Lesson 5: Basic Care and Comfort Questions are numbered by the order in which they appeared in the test.

. * Represents the correct answer. Question 1 The nurse is planning care for a client with a cerebral vascular accident (CVA . !hich of the following measures planned by the nurse would be most effective in preventing s"in brea"down# $lace client in the wheelchair for four A hours each day % $ad the bony prominence C Reposition every two hours &

intestine rather than in the airways. Question 5 After a myocardial infarction* a client is placed on a sodium restricted diet. !hen the nurse is teaching the client about the diet* which meal plan would be the most appropriate to suggest# 7 o1. broiled fish* 8 ba"ed potato* 9 cup A canned beets* 8 orange* and mil" 7 o1. canned salmon* fresh broccoli* 8 % biscuit* tea* and 8 apple A bologna sandwich* fresh eggplant* . o1 C fresh fruit* tea* and apple +uice &

Question 3 The nurse has been teaching a client with congestive heart failure about proper nutrition. !hich of these lunch selections indicates the client has learned about sodium restriction# A Cheese sandwich with a glass of ./ mil" 0liced tur"ey sandwich and canned % pineapple C Cheeseburger and ba"ed potato & 'ushroom pi11a and ice cream Review Information( The correct answer is %( 0liced tur"ey sandwich and canned pineapple 0liced tur"ey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.

'assage reddened bony prominence

7 o1. tur"ey* 8 fresh sweet potato* 8:. cup fresh green beans* mil"* and 8 orange

Review Information( The correct answer is C( Reposition every two hours Clients who are at ris" for s"in brea"down develop fewer pressure ulcers when turned every two hours. %y relieving the pressure over bony prominences at fre)uent scheduled intervals* blood flow to areas of potential in+ury is maintained.

Review Information( The correct answer is &( 7 o1. tur"ey* 8 fresh sweet potato* 8:. cup fresh green beans* mil"* and 8 orange Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and:or vegetables or cured meats.

Question 2 After a client has an enteral feeding tube inserted* the most accurate method for verification of placement is A abdominal ,-ray % auscultation C flushing tube with saline & aspiration for gastric contents Review Information( The correct answer is A( abdominal ,-ray $lacement should be verified by radiograph to determine that the tube is in the stomach or

Question 4 The nurse is caring for a 2 year-old with acute glomerulonephritis (A34 . 5indings include moderate edema and oliguria. 0erum blood urea nitrogen and creatinine are elevated. !hat dietary modifications are most appropriate# A &ecreased carbohydrates and fat % &ecreased sodium and potassium C 6ncreased potassium and protein & 6ncreased sodium and fluids Review Information( The correct answer is %( &ecreased sodium and potassium Children with A34 who have edema* hypertension oliguria* and a1otemia have dietary restrictions limiting sodium* potassium* fluids* and protein.

Question 6 !hat finding of the nursing assessment of a paraly1ed client would indicate the probable presence of a fecal impaction# A $resence of blood in stools % ;o1ing li)uid stool

C Continuous rumbling flatulence & Absence of bowel movements Review Information( The correct answer is %( ;o1ing li)uid stool !hen the bowel is impacted with hardened feces* there is often a seepage of li)uid feces around the obstruction. This is often mista"en for uncontrolled diarrhea.

Review Information( The correct answer is %( continuously >sually gastrostomy and +e+unostomy feedings are given continuously to ensure proper absorption. ?owever* initial feedings may be given by bolus to assess the client@@s tolerance to formula.

C &

reassure him that this is not unusual for his age

encourage him to increase his activity

Question 7 The nurse is teaching the client to select foods rich in potassium to help prevent digitalis to,icity. !hich choice indicates the client understands dietary needs# A three apricots % medium banana C naval orange & ba"ed potato Review Information( The correct answer is &( ba"ed potato A ba"ed potato contains <8= milligrams of potassium.

