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A 38-year-old client, who is gravida 4, para 2 with gestational diabetes, is scheduled for an amniocentesis at 33 weeks’ gestation because of unstable blood sugar. The results of the amniocentesis reveal the lecithin/ sphingomyelin ratio (L/S) is 1:1, and the phosphatidyl- glycerol (PG) is negative. How should a nurse best interpret this data?


 
Answer A is incorrect because the amniocentesis in this case is not used to determine congenital anomalies.
Answer B is incorrect because the amniocentesis does not establish intrauterine growth retardation.
Answer C is correct because the test is performed to determine fetal lung maturity. The L/S ratio should be 2:1 with + PG for the infant who would be at low risk for respiratory distress syndrome.
Answer D is incorrect because the amniocentesis is not used to test for birth trauma.

■ TEST-TAKING TIP: Consider the client’s condition; an amniocentesis at 33 weeks’ gestation is used to establish lung maturity in an unborn fetus. Eliminate the answers that do not deal directly with this client’s condition.

Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Diagnostic Tests

CORRECT ANSWER: C
 
A client, who is overweight and has diabetes, has a blood pressure of 148/92 mm Hg. The client’s urinalysis reveals microalbuminuria. The client does not want to take drugs despite a family history of brain attack (cerebrovascular accident [CVA]). The correct response by a nurse is:


 
Answer A is incorrect because herbs have not been adequately tested for managing a disease this significant.
Answer B is correct because this is an impending disaster. The client has genetic risks and risks from hyper- tension (HTN), obesity, and diabetes. The client already has early renal disease. While losing weight and exercising potentially could bring down the client’s BP to under 130/80, the client will be exposed to risks over the months it will take to change.
Answer C is incorrect because, while losing weight and exercising potentially could bring down the client’s BP under 130/80 mm Hg, the client will be exposed to risks over the months it will take to change.
Answer D is incorrect because this is an impending disaster. A client has genetic risks, and risks from HTN, obesity, and diabetes. A client who already has renal disease needs treatment, not just assessment.

■ TEST-TAKING TIP: Only one option will definitely reduce the BP—drug therapy.

Content Area: Adult Health, Cardiovascular; Integrated Process: Communication and Documentation; Cognitive Level: Application; Client Need/Subneed: Psychosocial Integrity/ Therapeutic Communications

CORRECT ANSWER: B
 
A school nurse is called to the playground during recess to see a child with hemophilia who has collided with a friend. The child’s knee is bruised and swollen and the child reports significant pain. Which actions should the nurse take? Select all that apply.


 
Answer A is incorrect because emergency medical services (EMS) are not required for this joint injury because the condition is not immediately life threatening. The child should be seen by the regular physician.
Answer B is correct because the nurse should apply a wrap to the knee for immobility and compression.
Answer C is incorrect because the child should not continue to ambulate as it could worsen the injury.
Answer D is correct because ice should be applied to constrict blood vessels to reduce bleeding, swelling, and pain.
Answer E is correct because elevating the extremity will help to reduce swelling and bleeding.
Answer F is incorrect because keeping the child indoors is inappropriate. The child should be permitted to self-limit activities and lead as normal a life as possible.

■ TEST-TAKING TIP: Use the mnemonic RICE (rest, ice, compression, elevation) to remember the treatment for hemophilia.

Content Area: Child Health, Hematological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations

CORRECT ANSWERS: B, D, E
 
Which clinical feature found on assessment should indicate to a nurse that a client has congestive heart failure?


 
Answer A is correct because congestive heart failure (CHF) or right-sided heart failure reduces cardiac output; and circulating O2 is reduced, producing fatigue and shortness of breath.
Answer B is incorrect because Cheyne-Stokes breathing occurs from neurologic problems or problems with respiratory gas exchange.
Answer C is incorrect because the liver may be enlarged but not painful.
Answer D is incorrect because crackles would be more consistent with left-sided failure, not CHF (right-sided failure).

■ TEST-TAKING TIP: Review the clinical differences between right-sided versus left-sided heart failure.

Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application;
Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology

CORRECT ANSWER: A
 
A nurse is caring for a client at 32 weeks’ gestation who has been admitted to an obstetrical unit with complete placenta previa. Which symptoms should the nurse identify as being a result of this client’s condition? Select all that apply.


 
Answer A is correct because painless vaginal bleeding is the common symptom of complete placenta previa.
Answer B is incorrect because tetanic uterine contractions are a symptom of placental abruption, not placenta previa.
Answer C is incorrect because premature rupture of membranes is a symptom of placental abruption, not placenta previa.
Answer D is correct because the client’s hemoglobin level will drop in response to the bleeding caused by a complete placenta previa. It is common to draw serial blood counts to determine when to transfuse the mother or deliver the fetus.
Answer E is incorrect because a rigid, boardlike abdomen is a symptom of placental abruption, not placenta previa.

■ TEST-TAKING TIP: The important difference between abruption and previa is pain. Abruption is painful with many contractions; previa is painless without contractions.

Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology

CORRECT ANSWERS: A, D
 
A 4-year-old is hospitalized with acute glomerulonephritis. A nurse should feel most confident that the client teaching has been effective and the child has a basic understanding of this condition if the child states:


 
Answer A is incorrect because the child’s statement demonstrates the magical thinking of a pre-schooler. This child needs additional teaching and reassurance that hospitalization is not a punishment.
Answer B is incorrect because, although the child may be experiencing a stomachache, this statement is not the best evidence that the child has a basic understanding of the illness.
Answer C is correct because the child’s statement demonstrates a basic knowledge that the main reason for hospitalization pertains to a urinary problem. Acute glomerulonephritis involves altered kidney function, resulting in decreased urine output.
Answer D is incorrect because acute glomerulonephritis is thought to be an immune-complex response to a previous streptococcal illness. Although the child may have a persistent infection and may be receiving antibiotics, Answer C demonstrates greater understanding of the rationale for hospitalization—so that kidney functioning may be monitored and restored.

■ TEST-TAKING TIP: Note that only one answer describes a symptom specific to kidney functioning while the others indicate no understanding (Answer A) or are too generalized (Answers B and D). Select the option that is specific to the kidneys.

Content Area: Child Health, Genitourinary; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

CORRECT ANSWER: C
 
A 34-year-old client, who is gravida 6, para 4, delivered a healthy infant at full term about 18 hours ago. She reports a sharp pain in her left calf while walking to the bathroom. A nurse assesses the client’s left calf, which has a confined area of redness, warmth, and tenderness. Which nursing actions are appropriate for this client’s nursing care? Select all that apply.


 
Answer A is incorrect because it is contraindicated to massage the site of the deep vein thrombosis (DVT). Massaging the calf can dislodge the clot and lead to an embolism.
Answer B is correct because the client should be encouraged to ambulate in addition to receiving anticoagulant therapy, since bedrest itself may  enhance venous stasis.
Answer C is correct because the most important goal is to prevent a pulmonary embolism or its recurrence. Incidence of pulmonary embolism depends on whether or not DVT is adequately treated with anticoagulant therapy.
Answer D is correct because elevation of the affected extremity is important initially because it promotes venous return and decreases edema.
Answer E is incorrect because sitting with legs dependent is contraindicated because it increases stasis and edema.

Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments 

CORRECT ANSWERS: B, C, D

 
The nurse is conducting a seminar on sudden infant death syndrome (SIDS) with a group of first-time parents of newborns. The nurse’s teaching should emphasize:


 
Answer A is correct because the use of soft bedding for a newborn should be avoided. It is believed that newborns sleeping on soft bedding may not be able to move their heads to the side, increasing the risk of suffocation, which may be a cause of SIDS.
Answer B is incorrect because the use of a pillow for a newborn should be avoided. It is believed that infants sleeping with a pillow may not be able to move their heads to the side, increasing the risk of suffocation, which may be a cause of SIDS.
Answer C is incorrect because the use of a soft sleep surface for a newborn should be avoided. It is believed that infants sleeping on a soft sleep surface may not be able to move their heads to the side, increasing the risk of suffocation, which may be a cause of SIDS.
Answer D is incorrect because co-sleeping with parents should be avoided. Studies reveal that bed-sharing has a positive association with SIDS. The leading theory suggests that suffocation is the cause. Parents who wish to share a bed with the newborn are advised to follow the same safeguards in the bed as in the crib (e.g., avoiding soft bedding, pillows, soft sleeping surfaces, and overheating [thermal stress]).

TEST-TAKING TIP: Think “suffocation” when answering this question and eliminate answers that might increase the possibility of this happening. The question asks for what will prevent the possibility of suffocation. 

Content Area: Child Health, Respiratory; Integrated Process: Teaching and Learning; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Health Promotion Programs

CORRECT ANSWER: A
 
The laboratory values for an adult client who is NPO are: Na+ 128, K+ 3.5, and glucose 130. Which IV solution should a nurse expect will be ordered?


 
Answer A is incorrect because when the sugar of D10W is metabolized, free water remains. At a rate of 150 mL/hr, this would further decrease the serum sodium.
Answer B is incorrect because, although the fluid rate and potassium in this order are reasonable, the 1/4 normal saline (NS) contains relatively more free water than normal saline does, which would decrease the serum sodium further. Clients who are NPO generally need an energy source order as dextrose.
Answer C is incorrect because the rate is a little slow for normal fluid balance, but could be acceptable if the client was n fluid overload. A client needs potassium, which is not present in this IV. 1/4 NS would dilute the serum sodium further.
Answer D is correct because the client needs potassium, which cannot be replaced with enteral feedings. Fluids are needed when NPO, but the low serum sodium should not be further diluted with rapid administration of hypotonic solutions; thus, normal saline is appropriate. Even though the blood sugar is slightly elevated, it is appropriate to give clients who are NPO some energy source. Dextrose 5% contains only 17 calories/100 mL.

■ TEST-TAKING TIP: The variables to look at for inclusion are: dextrose, NS, KCl, and at a moderate rate. Consider the effect the solution will have on the laboratory values.  

Content Area: Adult Health, Fluid and Electrolyte Imbalances; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/ Pharmacological and Parenteral Therapies/Parenteral/ Intravenous Therapies

CORRECT ANSWER: D
 
A nurse is caring for a teenager immediately following surgical correction of severe scoliosis. Which interventions should the nurse expect to be part of the care plan? Select all that apply.


