COMPETENCY APPRAISAL II - QUESTIONS AND RATIONALE

NURSING
BOARD REVIEW QUESTIONS

COMPETENCY APPRAISAL II  - QUESTIONS AND RATIONALE

1. Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Nurse Trish should tell the client that the only effective treatment for alcoholism is:
A. Psychotherapy
B. Alcoholics anonymous (A.A.)
C. Total abstinence
D. Aversion Therapy

2.Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as:
A. Hallucinations
B. Delusions
C. Loose associations
D. Neologisms

3. Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should…
A. Give her privacy
B. Allow her to urinate
C. Open the window and allow her to get some fresh air
D. Observe her

4. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan?
A. Provide privacy during meals
B. Set-up a strict eating plan for the client
C. Encourage client to exercise to reduce anxiety
D. Restrict visits with the family

5. A client is experiencing anxiety attack. The most appropriate nursing intervention should include?
A. Turning on the television
B. Leaving the client alone
C. Staying with the client and speaking in short sentences
D. Ask the client to play with other clients

6. A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is:
A. Being Killed
B. Highly famous and important
C. Responsible for evil world
D. Connected to client unrelated to oneself
7.A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not most likely to be evidence of ineffective individual coping?
A. Recurrent self-destructive behavior
B. Avoiding relationship
C. Showing interest in solitary activities
D. Inability to make choices and decision without advise

8. A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation?
A. Paranoid thoughts
B. Emotional affect
C. Independence need
D. Aggressive behavior

9. Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is?
A. Encourage to avoid foods
B. Identify anxiety causing situations
C. Eat only three meals a day
D. Avoid shopping plenty of groceries

10. Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development?
A. Generates new levels of awareness
B. Assumes responsibility for her actions
C. Has maximum ability to solve problems and learn new skills
D. Her perception are based on reality

11. A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for?
A. Respiratory difficulties
B. Nausea and vomiting
C. Dizziness
D. Seizures

12. A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer’s type and depression. The symptom that is unrelated to depression would be?
A. Apathetic response to the environment
B. “I don’t know” answer to questions
C. Shallow of labile effect
D. Neglect of personal hygiene

13. Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to?
A. Teach client to measure I & O
B. Involve client in planning daily meal
C. Observe client during meals
D. Monitor client continuously

14. Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be?
A. Cardiac dysrhythmias resulting to cardiac arrest
B. Glucose intolerance resulting in protracted hypoglycemia
C. Endocrine imbalance causing cold amenorrhea
D. Decreased metabolism causing cold intolerance


15. Nurse Anna can minimize agitation in a disturbed client by?
A. Increasing stimulation
B. limiting unnecessary interaction
C. increasing appropriate sensory perception
D. ensuring constant client and staff contact

16. A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:
A. Problems with being too conscientious
B. Problems with anger and remorse
C. Feelings of guilt and inadequacy
D. Feeling of unworthiness and hopelessness

17. Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?
A. Allowing a snack to be kept in his room
B. Reprimanding the client
C. Ignoring the clients behavior
D. Setting limits on the behavior

18. Conney with borderline personality disorder who is to be discharge soon threatens to “do something” to herself if discharged. Which of the following actions by the nurse would be most important?
A. Ask a family member to stay with the client at home temporarily
B. Discuss the meaning of the client’s statement with her
C. Request an immediate extension for the client
D. Ignore the clients statement because it’s a sign of manipulation

19. Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do you know why people find you repulsive?” this statement most likely would elicit which of the following client reaction?
A. Depensiveness
B. Embarrassment
C. Shame
D. Remorsefulness

20. Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist?
A. Rationalization
B. Supportive confrontation
C. Limit setting
D. Consistency

21. Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to administer?
A. Naloxone (Narcan)
B. Benzlropine (Cogentin)
C. Lorazepam (Ativan)
D. Haloperidol (Haldol)

22. Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal?
A. Milk
B. Orange Juice
C. Soda
D. Regular Coffee

23. Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal?
A. Yawning & diaphoresis
B. Restlessness & Irritability
C. Constipation & steatorrhea
D. Vomiting and Diarrhea
24. To establish open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should?
A. Encourage the staff to have frequent interaction with the client
B. Share an activity with the client
C. Give client feedback about behavior
D. Respect client’s need for personal space

25. Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:
A. Manipulate the environment to bring about positive changes in behavior
B. Allow the client’s freedom to determine whether or not they will be involved in activities
C. Role play life events to meet individual needs
D. Use natural remedies rather than drugs to control behavior

26. Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to:
A. Have more positive relation with the father than the mother
B. Cling to mother & cry on separation
C. Be able to develop only superficial relation with the others
D. Have been physically abuse

27. When teaching parents about childhood depression Nurse Trina should say?
A. It may appear acting out behavior
B. Does not respond to conventional treatment
C. Is short in duration & resolves easily
D. Looks almost identical to adult depression





28. Nurse Perry is aware that language development in autistic child resembles:
A. Scanning speech
B. Speech lag
C. Shuttering
D. Echolalia

29. A 60 year old female client who lives alone tells the nurse at the community health center “I really don’t need anyone to talk to”. The TV is my best friend.
The nurse recognizes that the client is using the defense mechanism known as?
A. Displacement
B. Projection
C. Sublimation
D. Denial

30. When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a problem for this client would be?
A. Anxiety when discussing phobia
B. Anger toward the feared object
C. Denying that the phobia exist
D. Distortion of reality when completing daily routines

31. Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Linda’s anxiety. The most therapeutic question by the nurse would be?
A. Would you like to watch TV?
B. Would you like me to talk with you?
C. Are you feeling upset now?
D. Ignore the client

32. Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be:
A. Avoidance of situation & certain activities that resemble the stress
B. Depression and a blunted affect when discussing the traumatic situation
C. Lack of interest in family & others
D. Re-experiencing the trauma in dreams or flashback

33. Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of?
A. Flight of ideas
B. Associative looseness
C. Confabulation
D. Concretism

34. Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are?
A. Excessive weight loss, amenorrhea & abdominal distension
B. Slow pulse, 10% weight loss & alopecia
C. Compulsive behavior, excessive fears & nausea
D. Excessive activity, memory lapses & an increased pulse
35. A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:
A. Frequent regurgitation & re-swallowing of food
B. Previous history of gastritis
C. Badly stained teeth
D. Positive body image

36. Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have:
A. Multiple stimuli
B. Routine Activities
C. Minimal decision making
D. Varied Activities

37. To further assess a client’s suicidal potential. Nurse Katrina should be especially alert to the client expression of:
A. Frustration & fear of death
B. Anger & resentment
C. Anxiety & loneliness
D. Helplessness & hopelessness

38. A nursing care plan for a male client with bipolar I disorder should include:
A. Providing a structured environment
B. Designing activities that will require the client to maintain contact with reality
C. Engaging the client in conversing about current affairs
D. Touching the client provide assurance

39. When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual:
A. Helps the client focus on the inability to deal with reality
B. Helps the client control the anxiety
C. Is under the client’s conscious control
D. Is used by the client primarily for secondary gains

40. A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:
A. Low self esteem
B. Concrete thinking
C. Effective self boundaries
D. Weak ego




41. A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, March is little woman”. That’s literal you know”. These statement illustrate:
A. Neologisms
B. Echolalia
C. Flight of ideas
D. Loosening of association

42. A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:
A. Insight into his behavior
B. Better self control
C. Feeling of self worth
D. Faith in his wife

43. A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?
A. Focusing on self-disclosure of own food preference
B. Using open ended question and silence
C. Offering opinion about the need to eat
D. Verbalizing reasons that the client may not choose to eat

44. Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should?
A. Ask the client direct questions to encourage talking
B. Rake the client into the dayroom to be with other clients
C. Sit beside the client in silence and occasionally ask open-ended question
D. Leave the client alone and continue with providing care to the other clients

45. Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the client?
A. “You’re having hallucination, there are no spiders in this room at all”
B. “I can see the spiders on the wall, but they are not going to hurt you”
C. “Would you like me to kill the spiders”
D. “I know you are frightened, but I do not see spiders on the wall”

46. Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?
A. “Abuse occurs more in low-income families”
B. “Abuser Are often jealous or self-centered”
C. “Abuser use fear and intimidation”
D. “Abuser usually have poor self-esteem”

47. During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because?
A. Anesthesia is administered during the procedure
B. Decrease oxygen to the brain increases confusion and disorientation
C. Grand mal seizure activity depresses respirations
D. Muscle relaxations given to prevent injury during seizure activity depress respirations.

48. When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation?
A. The client eliminates all anxiety from daily situations
B. The client ignores feelings of anxiety
C. The client identifies anxiety producing situations
D. The client maintains contact with a crisis counselor

49. Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed?
A. Neuroleptic medication
B. Short term seclusion
C. Psychosurgery
D. Electroconvulsive therapy

50. Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:
A. Length of time on the med.
B. Name of the ingested medication & the amount ingested
C. Reason for the suicide attempt
D. Name of the nearest relative & their phone number

Defense Mechanisms

51. Which of the following is not one of the key steps in the grief process?
A. Denial
B. Anger
C. Bargaining
D. Rejection




52. Which of the following matches the definition: covering up a weakness by stressing a desirable or stronger trait?
A. Compensation
B. Projection
C. Rationalization
D. Dysphoria

53. Which of the following waveforms is most commonly found with light sleepers?
A. Theta   C. Beta
B. Alpha   D. Zeta

54. Which of the following months matches with an infant first having the ability to sit-up independently?
A. 4 months
B. 6 months
C. 8 months
D. 10 months

55. Object permanence for toddlers develops in this age range?
A. 5-10 months   C. 12-24 months
B. 10-14 months   D. 15-24 months

56. Which of the following matches the definition: attributing of our own unwanted trait onto another person?
A. Compensation   C. Rationalization
B. Projection   D. Dysphoria

57. Which of the following matches the definition: the justification of behaviors using reason other than the real reason?
A. Compensation   C. Rationalization
B. Projection   D. Dysphoria

58. Which of the following matches the definition: response to severe emotion stress resulting in involuntary disturbance of physical functions?
A. Conversion disorder
B. Depressive reaction
C. Bipolar disorder
D. Alzheimer's disease

59. Which of the following waveforms is most commonly found when you are awake?
A. Theta   C. Beta
B. Alpha   D. Zeta

60. The REM sleep cycle occur approximately every ____ minutes?
A. 45   C. 75
B. 60   D. 90

61. Which of the following reflexes is not found at birth?
A. Babinski   C. Moro
B. Palmar   D. Flexion

62. Parallel play for toddlers develops in this age range?
A. 5-10 months   C. 12-24 months
B. 10-14 months   D. 24-48 months

63. Which of the following is not a sign of anxiety?
A. Dyspnea
B. Hyperventilation
C. Moist mouth
D. GI symptoms

64. Which of the following best describes a person that is completely awake falling asleep spontaneously?
A. Cataplexy
B. Narcolepsy
C. Transitional sleep
D. REM absence

65. Which of the following best describes a person that is unable to tell you were there hand or foot is?
A. Autotopagnosia
B. Cataplexy
C. Ergophobia
D. Anosognosia

66. Which of the following is not a characteristic of a panic disorder?
A. Nausea
B. Excessive perspiration
C. Urination
D. Chest pain

67. Which of the following categories would a 70 year old adult be placed in?
A. Intimacy vs. Isolation
B. Generativitiy vs. Stagnation
C. Integrity vs. Despair
D. Longevity vs. Guilt

68. Which of the following categories would a 60 year old adult be placed in?
A. Intimacy vs. Isolation
B. Generativitiy vs. Stagnation
C. Integrity vs. Despair
D. Longevity vs. Guilt

69. Which of the following categories would a 20 year old adult be placed in?
A. Intimacy vs. Isolation
B. Generativitiy vs. Stagnation
C. Integrity vs. Despair
D. Longevity vs. Guilt

70. Which of the following describes a person using words that have no known meaning?
A. Neologisms
B. Neolithic
C. Verbalism
D. Delusional blocking



RATIONALE
1. C. Total abstinence is the only effective treatment for alcoholism.

