Answer Key

1. Ans: 2 Because clinical manifestations of PID should be improving with 3

days of effective antibiotic treatment, the client's ongoing pain indicates a
need for actions such as hospitalization for intravenous antibiotic therapy.
Nausea is an adverse effect of many antibiotics, but the client will be
instructed to continue the medications. The client's feeling of shame should
be addressed by the nurse but is not the most important finding. Because
Neisseria gonorrhoeae is a common cause of PID, all drug regimens that are
used will be effective in treating gonorrhea (and Chlamydia trachomatis).
Focus: Prioritization.
2. Ans: 3 The most commonly prescribed oral contraceptives are combination
estrogen-progestin medications, but estrogen-containing oral contraceptives
are contraindicated for women who are older than 35 years and who smoke
because of the increased risk for thromboembolism. A progestin-only oral
contraceptive or an intrauterine device (IUD) may be prescribed for this
client. Estrogen-containing contraceptives may stimulate fibroid growth and
elevate blood pressure, but these are relative contraindications. It is
recommended that estrogen-containing contraceptives be discontinued a few
weeks before surgeries that might impair mobility and increase venous
thromboembolism risk, but oral surgery will not affect mobility. Focus:
Prioritization.
3. Ans: 4 Raloxifene increases the risk for deep vein thrombosis and pulmonary
embolism, and the client should be evaluated further with an examination,
possible venous ultrasonography, and coagulation studies. Hot flashes and
nasal congestion are common side effects of raloxifene but are not reasons to
discontinue the medication. Raloxifene lowers myocardial infarction risk in
women at high risk. Focus: Prioritization.
4. Ans: 3 A palpable bladder and restlessness are indicators of urinary retention,
which would require action (e.g., insertion of a catheter) to empty the
bladder. The other data would be consistent with the client's diagnosis of
benign prostatic hyperplasia. More detailed assessment may be indicated, but
no immediate action is required. Focus: Prioritization.
5. Ans: 4 Irregularly shaped and nontender lumps are consistent with a
diagnosis of breast cancer, so this client needs immediate referral for
diagnostic tests such as mammography or ultrasonography. The other
information is not unusual and does not indicate the need for immediate
action. Focus: Prioritization; Test Taking Tip: Remember to investigate
further when a client has a nontender lump or swelling because lumps that
are not painful are a common clinical manifestation of cancer in areas such as
the breasts or lymph tissues. Pain is rarely an early manifestation of cancer
but occurs as tumors grow and place pressure on other organs or tissues.

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6. Ans: 1 An LPN/LVN working in a postanesthesia care unit would be
expected to check dressings for bleeding and alert RN staff members if
bleeding occurs. The other tasks are more appropriate for nursing staff with
RN-level education and licensure. Focus: Assignment.
7. Ans: 2 Positioning the client's arm is a task within the scope of practice for
UAP working on a surgical unit. Client teaching and assessment are RN-level
skills. The RN should reinforce dressings as necessary because this requires
assessment of the surgical site and possible communication with the surgeon.
Focus: Delegation.
8. Ans: 4 The bladder spasms may indicate that blood clots are obstructing the
catheter, which would indicate the need for irrigation of the catheter with 30
to 50 mL of normal saline using a piston syringe. The other data would all be
normal after a TURP, but the client may need some teaching about the usual
post-TURP symptoms and care. Focus: Prioritization.
9. Ans: 4 Because tamsulosin blocks alpha receptors in the peripheral arterial
system, the most significant side effects are orthostatic hypotension and
dizziness. To avoid falls, it is important that the client change positions
slowly. The other information is also accurate and may be included in client
teaching but is not as important as decreasing the risk for falls. Focus:
Prioritization; Test Taking Tip: When any medication might lower blood
pressure, be aware that safety is a priority. Avoid risk for falls by teaching
clients to change position slowly.
10. Ans: 2 Hemorrhage is a major complication after TURP and should be
reported to the surgeon immediately. The other assessment data also indicate
a need for nursing action but not as urgently. Focus: Prioritization.
11. Ans: 1 Reinforcement of previous teaching is an expected role of the
LPN/LVN. Planning and implementing client initial teaching and
documentation of a client's discharge assessment should be performed by
experienced RN staff members. Focus: Assignment.
12. Ans: 4 It is important to assess oxygenation because the client's calf
tenderness and shortness of breath suggest a possible venous
thromboembolism and pulmonary embolus, serious complications of
transurethral resection of the prostate. The other activities are appropriate but
are not as high a priority as ensuring that oxygenation is adequate. Focus:
Prioritization; Test Taking Tip: You should rapidly investigate any client
report of shortness of breath because oxygenation is the most basic
physiologic need.
13. Ans: 1 This client has symptoms of testicular torsion, an emergency that
needs immediate assessment and intervention because it can lead to testicular
ischemia and necrosis within a few hours. The other clients also have
symptoms of acute problems (primary syphilis, acute bacterial prostatitis,
and prostatic hyperplasia with urinary retention), which need rapid
assessment and intervention, but these are not as urgent as the possible

