Practice Test - Answers and Rationale

1.  Answer: A

Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damaged the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, there is no distention. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removal of the vein with the use of hook and wires via multiple small incisions in the leg.

2.  Answer: C

3: In rheumatic fever, the joints especially the knees, ankles, elbows, and wrists are painful, swollen, red, and hot to the touch. Limiting movement of the affected joints typically minimizes pain. 1: Massaging the joints likely will not aid in pain relief because the pain is due to the disease process and subsequent inflammation in the joint. 2: Applying ice to the affected joints likely will not aid in pain relief because of the inflammation, edema, and effusion in the joint tissue. 4: Exercise should be avoided because of the increased workload placed on the heart muscle. This is in contrast to usual recommendations for clients with other forms of arthritis. Despite joint involvement in rheumatic fever, permanent deformities do not occur.

3.  Answer: D

If 6 hours or fewer have passed since the onset of symptoms related to MI, thrombolytic therapy is indicated. (The client's chest pain began 4 hours before diagnosis.) The preferred choice is tPA, which is more specific for cardiac tissue than streptokinase. Stress testing shouldn't be performed during an MI. The client doesn't exhibit symptoms that indicate the use of lidocaine.

4.  Answer: A

Prinzmetal's or variant angina is triggered by coronary artery spasm. An unpredictable amount of activity may trigger unstable angina. Activities that increase myocardial oxygen demand may trigger predictable stable angina.

5.  Answer: D

The nursing diagnosis of Acute pain takes highest priority because pain increases the client's pulse and blood pressure. During an acute phase of an MI, low-grade fever is an expected result of the body's response to the myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis but it may be corrected by addressing the priority concern

6.  Answer: C

Standard management for the client with deep vein thrombosis includes bed rest for 5 to 7 days, limb elevation, relief of discomfort with warm moist heat, and analgesics as needed. Ambulation is contraindicated because activity such as ambulation can cause the thrombus to dislodge and travel to the lungs. Narcotic analgesics are not required to relieve pain, and pain normally is relieved by acetaminophen (Tylenol).

7.  Answer: D

The client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of MI is troponin level. The other tests can show evidence of muscle injury but they're less specific indicators of myocardial damage than troponin.

8. Answer: B

2: Common laboratory findings in the client who has suffered a MI include elevated CPK level. CPK is also released during muscle injury and brain injury. The CPK isoenzyme CPK-MB elevates only in response to myocardial damage. 1: Elevated serum cholesterol level is a risk factor for coronary artery disease (CAD). It is not a diagnostic tool for MI. 3: The erythrocyte sedimentation rate may be elevated with an MI but it is not diagnostic. 4: The white blood cell count is typically elevated but not diagnostic for MI.

9.  Answer: A

The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats per minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

10.  Answer: A

Initial treatment consists of avoiding cold, avoiding mechanical or chemical injury, and quitting smoking. Vasodilator drug therapy is generally reserved for severe cases. Hands are affected bilaterally, and amputation isn't usually done. Blood clots don't cause Raynaud's disease.

11.  Answer: D

The client should alert any health care provider of a history of infective endocarditis before any procedure that involves instrumentation. The provider should place the client on prophylactic antibiotics. The client should take antibiotics for the full course of therapy. The client should notify the physician if chest pain worsens or if dyspnea or other symptoms occur. The client should use a soft toothbrush and floss carefully to avoid any bleeding of the gums, which would provide a portal of entry for bacterial infection.

12.  Answer: D

D","The paralysis is not progressive and the prognosis is usually excellent. ","This is unnecessary; passive range of motion and intermittent splinting performed by a family member is all that is necessary; recovery usually occurs in 3 months. ","Intermittent splinting and passive range of motion are all that is required; only in rare instances when avulsion of the nerves results in permanent damage is orthopedic or surgical intervention necessary. ","The nerves that have been stretched normally take about 3 months to recover from the trauma sustained during delivery. "

13.  Answer: C

(3) For a confused patient with memory failure, supervision of medication administration is essential. In order for a patient to self-medicate, the patient needs to understand and comprehend drug information. The patient with cognitive changes has difficulty remembering, especially when multiple medications are given. (1) Not all medications are to be administered with meals. Some medications are better absorbed on an empty stomach. (2) A confused patient does not understand the implications of refusing medications, and therefore the nurse needs to instruct the family how to handle medications for the patient who refuses them. (4) Self-medication, even though it gives the patient control and independence, is not recommend¬ed in a confused patient for safety reasons.