2. A. Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.

3. D. The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse should watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.

4. B. Establishing a consistent eating plan and monitoring client’s weight are important to this disorder.

5. C. Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed.

6. B. Delusion of grandeur is a false belief that one is highly famous and important.

7. D. Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.

8. A. Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.

9. B. Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.

10. A. An adult age 31 to 45 generates new level of awareness.

11. A. Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.

12. C. With depression, there is little or no emotional involvement therefore little alteration in affect.

13. D. These clients often hide food or force vomiting; therefore they must be carefully monitored.

14. A. These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure, these electrolytes are necessary for cardiac functioning.

15. B. Limiting unnecessary interaction will decrease stimulation and agitation.

16. C. Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.

17. D. The nurse needs to set limits in the client’s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.

18. B. Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide.

19. A. When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.

20. B. The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.

21. C. The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.

22. D. Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness.

23. D. Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache.

24. D. Moving to a client’s personal space increases the feeling of threat, which increases anxiety.

25. A. Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area toward helping the client.

26. C. Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially

27. A. Children have difficulty verbally expressing their feelings, acting out behavior, such as temper tantrums, may indicate underlying depression.

28. D. The autistic child repeat sounds or words spoken by others.

29. D. The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist.

30. A. Discussion of the feared object triggers an emotional response to the object.

31. B. The nurse presence may provide the client with support & feeling of control.

32. D. Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other anxiety disorder.

33. C. Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits.

34. A. These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected weight).

35. C. Dental enamel erosion occurs from repeated self-induced vomiting.

36. B. Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and least anxiety producing.

37. D. The expression of these feeling may indicate that this client is unable to continue the struggle of life.

38. A. Structure tends to decrease agitation and anxiety and to increase the client’s feeling of security.

39. B. The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action.

40. C. A person with this disorder would not have adequate self-boundaries.

41. D. Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.

42. C. Helping the client to develop feeling of self worth would reduce the client’s need to use pathologic defenses.

43. B. Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner.

44. C. Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions. Communication with withdrawn clients requires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to provide opportunities for the client to respond.

45. D. When hallucination is present, the nurse should reinforce reality with the client.

46. A. Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.

47. D. A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.

48. C. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus.

49. D. Electroconvulsive therapy is an effective treatment for depression that has not responded to medication.

50. B. In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.

51. D  
52. A  
53. A  
54. B  
55. A  
56. B  
57. C  
58. A  
59. C  
60. D  
61. D  
62. D  
63. C  
64. A  
65. A  
66. C  
67. C  
68. B  
69. A  

70. A

INTENSIVE NURSING PRACTICE – PART 2 QUESTIONS AND ANSWERS

NURSING
BOARD REVIEW QUESTIONS

INTENSIVE NURSING PRACTICE – PART 2 QUESTIONS AND ANSWERS

1. A client is being weaned from total parenteral nutrition (TPN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hr. A nurse anticipates that which of the following orders regarding the TPN solution will accompany the diet order?

A. Discontinue the TPN.
B. Continue current infusion rate orders for TPN.
C. Decrease TPN rate to 50 mL/hr.
D. Hang 1000 mL 0.9% normal saline.

2. The nurse is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first?

A. Administer ipecac syrup.
B. Call an ambulance immediately.
C. Call the poison control center.
D. Punish the child for being bad.

3. A nurse is assigned to a client receiving total parenteral nutrition (TPN) who had a blood glucose measurement done at 06:00. The nurse documents on the client's clinical worksheet for the day that the blood glucose level should be checked at which of the following times?
A. 08:00
B. 12:00
C. 16:00
D. 18:00

4. A client is being weaned from total parenteral nutrition (TPN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hr. A nurse anticipates that which of the following orders regarding the TPN solution will accompany the diet order?
A. Discontinue the TPN.
B. Continue current infusion rate orders for TPN.
C. Decrease TPN rate to 50 mL/hr.
D. Hang 1000 mL 0.9% normal saline.

5. A toddler is admitted with a seizure disorder. According to the parents, the child stops breathing and turns blue after having a seizure. The physician prescribes phenytoin (Dilantin). Before discharge, the nurse teaches the parents how to handle seizures. Which instruction should the nurse include?
A. Give the child the medication as soon as a seizure begins.
B. Place a tongue blade in the child's mouth during a seizure.
C. Remove nearby objects that could cause injury during a seizure.
D. Keep the medication in the child's room so that it won't be forgotten.

6. The client with a total laryngectomy receives tube feedings to meet his fluid and nutrition needs. What is the primary rationale for tube feedings in this situation?
A. Prevent pain from swallowing.
B. Ensure adequate intake.
C. Prevent fistula development.
D. Allow for adequate suture line healing.

7. A client with worsening preeclampsia is hospitalized and placed in a private room. The nurse knows that this is important because a nonstimulating environment for a client with increased cerebral irritability:
A. Improves intracellular fluid reabsorption
B. Reduces the severity of frontal headaches
C. Reduces the probability of grand mal seizures
D. Prolongs the duration of hypotensive medications

8. Six hours after the initiation of total parenteral nutrition the client's serum glucose level is 240 mg/dl. When considering this client's elevated serum glucose level, the nurse should recognize that it is probably related to the fact that the:

A. Infusion is flowing too rapidly
B. Prescribed solution is too concentrated
C. Rise is an expected response that will eventually subside
D. Infusion is too slow to meet the client's total nutritional needs

9. A client receiving total parenteral nutrition (TPN) suddenly spikes a fever. A nurse notifies the physician, and the physician initially orders that the solution and tubing be changed. The nurse should do which of the following with the discontinued materials?