Question An A< year-old nursing home resident who has impaired mental status is hospitali1ed with pneumonic infiltrates in the right lower lobe. !hen the nurse assists the client with a clear li)uid diet* the client begins to cough. !hat should the nurse do ne,t# A Add a thic"ening agent to the fluids % Chec" the clientBs gag refle, C 5eed the client only solid foods &

Review Information( The correct answer is A( assess the severity and location of the pain 'ost older adults have 8 or more chronic painful illnesses* and in fact* they often must be as"ed about discomfort (rather than DpainD to reveal the presence of pain. There is no evidence that pain of older adults is less intense than younger adults. 6t is important for the nurse to assess the pain thoroughly before implementing pain relief measures.

6ncrease the rate of intravenous fluids

Question 8 !hen administering enteral feeding to a client via a +e+unostomy tube* the nurse should administer the formula A every four to si, hours % continuously C in a bolus & every hour

Review Information( The correct answer is %( Chec" the clientBs gag refle, !hen a new problem emerges* the nurse should perform appropriate assessment so that suitable nursing interventions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the trachea and finally the lung. A loss or an impairment of the protective cough refle, can result in aspiration.

Question 1! An AC year-old client complains of generali1ed muscle aches and pains. The first action by the nurse should be A assess the severity and location of the pain % obtain an order for an analgesic

Question 11 A client was +ust ta"en off the ventilator after surgery and has a nasogastric tube draining bile-colored li)uids. !hich nursing measure will provide the most comfort to the client# Allow the client to melt ice chips in the A mouth % $rovide mints to freshen the breath $erform fre)uent oral care with a tooth C sponge & 0wab the mouth with glycerin

swabs
Review Information( The correct answer is C( $erform fre)uent oral care with a tooth sponge 5re)uent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. 6ce chips or mints could be contraindicated* and do not stimulate the tissue. 3lycerin swabs do not cleanse since they only moisturi1e.

"i#"est ris" for development of decubitus ulcers# A 2E year-old malnourished client on bed A rest % An obese client who uses a wheelchair An incontinent client who has had 7 C diarrhea stools &

An A= year-old ambulatory diabetic client

Question 12 The nurse is instructing a <C year-old female client diagnosed with osteoporosis. The most important instruction regarding e,ercise would be to A e,ercise doing weight bearing activities % e,ercise to reduce weight avoid e,ercise activities that increase the C ris" of fracture &

Review Information( The correct answer is A( A 2E year-old malnourished client on bed rest !eighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus* malnutrition is a ma+or ris" factor for decubiti* due in part to poor hydration and inade)uate protein inta"e.

Question 15 A nurse is wor"ing with a client in an e,tended care facility. !hich bed position is preferred for a client* who is at ris" for falls* as part of a prevention protocol# All F side rails up* wheels loc"ed* bed A closest to door % Gower side rails up* bed facing doorway Hnees bent* head slightly elevated* bed in C lowest position &

%ed in lowest position* wheels loc"ed* place bed against wall

e,ercise to strengthen muscles and thereby protect bones

Review Information( The correct answer is A( e,ercise doing weight bearing activities !eight bearing e,ercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed* further loss can be greatly reduced if the client includes weight bearing e,ercises along with estrogen replacement and calcium supplements in their treatment protocol.

Question 14 Constipation is one of the most fre)uent complaints of elders. !hen assessing this problem* which action should be the nurse@s priority# A obtain a complete blood count % obtain a health and dietary history refer to a provider for a physical C e,amination & measure height and weight
Review Information( The correct answer is %( obtain a health and dietary history 6nitially* the nurse should obtain information about the chronicity of and details about constipation* recent changes in bowel habits* physical and emotional health* medications* activity pattern* and food and fluid history. This information may suggest causes as well as an appropriate* safe treatment plan.