14.  Answer: D

4: Nitroglycerin can cause hypotension. A priority nursing assessment after the administration of nitroglycerin is the client’s blood pressure. 1: This is not a priority nursing assessment after the administration of nitroglycerin. 2: This is not a priority nursing assessment after the administration of nitroglycerin. 3: This is not a priority nursing assessment after the administration of nitroglycerin.

15.  Answer: B

The cardiac cycle consists of contraction and relaxation of the heart muscle. The heart normally sends out about 5 L of blood every minute to the body.

16. Answer: A

Sickle cell anemia is an autosomal recessive trait found most commonly in African-American individuals. The treatment for this condition is heat, hydration, oxygenation, and pain relief. (SR 5381)

17.  Answer: A

Correct procedure for cardiopulmonary resuscitation with two rescuers includes a compression to ventilation ratio of 5 to 1. With adults, compressions are performed at a depth of 1 ½ to 2 inches. The 5:1 ratio yields an effective rate of 12 respirations per minute. With effective compressions, carotid pulsations should be present. At its best, cardiopulmonary resuscitation produces only 30 % of the normal cardiac output, so correct technique is vital.

18.  Answer: D

Clients undergoing PTCA receive abciximab because it inhibits platelet aggregation, thereby reducing cardiac ischemic complications. Before abciximab is administered, the client should have an up-to-date APTT result available. The drug isn't contraindicated in clients with a seizure history. Abciximab isn't an opioid narcotic; therefore, an opioid antagonist such as naloxone doesn't need to be at the bedside. Any client with refractory angina should be on continuous ECG monitoring; however, monitoring isn't a requirement for administering abciximab.

19.  Answer: C

Triamterene is a potassium-sparing diuretic, and the client should avoid foods high in potassium. Fruits that are naturally higher in potassium include avocado, bananas, fresh oranges, mangoes, nectarines, papayas, and dried prunes.

20.  Answer: C

1: Telling the mother that she didn't bring the child in for 2 weeks implies that the mother was at fault, possibly causing the mother to become defensive. 2: With congenital hypothyroidism, failure of normal development occurs during the embryonic period or when an inborn error of metabolism prevents the normal synthesis of thyroxine. Although the condition is present at birth, maternal thyroxine can pass through the placenta to the fetus, supplying the fetus and neonate sufficiently. Thus, in most neonates, the signs of hypothyroidism are commonly masked at birth. 3: With congenital hypothyroidism, failure of normal development occurs during the embryonic period or when an inborn error of metabolism prevents the normal synthesis of thyroxine. Although the condition is present at birth, maternal thyroxine can pass through the placenta to the fetus, supplying the fetus and neonate sufficiently. Thus, in most neonates, the signs of hypothyroidism are commonly masked at birth. 4: Telling the mother that she couldn't be reached is not therapeutic and may cause the mother to become defensive, implying that she was at fault.

21.  Answer: D

Acetazolamide is a carbonic unhydrase inhibitor that has sulfonamide properties. Before administration of this medication, the nurse should assess the client for an allergy to sulfonamides because the medication is contraindicated if an allergy exists. The nurse also should monitor the client during therapy for an allergic reaction and for photosensitivity.

22.  Answer: B

Elastic stockings are used to promote venous return. The nurse needs to remove them once per day to observe the condition of the skin underneath the stockings. Applying the stockings increases blood flow to the heart. When the stockings are in place, the leg muscles can still stretch and relax, and the veins can fill with blood.

23.  Answer: A

An anterior MI causes left ventricular dysfunction and can lead to manifestations of heart failure, which include pulmonary crackles and dyspnea. The other types of MI aren't usually associated with heart failure.

24.  Answer: D

Procainamide is an antidysrhythmic that may be used to treat ventricular dysrhythmias in clients who are allergic to lidocaine. Digoxin is a cardiac glycoside; metoprolol is a β-adrenergic blocking agent; and verapamil is a calcium channel blocking agent.

25.  Answer: B

B","Thickened formula is given to an infant with reflux problems, such as vomiting after each feeding. ","Because of the cleft (opening) in the lip, the infant tends to suck in more air than usual; burping will prevent frequent regurgitation of formula. ","The infant's bottle should never be propped; the infant can aspirate. ","The baby should be held while being fed. "

26.  Answer: C

The client should wear loose, comfortable clothing for the procedure. Electrocardiogram lead placement is enhanced if the client wears a shirt that buttons in front. The client should wear rubber-soled, supportive shoes such as sneakers. The client is NPO after bedtime or for a minimum of 2 hours before the test. The client should avoid smoking, alcohol, caffeine on the day of the test. Inadequate or incorrect preparation can interfere with the test and possibly yield false-positive findings.

