(PLACE FIGURE HERE (Fig. 20) For Q#1901)

PN~CD~Questions~1901-2000 - 1
Comprehensive Review CD Questions 1901-2000
{COMP: Equations/Formulas: 1963; <AQ> questions: 1901, 1907, 1919, 1922, 1925,
1957; note multiple figures/figure credits for Question 1919.}
{PLACE FIGURE HERE (Fig. 20) for Q#1901}

Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for
collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 693.
<AQ>1901. A nurse is checking the apical heart rate of a client with angina. The nurse
places the stethoscope in which anatomical area?
Answer: 4
Rationale: The apical heart rate is best assessed by placing the stethoscope in the mitral
area, which is located in the fifth intercostal space on the left side of the chest at the apex
of the heart. Erb’s point is located in the third intercostal space just left of the sternum.
The aortic area is located in the second intercostal space just right of the sternum. The
pulmonic area is located in the second intercostal space just left of the sternum.
Test-Taking Strategy: Recalling that the apical heart rate is best assessed at the apex of
the heart and knowledge that this area is located in the fifth intercostal space to the left of
the sternum will direct you to option 4. Review the procedure for taking the apical heart
rate if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Cardiovascular
References: Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical
thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 693.
Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.).
Philadelphia: W.B. Saunders, p. 561.

1902. A nurse is collecting data from a client with varicose veins. Which finding would
the nurse identify as an indication of a potential complication associated with this disorder?
1. Legs are unsightly in appearance and distress the client
2. The client complains of aching and feelings of heaviness in the legs
3. The physician finds that the legs become distended when the tourniquet is released
during the Trendelenburg test
4. The client complains of leg edema, and skin breakdown has started
Answer: 4
Rationale: Complications of varicose veins include leg edema, skin breakdown,
ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or
chronic insufficiency. The client with varicose veins may be distressed about the unsightly
appearance of the varicosities. Complaints of heaviness and aching in the legs are common.
Option 3 describes the Trendelenburg test findings, which are indicative of varicose veins.
In the test, the physician has the client lie down and elevate the legs to empty the veins. A
tourniquet is then applied to occlude the superficial veins, after which the client stands and
the tourniquet is released. If the veins are incompetent, they will quickly become distended
due to backflow.
Test-Taking Strategy: Use the process of elimination and note the key words potential
complication. Noting the words “skin breakdown” in option 4 will direct you to this option.
If you had difficulty with this question, review the complications associated with varicose
veins.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St.
Louis: Mosby, p. 343.
1903. A client is admitted to the hospital with acute exacerbation of chronic obstructive
pulmonary disease (COPD) and had an arterial blood gas test performed. Which of the
following results would the nurse expect to note?
1. pO2 of 70 mm Hg and pCO2 of 50 mm Hg
Answer: 4
Rationale: During an acute exacerbation of COPD, the arterial blood gases deteriorate
with a decreasing pO2 and an increasing pCO2. In the early stages of COPD, arterial blood
gases demonstrate a mild to moderate hypoxemia with the pO2 in the high 60’s to high
70’s and normal arterial pCO2. As the condition advances, hypoxemia increases and
hypercapnia may result.
Test-Taking Strategy: Use the process of elimination and note the key words acute
exacerbation. This will direct you to option 4. This is the option that indicates the lowest
pO2 level. If you had difficulty with this question, review the physiological alterations
that occur in COPD and the associated blood gas values.
Content Area: Adult Health/Respiratory
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing
(3rd ed.). Philadelphia: W.B. Saunders, pp. 497-499.
1904. A client scheduled for a thyroidectomy says to the nurse, “I am so scared to get cut
in my neck.” Based on the client’s statement, the nurse suggests including which nursing
diagnosis in the plan of care?
1. Anxiety related to inadequate knowledge about the surgical procedure
2. Ineffective Coping related to fear about impending surgery
3. Situational Low Self Esteem related to changes in personal appearance

4. Impaired Home Maintenance related to the surgical procedure
Answer: 2
Rationale: The client is having a difficult time coping with the scheduled surgery. The
client is able to express fears but is frightened. There are no data in the question to
support options 1, 3, and 4.
Test-Taking Strategy: Use the process of elimination. Focusing specifically on the
client’s statement in the question will direct you to option 2. Also note the relation
between the words “scared” in the question and “fear” in the correct option. Review the
defining characteristics for Ineffective Coping if you had difficulty with this question.
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Endocrine
(3rd ed.). Philadelphia: W.B. Saunders, pp. 1124-1127.
1905. A client with coronary artery disease has selected guided imagery to help cope
with psychological stress. Which statement by the client indicates the best understanding
of this stress reduction measure?
1. “This works for me only if I am alone in a quiet area.”
2. “This will help only if I play music at the same time.”
3. “I need to do this only when I lie down in case I fall asleep.”
4. “The best thing about this is that I can use it anywhere, anytime.”
Answer: 4
Rationale: Guided imagery involves the client’s creation of an image in the mind,
concentrating on the image, and gradually become less aware of the offending stimulus.
It does not require any adjuncts and does not need to be done in a quiet area only,
although some clients may use other relaxation techniques or play music with it.
Test-Taking Strategy: Use the process of elimination and note the key words best
understanding. Eliminate options 1, 2, and 3 because of the absolute word “only.”
Review guided imagery if you had difficulty with this question.
Integrated Process: Nursing Process/Evaluation
Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis:
Mosby, p. 914.
1906. A client who is 36-hours post-myocardial infarction has ambulated for the first
time. The nurse determines that the client best tolerated the activity if which observation
was made?
1. Skin cool but slightly diaphoretic
2. Dyspnea noted only at the end of the exercise
3. Preactivity pulse rate 86 beats per minute, postactivity pulse rate 94 beats per minute
4. Preactivity blood pressure (BP) 140/84 mm Hg, postactivity BP 110/72 mm Hg
Answer: 3
Rationale: The nurse checks vital signs and the level of fatigue with each activity. The
client is not tolerating the activity if there is a drop in systolic BP greater than 20 mm Hg,
changes in pulse rate of greater than 20 beats per minute, dyspnea, or chest pain. Cool,
diaphoretic skin is a sign of some degree of cardiovascular compromise.
Test-Taking Strategy: Use the process of elimination. The question asks about activity
tolerance, which tells you that you are looking for normal data. Look for the option that
identifies normal values or the least degree of variation. Options 1 and 2 clearly identify
abnormal data. Option 4 identifies a significant drop in BP, indicating an abnormal
condition. An increase in pulse rate as reflected in option 3 is a normal expectation after
exercise. Review the effects of exercise on the cardiovascular system if you had
difficulty with this question.
References: Black, J., & Hawks, J., (2005). Medical-surgical nursing: Clinical
management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1474.
Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby,
p 316.
{PLACE FIGURE HERE (Fig. 21). For Q#1907}

Wilson, S., & Giddens, J. (2005). Health assessment for nursing practice (3rd ed.). St.
<AQ>1907. A nurse is preparing to auscultate bowel sounds on a postoperative client.
The nurse places the stethoscope in which quadrant first?
Answer: 3
Rationale: To auscultate bowel sounds, the nurse should begin at the ileocecal valve area
in the right lower quadrant, because bowel sounds are normally present in this area. The
diaphragm end piece is used because bowel sounds are relatively high-pitched. The
stethoscope is held lightly against the skin because pushing too hard may stimulate more
bowel sounds.
Test-Taking Strategy: Knowledge regarding the anatomy and physiology of the
gastrointestinal tract and the procedure for assessing bowel sounds is required to answer
this question. Remember, begin at the ileocecal valve area in the right lower quadrant. If
you are unfamiliar with the auscultation of bowel sounds, review this procedure.
Content Area: Adult Health/Gastrointestinal
References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing
(3rd ed.). Philadelphia: W.B. Saunders, p. 655.

1908. A nurse observes that a client’s nasogastric tube has suddenly stopped draining.
The tube is connected to suction, the machine is on and functioning, and all connections
are snug. The tube is secured properly and does not appear to have been dislodged. After
checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but
the tube is still not draining. The nurse analyzes this problem as:
1. Channels of gastric secretions may be bypassing the holes in the tube, and turning the
client will promote stomach emptying
2. Thick gastric secretions may be blocking the tube, and removing this tube and
reinserting a new tube will correct the problem
3. It is a normal occurrence for a nasogastric tube to stop draining; no action is required
4. This is a potentially serious complication, and the physician must be notified
immediately
Answer: 1
Rationale: The nurse must check nasogastric tubes regularly to maintain the tube’s
patency and ensure that it is draining properly. Nasogastric tubes are used to decompress
the stomach. The gastric distention will be relieved only if the tube drains properly. One
cause of improper tube drainage results from channels of gastric secretions forming along
the walls of the stomach and bypassing the holes in the nasogastric tube. Turning the
client regularly helps to collapse the channels and promotes gastric emptying. The tube
has already been flushed, so it is unlikely that it is still blocked by thick secretions.
Although this is a problem that requires attention and intervention, it is not a potentially
serious complication.
Test-Taking Strategy: Use the process of elimination. Option 2 can be eliminated
because the tube has just been flushed. Option 3 can be eliminated because it is not
acceptable to ignore a tube that has suddenly stopped draining. Option 4 can be
eliminated because there are nursing options available to reestablish nasogastric tube
patency before notifying the physician. If you had difficulty with this question, review
nursing care to the client with a nasogastric tube.
References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical
Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p.
1408.
1909. A nurse is performing nasotracheal suctioning of the secretions of a client. The

nurse determines that the client is adequately tolerating the procedure if which
observation is made?
1. Secretions are becoming bloody
2. Heart rate decreases from 78 to 54 beats per minute
3. Coughing occurs with suctioning
4. Skin color becomes cyanotic

Answer: 3
Rationale: The nurse monitors for adverse effects of suctioning, which include cyanosis,
excessively rapid or slow heart rate, or the sudden development of bloody secretions. If
they occur, the nurse stops suctioning, and reports these signs to the physician
immediately. Coughing is a normal response to suctioning for the client with an intact
cough reflex, and does not indicate that the client cannot tolerate the procedure.
Test-Taking Strategy: Use the process of elimination. The wording of the question asks
you to select an option that would be a normal or expected finding while suctioning the
secretions of a client. Cyanosis (option 4) and bradycardia (option 2) are abnormal
findings, and are eliminated first. From the remaining options, the use of the word
“becoming” in association with bloody secretions in option 1 tells you that this has not
been an ongoing problem, making this an incorrect option also. Because the cough reflex
is normally present, and suction triggers coughing, this is the preferable option of those
remaining. Review the expected and unexpected findings during nasotracheal suctioning
if you had difficulty with this question.
Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia:
W.B. Saunders, p. 511.
1910. The nurse is caring for a client receiving digoxin (Lanoxin). The nurse monitors
the client for which early manifestation of digoxin toxicity?
1. Photophobia
2. Anorexia
3. Yellow color perception
4. Facial pain
Answer: 2
Rationale: Digoxin is a cardiac glycoside that is used to manage and treat heart failure
and to control ventricular rates in clients with atrial fibrillation. The most common early
manifestations of toxicity include gastrointestinal disturbances such as anorexia, nausea,
and vomiting. Neurological abnormalities can also occur early and include fatigue,
headache, depression, weakness, drowsiness, confusion, and nightmares. Facial pain,
personality changes, and ocular disturbances (photophobia, light flashes, halos around
bright objects, yellow or green color perception) are also signs of toxicity but are not
early signs.
Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 first
because they are similar and both relate to eye disturbances. From the remaining options,
focus on the key word early to direct you to option 2. Review the early signs of digoxin
toxicity if you had difficulty with this question.
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology

Reference: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004.
1911. A nurse is planning a dietary menu for a client with congestive heart failure (CHF)
being treated with digoxin (Lanoxin) and furosemide (Lasix). Which of the following
would be the best dinner choice from the daily menu?
1. Beef vegetable soup, macaroni and cheese, and a dinner roll
2. Beef ravioli, spinach soufflé, and Italian bread
3. Baked pollack, mashed potatoes, and carrot-raisin salad
4. Roasted chicken breast, brown rice, and stewed tomatoes
Answer: 3
Rationale: Furosemide depletes potassium levels, and a client taking digoxin and
furosemide needs to maintain normal potassium levels and moderate salt intake.
Hypokalemia may make the client more susceptible to digoxin toxicity. The
recommended daily intake for potassium is 2000 mg. Option 1 is not the best choice
because beef vegetable soup contains 1002 mg of sodium and only 76 mg of potassium.
Macaroni and cheese has 1029 mg of sodium and no potassium. Option 2 is not the best
choice because beef ravioli has 1150 mg of sodium and no potassium. Spinach soufflé is
a good source of potassium (345 mg) but also contains 820 mg of sodium. Option 4 is
not the best choice because roasted chicken breast contains only 218 mg of potassium and
very little sodium (63 mg). Stewed tomatoes contain 125 mg of potassium and 230 mg of
sodium. Brown rice contains only 42 mg of potassium. Option 3 is the best choice
because all three foods are high in potassium: potato (314 mg), pollack (388 mg), and
raisins (600 mg) and low in sodium.
Test-Taking Strategy: Use the process of elimination. Focusing on the client’s condition
will assist in determining that the client requires a high potassium and low sodium intake.
Next, review the foods in each option to direct you to option 3. If you had difficulty with
this question, review those foods that are high in potassium and low in sodium.
Reference: Nix, S. (2005). Williams’ basic nutrition & diet therapy (12th ed.). St. Louis:
Mosby, p. 137.
1912. A client has received instructions about an upcoming cardiac catheterization. The
nurse determines that the client has the best understanding of the procedure if the client
knew to report which of the following items?
1. Warm, flushed feeling
2. Pressure at the insertion site
3. Chest pain
4. Urge to cough
Answer: 3
Rationale: The client is instructed before cardiac catheterization to immediately report
chest pain or any unusual sensations. The client is informed that a warm, flushed feeling
may accompany dye injection, and occasional palpitations and the urge to cough may
occur as the catheter tip touches the cardiac muscle. The client may be asked to cough or
breathe deeply from time to time during the procedure. Because a local anesthetic is
used, the client should feel pressure, but not pain, at the insertion site.
Test-Taking Strategy: Use the process of elimination, noting the key words best
understanding. Focus on the issue—what the client should report. This indicates that
you are looking for an adverse consequence. This should direct you to option 3. Review
client teaching points regarding the cardiac catheterization procedure if you had difficulty
with this question.
Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th
ed.). Philadelphia: W.B. Saunders, p. 328.
1913. A nurse is caring for a client with Buerger’s disease. Which finding would the nurse
determine is a potential complication associated with this disease?
1. Discomfort in one digit
2. Cramping in the foot while resting
3. Pain with diaphoresis
4. Numbness and tingling in the legs
Answer: 4
Rationale: Buerger’s disease (thromboangiitis obliterans), which affects men between 20
and 40 years of age, has an unknown etiology. It is a recurring inflammation of the small-
sized and medium-sized arteries and veins of the upper and lower extremities that results in
thrombus formation and occlusion of blood vessels. Options 1, 2, and 3 are not
complications of this disorder. The finding that can be interpreted as a complication of the
disorder is numbness and tingling in the legs.
Test-Taking Strategy: Use the process of elimination and the ABCs—airway, breathing,
and circulation—to answer this question. This will direct you to option 4. If you had
difficulty with this question, review the complications associated with Buerger’s disease.
1914. A client with respiratory failure has a nursing diagnosis of Imbalanced Nutrition:
Less than Body Requirements, related to anorexia secondary to fatigue and dyspnea
while eating. The nurse determines that the client has followed the recommendations to
improve intake if the client:
1. Selected foods that are very dry
2. Ate the largest meal of the day at a time when most hungry
3. Increased the use of milk products
4. Increased the use of stimulants, such as caffeine
Answer: 2
Rationale: The client is taught to plan the largest meal of the day at a time when the
client is most likely to be hungry. It is also beneficial to eat four to six small meals per
day if needed. The client avoids dry foods, which are hard to chew and swallow. The
client also avoids milk and chocolate, which have a tendency to thicken saliva and
secretions. Finally, the client should avoid the use of caffeine, which contributes to
dehydration by promoting diuresis.
Test-Taking Strategy: Use the process of elimination. Eliminate option 1 first because
dry foods are hard to chew and swallow. Options 3 and 4 are eliminated next because
they thicken secretions and have a dehydrating effect, respectively. Review dietary
suggestions for the client with a respiratory disorder if you had difficulty with this
question.
Integrated Process: Teaching/Learning
Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical
1915. A client has undergone fluoroscopy-assisted aspiration biopsy of a chest lesion.

The nurse determines that the client is experiencing complications from the procedure if
the nurse notes which of the following?
1. Pulse rate of 80 beats per minute, up from 74 beats per minute
2. Skin pink, warm, and dry
3. Absence of breath sounds in the right upper lobe
4. Oxygen saturation 97% by pulse oximetry
Answer: 3
Rationale: Pneumothorax and bleeding are possible complications of this procedure. The
client is observed for signs of respiratory difficulty, such as dyspnea, change in breath
sounds, change in vital signs, pallor, and diaphoresis. Observation of the sputum for
traces of blood or hemoptysis is also indicated. The absence of breath sounds in the right
upper lobe indicates a potential pneumothorax.
Test-Taking Strategy: Use the process of elimination focusing on the issue—a
complication. Begin to answer this question by eliminating options 2 and 4 first, because
they indicate normal data. Option 1 identifies a slight change in pulse rate, and may be
expected with this procedure. Absence of breath sounds is always an abnormal finding.
Review postprocedure complications following fluoroscopy-assisted aspiration biopsy if
you had difficulty with this question.
References: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic
procedures (4th ed.). Philadelphia: W.B. Saunders, p. 238.

Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th
ed.). St. Louis: Mosby, p. 586.
1916. A client with acquired immunodeficiency syndrome (AIDS) has difficulty

swallowing, and the nurse has given the client suggestions to minimize the problem. The
nurse determines that the client has understood the instructions if the client verbalized to
increase intake of foods such as:
1. Raw fruits and vegetables
2. Hot soup
3. Peanut butter
4. Puddings
Answer: 4
Rationale: The client is instructed to avoid spicy, sticky, or excessively hot or cold foods.
The client is also instructed to avoid foods that are rough, such as uncooked fruits or
vegetables. The client is encouraged to consume foods that are mild, nonabrasive, and
easy to swallow. Examples of these include baked fish, noodle dishes, well-cooked eggs,
and desserts such as ice cream or pudding. Dry grain foods such as crackers, bread, or
cookies may be softened in milk or another beverage before eating.
Test-Taking Strategy: Use the process of elimination and focus on the issue—difficulty
swallowing. Evaluate each of the foods listed in terms of how easily they are swallowed.
The rough, hot, and sticky foods in options 1, 2, and 3, respectively, help you to choose
option 4 as the correct option. Review nutritional concepts and the AIDS client if you
had difficulty with this question.
Content Area: Adult Health/Immune
Reference: Peckenpaugh, N. (2003). Nutrition essentials and diet therapy (9th ed.).
1917. The nurse prepares to care for a client with inflamed joints and plans to use which
item to maintain proper positioning for rest of the inflamed joints?
1. Large pillows
2. Footboards
3. Small pillows
4. Soft mattress
Answer: 3
Rationale: Small pillows, trochanter rolls, and splints will properly and safely maintain
proper positions for rest of inflamed joints. Large pillows may cause positions of more
flexion than indicated. A soft mattress and footboards will not be helpful to inflamed
joints and should be avoided.
Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first because
there is no direct relation between this item and resting joints. In general, soft mattresses
are not beneficial, so eliminate option 4. From the remaining options, visualize each.
Small pillows will be most effective in positioning inflamed joints. If you had difficulty
with this question, review care to the client with inflamed joints.
Content Area: Adult Health/Musculoskeletal
Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing:
Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 1723-
1724.
1918. A client has received instructions on self-management of peritoneal dialysis. The

nurse determines that the client needs further instruction if the client states to:
1. Use a strong adhesive tape to anchor the catheter dressing
2. Use meticulous aseptic technique for dialysate bag changes
3. Take own vital signs daily
4. Monitor own weight daily
Answer: 1
Rationale: The client is at risk for impairment of skin integrity because of the presence of
the catheter, exposure to moisture, and irritation from tape and cleansing solutions. The
client should be instructed to use paper tape or nonallergenic tape to prevent skin
irritation and breakdown. It is proper procedure for the client to use aseptic technique,
and to self-monitor vital signs and weight on a daily basis.
Test-Taking Strategy: Use the process of elimination, noting the key words needs further
instruction. These words indicate a false response question and that you need to select
the incorrect client statement. Knowing that self-monitoring of weight and vital signs is
important guides you to eliminate options 3 and 4. To choose correctly between options
1 and 2, you should know either that meticulous aseptic technique is used to prevent the
occurrence of peritonitis or that the skin needs to be protected from maceration using a
variety of methods. Review the procedure for peritoneal dialysis if you had difficulty
with this question.
Content Area: Adult Health/Renal
{PLACE FIGUREs HERE (Figs. 22-25). For Q#1919}

{Fig. 22} Potter, P., & Perry, A. (2005). Fundamentals of nursing (5th ed.). St. Louis:
Mosby, pp. 1462.
Mosby, pp. 1463.
Mosby, pp. 1464.
Mosby, pp. 1465.
<AQ>1919. A nurse is preparing to administer a soapsuds enema to a client. Which
position does the nurse place the client to administer the enema?
Answer: 3
Rationale: To administer an enema, the nurse assists the client into the left side-lying
(Sims) position with the right knee flexed. This position allows the enema solution to
flow downward by gravity along the natural curve of the sigmoid colon and rectum, thus
improving the retention of solution. Option 1 is a supine position. Option 2 is a prone
position. Option 4 is a right side-lying (semiprone) position.
Test-Taking Strategy: Focus on the issue—administering an enema. Think about the
anatomy of the gastrointestinal tract to assist in directing you to option 3. If you had
difficulty with this question, review the procedure for administering an enema.
Content Area: Fundamental Skills
Mosby, pp. 1462-1465.
{PLACE FIGUREs HERE (Figs. 22-25). For Q#1919}

Mosby, pp. 1462.
Mosby, pp. 1463.
Mosby, pp. 1464.
Mosby, pp. 1465.
1920. A nurse has completed nutritional counseling with an overweight client about
weight reduction to modify the risk for coronary artery disease. The nurse would
determine the teaching as most successful if the client stated that a safe weight loss goal
is:
1. One half pound per day
2. Two pounds per week
3. Four pounds per week
4. Six pounds per week
Answer: 2
Rationale: Most people, including the mildly and moderately obese, can only lose about
2 pounds per week of weight from fat loss. Weight loss beyond that level is probably due
to protein and water loss alone.
Test-Taking Strategy: Use the process of elimination. Options 1 and 3 are similar and
may be eliminated. The word “safe” before weight loss implies an optimum value. Two
pounds of weight loss per week is safer than six. Therefore option 2 is the best option.
Review the components of a weight loss program if you had difficulty with this question.