Review Information( The correct answer is &( %ed in lowest position* wheels loc"ed* place bed against wall 6t is no longer advisable to use only the lower side rails. >sing all F side rails (upper and lower siderails at the top and bottom of the bed is an inappropriate use of restraint without an order. 6f all F are pulled up* an order for protective restraints is needed that usually has to be renewed in FA to 2. hours along with more fre)uent documentation. ?aving all F side rails raised limits the clientBs autonomy and freedom of movement. >sing 7 of the F side rails pulled up is acceptable* because clients can safely e,it the bed on their own initiative. $lacing the bed against the wall permits getting out of bed on only 8 side. Goc"ing the wheels "eeps the bed from sliding. Heeping the bed in the lowest position (without bending limbs to restrict movement provides a shorter distance to the ground if the client chooses to get out of bed.

Question 13 A nurse is assessing several clients in a long term health care facility. !hich client is at

Question 16 The nurse is teaching an A2 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to avoid A glycerine suppositories

% fiber supplements C la,atives & stool softeners

Review Information( The correct answer is C( la,atives 0ome elders are constipated because they have used over-the-counter la,atives for a long time. 6n addition* many people do not eat enough fiber* drin" enough water* or e,ercise ade)uately. Certain medications* including opioid analgesics* are constipating. Ilders are rarely constipated because of organic or pathological reasons.

6mmobility in children has similar physical effects to those found in adults Care of the immobile child includes efforts to prevent complications of muscle atrophy* contractures* s"in brea"down* decreased metabolism and bone deminerali1ation. 0econdary alterations also occur in the cardiovascular* respiratory and renal systems. 0imilar effects and alterations occur in adults. Question 18 A client with diarrhea should avoid which of the following# A orange +uice % tuna C eggs & macaroni Review Information( The correct answer is A( orange +uice ;range +uice is contraindicated for a client with diarrhea because it increases the motility of the gastrointestinal tract.

the client on heparin.

Question 2! A client in a long term care facility complains of pain. The nurse collects data about the clientBs pain. The first step in pain assessment is for the nurse to A have the client identify coping methods get the description of the location and % intensity of the pain C accept the clientBs report of pain &

determine the clientBs status of pain

Review Information( The correct answer is C( accept the clientBs report of pain Although all of the options above are correct* the first and most important piece of information in this clientBs pain assessment is what the client is telling you about the pain --Jthe clientBs report.K Q%&'Random (2 Questions are numbered by the order in which they appeared in the test. * Represents the correct answer. Question 1 The nurse is administering lidocaine (Lylocaine to a client with a myocardial infarction. !hich of the following assessment findings re)uires the nurse@s immediate action# A Central venous pressure reading of 88 % Respiratory rate of .. C $ulse rate of FA %$' & %lood pressure of 8FF:E. Review Information( The correct answer is C( $ulse rate of FA %$' ;ne of the side effects of lidocaine is bradycardia*

Question 17 !hich statement $est describes the effects of immobility in children# 6mmobility prevents the progression of A language and fine motor development 6mmobility in children has similar % physical effects to those found in adults Children are more susceptible to the C effects of immobility than are adults

Question 1 A client is being maintained on heparin therapy for deep vein thrombosis (&VT . The nurse must closely monitor which of the following laboratory values# A bleeding time % platelet count C activated $TT & clotting time Review Information( The correct answer is C( activated $TT ?eparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The Activated $rothromboplastin Time (A$TT test is a highly sensitive test to monitor

Children are li"ely to have & prolonged immobility with subse)uent complications
Review Information( The correct answer is %(

heart bloc"* cardiovascular collapse and cardiac arrest (this drug should never be administered without continuous IH3 monitoring .

and fast. 5eeling helpless to stop the behavior* feelings of self-disgust occur.

