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NCLEX-RN Pre-Test Exam #1

A nurse has been working with a battered woman who is being discharged and returning home with her husband. The nurse says, "All this work with her has been useless. She's just going back to him as usual." Which of the following statements by a nursing colleague would be most helpful to this nurse? A - "Her reasons for staying are complex. She can leave only when she is ready and can be safe." B - "I know it is frustrating to work with clients who don't follow our advice." C - "You did your best. You will see her again and have another chance." D - "These women almost never leave for good because of their emotional and financial dependency."

CORRECT ANSWER: A

RATIONALE: The colleague needs to provide the nurse with information about spouse abuse. Giving information about reasons for staying is useful for decreasing the nurse's frustration. Although expressing empathy is appropriate, it does not help the nurse understand the client's needs and behaviors. Telling the nurse that there will be another chance is not helpful and fails to educate the other nurse about the dynamics of abuse. Although dependence is a problem, women who are abused can overcome this and leave if they have support, not criticism. Saying that abused women almost never leave does not help the nurse understand the client's needs and behaviors. A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. Which of the following interventions would be most appropriate? Select all that apply. A - Change the feeding apparatus every 24 hours. B - Use a higher volume of formula because the formula may be too hypotonic. C - Slow the administration rate. D - Use a diluted formula, gradually increasing the volume and concentration. E - Anticipate changing to a lactose-free formula.

CORRECT ANSWERS: A,C,D,E

RATIONALE: Although about 50% of diarrhea in clients receiving tube feedings is caused by sorbitol containing medications, the nurse should assess for other possible causes. Diarrhea can occur as a result of bacterial contamination if fresh formula is not used or stored in a refrigerator, or if the feeding apparatus is not changed at least every 24 hours. Lactose intolerance, rapid formula administration, low serum albumin level, and hypertonic solutions may also cause diarrhea. Hypotonic solutions would not be a likely cause of diarrhea, abdominal distention, or cramping.


At a 6-month-old infant is being admitted from the emergency department with dehydration secondary to viral gastroenteritis. Which of the following room assignments is the most appropriate for this infant? A - A semiprivate room with an 8-year-old child who has had an appendectomy. B - A semiprivate room with a 10-year-old child with a closed head injury. C - A private room. D - A semiprivate room with a 4-year-old child with leukemia.

CORRECT ANSWER: C

RATIONALE: Viral gastroenteritis may be communicable, and all of the other children are already at risk for infection. The infant should be placed in a private room.

For which of the following should the nurse be especially alert when caring for a term neonate, who weighed 10 lb at birth, 1 hour after a vaginal delivery? A - Hypoglycemia. B - Hypercalcemia. C - Hypermagnesemia D - Hyperbilirubinemia

CORRECT ANSWER: A

RATIONALE: The neonate would be considered large for gestational age (LGA) because the neonate weighs more than 4,000 g (90th percentile). Therefore, the nurse needs to assess for the possibility of complications. Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly used to maintain the weight. Other common complications for an LGA neonate include hyperbilirubinemia from the bruising and polycythemia, cephalhematoma, caput succedaneum, molding, phrenic nerve paralysis, and a fractured clavicle. However, hyperbilirubinemia would not be evident 1 hour after birth. Hypercalcemia is not usually found in the LGA neonate. Hypocalcemia is common in infants of diabetic mothers. Hypermagnesemia may occur in neonates whose mothers received large doses of magnesium sulfate to treat severe preeclampsia.

A female client with infertility related to anovulatory cycles is prescribed menotropins (Pergonal). Which of the following, if stated by the client as a possible adverse effect of this medication, indicates successful teaching? A - Pulmonary edema. B - Ovarian enlargement. C - Visual disturbances. D - Breast tenderness.

CORRECT ANSWER: B

RATIONALE: Ovarian enlargement, hyperstimulation syndrome, febrile reaction, and multiple pregnancies are considered adverse effects of menotropins. If ovarian enlargement occurs, the drug should be discontinued to prevent damage to the ovary. Pulmonary edema is not associated with menotropin use. Visual disturbances and breast tenderness are associated with the use of clomiphene citrate (Clomid), another drug prescribed for infertility.