27.  Answer: B

Toxic shock syndrome is caused by infection and often is associated with tampon use. Disseminated intravascular coagulation is a complication of toxic shock syndrome. Options A, C, and D are unrelated to the cause of toxic shock syndrome.

28.  Answer: C

The normal activated partial thromboplastin time (aPPT) varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPPT between, 1.5 and 2.5 times normal. Thus the client’s aPPT is within the therapeutic range, and the dose should remain unchanged.

29.  Answer: C

The client undergoing pericardiocentesis is positioned supine with the head of bed raised to a 45- to 60- degree angle. This places the heart in close proximity to the chest wall for easier insertion of the needle into the pericardial sac. Options A, B, and D are incorrect positions.

30.  Answer: D

Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to drop reflexively. In addition, the manual pressure could interfere with the flow of blood to the brain, causing possible dizziness and syncope.

31.  Answer: B

The aortic valve separates the aorta from the left ventricle. Options A, C, and D describe the mitral, tricuspid, and pulmonic valves, respectively.

32.  Answer: A

1: Based on the mother's description, the child most likely is exhibiting signs and symptoms of laryngotracheal bronchitis. The mother should try to decrease the inflammation in the upper airway by exposing her child to a warm, steamy environment. The safest method is to steam up the bathroom and stay with the child. 2: Steam vaporizers work by boiling water. Their use is to be avoided because they can cause severe burns if the child comes in close contact with the steam or if the vaporizer spills. 3: A decongestant may assist in decreasing the rhinorrhea (runny nose) but it will not decrease the inflammation in the upper airway. 4: Laryngotracheal bronchitis is caused by a virus. Aspirin is contraindicated in children with viral infection because this combination is implicated in Reye's syndrome.

33.  Answer: B

The advanced cardiac life support nurse would place one gel pad to the right of the sternum just below the clavicle and the other gel pad to the left of the precordium. The nurse then would place the electrode paddles over the pads. Options A, C, and D identify incorrect positions.

34.  Answer: A

Following pericardiocentesis, a rise in blood pressure and fall in central venous pressure are expected. The client usually expresses immediate relief. Heart sounds are no longer muffled or distant.

35. Answer: D

QUESTION: Should you give the medication? STRATEGY: Determine the outcome of each answer choice. NEEDED INFO: Digoxin: loading dose 0.5 - 1 mg, maintenance dose 0.125 - .25 mg. S/S of toxicity: N + V, visual disturbances, bradycardia. Aldactone: potassium sparing diuretic that antagonizes aldosterone in distal tubules. Side effect: hyperkalemia. CORRECT ANSWER: (4) loading dose (1) inappropriate (2) not necessary (3) never change dose

36.  Answer: A

Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats per minute. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.

37.  Answer: D

Typical discharge activity instructions for the first 6 weeks include instructing the client to lift nothing heavier than 5 lb, not to drive, and to avoid any activities that cause straining. The nurse teaches the client to use the arms for balance, but not weight support, to avoid the effects of straining. These limitations are to allow for sternal healing, which takes about 6 weeks.

38.  Answer: D

Usually CVP ranges from 4 to 10 cm H₂0 or 3 to 7 mm Hg. The other options are outside this range.

39.  Answer: C

COPD causes pulmonary hypertension, leading to right ventricular failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. He should eat a low-sodium diet to avoid fluid retention and should engage in moderate exercise to avoid muscle atrophy.

40.  Answer: D

(4)The basic physiological defect caused by anemia is a decrease in the oxygen-carrying capacity of the blood and, consequently, a reduction in the amount of oxygen available to the cell! When the anemia develops slowly, the child usually adapts to the declining hemoglobin l~ in his/her body and can function quite well. When the hemoglobin level falls sufficiently low to produce clinical manifestations, the symptoms that result are due to tissue hypoxia. Manifestations include pallor and muscle weakness, and the child becomes fatigued easily. Central nervous system manifestations include headache, light-headedness, dizziness, irritability, slowed thought processes, decreased attention span, apathy and depression. (1)Abdominal pain and vomiting are not manifestations associated with iron deficiency anemia in a chil (2)Poor posture and unclear speech are not characteristic of a child with iron deficiency anemia. (3)Bradycardia is not seen in a child with a low hemoglobin level. Usually the child is tachycardic and has an increased cardiac output to compensate for the low hemoglobin level. Dyspnea on exertion is possible because of the decreased oxygen-carrying capacity of the blood.

