A client has been receiving digoxin (Lanoxin) 0.125 mgm daily for a week. When the nurse visits the client at home, he tells the nurse about several problems that have been developing over the last few days. Which of these complaints is most suggestive of digoxin toxicity?  A) Constipation.B) Urinary frequency. C) Ankle edema. D) Loss of appetite.

Answer: DD) Anorexia is a common, and early, manifestation of digoxin toxicity. The other complaints are not related to digoxin.

A client, 34 weeks pregnant, arrives at the emergency room complaining of painless vaginal bleeding. She states that she has had no contractions. Her vital signs are within normal range. The most important initial intervention is to  A) Obtain a blood sample for typing and cross-match.B) Complete a vaginal examination. C) Notify the physician. D) Place the client on strict bedrest.

Answer: DD) It is important to immediately place the client on bedrest, as the symptoms suggest placenta previa: a history of painless bleeding late in pregnancy. A vaginal examination should not be performed. The next interventions would be to notify the physician and obtain a blood sample because if the bleeding is excessive, delivery by C-section would be implemented.

Gentamycin is prescribed for a client with urinary tract infection. The nurse will observe for 8th cranial nerve toxicity indicated by  A) Facial tremors. B) Dilated pupils.C) Tinnitus. D) Vertigo.

Answer: CC) The primary side effect of gentamycin is toxicity affecting the 8th cranial nerve. The symptom is tinnitus. Vertigo would occur with 5th cranial nerve involvement.

The nurse has just completed the nursing assessment of a 4-year-old child. Which one of the following findings is most characteristic of thrombocytopenia? A) Urticaria, epistaxis, hypertension.B) Vertigo, petechiae, bradycardia.C) Purpura, tachycardia, hypotension.D) Petechiae, hematuria, purpura.

Answer: DD) Thrombocytopenia (a platelet count 50,000 or below) is characterized by petechiae, purpura, and, on occasion, spontaneous hematuria. The lower the platelet count, the greater the risk of spontaneous bleeding.

A client calls the diabetic hot-line and tells the nurse that she has flu-like symptoms with no fever, but has been vomiting and has had diarrhea since 4:00 am. She is taking NPH insulin. The nursing instruction (based on standard orders) about the amount of insulin she will need is A) An increased dose of her NPH insulin.B) A smaller dose of her NPH insulin.C) No insulin.D) Her regular dose of NPH insulin.

Answer: BB) Although she is unable to eat, the client still needs some insulin for body metabolism processes. If fever is not present, insulin is not increased.

After a normal labor and delivery, the infant weighed only 5 pounds and is considered premature. One of the most important principles in providing nutrition for this premature infant is to

A) Use a premie nipple for bottle feeding.B) Use a regular nipple with a large hole.C) Use milk high in fat for the formula.D) Feed every 4 to 6 hours.

Answer: AA) A regular nipple is too hard and will make it difficult for the infant to suck, causing unnecessary fatigue. A premie soft nipple should be used.

A client in a hospital for diagnostic tests is still awake at 1:00 A.M. He has refused a PRN medication for sleep. He says, "Well, to tell the truth, I don't dare go to sleep. I'm afraid I'll die in my sleep." Which first response by the nurse would be the best?  A) "Have you ever felt this way before?" B) "You feel that sleep is a kind of death?" C) "Would it help to talk about these fears?"D) "You must get the rest. If you take a pill, I'll keep an eye on you all night."

Answer: CC) The most therapeutic response is to acknowledge the fears (they are real to the client) and give him the opportunity to talk about the fears.

A client is receiving an antineoplastic drug. An important safety intervention in administering this drug is to A) Wear surgical latex gloves and a disposable gown for administration.B) Monitor the vital signs before administering.C) Check the drug with another nurse before administration.D) Request a special nurse to administer the drug.

Answer: AA) An important safety guideline issued by the Occupational Safety and Health Adminis-tration (OSHA) is to wear surgical gloves and a disposable gown. The nurse will need special training but there is not a special nurse assigned to give the drug, nor are these drugs checked with a second nurse.

A client is requesting "something for pain." She has 6 mgm of morphine sulfate ordered q 4 hours prn and there is 15 mgm/ml in the narcotic cupboard. How much medication will be given to the client?  A) 6 minims.B) 8 minims. C) 1/3 ml.D) 4 minims.

Answer: AA) The correct formula to calculate the amount is as follows: the dose desired divided by the dose on hand multiplied by the quantity on hand = amount to administer.

Variable decelerations in the fetal heart rate (FHR) during labor are severe dips occurring at the peak of contraction. This fetal heart pattern is usually associated with which of the following conditions?  A) Utero-placental insufficiency.B) Fetal head compression. C) Uterine insufficiency. D) Pressure on the umbilical cord.

