NCLEX practice #3

1. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client should

A) eat foods high in sodium to increase sputum liquefaction

B) use oxygen during meals to improve gas exchange

C) perform exercise after respiratory therapy to enhance appetite

D) cleanse the mouth of dried secretions to reduce risk of infection

The correct answer is B: use oxygen during meals to improve gas exchange

Clients with emphysema breathe easier when using oxygen while eating.

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.

2. In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and

A) increased retention of albumin in the vascular system

B) decreased colloidal osmotic pressure in the capillaries

C) fluid shift from interstitial spaces into the vascular space

D) reduced tubular reabsorption of sodium and water

The correct answer is B: decreased colloidal osmotic pressure in the capillaries

The increased glomerular permeability to protein causes a decrease in serum albumin, which results in decreased colloidal osmotic pressure.

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.

3. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would best prepare the child?

A) Introduce the child to all staff the day before surgery

B) Explain the surgery 1 week prior to the procedure

C) Arrange a tour of the operating and recovery rooms

D) Encourage the child to bring a favorite toy to the hospital

The correct answer is B: Explain the surgery 1 week prior to the procedure

A 5 year-old can understand the surgery, and should be prepared well before the procedure. Most of these procedures are "same day" surgeries and do not require an overnight stay.

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.

4. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?

A) All lesions crusted

B) Elevated temperature

C) Rhinorrhea and coryza

D) Presence of vesicles

The correct answer is A: All lesions crusted

The rash begins as a macule, with fever, and progresses to a vesicle that breaks open and then crusts over. When all lesions are crusted, the child is no longer in a communicable stage.

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 victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?

A) With acceptance and views the victim’s comment as an indication that their marriage is in trouble

B) With fear of rejection causing increased rage toward the victim

C) With a new commitment to seek counseling to assist with their marital problems

D) With relief, and welcomes the separation as a means to have some personal time

The correct answer is B: With fear of rejection causing increased rage toward the victim

The fear of rejection, abandonment, and loss only serve to increase the batterer’s rage at the partner.

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.

6. A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with

A) recreational and social needs

B) feelings of anger

C) life’s stressors

D) issues of guilt and disappointment

The correct answer is C: life’s stressors

Alcohol is used by some people to manage anxiety and stress. The overall intent is to decrease negative feelings and increase positive feelings, but substance abuse itself eventually increases negative feelings.

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.

7. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action?

A) Leave the room and return five minutes later and give the medicine

B) Explain to the child that the medicine must be taken now

C) Give the medication to the father and ask him to give it

D) Mix the medication with ice cream or applesauce

The correct answer is A: Leave the room and return five minutes later and give the medicine

Since the nurse gave the child a choice about taking the medication, the nurse must comply with the child''s response in order to build or maintain trust. Since toddlers do not have an accurate sense of time, leaving the room and coming back later is another episode to the toddler.

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.

8. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as the cause of the findings?

A) Decreased cardiac output

B) Tissue hypoxia

C) Cerebral edema

D) Reduced oxygen saturation

The correct answer is B: Tissue hypoxia

When the hemoglobin falls sufficiently to produce clinical manifestations, the findings are directly attributable to tissue hypoxia, resulting from a decrease in the oxygen carrying capacity of the blood.

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.

9. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus?

A) Discuss with the mother sharing parenting responsibilities

B) Set time aside to get the mother to express her feelings and concerns

C) Arrange for the parents to attend infant care classes

D) Talk with the father and help him accept the wife's decision

The correct answer is B: Set time aside to get the mother to express her feelings and concerns

Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be clarified.

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.

10. Which of these parents’ comments about a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?

A) "I noticed a little lump a little above the belly button."

B) "The baby seems hungry all the time."

C) "Mild vomiting turned into vomiting that shot across the room."

D) "We notice irritation and spitting up immediately after feedings."

The correct answer is C: "Mild vomiting turned into vomiting that shot across the room."