A family has been notified that their son is brain dead, and the physician has discussed the possibility of donating organs. The nurse should collaborate with the physician to contact which referral source that is responsible for organ recovery in the United States are the: A - Organ and Tissue Procurement Organizations. B - American Transplant Association. C - American Hospice Foundation. D - American Association of Critical-Care Nurses.

CORRECT ANSWER: A

RATIONALE: Organ and Tissue Procurement Organizations are responsible for organ recovery in the United States. These organizations have offices in major cities, and provide services on a local, state, and regional basis. The agency is the repository for information about tissues and organs and their distribution. The American Transplant Association coordinates recipients of transplants. The American Hospice Foundation is involved with hospice care. The American Association of Critical-Care Nurses is involved with professional critical care nurses.

The nurse is involved in preoperative teaching with a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. The nurse explains that the purpose of the lower chest tube is to: A - Prevent clots. B - Remove air. C - Remove fluid. D - Facilitate "milking" of the tubes.

CORRECT ANSWER: C

RATIONALE: Fluid accumulates in the base of the pleura postoperatively. The lower chest tube, called the posterior or lower tube, will drain serous and serosanguineous fluid that accumulates as a result of the surgical procedure. A larger diameter tube is usually used for the lower tube to ensure drainage of clots. Air rises, and the anterior or upper tube is used to remove air from the pleural space. The practice of "milking" the tubes to prevent clots is becoming less common; the surgeon's orders must be followed regarding this procedure.

A nurse is assessing an 82-year-old for depression. Because of the client's age, the nurses' assessment should be guided by the fact that: A - Sadness of mood is usually present but it is masked by other symptoms. B - Impairment of cognition usually is not present. C - Psychosomatic tendencies do not tend to dominate. D - Antidepressant therapies are less effective in older adults .

CORRECT ANSWER: A

RATIONALE: Elderly clients are a high-risk group for depression. The classic symptoms of depression frequently are masked, and depression presents differently in the aging population. Depression in late life is under diagnosed because the symptoms are incorrectly attributed to aging or medical problems. Impairment of cognition in a previously well elderly client or psychosomatic complaints may be the presenting symptom of depression. Antidepressant therapy is usually effective.

A primary concern of the hospitalized adolescent is: A - Respect for the need for privacy. B - Allowing parents to visit after hours. C - Wearing a hospital gown. D - The fear of loss of control when in pain.

CORRECT ANSWER: D

RATIONALE: Fears of the adolescent include body changes and loss of control. The young adolescent is typically concerned about the inability to control body changes and feelings and about embarrassment. The typical adolescent is more concerned about being separated from the peer group than from the family and schoolwork and is realistically worried about experiencing pain and loss of control. The adolescent may prefer to wear her own clothes, but this is not a primary concern. The nurse should respect the client's privacy, but this is not a primary concern for this client.

A 20-year-old single parent brings her 3-yearold son into the emergency department because he "fell." The child has bruises on his face, arms, and legs; his mother says that she did not witness the fall. The nurse suspects child abuse. While examining the child, the mother says, "Sometimes I guess I'm pretty rough with him. I'm alone, and I just don't know how to manage him." The nurse should ask the mother if she would find it helpful to have a referral to: A - A program for single parents. B - A parenting education program. C - A women's support group. D - A support group for abusive parents.

CORRECT ANSWER: B

RATIONALE: The mother's statements reveal that she is having problems with parenting. Therefore, a referral to a parenting education program is the most appropriate measure at this time.

The nurse is planning to complete the following assessments during the last half hour of the shift. Which of the following assessments has the highest priority and should be accomplished first? A - A postpartum couplet with the infant who has had transient tachypnea of the newborn (TTN) at birth and now has a respiratory rate of 60 breaths/minute. B - A newly admitted postpartum client who is receiving magnesium sulfate at 3 g an hour initiated 10 hours ago for preeclampsia; her infant ate poorly previously and has not eaten for 4 hours. C - A mother who had a cesarean section and is 6 hours post delivery with the baby in special care nursery; the mother has not yet seen her baby. D - A couplet that delivered at 36 weeks' gestation; the 5 lb infant had initial blood glucose of 35 mg/dL and when taken to the room had a glucose of 46 mg/dL.