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 testicular torsion. Focus: Prioritization.
14. Ans: 4 Painless vaginal bleeding in postmenopausal women may indicate
endometrial or cervical cancer and will require diagnostic testing such as
endometrial biopsy. Breast atrophy, vaginal dryness and painful intercourse,
and hot flashes are common after menopause, although these symptoms
should also be discussed with the HCP and may need treatment. Focus:
Prioritization.
15. Ans: 3 Current guidelines state that there is no effective screening tool for
low-risk women, but women who are high risk because of family history or
the BRCA genes may be screened with transvaginal ultrasonography and
serum marker CA-125 levels. The other statements are accurate but do not
respond as well to the client's concern. Focus: Prioritization.
16. Ans: 2, 1, 3, 4 Bladder spasms after a TURP are usually caused by the
presence of clots that obstruct the catheter, so irrigation should be the first
action taken. Administration of analgesics may help to reduce spasm.
Administration of a bolus of IV fluids is commonly used in the immediate
postoperative period to help maintain fluid intake and increase urinary flow.
Oral fluid intake should be encouraged when the nurse is sure that the client
is not nauseated and has adequate bowel tone. Focus: Prioritization.
17. Ans: 3 Sildenafil is a potent vasodilator and has caused cardiac arrest in
clients who were also taking nitrates such as nitroglycerin. The other client
data indicate the need for further assessment or teaching, but it is essential for
the client who uses nitrates to avoid concurrent use of sildenafil. Focus:
Prioritization.
18. Ans: 2 Administration of narcotics and the associated client monitoring are
included in LPN/LVN education and scope of practice. Assessments and
teaching are more complex skills that require RN-level education and are best
accomplished by an RN with experience in caring for clients with this
diagnosis. Focus: Assignment.
19. Ans: 3 An RN from the emergency department would be experienced in
assessment and management of pain. Because of their diagnoses and
treatments, the other clients should be assigned to RNs who are experienced
in caring for clients with cancer. Focus: Assignment; Test Taking Tip: When
making assignments for nurses who have floated to a specialty area, it is best
to assign the float nurse to clients who require actions that are commonly
used in many areas of nursing, such as administration of analgesics, dressing
changes, and fluid infusions.
20. Ans: 4, 3, 2, 1 The bilateral orchiectomy client needs immediate assessment
because confusion may be an indicator of serious postoperative complications
such as hemorrhage, infection, or pulmonary embolism. The client who had a
perineal prostatectomy should be assessed next because pain medication may
be needed to allow him to perform essential postoperative activities such as
deep breathing, coughing, and ambulating. The vaginal hysterectomy client's