Answer: DD) These decelerations are common during labor. The FHR drops during the contraction, resulting from stimulation of the chemoreceptors and baroreceptors as the cord is compressed. The nurse should recognize these readings on the fetal monitor as normal.

A college student failed her psychology final exam and spent the entire evening berating the teacher and the course. This behavior is an example of A) Reaction-formation.B) Compensation.C) Acting out.D) Projection. 

Answer: DD) The student is projecting her own inadequacies on the teacher and not taking responsibility for her own behavior.

Sunken or soft eyeballs and the loss of skin turgor seen in a dehydrated child are evidence of  A) Decreased protein concentration of the blood. B) A fluid shift from the intracellular spaces. C) A fluid shift from the extracellular spaces. D) Increased fat concentration of the blood.

Answer: BB) Fluid shifts by the process of osmosis. With dehydration, by the time these signs occur fluid has been lost from the intracellular spaces. Extracellular fluid loss occurs first, and then by osmosis fluid is pulled from the cell (area of lesser concentration) to the extracellular compartment (area of greater concentration), resulting in cellular crenation.

Assessing a two-year old, which one of the following findings would concern the nurse?  A) Setting-sun eyes. B) Closed fontanels. C) Telegraphic speech.D) Pulse 110, blood pressure 90/60.

Answer: AA) All the other options are normal for a two year old. The setting-sun eyes is seen in children with neurological defects. Specifically, it is reflective of increased intracranial pressure.

If a client needs oxygen therapy, the nurse would be alert for the sign or symptom of  A) Rosy lips.B) Bradycardia. C) Yawning. D) Hypercapnia.

Answer: CC) Hypoxia results in yawning, restlessness, and shortness of breath. Tachycardia is present in early hypoxia. Lips may be cyanotic, not rosy as in carbon dioxide narcosis.

The nurse is assessing a client with cirrhosis. The nurse would assess for which change in laboratory values directly related to faulty protein metabolism?  A) Creatinine. B) BUN. C) Ammonia.D) SGPT.

Answer: CC) The nurse would assess if the ammonia is increased-a direct result of faulty protein metabolism. In the late stages of cirrhosis, the BUN decreases because the liver cannot metabolize proteins. The creatinine increases if there is renal failure. The SGPT increases due to damaged liver cells.

A client awakens with severe substernal chest pressure and dyspnea. He takes 2 nitroglycerin tablets without relief. In 5 minutes, he takes 2 more without relief. He calls his physician who instructs him to go directly to the hospital. Understanding the rationale for the physician's instructions, the nurse knows that sudden death (outside the hospital) in association with coronary artery disease is most often due to A) Arrhythmias.B) Papillary muscle dysfunction.C) Pump failure accompanied by pulmonary congestion.D) Acute myocardial infarction. 

Answer: AA) About 50 percent of the people who do die outside the hospital have a fatal arrhythmia, usually shortly after experiencing the onset of symptoms.

Following an anxiety attack, the client is admitted to the psychiatric unit. The client begins to talk to the others and appears more relaxed. The nurse would conclude the client is improving when observing that she  A) Requests that she be discharged the next day because she is better. B) Refuses to take her medication, saying she doesn't need it anymore. C) Asks that her husband and her parents come to visit her. D) Begins to participate in unit activities with the other clients.  

Answer: DD) When the client's anxiety has decreased, she can begin to concentrate on others and activities. Refusing medication or requesting discharge do not necessarily imply improvement. Asking to see her husband might imply improvement, but not necessarilyÑshe may just be feeling more anxious about what is happening at home.

To obtain an apical pulse on an infant, the diaphragm of the stethoscope is placed at the apex of the heart. When placing the diaphragm on the infant's chest, it should be located A) At the left nipple, where the heart's point of maximum impulse is located.B) At the left edge of the sternum and fifth intercostal space.C) To the left of the midclavicular line, at the third to fourth intercostal space.D) At the left midclavicular line and fifth intercostal space. 

Answer: CC) This is the appropriate location on an infant's chest for an apical pulse. Over age 7, the apical pulse is located at answer (D).

Following surgery, a client is returned to the unit with a T-tube in place. To ensure optimal functioning, the A) T-tube would be connected to the drainage bottle at the level of the bed to prevent bile backflow.B) T-tube would not be clamped.C) Client would be positioned in a prone position to promote bile drainage.D) Client would be positioned to prevent backflow of bile into the liver.

Answer: DD) Clients are positioned in a semi-Fowler's position to assist in drainage. The T-tube can be clamped before meals to accumulate enough bile for digestion. The drainage bottle is positioned below the level of the bed to facilitate drainage.

