MS Test Drill IV: musculoskeletal

Musculoskeletal Examination

1. A client is 1 day postoperative after a total hip replacement. The client should be placed in which of the following position?

a. Supine
b. Semi Fowler's
c. Orthopneic
d. Trendelenburg

2. A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make?

a. Observe the color of the fingers
b. Palpate the radial pulse under the cast
c. Check the cast for odor and drainage
d. Evaluate the response to analgesics

3. After a computer tomography scan with intravenous contrast medium, a client returns to the unit complaining of shortness of breath and itching. The nurse should be prepared to treat the client for:

a. An anaphylactic reaction to the dye
b. Inflammation from the extravasation of fluid during injection.
c. Fluid overload from the volume of the infusions
d. A normal reaction to the stress of the diagnostic procedure.

4. While caring for a client with a newly applied plaster of Paris cast, the nurse makes note of all the following conditions. Which assessment finding requires immedite notification of the physician?

a. Moderate pain, as reported by the client
b. Report, by client, the heat is being felt under the cast
c. Presence of slight edema of the toes of the casted foot
d. Onset of paralysis in the toes of the casted foot

5. Which of these nursing actions will best promote independence for the client in skeletal traction?

a. Instruct the client to call for an analgesic before pain becomes severe.
b. Provide an overhead trapeze for client use
c. Encourage leg exercise within the limits of traction
d. Provide skin care to prevent skin breakdown.

6. A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis.

a. The client reports pain in the affected leg
b. A large hematoma is visible in the affected extremity
c. The affected extremity is shortenend, adducted, and extremely rotated
d. The affected extremity is edematous.

7. The nurse is caring for a client with compound fracture of the tibia and fibula. Skeletal traction is applied. Which of these priorities should the nurse include in the care plan?

a. Order a trapeze to increase the client's ambulation
b. Maintain the client in a flat, supine position at all times.
c. Provide pin care at least every hour
d. Remove traction weights for 20 minutes every two hours.

8. To prevent foot drop in a client with Buck's traction, the nurse should:

a. Place pillows under the client's heels.
b. Tuck the sheets into the foot of the bed
c. Teach the client isometric exercises
d. Ensure proper body positioning.

9. Which nursing intervention is appropriate for a client with skeletal traction?

a. Pin care
b. Prone positioning
c. Intermittent weights
d. 5lb weight limit

10. In order for Buck's traction applied to the right leg to be effective, the client should be placed in which position?

a. Supine c. Sim's
b. Prone d. Lithotomy

11. An elderly client has sustained intertrochanteric fracture of the hip and has just returned from surgery where a nail plate was inserted for internal fixation. The client has been instructed that she should not flex her hip. The best explanation of why this movement would be harmful is:

a. It will be very painful for the client
b. The soft tissue around the site will be damaged
c. Displacement can occur with flexion
d. It will pull the hip out of alignment

12. When the client is lying supine, the nurse will prevent external rotation of the lower extremity by using a:

a. Trochanter roll by the knee
b. Sandbag to the lateral calf
c. Trochanter roll to the thigh
d. Footboard

13. A client has just returned from surgery after having his left leg amputated below the knee. Physician's orders include elevation of the foot of the bed for 24 hours. The nurse observes that the nursing assistant has placed a pillow under the client's amputated limb. The nursing action is to:

a. Leave the pillow as his stump is elevated
b. Remove the pillow and elevate the foot of the bed
c. Leave the pillow and elevate the foot of the bed
d. Check with the physician and clarify the orders

14. A client has sustained a fracture of the femur and balanced skeletal traction with a Thomas splint has been applied. To prevent pressure points from occurring around the top of the splint, the most important intervention is to:

a. Protect the skin with lotion
b. Keep the client pulled up in bed
c. Pad the top of the splint with washcloths
d. Provide a footplate in the bed

15. The major rationale for the use of acetylsalicylic acid (aspirin) in the treatment of rheumatoid arthritis is to:

a. Reduce fever
b. Reduce the inflammation of the joints
c. Assist the client's range of motion activities without pain
d. Prevent extension of the disease process

16. Following an amputation, the advantage to the client for an immediate prosthesis fitting is:

a. Ability to ambulate sooner
b. Less change of phantom limb sensation
c. Dressing changes are not necessary
d. Better fit of the prosthesis

17. One method of assessing for sign of circulatory impairment in a client with a fractured femur is to ask the client to:

a. Cough and deep breathe
b. Turn himself in bed
c. Perform biceps exercise
d. Wiggle his toes

18. The morning of the second postoperative day following hip surgery for a fractured right hip, the nurse will ambulate the client. The first intervention is to:

a. Get the client up in a chair after dangling at the bedside.
b. Use a walker for balance when getting the client out of bed
c. Have the client put minimal weight on the affected side when getting up
d. Practice getting the client out of bed by having her slightly flex her hips

19. A young client is in the hospital with his left leg in Buck's traction. The team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to:

a. Anchor the traction
b. Prevent footdrop
c. Keep the client from sliding down in bed
d. Prevent pressure areas on the foot

20. When evaluating all forms of traction, the nurse knows the direction of pull is controlled by the:

a. Client's position
b. Rope/pulley system
c. Amount of weight
d. Point of friction

21. When a client has cervical halter traction to immobilize the cervical spine counteraction is provided by:

a. Elevating the foot of the bed
b. Elevating the head of the bed
c. Application of the pelvic girdle
d. Lowering the head of the bed

22. After falling down the basement steps in his house, a client is brought to the emergency room. His physician confirms that his leg is fractured. Following application of a leg cast, the nurse will first check the client's toes for:

a. Increase in the temperature
b. Change in color
c. Edema
d. Movement

23. A 23 year old female client was in an automobile accident and is now a paraplegic. She is on an intermittent urinary catheterization program and diet as tolerated. The nurse's priority assessment should be to observe for:

a. Urinary retention
b. Bladder distention
c. Weight gain
d. Bower evacuation

24. A female client with rheumatoid arthritis has been on aspirin grain TID and prednisone 10mg BID for the last two years. The most important assessment question for the nurse to ask related to the client's drug therapy is whether she has

a. Headaches
b. Tarry stools
c. Blurred vision
d. Decreased appetite

25. A 7 year old boy with a fractured leg tells the nurse that he is bored. An appropriate intervention would be to

a. Read a story and act out the part
b. Watch a puppet show
c. Watch television
d. Listen to the radio

26. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. Which of the following would be the nurse most likely to asses:

a. Limited motion of joints
b. Deformed joints of the hands
c. Early morning stiffness
d. Rheumatoid nodules

27. After teaching the client about risk factors for rheumatoid arthritis, which of the following, if stated by the client as a risk factor, would indicate to the nurse that the client needs additional teaching?

a. History of Epstein-Barr virus infection
b. Female gender
c. Adults between the ages 60 to 75 years
d. Positive testing for human leukocyte antigen (HLA) DR4 allele

28. When developing the teaching plan for the client with rheumatoid arthritis to promote rest, which of the following would the nurse expect to instruct the client to avoid during the rest periods?

a. Proper body alignment
b. Elevating the part
c. Prone lying positions
d. Positions of flexion

29. After teaching the client with severe rheumatoid arthritis about the newly prescribed medication methothrexate (Rheumatrex 0), which of the following statements indicates the need for further teaching?

a. "I will take my vitamins while I am on this drug"
b. "I must not drink any alcohol while I'm taking this drug"
c. I should brush my teeth after every meal"
d. "I will continue taking my birth control pills"

30. When completing the history and physical examination of a client diagnosed with osteoarthritis, which of the following would the nurse assess?

a. Anemia c. Weight loss
b. Osteoporosis d. Local joint pain

31. At which of the following times would the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?

a. At bedtime c. Immediately after meal
b. On arising d. On an empty stomach

32. When preparing a teaching plan for the client with osteoarthritis who is taking celecoxib (Celebrex), the nurse expects to explain that the major advantage of celecoxib over diclofenac (Voltaren), is that the celecoxib is likely to produce which of the following?

a. Hepatotoxicity
b. Renal toxicity
c. Gastrointestinal bleeding
d. Nausea and vomiting

33. After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse interprets these findings as indicating which of the following?

a. A developing infection
b. Bleeding in the operative site
c. Joint dislocation
d. Glue seepage into soft tissue

34. Which of the following would the nurse assess in a client with an intracapsular hip fracture?

a. Internal rotation c. Shortening of the affected leg
b. Muscle flaccidity d. Absence of pain the fracture area

35. Which of the following would be inappropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a rupture disc?

a. Informing the client that the procedure is painless
b. Taking a thorough history of past surgeries
c. Checking for previous complaints of claustrophobia
d. Starting an intravenous line at keep-open rate