Question 2 The nurse is teaching a group of college students about breast self-e,amination. A woman as"s for the best time to perform the monthly e,am. !hat is the best reply by the nurse# DThe first of every month* because it is A easiest to rememberD DRight after the period* when your breasts % are less tenderD D&o the e,am at the same time every C monthD &

Question 4 The nurse is assessing a client with chronic obstructive pulmonary disease receiving o,ygen for low $a;. levels. !hich assessment is a nursing )riorit*# A Ivaluating 0a;. levels fre)uently % ;bserving s"in color changes C Assessing for clubbing fingers & 6dentifying tactile fremitus
Review Information( The correct answer is A( Ivaluating 0a;. levels fre)uently The best method to evaluate a client@@s o,ygenation is to evaluate the 0a;.. This is +ust as effective as an arterial blood gas reading to evaluate o,ygenation status* and is less traumatic and e,pensive.

Review Information( The correct answer is %( 6t can occur in clients ta"ing antipsychotic drugs longer than . years Tardive dys"inesia is a e,trapyramidal side effect that appears after prolonged treatment with antipsychotic medication. Iarly symptoms of tardive dys"inesia are fasciculations of the tongue or constant smac"ing of the lips.

D;vulation* or mid-cycle is the best time to detect changesD

Review Information( The correct answer is %( DRight after the period* when your breasts are less tenderD The best time for a breast self e,am (%0I is a wee" after a menstrual cycle* when the breasts are no longer swollen and tender due to hormone elevation.

Question 3 !hich medication is more helpful in treating bulimia than anore,ia# A Amphetamines % 0edatives C Anticholinergics & 4arcotics
Review Information( The correct answer is C( Anticholinergics 6n contrast to anore,ics* individuals with bulimia are troubled by their behavioral characteristics and become depressed. The person feels compelled to binge* purge

Question 5 The nurse is teaching a client about the difference between tardive dys"inesia (T& and neuroleptic malignant syndrome (4'0 . !hich statement is true with regards to tardive dys"inesia# T& develops within hours or years of A continued antipsychotic drug use in people under .= and over 7= 6t can occur in clients ta"ing antipsychotic % drugs longer than . years Tardive dys"inesia occurs within minutes C of the first dose of antipsychotic drugs and is reversible &

Question 6 A client is treated in the emergency room for diabetic "etoacidosis and a glucose level of <C=mg.&:G. 6n assessing the client* the nurse@s review of which of the following tests suggests an understanding of this health problem# A 0erum calcium % 0erum magnesium C 0erum creatinine & 0erum potassium Review Information( The correct answer is &( 0erum potassium $otassium is lost in diabetic "etoacidosis during rehydration and insulin administration. Review of this lab finding suggests the nurse has "nowledge of this problem.

T& can easily be treated with anticholinergic drugs

Question 7 A client is discharged on warfarin sulfate (Coumadin . !hich statement by the client indicated a need for further teaching# A D6 "now 6 must avoid crowds.D % D6 will "eep all laboratory appointments.D

D6 plan to use an electric ra1or for shaving.D

D6 will report any bruises for & bleeding.D

Review Information( The correct answer is A( D6 "now 6 must avoid crowds.D There are no specific reasons for the client on Coumadin to avoid crowds. 3eneral instructions for any cardiac surgical client include limiting e,posure to infection.

C 0erum glucose E= mg:dl & R%C C.= million:mm7 Review Information( The correct answer is A( 0erum albumin ..C g:dl 0erum albumin level is low (normal 7.= M C.= g:dl in elders * indicating nutritional counseling to increase dietary protein is needed. 0ocioeconomic factors may need to be addressed to help the client comply with the recommendation.

solutions &

formula or breast mil" as tolerated

Review Information( The correct answer is C( 4$; then glucose and electrolyte solutions $ost-operatively* the initial feedings are clear li)uids in small )uantities to provide calories and electrolytes.

Question 8 !hen teaching a client with a new prescription for lithium (Githane for treatment of a bi-polar disorder which of these should the nurse emphasi1e# A 'aintaining a salt restricted diet % Reporting vomiting or diarrhea C Ta"ing other medication as usual & 0ubstituting generic form if desired Review Information( The correct answer is %( Reporting vomiting or diarrhea 6f dehydration results from vomiting* diarrhea or e,cessive perspiration* tolerance to the drug may be altered and symptoms may return.