Mild regurgitation or emesis that progresses to projectile vomiting is a pattern associated with pyloric stenosis as an initial finding. The other findings are present, though not immediately.

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

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.

11. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction?

A) "I should position my baby completely facing me with my baby's mouth in front of my nipple."

B) "The baby should latch onto the nipple and areola areas."

C) "There may be times that I will need to manually express milk."

D) " I can switch to a bottle if I need to take a break from breast feeding."

The correct answer is D: " I can switch to a bottle if I need to take a break from breast feeding."

Babies adapt more quickly to the breast when they are not confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple weakens the baby''s suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the learning stage of breast feeding.

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

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

12. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values?

A) Blood urea nitrogen

B) Acid phosphatase

C) Bilirubin

D) Sedimentation rate

The correct answer is C: Bilirubin

In the laboratory data provided, the only elevated level expected is bilirubin. Additional liver function tests will confirm the diagnosis.

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.

13. The nurse, assisting in applying a cast to a client with a broken arm, knows that the

A) cast material should be dipped several times into the warm water

B) cast should be covered until it dries

C) wet cast should be handled with the palms of hands

D) casted extremity should be placed on a cloth-covered surface

The correct answer is C: wet cast should be handled with the palms of hands

Handle cast with palms of the hands and lift at 2 points of the extremity. This will prevent stress at the injury site and pressure areas on the cast.

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

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

14. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?

A) Increased 10% in height

B) 2 deciduous teeth

C) Tripled the birth weight

D) Head > chest circumference

The correct answer is C: Tripled the birth weight

The infant usually triples his birth weight by the end of the first year of life. Height usually increases by 50% from birth length. A 12 month- old child should have approximately 6 teeth. ( estimate number of teeth by subtracting 6 from age in months, ie 12 – 6 = 6). By 12 months of age, head and chest circumferences are approximately equal.

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.

15. A nurse is doing preconception counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?

A) "I understand that a glass of wine with dinner is healthy."

B) "Beer is not really hard alcohol, so I guess I can drink some."

C) "If I drink, my baby may be harmed before I know I am pregnant."

D) "Drinking with meals reduces the effects of alcohol."

The correct answer is C: "If I drink, my baby may be harmed before I know I am pregnant."

Alcohol has the greatest teratogenic effect during organogenesis, in the first weeks of pregnancy. Therefore women considering a pregnancy should not drink.

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

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

16. The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate?

A) Retractions in the intercostal tissues of the thorax

B) Chest pain aggravated by respiratory movement

C) Cyanosis and mottling of the skin

D) Rapid, shallow respirations

The correct answer is A: Retractions in the intercostal tissues of the thorax

Slight intercostal retractions are normal, however in disease states, especially in severe airway obstruction, retractions become extreme.

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

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.

17. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?

A) "Do you want to take this pretty red medicine?"

B) "You will feel better if you take your medicine."

C) "This is your medicine, and you must take it all right now."

D) "Would you like to take your medicine from a spoon or a cup?"

The correct answer is D: "Would you like to take your medicine from a spoon or a cup?"

At 3 years of age, a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine will allow the child to express an opinion and have some control.

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.

18. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best?

A) "A recovering person has to be very careful not to lose control, therefore, confine your drinking only to family gatherings."

B) "At your next AA meeting discuss the possibility of limited drinking with your sponsor."

C) "A recovering person needs to get in touch with their feelings. Do you want a drink?"

D) "A recovering person cannot return to drinking without starting the addiction process over."

The correct answer is D: "A recovering person cannot return to drinking without starting the addiction process over."

Recovery requires total abstinence from all drugs.

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.

19. The nurse prepares for a Denver Screening of a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver?

A) "It measures a child’s intelligence."

B) "It assesses a child's development."

C) "It evaluates psychological responses."

D) " It helps to determine problems."

The correct answer is B: "It assesses a child''s development."

The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test.

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.

20. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?

