NCLEX practice #7

1. When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach?

A) Speak directly to the interpreter while presenting information and use pauses for questions

B) Talk to the interpreter in advance and leave the client and interpreter alone

C) Include a family member and direct communications to that person

D) Face the client while presenting the information as the interpreter talks in the native language

The correct answer is D: Face the client while presenting the information as the interpreter talks in the native language

Communication is the cornerstone of an effective teaching plan, especially when the nurse and client do not share the same cultural heritage. Even if the nurse uses an interpreter, it is critical that the nurse use conversational style and spacing, personal space, eye contact, touch, and orientation to time strategies that are acceptable to the client. Therefore, face the client and present the information to the client, allow the interpreter to translate the content. Facing the client allows non-verbal communication to take place between the client and nurse.

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.

2. Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children?

A) Sports and games with rules

B) Finger paints and water play

C) "Dress-up" clothes and props

D) Chess and television programs

The correct answer is A: Sports and games with rules

The purpose of play for the 7 year-old is developing cooperation. Rules are very important. Logical reasoning and social skills are developed through play.

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

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

3. While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?

A) Compulsive behavior

B) Sense of impending doom

C) Fear of flying

D) Predictable episodes

The correct answer is B: Sense of impending doom

The feeling of overwhelming and uncontrollable doom is characteristic of a panic attack.

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

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

4. A nurse who is evaluating a developmentally challenged 2 year-old should stress which goal when talking to the child's mother?

A) Teaching the child self care skills

B) Preparing for independent toileting

C) Promoting the child's optimal development

D) Helping the family decide on long term care

The correct answer is C: Promoting the child''s optimal development

The primary goal of nursing care for a developmentally challenged child is to promote the child''s optimum development.

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. Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)?

A) Neuro malignant syndrome

B) Acute extrapyramidal syndrome

C) Glaucoma, prostatic hypertrophy

D) Parkinson's disease, atypical tremors

The correct answer is C: Glaucoma, prostatic hypertrophy

Glaucoma and prostatic hypertrophy are contraindications to the use of benztropine (Cogentin) because the drug is an anticholinergic agent. Cogentin is used to treat the side effects of antipsychotic 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.

6. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?

A) They are able to make simple association of ideas

B) They are able to think logically in organizing facts

C) Interpretation of events originate from their own perspective

D) Conclusions are based on previous experiences

The correct answer is B: They are able to think logically in organizing facts

The child in the concrete operations stage, according to Piaget, is capable of mature thought when allowed to manipulate and organize objects.

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.

7. While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?

A) Strange bed and surroundings

B) Separation from parents

C) Presence of other toddlers

D) Unfamiliar toys and games

The correct answer is B: Separation from parents

Separation anxiety if most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress.

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.

8. A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?

A) High Fowler's

B) Supine

C) Left lateral

D) Low Fowler's

The correct answer is A: High Fowler''s

Sitting in a chair or resting in a bed in high Fowler''s position decreases the cardiac workload and facilitates breathing.

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.

9. The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?

A) Administration of cough suppressants

B) Increasing oral fluid intake to 3000 cc per day

C) Maintaining bed rest with bathroom privileges

D) Performing chest physiotherapy twice a day

The correct answer is B: Increasing oral fluid intake to 3000 cc per day

Secretion removal is enhanced with adequate hydration which thins and liquefies secretions.

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.

10. The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to

A) reports of difficulty falling and staying asleep

B) expression of persistent suicidal thoughts

C) lack of enjoyment in usual pleasures

D) reduced senses of taste and smell

The correct answer is C: lack of enjoyment in usual pleasures

Lack of enjoyment in usual pleasures is the definition of “anhedonia,” which is a common finding in depression.

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

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

11. The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?

A) A 13 month-old unable to walk

B) A 20 month-old only using 2 and 3 word sentences

C) A 24 month-old who cries during examination

D) A 30 month-old only drinking from a sippy cup

The correct answer is D: A 30 month-old only drinking from a sippy cup

A 30 month-old should be able to drink from a cup without a cover.

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 has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?

A) Elevate the leg on 2 pillows

B) Apply support stockings

C) Apply warm compresses

D) Maintain complete bed rest

The correct answer is A: Elevate the leg on 2 pillows

The first goal of nonpharmacologic interventions is to minimize edema of the affected extremity by leg elevation.

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.

13. A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse?

A) elbow

B) mummy

C) jacket

D) clove hitch

The correct answer is A: elbow

The elbow restraint will prevent the child from touching the surgical site without hindering movement of other parts of the body.

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.

14. Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes?

A) Give written pre and post tests

B) Ask questions during practice

C) Allow another diabetic to assist

D) Observe a return demonstration

The correct answer is D: Observe a return demonstration

Since this is a psychomotor skill, this is the best way to know if the client has learned the proper technique.

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.

15. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child?