Reference: Peckenpaugh, N. (2003). Nutrition essentials and diet therapy (9th ed.).
1921. A postgastrectomy client is at high risk for hyperglycemia related to uncontrolled

gastric emptying of fluid and food into small intestine (dumping syndrome). Because of
this risk, the nurse plans to monitor the:
1. Fasting blood glucose readings
2. Postprandial blood glucose readings
3. Client’s daily weight
4. Calorie counts from the dietary department
Answer: 2
Rationale: Late manifestations of dumping syndrome following a gastrectomy occur 2 to
3 hours after eating and result from a rapid entry of increased carbohydrate food into the
jejunum, a rise in blood glucose levels, and excessive insulin secretion. To monitor this,
the nurse checks the blood glucose level 2 hours after meals. Options 3 and 4 are
unrelated to the issue of the question. A fasting blood glucose level would not accurately
determine hyperglycemia.
Test-Taking Strategy: Use the process of elimination focusing on the key words
postgastrectomy and hyperglycemia. Recalling that manifestations of dumping syndrome
following a gastrectomy occur 2 to 3 hours after eating will direct you to option 2.
Review the manifestations of dumping syndrome if you had difficulty with this question.
{PLACE FIGURE HERE (FIG. 26) for Q#1922}

Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and
specialty areas (5th ed.). Philadelphia: W.B. Saunders, p. 201.
<AQ>1922. A nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water
(D5W) at 7:00 AM. The IV is to infuse at 100 mL per hour, and the nurse places a time
tape on the IV bag. At noon the nurse would expect that the infusion line on the IV bag
would be at which point?
Answer: 2
Rationale: If an IV is to infuse at 100 mL per hour, in a 5-hour period (7:00 AM to noon) a
total of 500 mL would have infused. Therefore the infusion line would be at the 500 mL
point.
Test-Taking Strategy: Focus on the issue of the question—the amount of IV solution to
infuse in a 5-hour period. Note that the IV bag contains 1000 mL: 1000 mL minus 500
mL equals 500 mL. Review the procedure for monitoring IV infusions if you had
Level of Cognitive Ability: Comprehension

Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to
general and specialty areas (5th ed.). Philadelphia: W.B. Saunders, p. 201.
{PLACE FIGURE HERE (FIG. 26) for Q#1922}

specialty areas (5th ed.). Philadelphia: W.B. Saunders, p. 201.
1923. A nurse has finished suctioning the secretions of a client. The nurse would use
which of the following parameters to best determine the effectiveness of suctioning?
1. SaO2 is 98% by pulse oximetry
2. Clear breath sounds
3. Client statement of comfort
4. Client’s color is pink
Answer: 2
Rationale: The nurse evaluates the effectiveness of the suctioning procedure by
auscultating breath sounds. This helps to determine if the respiratory tract is clear of
secretions. Options 1, 3, and 4 do not determine the effectiveness of suctioning.
Test-Taking Strategy: Use the process of elimination, noting the key words best
determine the effectiveness. Focusing on the purpose of suctioning—to clear secretions
—will direct you to option 2. Review the purpose of suctioning if you had difficulty with
this question.
Mosby, p. 1108.
1924. A client who underwent bronchoscopy was returned to the nursing unit 1 hour ago.
The nurse determines that the client is experiencing complications of the procedure if the
nurse notes:
1. Breath sounds greater on the right side than the left side
2. Respiratory rate of 22 breaths per minute
3. Oxygen saturation of 95%
4. Weak gag and cough reflex
Answer: 1
Rationale: Asymmetrical breath sounds could indicate pneumothorax, and this should be
reported to the physician. A weak cough and gag reflex 1-hour postprocedure is an
expected finding, due to residual effects of intravenous sedation and local anesthesia. A
respiratory rate of 22 breaths per minute and oxygen saturation of 95% are acceptable
measurements.
Test-Taking Strategy: Use the process of elimination focusing on the issue—a
complication. Therefore look for the abnormal piece of data. Begin to answer this
question by eliminating options 2 and 3, which are acceptable data. From the remaining
options, recall that the client is premedicated before this procedure, which would cause a
weak gag and cough reflex. Remember, unequal breath sounds are always abnormal.
Review postbronchoscopy complications if you had difficulty with this question.
References: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic

483.
<AQ>1925. A nurse is reading a physician’s order and notes that a client is to receive a
medication at 1:00 PM. Using the military time clock, the nurse administers the
medication at which military time?
Answer: 1
Rationale: Many health care agencies use military time, which is a 24-hour system that
avoids misinterpretation of AM and PM times. Instead of two 12-hour cycles in standard
time, the military clock is one 24-hour time cycle. Therefore 1:00 PM is 1300 military
time.
Test-Taking Strategy: Specific knowledge regarding the military time clock is required to
answer this question. Recalling that the military time clock is one 24-hour time cycle
will direct you to option 1. If you are unfamiliar with military time, review this
information.
Mosby, p. 483.

483.
1926. A nurse is monitoring the respiratory status of a client following insertion of a

tracheostomy tube. The nurse understands that oxygen saturation measurements obtained
by pulse oximetry may be inaccurate if the client has which of the following coexisting
problems?
1. Hypotension
2. Fever
3. Respiratory failure
4. Epilepsy
Answer: 1
Rationale: Hypotension, shock, or the use of peripheral vasoconstricting medications
may result in inaccurate pulse oximetry readings because of impaired peripheral
perfusion. Fever and epilepsy would not affect the accuracy of measurement.
Respiratory failure would also not affect the accuracy of measurement, although the
readings may be abnormally low.
Test-Taking Strategy: Use the process of elimination focusing on the key word
inaccurate. Recall that pulse oximetry measures oxygen saturation in blood flowing
through the blood vessels in the periphery of the body. Inaccurate measurement may
result from any factor that impairs blood flow through the periphery. Evaluating each of
the options from this viewpoint helps you to select hypotension as the answer. Review
the procedure for measuring pulse oximetry if you had difficulty with this question.
Louis: Mosby, pp. 361-362.
1927. A nurse is caring for a client with pneumonia who has a history of bleeding
esophageal varices. Based on this information, the nurse plans care knowing that it is
important to prevent:
1. Nausea
2. Diarrhea
3. Pain
4. Constipation
Answer: 4
Rationale: Increased intrathoracic pressure contributes to rupturing of varices. Straining
during defecating, coughing, and vomiting all increase intrathoracic pressure. The nurse
needs to implement measures that will prevent increased intrathoracic pressure. Options
1, 2, and 3 will not increase intrathoracic pressure.
Test-Taking Strategy: Use the process of elimination focusing on the client’s diagnosis
and noting the key word prevent. Recalling that activities that increase intrathoracic
pressure can cause rupture will direct you to option 4. If you had difficulty with this
question, review the measures to prevent the rupturing of esophageal varices.
Reference: Black, J., & Hawks, J., (2005). Medical-surgical nursing: Clinical
1928. An adult client has been defibrillated three times unsuccessfully for ventricular
fibrillation, and cardiopulmonary resuscitation (CPR) is ongoing by two health care
workers. The best indicator that CPR is being performed effectively is if:
1. The chest compressions are given at a depth of 1.5 to 2 inches

2. The ratio of compressions to ventilations given is 15:2
3. Respirations are given after 15 compressions
4. The carotid pulse is palpable with each compression
Answer: 4
Rationale: Correct procedure for basic life support with two rescuers includes a
compression to ventilation ratio of 15:2. With adults, compressions are performed at a
depth of 1.5 to 2 inches. With effective compressions, carotid pulsations should be
present. At its best, CPR produces only 30% of the normal cardiac output, so correct
technique is vital.
Test-Taking Strategy: Use the process of elimination noting the key words best indicator
and the issue—that CPR is being performed effectively. Eliminate options 2 and 3 first
because they are similar. Also note that options 1, 2, and 3 are procedural and do not
reflect an outcome. The issue of the question guides you to look for an end result of the
procedure, which then directs you to option 4. Review the findings that determine the
effectiveness of CPR if you had difficulty with this question.
References: Harkreader, H., & Hogan, M. A. (2004). Fundamentals of nursing: Caring
and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, p. 912.
Linton, A. & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.).
1929. A nurse checks the water seal chamber of a closed chest drainage system and notes
fluctuations in the chamber. The nurse analyzes this finding as indicative of which of the
following?
1. An air leak is present
2. The tubing is kinked
3. The lung has re-expanded
4. The system is functioning as expected
Answer: 4
Rationale: Fluctuations (tidaling) in the water seal chamber are normal during inhalation
and exhalation. Fluctuations of 5 to 10 cm (2 to 4 inches) during normal breathing are
common. The absence of fluctuations could mean that the tubing is obstructed by a kink,
the client is lying on the tubing, or dependent fluid has filled a loop of tubing. Expanded
lung tissue can also block the chest tube eyelets during expiration. The absence of
fluctuations could also mean that air is no longer leaking into the pleural space.
Test-Taking Strategy: Use the process of elimination and knowledge of the functioning
of the chest tube drainage system to answer the question. Focusing on the issue—
fluctuations in the water seal chamber—and recalling the purpose of this chamber will
direct you to option 4. Review the expected and unexpected findings in a closed chest
drainage system if you had difficulty with this question.