 
Answer A is correct because the nurse can expect that the child will experience pain related to surgery, and pain medication needs to be provided on a schedule to prevent and treat pain.
Answer B is correct because circulation, sensation, and movement (CSM) must be assessed often to detect potential neurological complications of spinal surgery.
Answer C is correct because the child will have a urinary catheter in place and monitoring of the output is essential to protect against the complication of urinary retention.
Answer D is incorrect because initial care of this child involves careful logroll turning, not placing the child in a chair as this could injure the surgical area.
Answer E is incorrect because bowel sounds should be assessed frequently to monitor for possible paralytic ileus after surgery. Monitoring bowel sounds once daily is not sufficient.

■ TEST-TAKING TIP: The key phrase in the stem of the question is “immediately following” surgery. Select priorities that are part of the immediate postsurgical period.

Content Area: Child Health, Musculoskeletal; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations

CORRECT ANSWERS: A, B, C
 
A client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion has a Na+ of 128 mEq/L and is confused. A nurse’s primary goal should be to:


 
Answer A is incorrect because the client needs sodium replacement and fluid restriction.
Answer B is incorrect because the client already has developed complications.
Answer C is incorrect because the confusion is due to cerebral edema from the hyponatremia, which needs to be corrected. Physiological intervention is needed now, not psychosocial (orientation).
Answer D is correct because SIADH causes water retention and dilutional hyponatremia.

■ TEST-TAKING TIP: Only one answer corrects both the fluid and electrolyte problem.

Content Area: Adult Health, Fluid and Electrolyte Imbalances; Integrated Process:Nursing Process, Planning; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/ Physiological Adaptation/Fluid and Electrolyte Imbalances

CORRECT ANSWER: D
 
A group of clients who are pregnant are attending a childbirth preparation class. A nurse is discussing the effects of cigarette smoke on fetal development. Which characteristic should the nurse describe as being associ- ated with babies born to mothers who smoked during pregnancy?


 
Answer A is correct because smoking has a direct association with low birth weight, doubling the risk of an infant who may have a low birth weight.
Answer B is incorrect because smoking results in low birth weight, not large-for-gestational-age infants.
Answer C is incorrect because, although smoking does have an association with preterm birth, the infant would be low birth weight, not an appropriate size for gestation.
Answer D is incorrect because smoking results in low birth weight, not macrosomia.

■ TEST-TAKING TIP: Eliminate macrosomia and large for gestational age because they are essentially the same condition. Smoking causes low-birth-weight, not large infants.

Content Area: Maternity, Antepartum; Integrated Process: Teaching and Learning;Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/ Intra/Postpartum and Newborn Care

CORRECT ANSWER: A
 
The school nurse inspects the toddlers attending the school’s day-care center. Which observation by the nurse is cause for follow-up for pinworms?


 
Answer A is incorrect because the wearing of shoes and socks is encouraged to prevent toddlers from acquiring the infestation from contaminated soil. This observation would not be cause for follow-up by the school nurse.
Answer B is incorrect because the wearing of one-piece outfits prevents the toddlers from touching or scratching their perianal areas and continually reinfecting themselves. This observation would not be cause for follow-up by the school nurse.
Answer C
 is incorrect because short fingernails prevent the eggs from being deposited on the hands and under the fingernails of the toddlers, with continual reinfection through scratching their perianal areas. This observation would not be cause for follow-up by the school nurse.
Answer D is correct because the use of superabsorbent disposable diapers, which prevent leakage, are preferred over cloth diapers. Cloth diapers leak, which could result in feces that may be infested with pinworms (enterobiasis) to be spread from toddler to toddler. Cloth diapers would also be taken home to be laundered, which is another way to spread the infestation. The superabsorbent disposable diapers should be disposed of in a closed receptacle as soon as they are soiled.


■ TEST-TAKING TIP: Ask yourself: What is the relationship between diapers and infestations?
Picture this: Diapers cover → Perianal Area ← Infestations occur in Remember that diapers come in direct contact with the toddler’s perianal area, which is where the infestation is located. Superabsorbent disposable diapers would be preferred over cloth diapers because they may prevent leakage of contaminated feces.

Content Area: Child Health, Gastrointestinal; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Health Screening

CORRECT ANSWER: D
 
A client, who is gravida 4, para 2, is admitted to a labor and delivery unit. A nurse performs a vaginal examination and determines that the client’s cervix is 6 cm dilated, 75% effaced, and a +1 station. Based on the nurse’s assessment, in which stage of labor is this client?


 
Answer A is incorrect because there is no first phase of labor, only the first stage of labor.
Answer B is correct because there are four stages of labor and the first stage covers all phases of cervical dilation. This client is in the first stage, active phase, which is 4 to 8 cm dilation. 
Answer C is incorrect because first stage, transition phase would mean the client was 8 to 10 cm dilated. This client is 6 cm dilated, in the active phase of labor.
Answer D is incorrect because there is no first phase of labor, only the first stage of labor.

■ TEST-TAKING TIP: Eliminate Answers A and D because there are four stages of labor and three phases in the first stage of labor. Eliminate Answer C because the woman is not yet in transition phase with 6 cm dilation.

Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

CORRECT ANSWER: B
 
A client is admitted with a history of an abdominal aortic aneurysm. A nurse should know that the client has an impending rupture of the aneurysm if the client reports:


 
Answer A is incorrect because abdominal pain from an impending rupture is localized in the middle or lower abdomen to the left of the midline.
Answer B is correct because the aneurysm is pressing on the lumbar nerves. Severe back or middle or lower abdominal pain are signs of impending rupture. If the aneurysm ruptures, the back pain will be constant.
Answer C is incorrect because circulation would not be impaired before rupture.
Answer D is incorrect because the pain is lower abdomen or back. Epigastric pain is more consistent with cardiac or gastric problems.

■ TEST-TAKING TIP: Visualize the location of the abdominal aorta.

Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/ Physiological Adaptation/Medical Emergencies

CORRECT ANSWER: B
 
A clinic nurse is preparing to administer several scheduled immunizations to a 6-month-old infant. What are the appropriate actions for the nurse to take when preparing and administering immunizations? Select all that apply.


 
Answer A is incorrect because the nurse should not combine immunizations together in a syringe.
Answer B is correct because the appropriate injection site for an infant is the thigh muscle.
Answer C is incorrect because the dorsogluteal muscle is contraindicated for use in infants due to the risk of injury to the sciatic nerve.
Answer D is incorrect because parents should be given the option to stay with the child during painful procedures.
Answer E is correct since a 1-inch needle is appropriate for infants 4 months of age and older. This length allows the tip of the needle to penetrate deep into the muscle and avoids accidental administration into the subcutaneous tissue. A longer needle (e.g., 11/2 inch) would be better for adults or older children who are significantly overweight.
Answer F is correct since the nurse should first wash hands prior to any procedure.

■ TEST-TAKING TIP: Recall that immunizations are intramuscular injections. The best site for injections in an infant is a well-developed muscle, such as the thigh.

Content Area: Child Health, Immunizations; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Immunizations

CORRECT ANSWERS: B, E, F
 
A nursing student is assigned to care for a client who is 2 days post–total left hip replacement. Which observation should be reported immediately to a staff nurse?


 
Answer A is incorrect because this is not unexpected following surgery. If the client were unresponsive to pain medication, there might be a greater concern.
Answer B is correct because an infection following hip replacement is a serious complication that may require removal of the implant. Total joint infections may be disastrous, with prevention of an infection a priority. Usually prophylactic antibiotics are ordered; therefore, the appearance of a wound infection would be a grave concern.
Answer C is incorrect because a deep vein thrombosis (DVT) would not be expected until 5 to 7 days after surgery. DVTs do occur in 45% to 70% of clients after hip surgery. Further assessment would be needed, such as the presence of a positive Homans’ sign and calf swelling.
Answer D is incorrect because the ability to tolerate weight-bearing varies with the client’s condition, the procedure done, and the type of fixation device used. There is insufficient information to know if this is a problem.

■ TEST-TAKING TIP: When all options are important nursing concerns, look for the one where an immediate response could prevent a serious consequence.

Content Area: Adult Health, Musculoskeletal; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity /Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations

CORRECT ANSWER: B
 
A client, who is gravida 2, para 1, ruptures her mem- branes spontaneously with a large amount of clear fluid. A nurse performs a vaginal examination and discovers a loop of umbilical cord in the vagina. Which immediate action should be taken by the nurse?


 
Answer A is incorrect because placing the client on her left side does not relieve the umbilical cord compression that results in fetal bradycardia.
Answer B is incorrect because it is contraindicated for the nurse to attempt to replace the cord.
Answer C is correct because elevating the client’s hips is the immediate intervention that helps to release the pressure from the umbilical cord until an emergency cesarean section can be performed.
Answer D
 is incorrect because covering the cord with a dry, sterile gauze does not relieve the umbilical cord compression and the fetal bradycardia that results.

■ TEST-TAKING TIP: The most important intervention is to relieve the umbilical cord compression. Covering the cord with a dry, sterile gauze causes a delay in relieving the compression. Eliminate the two options (Answers 2 and 4) that specifically focus on the visible cord. Focus on positioning the mother—one position releases cord compression and the other position (Answer 1) does not relieve the compression.

Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies

CORRECT ANSWER: C
 
When assessing a child for symptoms of neurogenic diabetes insipidus, what should a nurse anticipate?


 
Answer A is incorrect because the child should have a normal blood sugar; the child with diabetes mellitus will have elevated blood glucose.
Answer B is incorrect because the condition is caused by decreased secretion of anti- diuretic hormone (ADH).
Answer C is correct because the child with neurogenic diabetes insipidus (DI) will experience severe diuresis resulting from a decrease in ADH secretion.
Answer D is incorrect because the child is likely to have increased serum sodium due to massive amounts of fluid loss through the urine.

■ TEST-TAKING TIP: Recall that neurogenic diabetes insipidus and diabetes mellitus share the common symptom of polyuria.