A female client gave birth to a 7 pound baby boy with a cleft lip. The nurse knows that this infant will be fed with a A) Rubber-tipped medicine dropper placed on the side without the cleft.B) Nipple on the side without the cleft.C) Gavage tube.D) Nipple on the side with the cleft. 

Answer: BB) A nurse should use a soft or regular nipple with a slightly enlarged hole and feed the infant on the side opposite the cleft.

A mother who is breast-feeding comes to the clinic with concerns about her baby's stool, which she describes as yellow and watery. The nurse's response would be A) "The baby is probably getting too much water which should be decreased." B) "I'll notify the physician so we can do a thorough work-up." C) "This is a normal stool for a baby who is breast-feeding." D) "It is probably something you are eating. Let's take a look at your diet." 

Answer: CC) This is a description of a normal stool which may number 3 or 4 per day. It is not related to the amount of water or the mother's diet.

The nurse, in counseling the parents of a child with sickle cell anemia, explains that the treatment for sickle cell anemia crisis is  A) Broad-spectrum antibiotics. B) Feosol and high-potency vitamins. C) Monthly transfusions.D) Mainly palliative with prevention of sickling.

Answer: DD) Treatment (e.g., oxygen, anticoagulants, transfusion, analgesics) is mainly palliative during the crisis, because there is no cure at the present time.

An elderly client with dementia suffers from insomnia. The nurse anticipates that the physician will not order barbiturates because their use could result in A) Delirium and paradoxical excitement. B) Habituation and dependence. C) Potential liver damage. D) Central nervous system depression

Answer: AA) In organic brain disorder (dementia), barbiturates commonly cause delirium, confusion, and paradoxical excitement. These drugs would be contraindicated in this condition.

A client who developed cerebral edema following a head injury is given mannitol (Osmitrol) intravenously. The outcome that most clearly indicates that the drug has achieved its desired therapeutic effect is when the  A) Respirations drop to 12 and become regular. B) Client's level of awareness improves.C) Urinary output increasesD) Client has no seizures.

Answer: BB) Mannitol is given to reduce cerebral edema by promoting the movement of water from the tissues into the plasma followed by its excretion through the kidneys. The client's level of awareness is the most sensitive indicator of the effects of increased intracranial pressure. Improvement in the level of awareness, therefore, indicates a therapeutic response to the mannitol. The increased urinary output is simply a means through which the desired therapeutic effect is achieved. The absence of seizures does not indicate a therapeutic response to mannitol. Slowing of respirations may indicate increased cerebral edema.

The nurse, instructing a client in renal failure who has orders for a low potassium diet, teaches the client that a menu with the lowest amount of potassium is  A) Cottage cheese, tomato slices, salmon.B) Vegetable soup, applesauce, broiled halibut. C) Yogurt, rye wafer, tuna. D) Apple, cheese pizza, beer.

Answer: DD) This menu provides 504 mgm of potassium (apple, 159; cheese pizza, 230; beer, 115). Answer (A) provides 777 mgm; (B) provides 807 mgm; and (C) provides 851 mgm. Fish, eggs, meat, chicken, yogurt, and some vegetables and fruits are high sources of potassium.

Which of the following statements best explains why premature infants are more likely to develop hyperbilirubinemia? A) Premature infants receive few antibodies from the mother.B) Antibody formation is immature.C) White blood cells are immature.D) Liver enzymes are immature.

Answer: DD) Immaturity of the liver is responsible for hyperbilirubinemia; the white cell count would be related to potential infection.

A client is given Mannitol to decrease cerebral edema. To evaluate the effect of this medication, the nurse will assess for a/an  A) Decrease in edema. B) Increase in blood pressure. C) Increase in urine output. D) Decrease in blood pressure.

Answer: CC) The action of Mannitol is to decrease cerebral edema. It stimulates diuretic action and fluid is carried out through the kidneys, thereby increasing urine output. This action may then result in decreased blood pressure.

A client is told by his physician that he will be taking a medication with an enteric coating. The nurse explains that this coating  A) Speeds the action of the drug when administered orally. B) Prevents the stomach juices from destroying the effect of the drug. C) Reduces toxic effects of the drug. D) Prolongs the action of the drug over an 8 to 12 hour span.

Answer: BB) An enteric coating on a pill or tablet is a hard coating which prevents the material from dissolving in the stomach and allows the medication to be absorbed in the intestine.

After application of a leg cast following a fracture, the client is unable to feel pressure on his toes and complains of tingling. These signs indicate  A) Phantom pain syndrome.B) Improper alignment of the fracture.C) Overmedication with an analgesic.D) Pressure on a nerve.