Mosby, pp. 1117, 1121.
1930. A client who is scheduled for surgery to be placed in skeletal traction says to the
nurse, “I’m not sure if I want to have this skeletal traction or if the skin traction would be
best to stabilize my fracture.” Based on the client’s statement, the nurse should make
which response to the client?
1. “Your fracture is very unstable. You will die if you don’t have this surgery
performed.”
2. “There is no reason to be concerned. I have seen lots of these procedures.”
3. “Skeletal traction is much more effective than skin traction in your situation.”
4. “You have concerns about skeletal versus skin traction for your type of fracture?”
Answer: 4
Rationale: Option 4 identifies the therapeutic communication technique of paraphrasing.
Paraphrasing is restating the client’s message in the nurse’s own words. Option 1
identifies a communication block that reflects a lack of the client’s right to an opinion. It
will also cause fear in the client. In option 2, the nurse is offering a false reassurance and
this type of response will block communication. Option 3 is also a communication block
and reflects a lack of the client’s right to an opinion.
Test-Taking Strategy: Use the process of elimination and therapeutic communication
techniques. Select the option that enhances communication and addresses the client’s
feelings and concerns. Review therapeutic communication techniques if you had
Integrated Process: Communication and Documentation
Mosby, p. 437.
1931. The nurse is collecting data on a client with Parkinson’s disease. Which finding
indicates a serious complication of this disorder?
1. Congested cough and coarse rhonchi heard on auscultation
2. Last bowel movement was 48 hours ago
3. Resting and pill-rolling tremors
4. Shuffling and propulsive gait
Answer: 1
Rationale: Clients with Parkinson’s disease are at risk for aspiration. A congested cough
and coarse rhonchi may be present after a client aspirates. Although constipation is a
problem for clients with Parkinson’s disease, the concern is greater if the client has not
had a bowel movement by the third day. Resting and pill-rolling tremors and a shuffling,
propulsive gait are characteristic findings in Parkinson’s disease.
Test-Taking Strategy: Use the process of elimination noting the key word serious. Use
the ABCs—airway, breathing, and circulation. Aspiration presents a serious risk to the
client and may be suspected if the client with Parkinson’s develops a congested cough
and coarse rhonchi. Review the signs of aspiration and the serious complications of
Parkinson’s disease if you had difficulty with this question.
Content Area: Adult Health/Neurological
1932. The client with acquired immunodeficiency syndrome (AIDS) is experiencing

shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should
the nurse suggest including in the plan of care to assist the client in performing activities
of daily living?
1. Provide supportive care with hygiene needs
2. Provide meals and snacks with high protein, high calorie, and high nutritional value
3. Provide small, frequent meals
4. Offer low microbial food
Answer: 1
Rationale: Providing supportive care with hygiene needs reduces the client’s physical
and emotional energy demands and conserves energy resources for other functions such
as breathing. Options 2, 3, and 4 are important interventions for the client with AIDS, but
do not address the issue of activities of daily living. Option 2 will assist the client in
maintaining appropriate weight and proper nutrition. Option 3 will assist the client in
tolerating meals better. Option 4 will decrease the client’s risk of infection.
Test-Taking Strategy: Focus on the issue—performing activities of daily living. Options
2, 3, and 4 are all important interventions for the client with AIDS, but do not address the
issue. Option 1 is the only option that addresses the issue of the question. Also, note that
options 2, 3, and 4 are similar and relate to nutrition. Review care to the client with
AIDS if you had difficulty with this question.
management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 2387-
2388, 2397-2398.
1933. While doing discharge planning for a female teenager with anorexia nervosa, the
nurse suggests that the teenager attend a meeting of the local chapter of Anorexia
Nervosa and Associated Disorders. Which response by the teenager indicates that she
will most likely be compliant with this suggestion?
1. “I’ll go once, but if I don’t like it I won’t go back.”
2. “I’ll think about it.”
3. “I’ll do whatever I have to do to get out of this place.”
4. “I’m going to do whatever it takes to get better.”
Answer: 4
Rationale: Self-help groups serve to reduce the possibilities of further emotional distress,
leading to pathology and necessary treatment. Option 1 indicates that the client already
has doubts about participation and has given herself permission to terminate participation
in a self-help group. Option 2 identifies an ambivalent attitude that promises nothing.
Option 3 indicates that the client’s thinking is limited to short-term goals. Option 4
indicates that the client is a proactive participant in her plan of care.
Test-Taking Strategy: Use the process of elimination and focus on the key words most
likely be compliant. The option that demonstrates the most positive client response in
terms of participation is option 4. Review care to the client with anorexia nervosa if you
Content Area: Mental Health
Reference: Keltner, N., Schwecke, L., & Bostro, C. (2003). Psychiatric nursing (4th ed.).
St. Louis: Mosby, pp. 506, 512.
1934. A nurse notices that a client with trigeminal neuralgia has been withdrawn, is
having frequent episodes of crying, and is sleeping excessively. The best way for the
nurse to explore issues with the client regarding this behavior is to:
1. Conduct a group discussion with the client’s family
2. Have the client express the feelings in writing
3. Have the physician speak to the client
4. Ignore the behavior since it is expected in clients with trigeminal neuralgia
Answer: 2
Rationale: Speaking can exacerbate the pain that occurs with trigeminal neuralgia.
Having the client record feelings in writing will help the nurse to gain an understanding
of the client’s concerns without increasing the client’s pain. Discussing the issue with the
family will not provide insight into the client’s feelings. It is not in the client’s best
interest to refer the matter to the physician or to ignore the behavior. The nurse should
explore the client’s concerns and offer support.
Test-Taking Strategy: Use the process of elimination and therapeutic communication
techniques. Identifying the client in the question will assist in eliminating options 1 and
3. From the remaining options, recall that ignoring the behavior blocks communication
and places the client’s issues on hold. Remember to address the client’s feelings first.
Review therapeutic communication techniques and care to the client with trigeminal
neuralgia if you had difficulty with this question.
Integrated Process: Communication and Documentation
Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1604.
1935. A client is scheduled to have electroconvulsive therapy (ECT). The nurse tells the
client that:
1. There are no expected side effects associated with ECT

2. Amnesia of events occurring near the period of the therapy is common
3. Many clients experience long-term memory loss
4. The client will receive no medications during the procedure
Answer: 2
Rationale: The most common side effects of ECT include amnesia of events occurring
near the period of the therapy and the potential for transient confusion as a result of the
seizure and barbiturate anesthetic. Option 1 is incorrect. Option 3 is incorrect because in
most cases clients experience little long-term memory loss. Option 4 is incorrect because
general anesthesia and a muscle relaxant (often succinylcholine) are usually
administered.
because of the absolute word “no.” From the remaining options recalling that most
clients experience little long-term memory loss will direct you to option 2. Review the
side effects related to ECT if you had difficulty with this question.
St. Louis: Mosby, p. 528.
1936. A client with a burn injury begins to cry and states to the nurse, “I don’t want
anyone seeing me. I look awful.” The nurse determines that the client is at risk for
which of the following?
1. Disturbed Body Image
2. Anxiety
3. Situational Low Self Esteem
4. Powerlessness
Answer: 1
Rationale: The client with a burn injury experiences structural and functional changes of
the integumentary system changes as a result of this injury. The nursing diagnosis of
Disturbed Body Image refers to a disruption in the way one perceives one’s body image.
A verbal or nonverbal response to an actual or perceived change in structure or function
of the body must be present to justify this nursing diagnosis. Options 2, 3, and 4 do not
relate to the client’s statement.
Test-Taking Strategy: Use the process of elimination and focus on the data in the
question. Noting the client’s statement “I look awful” will direct you to option 1.
Review the defining characteristics for Disturbed Body Image if you had difficulty with
this question.
Content Area: Adult Health/Integumentary
1937. A client had thoracic surgery 2 days ago and has a chest tube in place connected to
a Pleur-Evac drainage system. The nurse notes that there is continuous bubbling in the
water seal chamber. The nurse determines that:
1. The client has a large amount of fluid that is being evacuated by the system
2. This is a result of the suction applied to the system, which is set at 20 mm Hgof
suction pressure
3. There is a leak in the system, which requires immediate investigation and correction
4. This is normal on the second postoperative day
Answer: 3
Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates that
there is a leak somewhere in the system, and air is being sucked into the apparatus. The
nurse needs to assess the system and initiate corrective action, which may include
notifying the physician. Bubbling may occur intermittently with the evacuation of a
pneumothorax, but it should not be continuous, especially with a client who had surgery 2
days earlier. Hemothorax results in accumulation of drainage in the collection chamber,
but does not cause bubbling in the water seal chamber. Application of suction to the
system causes bubbling in the suction control chamber, but not the water seal chamber.
Test-Taking Strategy: Use the process of elimination and knowledge of the function and
normal findings for each of the chambers of the Pleur-Evac closed chest drainage system.
Remember that continuous bubbling in the water seal chamber indicates leakage of air
into the system, while intermittent bubbling indicates drainage of pneumothorax. If you
had difficulty with this question or are unfamiliar with the care of the chest tube drainage
system, review this content.
1938. A client scheduled for pulmonary angiography is fearful about the procedure and
asks the nurse if the procedure involves significant pain and radiation exposure. The
nurse gives a response to the client that provides reassurance, based on the understanding
that:
1. The procedure is somewhat painful, but there is minimal exposure to radiation
2. Discomfort may occur with needle insertion, and there is minimal exposure to
radiation
3. There is absolutely no pain, although a moderate amount of radiation must be used to
get accurate results
4. There is no pain from the procedure, and the exposure to radiation is negligible
Answer: 2
Rationale: Pulmonary angiography involves minimal exposure to radiation. The
procedure is painless, although the client may feel discomfort with insertion of the needle
for the catheter that is used for dye injection. Options 1, 3, and 4 are incorrect.
Test-Taking Strategy: Use the process of elimination. Recalling that radiation exposure
is minimal helps to eliminate option 3 first. To select from the remaining options, it is
necessary to know that the discomfort occurs only with needle insertion. If you had
difficulty with this question, review the description and procedure for pulmonary
angiography.
Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test
reference (6th ed.). St. Louis: Mosby, p. 735.
1939. A nurse enters a client’s room and finds the client slumped in the chair. Breathing
is shallow and a pulse is present. Based on these data, the nurse determines that the
priority would be to:
1. Call the doctor immediately
2. Check the vital signs and level of consciousness
3. Have the secretary call a Code Blue
4. Ask the unit clerk to call the family immediately
Answer: 2
Rationale: The client is breathing and has a pulse; therefore further data are needed
before any other action. The vital signs and level of consciousness should be checked.
Once that assessment is made, the physician is notified, who will then contact the family.
Code Blue is not indicated at the present time.
Test-Taking Strategy: Focus on the data in the question and use the steps of the nursing
process. Option 2 is the only option that addresses data collection. Also, use of the
ABCs—airway, breathing, and circulation—will direct you to option 2. Review
emergency care measures if you had difficulty with this question.
Philadelphia: W.B. Saunders, pp. 371-372.
1940. A nurse has given instructions to the family of an older client who seems anxious
about being discharged after cardiac surgery. The nurse would need to reinforce the
teaching if a family member made which of the following statements?
1. “Fatigue, discomfort, and lack of appetite occur more commonly with older people,
and may last for 2 to 5 weeks.”
2. “A daily half-mile long brisk walk generally helps people bounce back more quickly
and provides more of a sense of control.”
3. “Recuperation after cardiac surgery is generally slower for older people.”
4. “It’s important to get out of bed every day, even if tired or weak at first.”
Answer: 2
Rationale: Clients generally increase activity by beginning a simple walking program,

