NCLEX practice #13

1. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?

A) "I want to protect my child from any falls."

B) "I will set limits on exploring the house."

C) "I understand our child’s need to use those new skills."

D) "I intend to keep control over our child’s behavior."

The correct answer is C: "I understand our child’s need to use those new skills."

Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

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.

2. The nurse is performing a neurological assessment on a client post right cerebral vascular accident (CVA). Which finding, if observed by the nurse, would warrant immediate attention?

A) Decrease in level of consciousness

B) Loss of bladder control

C) Altered sensation of stimuli

D) Emotional lability

The correct answer is A: Decrease in level of consciousness

A further decrease in the level of consciousness would be indicative of a further progression of the CVA.

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.

3. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?

A) "You need to regain your strength before attempting such exertion.

B) "When you can climb 2 flights of stairs without problems, it is generally safe."

C) "Have a glass of wine to relax you, then you can try to have sex."

D) "If you can maintain an active walking program, you will have less risk."

The correct answer is B: "When you can climb 2 flights of stairs without problems, it is generally safe."

There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

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.

4. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?

A) Polyphagia

B) Dehydration

C) Bed wetting

D) Weight loss

The correct answer is C: Bed wetting

In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.

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.

5. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?

A) Raise the side rails on the bed

B) Place the call bell within reach

C) Instruct the client to remain in bed

D) Have the client empty bladder

The correct answer is D: Have the client empty bladder

The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: D, C, B, A. Note: It is much easier to administer IM meds with the side rails down, and then raising them when the nurse is done. Other activities can then be carried out more safely.

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

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

6. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is to

A) verify correct placement of the tube

B) check that the feeding solution matches the dietary order

C) aspirate abdominal contents to determine the amount of last feeding remaining in stomach

D) ensure that feeding solution is at room temperature

The correct answer is A: verify correct placement of the tube

Proper placement of the tube prevents aspiration.

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.

7. A nurse is evaluating the quality of home care for a client with Alzheimer's disease. It would be a priority to reinforce which statement by a family member?

A) "At least 2 full meals a day should be eaten."

B) "We go to a group discussion every week at our community center."

C) "We have safety bars installed in the bathroom and have 24 hour alarms on the doors."

D) "Taking the medication 3 times a day is not a problem."

The correct answer is C: "We have safety bars installed in the bathroom and have 24 hour alarms on the doors."

Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are positive statements, however safety is most important to reinforce.

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

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

8. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to

A) increase fluids that are high in protein

B) restrict fluids

C) force fluids and reassess blood pressure

D) limit fluids to non-caffeine beverages

The correct answer is C: force fluids and reassess blood pressure

Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

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

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

9. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which

A) increase the heart rate

B) lead to dehydration

C) are considered aerobic

D) may be competitive

The correct answer is B: lead to dehydration

The client must take in adequate fluids before and during exercise periods.

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.

10. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?

A) Gravida 4 para 2

B) Gravida 2 para 1

C) Gravida 3 para 1

D) Gravida 3 para 2

The correct answer is C: Gravida 3 para 1

Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).

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.

11. The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse’s immediate attention?

A) "I have bad muscle spasms in my lower leg of the affected extremity."

B) "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger."

C) "I have to use the bedpan to pass my water at least every 1 to 2 hours."

D) "It seems that the pain medication is not working as well today."

The correct answer is B: "I just can''t ''catch my breath'' over the past few minutes and I think I am in grave danger."

The nurse would be concerned about all of these comments, however the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. Although option D requires further investigation, it is not life threatening.

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

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

12. What would the nurse expect to see while assessing the growth of children during their school age years?

A) Decreasing amounts of body fat and muscle mass

B) Little change in body appearance from year to year

C) Progressive height increase of 4 inches each year

D) Yearly weight gain of about 5.5 pounds per year

The correct answer is D: Yearly weight gain of about 5.5 pounds per year

School age children gain about 5.5 pounds each year and increase about 2 inches in height.

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.

13. Which of the following should the nurse implement to prepare a client for a kidney, ureter, bladder (KUB) radiograph test?

A) Client must be NPO before the examination

B) Enema to be administered prior to the examination

C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination

D) No special orders are necessary for this examination

The correct answer is D: No special orders are necessary for this examination

No special preparation is necessary for this examination.

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

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

14. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease (PID). The nurse recognizes that this condition most frequently follows which type of infection?