Question 1! The nurse is assessing a woman in early labor. !hile positioning for a vaginal e,am* she complains of di11iness and nausea and appears pale. ?er blood pressure has dropped slightly. !hat should be the initial nursing action# A Call the health care provider % Incourage deep breathing C Ilevate the foot of the bed & Turn her to her left side
Review Information( The correct answer is &( Turn her to her left side The weight of the uterus can put pressure on the vena cava and aorta when a pregnant woman is flat on her bac" causing supine hypotension. Action is needed to relieve the pressure on the vena cava and aorta. Turning the woman to the side reduces this pressure and relieves postural hypotension.

Question 12 A client is receiving lithium carbonate <== mg T.6.&. to treat bipolar disorder. !hich of these indicate early signs of to,icity# A Ata,ia and course hand tremors % Vomiting* diarrhea and lethargy C $ruritus* rash and photosensitivity &

Ilectrolyte imbalance and cardiac arrhythmias

Review Information( The correct answer is %( Vomiting* diarrhea and lethargy These are early signs of lithium to,icity.

Question After assessing a 2= year-old male client@s laboratory results during a routine clinic visit* which one of the following findings would indicate an area in which teaching is needed( A 0erum albumin ..C g:dl % G&G Cholesterol 8F= mg:dl

Question 11 6nitial postoperative nursing care for an infant who has had a pyloromyotomy would initia++* include A bland diet appropriate for age % intravenous fluids for 7-F days C 4$; then glucose and electrolyte

Question 13 The nurse is caring for a . month-old infant with a congenital heart defect. !hich of the following is a priority nursing action# A $rovide small feedings every 7 hours % 'aintain intravenous fluids C Add strained cereal to the diet & Change to reduced calorie formula Review Information( The correct answer is A( $rovide small feedings every 7 hours 6nfants with congenital heart defects are at increased ris" for developing congestive heart failure. 6nfants with congestive heart failure have

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an increased metabolic rate and re)uire additional calories to grow. At the same time* however* rest and conservation of energy for eating is important. 5eedings should be smaller and every 7 hours rather than the usual F hour schedule.

Question 14 Clients ta"ing lithium must be particularly sure to maintain ade)uate inta"e of which of these elements# A $otassium % 0odium C Chloride & Calcium Review Information( The correct answer is %( 0odium Clients ta"ing lithium need to maintain an ade)uate inta"e of sodium. 0erum lithium concentrations may increase in the presence of conditions that cause sodium loss.

Iarly findings of shoc" reveal hypo,ia with rapid heart rate and rapid respirations* and o,ygen is the most critical initial intervention. The other interventions are secondary to o,ygen therapy. Question 16 A woman in labor calls the nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on the bed linens. The nurse "nows that fetal monitoring must now assess for what complication# A Iarly decelerations % Gate accelerations C Variable decelerations & $eriodic accelerations Review Information( The correct answer is C( Variable decelerations !hen the membranes rupture* there is increased ris" initially of cord prolapse. 5etal heart rate patterns may show variable decelerations* which re)uire immediate nursing action to promote gas e,change.

wrist This type of identification band easily trac"s the client@@s movements and ensures safety while the client wanders on the unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.

Question 18 A client is ta"ing tranylcypromine ($arnate and has received dietary instruction. !hich of the following food selections would be contraindicated for this client# A 5resh +uice* carrots* vanilla pudding % Apple +uice* ham salad* fresh pineapple C ?amburger* fries* strawberry sha"e & Red wine* fava beans* aged cheese Review Information( The correct answer is &( Red wine* fava beans* aged cheese Red wine and cheese contain tyramine (as do chic"en liver and ripe bananas and so are contraindicated when ta"ing 'A;6s. 5ava beans contain other vasopressors that can interact with 'A;6s also causing malignant hypertension.