A. Return them to the hospital pharmacy.
B. Send them to the laboratory for culture.
C. Save them for return to the manufacturer.
D. Discard them in the unit trash.

10. In teaching a mother of an 18-month-old about prevention and safety in the home, the nurse should include which of the following measures in response to accidental ingestion?

A. Induce vomiting with one dose of ipecac syrup
B. Call the local Poison Control Center for advice prior to treatment
C. Give the child several glasses of water to flush the substance
D. Have the child eat the inner portion of a piece of bread

11. The physician has just inserted a central line for total parenteral nutrition (TPN) into a client who has a perforated bowel. The physician asks the nurse to begin infusing lactated Ringer's solution. Prior to starting the infusion, the nurse should verify which of the following?

A. Clarity of the physician's order for I.V. solution
B. The temperature of the solution
C. The results of the chest X-ray taken after the insertion of the catheter
D. The rate of the I.V. infusion

12. A child with Down syndrome has an intelligence quotient (IQ) of about 40. The nurse would expect which of the following as the type of environment and interdisciplinary program to most likely benefit this child?
A. Custodial.
B. Institutional.
C. Task analysis.
D. Vocational training.

13. A nurse is planning to hang the first bag of total parenteral nutrition (TPN) solution via the central line of an assigned client. The nurse plans to obtain which of the following most essential pieces of equipment before hanging the solution?
A. Electronic infusion pump
B. Blood glucose meter
C. Urine test strips
D. Noninvasive blood pressure monitor

14. A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When administering TPN, the nurse must take care to maintain the prescribed flow rate because giving TPN too rapidly may cause:
A. hyperglycemia.
B. air embolism.
C. constipation.
D. dumping syndrome.

15. In developing a plan of care for a patient with Alzheimer's disease who is confused and incontinent of urine, the nurse should include which of the following measures?

A. Insert an indwelling urinary drainage catheter.
B. Perform intermittent catheterization every four hours.
C. Offer the bedpan to the patient every two hours.
D. Assist the patient to a bedside commode every two hours.

16. A client has been discharged to home on total parenteral nutrition (TPN). With each visit, a home care nurse assesses which of the following parameters most closely in monitoring this therapy?

A. Temperature and weight
B. Temperature and blood pressure
C. Pulse and weight
D. Pulse and blood pressure

17. A nurse is preparing to hang a fat emulsion. The nurse notes that fat globules are visible at the top of the solution. The nurse takes which of the following actions?

A. Runs the bottle of solution under warm water.
B. Rolls the bottle of solution gently.
C. Shakes the bottle of solution vigorously.
D. Obtains a different bottle of solution.

18. A client is admitted to the emergency room with a cut finger that is bleeding profusely. She displays signs of alcohol intoxication, and a blood test confirms this. After the client's wound is sutured but before she leaves the emergency room, it would be best for the nurse to ensure that the client:

A. Takes a nap.
B. Does some exercising.
C. Restricts fluid intake.
D. Drinks generous amounts of black coffee.

19. A nurse is assigned to a client receiving total parenteral nutrition (TPN) who had a blood glucose measurement done at 06:00. The nurse documents on the client's clinical worksheet for the day that the blood glucose level should be checked at which of the following times?
A. 08:00
B. 12:00
C. 16:00
D. 18:00

20. A nurse is preparing to change the total parenteral nutrition (TPN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to do which of the following most essential items during the tubing change?
A. Take a deep breath, hold it, and bear down.
B. Exhale slowly and evenly.
C. Turn the head to the right.
D. Breathe normally.

21. Evaluation of an elderly patient first day postoperative reveals a temperature of 100.6°F. Which of the following actions should the nurse take first?
A. Examine the patient
B. Set up the intravenous antibiotic dose two hours early
C. Call the physician
D. Obtain STAT blood cultures

22. A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The nurse notes that the catheter insertion site appears reddened. The nurse next assesses which of the following items?
A. Tightness of tubing connections
B. Client's temperature
C. Expiration date on the bag
D. Time of last dressing change

23. The nurse is preparing the client with heart failure to go home. The nurse should instruct the client to:
A. Monitor urine output daily.
B. Maintain bed rest for at least 1 week.
C. Monitor daily potassium intake.
D. Weigh daily.

24. When teaching a caregiver in the home about flushing a child's central venous catheter, the nurse should instruct the caregiver to:
A. keep the telephone nearby to call the physician should problems occur.
B. make certain the child has eaten before the procedure.
C. use good hand-washing technique before and after the procedure.
D. have all siblings out of the room during the procedure.

25. A nurse is caring for a group of adult clients on an acute care medical-surgical nursing unit. The nurse understands that which of the following clients would be the least likely candidate for total parenteral nutrition (TPN)?
A. A 66-year-old client with extensive bums
B. A 42-year-old client who had an open cholecystectomy
C. A 35-year-client with persistent nausea and vomiting from chemotherapy
D. A 27-year-old client with severe exacerbation of regional enteritis (Crohn's disease)

26. A nurse is caring for a restless client who is beginning nutritional therapy with total parenteral nutrition (TPN). The nurse should plan to ensure that which of the following is done to prevent the client from injury?
A. Monitor blood glucose levels every 12 hours.
B. Secure all connections in the TPN system.
C. Monitor the temperature once daily.
D. Calculate daily intake and output.

27. Abnormalities in diagnostic tests indicate that a 3-year-old boy has epilepsy. Which of the following items should the nurse have available at the bedside?
A. Suction machine and oxygen set up.
B. Catheterization set.
C. Intermittent positive pressure breathing machine (IPPB).
D. Restraints.