41.  Answer: C

3: Rheumatic fever is an inflammatory collagen disease that typically follows an infection by group A beta-hemolytic streptococci, ordinarily occurring in the throat. Rheumatic fever generally follows infection with streptococci within about 2 weeks. It is believed that the disease involves an autoimmune or allergic response to the organism. 1: Rheumatic fever typically follows an infection by group A beta-hemolytic streptococci, ordinarily occurring in the throat. Infection with measles, a virus, does not predispose the child to develop rheumatic fever. 2: Rheumatic fever typically follows an infection by group A beta-hemolytic streptococci, ordinarily occurring in the throat. Infection with mumps, a virus, does not predispose the child to develop rheumatic fever. 4: Rheumatic fever typically follows an infection by group A beta-hemolytic streptococci, ordinarily occurring in the throat. Infection with influenza virus does not predispose the child to develop rheumatic fever.

42.  Answer: D

D","This is not essential to the accomplishment of the procedure. ","The child should have had the local anesthetic applied before the procedure. ","This will not guarantee that the child will keep still during the procedure. ","Movement by the child will impede the procedure and may cause additional injuries to the surrounding structures. "

43.  Answer: B

The normal fibrinogen level is 180 to 340 mg/dL for males and 190 to 420 mg/dL for females. A critical value is one that is less than 100 mg/dL. With disseminated intravascular coagulation the fibrinogen level drops because fibrinogen is used up in the clotting process. Option 2 is the only option that identifies a normal level for a female client.

44.  Answer: D

4: The characteristic of anginal pain that helps differentiate it from the pain of a heart attack is that anginal pain is transient and usually alleviated by resting or lying down. In unstable angina, however, there is increasing frequency, intensity, or duration of pain. 1: Anginal pain is not always less severe than that of an MI. 2: Anginal pain may radiate down the arm or into the jaw. 3: Anginal pain may be relieved with rest, while the pain related to an MI is not.

45.  Answer: B

Foods that are lower in sodium include fruits and vegetables (option B), because they do not contain physiological saline. Highly processed or refined foods (option A and C) are higher in sodium unless their food labels specifically state “low sodium.” Saltwater fish and shellfish are high in sodium.

46.  Answer: A

The client with uncontrolled atrial fibrillation and a ventricular rate of more than 100 beats per minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

47.  Answer: D

4: Coldness is the assessment finding most consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor. 1: Aching pain, an earlier sign of tissue hypoxia and ischemia, is associated with incomplete obstruction. 2: Burning sensations are earlier signs of tissue hypoxia and ischemia and are associated with incomplete obstruction. 3: Numbness and tingling, which are earlier signs of tissue hypoxia and ischemia, are associated with incomplete obstruction.

48.  Answer: A

Iron is necessary for hemoglobin (HB) synthesis. HB is responsible for oxygen transport in the body. Iron deficiency anemia causes subnormal HB levels, which impair tissue oxygenation and bring about a nursing diagnosis of Impaired gas exchange. Iron deficiency anemia doesn't cause fluid volume deficit and is less directly related to ineffective airway clearance and impaired breathing pattern than it is to ineffective gas exchange.

49.  Answer: A

The normal left atrial pressure is 1 to 10 mm Hg. Because the left atrium does not generate significant pressure during atrial contraction, the atrial pressure as an average (mean) pressure rather than as a systolic or diastolic pressure. Options 2, 3, and 4 are incorrect.

50.  Answer: B

The client commonly is fatigued following the cardiac catheterization procedure. Other preprocedure teaching points include that the procedure is done in a darkened cardiac catheterization room. A local anesthetic is used so there is little to no pain with catheter insertion. General anesthesia is not used. The x-ray table is hard and may be tilted periodically, and the procedure may take 1 to 2 hours. The client may feel various sensations with the catheterization.

51.  Answer: A

The symptoms of hyperkalemia relate to its effect on the myocardial muscle. These include changes noted on the electrocardiogram, such as tall, peaked T waves; prolonged PR interval; and widening of the QRS complex. Other cardiac symptoms include ventricular dysrhythmias that may lead to cardiac arrest. ST segment depression is noted in hyperkalemia.

52.  Answer: C

3: Feeding methods should produce the least tension possible on the sutures to promote effective healing of the cleft lip repair. Therefore, a rubber-tipped medicine dropper has been found to be a satisfactory method for feeding an infant who has had surgical repair of a cleft lip. 1: Ordinarily, gastric gavage is not used unless the infant develops respiratory problems. 2: Intravenous fluids do not supply complete nutrition for the infant; therefore, they would not be used as a feeding method. 4: A lamb's nipple may be successful for feeding a child with a cleft palate once the lip is healed; however, the action of making a seal around the nipple would put tension on the suture line.