36. Which of the following actions would be a priority for a client who has been in the postanesthesia care unit (PACU) for 45 minutes after an above the knee amputation and develops a dime size bright red spot on the ace bondage above the amputation site?

a. Elevate the stump
b. Reinforcing the dressing
c. Calling the surgeon
d. Drawing a mark around the site

37. A client in the PACU with a left below the knee amputation complains of pain in her left big toe. Which of the following would the nurse do first?

a. Tell the client it is impossible to feel the pain
b. Show the client that the toes are not there
c. Explain to the client that the pain is real
d. Give the client the prescribed narcotic analgesic

38. The client with an above the knee amputation is to use crutches until the prosthesis is being adjusted. In which of the following exercises would the nurse instruct the client to best prepare him for using crutches?

a. Abdominal exercises
b. Isometric shoulder exercises
c. Quadriceps setting exercises
d. Triceps stretching exercises

39. The client with an above the knee amputation is to use crutches until the prosthesis is properly lifted. When teaching the client about using the crutches, the nurse instructs the client to support her weight primarily on which of the following body areas?

a. Axillae
b. Elbows
c. Upper arms
d. Hands

40. Three hours ago a client was thrown from a car into a ditch, and he is now admitted to the ED in a stable condition with vital signs within normal limits, alert and oriented with good coloring and an open fracture of the right tibia. When assessing the client, the nurse would be especially alert for signs and symptoms of which of the following?

a. Hemorrhage
b. Infection
c. Deformity
d. Shock

41. The client with a fractured tibia has been taking methocarbamol (Robaxin), when teaching the client about this drug, which of the following would the nurse include as the drug's primary effect?

a. Killing of microorganisms
b. Reduction in itching
c. Relief of muscle spasms
d. Decrease in nervousness

42. A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mmHg, a pulse rate of 115bpm, and respirations of 8 breaths/minute and shallow, the nurse interprets these finding as indicating which of the following?

a. Expected common side effects
b. Hypersensitivity reactions
c. Possible habituating effects
d. Hemorrhage from GI irritation

43. When admitting a client with a fractured extremity, the nurse would focus the assessment on which of the following first?

a. The area proximal to the fracture
b. The actual fracture site
c. The area distal to the fracture
d. The opposite extremity for baseline comparison

44. A client with fracture develops compartment syndrome. When caring for the client, the nurse would be alert for which of the following signs of possible organ failure?

a. Rales c. Generalized edema
b. Jaundice d. Dark, scanty urine

45. Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?

a. Acute respiratory distress syndrome
b. Migraine like headaches
c. Numbness in the right leg
d. Muscle spasms in the right thigh

46. The client who had an open femoral fracture was discharged to her home, where she developed, fever, night sweats, chills, restlessness and restrictive movement of the fractured leg. The nurse interprets these finding as indicating which of the following?

a. Pulmonary emboli
b. Osteomyelitis
c. Fat emboli
d. Urinary tract infection

47. When antibiotics are not producing the desired outcome for a client with osteomyelitis, the nurse interprets this as suggesting the occurrence of which of the following as most likely?

a. Formation of scar tissue interfering with absorption
b. Development of pus leading to ischemia
c. Production of bacterial growth by avascular tissue
d. Antibiotics not being instilled directly into the bone

48. Which of the following would the nurse use as the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury?

a. Homan's sign c. Tenderness
b. Pain d. Leg girth

49. The nurse is caring for the client who is going to have an arthogram using a contrast medium. Which of the following assessments by the nurse are of highest priority?

a. Allergy to iodine or shellfish
b. Ability of the client to remain still during the procedure
c. Whether the client has any remaining questions about the procedure
d. Whether the client wishes to void before the procedure

50. The client immobilized skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse formulates which of the following nursing diagnoses for this client?

a. Divertional activity deficit
b. Powerlessness
c. Self care deficit
d. Impaired physical mobility

51. The nurse is teaching the client who is to have a gallium scan about the procedure. The nurse includes which of the following items as part of the instructions?

a. The gallium will be injected intravenously 2 to 3 hours before the procedure
b. The procedure takes about 15 minutes to perform
c. The client must stand erect during the filming
d. The client should remain on bed rest for the remainder of the day after the scan

52. The nurse is assessing the casted extremity of a client. The nurse assesses for which of the following signs and symptoms indicative of infection?

a. Coolness and pallor of the extremity
b. Presence of a "hot spot" on the cast
c. Diminished distal pulse
d. Dependent edema

53. The client has Buck's extension applied to the right leg. The nurse plans which of the following interventions to prevent complications of the device?

a. Massage the skin of the right leg with lotion every 8 hours
b. Give pin care once a shift
c. Inspect the skin on the right leg at least once every 8 hours
d. Release the weights on the right leg for range of motion exercises daily

54. The nurse is giving the client with a left cast crutch walking instructions using the three point gait. The client is allowed touchdown of the affected leg. The nurse tells the client to advance the:

a. Left leg and right crutch then right leg and left crutch
b. Crutches and then both legs simultaneously
c. Crutches and the right leg then advance the left leg
d. Crutches and the left leg then advance the right leg

55. The client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the cane by holding it with the:

a. Left hand and placing the cane in front of the left foot
b. Right hand and placing the cane in front of the right foot
c. Left hand and 6 inches lateral to the left foot
d. Right hand and 6 inches lateral to the left foot

56. The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. The nurse uses a:

a. Pillow to keep the right leg abducted during turning
b. Pillow to keep the right leg adducted during turning
c. Trochanter roll to prevent external rotation while turning
d. Trochanter roll to prevent abduction while turning

57. The nurse has an order to get the client out of bed to a chair on the first postoperative day after a total knee replacement. The nurse plans to do which of the following to protect the knee joint:

a. Apply a knee immobilizer before getting the client up and elevate the client's surgical leg while sitting
b. Apply an Ace wrap around the dressing and put ice on the knee while sitting
c. Lift the client to the bedside change leaving the CPM machine in place
d. Obtain a walker to minimize weight bearing by the client on the affected leg

58. The nurse is caring for the client who had an above the knee amputation 2days ago. The residual limb was wrapped with an elastic compression bandage which has come off. The nurse immediately:

a. Calls the physician
b. Rewrap the stump with an elastic compression bandage
c. Applies ice to the site
d. Applies a dry sterile dressing and elevates it on a pillow

59. The nurse has taught the client with a below the knee amputation about prosthesis and stump care. The nurse evaluates that the client states to:

a. Wear a clean nylon stump sock daily
b. Toughen the skin of the stump by rubbing it with alcohol
c. Prevent cracking of the skin of the stump by applying lotion daily
d. Using a mirror to inspect all areas of the stump each day

60. The nurse is caring for a client with a gout. Which of the following laboratory values does the nurse expect to note in the client?

a. Uric acid level of 8 mg/dl
b. Calcium level of 9 mg/dl
c. Phosphorus level of 3 mg/dl
d. Uric acid level of 5 mg/dl




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MS Test Drill IV: musculoskeletal (answers)

Musculoskeletal Examination Answers

1. A client is 1 day postoperative after a total hip replacement. The client should be placed in which of the following position?

a. Supine
b. Semi Fowler's
c. Orthopneic
d. Trendelenburg

2. A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make?

a. Observe the color of the fingers
b. Palpate the radial pulse under the cast
c. Check the cast for odor and drainage
d. Evaluate the response to analgesics

3. After a computer tomography scan with intravenous contrast medium, a client returns to the unit complaining of shortness of breath and itching. The nurse should be prepared to treat the client for:

a. An anaphylactic reaction to the dye
b. Inflammation from the extravasation of fluid during injection.
c. Fluid overload from the volume of the infusions
d. A normal reaction to the stress of the diagnostic procedure.

4. While caring for a client with a newly applied plaster of Paris cast, the nurse makes note of all the following conditions. Which assessment finding requires immedite notification of the physician?

a. Moderate pain, as reported by the client
b. Report, by client, the heat is being felt under the cast
c. Presence of slight edema of the toes of the casted foot
d. Onset of paralysis in the toes of the casted foot

5. Which of these nursing actions will best promote independence for the client in skeletal traction?

a. Instruct the client to call for an analgesic before pain becomes severe.
b. Provide an overhead trapeze for client use
c. Encourage leg exercise within the limits of traction
d. Provide skin care to prevent skin breakdown.

6. A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis.

a. The client reports pain in the affected leg
b. A large hematoma is visible in the affected extremity
c. The affected extremity is shortenend, adducted, and extremely rotated
d. The affected extremity is edematous.