Question 15 A client is admitted with severe in+uries from an auto accident. The client@s vital signs are %$ 8.=:C=* pulse rate 88=* and respiratory rate of .A. The initia+ nursing intervention would be to A begin intravenous therapy initiate continuous blood pressure % monitoring C administer o,ygen therapy & institute cardiac monitoring Review Information( The correct answer is C( administer o,ygen therapy

Question 17 The nurse can $est ensure the safety of a client suffering from dementia who wanders from the room by which action# Repeatedly remind the client of the time A and location I,plain the ris"s of wal"ing with no % purpose >se protective devices to "eep the client C in the bed or chair in the room &

Attach a wander-guard sensor band to the client@s wrist

Review Information( The correct answer is &( Attach a wander-guard sensor band to the client@@s

Question 1 The nurse is assessing a client@s home in preparation for discharge. !hich of the following should be given priority consideration# A 5amily understanding of client needs % 5inancial status C Gocation of bathrooms & $ro,imity to emergency services

Review Information( The correct answer is A( 5amily understanding of client needs 5unctional communication patterns between family members are fundamental to meeting the needs of the client and family. Question 2! A client* admitted to the unit because of severe depression and suicidal threats* is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is #reatest during the night shift when staffing is A limited when the clientBs mood improves with an % increase in energy level C at the time of the client@s greatest despair &

Question 21 A male client calls for a nurse because of chest pain. !hich statement by the client would re)uire the most immediate action by the nurse# D!hen 6 ta"e in a deep breath* it stabs li"e A a "nife.D DThe pain came on after dinner. That soup % seemed very spicy.D D!hen 6 turn in bed to reach the remote C for the TV* my chest hurts.D &

Question 22 A client has been started on a long term corticosteroid therapy. !hich of the following comments by the client indicate the need for further teaching# A D6 will "eep a wee"ly weight record.D % D6 will ta"e medication with food.D D6 will stop ta"ing the medication for 8 C wee" every month.D &

D6 feel pressure in the middle of my chest* li"e an elephant is sitting on my chest.D

D6 will eat foods high in potassium.D

after a visit from the client@s estranged partner

Review Information( The correct answer is %( when the clientBs mood improves with an increase in energy level 0uicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.

Review Information( The correct answer is &( D6 feel pressure in the middle of my chest* li"e an elephant is sitting on my chest.D This is a classic description of chest pain in men caused by myocardial ischemia. !omen e,perience vague feelings of fatigue and bac" and +aw pain.

Review Information( The correct answer is C( D6 will stop ta"ing the medication for 8 wee" every month.D Imphatically warn against discontinuing steroid dosage abruptly because that may produce a fatal adrenal crisis.

Question 23 The visiting nurse ma"es a postpartum visit to a married female client. >pon arrival* the nurse observes that the client has a blac" eye and numerous bruises on her arms and legs. The initia+ nursing intervention would be to call the police to report indications of A domestic violence confront the husband about abusing his % wife leave the home because of the unsafe C environment &

interview the client alone to determine the origin of the in+uries

Review Information( The correct answer is &( interview the client alone to determine the origin of the in+uries 6t would be wrong to assume domestic violence

without further assessment. 0eparate the suspected victim from the partner until battering has been ruled out.

Question 24 A nurse is caring for a client who has +ust been admitted with an overdose of aspirin. The following lab data is available( $a;. EC* $aC;. 7=* p? 2.C* H 7.. mI):l. !hich should be the nurse@s first action# A 'onitor respiratory rate % 'onitor inta"e and output every hour Assist the client to breathe into a paper C bag &

e,presses concern about the burden of caregiving. !hich of the following actions by the nurse should be a )riorit*# A Gin" the caregiver with a support group % As" friends to visit regularly C 0chedule a home visit each wee" & Re)uest anti-an,iety prescriptions Review Information( The correct answer is A( Gin" the caregiver with a support group Assisting caregivers to locate and +oin support groups is most helpful. 5amilies share feelings and learn about services such as respite care. ?ealth education is also available through local and national Al1heimer@@s chapters.

hypoglycemic medication* the nurse should place primary emphasis on A recogni1ing findings of to,icity % ta"ing the medication at specified times increasing the dosage based on blood C glucose &

distinguishing hypoglycemia from hyperglycemia

Review Information( The correct answer is %( ta"ing the medication at specified times A regular interval between doses should be maintained since oral hypoglycemics stimulate the islets of Gangerhans to produce insulin.