28. Which of the following would be the best indication that the goals for total parenteral nutrition (TPN) are being achieved for the client?
A. Urine negative for glucose.
B. Serum potassium level of 4 mEq/L.
C. Serum glucose level of 96.
D. Weight gain of 0.5 pounds/day.

29. The nurse attempts to interact with a client who barely responds with yes or no. The client states, "Don't bother me. I want to die." The nurse's best action is to:
A. Leave the client alone.
B. Send another staff member to interact with the client.
C. Sit with the client for 10 minutes.
D. Turn on the television for the client.

30. Which client should receive a private room?
A. A client with diabetes
B. A client with Cushing's disease
C. A client with Grave's disease
D. A client with gastric ulcers

31. Which of the following techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach?
A. Aspirating with a syringe and observing for the return of gastric contents.
B. Irrigating with normal saline and observing for the return of solution.
C. Placing the tube's free end in water and observing for air bubbles.
D. Instilling air and auscultating over the epigastric area for the presence of the tube.

32. A 10-month-old child with bronchitis is taken out of the 30% oxygen tent for breakfast because he refuses to eat unless in a high chair. During the feeding, the nurse notes that the child's respiratory rate has increased, he is becoming more irritable, and he is using accessory muscles to breathe. The first action of the nurse should be to:

A. Discontinue the feeding and place the child back in the tent.
B. Assess the pulse rate and respirations and notify the physician.
C. Perform postural drainage then complete the feeding.
D. Suction the child's nose with a bulb syringe.
33. Which of the following would the nurse suggest to a family living in a rural area where the drinking water is not fluoridated as the most appropriate means for obtaining a significant amount of fluoride?

A. Tea.
B. Yogurt.
C. Citrus juices.
D. Natural cheeses.

34. A nurse is preparing to change the total parenteral nutrition (TPN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to do which of the following most essential items during the tubing change?

A. Take a deep breath, hold it, and bear down.
B. Exhale slowly and evenly.
C. Turn the head to the right.
D. Breathe normally.


35. A nurse is making initial rounds at the beginning of the shift. The total parenteral nutrition (TPN) bag of an assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another TPN solution is mixed and delivered to the nursing unit?

A. 5% dextrose in water
B. 5% dextrose in 0.9% sodium chloride
C. 5% dextrose in Ringer's lactate
D. 10% dextrose in water

36. During a meal, a client with hepatitis B dislodges her I.V. line and bleeds on the surface of the over-the-bed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:

A. alcohol.
B. ammonia.
C. acetone.
D. bleach.

37. A client with bacterial pneumonia is coughing up tenacious, purulent sputum. Which of the following measures would most likely help liquefy these viscous secretions?

A. Performing postural drainage.
B. Breathing humidified air.
C. Clapping and percussing over the affected lung.
D. Performing coughing and deep-breathing exercises.

38. A nurse enters the room of a client receiving total parenteral nutrition (TPN) and discovers that the electronic infusion pump has been shut off After checking the line for patency and restarting the infusion, the nurse assesses the client for which of the following signs and symptoms?
A. Weakness, thirst, and excessive urination
B. Fever and chills
C. Weakness, shakiness, diaphoresis, and complaints of hunger
D. Dyspnea and hypotension

39. A home care nurse is monitoring a client's response to total parenteral nutrition (TPN). The client's weight 1 week ago was 114 pounds. The nurse determines that the client is not gaining weight too rapidly if this morning's weight was:
A. 116 lb.
B. 119 lb.
C. 120 lb.
D. 122 lb.

40. Which intervention should the nurse try for a client that exhibits signs of sleep disturbance?
A. Administer sleeping medication before bedtime.
B. Ask the client each morning to describe the quality of sleep during the previous night.
C. Teach the client relaxation techniques, such as guided imagery, meditation, and progressive muscle relaxation.
D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.

41. Which of the following reasons, given by a mother who permits her preschool-aged child to sleep in the same bed (co-sleeping) as the parents, requires further investigation by the nurse?

A. "I am too tired to get up at night to check on the baby in the other room."
B. "This promotes bonding between us and our child."
C. "I slept with my parents when I was a small child."
D. "I can be certain my husband is not being inappropriate."

42. A client has been discharged to home on total parenteral nutrition (TPN). With each visit, a home care nurse assesses which of the following parameters most closely in monitoring this therapy?

A. Temperature and weight
B. Temperature and blood pressure
C. Pulse and weight
D. Pulse and blood pressure

43. When administering total parenteral nutrition (TPN) through a peripheral I.V. line to a school-age child, what is the lowest amount of glucose considered safe and not caustic to small veins that will also provide adequate TPN?

A. 5% glucose
B. 10% glucose
C. 15% glucose
D. 17% glucose

44. A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The nurse notes that the catheter insertion site appears reddened. The nurse next assesses which of the following items?
A. Tightness of tubing connections
B. Client's temperature
C. Expiration date on the bag
D. Time of last dressing change

45. A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?
A. Give the feedings at room temperature.
B. Decrease the rate of feedings and the concentration of the formula.
C. Place the client in semi-Fowler's position while feeding.
D. Change the feeding container every 12 hours.

46. The physician orders total parenteral nutrition (TPN) 1 L q12 hours. The primary nursing responsibility should be to monitor the client's:
A. Electrolytes
B. Urinary output
C. Administration rate
D. Serum glucose levels

47. During the flushing of a peripherally inserted central catheter (PICC), the nurse realizes the line will not flush. The nurse's next step would be to
A. contact the primary practitioner on call.
B. continue to flush the catheter using a smaller-size syringe.
C. examine the line for kinks.
D. hold the medication until the next dose is due.

