Answers and Rationales
1. A. The oxytocic effect of Pitocin increases the intensity
and durations of contractions; prolonged contractions
will jeopardize the safetyof the fetus and necessitate
discontinuing the drug.
2. B. It is of paramount importance to prevent the client
from hurting himself or herself or others.
3. B. After tonsillectomy, clear, cool liquids should be given.
Citrus, carbonated, and hot or cold liquids should be
avoided because they may irritate the throat. Red liquids
should be avoided because they give the appearance of
blood if the child vomits. Milk and milk products
including pudding are avoided because they coat the
throat, cause the child to clear the throat, and increase
the risk of bleeding.
4. A. Phenylephrine, with frequent and continued use, can
cause rebound congestion of mucous membranes.
5. B. The N 95 respirator is a high-particulate Qltration mask
that meets the CDC performance criteria for a
tuberculosis respirator.
6. C. The most frequent cause of noncompliance to the
treatment of chronic, or open-angle glaucoma is the
miotic effects of pilocarpine. Pupillary constriction
impedes normal accommodation, making night driving
diqcult and hazardous, reducing the client’s ability to
read for extended periods and making participation in
games with fast-moving objects impossible.
7. B. This stops the sucking of air through the tube and
prevents the entry of contaminants. In addition, clamping
near the chest wall provides for some stability and may
prevent the clamp from pulling on the chest tube.
8. D. Because umbilical cord’s insertion site is born before
the fetal head, the cord may be compressed by the after-
coming head in a breech birth.
9. B. It is important to externalize the anger away from self.
10. D. Development normally proceeds cephalocaudally; so
the Qrst major developmental milestone that the infant
achieves is the ability to hold the head up within the Qrst
8-12 weeks of life. In hypothyroidism, the infant’s muscle
tone would be poor and the infant would not be able to
achieve this milestone.
11. D. Get a senior nurse who know s the policies, the client,
and the doctor. Generally speaking, a nurse should not
accept telephone orders. However, if it is necessary to
take one, follow the hospital’s policy regarding telephone
orders. Failure to followhospital policy could be
considered negligence. In this case, the nurse was new
and did not know the hospital’s policy concerning
telephone orders. The nurse was also unfamiliar with the
doctor and the client. Therefore the nurse should not
take the order unless a) no one else is available and b) it
is an emergency situation.
12. C. The nurse is obligated to inform the nurse manager
about changes in the condition of the client, which may
change the decision made by the nurse manager.
13. A. Perinatal risk factors for the development of Down
syndrome include advanced maternal age, especially
with the Qrst pregnancy.
14. B. Assignments should be based on scope of practice
and expertise.
15. B. The child who is concurrently taking digoxin and
diuretics is at increased risk for digoxin toxicity due to
the loss of potassium. The child and parents should be
taught what foods are high in potassium, and the child
should be encouraged to eat a high-potassium diet. In
addition, the child’s serum potassium level should be
carefully monitored.
16. A. The responsible for an accurate informed consent is
the physician. An exception to this answer would be a
life-threatening emergency, but there are no data to
support another response.
17. D. Asking the client to cough and take a deep breath will
help determine if the chest tube is kinked or if the lungs
has reexpanded.
18. B. Every event that exposes a client to harm should be
recorded in an incident report, as well as reported to the
appropriate supervisors in order to resolve the current
problems and permit the institution to prevent the
problem from happening again.
19. D. One of the earliest signs of digoxin toxicity is
Bradycardia. For a toddler, any heart rate that falls below
the norm of about 100-120 bpm would indicate
Bradycardia and would necessitate holding the
medication and notifying the physician.
20. B. This option is least threatening.
21. D. In preparing the client for discharge that is receiving
prednisone, the nurse should caution the client to (a)
take oral preparations after meals; (b) remember that
routine checks of vital signs, weight, and lab studies are
critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF
MEDICATION WITHOUT MEDICAL ADVICE; (d) store the
medication in a light-resistant container.