Content Area: Child Health, Endocrine; Integrated Process: Nursing Process, Planning; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/ Physiological Adaptation/Fluid and Electrolyte Imbalances

CORRECT ANSWER: C
 
A client, who is gravida 1, para 0, delivered an infant at 39 weeks’ gestation this morning. The client tells a nurse that she plans to breastfeed her baby and has taken a class about breastfeeding. The nurse is aware that successful breastfeeding is most dependent on:


 
Answer A is incorrect because successful breastfeeding is not necessarily dependent on the mother’s educational level.
Answer B is incorrect because successful breastfeeding is not dependent on the size of the mother’s breasts.
Answer C is correct because successful breastfeeding is most dependent on the mother’s desire and commitment to breastfeed.
Answer D is incorrect because successful breastfeeding is not dependent on the infant’s birth weight


■ TEST-TAKING TIP: This question is asking about factors that are important for breastfeeding success. The size of the breasts, infant’s birth weight, and mother’s educational level are not factors in breastfeeding. Select the psychosocial factor (“desire”) over physical factors (breast size, weight).

Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Comprehension; Client Need/Subneed: Health Promotion and Maintenance/ Ante/Intra/Postpartum and Newborn Care

CORRECT ANSWER: C
 
Which observation in the newborn of a mother with diabetes would require an immediate nursing intervention?


 
Answer A is incorrect because crying is not a specific finding for immediate nursing intervention.
Answer B is incorrect because wakefulness is not associated with hypoglycemia, which is the main complication in a newborn of a mother with diabetes.
Answer C is correct because jitteriness can be indicative of hypoglycemia and the nurse needs to obtain a heel stick blood glucose.
Answer D is incorrect because yawning is a normal response in a newborn and is not associated with hypoglycemia.

■ TEST-TAKING TIP: Restate the question. This question is asking for the symptoms of hypoglycemia. Examine the answers for the observation that is consistent with hypoglycemia.

Content Area: Child Health, Newborn; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

CORRECT ANSWER: C
 
In teaching a client with vision loss from glaucoma about proper lighting, a nurse knows that:


 
Answer A is incorrect because overhead or ceiling lights cause glare or shadows.
Answer B is correct because glaucoma causes tunnel vision (loss of peripheral vision) and low vision. The client needs increased light, and sees best in natural lighting (sunlight). Fluorescent lighting does not produce glare and reduces shadows. A task light that can be directed is helpful.
Answer C is incorrect because bright lights will cause glare and impair vision.
Answer D is incorrect because the client needs increased lighting and preferably natural light, not dim lighting.

■ TEST-TAKING TIP: Remember that the client has lost peripheral vision, so that lighting needs to enhance central vision without glare or shadows.

Content Area: Adult Health, Sensory; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity /Physiological Adaptation/Illness Management

CORRECT ANSWER: B
 
A nursing student is performing an initial newborn assessment. The newborn is observed to have a caput succedaneum. What are likely causes of this condition? Select all that apply.


 
Answer A is incorrect because a scheduled cesarean section does not increase the pressure on the fetal head or lead to development of caput succedaneum.
Answer B is correct because caput succedaneum is a diffuse swelling of the scalp in a newborn caused by pressure from the uterus or vaginal wall during a head- first (vertex) delivery. Prolonged active phase increases the pressure on the fetal head.
Answer C is incorrect because a breech delivery does not increase the pressure on the fetal head or lead to development of caput succedaneum.
Answer D is correct because vacuum-assisted vaginal delivery increases the pressure on the fetal head and can result in caput succedaneum.
Answer E is correct because caput succedaneum is a diffuse swelling of the scalp in a newborn caused by pressure from the uterus or vaginal wall during a head-first (vertex) delivery. Prolonged second stage increases the pressure on the fetal head.

■ TEST-TAKING TIP: Think about the forces that increase pressure on the fetal head and can cause caput succedaneum.

Content Area: Child Health, Newborn; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/ Intra/Postpartum and Newborn Care

CORRECT ANSWERS: B, D, E
 
A 65-year-old man with a 45-year history of smoking reports a change in his cough pattern, a nonproductive cough, and generally not feeling well. The chest x-ray reveals an infiltrate. A nurse should suspect:


 
Answer A is correct because the symptoms are characteristic of pneumonia.
Answer B is incorrect because the client reports a “change.” COPD is a chronic condition with sputum production.
Answer C is incorrect because the development of pulmonary edema includes frothy sputum. The client indicates a nonproductive cough.
Answer D is incorrect because tuberculosis includes a productive cough, fever, sweats, and weight loss.

■ TEST-TAKING TIP: Only pneumonia has a non-productive cough—the others all produce sputum.

Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity /Physiological Adaptation/Pathophysiology

CORRECT ANSWER: A
 
A nurse is monitoring the progress of a gravida 3, para 1 client in active labor. Which finding should be reported to a physician immediately?


 
Answer A is incorrect because moderate uterine contractions are a normal finding in active labor.
Answer B is incorrect because frequent urination is a normal finding in active labor as a result of descent of the fetal head and decreased bladder capacity.
Answer C is correct because the presence of green-tinged amniotic fluid is not a normal finding and needs to be reported to the physician immediately. Meconium staining can be indicative of fetal distress.
Answer D is incorrect because presence of scant bloody discharge is a normal finding in active labor, called bloody show. It is an indicator of cervical progress.

 ■ TEST-TAKING TIP: The question is asking about what is not a normal part of active labor. Eliminate the options that are a part of normal labor: moderate contractions, frequent urination, and the presence of scant bloody discharge.

Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations

CORRECT ANSWER: C
 
The blood pressure of a 28-year-old client who is over- weight and does not have diabetes is 136/78 mm Hg. Client education should include:


 
Answer A is correct because this client has prehypertension without compelling indications for drug treatment. Lifestyle changes are indicated. The client is not recognizing the risk. In one sentence, the risk to the client and how to control the risk were addressed.
Answer B
 is incorrect because this is prehypertension and should be managed with lifestyle changes to include at least weight loss.
Answer C is incorrect because this is prehypertension without compelling indications for drug treatment.
Answer D is incorrect because this is prehypertension, not a normal blood pressure.

■ TEST-TAKING TIP: For prehypertension, look for a nondrug option first. Eliminate Answers B and C with “medications” in the options.

Content Area: Adult Health, Cardiovascular; Integrated Process: Teaching and Learning; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Lifestyle Choices

CORRECT ANSWER: A
 
A group of clients is attending a childbirth preparation class. A client asks a nurse how to measure the duration of the uterine contractions. Which is the best description by the nurse about the measurement of the duration of contractions?


 
Answer A is incorrect because timing from the beginning of one contraction to the beginning of the next contraction is the correct method for measuring the frequency and not the duration of a contraction.
Answer B is incorrect because timing from the end of one contraction to the beginning of the next contraction is not the measurement for the duration of the contraction; it is the resting period between contractions.
Answer C is correct because duration is measured by timing from the beginning of one contraction to the end of the same contraction.
Answer D
 is incorrect because timing from the peak of one contraction to the end of the same contraction is not the measure of duration or frequency of a contraction.

■ TEST-TAKING TIP: There are similar options for answers in this question. Visualize each of the options and try drawing it out if needed. Focus on “beginning . . . end . . .” as the best answer not “beginning . . . beginning . . .” and not
“end . . . beginning . . .”

Content Area: Maternity, Antepartum; Integrated Process: Teaching and Learning; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/ Postpartum and Newborn Care

CORRECT ANSWER: C
 
A client with a history of Graves’ disease is admitted for uncontrolled hyperglycemia and a foot ulcer. This client requires close monitoring because of the increased risk of: Select all that apply.


 
Answer A is correct because the client is at risk for thyroid storm because of a second illness, which can lead to hypotension and if untreated, heart failure.
Answer B is correct because an elevated temperature is a sign of thyroid storm, which is a life-threatening form of hyperthyroidism. When a client with hyperthyroidism suffers a second illness, thyroid storm is a risk.
Answer C is incorrect because Graves’ disease is a hyperthyroid state.
Answer D is incorrect because the added illnesses of hyperglycemia and a foot ulcer may potentiate a thyroid storm. Hypoglycemia may be a concern later with treatment.
Answer E is correct because thyroid storm is an acute episode of thyroid overactivity. The metabolism is markedly increased, and extreme tachycardia occurs.

■ TEST-TAKING TIP: Focus on the options that would result from a metabolic “storm”—a thyroid storm. Recall that thyroid storm is rare but a life-threatening medical emergency.

Content Area: Adult Health, Endocrine; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies

CORRECT ANSWERS: A, B, E
 
Which order written by a pediatrician for a 2-month-old infant during a well-infant visit should a nurse question?


 
Answer A is incorrect because the DTaP (diphtheria, tetanus, and acellular pertussis) vaccine is given at 2 months of age.
Answer B is incorrect because the Hib (Haemophilus influenzae type b) vaccine is given at 2 months of age.
Answer C is incorrect because IPV (inactivated poliovirus) vaccine is given at 2 months of age.
Answer D is correct because MMR (measles, mumps, and rubella) vaccine is not administered until the infant is 12 to 15 months of age. The second dose of this vaccine is given at 4 to 6 years of age.

■ TEST-TAKING TIP: Select as the “correct” answer the order that is not correct.

Content Area: Child Health, Immunizations; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Safety and Infection Control/Error Prevention

CORRECT ANSWER: D
 
Treatment for hypertension is important in the prevention of heart failure. A nurse tells a client that the greatest decrease in blood pressure is most likely to occur with:


 
Answer A is incorrect because increasing activity may drop the systolic BP up to 9 mm Hg.
Answer B is incorrect because limiting sodium only lowers the systolic BP by 8 mm Hg.
Answer C is incorrect because limit- ing alcohol will likely only lower the systolic BP by 2 to 4 mm Hg.
Answer D is correct because a weight loss of 10 kg can reduce the systolic BP up to 20 mm Hg.

weight ↓ Alcohol intake → ↓ weight

■ TEST-TAKING TIP: All options are correct, but weight loss produces the greatest drop. Diagrammatically visualize these measures: ↑ Physical activity → ↓ weight ↓ Na+ → ↓ 

Content Area: Adult Health, Cardiovascular; Integrated Process: Teaching and Learning; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Health and Wellness

CORRECT ANSWER: D
 
A client, who is gravida 3, para 1, is diagnosed with diabetes at 28 weeks’ gestation. A nurse is providing instruction about the role of insulin in managing the client’s diabetes. Which statement by the nurse is true regarding insulin needs during pregnancy?