7. The nurse is caring for a client with compound fracture of the tibia and fibula. Skeletal traction is applied. Which of these priorities should the nurse include in the care plan?

a. Order a trapeze to increase the client's ambulation
b. Maintain the client in a flat, supine position at all times.
c. Provide pin care at least every hour
d. Remove traction weights for 20 minutes every two hours.

8. To prevent foot drop in a client with Buck's traction, the nurse should:

a. Place pillows under the client's heels.
b. Tuck the sheets into the foot of the bed
c. Teach the client isometric exercises
d. Ensure proper body positioning.

9. Which nursing intervention is appropriate for a client with skeletal traction?

a. Pin care
b. Prone positioning
c. Intermittent weights
d. 5lb weight limit

10. In order for Buck's traction applied to the right leg to be effective, the client should be placed in which position?

a. Supine c. Sim's
b. Prone d. Lithotomy

11. An elderly client has sustained intertrochanteric fracture of the hip and has just returned from surgery where a nail plate was inserted for internal fixation. The client has been instructed that she should not flex her hip. The best explanation of why this movement would be harmful is:

a. It will be very painful for the client
b. The soft tissue around the site will be damaged
c. Displacement can occur with flexion
d. It will pull the hip out of alignment

12. When the client is lying supine, the nurse will prevent external rotation of the lower extremity by using a:

a. Trochanter roll by the knee
b. Sandbag to the lateral calf
c. Trochanter roll to the thigh
d. Footboard

13. A client has just returned from surgery after having his left leg amputated below the knee. Physician's orders include elevation of the foot of the bed for 24 hours. The nurse observes that the nursing assistant has placed a pillow under the client's amputated limb. The nursing action is to:

a. Leave the pillow as his stump is elevated
b. Remove the pillow and elevate the foot of the bed
c. Leave the pillow and elevate the foot of the bed
d. Check with the physician and clarify the orders

14. A client has sustained a fracture of the femur and balanced skeletal traction with a Thomas splint has been applied. To prevent pressure points from occurring around the top of the splint, the most important intervention is to:

a. Protect the skin with lotion
b. Keep the client pulled up in bed
c. Pad the top of the splint with washcloths
d. Provide a footplate in the bed

15. The major rationale for the use of acetylsalicylic acid (aspirin) in the treatment of rheumatoid arthritis is to:

a. Reduce fever
b. Reduce the inflammation of the joints
c. Assist the client's range of motion activities without pain
d. Prevent extension of the disease process

16. Following an amputation, the advantage to the client for an immediate prosthesis fitting is:

a. Ability to ambulate sooner
b. Less change of phantom limb sensation
c. Dressing changes are not necessary
d. Better fit of the prosthesis

17. One method of assessing for sign of circulatory impairment in a client with a fractured femur is to ask the client to:

a. Cough and deep breathe
b. Turn himself in bed
c. Perform biceps exercise
d. Wiggle his toes

18. The morning of the second postoperative day following hip surgery for a fractured right hip, the nurse will ambulate the client. The first intervention is to:

a. Get the client up in a chair after dangling at the bedside.
b. Use a walker for balance when getting the client out of bed
c. Have the client put minimal weight on the affected side when getting up
d. Practice getting the client out of bed by having her slightly flex her hips

19. A young client is in the hospital with his left leg in Buck's traction. The team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to:

a. Anchor the traction
b. Prevent footdrop
c. Keep the client from sliding down in bed
d. Prevent pressure areas on the foot

20. When evaluating all forms of traction, the nurse knows the direction of pull is controlled by the:

a. Client's position
b. Rope/pulley system
c. Amount of weight
d. Point of friction

21. When a client has cervical halter traction to immobilize the cervical spine counteraction is provided by:

a. Elevating the foot of the bed
b. Elevating the head of the bed
c. Application of the pelvic girdle
d. Lowering the head of the bed

22. After falling down the basement steps in his house, a client is brought to the emergency room. His physician confirms that his leg is fractured. Following application of a leg cast, the nurse will first check the client's toes for:

a. Increase in the temperature
b. Change in color
c. Edema
d. Movement

23. A 23 year old female client was in an automobile accident and is now a paraplegic. She is on an intermittent urinary catheterization program and diet as tolerated. The nurse's priority assessment should be to observe for:

a. Urinary retention
b. Bladder distention
c. Weight gain
d. Bower evacuation

24. A female client with rheumatoid arthritis has been on aspirin grain TID and prednisone 10mg BID for the last two years. The most important assessment question for the nurse to ask related to the client's drug therapy is whether she has

a. Headaches
b. Tarry stools
c. Blurred vision
d. Decreased appetite

25. A 7 year old boy with a fractured leg tells the nurse that he is bored. An appropriate intervention would be to

a. Read a story and act out the part
b. Watch a puppet show
c. Watch television
d. Listen to the radio

26. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. Which of the following would be the nurse most likely to asses:

a. Limited motion of joints
b. Deformed joints of the hands
c. Early morning stiffness
d. Rheumatoid nodules

27. After teaching the client about risk factors for rheumatoid arthritis, which of the following, if stated by the client as a risk factor, would indicate to the nurse that the client needs additional teaching?

a. History of Epstein-Barr virus infection
b. Female gender
c. Adults between the ages 60 to 75 years
d. Positive testing for human leukocyte antigen (HLA) DR4 allele

28. When developing the teaching plan for the client with rheumatoid arthritis to promote rest, which of the following would the nurse expect to instruct the client to avoid during the rest periods?

a. Proper body alignment
b. Elevating the part
c. Prone lying positions
d. Positions of flexion

29. After teaching the client with severe rheumatoid arthritis about the newly prescribed medication methothrexate (Rheumatrex 0), which of the following statements indicates the need for further teaching?

a. "I will take my vitamins while I am on this drug"
b. "I must not drink any alcohol while I'm taking this drug"
c. I should brush my teeth after every meal"
d. "I will continue taking my birth control pills"

30. When completing the history and physical examination of a client diagnosed with osteoarthritis, which of the following would the nurse assess?

a. Anemia c. Weight loss
b. Osteoporosis d. Local joint pain

31. At which of the following times would the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?

a. At bedtime c. Immediately after meal
b. On arising d. On an empty stomach

32. When preparing a teaching plan for the client with osteoarthritis who is taking celecoxib (Celebrex), the nurse expects to explain that the major advantage of celecoxib over diclofenac (Voltaren), is that the celecoxib is likely to produce which of the following?

a. Hepatotoxicity
b. Renal toxicity
c. Gastrointestinal bleeding
d. Nausea and vomiting

33. After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse interprets these findings as indicating which of the following?

a. A developing infection
b. Bleeding in the operative site
c. Joint dislocation
d. Glue seepage into soft tissue

34. Which of the following would the nurse assess in a client with an intracapsular hip fracture?

a. Internal rotation c. Shortening of the affected leg
b. Muscle flaccidity d. Absence of pain the fracture area

35. Which of the following would be inappropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a rupture disc?

a. Informing the client that the procedure is painless
b. Taking a thorough history of past surgeries
c. Checking for previous complaints of claustrophobia
d. Starting an intravenous line at keep-open rate

36. Which of the following actions would be a priority for a client who has been in the postanesthesia care unit (PACU) for 45 minutes after an above the knee amputation and develops a dime size bright red spot on the ace bondage above the amputation site?

a. Elevate the stump
b. Reinforcing the dressing
c. Calling the surgeon
d. Drawing a mark around the site

37. A client in the PACU with a left below the knee amputation complains of pain in her left big toe. Which of the following would the nurse do first?

a. Tell the client it is impossible to feel the pain
b. Show the client that the toes are not there
c. Explain to the client that the pain is real
d. Give the client the prescribed narcotic analgesic

38. The client with an above the knee amputation is to use crutches until the prosthesis is being adjusted. In which of the following exercises would the nurse instruct the client to best prepare him for using crutches?

a. Abdominal exercises
b. Isometric shoulder exercises
c. Quadriceps setting exercises
d. Triceps stretching exercises

39. The client with an above the knee amputation is to use crutches until the prosthesis is properly lifted. When teaching the client about using the crutches, the nurse instructs the client to support her weight primarily on which of the following body areas?

a. Axillae
b. Elbows
c. Upper arms
d. Hands

40. Three hours ago a client was thrown from a car into a ditch, and he is now admitted to the ED in a stable condition with vital signs within normal limits, alert and oriented with good coloring and an open fracture of the right tibia. When assessing the client, the nurse would be especially alert for signs and symptoms of which of the following?

a. Hemorrhage
b. Infection
c. Deformity
d. Shock

41. The client with a fractured tibia has been taking methocarbamol (Robaxin), when teaching the client about this drug, which of the following would the nurse include as the drug's primary effect?

a. Killing of microorganisms
b. Reduction in itching
c. Relief of muscle spasms
d. Decrease in nervousness