48. What should the nurse do to ensure a safe hospital environment for a toddler?

A. Place the child in a youth bed.
B. Move stacking toys out of reach.
C. Pad the crib rails.
D. Move the equipment out of reach.
49. The nurse is preparing to care for a client diagnosed with catatonic schizophrenia. In anticipation of this client's arrival, what should the nurse do?

A. Notify security.
B. Prepare a magnesium sulfate drip.
C. Place a specialty mattress overlay on the bed.
D. Communicate the client’s nothing-by-mouth status to the dietary department.

50. At the beginning of a shift a nurse assesses a client receiving total parenteral nutrition (TPN) with fat emulsion piggybacked to the line. The nurse notes that the fat emulsion tubing has a 0.22-l.tm filter. Which of the following actions by the nurse is most appropriate?

A. Inspect the filter for clogging.
B. Replace with a tubing without a filter.
C. Leave the system alone.
D. Check the line for patency.

51. The patient receiving rofecoxib (Vioxx) should be monitored for which of the following side effects?

A. Tiredness and somnolence
B. Hypotension and tachycardia
C. Dyspnea and chest pain
D. Irritability and agitation

52. When teaching a caregiver in the home about flushing a child's central venous catheter, the nurse should instruct the caregiver to

A. keep the telephone nearby to call the physician should problems occur.
B. make certain the child has eaten before the procedure.
C. use good hand-washing technique before and after the procedure.
D. have all siblings out of the room during the procedure.

53. A nurse is caring for a group of adult clients on an acute care medical-surgical nursing unit. The nurse understands that which of the following clients would be the least likely candidate for total parenteral nutrition (TPN)?

A. A 66-year-old client with extensive bums
B. A 42-year-old client who had an open cholecystectomy
C. A 35-year-client with persistent nausea and vomiting from chemotherapy
D. A 27-year-old client with severe exacerbation of regional enteritis (Crohn's disease)

54. A nurse is monitoring the status of a client's fat emulsion infusion. The nurse notes that the infusion is 1 hour behind. Which of the following actions by the nurse is most appropriate?
A. Adjust the infusion rate to run wide open until the solution is back on time.
B. Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.
C. Increase the infusion rate to catch up over the next 2 hours.
D. Adjust the infusion rate to catch up over the next hour.

55. A client receiving total parenteral nutrition (TPN) in the home setting has a weight gain of 5 lb in 1 week. The nurse next assesses the client to detect the presence of which of the following?
A. Crackles on auscultation of the lungs
B. Thirst
C. Decreased blood pressure
D. Polyuria

56. Which of the following measures is most appropriate for a nurse to take to prevent injury in a patient who is confused?
A. Apply a soft restraint on the patient's wrist
B. Administer lorazepam (Ativan) as ordered
C. Change the patient's environment
D. Keep the bed in the lowest position
57. A dient receiving total parenteral nutrition (TPN) complains of a headache. A nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse interprets that the dient is experiencing which complication of TPN therapy?

A. Hyperglycemia
B. Air embolism
C. Sepsis
D. Fluid overload

58. A nurse is making initial rounds at the beginning of the shift. The total parenteral nutrition (TPN) bag of an assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another TPN solution is mixed and delivered to the nursing unit?

A. 5% dextrose in water
B. 5% dextrose in 0.9% sodium chloride
C. 5% dextrose in Ringer

59. A client with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter. A nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which of the following positions?

A. On the left side with the head higher than the feet
B. On the left side with the head lower than the feet
C. On the right side with the head higher than the feet
D. On the right side with the head lower than the feet

60. The nurse observes that the client's total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was ordered for the day. The nurse should:

A. Increase the flow rate to infuse an additional 300 mL over the next hour.
B. Maintain the flow rate at the current rate and document any discrepancy in the chart.
C. Assess the infusion system, note the client's condition, and notify the physician.
D. Discontinue the solution and administer dextrose in 5% water until the infusion problem is resolved.

61. A nurse is monitoring the status of a client's fat emulsion infusion. The nurse notes that the infusion is 1 hour behind. Which of the following actions by the nurse is most appropriate?

A. Adjust the infusion rate to run wide open until the solution is back on time.
B. Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.
C. Increase the infusion rate to catch up over the next 2 hours.
D. Adjust the infusion rate to catch up over the next hour.

62. A client receiving total parenteral nutrition (TPN) suddenly spikes a fever. A nurse notifies the physician, and the physician initially orders that the solution and tubing be changed. The nurse should do which of the following with the discontinued materials?

A. Return them to the hospital pharmacy.
B. Send them to the laboratory for culture.
C. Save them for return to the manufacturer.
D. Discard them in the unit trash.

63. A patient in the emergency department has multiple fractured ribs and a right-sided tension pneumothorax. The nurse would expect to prepare the patient for which of the following procedures?

A. Electrocardiogram
B. Urinary catheter placement
C. Chest tube insertion
D. Gastric lavage

64. When observing the mother feed her infant diagnosed with failure to thrive, which of the following maternal behaviors would cause the nurse to be concerned?

A. Maintaining eye contact with the infant.
B. Talking to the infant during the feeding.
C. Placing the infant in the crib for the feeding.
D. Sitting on the floor to feed the infant.

65. A nurse is planning to hang the first bag of total parenteral nutrition (TPN) solution via the central line of an assigned client. The nurse plans to obtain which of the following most essential pieces of equipment before hanging the solution?
A. Electronic infusion pump
B. Blood glucose meter
C. Urine test strips
D. Noninvasive blood pressure monitor

66. Six hours after the initiation of total parenteral nutrition the client's serum glucose level is 240 mg/dl. When considering this client's elevated serum glucose level, the nurse should recognize that it is probably related to the fact that the:
A. Infusion is flowing too rapidly
B. Prescribed solution is too concentrated
C. Rise is an expected response that will eventually subside
D. Infusion is too slow to meet the client's total nutritional needs

67. A nurse is preparing to hang a fat emulsion. The nurse notes that fat globules are visible at the top of the solution. The nurse takes which of the following actions?

