The therapeutic blood-level range for lithium is:
A. 0.25–1.0 mEq/L
B. 0.5–1.5 mEq/L
C. 1.0–2.0 mEq/L
D. 2.0–2.5 mEq/L
Answer:
... [Show More] B
Explanation:
(A) This range is too low to be therapeutic. (B) This is the therapeutic range for lithium. (C) This range is above
the therapeutic level. (D) This range is toxic and may cause severe side effects.
QUESTION 94
Which of the following ECG changes would be seen as a positive myocardial stress test response?
A. Hyperacute T wave
B. Prolongation of the PR interval
C. ST-segment depression
D. Pathological Q wave
Answer: C
Explanation:
(A) Hyperacute T waves occur with hyperkalemi
A. (B) Prolongation of the P R interval occurs with first-degree AV block. (C) Horizontal ST-segment
depression of>1 mm during exercise isdefinitely a positive criterion on the exercise ECG test. (D) Patho-logical
Q waves occur with MI.
QUESTION 95
A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?
A. Somatic
B. Grandiose
C. Persecutory
D. Nihilistic
Answer: B
Explanation:
(A) These delusions are related to the belief that an individual has an incurable illness. (B) These delusions are
related to feelings of self-importance and uniqueness. (C) These delusions are related to feelings of being
conspired against. (D) These delusions are related to denial of self-existence.
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QUESTION 96
During burn therapy, morphine is primarily administered IV for pain management because this route:
A. Delays absorption to provide continuous pain relief
B. Facilitates absorption because absorption from muscles is not dependable
C. Allows for discontinuance of the medication if respiratory depression develops
D. Avoids causing additional pain from IM injections
Answer: B
Explanation:
(A) Absorption would be increased, not decreased. (B) IM injections should not be used until the client is
hemodynamically stable and has adequate tissue perfusion. Medications will remain in the subcutaneous tissue
with the fluid that is present in the interstitial spaces in the acute phase of the thermal injury. The client will
have a poor response to the medication administered, and a “dumping” of the medication can occur when the
medication and fluid are shifted back into the intravascular spaces in the next phase of healing. (C) IV
administration of the medication would hasten respiratory compromise, if present. (D) The desire to avoid
causing the client additional pain is not a primary reason for this route of administration.
QUESTION 97
Assessment of the client with pericarditis may reveal which of the following?
A. Ventricular gallop and substernal chest pain
B. Narrowed pulse pressure and shortness of breath
C. Pericardial friction rub and pain on deep inspiration
D. Pericardial tamponade and widened pulse pressure
Answer: C
Explanation:
(A) No S3 or S4 are noted with pericarditis. (B) No change in pulse pressure occurs. (C) The symptoms of
pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature,
and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep
inspiration. (D) Tamponade is not typically seen early on, and no change in pulse pressure occurs.
QUESTION 98
A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After
establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing
intervention would be to:
A. Pass a nasogastric tube through the left nostril
B. Place a 4 X 4 gauze in the nares to impede the flow
C. Gently suction the nasal drainage to protect the airway
D. Perform a halo test and glucose level on the drainage
Answer: D
Explanation:
(A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose.
Insertion of a tube could lead to CSF going into the brain tissue or sinuses.
(B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage
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and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the
head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy.
QUESTION 99
To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work
and O2 demand will occur with which of the following?
A. Positive inotropic therapy
B. Negative chronotropic therapy
C. Increase in balance of myocardial O2 supply and demand
D. Afterload reduction therapy
Answer: A
Explanation:
(A) Inotropic therapy will increase contractility, which will increase myocardial O2 demand.
(B) Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be
used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The
goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and
demand. (D) Decrease in
systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon
pump therapy, would decrease myocardial work and O2 demand.
QUESTION 100
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
A. Hypovolemia
B. Renal damage
C. Ventricular arrhythmias
D. Loss of peripheral pulses
Answer: D
Explanation:
(A) Hypovolemia could be a result of fluid loss from thermal injury, but not as a result of the circumferential
injury. (B) Renal damage is typically seen because of prolonged hypovolemia or myoglobinuri
A. (C) Electrical injuries and electrolyte changes typically cause arrhythmias in the burn client. (D) Fullthickness circumferential burns are nonelastic and result in an internal tourniquet effect that compromises distal
blood flow when the area involved is an extremity.Circumferential full-thickness torso burns compromise
respiratory motion and, when extreme, cardiac return.
QUESTION 101
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant
twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy
produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL
system to record her obstetrical history, the nurse should record:
A. 3-2-0-0-2
B. 2-2-0-2-2
C. 3-1-1-0-2
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D. 2-1-1-0-2
Answer: C
Explanation:
(A) This answer is an incorrect application of the GTPAL method.
One prior pregnancy was a preterm birth at 36 weeks (T =1, P= 1; not T = 2). (B) This answer is an incorrect
application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2), one prior
pregnancy was preterm (T= 1, P= 1; not T= 2), and she has had no prior abortions (A =0). (C) This answer is
the correct application of GTPAL method. The client is currently pregnant for the third time (G =3), her first
pregnancy ended at term (>37 weeks) (T = 1), her second pregnancy ended preterm 20–33 weeks) (P = 1), she
has no history of abortion (A=0), and she has two living children (L = 2). (D) This answer is an incorrect
application of the GTPAL method. The client is currently pregnant for
the third time (G =3, not 2).
QUESTION 102
A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is
started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is
drawn. Which of the following values represents a therapeutic level?