A) congenital cardiac defects

B) an acute febrile illness

C) prolonged hypoxemia

D) severe multiple trauma

The correct answer is C: prolonged hypoxemia

Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia. Children usually have both cardiac and respiratory arrest.

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.

16. The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that the client

A) should remain on bed rest in a semi-Fowler's position

B) should alternate ambulation with bed rest with legs elevated

C) may ambulate and sit in chair as tolerated

D) may ambulate as tolerated and remain in semi-Fowlers position in bed

The correct answer is B: should alternate ambulation with bed rest with legs elevated

Encourage alternating periods ambulation and bed rest with legs elevated to mobilize edema and ascites. Encourage and assist the client with gradually increasing periods of ambulation.

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.

17. The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?

A) perform defibrillation

B) administer epinephrine as ordered

C) assess for presence of pulse

D) institute CPR

The correct answer is C: assess for presence of pulse

Artifact (interference) can mimic ventricular fibrillation on a cardiac monitor. If the client is truly in ventricular fibrillation, no pulse will be present. The standard of care is to verify the monitor display with an assessment of the client’s pulse.

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.

18. The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is

A) "Eat a balanced diet for your age."

B) "Increase your intake of protein and Vitamin A."

C) "Decrease fatty foods from your diet."

D) "Do not use caffeine in any form, including chocolate."

The correct answer is A: "Eat a balanced diet for your age."

A diet for a teenager with acne should be a well balanced diet for their age. There are no recommended additions and subtractions from the diet.

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

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

19. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to

A) administer pain medication

B) suction excessive tracheobronchial secretions

C) assist client to turn, deep breathe and cough

D) monitor oxygen saturation

The correct answer is B: suction excessive tracheobronchial secretions

Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway which is always the priority nursing intervention.

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.

20. The nurse is performing physical assessments on adolescents. What finding would the nurse anticipate concerning female growth spurts?

A) They occur about 2 years earlier than for males.

B) They begin about the same time for males.

C) They begin just prior to the onset of puberty.

D) They are characterized by an increase in height of 4 inches each year.

The correct answer is A: They occur about 2 years earlier than for males.

Normally, females in their teenage years experience a growth spurt about 2 years earlier than their male peers.

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 client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to

A) Notify the primary care provider immediately

B) Suggest in-patient psychiatric care

C) Respect the client's confidential disclosure

D) Phone the family to warn them of the risk

The correct answer is A: Notify the primary care provider immediately

Not only does the client report suicidal intent, he had formulated a plan and taken steps to implement it. The primary care provider and the rest of the health care team will arrange for treatment given the client’s serious risk for self-destructive behavior. Hospitalization and most probably work with the family are indicated. The nurse should never agree to help a client “keep secrets” from the health care team.

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

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

22. The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds:

A) "The complaints of at least 3 common findings."

B) "The absence of any opportunistic infection."

C) "CD4 lymphocyte count is less than 200."

D) "Developmental delays in children."

The correct answer is C: "CD4 lymphocyte count is less than 200."

CD4 lymphocyte counts are normally 600 to 1000. In 1993 the Center for Disease Control defined AIDS as having a positive HIV plus one of these – the presence of an opportunistic infection or a CD4 lymphocyte count of less than 200.

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.

23. A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?

A) Altered nutrition: less than body requirements

B) Potential complication hemorrhage

C) Ineffective individual coping

D) Fluid volume excess

The correct answer is B: Potential complication hemorrhage

Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.

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.

24. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?

A) Offer ice cream every 2 hours

B) Place the child in a supine position

C) Allow the child to drink through a straw

D) Observe swallowing patterns

The correct answer is D: Observe swallowing patterns

The nurse should observe for increased swallowing frequency, which would signal hemorrhage.

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.

25. The nurse is caring for a client with trigeminal neuralgia (tic douloureux). To assist the client with nutrition needs, the nurse should

A) Offer small meals of high calorie soft food

B) Assist the client to sit in a chair for meals

C) Provide additional servings of fruits and raw vegetables

D) Encourage the client to eat fish, liver and chicken

The correct answer is A: Offer small meals of high calorie soft food

If the client is losing weight because of poor appetite due to the pain, assist in selecting foods that are high in calories and nutrients, to provide more nourishment with less chewing. Suggest that frequent, small meals be eaten instead of three large ones. To minimize jaw movements when eating, suggest that foods be pureed.

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

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

26. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most likely explain these findings?

A) Ingestion of tetracycline

B) Excessive fluoride intake

C) Oral iron therapy

D) Poor dental hygiene

The correct answer is B: Excessive fluoride intake

The described findings are indicative of fluorosis, a condition characterized by an increase in the extent and degree of the enamel''s porosity. This problem can be associated with repeated swallowing of toothpaste with fluoride or drinking water with high levels of fluoride.

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.