A) Trichomoniasis

B) Chlamydia

C) Staphylococcus

D) Streptococcus

The correct answer is B: Chlamydia

Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

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.

15. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to

A) go get a blood pressure check within the next 48 to 72 hours

B) check blood pressure again in 2 months

C) see the health care provider immediately

D) visit the health care provider within 1 week for a BP check

The correct answer is A: go get a blood pressure check within the next 48 to 72 hours

The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client states it is ‘usually much lower,’ a concern exists for complications such as stroke. An immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

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

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

16. Which of these statements best describes the characteristic of an effective reward-feedback system?

A) Specific feedback is given as close to the event as possible

B) Staff are given feedback in equal amounts over time

C) Positive statements precede a negative statement

D) Performance goals should be higher than what is attainable

The correct answer is A: Specific feedback is given as close to the event as possible

Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if what constitutes appropriate behavior is clearly understood.

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.

17. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

A) Blood pressure 94/60

B) Heart rate 76 BPM

C) Urine output 50 ml/hour

D) Respiratory rate 16

The correct answer is A: Blood pressure 94/60

Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100 BPM; systolic B/P over 100) in order to safely administer both medications.

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.

18. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize

A) eating 3 balanced meals a day

B) adding complex carbohydrates

C) avoiding very heavy meals

D) limiting sodium to 7 gms per day

The correct answer is C: avoiding very heavy meals

Eating large, heavy meals can pull blood away from the heart for digestion, which is dangerous for the client with coronary artery disease.

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.

19. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the discharge list in order to make room for a new admission?

A) A middle aged client with a 7 year history of being ventilator dependent and who was admitted with bacterial pneumonia five days ago

B) A young adult with Type 2 diabetes mellitus for over 10 years and who was admitted with antibiotic-induced diarrhea 24 hours ago

C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and who was admitted with Stevens-Johnson syndrome that morning

D) An adolescent with a positive HIV test and who was admitted for acute cellulitis of the lower leg 48 hours ago

The correct answer is A: A middle aged client with a 7 year history of being ventilator dependent and who was admitted with bacterial pneumonia five days ago

The best candidate for discharge is one who has a chronic condition and has an established plan of care. The client in option A is most likely stable and could continue medication therapy at home.

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.

20. A triage nurse has these 4 clients arrive in the emergency department within a 15 minute period. Which client should the triage nurse send back to be seen first?

A) A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying

B) A teenager who got a singed beard while camping

C) An elderly client with complaints of frequent liquid brown colored stools

D) A middle aged client with intermittent pain behind the right scapula

The correct answer is B: A teenager who got a singed beard while camping

This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

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.

21. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?

A) the muscles

B) the cerebellum

C) the kidneys

D) the leg bones

The correct answer is A: the muscles

Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word -- “myo” --which typically means muscle.

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.

22. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is

A) Maintain fluid and electrolyte balance

B) Control nausea

C) Manage pain

D) Prevent urinary tract infection

The correct answer is C: Manage pain

The immediate goal of therapy is to alleviate the client’s pain, which can be quite severe with kidney stones.

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.

23. While assessing a 1 month-old infant, which finding should the nurse report immediately?

A) Abdominal respirations

B) Irregular breathing rate

C) Inspiratory grunt

D) Increased heart rate with crying

The correct answer is C: Inspiratory grunt

Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.

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.

24. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?

A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest."

B) A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?"

C) An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10

D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room

The correct answer is C: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10

Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications occurring in the near future.

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

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

25. The nurse anticipates that for a family who practices Chinese medicine the priority therapeutic goal would be to

A) achieve harmony

B) maintain a balance of energy

C) respect life

D) restore yin and yang

The correct answer is D: restore yin and yang

For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.

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.

26. Which of these findings indicate that a pump set to deliver a basal rate of 10 ml per hour plus PRN morphine drip for breakthrough pain is not working?

A) The client complains of discomfort at the IV insertion site

B) The client states "I just can't get relief from my pain"

C) The level of the drug is 100 ml at 8 AM and is 80 ml at noon

D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon

The correct answer is C: The level of the drug is 100 ml at 8 AM and is 80 ml at noon

The minimal dose is 10 ml per hour, which would mean 40 mls are given in a 4 hour period. Only 60 mls should be left at noon. The pump is not functioning when more than expected medicine is left in the container.