53.  Answer: D

4: People with heart failure are taught to maintain a target weight and to weigh themselves daily to monitor increasing fluid retention. Fluid retention can lead to decompensation and hospitalization. 1: Monitoring daily urine output is not required of these clients. 2: A week of bed rest is not indicated for most people with heart failure. 3: Clients on potassium-wasting diuretics will be taught to include dietary sources of potassium or to take a potassium supplement. However, all clients with heart failure should weigh themselves daily to monitor fluid status.

54. Answer: C

The therapeutic range for prothrombin time is 1.5 to 2 times control for clients at high risk for thrombus. Based on the client’s control value, the therapeutic range for this individual would be 16.5 to 22 seconds. Therefore the result is within the therapeutic range.

55.  Answer: B

Giving acetaminophen is helpful but will not ease difficult breathing. | For the child with croup who is coughing and having difficulty breathing, the child should be taken into the shower where hot water is running to make the bathroom steamy. Steam helps to loosen secretion and relieve some of the respiratory distress. | Giving over-the-counter cough syrup is inappropriate because the underlying problem is airway inflammation and subsequent mucus accumulation and bronchoconstriction. | Getting the child to take as much fluid as possible is important but it will not be effective in easing difficult breathing.

56.  Answer: B

When given to treat acute MI, morphine sulfate eliminates pain, reduces venous return to the heart, reduces vascular resistance, reduces myocardial workload, and reduces the oxygen demand of the heart. Morphine sulfate doesn't increase myocardial contractility, raise blood pressure, or increase venous return.

57. Answer: A

1: Based on the report of the child’s signs and symptoms, the nurse would suspect otitis media. On assessment, the tympanic membrane would appear bulging and bright red (because of increased middle ear pressure), typically indicative of otitis media. Other characteristic findings include rhinorrhea, fever, cough, irritability, pulling at the ears, earache, vomiting, and diarrhea. A reddened, nonbulging tympanic membrane may indicate otitis media if the membrane has ruptured. 2: A clear, inverted membrane may indicate a blockage of the eustachian tubes. 3: A pearly gray tympanic membrane is normal. 4: A scarred tympanic membrane indicates that the membrane has burst due to pressure, but this condition would have occurred earlier if scar tissue has formed.

58.  Answer: A

Preload is the volume in the left ventricle at the end of diastole. It's also referred to as end-diastolic volume. Preload is reduced by any condition that reduces circulating volume, such as hemorrhage, sepsis, and anaphylaxis. Hemorrhage reduces circulating volume by loss of volume from the intravascular space. Sepsis and anaphylaxis reduce circulating volume by increased capillary permeability. Diuresis, vasodilation, and third spacing also reduce preload. Preload would increase with fluid overload and heart failure.

59.  Answer: A

As a response to shock, the renin-angiotensin-aldosterone system alters renal function by decreasing urine output and increasing reabsorption of sodium and water. Reduced renal perfusion stimulates the renin-angiotensin-aldosterone system in an effort to conserve circulating volume.

60. Answer: A

1: PTCA is best described as insertion of a balloon-tipped catheter into the coronary artery to compress a plaque, thereby opening a stenosed or blocked artery. 2: This is a description of an atherectomy. 3: This only describes a cardiac catheterization. 4: Inserting grafts to divert blood from blocked arteries describes coronary artery bypass graft surgery.

61.  Answer: D

4: Propranolol hydrochloride is a β-adrenergic blocking agent used to treat hypertension. In addition to lowering blood pressure by blocking sympathetic nervous system stimulation, the drug lowers the heart rate. Therefore, the client should be assessed for bradycardia and other dysrhythmias. 1: The client needs to be instructed not to discontinue medication because sudden withdrawal of propranolol hydrochloride may cause rebound hypertension. 2: Propranolol dosage is not typically adjusted based on weekly blood pressure readings. 3: Measurement of partial thromboplastin time values is not a factor in treatment of hypertension.

62.  Answer: B

B","This does not occur in celiac disease. ","Celiac disease is a primary defect in which the intestinal mucosal transport system is impaired; the inability to digest gliadin results in an accumulation of glutamine, which is toxic to mucosal cells and causes atrophy of the villi. ","This does not occur in celiac disease. ","The pancreatic acini degenerate in cystic fibrosis. "

63.  Answer: B

Nitroglycerin dilates arteries and veins, causing peripheral blood pooling and thus reducing preload, after load and myocardial work. The dilation also accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of continuous direct arterial pressure (intraarterial) monitoring, the nurse should use an automatic noninvasive blood pressure monitor. Options A, C, and D are not associated specifically with the administration of nitroglycerin intravenously.