42. A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mmHg, a pulse rate of 115bpm, and respirations of 8 breaths/minute and shallow, the nurse interprets these finding as indicating which of the following?

a. Expected common side effects
b. Hypersensitivity reactions
c. Possible habituating effects
d. Hemorrhage from GI irritation

43. When admitting a client with a fractured extremity, the nurse would focus the assessment on which of the following first?

a. The area proximal to the fracture
b. The actual fracture site
c. The area distal to the fracture
d. The opposite extremity for baseline comparison

44. A client with fracture develops compartment syndrome. When caring for the client, the nurse would be alert for which of the following signs of possible organ failure?

a. Rales c. Generalized edema
b. Jaundice d. Dark, scanty urine

45. Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?

a. Acute respiratory distress syndrome
b. Migraine like headaches
c. Numbness in the right leg
d. Muscle spasms in the right thigh

46. The client who had an open femoral fracture was discharged to her home, where she developed, fever, night sweats, chills, restlessness and restrictive movement of the fractured leg. The nurse interprets these finding as indicating which of the following?

a. Pulmonary emboli
b. Osteomyelitis
c. Fat emboli
d. Urinary tract infection

47. When antibiotics are not producing the desired outcome for a client with osteomyelitis, the nurse interprets this as suggesting the occurrence of which of the following as most likely?

a. Formation of scar tissue interfering with absorption
b. Development of pus leading to ischemia
c. Production of bacterial growth by avascular tissue
d. Antibiotics not being instilled directly into the bone

48. Which of the following would the nurse use as the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury?

a. Homan's sign c. Tenderness
b. Pain d. Leg girth

49. The nurse is caring for the client who is going to have an arthogram using a contrast medium. Which of the following assessments by the nurse are of highest priority?

a. Allergy to iodine or shellfish
b. Ability of the client to remain still during the procedure
c. Whether the client has any remaining questions about the procedure
d. Whether the client wishes to void before the procedure

50. The client immobilized skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse formulates which of the following nursing diagnoses for this client?

a. Divertional activity deficit
b. Powerlessness
c. Self care deficit
d. Impaired physical mobility

51. The nurse is teaching the client who is to have a gallium scan about the procedure. The nurse includes which of the following items as part of the instructions?

a. The gallium will be injected intravenously 2 to 3 hours before the procedure
b. The procedure takes about 15 minutes to perform
c. The client must stand erect during the filming
d. The client should remain on bed rest for the remainder of the day after the scan

52. The nurse is assessing the casted extremity of a client. The nurse assesses for which of the following signs and symptoms indicative of infection?

a. Coolness and pallor of the extremity
b. Presence of a "hot spot" on the cast
c. Diminished distal pulse
d. Dependent edema

53. The client has Buck's extension applied to the right leg. The nurse plans which of the following interventions to prevent complications of the device?

a. Massage the skin of the right leg with lotion every 8 hours
b. Give pin care once a shift
c. Inspect the skin on the right leg at least once every 8 hours
d. Release the weights on the right leg for range of motion exercises daily

54. The nurse is giving the client with a left cast crutch walking instructions using the three point gait. The client is allowed touchdown of the affected leg. The nurse tells the client to advance the:

a. Left leg and right crutch then right leg and left crutch
b. Crutches and then both legs simultaneously
c. Crutches and the right leg then advance the left leg
d. Crutches and the left leg then advance the right leg

55. The client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the cane by holding it with the:

a. Left hand and placing the cane in front of the left foot
b. Right hand and placing the cane in front of the right foot
c. Left hand and 6 inches lateral to the left foot
d. Right hand and 6 inches lateral to the left foot

56. The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. The nurse uses a:

a. Pillow to keep the right leg abducted during turning
b. Pillow to keep the right leg adducted during turning
c. Trochanter roll to prevent external rotation while turning
d. Trochanter roll to prevent abduction while turning

57. The nurse has an order to get the client out of bed to a chair on the first postoperative day after a total knee replacement. The nurse plans to do which of the following to protect the knee joint:

a. Apply a knee immobilizer before getting the client up and elevate the client's surgical leg while sitting
b. Apply an Ace wrap around the dressing and put ice on the knee while sitting
c. Lift the client to the bedside change leaving the CPM machine in place
d. Obtain a walker to minimize weight bearing by the client on the affected leg

58. The nurse is caring for the client who had an above the knee amputation 2days ago. The residual limb was wrapped with an elastic compression bandage which has come off. The nurse immediately:

a. Calls the physician
b. Rewrap the stump with an elastic compression bandage
c. Applies ice to the site
d. Applies a dry sterile dressing and elevates it on a pillow

59. The nurse has taught the client with a below the knee amputation about prosthesis and stump care. The nurse evaluates that the client states to:

a. Wear a clean nylon stump sock daily
b. Toughen the skin of the stump by rubbing it with alcohol
c. Prevent cracking of the skin of the stump by applying lotion daily
d. Using a mirror to inspect all areas of the stump each day

60. The nurse is caring for a client with a gout. Which of the following laboratory values does the nurse expect to note in the client?

a. Uric acid level of 8 mg/dl
b. Calcium level of 9 mg/dl
c. Phosphorus level of 3 mg/dl
d. Uric acid level of 5 mg/dl

MS Test Drill III

1. The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?

A) Chronic vessel plaque formation
B) Pulmonary embolism
C) Occlusions at the vessel bifurcations
D) Coronary artery aneurysms

2. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean."
B) "Would you please clarify what you have written so I am sure I am reading it correctly?"
C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful."
D) "Please print in the future so I do not have to spend extra time attempting to read your writing."

3. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?

A) Reprimand the child and give a 15 minute "time out"
B) Maintain a permissive attitude for this behavior
C) Use patience and a sense of humor to deal with this behavior
D) Assert authority over the child through limit setting

4. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
A) "Have you had a recent heart attack?"
B) "Do you become short of breath during your normal daily activities?"
C) "How many pillows do you use at night to sleep comfortably?"
D) "Do you smoke?"

5. The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate?
A) Fluid restriction 1000cc per day
B) Ambulate in hallway 4 times a day
C) Administer analgesic therapy as ordered
D) Encourage increased caloric intake

6. While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?
A) Sexual promiscuity
B) Poor body image
C) Dropping out of school
D) Drug experimentation

7. A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?
A) Pre-interaction
B) Orientation
C) Working
D) Termination

8. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to
A) Begin mouth to mouth resuscitation
B) Give the child water to help in swallowing
C) Perform 5 abdominal thrusts
D) Call for the emergency response team

9. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse?
A) "Do not worry. Epilepsy can be treated with medications."
B) "The seizure may or may not mean your child has epilepsy."
C) "Since this was the first convulsion, it may not happen again."
D) "Long term treatment will prevent future seizures."

10. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
A) Gestational age assessment suggested growth retardation
B) Meconium was cleared from the airway at delivery
C) Phototherapy was used to treat Rh incompatibility
D) The infant received mechanical ventilation for 2 weeks

11. Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby's diet. Which of the following should be added first?
A) Cereal
B) Eggs
C) Meat
D) Juice

12. A victim of domestic violence states, "If I were better, I would not have been beat." Which feeling best describes what the victim may be experiencing?
A) Fear
B) Helplessness
C) Self-blame
D) Rejection

13. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory?
A) "Name the year." "What season is this?" (pause for answer after each question)
B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number."
C) "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen."
D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"

14. Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
A) Venturi mask
B) Partial rebreather mask
C) Non-rebreather mask
D) Simple face mask

15. A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention?
A) Capillary refill of fingers on right hand is 3 seconds
B) Skin warm to touch and normally colored
C) Client reports prickling sensation in the right hand
D) Slight swelling of fingers of right hand

16. Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
A) Liver function
B) Kidney function
C) Blood sugar
D) Cardiac enzymes

17. Which client is at highest risk for developing a pressure ulcer?
A) 23 year-old in traction for fractured femur
B) 72 year-old with peripheral vascular disease, who is unable to walk without assistance
C) 75 year-old with left sided paresthesia and is incontinent of urine and stool
D) 30 year-old who is comatose following a ruptured aneurysm

18. Which contraindication should the nurse assess for prior to giving a child immunization?
A) Mild cold symptoms
B) Chronic asthma
C) Depressed immune system
D) Allergy to eggs

19. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
A) Neurotoxicity
B) Hepatomegaly
C) Nephrotoxicity
D) Ototoxicity

20. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?
A) Protect the eyes of the neonate from the heat lamp
B) Monitor the neonate’s temperature
C) Warm all medications and liquids before giving
D) Avoid touching the neonate with cold hands


21. At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?
A) "I give my insulin to myself in my thighs."
B) "Sometimes when I put my shoes on I don't know where my toes are."
C) "Here are my up and down glucose readings that I wrote on my calendar."
D) "If I bathe more than once a week my skin feels too dry."