 
Answer A is incorrect because insulin requirements increase as the pregnancy progresses. Increasing amounts of human placental lactogen cause the client to be more insulin resistant, increasing the need for insulin.
Answer B is incorrect because insulin needs decrease during the first trimester, but steadily increase as the pregnancy progresses.
Answer C is correct because insulin requirements will increase as the pregnancy progresses. The placenta creates increasing amounts of human placental lactogen, causing the client to be more insulin resistant, increasing the need for insulin.
Answer D is incorrect because elevations in human placental lactogen increase, not decrease, the need for insulin.

■ TEST-TAKING TIP: Remember that insulin needs decrease during the first trimester, steadily increase during the second and third trimesters, then decrease after delivery.

Content Area: Maternity, Antepartum; Integrated Process: Teaching and Learning; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/ Physiological Adaptation/Alterations in Body Systems

CORRECT ANSWER: C
 
A nursing student selects a 1/2-inch needle with which to administer a DTaP (diphtheria, tetanus, and acellular pertussis) vaccine to a 4-month-old infant. A nursing instructor’s best action would be to:


 
Answer A is incorrect because allowing the nursing student to continue would lead to an error that could jeopardize the infant.
Answer B is incorrect because just stopping the nursing student is not enough as it will not lead to critical thinking regarding the correct action that needs to be taken.
Answer C is correct because it will stimulate the nursing student to think in a critical manner. DTaP (diphtheria, tetanus, and acellular pertussis) vaccine is given intramuscularly and a 1-inch/2.5-cm needle must be used to deposit the vaccine deep in the muscle mass.
Answer D is incorrect because a longer, rather than a shorter needle, is needed for the correct administration of the vaccine (i.e., deep in the muscle mass).

■ TEST-TAKING TIP: Choose the “assessment” option (i.e., question the nursing student).

Content Area: Child Health, Immunizations; Integrated Process: Teaching and Learning; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/ Principles of Teaching and Learning

CORRECT ANSWER:C
 
A client, who is gravida 1, para 0 at 38 weeks’ gestation, is found to have a blood pressure of 170/90 mm Hg. Which action should a nurse take first?


 
Answer A is correct because a high blood pressure (170/90 mm Hg) may be indicative of preeclampsia, or may be due to gestational hypertension, pain, or severe anxiety. The nurse needs to determine if the client has proteinuria. If there is proteinuria, the high blood pressure is suggestive of preeclampsia.
Answer B is incorrect because administering an analgesic will not help to determine the cause of the high blood pressure in this client, and may delay the treatment if the client has preeclampsia.
Answer C is incorrect because assessing fetal heart tones is a general assessment for all clients in the prenatal clinic; it is not a specific evaluation for the client’s high blood pressure.
Answer D is incorrect because obtaining a diet history is not the first action to take for this client. A diet history is appropriate for a client with hyperemesis, not possible preeclampsia.

■ TEST-TAKING TIP: Choose the option that will not delay the evaluation of whether or not this client has preeclampsia. The question only states the client has a single high blood pressure, which does not mean that the client has preeclampsia.

Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

CORRECT ANSWER: A
 
A 12-year-old child is seen in a pediatrician’s office for a well-adolescent checkup. The adolescent’s most important vaccine status for a nurse to assess would be:


 
Answer A is incorrect because the adolescent would have received the hepatitis B vaccine series in infancy (birth, 1 to 2 months of age, and 6 to 18 months of age).
Answer B is incorrect because the adolescent would have received the hepatitis A vaccine series in infancy (2 doses between 12 and 23 months of age).
Answer C is incorrect because the adolescent would have received the MMR (measles, mumps, and rubella) vaccine series in infancy/ childhood (12 to 15 months of age and 4 to 6 years of age).
Answer D is correct because the HPV (human papillomavirus) vaccine is given between 11 and 12 years of age. This would be the most likely vaccine that the adolescent has yet to receive.

■ TEST-TAKING TIP: Focus on the age-relevant vaccine for a 12-year-old. Vaccines are not limited to infancy/childhood. Knowing the vaccine schedule for 7- to 18-year-olds is critical for correctly answering this question.

Content Area: Child Health, Immunizations; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/  Immunizations

CORRECT ANSWER: D
 
A client, who fell 10 feet onto a concrete floor, presents to an emergency department. The client does not speak English. The correct action by a nurse to determine the severity of the client’s pain would be to:


 
Answer A is incorrect because this may delay treatment, and the interpreter may not convey the client’s pain as accurately as the client with a nonverbal pain scale.
Answer B is incorrect because ethnic/cultural groups may “mask” the response to pain (e.g., by denial, rationalization as coping mechanisms).
Answer C is incorrect because, depending on the culture, responding to pain may not be acceptable.
Answer D is correct because pain scales, like the Oucher Scale, are accurate with many ethnic groups and languages.

■ TEST-TAKING TIP: Look for an assessment that is the client’s own description, even though it is through a projective device.

Content Area: Adult Health, Pain Control; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Psychosocial Integrity/Cultural Diversity

CORRECT ANSWER: D
 
The parents of a 6-month-old infant express their concerns regarding the number of vaccines their infant has already received. A nurse’s best action would be to:


 
Answer A is correct because information is always the best way to reduce parents’ anxieties and concerns over vaccines. The information should include the need for each vaccine and what disease each vaccine prevents. Lack of information could needlessly prevent an infant from getting protection against life-threatening diseases.
Answer B is incorrect because, while reassurance of the parents is important, it does not replace the need for information.
Answer C is incorrect because, while respect for the parents’ decisions is important, it does not replace the need for information.
Answer D is incorrect because, while involving the parents in minimizing potential adverse effects of the vaccine (e.g., administering an age-appropriate dose of acetaminophen prior to the vaccine, etc.) is important, it does not replace the need for information.

■ TEST-TAKING TIP: Think “knowledge” as the parents’ first need when concerns about their infant arise.

Content Area: Child Health, Immunizations; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Immunizations

CORRECT ANSWER: A
 
An undesired consequence of acute pain is the progression to a chronic pain syndrome. The correct approach by a nurse to prevent chronic pain syndrome would be to:


 
Answer A is correct because the most common cause of chronic pain syndrome is failure to control acute pain. Chronic pain syndrome consists of chronic anxiety and depression, anger, and changed lifestyle, all with a variable but significant level of genuine neurologically based pain.
Answer B is incorrect because opiates are effective in the treatment of acute pain.
Answer C is incorrect because pain medication should be offered as ordered. Some clients will not ask.
Answer D is incorrect because physical dependence is determined when the drug is discontinued. It is expected in all clients who take opioids continuously. It is not addiction.

■ TEST-TAKING TIP: Look for the answer that relieves acute pain.

Content Area: Adult Health, Pain Control; Integrated Process: Nursing Process, Implementation; Cognitive Level: Comprehension; Client Need/Subneed: Physiological Integrity/ Pharmacological and Parenteral Therapies/Pharmacological Pain Management

CORRECT ANSWER: A 
 
A 42-year-old, who is gravida 1, para 0, has a successful in-vitro fertilization and is 7 weeks pregnant. Based
on the client’s history, a nurse knows the infant is at risk for:


 
Answer A is incorrect because respiratory distress syndrome is associated with preterm birth, not related to the age of the client at conception.
Answer B
 is incorrect because there are no specific risk factors based on the information given that would put her infant at a higher risk for pathological jaundice. Pathological jaundice usually occurs with an ABO incompatibility.
Answer C is incorrect because the mutation that causes the missing or altered X chromosome takes place spontaneously. There’s no evidence that Turner’s syndrome is hereditary or is caused by any other environmental or health factors.
Answer D is correct because the client’s age (42) puts her at a higher risk for an infant with Down syndrome.

■ TEST-TAKING TIP: The in-vitro fertilization has nothing to do with risk factors that affect an infant. The risk factor is the client’s age of 42. Do not let the extraneous information distract from the true risk factor.

Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/ Ante/Intra/Postpartum and Newborn Care

CORRECT ANSWER: D 
 
A client delivers a 4-pound, 8-ounce neonate at 35 weeks’ gestation. A meconium drug screen shows the presence of heroin. The neonate is admitted to the nursery with narcotic abstinence syndrome. Nursing care of the neonate should include:


 
Answer A is incorrect because tactile stimulation can increase the hyper-irritability associated with narcotic abstinence syndrome.
Answer B is correct because wrapping the newborn snugly in a blanket decreases the hyper-irritability and increases feeling of security.
Answer C is incorrect because putting the neonate in the car seat can increase physical and sensory stimulation to the infant. The goal is to decrease these effects.
Answer D is incorrect because an early stimulation program increases physical and sensory stimulation to the infant. The goal is to decrease these effects.

■ TEST-TAKING TIP: A neonate with narcotic abstinence syndrome needs decreased tactile stimulation. Eliminate the three options that increase stimulation.

Content Area: Child Health, Newborn; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Psychosocial Integrity/Chemical and other Dependencies

CORRECT ANSWER: B 
 
A client, who is 32 years old, gravida 4, para 1 at 31 weeks’ gestation, has been recently diagnosed with gestational diabetes. She has attended a class about managing diabetes during pregnancy. Which statements should indicate to a nurse that the client understands what was taught about gestational diabetes? Select all that apply.


 
Answer A is incorrect because the client will be allowed some complex carbohydrates, but simple carbohydrates (such as sugar, juice, and cold cereal) are not allowed in a gestational diabetic diet.
Answer B is correct because keeping the blood sugar well controlled has a direct relationship to decreasing the risk for macrosomia and hypoglycemia in the neonate.
Answer C is incorrect because many clients with gestational diabetes are diet controlled or controlled with glyburide, and gestational diabetes is resolved after the pregnancy is over. All clients with gestational diabetes have a follow-up glucose tolerance test scheduled about 6 weeks after delivery.
Answer D is correct because the diet for gestational diabetes is based on the grams of carbohydrate allowed at each meal and snack.
Answer E is correct because clients with gestational diabetes are required to test their fasting blood sugar and 1 to 2 hours postprandial.