$repare to administer o,ygen by mas"

Review Information( The correct answer is C( Assist the client to breathe into a paper bag 0ide effects of aspirin to,icity include hyperventilation* which can result in respiratory al"alosis in the initial stages. %reathing into a paper bag will prevent further reduction in $aC;..

Question 26 6n response to a call for assistance by a client in labor* the nurse notes that a loop on the umbilical cord protrudes from the vagina. !hat is the )riorit* nursing action# A call the health care provider % chec" fetal heart beat C put the client in "nee-chest position & turn the client to the side Review Information( The correct answer is C( put the client in "nee-chest position 6mmediate action is needed to relieve pressure on the cord* which puts the fetus at ris" due to hypo,ia. The Trendelenburg position accomplishes this. The e,posed cord is covered with saline soa"ed gau1e* not reinserted. The fetal heart rate also should be chec"ed* and the provider called. A prolapsed umbilical cord is a medical emergency. Question 27 !hen teaching a client about an oral

Question 28 A male client is preparing for discharge following an acute myocardial infarction. ?e as"s the nurse about his se,ual activity once he is home. !hat would be the nurse@s initial response# 3ive him written material from the A American ?eart Association about se,ual activity with heart disease Answer his )uestions accurately in a % private environment 0chedule a private* uninterrupted teaching C session with both the client and his wife &

Assess the client@s "nowledge about his health problems

Question 25 The spouse of a client with Al1heimer@s disease

Review Information( The correct answer is &( Assess the client@@s "nowledge about his health problems The nursing process is continuous and cyclical in nature. !hen a client e,presses a specific concern* the nurse performs a focused assessment to gather additional data prior to planning and

implementing nursing interventions.

D&on@t get upset. The confusion will clear up in a day or two.D D6t is to be e,pected since most clients C have the same results.D % &

Question 2 The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 2C year-old client@s A poor nutritional status % decreased gastrointestinal motility C increased splanchnic blood flow & altered peripheral resistance Review Information( The correct answer is %( decreased gastrointestinal motility Together with shrin"age of the gastric mucosa* and changes in the levels of hydrochloric acid* this will decrease absorption of medications and interfere with their actions.

D6 can hear your concern and that your confusion is upsetting to you.D

Question 32 !hat must be the priority consideration for nurses when communicating with children# A $resent environment % $hysical condition C 4onverbal cues & &evelopmental level Review Information( The correct answer is &( &evelopmental level !hile each of the factors affect communication* the nurse recogni1es that developmental differences have implications for processing and understanding information. Conse)uently* a childBs developmental level must be considered when selecting communication approaches.

Review Information( The correct answer is &( D6 can hear your concern and that your confusion is upsetting to you.D Communicating caring and empathy with the ac"nowledgement of feelings is the initial response. Afterwards* teaching about the e,pected short term effects would be discussed.

Question 31 The client as"s the nurse how the health care provider could tell she was pregnant J+ust by loo"ing inside.K !hat is the best e,planation by the nurse# %luish coloration of the cervi, and A vaginal walls % $ronounced softening of the cervi, Clot of very thic" mucous that obstructs C the cervical canal &

0light rotation of the uterus to the right

Question 33 The nurse is caring for a post-operative client who develops a wound evisceration. The first nursing intervention should be to A medicate the client for pain % call the provider cover the wound with sterile saline C dressing & place the bed in a flat position Review Information( The correct answer is C( cover the wound with sterile saline dressing !hen evisceration occurs* the wound should first be )uic"ly covered by sterile dressings soa"ed in sterile saline. This prevents tissue damage until a repair can be effected.