22. A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?

A) Place the child in the nearest bed
B) Administer IV medication to slow down the seizure
C) Place a padded tongue blade in the child's mouth
D) Remove the child's toys from the immediate area

23. The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information?

A) "I usually avoid driving at night since lights sometimes seem to make things blur."
B) "I take half of the usual dose for my sinuses to maintain my blood pressure."
C) "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem."
D) "I take extra fiber and drink lots of water to avoid getting constipated.”

24. The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
A) Irritability
B) Slight edema at site
C) Local tenderness
D) Temperature of 102.5 F

25. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering
A) Pulmonary embolectomy
B) Vena caval interruption
C) Increasing the coumadin therapy to an INR of 3-4
D) Thrombolytic therapy

26. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
A) Drink small amounts of liquids frequently
B) Eat the evening meal just before retiring
C) Take sodium bicarbonate after each meal
D) Sleep with head propped on several pillows

27. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?

A) "I'm going to try feeding my baby some rice cereal."
B) "When he wakes at night for a bottle, I feed him."
C) "I dip his pacifier in honey so he'll take it."
D) "I keep formula in the refrigerator for 24 hours."

28. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?
A) Institute seizure precautions
B) Weigh the child twice per shift
C) Encourage the child to eat protein-rich foods
D) Relieve boredom through physical activity

29. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?
A) "This action of my lips helps to keep my airway open."
B) "I can expel more when I pucker up my lips to breathe out."
C) "My mouth doesn't get as dry when I breathe with pursed lips."
D) "By prolonging breathing out with pursed lips the little areas in my lungs don't collapse."

30. A 57 year-old male client has hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?
A) Ask the client if he has noticed any bleeding or dark stools
B) Tell the client to call 911 and go to the emergency department immediately
C) Schedule a repeat Hemoglobin and Hematocrit in 1 month
D) Tell the client to schedule an appointment with a hematologist

31. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?
A) "Addiction usually causes people to feel guilty. Don’t worry, it is a typical response due to your drinking behavior."
B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?"
C) "Don’t focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs."
D) "You’ve caused a great deal of pain to your family and close friends, so it will take time to undo all the things you’ve done."

32. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?
A) Review the client's weight pattern over the year
B) Ask the mother to record her diet for the last 24 hours
C) Encourage her to talk about her view of herself
D) Give her several pamphlets on postpartum nutrition

33. Which of the following measures would be appropriate for the nurse to teach the parent of a nine month-old infant about diaper dermatitis?
A) Use only cloth diapers that are rinsed in bleach
B) Do not use occlusive ointments on the rash
C) Use commercial baby wipes with each diaper change
D) Discontinue a new food that was added to the infant's diet just prior to the rash

34. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is
A) Progressive failure to adapt
B) Feelings of anger or hostility
C) Reunion wish or fantasy
D) Feelings of alienation or isolation

35. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
A) Trust
B) Initiative
C) Independence
D) Self-esteem

36. Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 microdrops/cc. What rate would deliver 4 mgm of Lidocaine/minute?
A) 60 microdrops/minute
B) 20 microdrops/minute
C) 30 microdrops/minute
D) 40 microdrops/minute

37. A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?
A) Norplant is safe and may be removed easily
B) Oral contraceptives should not be used by smokers
C) Depo-Provera is convenient with few side effects
D) The IUD gives protection from pregnancy and infection

38. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
A) Confusion
B) Loss of half of visual field
C) Shallow respirations
D) Tonic-clonic seizures

39. A client experiences post partum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale?
A) "Nursing will help contract the uterus and reduce your risk of bleeding."
B) "Breastfeeding twins will take too much energy after the hemorrhage."
C) "The blood transfusion may increase the risks to you and the babies."
D) "Lactation should be delayed until the "real milk" is secreted."

40. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings?
A) These side effects are common and should subside in a few days
B) The client is probably having an allergic reaction and should discontinue the drug
C) Taking the lithium on an empty stomach should decrease these symptoms
D) Decreasing dietary intake of sodium and fluids should minimize the side effects

41. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
A) Place pillows under the knees
B) Use elastic stockings continuously
C) Encourage range of motion and ambulation
D) Massage the legs twice daily

42. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that
A) Circumcision is delayed so the foreskin can be used for the surgical repair
B) This procedure is contraindicated because of the permanent defect
C) There is no medical indication for performing a circumcision on any child
D) The procedure should be performed as soon as the infant is stable

43. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
A) Loss of consciousness
B) Feeding problems
C) Poor weight gain
D) Fatigue with crying

44. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?
A) Double the birth weight
B) Triple the birth weight
C) Gain 6 ounces each week
D) Add 2 pounds each month

45. The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?
A) Raise the head of the bed at least 30 degrees
B) Encourage ambulation within 24 hours
C) Maintain in a flat position, logrolling as needed
D) Encourage leg contraction and relaxation after 48 hours

46. A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
A) "Focus on your sons' needs during the first days at home."
B) "Tell each child what he can do to help with the baby."
C) "Suggest that your husband spend more time with the boys."
D) "Ask the children what they would like to do for the newborn."

47. A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
A) A cerebral vascular accident
B) Postoperative meningitis
C) Medication reaction
D) Metabolic alkalosis

48. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as what type of side effect?
A) Oculogyric crisis
B) Tardive dyskinesia
C) Nystagmus
D) Dysphagia

49. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
A) A social worker from the local hospital
B) An occupational therapist from the community center
C) A physical therapist from the rehabilitation agency
D) Another client with diabetes mellitus and takes insulin

50. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
A) Convince the client that the hospital staff is trying to help
B) Help the client to enter into group recreational activities
C) Provide interactions to help the client learn to trust staff
D) Arrange the environment to limit the client’s contact with other clients

51. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the
A) Surgical repair of a diseased coronary artery
B) Placement of an automatic internal cardiac defibrillator
C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
D) Non-invasive radiographic examination of the heart

52. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize
A) They can expect the child will be mentally retarded
B) Administration of thyroid hormone will prevent problems
C) This rare problem is always hereditary
D) Physical growth/development will be delayed

53. A priority goal of involuntary hospitalization of the severely mentally ill client is
A) Re-orientation to reality
B) Elimination of symptoms
C) Protection from harm to self or others
D) Return to independent functioning

54. A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"?
A) "I don't remember anything about what happened to me."
B) "I'd rather not talk about it right now."
C) "It's the other entire guy's fault! He was going too fast."
D) "My mother is heartbroken about this."

55. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
A) Altered tissue perfusion
B) Risk for fluid volume deficit
C) High risk for hemorrhage
D) Risk for infection

56. A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should
A) Expose the cast to air and turn the child frequently
B) Use a heat lamp to reduce the drying time
C) Handle the cast with the abductor bar
D) Turn the child as little as possible

57. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
A) Instruct the client to maintain a regular diet the day prior to the examination
B) Restrict the client's fluid intake 4 hours prior to the examination
C) Administer a laxative to the client the evening before the examination
D) Inform the client that only 1 x-ray of his abdomen is necessary

58. Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parent’s remark: “We just don’t know how he caught the disease!” The nurse's response is based on an understanding that
A) AGN is a streptococcal infection that involves the kidney tubules
B) The disease is easily transmissible in schools and camps
C) The illness is usually associated with chronic respiratory infections
D) It is not "caught" but is a response to a previous B-hemolytic strep infection

59. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?
A) 3 episodes of vomiting in 1 hour
B) Periodic crying and irritability
C) Vigorous sucking on a pacifier
D) No measurable voiding in 4 hours

60. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
A) Check vital signs
B) Massage the fundus
C) Offer a bedpan
D) Check for perineal lacerations

61. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
A) Unequal leg length
B) Limited adduction
C) Diminished femoral pulses
D) Symmetrical gluteal folds

62. To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would
A) Assist the client to use the bedside commode
B) Administer stool softeners every day as ordered
C) Administer antidysrhythmics prn as ordered
D) Maintain the client on strict bed rest

63. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to
A) Give the client orientation materials and review the unit rules and regulations
B) Introduce him/her and accompany the client to the client’s room
C) Take the client to the day room and introduce her to the other clients
D) Ask the nursing assistant to get the client’s vital signs and complete the admission search

64. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?
A) "I have constant blurred vision."
B) "I can't see on my left side."
C) "I have to turn my head to see my room."
D) "I have specks floating in my eyes."

