presents with a pronounced cephalhematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?

A) Pain related to periosteal injury

B) Impaired mobility related to bleeding

C) Parental anxiety related to knowledge deficit

D) Injury related to intracranial hemorrhage

The correct answer is C: Parental anxiety related to knowledge deficit

This hematoma is related to pressure at the time of labor and birth. The condition resolves within a few days. Parental anxiety must be addressed by listening to their fears and explaining the nature of this common alteration.

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.

39. A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?

A) Playing with toys in a back yard flower garden

B) Eating small amounts of grass while playing "farm"

C) Playing with cars on the pavement near burning leaves

D) Throwing a ball to a neighborhood child who has poison ivy

The correct answer is C: Playing with cars on the pavement near burning leaves

Smoke from burning leaves or stems of the poison ivy plant can produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis.

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.

40. The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins?

A) B, D, and K

B) A, D, and K

C) A, C, and D

D) A, B, and C

The correct answer is B: A, D, and K

The uptake of fat soluble vitamins is decreased in children with Cystic Fibrosis. Vitamins A, D, and K are fat soluble and are likely to be deficient in clients with Cystic Fibrosis.

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

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