starting with distances of 400 feet twice daily and gradually increasing distance until able
to walk ¼ mile (usually at the end of the second week). Exercise has physiological and
psychological benefits. The statements made in options 1, 3, and 4 are correct.
Test-Taking Strategy: Use the process of elimination noting the key words need to
reinforce the teaching. These words indicate a false response question and that you need
to select the incorrect statement. Noting that the client is older and recalling that activity
is resumed gradually after surgery will direct you to option 2. Review home care
instructions for the client who had cardiac surgery if you had difficulty with this question.
1649.
1941. A nurse monitors the laboratory data on a client at risk for coronary artery disease.
A fasting blood glucose reading of 200 mg/dl is recorded on the chart. The nurse
analyzes this result as:
1. Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery
disease
2. Decreased, indicating a decreased risk of coronary artery disease
3. Normal, indicating adequate blood glucose control with no risk for coronary artery
disease
4. Elevated, but would not present a risk for coronary artery disease
Answer: 1
Rationale: A fasting blood glucose level of 200 mg/dl signals the presence of diabetes
mellitus. Diabetes mellitus predisposes a client to coronary artery disease. Options 2, 3,
and 4 are inaccurate interpretations.
Test-Taking Strategy: Use the process of elimination. Recalling the normal blood
glucose level and recalling the association between diabetes mellitus and the risk for
coronary artery disease will direct you to option 1. If you had difficulty with this
question, review the normal blood glucose level and the risk factors associated with
coronary artery disease.
References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing:
805.
1942. After 5 days in the psychiatric unit, a manic client is able to tolerate short periods
of time in the dayroom. The nurse overhears the client telling another client that he is a
journalist posing as a client in order to write an article for a magazine. The nurse’s best
response/action is to:
1. Ignore the delusion
2. Confront the client with reality
3. Take the client to a quiet room
4. Support the client’s denial of illness
Answer: 2
Rationale: When dealing with a delusional client, it is important to clearly state that you
do not share his or her perceptions. Options 1, 3, and 4 do not focus on reality and ignore
the issue. Option 2 focuses on reality orientation.
Test-Taking Strategy: Use the process of elimination with the knowledge that reality
orientation is the priority. Options 1 and 4 are nontherapeutic and can be eliminated.
Option 3 takes the client out of the setting. Option 2, the correct answer, provides reality
orientation for the client. Review care of the delusional client if you had difficulty with
this question.
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St.
1943. A 4-year-old child is reluctant to take deep breaths following abdominal surgery.
The most effective measure to encourage deep breathing is to:
1. Have the child pretend he is the big, bad wolf blowing the little pig’s house down
2. Give the child colorful latex balloons to blow up
3. Tell the child to exhale forcefully through the peak flow meter
4. Administer chest percussion in several postural drainage positions
Answer: 1
Rationale: The preschooler has a vivid imagination and loves to pretend. Engaging the
child in therapeutic play appropriate to age is considered the most effective way to
intervene. Balloons are unsafe because of the potential aspiration of latex. The peak
flow meter is used to assess vital capacity rather than to encourage breathing. Chest
percussion and postural drainage will not affect depth of respiration.
Test-Taking Strategy: Note the age of the child. Eliminate option 2 first for safety
reasons. Next eliminate option 3 because the language is too advanced for the age of the
child. From the remaining options, note that option 4 does not relate directly to the
outcome of deep breathing. Review the stages of growth and development and the
relation to the hospitalized child if you had difficulty with this question.
Content Area: Child Health
Reference: James, S., Ashwill, J., & Droske, S. (2002). Nursing care of children:
Principles & practice (2nd ed.). Philadelphia: W.B. Saunders, p. 311.
1944. The nurse’s teaching plan for a client with a family history of breast cancer should
include which most important item?
1. Teaching the breast self-exam technique to be done every month
2. Teaching the importance of weight-bearing exercises
3. Monitoring for grief reactions
4. Implementing measures to prevent cancer
Answer: 1
Rationale: Monthly breast self-examination is recommended for all adult women. It is
especially important for those with a familial history of breast cancer. Weight-bearing
exercises are specifically important in preventing osteoporosis, not breast cancer. There
are no data in the question that indicate that assessing for grief reactions is necessary.
Implementing measures to prevent cancer are important, but option 1 relates to the issue
of breast cancer.
Test-Taking Strategy: Use the process of elimination and note the key words most
important. The only option that directly relates to the data in the question is option 1.
Note the relation of the words “family history of breast cancer” in the question and the
words “breast self-exam technique” in option 1. Review health promotion measures for
breast cancer if you had difficulty with this question.
Content Area: Adult Health/Oncology
management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p.353.
1945. A nurse is caring for a client with Addison’s disease. The nurse checks the vital
signs and determines that the client has orthostatic hypotension. The nurse determines
that this finding relates to which of the following?
1. A decrease in cortisol release
2. A decreased secretion of aldosterone
3. An increase in epinephrine secretion
4. Increased levels of androgens
Answer: 2
Rationale: A decreased secretion of aldosterone results in a limited reabsorption of
sodium and water; therefore the client experiences fluid volume deficit and resultant
orthostatic hypotension. A decrease in cortisol, an increase in epinephrine, and an
increase in androgen secretion do not result in orthostatic hypotension.
Test-Taking Strategy: Use the process of elimination. Recalling the action of aldosterone
in the regulation of intravascular volume and blood pressure will assist in answering this
question. Determine the relationship between blood pressure control and aldosterone
secretion when selecting the correct option. If you had difficulty with this question,
review the action of aldosterone.

References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St.
1946. Which nursing measure would be most effective in preventing complications in a

client with Addison’s disease?
1. Restricting fluid intake
2. Offering foods high in potassium
3. Checking family support systems
4. Monitoring the blood glucose level
Answer: 4
Rationale: The decrease in cortisol secretion that characterizes Addison’s disease can
result in hypoglycemia. Fluid intake should be encouraged to compensate for
dehydration. Potassium intake should be restricted because of hyperkalemia. Option 3 is
not a priority for this client in the question as stated.
Test-Taking Strategy: Use the steps of the nursing process remembering that data
collection is first. This will assist in eliminating options 1 and 2. From the remaining
options, note that both options 3 and 4 address data collection; however, option 4
addresses the physiological need. According to Maslow’s Hierarchy of Needs theory,
physiological needs come first. Review the pathophysiology associated with Addison’s
disease and the nursing care involved if you had difficulty with this question.
1220.
1947. An older client with advanced Alzheimer’s disease is placed in balanced

suspension traction, and the physician expects to internally fixate the client’s femur in 1
week. Based on this information, the nurse determines that the first priority relates to
addressing which of the following nursing diagnoses?
1. Risk for Constipation
2. Risk for Activity Intolerance
3. Impaired Tissue Integrity
4. Disturbed Thought Process
Answer: 1
Rationale: While all of these nursing diagnoses may apply to this client, lying supine,
being older, and having cognitive impairment place the client at extreme risk for
constipation and possibly impaction. While the client likely does have disturbed thought
processes because of Alzheimer’s disease and impaired tissue integrity as a result of the
fracture, activity is restricted and tolerance therefore is unknown.
Test-Taking Strategy: Use the process of elimination focusing on the data in the question.
Recalling the effects of cognitive impairment, skeletal traction, analgesics, immobility,

and aging on the gastrointestinal tract will assist in answering this question. Also, note the
length of time before the surgical procedure. Review care to the older, immobile client
with advanced Alzheimer’s disease if you had difficulty with this question.
Wold, G. (2004). Basic geriatric nursing (3rd ed.). St. Louis: Mosby, p. 141.
1948. A nurse is reading the results of the Mantoux skin test for a client who has no
documented health problems. The site has no induration and a 1-mm area of ecchymosis.
The nurse interprets that the result is:
1. Positive
2. Negative
3. Uncertain
4. Borderline
Answer: 2
Rationale: A positive Mantoux skin test reading has an induration measuring 15 mm or
more in clients at low risk, and is considered abnormal. An area of ecchymosis is
insignificant, and is probably related to the injection technique. A Mantoux skin test
result that shows no induration is negative.
Test-Taking Strategy: To answer this question accurately, it is necessary to know that
induration is necessary for a positive result. Because the client in this question has no
induration, the result can only be negative. Review the procedures for reading the results
of a Mantoux skin test if you had difficulty with this question.
Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic
1949. A nurse is collecting data on a client with a diagnosis of hypothyroidism. Which

of these behaviors, if present in the client’s history, would the nurse determine as being
most likely related to the manifestations of this disorder?
1. Depression
2. Nervousness
3. Irritability
4. Anxiety
Answer: 1
Rationale: Hypothyroid clients experience a slow metabolic rate, and its manifestation
includes apathy, fatigue, sleepiness, and depression. Options 2, 3, and 4 identify the
clinical manifestations of hyperthyroidism.
Test-Taking Strategy: Use the process of elimination and knowledge of the differences
between hypothyroidism and hyperthyroidism to answer this question. Remember,
“hypo” means “down” and “hyper” means “up.” This may assist you in remembering the
symptoms that occur in each condition. If you had difficulty with this question, review
the differences between each of these disorders.
1950. An older client is transferred to the nursing unit following a graft to a stage 4
decubitus ulcer. Which combination of dietary items would the nurse encourage the
client to eat to promote wound healing?
1. Chicken breast, broccoli, strawberries, milk
2. Salad, watermelon, tea
3. Baked potatoes, Jell-O, water
4. Spaghetti, bread, cola
Answer: 1
Rationale: Protein and vitamin C are necessary for wound healing. Poultry and milk are
good sources of protein. Broccoli and strawberries are good sources of vitamin C.
Options 2, 3, and 4 do not provide protein or vitamin C.
Test-Taking Strategy: Use the process of elimination and knowledge of nutrition related
to wound healing to answer the question. Recalling that protein and vitamin C are
necessary for wound healing will direct you to option 1. Also, remember that when an
option contains more than one item, be sure that all items in the option relate to what the
question is asking. Review nutrition related to wound healing if you had difficulty with
this question.
1951. A client is admitted to the hospital with a diagnosis of acute pancreatitis. The
nurse plans care knowing that which problem occurs with this disorder?
1. Excess fluid volume related to sodium retention
2. Alteration in fluid and electrolyte balance related to hyperkalemia
3. Alteration in comfort related to abdominal pain
4. Potential for hypoglycemia related to a low blood glucose level secondary to increased
insulin secretion
Answer: 3
Rationale: Abdominal pain is the predominant symptom of acute pancreatitis. Shock and
hypovolemia may occur from hemorrhage, toxemia, or loss of fluid into the peritoneal
space. Potassium and sodium may be lost from gastric suction and frequent vomiting.
Hyperglycemia may result from impaired carbohydrate metabolism.
Test-Taking Strategy: Use the process of elimination. Recalling that the predominant
symptom of acute pancreatitis is abdominal pain will direct you to option 3. If you had
difficulty with this question, review the signs and symptoms associated with acute
pancreatitis.
1952. What equipment should the nurse plan to have at the bedside when initiating a
clear liquid diet in a postoperative client who has had general anesthesia?
1. Oxygen via nasal cannula
2. Suction equipment
3. Cardiac monitor
4. A straw and a Styrofoam cup
Answer: 2
Rationale: General anesthesia depresses the gag reflex that, in turn, increases the risk for
aspiration. Suction equipment must be available in the event the client aspirates. Oxygen
may be administered postoperatively and a cardiac monitor may be present, but these
options have nothing to do with initiation of postoperative diet intake. A straw may help
the client sip fluids, but is not necessary. Use of a Styrofoam cup is unnecessary.
Test-Taking Strategy: Focus on the issue of the question—the risk for aspiration and
airway clearance. Option 2 addresses and maintains airway clearance. Review care to
the postoperative client if you had difficulty with this question.
Client Needs: Safe, Effective Care Environment
Mosby, p. 1638.
1953. While collecting data on a client being prepared for an adrenalectomy, the nurse
obtains a temperature reading of 100.8° F. The nurse analyzes this temperature reading
as:
1. Within normal limits
2. A finding that needs to be reported immediately
3. An expected finding caused by the operative stress response
4. Slightly abnormal but an insignificant finding
Answer: 2
Rationale: An adrenalectomy is performed because of excess adrenal gland function.
Excess cortisol production impairs the immune response, making the client at risk for
infection. Because of this, the client needs to be protected from infection, and minor
variations in normal vital sign values need to be reported so that infections are detected
early and before they become overwhelming. Options 1, 3, and 4 are not correct
interpretations.
Test-Taking Strategy: Use the process of elimination noting that the temperature is
elevated and that the client is being prepared to undergo an adrenalectomy. Knowing that
a temperature is an indication of infection and keeping in mind that the adrenal glands are
needed to fight infection will direct you to option 2. If you had difficulty with this
question, review preoperative nursing care of the client undergoing adrenalectomy.
References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing
1599.
1954. A nurse is working in a tuberculosis (TB) screening clinic. The nurse understands
that which population is at highest risk for TB?
1. Persons admitted to the hospital for same-day surgery
2. Children over 6 years of age in a summer school program
3. Residents of a long-term care facility
4. A family who has recently emigrated from Australia
Answer: 3
Rationale: Residents of long-term care facilities are considered high-risk candidates for
TB. Children under 4 years of age would also be considered a high-risk group. Persons
admitted for same-day surgery are not high-risk candidates. Foreign immigrants
(especially from Mexico, the Philippines, and Vietnam) are considered high risk, but
persons from Australia are not.
Test-Taking Strategy: Use the process of elimination. Recall that the very young and
very old are often susceptible to infection, as are persons with chronic or debilitating
diseases. Persons residing in a long-term care facility may fall into the category of being
older and/or having chronic health problems. If you had difficulty with this question,
review the high-risk populations for TB.
1955. A client with suspected Guillain-Barré syndrome has a lumbar puncture