Answer: DD) Because the client cannot feel sensory stimuli, a blockage of the nerves between the central nervous system and the peripheral system is suspected.

The nurse will anticipate that the major postoperative complication following a cholecystectomy is A) Thrombophlebitis.B) Pneumonia.C) Paralytic ileus.D) Hemorrhage.

Answer: BB) Pneumonia, because clients with high abdominal incisions tend to splint and do not like to cough and deep breathe due to the resulting pain.

A child with cystic fibrosis will take pancreatic enzymes 3 times a day. The nurse will know the mother understands the purpose of these enzymes if she says  A) "My son should take them prior to meals."B) "My son can take them at any time from 6 to 8 hours apart depending on the family schedule."C) "They should be given following breakfast, lunch and dinner."D) "They should be taken at intervals of 8 hours with a large glass of milk." 

Answer: AA) The purpose of the pancreatic enzymes is to replace the enzymes unavailable in the child's system that assist with the digestion of fats. Therefore, they should be taken prior to the ingestion of food.

The symptoms of "malingering" are most like those of conversion reaction in that they  A) Are physically incapacitating.B) Serve to decrease anxiety. C) Are produced on a conscious level. D) Provide a "secondary gain."

Answer: DD) Both behaviors benefit from the secondary gains (attention and sympathy) they receive. Conversion reaction may be physically incapacitating (paralysis), but it is not produced on a conscious level. The conversion reaction is a response to a level of anxiety; malingering may have a degree of anxiety, but the behavior does not usually decrease it.

A premature infant was placed in a heated isolette because  A) Her temperature control mechanism is immature.B) Heat within the isolette facilitates drainage of mucus.C) The infant has a small body surface for her weight.D) Heat increases the flow of oxygen to extremities.

Answer: AA) The premature infant has poor body control of temperature and needs immediate attention to keep from losing heat. Reasons for heat loss include little subcutaneous fat and poor insulation, large body surface for weight, immaturity of temperature control, and lack of activity.

Moving the client from the bed to a chair, the first appropriate intervention is to A) Rock the client and pivot.B) Dangle the client at his bedside.C) Put nonslip shoes or slippers on client's feet.D) Position client so that he is comfortable.

Answer: BB) Before moving the client, dangling at the bedside is important. This procedure stabilizes the client and allows the nurse time to assess whether he develops vertigo from a drop in blood pressure.

Nursing responsibility working on a psychiatric unit includes being able to recognize indications or signals of impending violent or assaultive behavior. This behavior could be  A) Increased tendency to approach people and make physical contact, such as touching faces.B) Foul language.C) Sudden withdrawal and refusal to speak.D) Hallucinations that are threatening, new, and commanding in nature.

Answer: DD) Violent behavior often occurs as a response to a real or imagined threat. Hallucinations can be threatening in nature.

A client undergoing chemotherapy is suspected of developing thrombocytopenia. The most relevant finding indicating that this condition has occurred is  A) The client has developed an infection. B) Listless behavior experienced by the client.C) The appearance of tarry stools. D) A platelet count of 180,000/cu mm.  

Answer: CC) A low platelet count leads to bleeding. A normal platelet count is 130,000 to 137,000/cu mm. A count below 50,000/cu mm indicates possible bleeding. Infections occur as a result of lowered white blood cell counts. Listlessness can be a result of decreased red blood cells.

When a client experiences a severe anaphylactic reaction to a medication, the nurse's initial action is to A) Place the client in a supine position.B) Start an IV.C) Prepare equipment for intubation.D) Assess vital signs.

Answer: AA) The shock position is necessary to maintain vital signs. The other interventions may be carried out, but are not initial actions.

A 32-year-old mother of three has come to the OB clinic. Her last menstrual period (LMP) began 8 weeks ago (1/21/01). The results of her tests indicate that she is pregnant. According to Nägele's Rule, the expected date of confinement (EDC) would be A) 11/21/01.B) 10/14/01.C) 10/28/01.D) 10/l/01.

Answer: CC) Nagele's Rule is to subtract 3 months and add 7 days. Using this formula, the client's EDC would be 10/28/01.

In dealing with a schizophrenic client's delusion, it is important that the nurse  A) Avoid directly talking about the delusion. B) Not disagree or argue with the delusion. C) Point out the reality as contrasted with the delusion. D) Reassure the client that it is only a delusion.  

Answer: BB) Arguing or disagreeing with the client's delusion will only tend to make it more fixed. Pointing out the reality of the information may make the client more defensive and will do little to increase his insight. Reassurance will not be therapeutic, nor will direct avoidance.