A) May drink as much milk as desired

B) Can have milk mixed with other foods

C) Will benefit from fat-free cow's milk

D) Should be limited to 3-4 cups of milk daily

The correct answer is D: Should be limited to 3-4 cups of milk daily

More than 32 ounces of milk a day considerably limits the intake of solid foods, resulting in a deficiency of dietary iron, as well as other nutrients.

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.

21.A nurse is assigned to a client who is newly admitted for treatment of a frontal lobe brain tumor. Which history offered by the family members would be recognized by the nurse as associated with the diagnosis, and communicated to the provider?

A) "My partner's breathing rate is usually below 12."

B) "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."

C) "It seems our sex life is nonexistent over the past 6 months."

D) "In the morning and evening I hear complaints that reading is next to impossible from blurred print."

The correct answer is B: "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."

The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.

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

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

22. The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should

A) review the medications the client is receiving

B) increase the formula infusion rate

C) increase the amount of water used to flush the tube

D) attach a rectal bag to protect the skin

The correct answer is A: review the medications the client is receiving

Antibiotics and medications containing sorbitol may induce diarrhea.

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. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?

A) Jumping rope

B) Tying shoelaces

C) Riding a tricycle

D) Playing hopscotch

The correct answer is C: Riding a tricycle

Coordination is gained through large muscle use. A child of 3 has the ability to ride a tricycle.

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.

24. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?

A) 14 minutes

B) 10 minutes

C) 15 minutes

D) Nine minutes

The correct answer is C: 15 minutes

Frequency is the time from the beginning of one contraction to the beginning of the next contraction.

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

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

25. The father of an 8 month-old infant asks the nurse if his child's vocalizations are normal for his age. Which of the following would the nurse expect at this age?

A) Cooing

B) Imitation of sounds

C) Throaty sounds

D) Laughter

The correct answer is B: Imitation of sounds

Imitation of sounds such as "da-da" is expected at this time.

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.

26. The school nurse suspects that a third grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, the nurse should

A) observe the child's behavior on at least 2 occasions

B) consult with the teacher about how to control impulsivity

C) compile a history of behavior patterns and developmental accomplishments

D) compare the child's behavior with classic signs and symptoms

The correct answer is C: compile a history of behavior patterns and developmental accomplishments

A complete behavioral, and developmental history plays an important role in determining the diagnosis.

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.

27. Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?

A) Touring the coronary intensive unit

B) Mailing a video tape to the home

C) Assessing the client's learning style

D) Administering a written pre-test

The correct answer is C: Assessing the client''s learning style

As with any anticipatory teaching, assess the client''s level of knowledge and learning style first.

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

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

28. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?

A) Seizures

B) Withdrawal

C) Craving

D) Marked tolerance

The correct answer is B: Withdrawal

The early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol intake. Seizure activity is one withdrawal symptom but there are many others, like nausea and tremor.

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.

29. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is

A) transparent film dressing

B) wet dressing with debridement granules

C) wet to dry with hydrogen peroxide

D) moist saline dressing

The correct answer is D: moist saline dressing

This wound is a stage III pressure ulcer. The wound is red (granulation tissue) and does not require debridement. The wound must be protected for granulation tissue to proliferate. A moist dressing allows epithelial tissues to migrate more rapidly.

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

White, L., and Duncan, G,. (2002). Medical-Surgical Nursing An Integrated Approach (2nd ed.). Australia: Delmar.

30, An 18 month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin, and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of

A) septicemia

B) dehydration

C) hypokalemia

D) hypercalcemia

The correct answer is B: dehydration

Clinical findings of dehydration include lethargy, irritability, dry skin, and increased pulse.

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.

31 The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client’s remarks most likely indicate

A) neologisms

B) flight of ideas

C) loose associations

D) word salad

The correct answer is C: loose associations

Though the client’s statements are not typical of logical communication, remarks 2 and 3 contain elements of the preceding sentence (moon, walk). Option A refers to making up words that have personal meaning to the client, and option B – flight of ideas defines nearly continuous flow of speech, jumping from one unconnected topic to another. Option D – word salad refers to stringing together real words into nonsense “sentences” that have no meaning for the listener.