■ TEST-TAKING TIP: Look for phrases like “can’t eat any” (meaning none) and “for the rest of my life”; those are both very definitive phrases. Be sure they are totally true before choosing these responses.

Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/ Intra/Postpartum and Newborn Care

CORRECT ANSWERS: B, D, E
 
A client with a known history of IV drug use is found to have acute appendicitis with perforation. Following surgery, the client reports severe pain at the surgical incision. There are no signs of abscess formation or other postoperative complications. The correct approach to manage the client’s pain would be to:


 
Answer A is correct because the client must be treated for pain as expressed. The IV drug use may require that a higher dose be given, but the presence of pain as expressed by the client should not be ignored.
Answer B is incorrect because IV drug use may only alter the drug effectiveness, not the feeling of pain.
Answer C is incorrect because these drugs are not effective for moderate to severe pain.
Answer D is incorrect because nondrug therapies alone are not adequate for pain management.

■ TEST-TAKING TIP: Remember: pain is what the client says it is—severe. Three of the options involve other measures, but not what was ordered. Select this option that is different.

Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/ Subneed: Physiological Integrity/ Pharmacological and Parenteral Therapies/ Pharmacological Pain Management

CORRECT ANSWER: A 
 
The mother of a school-age child who is isolated at home with chickenpox (varicella) informs a school nurse that, “My child is miserable from the itching. What can I do?” The school nurse’s best response would be to suggest:


 
Answer A is correct because diphenhydramine hydrochloride (Benadryl) is a nonprescription antihistamine that will safely and effectively reduce the child’s itching for up to 4 to 6 hours following a dose of the medication.
Answer B is incorrect because, while keeping the child cool will assist in reducing the child’s itching, it is not as effective as diphenhydramine hydrochloride (Benadryl).
Answer C is incorrect because, while changing the linens daily will assist in reducing the child’s itching, it is not as effective as diphenhydramine hydrochloride (Benadryl).
Answer D is incorrect because, while keeping the child’s fingernails short and clean will assist in reducing the child’s itching, it is not as effective as diphenhydramine hydrochloride (Benadryl).

■ TEST-TAKING TIP: Choose the direct, most immediate suggestion (Benadryl) rather than the indirect, supportive suggestions (focusing on linens and fingernails). Note that the mother’s concern is reducing itching.

Content Area: Child Health, Integumentary; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Illness Management

CORRECT ANSWER: A
 
An 84-year-old with diabetes and left leg cellulitis is brought to an emergency department. Vital signs are: BP 132/90 mm Hg, T 99.4°F, P 95, and R 20. Blood glucose is 98. Left leg is red and swollen. The client is admitted to a nursing unit. Which order should be a priority for the nurse?


 
Answer A is incorrect because blood cultures are done before treatment.
Answer B is incorrect because there is no indication of cardiac involvement.
Answer C is incorrect because blood glucose is not elevated at this time (although diabetes is a risk factor for cellulitis).
Answer D is correct because a low-grade temperature and elevated pulse in an older adult are consistent with infection. The specific bacteria causing the infection of the skin and subcutaneous tissue should be identified to prevent sepsis.

■ TEST-TAKING TIP: This is a priority question—more data are needed to identify the cause of the infection (“itis”).

Content Area: Adult Health, Integumentary; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

CORRECT ANSWER: D 
 
A client, who is gravida 4, para 0 at 39 weeks’ gestation, states, “I would like to breastfeed, but my mother-in-law told me my breasts are too small and I won’t have enough milk for my baby.” Which would be the best response by the nurse?


 
Answer A is incorrect because the volume of breast milk produced is related to how often the breasts are emptied of milk. Formula supplementation decreases breast milk production since the infant nurses less often.
Answer B is incorrect because an infant is more efficient at emptying a breast than a breast pump. In addition, oral stimulation of the nipples by the infant stimulates the release of oxytocin, which triggers the let-down reflex.
Answer C is incorrect because estrogen does not stimulate milk production. Oxytocin and prolactin are the hormones responsible for breast milk production.
Answer D is correct because the amount of milk- producing glandular tissue in all women is approximately the same. The size of large breasts is due to increased fatty tissue.

■ TEST-TAKING TIP: Milk production is directly related to the amount of time the infant is nursing. Any other option will lead to decreased milk production.

Content Area: Maternity, Antepartum; Integrated Process: Communication and Documentation; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

CORRECT ANSWER: D


 
An African American infant with an umbilical hernia is brought to a well-infant clinic for routine immunizations. During the visit, a nurse notes that the parent has taped the umbilical hernia down on the abdomen to flatten the protrusion. The nurse would be correct in telling the parent that:


 
Answer A is incorrect because taping the umbilical hernia down to the abdomen does not aid in resolution, and it can produce skin irritation and breakdown. This practice should be discouraged.
Answer B is incorrect because taping the umbilical hernia down to the abdomen does not replace a surgical repair of the umbilical hernia; it will not result in resolution of the umbilical hernia, and it can produce skin irritation and breakdown. Umbilical hernias that do not resolve spontaneously by 3 to 5 years of age should be corrected surgically on an elective basis.
Answer C is correct because taping the umbilical hernia down to the abdomen does not aid in resolution of the hernia. It can produce skin irritation and breakdown. This practice should be discouraged.
Answer D is incorrect because manual reduction of the umbilical hernia should never be attempted by the parents. This procedure should only be done by a pediatrician and/or surgeon.

■ TEST-TAKING TIP: Select the one option that implies “do not do” the taping of the hernia.

Content Area: Child Health, Gastroenterological; Integrated Process: Teaching and Learning; Cognitive Level: Application; Client Need/Subneed: Psychosocial Integrity/Cultural Diversity

CORRECT ANSWER: C
 
A client, who is gravida 3, para 2, is asking a nurse for advice concerning her nightly leg cramps. Which response by the nurse is correct?


 
Answer A is incorrect because increasing fluid intake is good general advice for pregnancy, but will not resolve the client’s concern.
Answer B is incorrect because increasing protein intake is a good suggestion for clients with gestational diabetes.
Answer C is correct because leg cramps are caused by low blood calcium levels; increasing calcium intake can decrease leg cramps.
Answer D
 is incorrect because increasing fiber intake is good general advice for pregnancy, but will not resolve the client’s concern.

■ TEST-TAKING TIP: Eliminate the answers that are good general suggestions for pregnancy, but do not address the specific concerns of the client.

Content Area: Maternity, Antepartum; Integrated Process: Teaching and Learning; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/ Ante/Intra/  Postpartum and Newborn Care

CORRECT ANSWER: C
 
A child hospitalized with measles (rubeola) cries every time a nurse enters the room and turns on the overhead light. The nurse should investigate if the child has:


 
Answer A is incorrect because a fear of bright lights is not associated with measles (rubeola) nor is it common in childhood.
Answer B is correct because an intolerance of light (photophobia) is a common side effect of measles (rubeola). Dimming lights in the child’s room is suggested if photophobia is present.
Answer C is incorrect because, while children with measles (rubeola) frequently rub their eyes, this leads to eye redness and irritation as opposed to intolerance of light (photophobia).
Answer D is incorrect because an enhanced reaction to unanticipated events (such as turning on the overhead light) is not associated with measles (rubeola), nor is it common in childhood.

■ TEST-TAKING TIP: Focus on the two answers that refer to lights (Answers A and B). Note the word “light” in the stem and in the two answers with the word “light,” as opposed to “rubbing” (Answer C) and “unanticipated events” (Answer D). Correlate side effects of the disease with the child’s behavior.

Content Area: Child Health, Infectious Disease; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations

CORRECT ANSWER: B
 
A nurse knows that a client with hypercalcemia may experience:
Select all that apply.


 
Answer A is correct because severe thirst may be secondary to the polyuria from the high solute (calcium) load.
Answer B is correct because constipation is a common side effect from decreased tone in the bowel.
Answer C is incorrect because diarrhea is not common with hypercalcemia until levels above 17 mg/dL, which is considered a crisis.
Answer D is correct because the high calcium increases gastric acid secretion and may intensify gastrointestinal manifestation. Anorexia, nausea, and vomiting are intensified by increased gastric residual volume.
Answer E is correct because high calcium levels depress brain function, leading to ↓ activity.
Answer F is incorrect because hypercalcemia depresses neuromuscular excitability, leading to muscle weakness and lethargy.

■ TEST-TAKING TIP: Look at pairs of contradictory options (Answers B and C, and Answers E and F) where both can’t be correct answers. Hypercalcemia depresses functions (e.g., bowels and activity).

Content Area: Adult Health, Fluid and Electrolyte Imbalances; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Fluid and Electrolyte Imbalances

CORRECT ANSWERS: A, B, D, E
 
A child is hospitalized with scarlet fever. Which food item should the nurse remove from the child’s breakfast tray?


 
Answer A is incorrect because chocolate milk is not an irritating fluid.
Answer B is correct because scarlet fever is associated with an inflamed oral cavity. Because of this, rough foods and irritating fluids are to be avoided. Citrus juices, such as orange juice, would further irritate the inflamed oral cavity.
Answer C is incorrect because apple juice is not an irritating fluid.
Answer D is incorrect because 2% milk is not an irritating fluid.

■ TEST-TAKING TIP: Three of the choices are bland in nature and one choice is irritating in nature. Select the choice that is different from the rest of the choices.

Content Area: Child Health, Infectious Disease; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Basic Care and Comfort/ Nutrition and Oral Hydration

CORRECT ANSWER: B 
 
Positioning to prevent skin breakdown is a nursing concern. Which site is at greatest risk for breakdown in this position?


 
Right lateral recumbent positioning provides for drainage of oral secretions, which is important with clients who are immobile following a stroke. However, a pillow must be placed between the lower limbs to avoid redness and skin breakdown.



■ TEST-TAKING TIP: Think about what happens when two surfaces rub together.

Content Area: Adult Health, Integumentary; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems

CORRECT ANSWER: A
 
A client comes to the prenatal clinic to begin care. The nurse would advise her that the routine test(s) during the initial examination is/are:
Select all that apply.