A. Runs the bottle of solution under warm water.
B. Rolls the bottle of solution gently.
C. Shakes the bottle of solution vigorously.
D. Obtains a different bottle of solution.

68. The nurse determines that the client's nutritional status has been severely compromised through prolonged episodes of nausea and vomiting. Which of the following therapies would the nurse anticipate to be the most effective in correcting nutritional deficits before surgery?
A. High-protein between-meal nourishment four times a day.
B. Continuous enteral feedings at 200 mL/hour.
C. Total parenteral nutrition (TPN) for several days.
D. Intravenous infusion of normal saline solution at 125 mL/hour.

69. When preparing the equipment and intravenous tubing for administration of total parenteral nutrition, the nurse is aware that the most important equipment is:
A. A steady IV pole
B. An automatic infusion pump
C. An infusion set delivering 60 gtt/ml
D. A clamp (hemostat) taped at the bedside


70. At 8 AM a nurse checks the amount of solution left in a total parenteral nutrition (TPN) infusion bag for an assigned client. It is a 3000-mL bag with 1000 mL remaining. The solution is running at a rate of 100 mL/hr. The bag was hung the previous day at noon. The nurse plans to change the infusion bag and tubing today at
A. Noon.
B. 2 PM.
C. 4 PM.
D. 8 PM.

71. A 2-year-old child is brought to the emergency department (ED) after ingesting an unknown number of children's aspirin about 30 minutes ago. On entering the examination room, the child is crying and clinging to the mother. Which assessment data should the nurse obtain first?

A. Heart rate, respiratory rate, and blood pressure
B. Recent exposure to communicable diseases
C. Number of immunizations received
D. Height and body weight

72. A 2-year-old child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate, an increased work of breathing, and a decreased oxygen saturation level. Which of the following should be the nurse's first action?

A. Suction the tracheostomy.
B. Turn the child to a side-lying position.
C. Administer pain medication.
D. Perform chest physiotherapy.

73. A client is receiving nutrition by means of total parenteral nutrition (TPN). A nurse monitors the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia?

A. Nausea, vomiting, and oliguria
B. Sweating, chills, and abdominal pain
C. Fever, weak pulse, and thirst
D. Weakness, thirst, and increased urine output

74. A client is admitted with a diagnosis of meningitis caused by Neisseria meningitidis. The nurse should institute which type of isolation precautions?

A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions

75. Which toy would be most appropriate for a 3-year-old?

A. A bicycle
B. A puzzle with large pieces
C. A pull toy
D. A computer game

76. A client with chronic obstructive lung disease tells the nurse that he feels short of breath. The client's respiratory rate is 36 breaths/minute and the nurse auscultates diffuse wheezes. His arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer a prescribed nebulizer treatment. The therapist says, "I have several more percussions to do on the unit where I am now. As soon as I'm done, I'll come assess the client." The nurse's most appropriate action is to:

A. notify the primary physician immediately.
B. stay with the client until the therapist arrives.
C. administer the treatment by metered-dose inhaler.
D. give the nebulizer treatment herself.

77. The single most effective way to decrease the spread of microorganisms is:

A. Frequent handwashing.
B. Having separate personal care items for each person.
C. Using disposable equipment whenever possible.
D. Isolating people known to be harboring disease-causing microorganisms.

78. A client is receiving nutrition by means of total parenteral nutrition (TPN). A nurse monitors the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia?

A. Nausea, vomiting, and oliguria
B. Sweating, chills, and abdominal pain
C. Fever, weak pulse, and thirst
D. Weakness, thirst, and increased urine output

79. At the beginning of a shift a nurse assesses a client receiving total parenteral nutrition (TPN) with fat emulsion piggybacked to the line. The nurse notes that the fat emulsion tubing has a 0.22-l.tm filter. Which of the following actions by the nurse is most appropriate?

A. Inspect the filter for clogging.
B. Replace with a tubing without a filter.
C. Leave the system alone.
D. Check the line for patency.
80. A home care nurse is monitoring a client's response to total parenteral nutrition (TPN). The client's weight 1 week ago was 114 pounds. The nurse determines that the client is not gaining weight too rapidly if this morning's weight was

A. 116 lb.
B. 119 lb.
C. 120 lb.
D. 122 lb.

81. At 8 AM a nurse checks the amount of solution left in a total parenteral nutrition (TPN) infusion bag for an assigned client. It is a 3000-mL bag with 1000 mL remaining. The solution is running at a rate of 100 mL/hr. The bag was hung the previous day at noon. The nurse plans to change the infusion bag and tubing today at

A. Noon.
B. 2 PM.
C. 4 PM.
D. 8 PM.

82. A nurse enters the room of a client receiving total parenteral nutrition (TPN) and discovers that the electronic infusion pump has been shut off After checking the line for patency and restarting the infusion, the nurse assesses the client for which of the following signs and symptoms?

A. Weakness, thirst, and excessive urination
B. Fever and chills
C. Weakness, shakiness, diaphoresis, and complaints of hunger
D. Dyspnea and hypotension

83. A nurse is caring for a restless client who is beginning nutritional therapy with total parenteral nutrition (TPN). The nurse should plan to ensure that which of the following is done to prevent the client from injury?

A. Monitor blood glucose levels every 12 hours.
B. Secure all connections in the TPN system.
C. Monitor the temperature once daily.
D. Calculate daily intake and output.

84. A 16-year-old who is depressed cheers up and gives her teddy bear to her favorite nurse. Which of the following is the priority for the nurse at this time?