CORRECT ANSWER: B

RATIONALE: The infant who has not eaten in 4 hours is the highest priority of this group of couplets. The last feeding was 4 hours ago and the prior poor feeding puts this infant at risk. An assessment of this infant is needed from a safety perspective since the mother had magnesium sulfate. The nurse should question whether the poor feeding may be a result of magnesium sulfate in the newborn's system by evaluating respiratory rate, tone, and current ability to feed. The couplet with an infant with TTN and a respiratory rate of 60 is within normal limits but should have the respiratory rate reevaluated to assure normalcy. The mother who had a Cesarean section should be evaluated to determine when she will be able to go to SCN to see her infant. Urgency concerning taking her to the nursery will also depend on the condition of the newborn. The newborn of 36 weeks' gestation is currently within normal blood glucose range, but would need to be monitored frequently because of the small infant size and prior low blood glucose.

A nurse who fails to check a client's armband before administering his medications is: A - Res judicata. B - Negligent. C - Stare decisis. D - Vicariously liable.

CORRECT ANSWER: B

RATIONALE: The nurse acts in a reasonable and prudent manner to correctly identify a client by checking the client's armband and asking the client's name. Omitting to do so is an act of negligence. Res judicata and stare decisis are legal doctrines used to guide the courts in making decisions. Vicarious liability is a concept in which the employer is held liable for the nurse's act. It was established after precedent setting cases in the 1960s.

Before administering morphine to a client, the nurse should assess the client's: A - Blood pressure. B - Respiration rate. C - Pulse. D - Temperature.

CORRECT ANSWER: B

RATIONALE: Morphine can cause respiratory depression, leading to respiratory arrest. The nurse should assess the client's respiratory rate before administration and throughout the course of analgesic treatment. Morphine does not affect blood pressure, pulse rate, or temperature.

A 30-year-old client is hospitalized with a fractured femur, which is being treated with skeletal traction. He states that he has not had a bowel movement for 2 days. Which of the following interventions is most appropriate at this time? A - Administer a tap water enema. B - Place the client on the bedpan every 2 to 3 hours. C - Increase the client's fluid intake to 3,000 mL/day. D - Perform range of motion movements to all extremities.

CORRECT ANSWER: C

RATIONALE: Increasing the client's fluid intake to 3,000 mL/day, unless contraindicated, is the most appropriate action. Typically, clients who are immobilized by skeletal traction are given stool softeners. Treating constipation with diet, increased fluids, and stool softeners is preferred to the administration of an enema. Placing the client on the bedpan will not encourage a bowel movement. Range of motion movements maintain joint mobility but do not stimulate peristalsis.

A mother states that she is very angry with the physician who diagnosed her child with leukemia. Which statement helps the nurse understand this mother's reaction? A - Anger is a natural result of a sense of loss and helplessness. B - Parents of sick children are usually unable to control their anger. C - Anger is rarely demonstrated by parents when coping with a sick child. D - The mother cannot overcome her anger in an acceptable manner.

CORRECT ANSWER: A

RATIONALE: Anger is a natural result of feelings of loss and helplessness in normal, healthy people. It is a natural response to coping with a sick child. Nurses should recognize anger in clients and families. Parents are usually able to control their anger in a socially acceptable manner. Nurses can assist clients and families to overcome helplessness and anger in an acceptable manner.

Which of the following nursing strategies would be effective in managing a resident in a long-term care facility who has Alzheimer's disease and wanders? A - Encourage participation in activities such as board games. B - Discourage wandering by allowing the behavior at selected intervals. C - Involve the client in activities that promote walking. D - Promote safety by restraining the client in a geriatric chair.

CORRECT ANSWER: C

RATIONALE: Supervised activities that promote walking are behavioral management strategies that help a client such as this. The client's cognitive and memory impairment would not be conducive to playing board games. Allowing the behavior at selected intervals would further encourage the client to wander. The client should not be restrained in a chair.

A child who had a cast applied to his arm earlier this morning tells the nurse that his fingers are numb. The nurse should: A - Notify the physician who applied the cast. B - Cut the cast to loosen it. C - Assess the circulation to the fingers. D - Ensure that the arm is positioned correctly.