 
Answer A is correct because rubella titer is part of the initial prenatal laboratory panel.
Answer B is correct because the CBC is part of the initial prenatal laboratory panel.
Answer C is incorrect because the glucose tolerance test is not usually part of the initial prenatal panel; it is obtained during the 28th week of pregnancy.
Answer D is incorrect because the ultrasound is not part of the initial prenatal examination.
Answer E is correct because blood type and Rh are part of the initial prenatal laboratory panel.

■ TEST-TAKING TIP: Use the process of elimination to discard the nonroutine tests for an initial visit (Answers C and D).

Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Diagnostic Tests

CORRECT ANSWERS: A, B, E
 
The most appropriate nursing intervention to encourage a child to eat who had a tonsillectomy 24 hours ago is to:


 
Answer A is incorrect because milk products, such as ice cream, coat the mouth and throat, causing the child to clear the throat, which may initiate bleeding from the surgical site.
Answer B is correct because an ice collar applied to the throat 30 minutes prior to the meal will serve as a local anesthetic and reduce the child’s oral and throat pain, which will assist in eliciting the child’s cooperation with eating.
Answer C is incorrect because gargling is to be avoided in the immediate postoperative period because it can start bleeding from the surgical site.
Answer D is incorrect because it is punitive. It is not the nurse’s role to threaten or punish the child for not eating. It is the nurse’s role to find a way to make eating more comfortable for the child.

■ TEST-TAKING TIP: Think “comfort measures” to encourage the child to eat. Oral and throat pain following a tonsillectomy will prevent a child from eating. Eliminate answers that promise or threaten (Answers A and D).

Content Area: Child Health, Pediatric Surgery; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/ Basic Care and Comfort/Non-pharmacological Comfort Interventions

CORRECT ANSWER: B
 
With which conditions is a risk of postpartum hemorrhage associated?
Select all that apply.


 
Answer A is incorrect because pregnancy-induced hypertension is not related to uterine atony or other causes of postpartum hemorrhage.
Answer B
 is correct because a macrosomatic (very large) baby can predispose a woman to uterine atony, and thus to hemorrhage.
Answer C is correct because retained placental fragments are a cause of postpartum hemorrhage.
Answer D is correct because a full urinary bladder may result in uterine atony, and thus hemorrhage.
Answer E is incorrect because maternal age is not a risk factor for hemorrhage. Increased parity is related to an increased risk of hemorrhage.

■ TEST-TAKING TIP: The stem asks for conditions that are associated with a risk for hemorrhage.

Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology

CORRECT ANSWERS: B, C, D
 
A client with Sjögren’s syndrome, an autoimmune disorder in women, is scheduled for surgery. The correct nursing action would be:


 
Answer A is incorrect because pulmonary dryness is not the problem.
Answer B is correct because, with Sjögren’s syndrome, lacrimal glands are destroyed, resulting in dry eyes (keratoconjunctivitis).
Answer C is incorrect because dry mouth is a problem. Twelve hours is too long.
Answer D is incorrect because anti-depressants are not a treatment for Sjögren’s syndrome.

■ TEST-TAKING TIP: Note that three options focus on after surgery (Answers A, C, and D). Select the option that is “before surgery.” Review Sjögren’s syndrome—remember dry eyes and mouth.

Content Area: Adult Health, Immunological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/ Reduction of Risk Potential/Therapeutic Procedures

CORRECT ANSWER: B
 
A school-age child is hospitalized with mumps (parotitis). Which food item should the nurse remove from the child’s lunch tray?


 
Answer A is incorrect because eating gelatin would require no chewing on the child’s part.
Answer B is incorrect because eating applesauce would require no chewing on the child’s part.
Answer C is correct because mumps (parotitis) is associated with swelling at the jaw line, followed by an earache that is aggravated by chewing. A soft, bland diet is suggested, as well as avoiding foods that require chewing. An apple would require chewing on the child’s part.
Answer D is incorrect because eating a banana would require little, if any, chewing on the child’s part.

■ TEST-TAKING TIP: Think “soft” or “no chewing” in terms of the child’s diet. Relate clinical manifestations of the disease to the child’s dietary requirements.

Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/ Subneed: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

CORRECT ANSWER: C
 
A client with a history of GI bleeding is admitted with complaints of fatigue, weakness, and shortness of breath. Hgb is 7.4 mg/dL, T 97.8°F, BP 86/45 mm Hg, P 118, and R 22. Two units of packed RBCs are ordered. As a nurse begins the blood transfusion, the client suddenly complains of chills and chest pain. Which actions should be taken by the nurse? Select all that apply.


 
Answer A is correct because a transfusion reaction can lead to anaphylactic shock and life-threatening vasodilation and hypotension.
Answer B is incorrect because treating pain or a fever is not the priority.
Answer C is correct because the client should not receive any more blood, which is the source of the antigen that is causing the allergic response.
Answer D is correct because a patent IV may be needed for emergency treatment.
Answer E is incorrect because the blood needs to be returned to the laboratory, not disposed of.
Answer F is correct because the reason for the allergic reaction needs to be determined.

■ TEST-TAKING TIP: Note that Answers E and F are contradictory. Select Answer F—keep rather than dispose of the blood product. With each option, ask if the statement is a true or false action with a transfusion reaction.

Content Area: Adult Health, Hematological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Blood and Blood Products

CORRECT ANSWERS: A, C, D, F
 
A client, who is gravida 5, para 4, delivered a 6-pound, 5-ounce infant 2 hours ago. The client is complaining of severe uterine cramping while breastfeeding. A nurse knows that these symptoms are most likely due to:


 
Answer A is incorrect because mastitis is an infection of the breast that occurs postpartum, but is unrelated to uterine cramping.
Answer B is correct because breastfeeding causes the release of prolactin and oxytocin. Oxytocin is a hormone that causes uterine contractions. The release of oxytocin while breastfeeding speeds uterine involution. This may also cause cramps while breastfeeding in the postpartum period. Cramping is more severe in clients who are multiparous.
Answer C is incorrect because uterine atony is the failure of the uterine muscles to contract normally after the baby and placenta are delivered; there is no cramping with uterine atony.
Answer D is incorrect because postpartum endometritis is an infection of the endometrium or decidua, extending into the myometrium and parametrial tissues, which is the most common cause of postpartum fever. It does not cause cramping during breastfeeding.

■ TEST-TAKING TIP: Cramping is a sign of contracting of the uterus, not uterine atony, which is the opposite (a lack of cramping). Therefore, eliminate that option.

Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/ Ante/ Intra/Postpartum and Newborn Care

CORRECT ANSWER: B 


 
A child is isolated at home with whooping cough (pertussis). Which parental behavior indicates the need for additional teaching by the nurse?


 
Answer A is incorrect because it is a desirable behavior by the parents. Confining cigarette smoke to the outdoors can prevent paroxysms of coughing associated with whooping cough (pertussis).
Answer B is incorrect because it is a desirable behavior by the parents. Avoiding sudden changes in household temperature can prevent paroxysms of coughing associated with whooping cough (pertussis).
Answer C is incorrect because it is a desirable behavior by the parents. Keeping the child’s room well ventilated can prevent paroxysms of coughing associated with whooping cough (pertussis).
Answer D is correct because using the fireplace as an additional means of heating the house creates dust and smoke that may cause paroxysms of coughing associated with whooping cough (pertussis).

■ TEST-TAKING TIP: The question asks for the answer that is not a correct action by the parents. Think “triggers” that pro- mote coughing and select the behavior by the parents that may cause paroxysms of coughing.

Content Area: Child Health, Infectious Disease; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/ Physiological Adaptation/Alterations in Body Systems

CORRECT ANSWER: D
 
A client, who is a 22-year-old primigravida, is at 38 weeks’ gestation and 9 cm of dilation. Her contractions are 2 to 4 minutes apart and her uterus palpates soft between very firm contractions. She is very irritable and screaming in pain. A nurse should instruct this client to:


 
Answer A is incorrect because deep breathing is the correct technique for the latent phase of the first stage of labor, when the client is trying to relax and allow labor to progress. Taking deep breaths in this phase of labor can lead to hyperventilation.
Answer B is incorrect because patterned breathing is the correct technique for the active phase of the first stage of labor when the client is trying to relieve the pain of labor. Using patterned breathing in this phase of labor can lead to bearing down before complete dilation and hyperventilation.
Answer C is incorrect because this client is not completely dilated and it is inappropriate to bear down with contractions. Pushing before being completely dilated can cause cervical lacerations and edema of the cervix.
Answer D is correct because this client is in the transition phase of the first stage of labor. The proper breathing technique is shallow chest breathing, which prevents hyperventilation and bearing down before she is completely dilated.

■ TEST-TAKING TIP: Remember the stages and phases of labor and how the client would respond to latent, active, and transition phases of labor. Knowing what could be the client’s expected response will guide appropriate coaching for breathing.

Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/ Basic Care and Comfort/Non-pharmacological Comfort Interventions

CORRECT ANSWER: D 
 
A charge nurse on a pediatric unit is preparing the daily assignment sheet. Which nurse is the best choice to care for a child hospitalized with German measles (rubella)?


 
Answer A is incorrect because German measles (rubella) has a teratogenic effect on fetuses. At 25 years of age, pregnancy could be a concern for this nurse.
Answer B is incorrect because German measles (rubella) has a teratogenic effect on fetuses. At 32 years of age, pregnancy could be a concern for this nurse.
Answer C is incorrect because the nurse is a new graduate, and it may be unlikely that she had experience in caring for a child with German measles (rubella). However, at 45 years of age, pregnancy would be an unlikely concern.
Answer D is correct because German measles (rubella) has a teratogenic effect on fetuses. At 50 years of age, this likely would not be a concern. And, the nurse’s 25 years of pediatric nursing experience would be a plus in caring for the child.

■ TEST-TAKING TIP: The clue is in the age of the nurse. Correlate the most severe side effect of this disease (teratogenic) with the childbearing ages of the nurses.

Content Area: Child Health, Infectious Disease; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/ Management of Care/ Delegation

CORRECT ANSWER: D
 
A client with a brain tumor has been unresponsive to verbal commands and is showing signs of abnormal motor responses. Which motor change should indicate to the nurse that a critical change in the client’s condition has occurred?