performed. The cerebrospinal fluid (CSF) protein level is 750 mg/dl. The nurse analyzes
these results as:
1. Normal
2. Lower than normal, ruling out Guillain-Barré
3. Higher than normal, supporting the diagnosis of Guillain-Barré

4. Not significant and unrelated to Guillain-Barré
Answer: 3
Rationale: Approximately 7 to 10 days following the onset of symptoms of Guillain-
Barré, the spinal fluid protein levels become extremely high. Normal CSF protein level
is 15 to 45 mg/dl. A value of 750 mg/dl is higher than normal, supporting the diagnosis
of Guillain- Barré.
Test-Taking Strategy: Use the process of elimination and knowledge regarding the
diagnostic results associated with Guillain-Barré to answer the question. Recalling the
normal level of CSF protein will direct you to option 3. Also, note that options 1, 2, and
4 are similar in that they indicate that there is no relationship between the protein value
identified in the question and Guillain-Barré syndrome. If you had difficulty with this
question, review the diagnostic results associated with Guillain-Barré and the normal
level of CSF protein.
1956. The client is scheduled for an endoscopic retrograde cholangiopancreatography

(ERCP). The nurse includes which intervention in the plan of care for the client?
1. Administer enemas the evening before and the morning of the procedure
2. After the procedure, keep the client NPO until the gag reflex returns
3. Keep the client on clear liquids for 24 hours before the procedure
4. Tell the client that the substances used for the test contain only traces of radioactivity
Answer: 2
Rationale: An ERCP requires that a client is NPO for 12 hours before the procedure.
Since an endoscope is inserted through the oral cavity, the throat will be sprayed with an
anesthetic and the client will be kept NPO until the gag reflex returns. Enemas are not
needed. Radioactive isotopes are not used for this test. Contrast dye is injected via a
catheter into the pancreatic or bile ductal systems.
Test-Taking Strategy: Focus on the name of the diagnostic procedure. Recalling that
ERCP involves endoscopic insertion through the throat will direct you to option 2.
Review this procedure if you had difficulty with this question.

<AQ>1957. A mother of a 5-year-old child brings the child to the emergency department
and tells the nurse that the child fell. A fracture is suspected, and an x-ray is taken. The
results indicate that the child has a comminuted fracture of the right humerus. The
mother asks the nurse to describe this type of fracture and the nurse draws a picture for
the mother. Which picture identifies this type of fracture?
Answer: 2
Rationale: When small fragments of bone are broken from the fracture shaft and lie in
the surrounding tissues, the fracture is called comminuted. An open or compound
fracture (option 1) is a fracture with an open wound from which the bone is or has
protruded. In an oblique fracture (option 3), a diagonal line across the bone is noted. In a
greenstick fracture (option 4), the bone is partially bent and partially broken.
Test-Taking Strategy: Note the issue of the question—a comminuted fracture. Recalling
the definition of comminuted (fragmented) will assist in directing you to the correct
option. If you had difficulty with this question, review the descriptions of the various
types of fractures.
Content Area: Child Health
Philadelphia: W.B. Saunders, pp. 821-822.

1958. A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies
the visitor to the client’s room and takes which action?
1. Lets the visitor spend time alone with the client
2. Tells the client what a beautiful package this is
3. Suggests that the client open the gift
4. Reinforces the safety policies with the client
Answer: 3
Rationale: The nurse must be concerned with the safety of the client. The visitor may or
may not be aware of the client’s suicidal thoughts or the hospital safety policies. The
client should open the gift in the presence of the nurse so that sharp or unsafe objects
could be locked in the client’s safety box. Leaving the package unattended in the room
with the client is hazardous. Options 1, 2, and 4 are incorrect and unsafe.
Test-Taking Strategy: Note the key words suicidal client. Because the client’s safety is
the priority, the only option that assures that the gift is not dangerous for the suicidal
client is for the nurse to ask the client to open the gift in the nurse’s presence. Review
care to the suicidal client if you had difficulty with this question.

Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St.
1959. A client who had a lung resection for cancer has been told that bone metastasis has
occurred. The client is considering megavitamin and diet therapy, since the original
surgery did not provide a cure. The client asks the nurse for an opinion of these
therapies. In formulating a response, the nurse incorporates which of the following
concepts?
1. The client’s right to justice, and the nurse’s obligation to protect this right
2. The client’s right to privacy, and the nurse’s obligation to uphold the law
3. The client’s right to freedom of speech, and the nurse’s obligation to support the client
4. The client’s right to autonomy, and the nurse’s obligation to behave ethically
Answer: 4
Rationale: The client has the right to autonomy, or the exercise of personal choice. At
the same time, the nurse has the obligation to behave ethically. Some unconventional
cancer treatments have not been proven to be effective, may be toxic to the client, and
may be extremely expensive. The nurse balances the client’s right to self-determination
with the obligation to share with the client knowledge about the ineffectiveness of these
methods. Privacy is the right of a client to be free from intrusion by someone into their
own personal affairs. Justice is the ethical principle of treating people fairly.
Test-Taking Strategy: Use the process of elimination. Begin to answer this question by
eliminating options 1 and 2, because they are unrelated to the issue of the question. From
the remaining options, select option 4 knowing that the nurse must behave ethically, and
that the client ultimately has the right to exercise personal choice. Review these ethical
issues if you had difficulty with this question.
Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia:
W.B. Saunders, pp. 39-40.
1960. The anticipated intended effect of fludrocortisone acetate (Florinef) for the
treatment of Addison’s disease is to:
1. Stimulate the immune response
2. Promote electrolyte balance
3. Stimulate thyroid production
4. Stimulate thyrotropin production
Answer: 2
Rationale: Florinef is a long-acting oral medication with mineralocorticoid and moderate
glucocorticoid activity that is used for long-term management of Addison’s disease.
Mineralocorticoids act on the renal distal tubules to enhance the reabsorption of sodium
and chloride ions and the excretion of potassium and hydrogen ions. In small doses,
fludrocortisone acetate causes sodium retention and increased urinary potassium

excretion. The client can rapidly develop hypotension and fluid and electrolyte
imbalance if the medication is discontinued abruptly. Options 1, 3, and 4 are not
associated with the effects of this medication.
Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 because
they are similar. From the remaining options, recall that Addison’s disease is not related
to the immune system and that Addison’s disease produces deficiencies of
glucocorticoids, mineralocorticoids, and androgens. This will direct you to option 2.
Review the action of this medication if you had difficulty with this question.
1961. This morning a client sustained a right proximal fibula and tibia fracture that was
casted in a long leg plaster cast. During evening rounds, the nurse notes that the right
lower extremity capillary refill is greater than 3 seconds and the toes are edematous and
dusky. The client states that the pain medication is not working anymore and that the
right foot feels like it is asleep. The nurse analyzes the data and determines that the
client’s symptoms are indicative of:
1. Fat embolism
2. Volkmann’s contracture
3. Venous thrombosis
4. Compartment syndrome
Answer: 4
Rationale: In this situation, the edema and the cast are compressing the structures within
the leg. As pressure within the fascia compartment increases, nerves and blood vessels
are occluded, resulting in ischemia and unrelieved pain, known as compartment
syndrome. Fat embolism may result from a fracture, but the client is not experiencing
any signs or symptoms of this complication. Venous thrombosis may occur after
fractures, but would not affect sensation. Volkmann’s contracture is a result of
compartment syndrome in an upper extremity following a fractured humerus.
Test-Taking Strategy: Specific knowledge of the complications associated with lower
extremity fractures and with casting is needed to answer this question. Focusing on the
data in the question and noting the relation of these data to option 4 will direct you to this
option. If you had difficulty with this question, review the complications associated with
a fracture.
1962. A client has a newly fractured fibula, which is plaster casted in the emergency
department. Because the client will need to use crutches, the nurse plans to teach the
client which crutch walking gait before discharge?
1. Four-point alternate gait
2. Three-point gait
3. Two-point gait
4. Swing-through gait
Answer: 2
Rationale: The client with a new fracture that is casted with a plaster cast needs to avoid
weight-bearing movements. Option 2 is the only option that identifies a gait that allows
non–weight-bearing movement on the affected extremity. The client should not bear
weight on the affected extremity until the physician evaluates the client on the follow-up
examination.
Test-Taking Strategy: Use the process of elimination and visualize each of the gaits
identified in the options. Recalling the different crutch walking gaits and the amount of
weight-bearing necessary for each gait will direct you to the correct option. Remember
that plaster casts are weak until they dry in about 48 to 72 hours, so non–weight-bearing
movement is essential until follow-up by the physician. If you had difficulty with this
question and are unfamiliar with the different types of crutch walking gaits, review this
content.
References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia:
W.B. Saunders, pp. 805-806.
950.

specialty areas (5th ed). Philadelphia: W.B. Saunders, p. 175.
<AQ>1963. A physician has prescribed prochlorperazine (Compazine) 4 mg
intramuscularly for a client who is vomiting. The nurse reads the label on the medication
vial and administers how many milliliters to the client?
1. 0.8 mL
2. 1.2 mL
3. 4.0 mL
4. 5.0 mL
Answer: 1
Rationale: Use the following formula for calculating medication dose:
Desired
_________ × Volume = mL per dose
Available
4 mg
_____ × 1 mL = 0.8 mL
5 mg
Test-Taking Strategy: Follow the formula for the calculation of the correct dose. Use a
calculator to verify the answer and make sure that the answer makes sense. If you had
difficulty with this question, review medication calculation problems.
References: Harkreader, H. (2000). Fundamentals of nursing: Caring and clinical
judgment. Philadelphia: W.B. Saunders, p. 548.
specialty areas (5th ed). Philadelphia: W.B. Saunders, pp. 80, 175.