A. 14 µ g/mL
B. 25 µ g/mL
C. 4 µ g/mL
D. 30 µ g/mL
Answer: A
Explanation:
(A) The therapeutic blood level range of theophylline is 10–20 mg/mL. Therapeutic drug monitoring determines
effective drug dosages and prevents toxicity. (B, D) This value is a toxic level of the drug. (C) This value is a
nontherapeutic level of the drug.
QUESTION 103
A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG
tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is
most likely experiencing:
A. Hyperkalemia
B. Hyponatremia
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: D
Explanation:
(A) Sodium level is within normal limits. (B) Sodium level is within normal limits. (C) pH level is consistent
with alkalosis. (D) With an NG tube attached to low, intermittent suction, acids are removed and a client will
develop metabolic alkalosis.
QUESTION 104
A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best
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auscultated just:
A. Below the umbilicus toward left side of mother’s abdomen
B. Below the umbilicus toward right side of mother’s abdomen
C. At the umbilicus
D. Above the umbilicus to the left side of mother’s abdomen
Answer: A
Explanation:
(A) LOA identifies a fetus whose back is on its mother’s left side, whose head is the presenting part, and whose
back is toward its mother’s anterior. It is easiest to auscultate fetal heart tones (FHTs) through the fetus’s back.
(B) The identified fetus’s back is on its mother’s left side, not right side. It is easiest to auscultate FHTs through
the fetus’s back.
(C) In an LOA position, the fetus’s head is presenting with the back to the left anterior side of the mother. The
umbilicus is too high of a landmark for auscultating the fetus’s heart rate through its back. (D) This is the
correct auscultation point for a fetus in the left sacroanterior position, where the sacrum is presenting, not LOA.
QUESTION 105
A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet
training. What should the nurse teach her about implementing toilet training?
A. Take two or three favorite toys with the child.
B. Have a child-sized toilet seat or training potty on hand.
C. Explain to the child she is going to “void” and “defecate.”
D. Show disapproval if she does not void or defecate.
Answer: B
Explanation:
(A) Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement. (B)
A child-sized toilet seat or training potty gives a child a feeling of security. (C) She should use words that are
age appropriate for the child. (D) Children should be praised for cooperative behavior and/or successful
evacuation.
QUESTION 106
Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in
a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body?
A. Urine output
B. Edema
C. Hypertension
D. Bulging fontanelle
Answer: A
Explanation:
(A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is
adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. (B) Edema is
an indication of increased capillary permeability following a burn injury. (C) Hypertension is an indicator of
fluid volume excess. (D) Fontanelles close by 18 months of age.
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QUESTION 107
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
A. Immediate treatment of mild PIH includes the administration of a variety of medications
B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
C. Self-discipline is required to control caloric intake throughout the pregnancy
D. The client may not recognize the early symptoms of PIH
Answer: D
Explanation:
(A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation
in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not
aware of the signs and symptoms in mild PIH.
QUESTION 108
A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was
at station plus two. Station 12 means that the:
A. Presenting part is 2 cm above the level of the ischial spines
B. Biparietal diameter is at the level of the ischial spines
C. Presenting part is 2 cm below the level of the ischial spines
D. Biparietal diameter is 5 cm above the ischial spines
Answer: C
Explanation:
(A) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the
presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the
level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of
the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the
ischial spines, the station is positive. Thus, 2 cm below the ischial spines is the station +2. (D) When the
biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0.
QUESTION 109
To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:
A. Rinse the plastic holder that aerosolizes the drug with hydrogen peroxide every other day
B. Rinse the mouth and gargle with warm water after each use of the inhaler
C. Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection
D. Rinse the mouth before each use to eliminate colonization of bacteria
Answer: B
Explanation:
(A) It is sufficient to rinse the plastic holders with warm water at least once per day. (B) It is important to rinse
the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid
left in the oral cavity. (C) Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the
stomach. “Neutralizing” the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of
fungal
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infections. (D) Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral
mucous membranes following the use of the inhaler.
QUESTION 110
A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her
7th to 8th month; her face and hands indicate edem
A. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client’s weight increase is
most likely due to:
A. Overeating and subsequent obesity
B. Obesity prior to conception
C. Hypertension due to kidney lesions
D. Fluid retention
Answer: D
Explanation:
(A) Overeating can lead to obesity, but not to edem
A. (B) There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the
obese in this age group. (C) Hypertension can be due to kidney lesions, but it would have been apparent earlier
in the pregnancy. (D) The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the
three cardinal symptoms of PIH.
QUESTION 111
A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a
growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal
deprivation?
A. Responsive to touch, wants to be held
B. Uncomforted by touch, refuses bottle
C. Maintains eye-to-eye contact
D. Finicky eater, easily pacified, cuddly
Answer: B
Explanation:
(A) Normal infant attachment behaviors include responding to touch and wanting to be held. (B) Maternal
deprivation behaviors include poor feeding, stiffening and refusal to eat,
and inconsistencies in responsiveness. (C) Attachment behavior includes maintaining eye
contact. (D) Maternal deprivation behaviors include displeasure with touch and physical
contact.
QUESTION 112
The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the
following indicates that he understands this teaching?
A. “I’ll be sure to rise slowly and sit for a few minutes after lying down.”
B. “I’ll be sure to walk at least 2–3 blocks every day.”
C. “I’ll be sure to restrict my fluid intake to four or five glasses a day.”
D. “I’ll be sure not to take any more aspirin while I am [Show Less]