27. The nursing care plan for a client with decreased adrenal function should include

A) encouraging activity

B) placing client in reverse isolation

C) limiting visitors

D) measures to prevent constipation

The correct answer is C: limiting visitors

Any exertion, either physical or emotional, places additional stress on the adrenal glands which could precipitate an Addisonian crisis. The plan of care should protect this client from the physical and emotional exertion of visitors.

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.

28. Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)?

A) Direct sunlight

B) Foods containing tyramine

C) Foods fermented with yeast

D) Canned citrus fruit drinks

The correct answer is A: Direct sunlight

Phenothiazine increases sensitivity to the sun, making clients especially susceptible to sunburn. The nurse should recommend that clients treated with phenothiazines use sunblock consistently.

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.

29. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis?

A) Several otitis media episodes in the last year

B) Weight and height in the 10th percentile since birth

C) Takes frequent rest periods while playing

D) Changing food preferences and dislikes

The correct answer is C: Takes frequent rest periods while playing

Children with heart disease tend to have exercise intolerance. The child self-limits activity, which is consistent with manifestations of congenital heart disease in children.

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.

30. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?

A) Arrange to change client care assignments

B) Explain that this behavior is expected

C) Discuss the appropriate use of "time-out"

D) Explain that the child needs extra attention

The correct answer is B: Explain that this behavior is expected

During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parent, crying, and turning away from the stranger. These fears/behaviors extend into the toddler period and may persist into preschool.

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. The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is

A) "You think that someone wants to poison you?"

B) "Why do you think the food is poisoned?"

C) "These feelings are a symptom of your illness."

D) "You’re safe here. I won’t let anyone poison you."

The correct answer is A: "You think that someone wants to poison you?"

This response acknowledges perception through a reflective question which presents opportunity for discussion, clarification of meaning, and expressing doubt.

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

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

32. A client is in the third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?

A) Counsel the woman to consent to HIV screening

B) Perform tests for sexually transmitted diseases

C) Discuss her high risk for cervical cancer

D) Refer the client to a family planning clinic

The correct answer is A: Counsel the woman to consent to HIV screening

The client''s behavior places her at high risk for HIV. Testing is the first step. If the woman is HIV positive, the earlier treatment begins, the better the outcome.

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

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

33. A 15 year-old client with a lengthy confining illness is most at risk for altered psycho-emotional growth and development due to

A) loss of control

B) insecurity

C) dependence

D) lack of trust

The correct answer is C: dependence

The client role fosters dependency. Adolescents may react to dependency with rejection, uncooperativeness, or withdrawal.

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

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

34. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is

A) urinary output of 30 ml per hour

B) no complaints of thirst

C) increased hematocrit

D) good skin turgor around burn

The correct answer is A: urinary output of 30 ml per hour

For a child of this age, this is adequate output, yet does not suggest overload.

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.

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

35. Which of these variations in the newborn results from the presence of maternal hormones?

A) Engorgement of the breasts

B) Mongolian spots

C) Edema of the scrotum

D) Lanugo

The correct answer is A: Engorgement of the breasts

Breast engorgement occurs in both sexes as a result of the withdrawal of maternal hormones after birth.

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.

36. The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse perform first?

A) Clear the area of any hazards

B) Place the child on its side

C) Restrain the child

D) Give the prescribed anticonvulsant

The correct answer is B: Place the child on its side

Protecting the airway is the top priority in a seizure. If a child is actively convulsing, a patent airway and oxygenation must be assured.

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.

37. A registered nurse (RN) is assigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice?

A) An 18 month-old who ate an undetermined amount of crystal drain cleaner

B) A 14 month-old who chewed 2 leaves of a philodendron plant

C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium)

D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid

The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain cleaner

Drain cleaner is very alkaline. Orange juice is acidic and will help to neutralize this substance.

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.

38. The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?

A) Encourage the client to cough and deep breathe every 2 hours

B) Place the client in contact isolation

C) Provide a diet high in protein

D) Institute seizure precautions

The correct answer is A: Encourage the client to cough and deep breathe every 2 hours

Respiratory infections are common because of fluid in the retro-peritoneum pushing up against the diaphragm, causing shallow respirations. Coughing and deep breathing every 2 hours will diminish the occurrence of this complication.

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.

39. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize?

A) Acceptance of the pregnancy

B) Focus on fetal development

C) Anticipation of the birth

D) Ambivalence about pregnancy

The correct answer is C: Anticipation of the birth

Directing activities toward preparation for the newborn''s needs and personal adjustment are indicators of appropriate emotional response in the third trimester.

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

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

40. The registered nurse has just admitted a client with severe depression. What domain should be the priority focus as the nurse identifies the nursing diagnoses?

A) Nutrition

B) Elimination

C) Activity

D) Safety

The correct answer is D: Safety

Safety is a care priority for all inpatients, and a depressed client is at acute risk for self-destructive behavior. Precautions to prevent suicide must be a part of the nursing care plan.

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.