CORRECT ANSWER: C

RATIONALE: With a new complaint of numbness in the fingers, the nurse needs to first assess the circulation to evaluate color, evidence of swelling, and presence of pulses to determine whether there is any circulatory compromise. Once the nurse had evaluated the child's circulatory status, the next action would be to verify the arm's position above the level of the heart. Notifying the physician would not be done until the child's neurovascular status and position are checked. Cutting the cast would be done only with a physician's order.

A client is admitted with low back pain (LBP). The nurse should further assess the client for: A - Osteoporosis. B - Herniated disk. C - Muscle strain. D - Spondylosis.

CORRECT ANSWER: C

RATIONALE: LBP is commonly associated with overuse or an injury to the soft-tissue structures. It is estimated that 50% to 70% of people will experience musculoskeletal back pain at some time. Although the other causes of pain must be excluded, the initial treatment of LBP is usually aimed at decreasing the inflammatory response to the tissue injury.

While helping clients brought to a crisis center during a severe flood, the nurse interviews a client whose pregnant wife is missing and whose home has been destroyed. The client keeps talking rapidly about his experience and says, "I can't see how I can ever rebuild my life." Which of the following responses by the nurse would be most appropriate? A - "If you start organizing your life now, I'm sure all will be fine." B - "This has been a terrible experience. Tell me more about how you feel." C - "Let me note a few of the things you said before you continue with your story." D - "Tonight, think some more of what happened, so that we can continue with this tomorrow."

CORRECT ANSWER: B

RATIONALE: At the time of a major crisis, the client suffering a great loss is best helped by being encouraged to talk about his experience and describe his feelings. Crisis interventions focus on reestablishing emotional equilibrium and preventing decompensation. Telling the client that everything will be fine is a cliché and inappropriate. Asking the client to stop talking so that the nurse can write notes places more emphasis on the nurse's needs than on the client's needs. Telling the client to think more about what happened for further discussion the next day is not helping him with the crisis.

A client with asthma has been prescribed beclomethasone (Beclovent) via metered-dose inhaler. To determine if the client has been rinsing the mouth after each use of the inhaler, the nurse should inspect the client's mouth for: A - Gingival hyperplasia. B - Oral candidiasis. C - Ulceration. D - Dental caries.

CORRECT ANSWER: B

RATIONALE: Beclomethasone is an inhaled steroid used for the maintenance treatment of asthma. The steroid can precipitate overgrowth of fungus, such as oral Candida albicans. Rinsing the mouth well after each use decreases the incidence of oral fungal infections. Beclomethasone does not cause gingival hyperplasia, ulceration, or caries.

The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the physician, the nurse fills out an incident report. Which of the following is the nurse's next action? A - Give the incident report to the nurse manager. B - Place the incident report on the chart. C - Call the family to inform them. D - Omit mentioning the fall in the chart documentation.

CORRECT ANSWER: A

RATIONALE: The incident report should be given to the nurse manager. The incident report should not be placed on the chart because it is considered a confidential communication and cannot be subpoenaed by a client or used as evidence in lawsuits. It is appropriate, ethical, and legally required that the fall be documented in the chart. Unless there is a change in the client's condition reflecting an injury from the fall, there is no need to notify the family. If the family does need to be notified, the nurse manager or the physician should place the call.

The charge nurse on an antepartal unit is preparing to complete assignments for the day. There is an RN, licensed practical nurse (LPN), and an unlicensed personnel (UAP) to care for 25 clients. The nurse should assign which of the following clients to the LPN? A - A newly admitted G5 P2 Ab 2 with second trimester bleeding, reportedly currently saturating 1-2 pads in 12 hours. B - A 22-year-old G2 P1 with urinary retention who is being catheterized with an intermittent in and out every 4 to 6 hours p.r.n. while awaiting urine cultures to be returned. C - A G4 P2 with a twin pregnancy who was admitted in preterm labor and is now able to ambulate 2 to 3 times daily and having no contraction. D - A 30-year-old G4 P0 who was admitted in sickle cell crisis currently receiving blood and pain medication.

CORRECT ANSWER: B

RATIONALE: The 22-year-old G2 with urinary retention and needing to be I & O catheterized by a health care provider can be cared for by the LPN. There is nothing else indicating a need for a higher level of care. The newly admitted G5 client is in need of an admission assessment and assessment of fetal well-being and bleeding which will need to be done by an RN. The G4 P2 with a twin pregnancy who has been in preterm labor can be cared for by a UAP since there is no active labor and no indication of distress in the fetuses. The client in sickle cell crisis requires a high level of care to be provided by an RN.