22. A. Progesterone also reduces smooth muscle motility in
the urinary tract and predisposes the pregnant woman to
urinary tract infections. Women should contact their
doctors if they exhibit signs of infection. Kegel exercise
will help strengthen the perineal muscles; limiting iuids
at bedtime reduces the possibility of being awakened by
the necessity of voiding.
23. B. This is the proper use of anger.
24. C. There are several models of case management, but
the commonality is comprehensive coordination of care
to better predict needs of high-risk clients, decrease
exacerbations and continually monitor progress
overtime.
25. A. Phenytoin should be infused or injected into larger
veins to avoid the discoloration know as purple glove
syndrome; infusing into a smaller vein is not appropriate.
26. C. Serum radioimmunoassay (RIA) is accurate within
7days of conception. This test is speciQc for HCG, and
accuracy is not compromised by confusion with LH.
27. D. Surgery and anesthesia can increase mucus
production. Deep breathing and coughing are essential to
prevent atelectasis and pneumonia in the client’s only
remaining lung.
28. B. Newborns can get pneumonia (tachypnea, mild
hypoxia, cough, eosinophilia) and conjunctivitis from
Chlamydia.
29. D. The client may perceive this as avoidance, but it is
more important to redirect back to the client, especially
in light of the manipulative behavior of drug abusers and
adolescents.
30. C. It describes a democratic process in which all
members have input in the client’s care.
31. A. Contraction of the milk ducts and let-down reiex
occur under the stimulation of oxytocin released by the
posterior pituitary gland.
32. B. In case management, the nurse assumes total
responsibility for meeting the needs of the client during
the entire time on duty.
33. A. Smoke inhalation affects gas exchange.
34. C. Sperm deposited during intercourse may remain
viable for about 3 days. If ovulation occurs during this
period, conception may result.
35. B. This option shows acceptance (key concept) of this
age-typical sleep pattern (that of waking in the early
morning).
36. D. Taking the mother’s pulse while listening to the FHR
will differentiate between the maternal and fetal heart
rates and rule out fetal Bradycardia.
37. A. Antihistamines cause pupil dilation and should be
avoided with glaucoma.
38. A. This suggests that the level of consciousness is
decreasing.
39. D. An advance directive is a form of informed consent,
and only a competent adult or the holder of a durable
power of attorney has the right to consent or refuse
treatment. If the spouse does not hold the power of
attorney, the decisions of the holder, even if opposed by
the spouse, are enforced.
40. C. Gentle but Qrm guidance and nonverbal direction is
needed to intervene when a client with schizophrenic
symptoms is being disruptive.
41. C. Suctioning is only done for 10 seconds, intermittently,
as the catheter is being withdrawn.
42. D. The priority for this client is being able to establish an
airway.
43. A. Signs of placental separation include a change in the
shape of the uterus from ovoid to globular.
44. B. This could indicate intracranial bleeding. Alteplase is a
thrombolytic enzyme that lyses thrombi and emboli.
Bleeding is an adverse effect. Monitor clotting times and
signs of any gastrointestinal or internal bleeding.
45. D. Because iank incision in nephrectomy is directly
below the diaphragm, deep breathing is painful.
Additionally, there is a greater incisional pull each time
the person moves than there is with abdominal surgery.
Incisional pain following nephrectomy generally requires
analgesics administration every 3-4 hours for 24-48
hours after surgery. Therefore, turning, coughing and
deep-breathing exercises should be planned to maximize
the analgesic effects.
46. B. Under high estrogen levels, during the period
surrounding ovulation, the cervical mucus becomes thin,
clear, and elastic (spinnbarkeit), facilitating sperm
passage.
47. D. After surgery for a ruptured appendix, the client should
be placed in a semi-Fowler’s position to promote
drainage and to prevent possible complications.
48. C. Directing and evaluation of staff is a major
responsibility of a nursing manager.
49. A. The recommended procedure for administering
eyedrops to any client calls for the drops to be placed in
the middle of the lower conjunctival sac.