65. A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
A) Has increased airway obstruction
B) Has improved airway obstruction
C) Needs to be suctioned
D) Exhibits hyperventilation

66. Which behavioral characteristic describes the domestic abuser?
A) Alcoholic
B) Over confident
C) High tolerance for frustrations
D) Low self-esteem
67. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend
A) Isometric
B) Range of motion
C) Aerobic
D) Isotonic

68. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
A) Counsel the woman to consent to HIV screening
B) Perform tests for sexually transmitted diseases
C) Discuss her high risk for cervical cancer
D) Refer the client to a family planning clinic

69. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?
A) Arrange to change client care assignments
B) Explain that this behavior is expected
C) Discuss the appropriate use of "time-out"
D) Explain that the child needs extra attention

70. While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
A) Strange bed and surroundings
B) Separation from parents
C) Presence of other toddlers
D) Unfamiliar toys and games

71. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?
A) They are able to make simple association of ideas
B) They are able to think logically in organizing facts
C) Interpretation of events originate from their own perspective
D) Conclusions are based on previous experiences

72. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a prioriy nursing diagnosis?
A) Nutrition
B) Elimination
C) Activity
D) Safety

73. Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children?
A) Sports and games with rules
B) Finger paints and water play
C) "Dress-up" clothes and props
D) Chess and television programs

74. A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
A) High Fowler's
B) Supine
C) Left lateral
D) Low Fowler's

75. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
A) Urinary output of 30 ml per hour
B) No complaints of thirst
C) Increased hematocrit
D) Good skin turgor around burn

for answers and rationale: click me

MS Test Drill III (answers and rationale)

1. The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
A)Chronic vessel plaque formation
B)Pulmonary embolism
C)Occlusions at the vessel bifurcations
D)Coronary artery aneurysms

The correct answer is D: Coronary artery aneurysms
Kawasaki Disease involves all the small and medium-sized blood vessels. There is progressive inflammation of the small vessels which progresses to the medium-sized muscular arteries, potentially damaging the walls and leading to coronary artery aneurysms.

2. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
A)"I cannot give this medication as it is written. I have no idea of what you mean."
B)"Would you please clarify what you have written so I am sure I am reading it correctly?"
C)"I am having difficulty reading your handwriting. It would save me time if you would be more careful."
D)"Please print in the future so I do not have to spend extra time attempting to read your writing."

The correct answer is B: "Would you please clarify what you have written so I am sure I am reading it correctly?"
Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information.

3. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?
A)Reprimand the child and give a 15 minute "time out"
B)Maintain a permissive attitude for this behavior
C)Use patience and a sense of humor to deal with this behavior
D)Assert authority over the child through limit setting

The correct answer is C: Use patience and a sense of humor to deal with this behavior
The nurse should help the parents see the negativism as a normal growth of autonomy in the toddler. They can best handle the negative toddler by using patience and humor.

4. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
A)"Have you had a recent heart attack?"
B)"Do you become short of breath during your normal daily activities?"
C)"How many pillows do you use at night to sleep comfortably?"
D)"Do you smoke?"

The correct answer is B: "Do you become short of breath during your normal daily activities?"

These are the symptoms of right-sided heart failure, which causes increased pressure in the systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces causing edema. Because of gravity, the lower extremities are first affected in an ambulatory patient. This question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid volume excess both associated with right-sided heart failure.

5. The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate?
A)Fluid restriction 1000cc per day
B)Ambulate in hallway 4 times a day
C)Administer analgesic therapy as ordered
D)Encourage increased caloric intake

The correct answer is C: Administer analgesic therapy as ordered
The main general objectives in the treatment of a sickle cell crisis is bed rest, hydration, electrolyte replacement, analgesics for pain, blood replacement and antibiotics to treat any existing infection.

6. While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?
A)Sexual promiscuity
B)Poor body image
C)Dropping out of school
D)Drug experimentation

The correct answer is B: Poor body image
As the adolescent gains weight, there is a lessening sense of self esteem and poor body image.

7. A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?
A)Pre-interaction
B)Orientation
C)Working
D)Termination

The correct answer is C: Working
During the working phase alternative behaviors and techniques are explored. The nurse and the client discuss the meaning behind the behavior.

8. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to
A)Begin mouth to mouth resuscitation
B)Give the child water to help in swallowing
C)Perform 5 abdominal thrusts
D)Call for the emergency response team

The correct answer is C: Perform 5 abdominal thrusts
At this age, the most effective way to clear the airway of food is to perform abdominal thrusts.

9. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse?
A)"Do not worry. Epilepsy can be treated with medications."
B)"The seizure may or may not mean your child has epilepsy."
C)"Since this was the first convulsion, it may not happen again."
D)"Long term treatment will prevent future seizures."

The correct answer is B: "The seizure may or may not mean your child has epilepsy."
There are many possible causes for a childhood seizure. These include fever, central nervous system conditions, trauma, metabolic alterations and idiopathic (unknown).

10. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
A)Gestational age assessment suggested growth retardation
B)Meconium was cleared from the airway at delivery
C)Phototherapy was used to treat Rh incompatibility
D)The infant received mechanical ventilation for 2 weeks

The correct answer is D: The infant received mechanical ventilation for 2 weeks
Bronchopulmonary dysplasia is an iatrogenic disease caused by therapies such as use of positive-pressure ventilation used to treat lung disease.

11. Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby's diet. Which of the following should be added first?
A)Cereal
B)Eggs
C)Meat
D)Juice

The correct answer is A: Cereal
The guidelines of the American Academy of Pediatrics recommend that one new food be introduced at a time, beginning with strained cereal.

12. A victim of domestic violence states, "If I were better, I would not have been beat." Which feeling best describes what the victim may be experiencing?
A)Fear
B)Helplessness
C)Self-blame
D)Rejection

The correct answer is C: Self-blame
Domestic violence victims may be immobilized by a variety of affective responses, one being self-blame. The victim believes that a change in their behavior will cause the abuser to become nonviolent, which is a myth.

13. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory?
A)"Name the year." "What season is this?" (pause for answer after each question)
B)"Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number."
C)"I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen."
D)"What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"

The correct answer is C: "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen."

14. Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
A) Venturi mask
B) Partial rebreather mask
C) Non-rebreather mask
D) Simple face mask

The correct answer is C: The non-rebreather mask has a one-way valve that prevents exhales air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of oxygen is available.

15. A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention?
A) Capillary refill of fingers on right hand is 3 seconds
B) Skin warm to touch and normally colored
C) Client reports prickling sensation in the right hand
D) Slight swelling of fingers of right hand

The correct answer is C: Prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.

16. Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
A) Liver function
B) Kidney function
C) Blood sugar
D) Cardiac enzymes

The correct answer is A: INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.

17. Which client is at highest risk for developing a pressure ulcer?
A) 23 year-old in traction for fractured femur
B) 72 year-old with peripheral vascular disease, who is unable to walk without assistance
C) 75 year-old with left sided paresthesia and is incontinent of urine and stool
D) 30 year-old who is comatose following a ruptured aneurysm

The correct answer is C: Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

18. Which contraindication should the nurse assess for prior to giving a child immunization?
A) Mild cold symptoms
B) Chronic asthma
C) Depressed immune system
D) Allergy to eggs

The correct answer is C: Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.

19. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
A) Neurotoxicity
B) Hepatomegaly
C) Nephrotoxicity
D) Ototoxicity

The correct answer is C: Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general.

20. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?
A) Protect the eyes of the neonate from the heat lamp
B) Monitor the neonate’s temperature
C) Warm all medications and liquids before giving
D) Avoid touching the neonate with cold hands

The correct answer is B: When using a warming device the neonate’s temperature should be continuously monitored for undesired elevations. The use of heat lamps is not safe as there is no way to regulate their temperature. Warming medications and fluids is not indicated. While touching with cold hands can startle the infant it does not pose a safety risk.

21. At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?
A) "I give my insulin to myself in my thighs."
B) "Sometimes when I put my shoes on I don't know where my toes are."
C) "Here are my up and down glucose readings that I wrote on my calendar."
D) "If I bathe more than once a week my skin feels too dry."

The correct answer is B: Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients do not feel pressure and/or pain and are at high risk for skin impairment.

22. A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?

A) Place the child in the nearest bed
B) Administer IV medication to slow down the seizure
C) Place a padded tongue blade in the child's mouth
D) Remove the child's toys from the immediate area

The correct answer is D: Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child''s mouth and they should not be moved. Of the choices given, first priority would be for safety.

23. The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information?

A) "I usually avoid driving at night since lights sometimes seem to make things blur."
B) "I take half of the usual dose for my sinuses to maintain my blood pressure."
C) "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem."
D) "I take extra fiber and drink lots of water to avoid getting constipated.”

The correct answer is D: Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase intraocular pressure.