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 anxiety needs further assessment next. Although the breast implant client has
questions about care of the drains at the surgical site, there is nothing in the
report indicating that these need to be addressed immediately. Focus:
Prioritization.
21. Ans: 3 Although infection occurs only rarely as a complication of transrectal
prostate biopsy, it is important that the client receive teaching about checking
his temperature and calling the HCP if there is any fever or other signs of
systemic infection. The client should understand that the test results will not
be available immediately but that he will be notified about the results.
Transient rectal bleeding may occur after the biopsy, but bleeding that lasts
for more than a few hours indicates that there may have been rectal trauma.
Focus: Prioritization.
22. Ans: 4 Cramping or aching abdominal pain is common after dilation and
curettage; however, sharp, continuous pain may indicate uterine perforation,
which would require rapid intervention by the surgeon. The other data
indicate a need for ongoing assessment or interventions. Transient blood
pressure elevation may occur because of the stress response after surgery.
Bleeding after the procedure is expected but should decrease over the first 2
hours. Although the oxygen saturation is not at an unsafe level, interventions
to improve the saturation should be carried out. Focus: Prioritization.
23. Ans: 2, 4, 5 Assisting with catheter care, ambulation, and hygiene are
included in home health aide education and would be expected activities for
this staff member. Client assessments are the responsibility of RN members of
the home health care team. Focus: Delegation.
24. Ans: 1 Because the most likely source of the bacteria causing the toxic shock
syndrome is the client's tampon, it is essential to remove it first. The other
actions should be implemented in the following order: obtain blood culture
samples (best done before initiating antibiotic therapy to ensure accurate
culture and sensitivity results), infuse nafcillin (rapid initiation of antibiotic
therapy will decrease bacterial release of toxins), and administer
acetaminophen (fever reduction may be necessary, but treating the infection
has the highest priority). Focus: Prioritization.
25. Ans: 1, 3, 4 Emergency contraception with levonorgestrel (Plan B) may cause
heavy menstrual bleeding and nausea with vomiting. Risk for pregnancy
complications is not increased. The medication is most effective if taken
within 72 hours, but it can be used up to 5 days after unprotected intercourse.
Levonorgestrel does not need a prescription when used for emergency
contraception by clients age 17 years or older. Focus: Prioritization.
26. Ans: 2 Current guidelines indicate that Pap testing should be started at age
21 years, regardless of when a woman has become sexually active. The 19-
year-old client should be counseled that there is an increased risk for cervical
cancer associated with sexual activity before age 17 years and encouraged to
schedule Pap testing, human papillomavirus testing, or both at age 21 years.

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 The 33-year-old client will need screening every 3 years, and the 67-year-old
will not need further Pap screening if she has had several normal Pap test
results within the past 2 to 3 years. Focus: Prioritization.
27. Ans: 2 Right calf swelling and tenderness indicate the possible presence of
deep vein thrombosis. This will change the plan of care because the client
may be placed on bed rest and will require diagnostic testing and possible
anticoagulant therapy. The other data indicate the need for common
postoperative nursing actions such as having the client cough, assessing her
pain, and increasing her fluid intake. Focus: Prioritization.
28. Ans: 3 Clients with intracavitary implants are kept in bed during the
treatment to avoid dislodgement of the implant. The other actions may also
require the nurse to intervene by providing guidance to the student. Minimal
time should be spent close to clients who are receiving internal irradiation.
Asking the client about her reaction to losing childbearing abilities may be
inappropriate at this time. Clients are frequently placed on low-residue diets
to decrease bowel distention while implants are in place. Focus:
Prioritization.
29. Ans: 1 The client has symptoms of a urinary tract infection. Inserting a
straight catheter will enable the nurse to obtain an uncontaminated urine
specimen for culture and sensitivity testing before the antibiotic is started. In
addition, the client is probably not emptying her bladder fully because of the
painful urination. The antibiotic therapy should be initiated as rapidly as
possible after the urine specimen is obtained. Administration of
acetaminophen is the lowest priority because the client's temperature is not
dangerously elevated. Focus: Prioritization.
30. Ans: 2 After an A & P repair, it is essential that the bladder be empty to
avoid putting pressure on the suture lines. The abdominal firmness and
tenderness indicate that the client's bladder is distended. The health care
provider should be notified and an order for catheterization obtained. The
other data also indicate a need for further assessment of her cardiac status
and actions such as having the client cough and deep breathe, but these are
not such immediate concerns. Focus: Prioritization.
31. Ans: 1 Testosterone is contraindicated in clients who have prostate cancer
because it can promote growth of prostate cancer. Although metformin is
most commonly prescribed for type 2 diabetes, it can be helpful in restoring
ovulation in clients with polycystic ovary syndrome. Sildenafil lowers blood
pressure and should not be used by clients who are taking nitrates or alpha-
adrenergic blockers but may be used in clients taking other
antihypertensives. Progestin therapy alone will not treat infertility caused by
endometriosis but may be used to shrink endometrial tissue. Focus:
Prioritization.
32. Ans: 3 The client should be positioned in a semi-Fowler position to decrease
pain and minimize the risk of abscess development higher in the abdomen.