The mother of 2-year-old who has been bitten by the family dog asks the nurse what to do about the bite. What should the nurse tell the mother? A - "You need to take the child to the local urgent care center immediately." B - "Wash the bite area with lots of running water, and then check the injury." C - "Determine when the child's latest tetanus vaccine was administered." D - "Make an appointment to see the child's physician now to start rabies shots."

CORRECT ANSWER: B

RATIONALE: General wound care is appropriate initially. This includes washing the bite area with lots of water because infections occur frequently with animal bites, especially those on the arms or hands. Next, the mother should be advised to determine the extent of the injury and then to follow-up with the child's physician if needed. A trip to the local care center would be warranted if the bite injury was extensive or there was severe bleeding. Although knowledge of when the child last had a tetanus vaccination is important, the child's wound takes priority. For rabies injections, there needs to be a history of rabies or unusual behavior in the pet.

The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when she says: A - "If I think I have a bladder infection, I need to see my obstetrician." B - "If I have contractions, I should contact my health care provider." C - "Drinking water may help prevent early labor for me." D - "If I travel on long trips, I need to get out of the car every 4 hours."

CORRECT ANSWER: D

RATIONALE: Traveling is usually discouraged if preterm labor has been a problem as it restricts normal movement. A client should be able to walk around frequently to prevent blood clots and to empty her bladder at least every 1 to 2 hours. Bladder infections often stimulate preterm labor and to prevent them is of great importance to this client. Contractions that recur indicate the return of preterm labor and the health care provider needs to be notified. Dehydration is known to stimulate preterm labor and encouraging the client to drink adequate amounts of water helps to prevent this problem.

A school teacher asks the nurse whether all the children at school need treatment after exposure to a 7-year-old child with bacterial meningitis. The nurse responds that chemoprophylaxis should be given to: A - All children at the school. B - All household contacts and close contacts. C - The entire community. D - Household contacts only.

CORRECT ANSWER: B

RATIONALE: Chemoprophylaxis should be given to household contacts and close contacts only. To prevent community outbreaks, chemoprophylaxis with rifampin 600 mg twice a day for 2 days or a single dose of Cipro 500 mg is indicated.

The mother of a newborn is concerned about the number of persons with heart disease in her family. She asks the nurse when she should start her baby on a low fat, low cholesterol diet to lower the risk of heart disease. The nurse should tell her to start diet modifications: A - At birth. B - At age 2. C - At age 5. D - At age 10.

CORRECT ANSWER: B

RATIONALE: Infants and toddlers younger than age 2 should not be placed on a fat restricted diet because cholesterol and other fatty acids are required for continued neural growth. After age 2 it is believed that no harm is done by encouraging a child to eat a variety of foods, maintain a desirable body weight, limit saturated fat and cholesterol, and increase fiber.

A client is being treated for severe pediculosis. The nurse should instruct the client to treat the problem in the eyebrows and eyelashes by: A - Applying petroleum jelly to lashes and brows three to four times a day. B - Applying a pediculicide with a cotton-tipped swab three to four times a day. C - Applying lindane ointment to the lashes and eyebrows three times a day. D - Applying bacitracin ointment to the lashes and brows three times a day.

CORRECT ANSWER: A

RATIONALE: Petroleum jelly is thought to smother the lice. A pediculicide should not be applied to the face or close to the eyes. Bacitracin ointment will not kill the lice.

The nurse is discussing safety and accident prevention with the mother of a 9-month-old. The teaching has been effective when the mother states which of the following? A - "I make sure that I keep my cleaning supplies locked up." B - "Sometimes she plays in the bathroom when I'm cleaning in there." C - "Occasionally she gets under the chair and plays with the telephone cord." D - "I've found that those child protective cabinet locks don't work very well."

CORRECT ANSWER: A

RATIONALE: A major goal of safety and accident prevention focuses on having all cleaning supplies and medications locked up. Toddlers are great climbers and can very quickly get into what they should not. The child should not play in the bathroom even if the parent is present because the child will think that it is okay to play with these items when the parent is not present. Playing with cords could lead to possible strangulation. The child protective cabinet locks should work unless they were installed incorrectly or are defective.