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

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri.

27. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?

A) Narrowed QRS complex

B) Shortened "PR" interval

C) Tall peaked T waves

D) Prominent "U" waves

The correct answer is C: Tall peaked T waves

A tall peaked T wave is a sign of hyperkalemia. The provider should be notified regarding discontinuing the medication.

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

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

28. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:

A) Should be taken in the morning

B) May decrease the client's energy level

C) Must be stored in a dark container

D) Will decrease the client's heart rate

The correct answer is A: Should be taken in the morning

Thyroid supplement should be taken in the morning to minimize the side effect of insomnia.

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.

29. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His partner states he fell down the stairs 2 hours ago. The nurse should

A) place a call to the client's provider for instructions

B) send him to the emergency room for evaluation

C) reassure the client's partner that the symptoms are transient

D) instruct the client's partner to call the provider if his symptoms become worse

The correct answer is B: send him to the emergency room for evaluation

This client requires immediate evaluation. A delay in treatment could result in further deterioration of his condition and possibly permanent harm. Home care nurses must prioritize interventions based on assessment findings that are in the client''s best interest.

Beare, P. and Myers, J. (1998). Adult Health Nursing. (3rd Edition). St. Louis, Missouri: Mosby.

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

30. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to

A) Excessive fetal weight

B) Low blood sugar levels

C) Depletion of subcutaneous fat

D) Progressive placental insufficiency

The correct answer is D: Progressive placental insufficiency

The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.

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.

31. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the registered nurse implement first?

A) Gastric lavage PRN

B) Antidote N-acetylcysteine (NAC) (Mucomyst) for age per pharmacy

C) Start a Dextrose 5% with 0.33% normal saline IV to keep vein open

D) Activated charcoal per pharmacy

The correct answer is A: Gastric lavage PRN

Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next actions to complete would be to administer activated charcoal, then Mucomyst and lastly the IV fluids.

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.

32. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure

A) right heart function

B) left heart function

C) renal tubule function

D) carotid artery function

The correct answer is B: left heart function

The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. It can provide hemodynamic information such as intracardiac pressure readings and oxygen saturation data, and even transvenous pacing. Information about left ventricular function is important because it directly affects tissue perfusion. Right-sided heart function is assessed through the evaluation of the central venous pressure (CVP).

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

33. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?

A) Weight gain of 5 pounds

B) Edema of the ankles

C) Gastric irritability

D) Decreased appetite

The correct answer is D: Decreased appetite

Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, and dysrhythmias.

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.

34.A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, skin hot to touch, sits leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?

A) Prepare the child for x-ray of upper airways

B) Examine the child's throat

C) Collect a sputum specimen

D) Notify the healthcare provider of the child's status

The correct answer is D: Notify the healthcare provider of the child''s status

These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

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.

35. Which individual is at greatest risk for developing hypertension?

A) 45 year-old African American attorney

B) 60 year-old Asian American shop owner

C) 40 year-old Caucasian nurse

D) 55 year-old Hispanic teacher

The correct answer is A: 45 year-old African American attorney

The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.

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

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

36. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?

A) Electrical energy fields

B) Spinal column manipulation

C) Mind-body balance

D) Exercise of joints

The correct answer is B: Spinal column manipulation

The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the misalignment (subluxation).

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

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

37. A child who has recently been diagnosed with cystic fibrosis (CF) is being assessed by a pediatric clinic nurse. Which finding of this disease would the nurse not expect to see at this time?

A) Positive sweat test

B) Bulky greasy stools

C) Moist, productive cough

D) Meconium ileus

The correct answer is C: Moist, productive cough

Option C is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with CF. The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.

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

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

38. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is

A) start a peripheral IV

B) initiate closed-chest massage

C) establish an airway

D) obtain the crash cart

The correct answer is C: establish an airway

Establishing an open airway is always the primary objective in a cardiopulmonary arrest.

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.

39. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?

A) Apply dressing using sterile technique

B) Improve the client's nutrition status

C) Initiate limb compression therapy

D) Begin proteolytic debridement

The correct answer is B: Improve the client''s nutrition status

The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help.

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.

40. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?

A) Angina at rest

B) Thrombus formation

C) Dizziness

D) Falling blood pressure

The correct answer is B: Thrombus formation

Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is within the first 12 hours after the procedure.

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

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.