specialty areas (5th ed). Philadelphia: W.B. Saunders, p. 175.
1964. A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia
(hypereflexia). Which finding is indicative of this complication?
1. Knee jerk reaction is absent bilaterally
2. The client complains of a headache and the blood pressure is elevated
3. 100 mL of residual urine remains after the client voids
4. Pupil responses are brisk bilaterally
Answer: 2
Rationale: Autonomic dysreflexia, also known as autonomic hyperreflexia, is a life-
threatening syndrome. It is a cluster of clinical manifestations that results when multiple
spinal cord autonomic responses discharge simultaneously. Exaggerated autonomic
nervous system reactions to stimuli result in sudden hypertensive episodes with severe
headache. The client may sweat profusely above the level of the cord lesion and
complain of a stuffy nose. Pupil and knee jerk responses are not affected. While a
distended bladder is often the precipitating event, not all clients with bladder distention
exhibit dysreflexia.
Test-Taking Strategy: Note the key word autonomic, which indicates that involuntary
organ function is involved. Because knee jerk reactions involve skeletal muscles,
eliminate option 1. Eliminate option 3 because catheterization (checking residual urine)
is a treatment for dysreflexia, not an assessment technique. Eliminate option 4 because
the pupils are above the level of the injury, so are unlikely to be affected. Because blood
pressure is an autonomic function and headache can result from hypertension, option 2 is
correct. If you had difficulty with this question, review the manifestations of autonomic
dysreflexia (hyperreflexia).
1965. A nurse is monitoring a client with a spinal cord injury for signs of spinal shock.
Which of the following is indicative of this complication of a spinal cord injury?
1. Hypertension
2. Tachycardia
3. Profuse diaphoresis
4. Areflexia below the level of injury
Answer: 4
Rationale: Spinal shock represents a temporary but profound disruption of spinal cord
function, which occurs immediately after injury, and is clinically evident within 30 to 60
minutes. It is a state of areflexia characterized by the loss of all neurological function
below the level of injury. Flaccid paralysis occurs along with bradycardia, and
hypotension. The body is unable to use either shivering or perspiring as a means of
controlling body temperature.
Test-Taking Strategy: Focus on the issue—spinal shock. Recalling that this complication
is characterized by a state of areflexia will direct you to the correct option. If you had
difficulty with this question, review the signs and symptoms of spinal shock.
Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003).
Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p.
1409.
1966. A client with quadriplegia complains bitterly about the nurse’s slow response to
the call bell and the rigidity of the therapy schedule. Which interpretation of this
behavior would serve as a basis for planning nursing care?
1. The client is reacting to loss of control
2. The client’s complaints indicate depression
3. The client must adjust to institutional schedules
4. Limits must be set on staff response time to call bells
Answer: 1
Rationale: Clients who feel a sense of control over their situation will adapt to their
limitations more readily that those who think that they have lost control. Both of the
client’s complaints indicate a need for greater control. Clients should be offered an
opportunity for input into scheduling and planning for staff response to their needs. For
this reason, options 2, 3, and 4 are incorrect interpretations of the client’s behavior.
Test-Taking Strategy: Use the process of elimination focusing on the data in the question.
There are not sufficient data to indicate depression. Since self-care is usually a desired
outcome, interventions that limit client control, such as option 3, should be avoided.
Option 4 addresses only one of the client’s complaints without a focus on the real
problem. It would not serve as the basis for a plan of care. Review psychosocial
behaviors that occur in a quadriplegia client if you had difficulty with this question.

management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2231
1967. The client diagnosed with paranoid schizophrenia has been exceedingly agitated,
is threatening and shouting at everyone, and is refusing to participate in therapy. The
nurse determines that the client is using the defense mechanisms of denial and projection
and takes which initial action?
1. Collects information to develop a database
2. Determines the client’s past experiences with acting out
3. Explains to the client that nothing is wrong and accepts the behavior
4. Recognizes the level of client anxiety and sets limits
Answer: 4
Rationale: Denial is a failure to recognize what is occurring in a situation and generates
inappropriate behavior. Projection is the disowning and attributing process that enables a
person to remain blind to aspects of self and distant to the perception of others. Setting
firm limits on unacceptable and inappropriate behaviors in a nondefensive manner is the
initial nursing action in this situation. Because the client’s behavior is inappropriate,
option 3 is incorrect. Options 1 and 2 may be appropriate at some point but not initially.
Test-Taking Strategy: Note the key words initial action. Also note the behaviors of the
client identified in the question. These types of behaviors require intervention by the
nurse. This should direct you to option 4, because this option is the only one that
specifically provides client intervention. Review interventions for the client with
paranoid schizophrenia if you had difficulty with this question.
Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing
(8th ed.). St. Louis: Mosby, p. 414.
1968. A client experiencing delusions of being poisoned is admitted to the hospital after
not eating or drinking for several days. On data collection the nurse notes no evidence of
dehydration and malnutrition at this time. The nurse should immediately plan to address
the client’s need for:
1. Physiological care
2. Safety and security
3. Self-esteem
4. Love and belonging
Answer: 2
Rationale: An important consideration when working with clients who have delusions is
the maintenance of safety. Positive symptoms such as delusions may compel a client to
take risks. Because the client shows no evidence of dehydration and malnutrition at this
time, safety and security is the priority need. Psychosocial needs (options 3 and 4) are
not immediate client needs.
Test-Taking Strategy: Note the key words no evidence of dehydration and malnutrition
at this time and focus on the issue—the immediate nursing action. Use Maslow’s
Hierarchy of Needs theory. Since a physiological need is not present, then safety and
security needs take priority. This will direct you to option 2. Review care to the client
with delusions if you had difficulty with this question.
St. Louis: Mosby, p. 107.
1969. The nurse is caring for a client with hypothyroidism who has a nursing diagnosis
of Imbalanced Nutrition. Which food items would the nurse suggest to include in the
plan?
1. Peanut butter, avocado, and red meat
2. Skim milk, apples, and whole-grain bread and cereal
3. Organ meat, carrots, and skim milk
4. Seafood, spinach, and cream cheese
Answer: 2
Rationale: Clients with hypothyroidism have a diagnosis of Imbalanced Nutrition: More
than body requirements because of their decreased metabolic need. They should
consume foods from all food groups, which will provide them with the necessary
nutrients; however, the foods should be low in calories. Option 2 is the only option that
identifies food items that are low in calories.
Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis,
recalling that the client with hypothyroidism has a decreased metabolic need. In options
1, 3, and 4, at least one of the food items is high in fat content; therefore eliminate these
options. In option 2 all foods listed are low in fat. Review dietary needs for the client
with hypothyroidism if you had difficulty with this question.
1970. A client with Parkinson’s disease quickly develops akinesia while ambulating,
increasing the risk for falls. Which suggestion should the nurse provide to the client to
alleviate this problem?
1. Stand erect and use a cane to ambulate
2. Keep the feet close together while ambulating and use a walker
3. Consciously think about walking over imaginary lines on the floor
4. Use a wheelchair to move around
Answer: 3
Rationale: Clients with Parkinson’s disease can develop bradykinesia (slow movement)
or akinesia (freezing or no movement). Having these individuals imagine lines on the

floor to step over can keep them moving forward. While standing erect and using a cane
can help prevent falls, these measures will not help a person with akinesia move forward.
Clients with Parkinson’s disease should walk with a wide gait, not with the feet close
together. A wheelchair should be used only when the client can no longer ambulate with
assistive devices such as canes or walkers.
Test-Taking Strategy: Focus on the issue—akinesia. Recalling the manifestations
associated with this condition will direct you to option 3. Option 3 encourages forward
movement while ambulating. Review ambulation measures associated with Parkinson’s
disease if you had difficulty with this question.
Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment
and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1573.
1971. A nurse has completed counseling about smoking cessation with a client with
coronary artery disease. The nurse determines that the client has understood the material
best if the client states that:
1. “A smoker has twice the risk of having a heart attack than a nonsmoker.”
2. “I may try just cutting down first, since most of the damage has already been done.”
3. “I’m never going to start again, since I can cut my risk of cardiovascular disease to
zero within a year.”
4. “I don’t think I want to quit, since none of the effects are reversible anyway.”
Answer: 1
Rationale: Cigarette smokers have twice the risk of having a myocardial infarction than a
nonsmoker and have two to four times the risk of having sudden cardiac death. Smoking
cessation will reduce its damaging effects on the cardiovascular system.
Test-Taking Strategy: Use the process of elimination. The words “zero” and “none” in
options 3 and 4 are absolute words, and these options are eliminated first. From the
remaining options focus on the issue (smoking cessation) and note the key word best in
the stem of the question to direct you to option 1. Review the relation of smoking
cessation and the risk of cardiovascular disease if you had difficulty with this question.
1972. A nurse has given a client with a myocardial infarction simple instructions on
preventing some of the complications of bed rest. The nurse would intervene if the client
was performing which of these activities, which would be contraindicated?
1. Repositioning self from side to side

2. Deep breathing and coughing
3. Isometric exercises of the arms and legs
4. Ankle circles, plantar flexion and dorsiflexion exercises
Answer: 3
Rationale: The client with myocardial infarction should avoid activities that tense the
muscles, such as isometric exercises. These increase intraabdominal and intrathoracic
pressures and can decrease the cardiac output. They can also trigger vagal stimulation,
causing bradycardia. The exercises in options 1, 2, and 4 are acceptable.
Test-Taking Strategy: Focus on the client’s diagnosis. Note that the question is
addressing a cardiac client and note the key word contraindicated. This word indicates a
false response question and that you need to select the incorrect exercise. Eliminate
options 1, 2, and 4 because they are basic and nonstressful exercises. Review activities
related to the cardiac client if you had difficulty with this question.
1973. A nurse is preparing a client for skin grafting and notes that the physician has
documented that the client is scheduled for heterograft. The nurse understands that
heterograft used for the burn client is skin from:
1. Another species
2. A cadaver
3. The burned client
4. A skin bank
Answer: 1
Rationale: Biological dressings are obtained from living or deceased humans (homograft
or allograft) or animals (heterograft or xenograft). Heterograft is skin from another
species. The most commonly used type of heterograft is pig skin because of its relative
compatibility with human skin. Homograft is skin from another human, which is usually
obtained from a cadaver and is provided through a skin bank.
Test-Taking Strategy: Use the process of elimination. Note that options 2, 3, and 4 are
similar and all refer to donor skin from the human species. Option 1, the correct option,
identifies skin from a different species. If you had difficulty with this question, review
the types of skin grafting.
thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, pp. 1641-1642.
1974. A nurse is caring for a client that is comatose and notes in the client’s chart that the
client is exhibiting decerebrate posturing. The nurse understands that decerebrate

posturing is characterized by:
1. The extension of the extremities and pronation of the arms
2. The flexion of the extremities and pronation of the arms
3. Upper extremity flexion with lower extremity extension
4. Upper extremity extension with lower extremity flexion
Answer: 1
Rationale: Posturing is a late sign of deterioration in the client’s neurological status and
warrants immediate physician notification. Decerebrate posturing (abnormal extension),
which is associated with dysfunction in the brainstem area, is the extension of the
extremities and the pronation of the arms. Options 2, 3, and 4 are incorrect descriptions
of decerebrate posturing.
Test-Taking Strategy: Knowledge regarding the characteristics of posturing is required to
answer the question. Remembering that decerebrate posturing indicates abnormal
extension will assist in answering questions similar to this one. If you had difficulty with
this question, review assessment data related to posturing.
1975. A postgastrectomy client who is being discharged from the hospital tells the nurse,
“I hope my stomach problems are over. I need to get back to work right away. I’ve
missed a lot of work and I’m really behind. If I don’t get my act together, I may lose my
job.” Based on the client’s statement, the nurse determines that at this time it is most
appropriate to discuss:
1. Reducing stressors in life
2. The postgastrectomy diet
3. An exercise program
4. Wound care
Answer: 1
Rationale: Some clients need help reducing stressors in their lives. This may be
extremely important for recovery. Clients may expect a rapid recovery and are
disappointed when this does not occur. The client’s statement provides an opportunity for
the nurse to discuss stress and its relationship to gastrointestinal disorders. The data in
the question are unrelated to options 2, 3, and 4.
Test-Taking Strategy: Use the process of elimination noting the key words most
appropriate. Focusing on the client’s statement in the question and noting that it relates
to a psychosocial issue will direct you to option 1. Review the indicators of stress if you