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 The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?

A) Take the client's vital signs

B) Place the client in a sitting position with legs dangling

C) Contact the health care provider

D) Administer the PRN antianxiety agent

The correct answer is B: Place the client in a sitting position with legs dangling

Place the client in a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and minimize the pulmonary edema. The result will enhance the client’s ability to breathe. The next actions would be to contact the heath care provider, then take the vital signs and then the administration of the antianxiety agent.

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

Saxton, D. & Nugent, P. (2002). Mosby''s Comprehensive Review of Nursing for NCLEX-RN. St. Louis, Missouri: Mosby

33.The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet

A) high in carbohydrates and proteins

B) low in carbohydrates and proteins

C) high in carbohydrates, low in proteins

D) low in carbohydrates, high in proteins

The correct answer is A: high in carbohydrates and proteins

Provide a high-energy diet by increasing carbohydrates, protein and fat (possibly as high as 40%). A favorable response to the supplemental pancreatic enzymes is based on tolerance of fatty foods, decreased stool frequency, absence of steatorrhea, improved appetite and lack of abdominal pain.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: 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 toddler with atopic dermatitis. The nurse should instruct the parents to

A) Dress the child warmly to avoid chilling

B) Keep the child away from other children for the duration of the rash

C) Clean the affected areas with tepid water and detergent

D) Wrap the child's hand in mittens or socks to prevent scratching

The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching

A toddler with atopic dermatitis needs to have fingernails cut short and covered so the child will not be able to scratch the skin lesions, thereby causing new lesions and possibly a secondary infection.

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 of the actions suggested to the registered nurse (RN) by the practical nurse (PN) during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?

A) measure head circumference

B) place in airborne isolation

C) provide passive range of motion

D) provide an over-the-crib protective top

The correct answer is A: measure head circumference

In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client will have already been on airborne precautions and crib top applied to the bed on admission to the unit.

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. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?

A) Age 40 years

B) Lactose intolerance

C) Family history of breast cancer

D) Use of cocaine on weekends

The correct answer is D: Use of cocaine on weekends

Binge use of cocaine can be just as harmful to the breast fed newborn as regular use.

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.

37.A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor when a client is receiving this medication?

A) Potassium level

B) Arterial blood gasses

C) Blood urea nitrogen

D) Thiocyanate

The correct answer is D: Thiocyanate

Thiocyanate levels rise with the metabolism if nitroprusside is taken, and this can cause cyanide toxicity. Thiocyanate should not be over 1 millimole/liter.

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

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

38. During the evaluation phase for a client, the nurse should focus on

A) All finding of physical and psychosocial stressors of the client and in the family

B) The client's status, progress toward goal achievement, and ongoing re-evaluation

C) Setting short and long-term goals to insure continuity of care from hospital to home

D) Select interventions that are measurable and achievable within selected timeframes

The correct answer is B: The client''s status, progress toward goal achievement, and ongoing re-evaluation

The evaluation step of the nursing process focuses on the client''s status, progress toward goal achievement and ongoing re-evaluation of the plan of care. The other possible answers focus on other steps of the nursing process.

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

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

39. A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to

A) have the unlicensed assistive personnel (UAP) reheat the food if the client wishes

B) ask the client what foods are acceptable or are unacceptable

C) encourage her to eat for healing and strength

D) schedule the dietitian to meet with the client as soon as possible

The correct answer is B: ask the client what foods are acceptable or are unacceptable

Many Hispanic women subscribe to the balance of hot and cold foods in the post partum period. What defines "cold" can best be explained by the client or family.

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

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

40. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by

A) seeking medical help for the victim's injuries

B) minimizing the episode and underestimating the victim’s injuries

C) contacting a close friend and asking for help

D) being very remorseful and assisting the victim with medical care

The correct answer is B: minimizing the episode and underestimating the victim’s injuries

Many batterers lack an understanding of the effects of their behavior on the victim and use excessive minimization and denial.

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.