A. Assess the adolescent for possible suicidal ideation
B. Tell her mother to call for a psychiatric referral
C. Give the bear back and discuss transitional objects
D. Praise her mood change and her passage from childhood

85. A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

A. hold the client's arm still to keep him from hitting anything.
B. carefully move him to a flat surface and turn him on his side.
C. allow him to remain in the chair but move all objects out of his way.
D. place an oral airway in his mouth to maintain an open airway.

86. A client is admitted for an amniocentesis. Initial assessment findings include the following: 16 weeks pregnant, vital signs within normal limits, hemoglobin 12.2 g/dl, hematocrit 35%, and type O-negative blood. Which action would be most important to include in the client's plan of care after the 20-minute amniocentesis has been completed?

A. Administer RhoGAM.
B. Check for rupture of membranes.
C. Assess uterine activity.
D. Provide additional fluid.

87. A client receiving total parenteral nutrition (TPN) in the home setting has a weight gain of 5 lb in 1 week. The nurse next assesses the client to detect the presence of which of the following?

A. Crackles on auscultation of the lungs
B. Thirst
C. Decreased blood pressure
D. Polyuria

88. A client with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter. A nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which of the following positions?

A. On the left side with the head higher than the feet
B. On the left side with the head lower than the feet
C. On the right side with the head higher than the feet
D. On the right side with the head lower than the feet

89. An 8-year-old child with suspected meningitis is admitted to the pediatric unit. Which of the following would be the best room assignment for this new client?

A. A room with an 8-year-old child with a perforated appendix.
B. A room with a child in sickle cell crisis.
C. A room with laminar air flow.
D. A single-bed room to decrease extraneous stimulation.

90. An 8-year-old child enters a health care facility. During assessment, the nurse discovers that the child is experiencing the anxiety of separation from his parents. The nurse makes the nursing diagnosis of Fear related to separation from familiar environment and family. Which nursing intervention is most likely to help the child cope with fear and separation?

A. Ask the parents not to visit the child until he has adjusted to the new environment.
B. Ask the physician to explain to the child why he needs to stay in the health care facility.
C. Explain to the child that he must act like an "adult" while he's in the facility.
D. Have the parents stay with the child and participate in his care.

91. The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (ACS) guidelines, the nurse should recommend that the women:

A. perform breast self-examination annually.
B. have a mammogram annually.
C. have a hormonal receptor assay annually.
D. have a physician conduct a clinical examination every 2 years.

92. A dient receiving total parenteral nutrition (TPN) complains of a headache. A nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse interprets that the dient is experiencing which complication of TPN therapy?

A. Hyperglycemia
B. Air embolism
C. Sepsis
D. Fluid overload

93. The adaptation that would indicate hyperglycemia in a client receiving total parenteral nutrition would be:

A. Polyuria
B. Paralytic ileus
C. Hypoventilation
D. A serum glucose of 115 mg/dl

94. An 80-year-old with right-sided weakness following a cerebrovascular accident (CVA) is to ambulate with the aid of a walker. What age-related changes in this individual will increase the risk of injury?

A. Improved muscle mass and strength
B. Slowed response to sensory stimuli
C. Increased cognitive functioning
D. Development of arcus senilis

95. A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take?

A. Clear the client's airway.
B. Make the client comfortable.
C. Start cardiopulmonary resuscitation.
D. Stop the feeding and remove the NG tube.

96. A 54-year-old female was found unconscious on the floor of her bathroom with self-inflicted wrist lacerations. An ambulance was called and the client was taken to the emergency department. When she was stable, she was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Now that the client is feeling better, which nursing intervention is most appropriate?

A. Observe for extrapyramidal symptoms.
B. Begin a therapeutic relationship.
C. Cancel any no-suicide contracts.
D. Continue suicide precautions.

97. A nurse working in a neonatal intensive care unit is developing infection control policies. Which of the following policies would the nurse expect to include as the single most effective means of preventing the spread of infection?

A. Having everyone coming in contact with neonates perform frequent hand and arm washing.
B. Keeping each neonate in an isolation incubator that is opened as infrequently as possible.
C. Maintaining a ventilation system in the unit that provides for continuous clean-air exchange.
D. Requiring everyone who comes in contact with neonates to wear gowns and masks.

98. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should:

A. apply suction to the NG tube every hour.
B. clamp the NG tube if the client complains of nausea.
C. irrigate the NG tube gently with normal saline solution.
D. reposition the NG tube if pulled out.


99. Which of the following nursing diagnoses would receive the greatest priority in the care of an unconscious client with a head injury?

A. Impaired Gas Exchange related to shallow irregular breathing.
B. Risk for Injury related to disorientation and decreased level of consciousness.
C. Disturbed Sensory Perception related to decreased level of consciousness.
D. Ineffective Airway Clearance related to inability to remove respiratory secretions.

100. The mother of a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons and that recently she had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to which of the following?

A. Bananas
B. Latex
C. Kiwifruit
D. Color dyes


ANSWERS

1. C
2. C
3. B
4. C
5. C
6. D
7. C
8. A
9. B
10. B
11. C
12. C
13. A
14. A
15. D
16. A
17. D
18. A
19. B
20. A
21. A
22. B
23. D
24. C
25. B
26. B
27. A
28. D
29. C
30. C
31. A
32. A
33. A
34. A
35. D
36. D
37. B
38. C
39. A
40. D
41. D
42. A
43. B
44. B
45. B
46. C
47. C
48. D
49. C
50. B
51. A
52. C
53. B
54. B
55. A
56. D
57. D
58. D
59. B
60. C
61. B
62. B
63. C
64. C
65. A
66. A
67. D
68. C
69. B
70. A
71. A
72. A
73. D
74. B
75. B
76. D
77. A
78. D
79. B
80. A
81. A
82. C
83. B
84. A
85. B
86. A
87. A
88. B
89. D
90. D
91. B
92. D
93. A
94. B
95. A
96. D
97. A
98. C
99. D

100. B