The nurse, in evaluating a client's lab results, identifies an increased reticulocyte count. A further assessment is indicated to determine if the client  A) Has had chemotherapy recently.B) Has had a history of recent blood loss. C) Received a transfusion of platelets within the last 2 days. D) Takes excessively high doses of vitamins.

Answer: BB) Reticulocytes are increased when the bone marrow is compensating for blood loss by releasing more young RBCs. Reticulocytes are immature red blood cells. They circulate in the blood for 24 to 48 hours as they mature. Chemotherapy causes a decrease in reticulocytes. A transfusion of platelets has no bearing on the reticulocyte count.

A client with a diagnosis of simple schizophrenia is given an antipsychotic drug, Trilafon. After 2 days, his behavior appears calmer. One week later he approaches the nurse and complains of sore throat, fever and fatigue. The nurse will assess the client for A) Akathisia.B) Agranulocytosis.C) The flu.D) German measles.

 Answer: BB) These are symptoms of a blood dyscrasia, agranulocytosis, which indicates the immune system is depressed. Akathisia is a side effect that also occurs with an antipsychotic drug, but it is an extrapyramidal effect.

A client is admitted to the hospital with a diagnosis of portal cirrhosis--late stage. He has generalized edema and ascites and has difficulty sleeping. He asks the nurse to get him something to help him sleep. The doctor orders phenobarbital (Luminal) 100 mg HS or PRN. The nursing intervention is to  A) Give the dose as ordered at bedtime. B) Question the drug that was ordered. C) Hold the dose until he asks for it during the night. D) Question the dose of the drug.

Answer: BB) It is appropriate and good nursing judgment to question the order because with late stage cirrhosis, the ability to detoxify the medication by the liver is limited. As a result, barbiturates or sedatives are not ordered for these clients.

The correct action for instilling eye drops is to instill the drops A) Directly on the cornea.B) Into the center of conjunctival sac.C) Over the conjunctiva.D) At the outer canthus of the eye.

Answer: BB) Drops instilled in the center of the sac will assist in distributing the medication over the entire surface of the conjunctiva and anterior eyeball.

Following a cesarean delivery, in addition to routine postpartum care, nursing interventions would be to  A) Check the abdominal dressings, check deep tendon reflexes, encourage fluids the first 48 hours. B) Auscultate for bowel sounds, check deep tendon reflexes, maintain strict bedrest. C) Auscultate for bowel sounds, check the abdominal dressing, encourage ambulation. D) Encourage ambulation, check lochia and fundus.  

Answer: CC) In addition to checking the fundus and lochia, bowel sounds must be auscultated, the dressing checked, and ambulation encouraged. Deep tendon reflexes are only checked routinely if preeclampsia or hypertension exists or is suspected. Answer (D) is incorrect because it does not include checking bowel sounds.

The nurse is to assess the capillary refill time of a client who has a leg cast. When the nurse compresses one of the client's toenails and releases the compression, the nurse would expect the color to return to the nail within  A) 3 seconds. B) 15 seconds. C) 10 seconds.D) 1 second.  

Answer: AA) Normal capillary refill time is 3 seconds or less. Prolonged refill time is indicative of circulatory impairment.

A 60-year-old male client with CA of the lung has had difficulty breathing due to a buildup of fluid in the left thoracic cavity. The physician has ordered a thoracentesis. For this procedure, the nurse will position the client  A) On his right side with his head elevated 30 degrees. B) In a supine position with his head elevated 30 degrees.C) In a sitting position leaning over the bedside table. D) On his abdomen. 

Answer: CC) Fluid is removed from the pleural space during a thoracentesis. This upright position ensures that the diaphragm is most dependent and facilitates removal of fluid from the base of the pleural space.

The nurse will instruct the client that activity allowed during an acute episode of thrombophlebitis should be  A) Bedrest with hourly leg exercises. B) Bedrest with legs flat for 1 week. C) Bedrest with legs elevated 20 degrees. D) Ambulation with short leg TEDs.

Answer: CC) The client is kept on bedrest until local tenderness and swelling have disappeared (usually 1 week). During bedrest, the legs are elevated about 20 degrees with the trunk horizontal and the head on a pillow. Support TEDs are not used on the involved extremity and exercise of the involved extremity is avoided until the thrombus has become adhered to the vein wall.

A young man, age 18, is admitted to the ICU following a car accident. He is unconscious and has multiple injuries. His most serious injury is a flail chest, which has resulted in hypoventilation. To begin treatment, the hospital staff must first  A) Immediately begin treatment without consent.B) Attempt to obtain parental consent.C) Wait for the client to regain consciousness. D) Obtain a court order.  