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 The other actions also require correction but not as rapidly. Tampon use is
not contraindicated after an episode of PID, although some sources
recommend not using tampons during the acute infection. Heat application
to the abdomen and pelvis is used for pain relief. Intercourse is safe a few
weeks after effective treatment for PID. Focus: Prioritization.
33. Ans: 3 Centers for Disease Control and Prevention guidelines indicate that
the HPV immunization should not be given during pregnancy. Ideally, the
immunization series should start at age 11 or 12 years for girls and boys, but
it may be started up through age 26 years. HPV immunization is most
effective in preventing HPV infection and cervical cancer when it is started
before the individual is sexually active and before any HPV infection, but
these are not contraindications for vaccination. Focus: Prioritization.
34. Ans: 2 The initial action should be to ensure that the abdominal contents
remain moist by covering the wound and loops of intestine with dressings
soaked with sterile normal saline. Because national guidelines addressing the
use of RRTs indicate that the role of the RRT is immediate assessment and
stabilization of the client, the nurse's next action should be to activate the
RRT. The surgeon should be notified after further assessments of the client
(e.g., pulse and blood pressure) are obtained. Wound cultures may be
obtained, but protection of the wound, further assessment of the client, and
then notification of the surgeon so that other actions can be taken are the
priority. Focus: Prioritization.
35. Ans: 3 LPN/LVN education includes vital sign monitoring after procedures
such as paracentesis; an experienced LPN/LVN would recognize and report
significant changes in vital signs to the RN. The paracentesis tray could be
obtained by a UAP. Client admission assessment and teaching require RN-
level education and experience, although part of the data gathering may be
done by an LPN/LVN. Focus: Assignment.
36. Ans: 3 The initial response by the charge nurse should be assessment of the
new nurse's concerns about caring for this client. Acknowledging the new
nurse's concerns will be more effective than mandating culturally sensitive
care. Changing the assignment and arranging training may be appropriate,
but more information about the new nurse's anxieties is needed first.
Treatment for pneumonia will not be different for a transgender client, but it
is important that the client's care is provided in a nonjudgmental manner.
Focus: Prioritization.
37. Ans: 4 The Joint Commission suggests that forms should use inclusive and
gender-neutral language to allow for client self-identification. Unisex or
single-stall bathrooms should be provided, but transgender clients should
also be able to use bathrooms consistent with their gender identity. Treating
all clients the same fails to acknowledge that sexual orientation and gender
identity may have an impact on health care needs. The nurse should be
receptive of information about client sexual orientation and gender identity,
but self-identification should be at the client's chosen time. Focus:

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 Prioritization.
38. Ans: 4 The current guidelines, supported by nonrandomized screening trials
and observational data, call for first-degree relatives of clients with the BRCA
gene to be screened with both annual mammography and MRI. Although
annual mammography, breast self-examination, and clinical breast
examination by a health care provider may help to detect cancer, the best
option for this client is annual mammography and MRI. Focus: Prioritization.
39. Ans: 100 To infuse 100 mL over 60 minutes, the nurse will need to set the
infusion pump to give 100 mL/hr. Focus: Prioritization.

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