64. Answer: C

3: A sleeping heart rate of 205 bpm is above the normal 200 bpm for this age. Increased heart rate is an early indication of ensuing septic shock. 1: Although the temperature is slightly elevated, it is not an indication of shock. A low axillary temperature may indicate the peripheral blood supply shutdown that occurs early in shock. 2: A blood pressure of 45/25 mm Hg is normal for a neonate. 4: The neonate's respiratory rate is within normal limits for age.

65. Answer: B

The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skin irritation and breakdown. Both cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers.

66.  Answer: C

The infant does not have a physiologic or psychological advantage related to surgery when compared with older children. | Infants, like any other child or adult, experience stress and fear when having surgery. | Inguinal hernia repair is ordinarily done promptly after diagnosis in healthy infants and children. Delaying surgery may result in a possible partial obstruction due to a loop of bowel protruding into the inguinal canal. Serious progression with complete obstruction and perhaps strangulation of the bowel requires emergency surgery to prevent gangrene, which could be fatal. | Although performing surgery around the genitals before the preschool years is recommended, the best reason for performing this surgery now would be to avoid having to perform emergency surgery later.

67.  Answer: A

The normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2 times greater than the client’s control level. Because the value of 30 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time.

68.  Answer: B

Morphine sulfate is a narcotic analgesic that may be administered to relieve pain in a client with myocardial infarction. Although monitoring mental status is a component of the nurse’s assessment, it is not the priority following administration of morphine sulfate. The nurse would monitor the client’s respirations and blood pressure. Signs of morphine toxicity include respiratory depression and hypotension. Apical pulse rate is unrelated to the administration of this medication. Monitoring the temperature also is not associated with the use of this medication.

69. Answer: C

Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Fish is also naturally lower in fat. Cream cheese is a high-fat food.

70.  Answer: D

In the client with a venous disorder, the legs are elevated above the level of the heart assist with the return of venous blood to the heart. Option B provides an infrequent time period and is not the priority. Alcohol is irritating and drying to tissues and should not be used in areas of skin breakdown.

71.  Answer: C

QUESTION: How would you know a patient with CHF was improving after receiving a diuretic? STRATEGY: Think about the answer choices and how they relate to CHF. CORRECT ANSWER: (3) reason for diuretics; crackles/rales: movement of air over fluid; diuretic reduces edema and pulmonary venous pressure (1) should decrease, no change in CHF (2) could be due to other causes (4) will increase but may not change CHF

72.  Answer: A

Medication-specific teaching points for quinidine sulfate include to take the medication exactly as prescribed; not to chew the sustained-release tablets; to take with food if stomach is upset occurs; to wear a Medic Alert bracelet or tag; and to have periodic checks of heart rhythm and blood counts. The client should not stop taking a prescribed medication unless specifically ordered by the physician.

73.  Answer: D

The normal therapeutic range for digoxin is 0.5 to 2 ng/mL. A value of 2.4 ng/mL exceeds the therapeutic range and could be toxic to the client. The most important action is notify the physician, who may give further orders about holding further doses of digoxin. Option A is incorrect because the value is not normal. The next dose should not be administered because the serum digoxin level exceeds the therapeutic range. Checking the client’s last pulse rate is not incorrect but may have limited value in this situation. Depending on the time that has elapsed since the last assessment, a current assessment of the client’s status may be more useful.

74.  Answer: C

Chest pain that is unrelieved by rest and three doses of nitroglycerin administered 5 minutes apart may not be typical anginal pain but may signal myocardial infarction. Because the risk of sudden cardiac death is greater in the first 24 hours after myocardial infarction, it is imperative that the client receive emergency cardiac care. A physician’s office is not equipped to treat myocardial infarction. Communication with the family or home care agency delays client treatment, which is needed immediately.

75.  Answer: D

D","Alcohol sponge baths are never used with children; the temperature may be decreased too quickly and this may shock the child; in addition, a fever of 101 degree F is not high enough for sponge bathing. ","There is no inoculation against Reye's syndrome. ","The child's metabolism is increased during illness; the child should have a high-caloric intake. ","Reye's syndrome is associated with viral infections, such as influenza or varicella, and commonly follows the ingestion of aspirin during the prodromal stage of these diseases. "

76.  Answer: A

Overflow incontinence with constant dribbling is common in neonates with myelomeningocele. Applying gentle pressure to the suprapubic area helps empty the neonate's bladder, thus preventing urinary tract infections. | Intermittent clean catheterization is an appropriate technique for management of urinary retention in older infants or when a urine specimen is urgently needed. | Inserting an indwelling urinary catheter is done most frequently when the neonate is unable to void. | Collecting a urine specimen provides urine for analysis but will do nothing to aid in relieving overflow incontinence.