Answer: BB) In most states age 18 is still considered to be minor status. Because this is an emergency situation, the staff will initiate treatment if they cannot immediately contact the client's parents. They do not have to obtain a court order to treat the minor.

Following an angry outburst the previous evening, on a psychiatric unit a client says , "I'm feeling calmer now. I don't know what got into me. You all must think I'm crazy." The best response to this statement would be A) "That's all right. We're here to help you."B) "Why would you think that?"C) "You think your behavior was crazy?"D) "How were you feeling last evening?"

Answer: DD) The client is encouraged to express his feelings. This may lead to further discussion of the client's reactions to his own feelings when he feels threatened. Answers (B) and (C) are incorrect and focus on the intellectual aspect of this reaction. Answer (A) is incorrect because it does not encourage the client to express his feelings and explore his behavior.

A client is being given Sucralfate (Carafate), ordered by his physician for treating his peptic ulcer. Before he leaves the hospital, the nurse will review the discharge orders. An important instruction for the client is that he should take the medication A) One hour before or after meals and at bedtime.B) One hour before or after meals on an empty stomach.C) With meals, on a full stomach.D) At bedtime only.

Answer: AA) Carafate stimulates the release of prostaglandins and stimulates the mucosal barrier so it is important to take the drug on an empty stomach, 1 hour before or after meals and at bedtime. The duration of drug action is 5 hours.

A 34-year-old client is admitted with a diagnosis of hypoparathyroidism. One of the parameters the nurse will assess for is hypocalcemia. If present, the nurse would expect to observe  A) Hyperventilation.B) Generalized edema. C) A negative Chvostek's sign.D) Spasms of the hands and feet.

Answer: DD) Calcium produces a sedative effect on nerve cells and is essential for the transmission of nerve impulses. A deficit of calcium produces abnormal muscle contractions and is manifested by carpopedal spasms. Acute muscular spasms (tetany) may be potentially fatal. The Chvostek's sign would be positive if hypocalcemia is present. Edema or hyperventilation would not be noted with this diagnosis.

A new mother-to-be is being counseled about her nutritional needs during her pregnancy. The nurse tells her that she should increase her intake of A) Carbohydrates.B) Vitamin B.C) Fat.D) Calories.

Answer: DD) During pregnancy, there is an increased need for calories, protein and iron. A high-fat, high-carbohydrate diet is not recommended because it may cause excessive weight gain and fat deposits, which are difficult to lose after pregnancy.

A client hospitalized for depression is preparing for discharge. The statement that best indicates improvement in the client's condition is  A) "I feel pretty helpless about the situation at home."B) "I think I'm ready to go home and manage my family."C) "I want to continue therapy after I am discharged."D) "I'm not sure I have the energy to do my household chores."

Answer: BB) The best indicator of improvement is the energy level and behavior that occurs as the depression lifts. When the client says she can manage her family, it indicates her depression has decreased. Continuing therapy does not necessarily indicate energy level.

The nurse has just inserted a nasogastric tube into a young male client. To check placement, the first method is to  A) Send the client to x-ray for an abdominal film as ordered.B) Insert air into the tubing and with a stethoscope, listen for a "whish" sound.C) Aspirate the stomach contents and test with litmus paper.D) Place the tip of the nasogastric tube in a glass of water and observe for bubbling. 

Answer: CC) Checking the aspirate with litmus paper indicates tube placement. An acidic response means the tube is in the stomach. The air insertion technique is commonly used, but it is not as accurate. X-ray check will be used for tube feedings, but it is not the initial method.

The physician asks the nurse to palpate the client's fundus immediately after delivery of the placenta. Normally, the nurse would expect it to be A) Firm and at the umbilicus.B) Soft and 3 cm below the umbilicus.C) Soft and at the umbilicus. D) Firm and 3 cm below the umbilicus.

Answer: AA) Normally, the uterus is contracting and, therefore, firm and palpable at the umbilicus. It would be very unusual for it to be palpated below the umbilicus at this time.

The nurse is teaching an insulin-dependent diabetic client to self-test her blood glucose. The nurse tells her that if she obtains a result that is over 250 mg/dL, she should  A) Reduce the amount of food that she eats.B) Test her urine for ketones. C) Do nothing unless the results remain elevated for 2 days. D) Increase her dose of regular insulin by 5 units.

Answer: BB) An elevated blood sugar may be accompanied by ketoacidosis; therefore, it is important to test for urinary ketones when the blood glucose is over 250 mg/dL. Reducing intake may provoke hypoglycemia in a Type I diabetic. Any change in insulin dosage needs to be medically prescribed. The client should not wait 2 days before taking action when the blood sugar is high.