 
Answer A is incorrect because decorticate posturing may result from painful stimulation.
Answer B is incorrect because decerebrate posturing, a poor prognostic sign, may occur with painful stimuli.
Answer C is correct because the lack of response to noxious stimuli signals a deepening coma.
Answer D is incorrect because the Babinski reflex is not normally present in adults. If present, it is a pathologic response.

■ TEST-TAKING TIP: Remember that a response to pain is desired.

Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

CORRECT ANSWER: C
 
A 5-year-old child is diagnosed with acute tonsillitis for the third time in a year. The mother asks the nurse, “Can’t the pediatrician just take the tonsils out now? Why wait until the infection is over?” The nurse’s most accurate response would be:


 
Answer A is incorrect because the nurse has the necessary knowledge base to correctly answer the parent’s question without referring to the pediatrician.
Answer B is incorrect because the nurse would not want to answer the parent’s question with a closed-ended response. It does not provide the parent with needed information and tends to abruptly terminate any communication between the nurse and the parent.
Answer C is incorrect because, while a healthy child is a better candidate for surgery than a sick child, this is a general response rather than a specific response to this parent’s question.
Answer D is the correct answer because acute inflammation and infection (“itis”) of tonsillar tissue increase the risk of bleeding at the time of surgery. The operative site for a tonsillectomy is highly vascular, with the risk of postoperative bleeding already a concern. An active inflammation and infection would increase this concern.

■ TEST-TAKING TIP: The stem in this question asks for the most accurate response. The most specific response is the most accurate response. Choose the specific pathophysiology-based answer.

Content Area: Child Health, Pediatric Surgery; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/ Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations

CORRECT ANSWER: D
 
A 30-year-old man has been recently diagnosed with Cushing’s syndrome. He asks a nurse if he will be able to continue riding off-road motorcycles. The correct response by the nurse is:


 
Answer A is incorrect because the clinical manifestations of weakness in Cushing’s syndrome will interfere with normal activities. There will be mood alterations as a result of the hormone imbalance.
Answer B is incorrect because continuing the activity will put the client at risk for injury (e.g., fractures).
Answer C is correct because the overproduction of adrenocortical hormone results in excessive protein breakdown, causing compression fractures and weakness.
Answer D is incorrect because the risk for falls is greatest because of weakness, not visual problems, although cataracts and glaucoma may result from Cushing’s syndrome.

■ TEST-TAKING TIP: The “3 Ss” are signs of Cushing’s syndrome—too much sugar, salt, and sex hormone, which weaken the client.

Content Area: Adult Health, Endocrine; Integrated Process: Teaching and Learning; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology

CORRECT ANSWER: C
 
The care of a client post–traumatic brain injury includes monitoring for signs of brainstem herniation and occlusion of cerebral blood flow. A nurse should recognize a deterioration in the client if which vital sign changes occurred? Select all that apply.


 
Answer A is incorrect because this change is characteristic of hypovolemic shock.
Answer B is incorrect because respirations would slow with herniation. Rapid respirations would be characteristic of hypovolemic shock.
Answer C is incorrect because blood pressure increases, not decreases.
Answer D is correct because bradycardia is one of the vital sign changes with Cushing’s triad, a grave sign, indicating herniation of the brainstem and occlusion of the cerebral blood flow if treatment is not initiated.
Answer E is correct because hypertension occurs with brainstem herniation initially (Cushing’s triad)—a widening pulse pressure (Cushing’s reflex) occurs earlier in an attempt to overcome the increased intracranial pressure (ICP).
Answer F is correct because bradypnea accompanies bradycardia and hypertension (Cushing’s triad) with brainstem herniation.

■ TEST-TAKING TIP: Recognize a of the pulse pressure with Cushing’s reflex versus hypertension with Cushing’s triad.

Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology

CORRECT ANSWERS: D, E, F
 
When counseling the parents of a child with severe hemophilia, the nurse would correctly inform the parents that:


 
Answer A is correct because primary prophylaxis (the infusion of factor VIII concentrate on a regularly scheduled basis before the onset of joint damage) has been proven to be effective in preventing arthropathy.
Answer B
 is incorrect because primary prophylaxis (the infusion of factor VIII concentrate on a regularly scheduled basis before the onset of joint damage) must be given prior to the development of arthropathy. Secondary, not primary, prophylaxis involves the infusion of factor VIII concentrate on a regular basis after the child experiences a first joint bleed.
Answer C is incorrect because primary prophylaxis (the infusion of factor VIII concentrate on a regularly scheduled basis before the onset of joint damage) is not associated with special circumstances, such as surgical procedures, which demand additional factor VIII concentrate at unscheduled times.
Answer D is incorrect because, while primary prophylaxis is very
costly, organizations such as the National Hemophilia Foundation exist to assist in providing resources for this therapy.

■ TEST-TAKING TIP: Think of primary prophylaxis as being “before” the problem occurs, and secondary prophylaxis as being “after” the problem occurs. Note that two answers focus on “after” (Answers B and C) and one answer refers to “before” (Answer A).

Content Area: Child Health, Hematological; Integrated Process: Teaching and Learning; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Safety and Infection Control/ Accident Prevention and Injury Prevention

CORRECT ANSWER: A


 
A child is being prepared for a tonsillectomy. The laboratory telephones the pediatric unit and reports that the child’s prothrombin time (PT) is 14.1 seconds. The nurse’s first action should be to:


 
Answer A is correct because a normal prothrombin time (PT) in a child is 11 to 15 seconds. A value of 14.1 seconds is within normal limits and the child is a safe candidate for the surgery. Because the tonsillar operative site is highly vascular, bleeding is a concern and coagulation studies are always conducted prior to the surgery. Since other health-care personnel (e.g., the pediatric surgeon, operating room surgical team, etc.) will also need this information before proceeding with the surgery, the nurse’s first action should be to note the laboratory result in the child’s chart.
Answer B is incorrect because the pediatric surgeon will routinely review the child’s chart prior to the surgery, and will specifically look for the results of the prothrombin time (PT) before starting the surgery. There is no need for the nurse to notify the pediatric surgeon at this time because the prothrombin time is within normal limits.
Answer C is incorrect because the prothrombin time (PT) is within nor- mal limits and the surgery can take place as planned. If the laboratory results were not within normal limits, the nurse would call the operating room and notify them. But, it is not the nurse’s role to cancel the surgery. It is the pediatric surgeon’s responsibility to cancel the surgery if needed.
Answer D
 is incorrect because, while it is safe to release the child to the operating room transporter, the nurse should only do so after noting the results of the prothrombin time (PT) in the child’s chart.

■ TEST-TAKING TIP: The stem asks for a priority nursing action. Eliminate the two options that imply that the laboratory result is a problem (Answers B and C).

Content Area: Child Health, Pediatric Surgery; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/ Reduction of Risk Potential/Laboratory Values

CORRECT ANSWER: A 
 
A client has mitral regurgitation. Where is the best place for a nurse to auscultate the associated murmur? A.


 
Answer A is correct because the murmur associated with mitral regurgitation would be best heard at the apex, which is the 5th intercostal space, left midclavicular line.
Answer B is incorrect because this is he tricuspid area. Although the murmur associated with mitral regurgitation would be audible in this area, it would be best heard at the apex.
Answer C is incorrect because it is the pulmonic area: the second intercostal space, left sternal border. Although the murmur associated with mitral regurgitation may be audible throughout the precordium, pulmonic and aortic valve dysfunction would be best heard in this area.
Answer D is incorrect because it is the aortic area: the second intercostal space, right sternal border. Although the murmur associated with mitral regurgitation may be audible throughout the precordium, aortic valve dysfunction would be best heard in this area.

■ TEST-TAKING TIP: Key words in the question stem are: best place and mitral.

Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

CORRECT ANSWER: A 
 
Which assessment findings should alert a nurse to the potential of an addisonian crisis in a client? Select all that apply.


 
Answer A is incorrect because hyperglycemia would not be expected with adrenal hypofunction.
Answer B is incorrect because these findings would be seen with Cushing’s syndrome, not addisonian crisis.
Answer C is correct because addisonian crisis is characterized by cyanosis and signs of circulatory collapse.
Answer D is incorrect because this describes Addison’s disease, not addisonian crisis.
Answer E is correct because circulatory collapse occurs with addisonian crisis.

■ TEST-TAKING TIP: Look for the findings that describe the worst clinical picture—circulatory collapse.

Content Area: Adult Health, Endocrine; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies

CORRECT ANSWERS: C, E 
 
A 92-year-old client, who recently had a below-the-knee leg amputation, is resisting attempts at rehabilitation. The most likely reason for the resistance is that the client:


 
Answer A is correct because resistance or noncompliance is often related to different priorities or goals.
Answer B is incorrect because there is no evidence to support this choice.
Answer C is incorrect because chronological age is not the determinant of rehabilitation potential.
Answer D is incorrect because rehabilitation plans may actually begin before surgery. It is unnecessary to wait for the client to feel comfortable changing the dressing.

■ TEST-TAKING TIP: Choose the option that requires further assessment of the situation—a review of the goals.

Content Area: Geriatrics, Musculoskeletal; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Psychosocial Integrity/Coping Mechanisms

CORRECT ANSWER: A 
 
A nurse prepares to discontinue the IV of a child with a low platelet count. Special precautions taken by the nurse when performing this nursing action should include:


 
Answer A is incorrect because a sterile pressure dressing is not necessary for the IV site. It would also be unnecessarily restrictive for the child.
Answer B is correct because a child with a low platelet count will have bleeding tendencies. When discontinuing the IV, the nurse should treat the IV site as an arterial puncture and apply direct pressure to the site for a minimum of 5 minutes.
Answer C is incorrect because sending the tip of the IV catheter to the laboratory for a culture would only be necessary when sepsis around the IV catheter is suspected. It would also be unnecessarily expensive and would not help the child’s bleeding tendencies.
Answer D is incorrect because it would be unnecessarily restrictive for the child and would not help the child’s bleeding tendencies.

■ TEST-TAKING TIP: Remember that a decreased platelet count will cause bleeding tendencies.

Content Area: Child Health, Hematological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/ Treatments/Procedures

CORRECT ANSWER: B
 
Physical assessment of a client admitted for a bronchoscopy reveals a thin, muscular man with wheezes in the left lung. Which area should a nurse identify as most likely to be partially obstructed?