When assessing a child receiving tobramycin sulfate (Nebcin), which findings would indicate that the child is experiencing adverse effects? Select all that apply. A - Increased blood pressure. B - Weight gain. C - Rash D - Fever. E - Ringing in the ears. F - Decreased heart rate.

CORRECT ANSWERS: C,D,E

RATIONALE: Common adverse effects of tobramycin include nephrotoxicity, ototoxicity, fever, and rash. Hypertension, weight gain, and decreased heart rate are not associated with this drug.

The nurse instructs the client who is taking gentamicin to monitor factors related to renal function. The nurse determines that the client needs additional instruction when he makes which of the following statements? A - "I should call you if I notice that I'm not urinating as much." B - "I should call you if my urine looks dark or unusual." C - "I should call you if my legs swell or I notice my skin looks puffy around my eyes." D - "I should call you if I have a fever."

CORRECT ANSWER: D

RATIONALE: Fever is generally not thought to be a sign of impaired renal function related to long term use of gentamicin. The client should report signs of decreasing urinary function, such as decreased output, unusual appearance of the urine, or edema.

A 15-month-old child is admitted to the pediatric unit with the diagnosis of pneumonia and is placed in a mist tent. Which of the following toys would be appropriate for this child? A - A pull toy. B - Storybooks. C - Crayons and paper. D - Plastic blocks.

CORRECT ANSWER: D

RATIONALE: Plastic blocks are the most appropriate toy for a toddler in a mist tent. Because the blocks are plastic, they can be washed. For the pull toy to be used, the child would need to leave the mist tent, which is not advisable at this time. Although crayons may be appropriate for a mist tent, any paper, including storybooks, would become damp, crumble, and provide an environment for the growth of microorganisms.

When teaching a group of parents about the potential for febrile seizures in children, which of the following facts should the nurse include? A - The exact cause is known. B - The seizures occur as the fever rises. C - Children older than age 3 are most at risk. D - These seizures commonly occur after immunization administration.

CORRECT ANSWER: B

RATIONALE: Febrile seizures commonly occur as the fever rises. The exact cause of febrile convulsions is not known. Infants and young toddlers are the age groups primarily affected. Febrile seizures typically do not follow immunization administration.

A 19-year-old G1 P0 is being discharged home after hospitalization for hyperemesis gravidarum and is being referred to home health care. The nurse should develop a discharge plan that includes which of the following? Select all that apply. A - Refer client to a nutritionist for the following day. B - Ensure that the client has a prescription for an antiemetic. C - Ask the health care provider (HCP) for an anxiolytic prescription. D - Encourage return to normal routine when client feels ready. E - Coordinate follow-up appointment with provider in 6 weeks. F - Discuss plan of care and discharge instructions with client.

CORRECT ANSWERS: A,B,D,F

RATIONALE: The nurse case manager should refer the client to a nutritionist so the client is aware of and can be monitored regarding her food intake to assure transition to a normal pregnancy diet with intake of adequate nutrients to support growth and development of the fetus. A p.r.n. (as needed) prescription for an antiemetic is useful to overcome occasional episodes of nausea and vomiting. Encouraging a return to normal activities when the client feels ready gives the client a goal to look forward to and activity is not contraindicated in hyperemesis when the client feels ready it initiate activity. Discussion of the plan of care and discharge instructions is a standard of care when discharging a client from a health care facility. There is no indication for an anxiolytic and hyperemesis gravidarum typically is not associated with anxiety. Six weeks is too long to wait for a follow-up appointment post hospitalization.

The nurse should instruct a woman taking folic acid supplements for folic acid-deficiency anemia that: A - It will take several months to notice an improvement. B - Folic acid should be taken on an empty stomach. C - Iron supplements are contraindicated with folic acid supplementation. D - Oral contraceptive use, pregnancy, and lactation increase daily requirements.

CORRECT ANSWER: D

RATIONALE: Oral contraceptive use, pregnancy, and lactation are situations that increase demand for folic acid. With supplementation, a response should cause the reticulocyte count to increase within 2 to 3 days after therapy has begun. It is not necessary to take folic acid on an empty stomach. A client may safely take both iron and folic acid supplementation.