77.  Answer: B

No evidence is presented to indicate that altered nutrition is the problem. In fact the mother reports that the child is taking the prescribed amounts of formula. The weight gain is due to the fluid overload. | The child is exhibiting characteristics of fluid volume excess related to congestive heart failure. These include decreased output, diaphoresis, weight gain, and crackles. The congestive heart failure is related to left to right shunting that occurs when the child has a large ventral septal defect. | The child’s digoxin level is within normal limits. Additionally, there is no evidence to suggest any risk for injury. | Although the child’s output is decreased, the weight gain is related to fluid overload systemically, not urinary retention.

78. Answer: C

3: The goal is to decrease the bleeding. This can be aided by decreasing circulation to the area. Elevating the part and applying cold decreases circulation to the area. The child will also receive cryoprecipitate. 1: Aspirin is contraindicated for clients who have bleeding disorders because it increases capillary fragility. 2: The dependent position will increase bleeding and swelling. 4: Lack of clotting factors, not lack of platelets, is the problem in children with hemophilia.

79.  Answer: D

Raising the infant's head would not ease the respiratory effort. The mouth needs to be opened. | Turning the infant onto the abdomen would not ease the respiratory effort. The mouth needs to be opened. | Oxygen is not necessary if opening the airway is successful. In any case, using a mask over the child's face may aggravate the problem and could potentially damage the suture line. | After the repair of a cleft lip, the infant must become accustomed to nasal breathing. If the infant is having difficulty breathing, it would be best to open the mouth by exerting downward pressure on the chin. In some instances, an airway is used postoperatively; when there is no airway in place, it is best to try pressure on the chin first.

80.  Answer: B

B","A positive, not a negative, C-reactive protein would be present; this is indicative of an inflammatory process. ","A positive antistreptolysin titer is present with rheumatic fever because of previous infection with streptococci. ","This is usually related to a decrease in mature RBCs caused by hemorrhage or other blood diseases; it is unrelated to an infectious or inflammatory process. ","The ESR would be elevated, not decreased, indicating the presence of an inflammatory process. "

81.  Answer: A

1: Infants who have failure to thrive often are fussy during feedings. This fussiness maybe related to the caretaker not recognizing cues about what the infant needs or wants. 2: Typically infants with failure to thrive are unafraid of strangers. This lack of fear would be abnormal for a 5-month-old. 3: Although they protest being put down, infants with failure to thrive often are not content while being held because they are not used to it. 4: Infants with failure to thrive often have difficulty sleeping for any length of time. They often awaken owing to hunger.

82.  Answer: D

The left coronary artery divides into the anterior descending and the circumflex artery providing blood for the left atrium and left ventricle. The right coronary artery supplies the right atrium and right ventricle. Options A, B, and C are correct.

83.  Answer: C

(3) Pulmonary edema is common in patients with patent ductus arteriosus (PDA). Both pul¬monary edema and cardiomegaly are seen on x-ray due to shunting of blood across the PDA. Patent ductus arteriosus is common in preterm infants. (1) Mitral valve prolapse is an uncommon finding in the newborn. (2) Inflammation of the pericardium is usually caused by infection and is not related to fetal circulation. (4) Bacterial endocarditis is an associated complication of valve replacement surgery in children with congenital heart defects (i.e., tetralogy of Fallot).

84.  Answer: B

Motion artifacts, or “noise”, can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference also can occur with electrode removal and cable disconnection.

85.  Answer: B

Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Diltiazem (calcium channel blockage) and propranolol and metoprolol (β-adrenergic blockers) have a negative inotropic effect and would worsen the failing heart.

86.  Answer: A

1: The blood sample for routine screening for phenylketonuria, done after the neonate has been eating for 48 hours, is obtained from a heel stick. The lateral heel is the best site because it prevents damage to the posterior tibial nerve and artery, plantar artery, and the important longitudinally oriented fat pad of the heel. 2: The radial artery is an inappropriate site to obtain the blood sample because of the risk for severe trauma. 3: The scalp vein is used for intravenous infusions, not to obtain a blood sample for PKU. 4: The brachial artery is not an appropriate site for obtaining a PKU blood sample because the artery is too small and severe trauma may result.