In preparing a care plan for a 14 year old, the nurse knows that her admission to the hospital may cause her to experience fears of  A) Loss of independence. B) The unknown. C) Being displaced.D) Separation.

Answer: AA) Adolescents, having recently achieved some measure of independence, have a fear of losing it. Fear of being displaced occurs in the school-age child and fear of separation occurs in the very young.

A client is suffering from severe side effects from chemotherapy. She is experiencing nausea, vomiting, and anorexia. In addition to antiemetic medications, the nurse might suggest A) Low-protein meals.B) High-calorie and high-protein supplements.C) Drinking fluids only between, not with meals.D) Eliminating salt and spices in the diet.

Answer: BB) The most effective deterrent to the nausea and vomiting is to offer the client high-calorie and high-protein supplements. If diarrhea is a problem, eliminating spices would be helpful. Food preferences of the client may also encourage eating (additional seasoning; small, more frequent meals; etc.) Not including fluids with meals may be helpful, but it is not known to help nausea and vomiting.

A 15-year-old client is receiving intensive IV antibiotic therapy for Lyme disease. The physician ordered 6.25 mg per minute of oxacillin. Using 500 ml D5W and 1.5 grams of medication, the mls per minute the nurse would administer are  A) 4 ml. B) 4. 1 ml. C) 2 ml. D) 3 ml.  

Answer: CC) Each 500 ml of IV fluid contains 1500 mg of oxacillin. One ml of IV fluid contains 3 mg; the client will receive 2 ml per minute.

Pregnancy during adolescence increases the risk to both the mother and fetus because A) Pregnancy increases the production of chorionic gonadotropin. B) Pelvic bone structure in adolescents is too soft due to lack of calcium. C) Pregnancy compounds the crisis of adolescence emotionally, physically and socially. D) Adolescents are usually emotionally unstable.

Answer: CC) Pregnancy is usually a period of increased stress for a woman because of the physical, emotional, and social changes it imposes upon her life. The maturational stress caused by adolescence, especially the young adolescent, can compound this crisis. The bone structure may not be fully developed, but it is not necessarily soft.

A client with a right side retinal detachment is admitted to the hospital and scheduled for surgery later that day. The most important nursing intervention in the preoperative hours is to position the client A) So that the area of the detachment is dependent.B) With the head of his bed flat.C) On his right side.D) With the head of his bed elevated.

Answer: AA) It is important to position the client so that the area of detachment is dependent; this will prevent blindness. All of the other responses are incorrect, as the position totally depends on the area of detachment.

The nurse is preparing a teaching plan for breast feeding for a new mother. Which one of the following factors is least likely to cause the "let-down" or "milk ejection" reflex?  A) Tension or stress. B) Sexual arousal. C) Exercise.D) A drink with alcohol.

Answer: AA) Tension, worry, pain, or fear are all emotions that can work to inhibit milk letdown; therefore, it is essential to provide as calm an environment as possible for the breast-feeding mother.

A client is admitted to the CCU with a diagnosis of anterior myocardial infarction. Shortly after admission, he states, "I might as well have died because now I won't be able to do anything." The best response is A) "You shouldn't be thinking about that because you are doing so well now."B) "What do you mean about not being able to do anything?"C) "Don't worry about it, everything will be all right."D) "Take life one day at a time. It will all work out."

Answer: BB) By keeping the lines of communication open, the client may be able to discuss his fears and concerns. If he can verbalize these issues, he can begin to cope with his condition and continue in the rehabilitative process. The other responses close off communication.

A young client on the pediatric unit weighs 10 kilograms and the adult dose of a medication is 10 mg. The closest correct dosage to give the child is  A) None of the above. B) 1.5 mg. C) 1.0 mg. D) 2.5 mg. 

Answer: BB) The adult dose is multiplied by the child's weight in pounds, so kilograms must first be changed to pounds. Then this number is divided by 150 and the closest number is selected. 10 kg = 22 lbs divided by 150 = 1.48 or 1.5.

Some clients with severely active lupus erythematosus are managed with steroids. A positive response to steroid therapy would be evidenced by  A) An increase in platelet count. B) A decrease in anti-DNA titer. C) A normal gamma globulin count.D) Negative syphilis serology.

Answer: BB) Anti-DNA antibody levels correlate most specifically with lupus disease activity. Positive response to steroids would show a decrease in these levels. Twenty percent of clients with lupus develop a positive syphilis serology, and many have hypergammaglobulinemia and a decreased platelet count.