The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal delivery. Which of the following findings should be reported to the physician? A - A scant amount of maternal lochia serosa. B - The presence of a neonatal tonic neck reflex. C - A nonpalpable maternal fundus. D - Neonatal central cyanosis.

CORRECT ANSWER: D

RATIONALE: Although acrocyanosis may be present for 24 to 48 hours after birth, central cyanosis of the trunk indicates decreased oxygenation from respiratory distress or another disease state (e.g., cardiac anomalies). This should be reported to the physician and evaluated further. Maternal lochia serosa in scant amount is a normal finding 1 week postpartum, as is a nonpalpable maternal fundus. Presence of a neonatal tonic neck reflex is a normal finding in a 1-week-old neonate.

The nurse is obtaining a health history for a client with osteoporosis. The nurse should specifically ask the client about which of the following? Select all that apply. A - Amount of alcohol consumed daily. B - Use of antacids. C - Dietary intake of fiber. D - Use of Vitamin K supplements. E - Intake of fruit juices .

CORRECT ANSWERS: A,B,C,D

RATIONALE: The nurse should ask the client about alcohol use, because heavy alcohol use causes fluid excretion resulting in heavy losses of calcium in urine. If the client uses antacids containing aluminum or magnesium, a net loss of calcium can occur. If the client has a high-fiber diet, the fiber can bind up some of the dietary calcium. People with hip fractures have been found to have low vitamin K intakes; vitamin K plays an important role in production of at least one bone protein. Fruit juices do not affect calcium absorption.

The nurse tells a rape victim that even if she was protected against pregnancy by a contraceptive and has no intention of taking any legal action against her assailant, she should still be checked by a physician for early detection of which of the following? A - Sexually transmitted disease. B - Anxiety reaction. C - Periurethral tears. D - Menstrual difficulties.

CORRECT ANSWER: A

RATIONALE: The postrape examination is important for detecting the possibility of sexually transmitted disease, which can be spread through rape. Additionally, if the victim or the rapist was not using a contraceptive, postcoital contraceptive methods should be discussed. The information provided does not indicate anxiety or physical injury, such as periurethral tears, and these are not the primary reason for the examination. Menstrual difficulties are not a common result of rape.

A hospitalized client fell on the floor and sustained a small laceration on her hand that required stitches. The intern will suture the client's hand at the client's bedside and asks for bupivacaine (Marcaine) with epinephrine and a suture kit in order to suture the laceration. The nurse should question which of the following? A - The intern's ability to suture. B - The client's room as an aseptic environment. C - Marcaine with epinephrine as the local anesthetic. D - The cosmetic effect from not having a plastic surgeon do the suturing.

CORRECT ANSWER: C

RATIONALE: The nurse should question the use of a local anesthetic agent with epinephrine on the hands or feet because the epinephrine is a vasoconstrictor and can cause ischemia and gangrene of extremities. The nurse should suggest that the intern use bupivacaine (Marcaine) without epinephrine as the local anesthetic agent. An intern should be trained in suturing small superficial incisions, and the cosmetic effect should be acceptable. The client's room should be a sufficiently aseptic environment because there is no other client in the room.

Which of the following signs and symptoms experienced by a child with suspected appendicitis should the nurse correctly judge to be unrelated to the transient sympathetic effects caused by the acute abdominal pain? A - Tachycardia. B - Chills. C - Rapid breathing. D - Dilated pupils.

CORRECT ANSWER: B

RATIONALE: Chills are a normal response of the body's immune system to infection and are not a response of the sympathetic nervous system to pain. Tachycardia, increased respiratory rate, and dilated pupils are sympathetic effects.

When assessing a dark-skinned client for cyanosis, the nurse should examine which of the following? A - The client's retinas. B - The client's nail beds. C - The client's oral mucous membranes. D - The inner aspects of the client's wrists.

CORRECT ANSWER: C

RATIONALE: In dark-skinned clients, cyanosis can best be detected by examining the conjunctiva, lips, and oral mucous membranes. Examining the retinas, nail beds, or inner aspects of the wrists is not an appropriate assessment for determining cyanosis in any client.


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