24. The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
A) Irritability
B) Slight edema at site
C) Local tenderness
D) Temperature of 102.5 F

The correct answer is D: An adverse reaction of a fever should be reported immediately. Other reactions that should be reported include crying for > 3 hours, seizure activity, and tender, swollen, reddened areas.

25. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering
A) Pulmonary embolectomy
B) Vena caval interruption
C) Increasing the coumadin therapy to an INR of 3-4
D) Thrombolytic therapy

The correct answer is B: Clients with contraindications to heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.

26. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
A) Drink small amounts of liquids frequently
B) Eat the evening meal just before retiring
C) Take sodium bicarbonate after each meal
D) Sleep with head propped on several pillows

The correct answer is D: Heartburn is a burning sensation caused by regurgitation of gastric contents that is best relieved by sleeping position, eating small meals, and not eating before bedtime.

27. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?

A) "I'm going to try feeding my baby some rice cereal."
B) "When he wakes at night for a bottle, I feed him."
C) "I dip his pacifier in honey so he'll take it."
D) "I keep formula in the refrigerator for 24 hours."

The correct answer is C: Honey has been associated with infant botulism and should be avoided. Older children and adults have digestive enzymes that kill the botulism spores.

28. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?
A) Institute seizure precautions
B) Weigh the child twice per shift
C) Encourage the child to eat protein-rich foods
D) Relieve boredom through physical activity

The correct answer is A: Institute seizure precautions
The severity of the acute phase of AGN is variable and unpredictable; therefore, a child with edema, hypertension, and gross hematuria may be subject to complications and anticipatory preparation such as seizure precautions are needed.

29. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?
A) "This action of my lips helps to keep my airway open."
B) "I can expel more when I pucker up my lips to breathe out."
C) "My mouth doesn't get as dry when I breathe with pursed lips."
D) "By prolonging breathing out with pursed lips the little areas in my lungs don't collapse."

The correct answer is D: "By prolonging breathing out with pursed lips my little areas in my lungs don''t collapse."
Clients with chronic obstructive pulmonary disease have difficulty exhaling fully as a result of the weak alveolar walls from the disease process . Alveolar collapse can be avoided with the use of pursed-lip breathing. This is the major reason to use it. The other options are secondary effects of purse-lip breathing.

30. A 57 year-old male client has hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?
A) Ask the client if he has noticed any bleeding or dark stools
B) Tell the client to call 911 and go to the emergency department immediately
C) Schedule a repeat Hemoglobin and Hematocrit in 1 month
D) Tell the client to schedule an appointment with a hematologist

The correct answer is A: Ask the client if he has noticed any bleeding or dark stools
Normal hemoglobin for males is 13.0 - 18 g/100 ml. Normal hemotocrit for males is 42 - 52%. These values are below normal and indicate mild anemia. The first thing the nurse should do is ask the client if he''s noticed any bleeding or change in stools that could indicate bleeding from the GI tract.

31. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?
A) "Addiction usually causes people to feel guilty. Don’t worry, it is a typical response due to your drinking behavior."
B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?"
C) "Don’t focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs." D) "You’ve caused a great deal of pain to your family and close friends, so it will take time to undo all the things you’ve done."

The correct answer is B: "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?"
This response encourages the client to get in touch with their feelings and utilize problem solving steps to reduce guilt feelings.

32. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?
A) Review the client's weight pattern over the year
B) Ask the mother to record her diet for the last 24 hours
C) Encourage her to talk about her view of herself
D) Give her several pamphlets on postpartum nutrition

The correct answer is C: Encourage her to talk about her view of herself
To an adolescent, body image is very important. The nurse must acknowledge this before assessment and teaching.

33. Which of the following measures would be appropriate for the nurse to teach the parent of a nine month-old infant about diaper dermatitis?
A) Use only cloth diapers that are rinsed in bleach
B) Do not use occlusive ointments on the rash
C) Use commercial baby wipes with each diaper change
D) Discontinue a new food that was added to the infant's diet just prior to the rash

The correct answer is D: Discontinue a new food that was added to the infant''s diet just prior to the rash
The addition of new foods to the infant''s diet may be a cause of diaper dermatitis.

34. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is
A) Progressive failure to adapt
B) Feelings of anger or hostility
C) Reunion wish or fantasy
D) Feelings of alienation or isolation

The correct answer is D: Feelings of alienation or isolation
The isolation may occur gradually resulting in a loss of all meaningful social contacts. Isolation can be self imposed or can occur as a result of the inability to express feelings. At this stage of development it is important to achieve a sense of identity and peer acceptance.

35. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
A) Trust
B) Initiative
C) Independence
D) Self-esteem

The correct answer is C: Independence
In Erikson’s theory of development, toddlers struggle to assert independence. They often use the word “no” even when they mean yes. This stage is called autonomy versus shame and doubt.

36. Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 microdrops/cc. What rate would deliver 4 mgm of Lidocaine/minute?
A) 60 microdrops/minute
B) 20 microdrops/minute
C) 30 microdrops/minute
D) 40 microdrops/minute

The correct answer is A: 60 microdrops/minute
2 gm=2000 mgm
2000 mgm/500 cc = 4 mgm/x cc
2000x = 2000
x= 2000/2000 = 1 cc of IV solution/minute
CC x 60 microdrops = 60 microdrops/minute

37. A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?
A) Norplant is safe and may be removed easily
B) Oral contraceptives should not be used by smokers
C) Depo-Provera is convenient with few side effects
D) The IUD gives protection from pregnancy and infection

The correct answer is B: Oral contraceptives should not be used by smokers
The use of oral contraceptives in a pregnant woman who smokes increases her risk of cardiovascular problems, such as thromboembolic disorders.

38. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
A) Confusion
B) Loss of half of visual field
C) Shallow respirations
D) Tonic-clonic seizures

The correct answer is C: Shallow respirations
A.L.S. is a chronic progressive disease that involves degeneration of the anterior horn of the spinal cord as well as the corticospinal tracts. When the intercostal muscles and diaphragm become involved, the respirations become shallow and coughing is ineffective.

39. A client experiences post partum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale?
A) "Nursing will help contract the uterus and reduce your risk of bleeding."
B) "Breastfeeding twins will take too much energy after the hemorrhage."
C) "The blood transfusion may increase the risks to you and the babies."
D) "Lactation should be delayed until the "real milk" is secreted."

The correct answer is A: "Nursing will help contract the uterus and reduce your risk of bleeding." Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage.

40. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings?
A) These side effects are common and should subside in a few days
B) The client is probably having an allergic reaction and should discontinue the drug
C) Taking the lithium on an empty stomach should decrease these symptoms
D) Decreasing dietary intake of sodium and fluids should minimize the side effects

The correct answer is A: These side effects are common and should subside in a few days
Nausea, metallic taste and fine hand tremors are common side effects that usually subside within days.

41. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
A) Place pillows under the knees
B) Use elastic stockings continuously
C) Encourage range of motion and ambulation
D) Massage the legs twice daily

The correct answer is C: Encourage range of motion and ambulation
Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk.

42. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that
A) Circumcision is delayed so the foreskin can be used for the surgical repair
B) This procedure is contraindicated because of the permanent defect
C) There is no medical indication for performing a circumcision on any child
D) The procedure should be performed as soon as the infant is stable

The correct answer is A: Circumcision is delayed so the foreskin can be used for the surgical repair
Even if mild hypospadias is suspected, circumcision is not done in order to save the foreskin for surgical repair, if needed.

43. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
A) Loss of consciousness
B) Feeding problems
C) Poor weight gain
D) Fatigue with crying

The correct answer is A: Loss of consciousness
While parents should report any of the observations, they need to call the health care provider immediately if the level of alertness changes. This indicates anoxia, which may lead to death. The structural defects associated with Tetralogy of Fallot include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy and overriding of the aorta. Surgery is often delayed, or may be performed in stages.

44. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?
A) Double the birth weight
B) Triple the birth weight
C) Gain 6 ounces each week
D) Add 2 pounds each month

The correct answer is A: Double the birth weight
Although growth rates vary, infants normally double their birth weight by 6 months.

45. The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?
A) Raise the head of the bed at least 30 degrees
B) Encourage ambulation within 24 hours
C) Maintain in a flat position, logrolling as needed
D) Encourage leg contraction and relaxation after 48 hours

The correct answer is C: Maintain in a flat position, logrolling as needed
The bed should remain flat for at least the first 24 hours to prevent injury. Logrolling is the best way to turn for the client while on bed rest.

46. A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
A) "Focus on your sons' needs during the first days at home."
B) "Tell each child what he can do to help with the baby."
C) "Suggest that your husband spend more time with the boys."
D) "Ask the children what they would like to do for the newborn."

The correct answer is A: "Focus on your sons'' needs during the first days at home."
In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.