50. B. Thirst and restlessness indicate hypovolemia and
hypoxemia. Internal bleeding is diqcult to recognized
and evaluate because it is not apparent.
51. C. Erythema toxicum is the normal, nonpathological
macular newborn rash.
52. D. The family needs to understand what brain death is
before talking about organ donation. They need time to
accept the death of their family member. An environment
conducive to discussing an emotional issue is needed.
53. A. Bending from the waist in pregnancy tends to make
backache worse.
54. B. Support and limit setting decrease anxiety and provide
external control.
55. C. The stoma drainage bag is applied in the operating
room. Drainage from the ileostomy contains secretions
that are rich in digestive enzymes and highly irritating to
the skin. Protection of the skin from the effects of these
enzymes is begun at once. Skin exposed to these
enzymes even for a short time becomes reddened,
painful and excoriated.
56. B. It is the most accurate statement of physiological
facts for a 28-day menstrual cycle: ovulation at day 14,
egg life span 24 hours, sperm life span of 72 hours.
Fertilization could occur from sperm deposited before
ovulation.
57. C. An advocate role encourage freedom of choice,
includes speaking out for the client, and supports the
client’s best interests.
58. A. Abstinence will eliminate any unnecessary pain during
intercourse and will reduce the possibility of transmitting
infection to one’s sexual partner.
59. B. Anxiety is generated by group therapy at 9:00 AM. The
ritualistic behavioral defense of hand washing decreases
anxiety by avoiding group therapy.
60. D. Denial is a very strong defense mechanism used to
allay the emotional effects of discovering a potential
threat. Although denial has been found to be an effective
mechanism for survival in some instances, such as
during natural disasters, it may in greater pathology in a
woman with potential breast carcinoma.
61. B. The registered nurse cannot delegate the
responsibility for assessment and evaluation of clients.
The status of the client in restraint requires further
assessment to determine if there are additional causes
for the behavior.
62. C. The client with chest pain may be having a myocardial
infarction, and immediate assessment and intervention
is a priority.
63. B. Is correct because semen analysis requires that a
freshly masturbated specimen be obtained after a rest
(abstinence) period of 48-72 hours.
64. C. Betamethasone, a form of cortisone, acts on the fetal
lungs to produce surfactant.
65. A. Secretions may have pooled above the tracheostomy
cuff. If these are not suctioned before deiation, the
secretions may be aspirated.
66. C. Proper handling of sputum is essential to allay droplet
transference of bacilli in the air. Clients need to be taught
to cover their nose and mouth with tissues when
sneezing or coughing. Chemotherapy generally renders
the client noninfectious within days to a few weeks,
usually before cultures for tubercle bacilli are negative.
Until chemical isolation is established, many institutions
require the client to wear a mask when visitors are in the
room or when the nurse is in attendance. Client should
be in a well-ventilated room, without air recirculation, to
prevent air contamination.
67. A. It is best to establish baseline information Qrst.
68. B. Listening is probably the most effective response of
the four choices.
69. A. Urine iow is continuous. The pouch has an outlet
valve for easy drainage every 3-4 hours. (the pouch
should be changed every 3-5 days, or sooner if the
adhesive is loose).
70. C. A high fever accompanied by a body rash could
indicate that the child has a communicable disease and
would have exposed other students to the infection. The
school nurse would want to investigate this telephone
call immediately so that plans could be instituted to
control the spread of such infection.
71. A. Severe abdominal pain may indicate complications of
pregnancy such as abortion, ectopic pregnancy, or
abruption placenta; iuid discharge from the vagina may
indicate premature rupture of the membrane.
72. D. Gentle aspiration of mucus helps maintain a patent
airway, required for effective gas exchange.
73. A. Somatoform disorders provide a way of coping with
coniicts.
74. C. Immunization should never be mixed together in a
syringe, thus necessitating three separate injections in
three sites. Note: some manufacturers make a premixed
combination of immunization that is safe and effective.