87. Answer: A

A","This is done because any attempt by the infant to maintain temperature further compromises physical status by increasing metabolic activity and O2 demands. ","Increased activity will increase oxygen demands. ","This is not accurate; the O2 percentage will vary with PO2 values of the infant. ","Increased activity will increase oxygen demands. "

88.  Answer: A

1: Before administering the medication, the nurse needs to evaluate the possibility of digitalis toxicity. A sign of digitalis toxicity is atrial fibrillation, sometimes with a heart rate of more than 100 bpm. The appropriate action by the nurse is to evaluate the cardiac rhythm of the client. 2: Tachycardia can be a sign of digitalis toxicity. The nurse should evaluate further before administering digoxin. 3: The nurse needs to further evaluate the client's cardiac rhythm before determining any intervention. 4: The cardiac rhythm is a higher assessment priority than the client's respiratory rate.

89.  Answer: A

When a client has congestive heart failure, the goal is to reduce fluid accumulation. One way to accomplish this is sodium reduction. Ham, cheese (and most cold cuts), and potato chips are high in sodium. Daily weight measurement is an appropriate intervention to help the client monitor fluid overload. Most fresh fruits and vegetables are low in sodium.

90.  Answer: D

Fluid surrounding the heart such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. Narrowing or widening complexes and amplitude increase aren't expected on the ECG of an individual with cardiac tamponade.

91.  Answer: C

3: Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia. 1: This would have no significance in diagnosing a potassium deficit. 2: This would have no significance in diagnosing a potassium deficit. 4: This would have no significance in diagnosing a potassium deficit.

92.  Answer: C

Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. Variant angina, or Prinzmetal’s angina, is prolonged and severe and occurs at the same time each day, most often in the morning.

93.  Answer: D

D","This would be difficult to determine accurately; it is far more important to assess the infant for signs of dehydration and metabolic alkalosis. ","These are not indicators of immediate needs; assessment for signs of dehydration and metabolic alkalosis are more important. ","Although this might help to confirm the diagnosis, the most important concern at this time is to assess for dehydration and metabolic alkalosis. ","When a baby has scanty dark urine, poor skin turgor, and increased depth of respirations, it is likely that dehydration and metabolic alkalosis are present; these occur because of the fluid and hydrochloric acid loss and the potassium depletion; immediate intervention is necessary. "

94.  Answer: C

Furosemide is a non-potassium-sparing diuretic, and insufficient replacement of potassium may lead to hypokalemia. Although the glucose, sodium, and magnesium levels may be monitored, these laboratory values are not specific to administering furosemide.

95.  Answer: C

The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness and warmth of the affected leg, tenderness at the site, possible dilated veins (if superficial), low-grade fever, edema distal to the obstruction, positive Homans’ sign, and increased calf circumference in the affected extremity. Pedal pulses are unchanged from baseline because this is a venous, not arterial, problem. Often clients silently develop thrombophlebitis; that is, they do not have any signs and symptoms unless they experience pulmonary embolism as a complication.

96.  Answer: B

Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular.

97.  Answer: C

Fast-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of an antidysrhythmic such as amiodarone (Cordarone), lidocaine (Xylocaine), and Procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate an already excitable ventricle and is contraindicated.

98.  Answer: A

In the postoperative period, intake and output are carefully monitored to prevent fluid overload that could lead to increased intracranial pressure. | Feedings will be started when the infant is fully awake. | The infant will need to be disturbed to check vital signs and be repositioned. | Age-appropriate activities are important but not until the infant is awake and less fussy.

99.  Answer: D

Each of the options indicates a positive outcome on the part of the client. However, option A most likely would indicate progress if the client had a nursing diagnosis of Imbalanced Nutrition. Option B would be a satisfactory outcome for Disturbed Sleep Pattern. Options C and D relate to the nursing diagnosis of Activity Intolerance. However, the question asks about progress. Option D is more action oriented and is therefore the better choice.

100.  Answer: C

Preoperative and postoperative pictures of babies with cleft palates and lips provide clear and concrete images of what to expect after corrective surgery. Providing these pictures is specific to the parents' behavior because the parents reflect societal values that emphasize an infant's facial appearance and responsive expressiveness. 

A: Encouraging the parents to visit more often may make them believe they are currently not visiting enough and could cause unwarranted guilt. There is no evidence they will not visit frequently. 

B: Although reassuring the parents that the defect can be corrected may be helpful, showing the parents pictures of infants before and after surgical correction provides them with objective evidence of what to expect. 

D: Allowing the completion of the grieving process before another interaction between the infant and parents could result in a separation for months.

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