 
Answer A is incorrect because the trachea is larger and a partial obstruction would most likely produce a crowing sound.
Answer B is incorrect because the wheezing was heard in the left lung.
Answer C, left bronchus, is correct because wheezes occur when there is partial obstruction of the bronchi or bronchioles. The sound is due to increased vibration of air molecules as they pass over the area that is narrowed or partially obstructed. In this client, the wheezing was heard in the left lung.
Answer D is incorrect because the sound produced by the pleura would be a grating sound called a friction rub.
Answer E is incorrect because the sound produced by the pleura would be a grating sound called a friction rub.

■ TEST-TAKING TIP: The question is looking for an area of the lung that, when narrowed, would produce a sound. Think “squeeze” with a “wheeze” as the air moves through a narrow tube—the bronchus or bronchioles.

Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

CORRECT ANSWER: C
 
A nursing student is being mentored by a charge nurse on a pediatric unit. The nursing student is assigned to care for a child who has increased intracranial pressure following a head trauma. The charge nurse questions the nursing student regarding positions that would be con- traindicated or ineffective when caring for the child. The nursing student should correctly identify: Select all that apply.


 
Answer A is correct because this position would not promote the drainage of cranial fluids that have accumulated due to increased intracranial pressure. In addition, placing the child on the abdomen (prone) could prevent an adequate airway from being maintained.
Answer B is correct because this position would not promote the drainage of cranial fluids that have accumulated due to increased intracranial pressure. In addition, placing the child on the back (supine) could increase the possibility of aspiration.
Answer C is incorrect because this position would promote the drainage of cranial fluids that have accumulated due to increased intracranial pressure. Semi-Fowler’s is a position in which the child lies on the back with the trunk elevated at approximately a 45-degree angle.
Answer D is correct because this position would not promote the drainage of cranial fluids that have accumulated due to increased intracranial pressure. (However, right side-lying would not prevent an adequate airway from being maintained or increase the possibility of aspiration.)
Answer E is correct because this position would not promote the drainage of cranial fluids that have accumulated due to increased intracranial pressure. (However, left side-lying would not prevent an adequate airway from being maintained or increase the possibility of aspiration.)

■ TEST-TAKING TIP: Gravity will assist in the drainage of fluids; select the positions that would prevent or are least likely to accomplish this.

Content Area: Child Health, Neurological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/ Safety and Infection Control/Accident Prevention and Injury Prevention 

CORRECT ANSWERS: A, B, D, E

 
A client is combative and demanding and refuses to swallow any medication following a brain attack (CVA). The correct nursing action is to:


 
Answer A is incorrect because the client cannot be forced to take an oral medication.
Answer B is correct because the behavior may be a pattern. Family may have suggestions that will help.
Answer C is incorrect because restraints should be a last resort if at all possible. The route may need to be changed.
Answer D is incorrect because the behavior may be the result of the brain injury and may not change.

■ TEST-TAKING TIP: Choose an option that recognizes the effect of the brain attack on behavior. Select the option for further assessment (“determine personality before . . .”) in an attempt to understand the behaviors.

Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Psychosocial Integrity/Behavioral Interventions

CORRECT ANSWER: B
 
A child is to receive digoxin 0.07 mg PO twice daily. The label on the bottle of digoxin reads 0.05 mg/mL. A nurse correctly calculates that this client should receive ______ mL of digoxin. Fill in the blank.





 
Dose desired (0.07 mg) is to dose on hand (0.05 mg) as amount desired (x) is to amount on hand (1 mL): 0.07 mg/0.05 mg = x/1 mL; x = 1.4 mL.



■ TEST-TAKING TIP: Know the standard ratio and proportion calculations and be careful with decimal points.

Content Area: Child Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Dosage Calculation

CORRECT ANSWER: 1.4
 
A nurse is concerned that a client may be at risk for oversedation from opioid therapy using a patient- controlled analgesia (PCA) pump. The most reliable assessment for possible oversedation would be to check:


 
Answer A is incorrect because the trachea is larger and a partial obstruction would most likely produce a crowing sound.
Answer B is incorrect because the wheezing was heard in the left lung.
Answer C, left bronchus, is correct because wheezes occur when there is partial obstruction of the bronchi or bronchioles. The sound is due to increased vibration of air molecules as they pass over the area that is narrowed or partially obstructed. In this client, the wheezing was heard in the left lung.
Answer D is incorrect because the sound produced by the pleura would be a grating sound called a friction rub.
Answer E is incorrect because the sound produced by the pleura would be a grating sound called a friction rub.

■ TEST-TAKING TIP: The question is looking for an area of the lung that, when narrowed, would produce a sound. Think “squeeze” with a “wheeze” as the air moves through a narrow tube—the bronchus or bronchioles.

Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

CORRECT ANSWER: C
 
The parents of a 2-year-old child ask a nurse how to best manage their child’s temper tantrums. What advice should the nurse give the parents?


 
Answer A is incorrect because tantrums are related to the child’s developmental stage, not his/her diet.
Answer B is correct because toddlers may have temper tantrums to express their frustration. Sudden changes in activities should be avoided, and the toddler should be given forewarning about what is coming next.
Answer C is incorrect because tantrums should be ignored. By holding the child, the parents will be providing reinforcement of the tantrum behavior.
Answer D is incorrect because even negative reinforcement can reinforce the tantrum behavior. Additionally, spanking should be avoided and it is inappropriate for the nurse to recommend corporal punishment as a behavior modification technique.

■ TEST-TAKING TIP: The key word to the best answer is “prevent.” Recall that the toddler needs to be autonomous. By providing the child with information about coming activities, the child will feel more in control and will be less likely to become frustrated.

Content Area: Child Health, Growth and Development; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Developmental Stages and Transitions 

CORRECT ANSWER: B
 
A nurse prepares to administer cardiopulmonary resuscitation (CPR). Which actions should the nurse take? Place in sequential order.


 




 
After determining that the client is nonresponsive and not breathing or is gasping for air, the nurse or someone else calls for help. The pulse is palpated for 10 seconds, and if no pulse is palpated, the client is positioned properly to perform CPR. The order is: 30 chest compressions at 100/min, open the airway, and then 2 breaths. ABC has been changed to CAB; the emphasis is on chest compressions.

■ TEST-TAKING TIP: Remember: the heart is the first priority.

Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies 

CORRECT ANSWERS: D,C,F,E,A,B,G
 
A client, who is a 24-year-old gravida 6, para 5, delivered a 10-pound, 10-ounce baby 6 hours ago, after a 26-hour labor. Upon assessment, an RN finds the client’s fundus is 2 fingerbreadths above the umbilicus and slightly devi- ated to the right. Based on the information provided, for which complication is this client at risk?


 
Answer A is correct because this client’s fundus is higher than expected for this stage after delivery and is deviated to the right, indicating she has a full bladder that can impede the uterus from contracting adequately. This can result in a postpartum hemorrhage.
Answer B is incorrect because this client is not a high risk for mastitis based on the information provided. Mastitis is a breast infection that can result from cracked or sore nipples or failure to fully drain the breast. Answer C is incorrect because endometriosis is a proliferation of endometrial tissue, not related to the delivery of an infant.
Answer D is incorrect because thrombo-phlebitis is a risk factor for all women who are pregnant; this client is not at any increased risk because of her history with this delivery.

■ TEST-TAKING TIP: Eliminate complications that are common to all women who are pregnant, but not directly related to this client’s specific risk factors.

Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/ Potential for Complications from Surgical Procedures and Health Alterations 

CORRECT ANSWER: A
 
A client is seen in an emergency department for rotator cuff tendonitis. What is the correct immediate treatment?


 
Answer A is incorrect because heat increases swelling.
Answer B is incorrect because pain control may be required, but muscle spasm is not the source of the pain.
Answer C is correct because the injured tissue needs to be immobilized.
Answer D is incorrect because the injured tissue should be immobilized and rested.

■ TEST-TAKING TIP: Look for an option that rests the extremity.

Content Area: Adult Health, Musculoskeletal; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Basic Care and Comfort/Assistive Devices 

CORRECT ANSWER: C
 
A 3-year-old child is admitted to an emergency department after being struck by an automobile. A nurse’s assessment reveals a child with spontaneous eye opening. The child is confused and does not obey commands but is able to localize pain. The nurse correctly calculates a score of __________ on the Glasgow Coma Scale. Fill in the blank.


 
To arrive at the correct score on the Glasgow Coma Scale (GCS), recall that the scale is composed of three scoring areas: eye opening (ranges from 1 to 4), best motor response (ranges from 1 to 6), and best auditory/visual response (ranges from 1 to 5). This child receives the maximum score of 4 for spontaneous eye opening, a score of 5 out of 6 for motor response, and 4 out of 5 for auditory/ visual response.


■ TEST-TAKING TIP
: Remember that the lowest score an individual can receive on the GCS is 3 (no eye opening and no motor nor auditory/visual response) and the highest is 15.

Content Area: Child Health, Neurological; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems 

CORRECT ANSWER: 13
 
The correct nursing action to prevent infection in a client with an external fixation device for an open fracture is to:


 
Answer A is incorrect because infections are generally introduced into the wound during the initial trauma and surgery. Although it is possible that infections could be introduced during postoperative wound care, double-gloving would not reduce the risk.
Answer B is incorrect because pin site care is controversial. Some surgeons prefer that pins be surrounded with scabs to protect the tissue. Some prefer cleansing with Betadine; however, it is irritating to tissue.
Answer C is correct because open fractures create opportunities for microbes to enter the wound. Antibiotics throughout the perioperative period reduce the risk.
Answer D is incorrect because contact isolation is used to prevent transmission of infection to other clients from the client who is isolated. It could not protect the client who is isolated.

■ TEST-TAKING TIP: Look for clues in the stem, such as “prevent,” and a similar word in the options—“prophylactic.”

Content Area: Adult Health, Musculoskeletal; Integrated Process: Nursing Process, Planning; Cognitive Level: Comprehension; Client Need/Subneed: Physiological Integrity/ Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/ Treatments/Procedures 

CORRECT ANSWER: C 
 
During the active phase of labor, a client, who is a gravida 2, para 0, begins to complain of dizziness, tingling in her fingers, and numbness in her lips.