47. A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
A) A cerebral vascular accident
B) Postoperative meningitis
C) Medication reaction
D) Metabolic alkalosis

The correct answer is A: A cerebral vascular accident
Polycythemia occurs as a physiological reaction to chronic hypoxemia which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events. Cerebrovascular accidents may occur. Signs and symptoms include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures.

48. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as what type of side effect?
A) Oculogyric crisis
B) Tardive dyskinesia
C) Nystagmus
D) Dysphagia

The correct answer is A: Oculogyric crisis
This refers to involuntary muscles spasm of the eye.

49. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
A) A social worker from the local hospital
B) An occupational therapist from the community center
C) A physical therapist from the rehabilitation agency
D) Another client with diabetes mellitus and takes insulin

The correct answer is B: An occupational therapist from the community center
An occupational therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.

50. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
A) Convince the client that the hospital staff is trying to help
B) Help the client to enter into group recreational activities
C) Provide interactions to help the client learn to trust staff
D) Arrange the environment to limit the client’s contact with other clients

The correct answer is C: Provide interactions to help the client learn to trust staff
This establishes trust, facilitates a therapeutic alliance between staff and client.

51. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the
A) Surgical repair of a diseased coronary artery
B) Placement of an automatic internal cardiac defibrillator
C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
D) Non-invasive radiographic examination of the heart

The correct answer is C: Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization. Aorta coronary bypass Graft is the surgical procedure to repair a diseased coronary artery.

52. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize
A) They can expect the child will be mentally retarded
B) Administration of thyroid hormone will prevent problems
C) This rare problem is always hereditary
D) Physical growth/development will be delayed

The correct answer is B: Administration of thyroid hormone will prevent problems
Early identification and continued treatment with hormone replacement corrects this condition.

53. A priority goal of involuntary hospitalization of the severely mentally ill client is
A) Re-orientation to reality
B) Elimination of symptoms
C) Protection from harm to self or others
D) Return to independent functioning

The correct answer is C: Protection from self-harm and harm to others
Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled.

54. A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"?
A) "I don't remember anything about what happened to me."
B) "I'd rather not talk about it right now."
C) "It's the other entire guy's fault! He was going too fast."
D) "My mother is heartbroken about this."

The correct answer is A: "I don''t remember anything about what happened to me."
Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A deliberate exclusion "voluntary forgetting" is generally used to protect one’s own self esteem.

55. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
A) Altered tissue perfusion
B) Risk for fluid volume deficit
C) High risk for hemorrhage
D) Risk for infection

The correct answer is D: Risk for infection
Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to both mother and the newborn.

56. A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should
A) Expose the cast to air and turn the child frequently
B) Use a heat lamp to reduce the drying time
C) Handle the cast with the abductor bar
D) Turn the child as little as possible

The correct answer is A: Expose the cast to air and turn the child frequently
The child should be turned every 2 hours, with surface exposed to the air.

57. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
A) Instruct the client to maintain a regular diet the day prior to the examination
B) Restrict the client's fluid intake 4 hours prior to the examination
C) Administer a laxative to the client the evening before the examination
D) Inform the client that only 1 x-ray of his abdomen is necessary

The correct answer is C: Administer a laxative to the client the evening before the examination
Bowel prep is important because it will allow greater visualization of the bladder and ureters.

58. Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parent’s remark: “We just don’t know how he caught the disease!” The nurse's response is based on an understanding that
A) AGN is a streptococcal infection that involves the kidney tubules
B) The disease is easily transmissible in schools and camps
C) The illness is usually associated with chronic respiratory infections
D) It is not "caught" but is a response to a previous B-hemolytic strep infection

The correct answer is D: It is not "caught" but is a response to a previous B-hemolytic strep infection
AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior, and is considered as a noninfectious renal disease.

59. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?
A) 3 episodes of vomiting in 1 hour
B) Periodic crying and irritability
C) Vigorous sucking on a pacifier
D) No measurable voiding in 4 hours

The correct answer is D: No measurable voiding in 4 hours
The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys.

60. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
A) Check vital signs
B) Massage the fundus
C) Offer a bedpan
D) Check for perineal lacerations

The correct answer is B: Massage the fundus
The nurse’s first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery.

61. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
A) Unequal leg length
B) Limited adduction
C) Diminished femoral pulses
D) Symmetrical gluteal folds

The correct answer is A: Unequal leg length
Shortening of a leg is a sign of developmental dysplasia of the hip.

62. To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would
A) Assist the client to use the bedside commode
B) Administer stool softeners every day as ordered
C) Administer antidysrhythmics prn as ordered
D) Maintain the client on strict bed rest

The correct answer is B: Administer stool softeners every day as ordered
Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent straining. If straining on defecation produced the valsalva maneuver and rhythm disturbances resulted then antidysrhythmics would be appropriate.

63. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to
A) Give the client orientation materials and review the unit rules and regulations
B) Introduce him/her and accompany the client to the client’s room
C) Take the client to the day room and introduce her to the other clients
D) Ask the nursing assistant to get the client’s vital signs and complete the admission search

The correct answer is B: Introduce him/herself and accompany the client to the client’s room
Anxiety is triggered by change that threatens the individual’s sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting.

64. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?
A) "I have constant blurred vision."
B) "I can't see on my left side."
C) "I have to turn my head to see my room."
D) "I have specks floating in my eyes."

The correct answer is C: "I have to turn my head to see my room."
Intraocular pressure becomes elevated which slowly produces a progressive loss of the peripheral visual field in the affected eye along with rainbow halos around lights. Intraocular pressure becomes elevated from the microscopic obstruction of the trabeculae meshwork. If left untreated or undetected blindness results in the affected eye.

65. A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
A) Has increased airway obstruction
B) Has improved airway obstruction
C) Needs to be suctioned
D) Exhibits hyperventilation

The correct answer is A: Has increased airway obstruction
The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions no support exists to indicate the need for suctioning.

66. Which behavioral characteristic describes the domestic abuser?
A) Alcoholic
B) Over confident
C) High tolerance for frustrations
D) Low self-esteem

The correct answer is D: Low self-esteem
Batterers are usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, have a low self-esteem, and have a great need to exercise control or power-over partner.

67. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend
A) Isometric
B) Range of motion
C) Aerobic
D) Isotonic

The correct answer is A: Isometric
The nurse should instruct the client on isometric exercises for the muscles of the casted extremity, i.e., instruct the client to alternately contract and relax muscles without moving the affected part. The client should also be instructed to do active range of motion exercises for every joint that is not immobilized at regular and frequent intervals.

68. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
A) Counsel the woman to consent to HIV screening
B) Perform tests for sexually transmitted diseases
C) Discuss her high risk for cervical cancer
D) Refer the client to a family planning clinic

The correct answer is A: Counsel the woman to consent to HIV screening
The client''s behavior places her at high risk for HIV. Testing is the first step. If the woman is HIV positive, the earlier treatment begins, the better the outcome.


69. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?
A) Arrange to change client care assignments
B) Explain that this behavior is expected
C) Discuss the appropriate use of "time-out"
D) Explain that the child needs extra attention

The correct answer is B: Explain that this behavior is expected
During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parent, crying, and turning away from the stranger. These fears/behaviors extend into the toddler period and may persist into preschool.

70. While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
A) Strange bed and surroundings
B) Separation from parents
C) Presence of other toddlers
D) Unfamiliar toys and games

The correct answer is B: Separation from parents
Separation anxiety if most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress.

71. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?
A) They are able to make simple association of ideas
B) They are able to think logically in organizing facts
C) Interpretation of events originate from their own perspective
D) Conclusions are based on previous experiences

The correct answer is B: Think logically in organizing facts
The child in the concrete operations stage, according to Piaget, is capable of mature thought when allowed to manipulate and organize objects.

72. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a prioriy nursing diagnosis?
A) Nutrition
B) Elimination
C) Activity
D) Safety

The correct answer is D: Safety
Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan.

73. Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children?
A) Sports and games with rules
B) Finger paints and water play
C) "Dress-up" clothes and props
D) Chess and television programs

The correct answer is A: Sports and games with rules
The purpose of play for the 7 year-old is cooperation. Rules are very important. Logical reasoning and social skills are developed through play.

74. A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
A) High Fowler's
B) Supine
C) Left lateral
D) Low Fowler's

The correct answer is A: High Fowler''s
Sitting in a chair or resting in a bed in high Fowler''s position decreases the cardiac workload and facilitates breathing.

75. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
A) Urinary output of 30 ml per hour
B) No complaints of thirst
C) Increased hematocrit
D) Good skin turgor around burn

The correct answer is A: Urinary output of 30 ml per hour
For a child of this age, this is adequate output, yet does not suggest overload.

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