Question 3! After F electroconvulsive treatments over . wee"s* a client is very upset and states J6 am so confused. 6 lose my money. 6 +ust canBt remember telephone numbers.K The most therapeutic response for the nurse to ma"e is DNou were seriously ill and needed the A treatments.D

Review Information( The correct answer is A( %luish coloration of the cervi, and vaginal walls Chadwic"@@s sign is a bluish-purple coloration of the cervi, and vaginal walls* occurring at F wee"s of pregnancy* that is caused by vasocongestion.

Question 34

8=

The nurse is caring for a client receiving intravenous nitroglycerin for acute angina. !hat is the most important assessment during treatment# A ?eart rate % 4eurologic status C >rine output & %lood pressure Review Information( The correct answer is &( %lood pressure The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client@@s blood pressure must be evaluated every 8C minutes until stable and then every 7= minutes to every hour.

!ine* beer* cheese* liver and chocolate These foods are tyramine rich and ingestion of these foods while ta"ing monoamine o,idase inhibitors ('A;6s can precipitate a lifethreatening hypertensive crisis.

counter sinus remedies

Review Information( The correct answer is &( 0he reports recent use of over-the counter sinus remedies ;ver-the-counter drugs are a possible danger in early pregnancy. A report by the client that she has ta"en medications should be followed up immediately.

Question 36 !hich clinical finding would the nurse e,pect to assess first in a newborn with spastic cerebral palsy# A cognitive impairment % hypotonic muscular activity C sei1ures & criss-crossing leg movement Review Information( The correct answer is &( criss-crossing leg movement Cerebral palsy is a neuromuscular impairment resulting in muscular and refle,ive hypertonicity and the criss-crossing* or scissoring leg movements.

Question 38 A client telephones the clinic to as" about a home pregnancy test she used this morning. The nurse understands that the presence of which hormone strongly suggests a woman is pregnant# A Istrogen % ?C3 C Alpha-fetoprotein & $rogesterone Review Information( The correct answer is %( ?C3 ?uman chorionic gonadotropin (?C3 is the biologic mar"er on which pregnancy tests are based. Reliability is about EA/* but the test does not conclusively confirm pregnancy.

Question 35 A client diagnosed with chronic depression is maintained on tranylcypromine ($arnate . An important nursing intervention is to teach the client to avoid which of the following foods# A !ine* beer* cheese* liver and chocolate % !ine* citrus fruits* yogurt and broccoli C %eer* cheese* beef and carrots &

!ine* apples* sour cream and beef stea"

Review Information( The correct answer is A(

Question 37 The nurse is wor"ing in a high ris" antepartum clinic. A F= year-old woman in the first trimester gives a thorough health history. !hich information should receive )riorit* attention by the nurse# ?er father and brother are insulin A dependent diabetics 0he has ta"en A== mcg of folic acid daily % for the past year ?er husband was treated for tuberculosis C as a child & 0he reports recent use of over-the

Question 3 As a general guide for emergency management of acute alcohol into,ication* it is important for the nurse initially to obtain data regarding which of the following# !hat and how much the client drin"s* A according to family and friends

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% The blood alcohol level of the client C The blood pressure level of the client &

The blood glucose level of the client

Gung sounds are critical assessments at this point. The nurse should be alert to crac"les or a pleural friction rub* highly suggestive of a pulmonary embolism.

Review Information( The correct answer is %( The blood alcohol level of the client %lood alcohol levels are generally obtained to determine the level of into,ication. The amount of alcohol consumed determines how much medication the client needs for deto,ification and treatment. Reports of alcohol consumption are notoriously inaccurate.

Question 4! A client is admitted to the hospital with a diagnosis of deep vein thrombosis. &uring the initial assessment* the client complains of sudden shortness of breath. The 0a;. is A2. The )riorit* nursing assessment at this time is A bowel sounds % heart rate C peripheral pulses & lung sounds Review Information( The correct answer is &( lung sounds

8.