In counseling parents of a retarded child, the nurse would formulate a nursing plan that  A) Will interpret feelings about their baby and the grief process for the parents. B) Is based on a careful family assessment, including the parents' grief reaction. C) Will help the parents make decisions about long-term plans for the child. D) Presents options about institutional placement for the child.

Answer: BB) Parents cannot be expected to make decisions and long-term plans for the child while they are still experiencing grief. The focus of nursing should be on accepting parents' feelings and promoting communication.

Management of mild diarrhea and dehydration in children includes  A) Encouraging oral intake of clear liquids such as juices, soft drinks and broth.B) Withholding all oral intake until the diarrhea stops. C) Rehydration with parenteral fluids containing 5% dextrose.D) Giving 60 to 80 mL per kilogram (body weight) oral rehydration solution over 2 hours.  

Answer: DD) Oral rehydration is now preferred in cases of mild dehydration. Parenteral fluids are necessary for moderate to severe dehydration. Withholding fluids may exacerbate dehydration. Juices and soft drinks containing sugars can add to or cause a relative hyperosmolar dehydration.

A client preparing for gallbladder surgery has an oral temperature of 101 degrees F and a white blood cell count of 15,000 per cu mm the evening of admission to the hospital. The most appropriate nursing intervention is to  A) Repeat the lab test as these results indicate possible infection. B) Notify the physician immediately, as this is not an expected clinical picture. C) Follow admission orders, as this is to be expected. D) Continue to observe the client for complications.

Answer: CC) The clinical manifestations are typical of gallbladder disease and thus the nurse would continue to follow admission orders.

The client with gastric pain is advised to take antacids to relieve pain. The nurse will teach him that the antacid contraindicated for this condition is A) Amphojel.B) Maalox.C) Soda bicarbonate.D) Aluminum hydroxide.

Answer: CC) Soda bicarbonate is absorbed into the system and destroys acid balance; it can lead to alkalosis.

A client with orders to receive 2000 ml/day has received 1000 ml of IV fluid in less than two hours. The changes in his condition that the nurse would expect to observe are  A) Hyperventilation and bradycardia. B) Dyspnea and tachycardia.C) Tachycardia and CVP of 45. D) Dyspnea and CVP of 10.

Answer: BB) Tachycardia and dyspnea would be present due to a cardiovascular overload of fluid. In answers (C) and (D) the CVP readings would not relate to the condition; it would be about 25-30 cm H2O in this condition. A CVP of 10 is normal.

An 11 year old with Type A hemophilia is brought to the emergency room after being knocked down in a touch football game. His mother says to the nurse, "This never would have happened if I had watched him more closely." The most appropriate response is to say A) "It is difficult not to feel guilty, particularly when you could have watched him more closely."B) "All mothers of chronically ill children feel this way, but it doesn't accomplish anything."C) "Hemophiliac children should not be allowed to play contact sports."D) "I understand how you feel, but at some point he is going to have to accept responsibility for monitoring his own activities."

Answer: DD) The nurse acknowledges the mother's feelings, but at the same time identifies a factor that must be dealt with as the child grows older and demands more independence.

The nurse is assisting a client to choose a meal that follows his dietary orders of high calorie, high protein, decreased sodium, and low potassium. The nurse will know he understands his dietary guidelines when he chooses A) Halibut, salad, rice, and instant coffee.B) Salmon, rice, green beans, sourdough bread, coffee, and ice cream.C) Sirloin steak, salad, baked potato with butter, and chocolate ice cream.D) Crab, beets and spinach, baked potato, and milk. 

Answer: BB) The best choice of meal is fish (not halibut or cod, both high in potassium), rice, and green beans. Bread and ice cream will add calories and protein. Instant coffee is high in potassium, and beets and spinach are high in sodium.

A 46-year-old male client has had a gastric resection for peptic ulcer disease. The nurse is preparing him for discharge by giving him guidelines to prevent "dumping syndrome." These guidelines would include  A) Eating salty foods with every meal. B) Drinking fluids with meals. C) Including simple carbohydrates (sugar, honey) in his meals. D) Eating foods with relatively high fat content.

Answer: DD) A high protein, high fat, low carbohydrate diet is maintained to prevent dumping syndrome. A diet low in carbohydrates and sodium will assist in decreasing the rapid shift of extracellular fluids into the bowel. Fluids should not be taken with meals.

The highest priority goal in the care of a newborn with tracheo-esophageal fistula (TEF) and esophageal atresia is to  A) Maintain tissue integrity.B) Promote hydration. C) Support maternal-infant bonding.D) Prevent aspiration.

Answer: DD) The anatomical malformation in this anomaly threatens the newborn's airway. Maintaining a patent airway is the highest priority in any situation where the airway is threatened.