75. A. Clients with radioactive implants should be positioned
iat in bed to prevent dislodgement of the vaginal
packing. The client may roll to the side for meals but the
upper body should not be raised more than 20 degrees.
76. A. Syrup of ipecac is not administered when the ingested
substances is corrosive in nature. Toilet bowl cleaners,
as a collective whole, are highly corrosive substances. If
the ingested substance “burned” the esophagus going
down, it will “burn” the esophagus coming back up when
the child begins to vomit after administration of syrup of
ipecac.
77. B. Inability to open eyelids on operative side is seen with
cranial nerve III damage.
78. A. Assessment of physical injuries (like bruises,
lacerations, bleeding and fractures) is the Qrst priority.
79. C. The nurse who is supervising others has a legal
obligation to determine that they are competent to
perform the assignment, as well as legal obligation to
provide adequate supervision.
80. D. Increasing hydrostatic pressure in the urinary tract will
facilitate passage of the calculi.
81. A. Infertility is not diagnosed until atleast 12months of
unprotected intercourse has failed to produce a
pregnancy. Older couples will experience a longer time to
get pregnant.
82. B. Determining how well the kidneys Qlter wastes states
the purpose of a Creatinine clearance test.
83. A. Acknowledging a feeling tone is the most therapeutic
response and provides a broad opening for the client to
elaborate feelings.
84. C. The behavior should be stopped. The Qrst is to remind
the staff that conQdentiality maybe violated.
85. C. With a right-sided cerebrovascular accident the client
would have left-sided hemiplegia or weakness. The
client’s good side should be closest to the bed to
facilitate the transfer.
86. D. Legos are small plastic building blocks that could
easily slip under the child’s cast and lead to a break in
skin integrity and even infection. Pencils, backscratchers,
and marbles are some other narrow or small items that
could easily slip under the child’s cast and lead to a break
in skin integrity and infection.
87. D. Oxytocin (Pitocin) is used to maintain uterine tone.
88. B. The submission of reports about incidents that
expose clients to harm does not remove the obligation to
report ongoing behavior as long as the risk to the client
continues.
89. C. The recommended dosage of tetracycline is 25-
50mg/kg/day. If the child weighs 20kg and the maximum
dose is 50mg/kg, this would indicate a total daily dose of
1000mg of tetracycline. In this case, the child is being
given this medication four times a day. Therefore the
maximum single dose that can be given is 250mg (1000
mg of tetracycline divided by four doses.)
90. C. An abnormality in the uterine muscle could reduce the
effectiveness of uterine contractions and lengthen the
duration of subsequent labors.
91. A. Personality disorders stem from a weak superego,
implying a lack of adequate controls.
92. C. The basal body temperature is the lowest body
temperature of a healthy person that is taken
immediately after waking and before getting out of bed.
The BBT usually varies from 36.2 ºC to 36.3ºC during
menses and for about 5-7 days afterward. About the
time of ovulation, a slight drop in temperature may be
seen, after ovulation in concert with the increasing
progesterone levels of the early luteal phase, the BBT
rises 0.2-0.4 ºC. This elevation remains until 2-3 days
before menstruation, or if pregnancy has occurred.
93. A. This choice implies concern for client care and self-
improvement.
94. C. The Qrst trimester is the period of organogenesis, that
is, cell differentiation into the various organs, tissues, and
structures.
95. C. This response does not contradict the client’s
perception, is honest, and shows empathy.
96. D. Tension on round ligament occurs because of the
erect human posture and pressure exerted by the
growing fetus.
97. D. The Good Samaritan Law does not impose a duty to
stop at the scene of an emergency outside of the scope
of employment, therefore nurses who do not stop are not
liable for suit.
98. C. Although reducing environment stimuli and activity is
necessary for a woman with mild preeclampsia, she will
most probably have bathroom privileges.
99. B. A normal respiratory rate for a newborn is 30-40
breaths per minute.
100. D. The behavior described is likely to be symptoms of
delirium tremens, or alcohol withdrawal (often
unsuspected on a surgical unit.)