1976. A client recovering from a craniotomy complains of a “runny nose.” Based on the
interpretation of the client’s complaint, the best nursing action is to:
1. Provide the client with tissues
2. Tell the client not to blow the nose
3. Monitor the client for signs of a cold
4. Notify the registered nurse (RN)
Answer: 4
Rationale: If the client has sustained a craniocerebral injury or is recovering from a
craniotomy, careful observation of any drainage from the eyes, ears, nose, or traumatic
area is critical. Cerebrospinal fluid is colorless and generally nonpurulent, and its
presence is indicative of a serious breach of cranial integrity. The nurse would check the
drainage for the presence of glucose, which would be indicative of the presence of
cerebrospinal fluid, and would also report the presence of any suspicious drainage to the
RN, who will then contact the physician.
Test-Taking Strategy: Use the process of elimination noting the key words best nursing
action. Remember, in a client with cranial trauma and injury, the nurse should suspect
cerebrospinal fluid leakage if drainage is noted from the eyes, ears, nose, or traumatic
area. Review care to the client following craniotomy if you had difficulty with this
question.
1977. The nurse is caring for a client with pneumonia who is to receive oxygen via nasal
cannula. To provide a safe and effective delivery of the oxygen, the nurse avoids which
of the following?
1. Secures the oxygen tubing to the client’s bottom sheet
2. Keeps the humidification jar filled with distilled water
3. Observes the client’s nares frequently for skin breakdown
4. Checks the oxygen flow rate and physician’s orders every shift
Answer: 1
Rationale: If the tubing is attached to the client’s bed linen, it will become dislodged
from the nares whenever the client moves. The tubing should have sufficient slack and
be secured to the client’s clothes. Keeping the humidification jar filled will help prevent
the client from breathing dehumidified oxygen. The nares should be checked frequently
because oxygen will dry the nasal mucosa. Oxygen is a medication and its order should
be verified every shift to ensure the correct rate.
Test-Taking Strategy: Note the key word avoids. This word indicates a false response
question and that you need to select the incorrect intervention. Options 2, 3, and 4 will
promote the safe delivery of oxygen. Option 1 could disrupt the flow of oxygen for the
client. If you had difficulty with this question, review the safety procedures associated
with the use of oxygen.
667.
1122.
1978. A nurse is collecting data on a client admitted to the hospital with suspected
carbon monoxide poisoning and notes that the client behaves as if intoxicated. The nurse
interprets that:
1. The client must also have a high blood alcohol level
2. The client probably suffers from alcoholism
3. The carbon monoxide has caused the blood glucose level to decrease
4. The behavior is most likely the result of hypoxia
Answer: 4
Rationale: The client with carbon monoxide poisoning may appear intoxicated. This is
the end result of hypoxia on the central nervous system (CNS). With carbon monoxide
poisoning, oxygen cannot easily bind onto the hemoglobin, which is carrying strongly
bound carbon monoxide. Since cerebral tissue has a critical need for oxygen, sustained
hypoxia may yield this typical finding. For this reason, options 1, 2, and 3 are incorrect
interpretations.
because they are similar and both address the issue of alcohol. From the remaining
options, recalling that carbon monoxide displaces oxygen on the hemoglobin molecule
will direct you to option 4. Additionally, option 4 addresses oxygen, the highest priority.
Review the manifestations associated with carbon monoxide poisoning if you had
1979. A client who is experiencing severe respiratory acidosis has a potassium level of
6.2 mEq/L. The nurse interprets that this result is:
1. Unexpected, and indicates a concurrent history of renal insufficiency
2. Unexpected, and indicates a deficit of hydrogen ions in the bloodstream

3. Expected, and indicates the result of massive hemolysis
4. Expected, and indicates that acidosis has driven hydrogen ions into the cell, forcing
potassium out
Answer: 4
Rationale: With severe respiratory acidosis, compensatory mechanisms fail. As
hydrogen ion concentrations continue to rise, they are driven into the cell, forcing
intracellular potassium out. This is an expected finding in this situation. Options 1, 2,
and 3 are incorrect interpretations.
effects of acidosis on the body. Note the relation between “acidosis” in the question and
in the correct option. Also note that the potassium level is elevated and the relation
between this elevated level and the issue of forcing potassium out of the cells in option 4.
Review the effects of acidosis on the body if you had difficulty with this question.
Louis: Mosby, pp. 360-361.
1980. A nurse gathers data from a client admitted to the hospital with gastrointestinal
reflux disease (GERD) who is scheduled for a Nissen fundoplication. Based on an
understanding of this disease, the nurse determines that the client may be at risk for
which complication?
1. Diarrhea
2. Belching
3. Aspiration
4. Abdominal pain
Answer: 3
Rationale: The primary symptom of GERD is heartburn, also called pyrosis. Another
symptom is regurgitation. The client reports the feeling of warm fluid traveling up the
throat. If the fluid reaches the level of the pharynx, the client notes a sour or bitter taste
in the mouth. This effortless regurgitation frequently occurs when the client is in the
upright position. If regurgitation occurs when the client is recumbent, the client is at risk
for aspiration. Belching may be a symptom of the disease. Diarrhea and abdominal pain
are not specifically associated with the disease.
and circulation—in answering the question. Note the key word complication and that
option 3 identifies the priority concern because it relates to airway. Review the
complications of GERD if you had difficulty with this question.
1981. A client has a blood glucose level drawn for suspected hyperglycemia. After
interviewing the client, the nurse determines that the client ate lunch approximately 2
hours before the blood specimen was drawn. The laboratory reports that the blood
glucose level is 180 mg/dl, and the nurse analyzes this result to be:
1. Normal
2. Lower than the normal value
3. Elevated from the normal value
4. A dangerously high value requiring immediate physician notification
Answer: 3
Rationale: Normal fasting blood glucose values range from 70 to 120 mg/dl. A 2-hour
postprandial blood glucose level should be less than 140 mg/dl. In this situation, the
blood glucose value was 180 mg/dl 2 hours after the client ate, which is an elevated value
as compared to normal. Although the result may be reported to the physician, it is not a
dangerously high one.
normal blood glucose value to answer this question. This will direct you to option 3.
Review the normal blood glucose value if you had difficulty with this question.
1982. In planning nutrition for the client with hypoparathyroidism, which diet would be
appropriate?
1. High in calcium and low in phosphorus
2. Low in vitamins A, D, E, and K
3. High in sodium with no fluid restriction
4. Low in water and insoluble fiber
Answer: 1
Rationale: Hypocalcemia is the end result of hypoparathyroidism due either to a lack of
parathyroid hormone (PTH) secretion or to ineffective PTH influence on tissue. Calcium
is the major controlling factor of PTH secretion. Because of this, the diet needs to be
high in calcium but low in phosphorus, since these two electrolytes must exist in inverse
proportions in the body. The other options are not dietary interventions with
hypoparathyroidism.
Test-Taking Strategy: Focus on the client’s diagnosis. Recalling that hypocalcemia is the
end result of hypoparathyroidism will direct you to option 1. The diets identified in
options 2, 3, and 4 do not correct hypocalcemia. Review these concepts related to
hypoparathyroidism if you had difficulty with this question.

1983. The nurse is planning care for a client with Bell’s palsy. Which measure should be
included in the plan?
1. Apply cold packs to the affected side four times a day
2. Ensure that the client avoids wearing dark glasses
3. Instill artificial tears and a patch over the affected eye at night
4. Ensure that the client avoids touching the affected side
Answer: 3
Rationale: Instilling artificial tears and patching the affected eye at night protect the eye
from corneal abrasions. Warm packs, not cold, will alleviate discomfort. Wearing dark
glasses is recommended, as is gentle massage of the affected side.
Test-Taking Strategy: Focus on the client’s diagnosis. Recalling the pathophysiology
associated with this disorder will direct you to option 3. If this question was difficult,
review this disorder and the nursing care.
1984. A nurse analyzes the results of laboratory studies performed on a client with peptic
ulcer disease. Which laboratory value would indicate a complication associated with the
disease?
1. White blood cell count of 5000 cells/mm3
2. Hemoglobin level of 10.2 g/dl
3. Platelet count of 400,000 cells/mm3
4. Creatinine level of 1 mg/dl
Answer: 2
Rationale: The most common complications of peptic ulcer disease are hemorrhage,
perforation, pyloric obstruction, and intractable disease. A low hemoglobin and
hematocrit level will indicate bleeding. The normal hemoglobin range in females is 12 to
16 g/dl and in males 14 to 18 g/dl. A white blood cell count is performed to indicate the
presence of infection or inflammation. The normal white blood cell count is 5000 to
10,000 cells/mm3. The normal platelet range is 150,000 to 400,000 cells/mm3. The
creatinine level measures renal function. The normal value is 0.6 to 1.3 mg/dl.
complications associated with peptic ulcer disease and normal laboratory values. The
only abnormal laboratory value in the options is the hemoglobin level, which is low,
indicating bleeding. If you had difficulty with this question, review both the
complications of peptic ulcer disease and these normal laboratory values.

Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical
nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1035.
1985. A client has had a set of arterial blood gases drawn. The results are: pH 7.34,
PaCO2 of 37, PaO2 of 79, HCO3 of 19. The nurse interprets that the client is experiencing:
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Answer: 3
Rationale: Metabolic acidosis occurs when the pH falls below 7.35 and the bicarbonate
level falls below 22 mEq/L. With respiratory acidosis, the pH drops below 7.35 and the
carbon dioxide level rises above 45 mm Hg. With respiratory alkalosis, the pH rises
above 7.45 and the carbon dioxide level falls below 35 mm Hg. With metabolic
alkalosis, the pH rises above 7.45 and the bicarbonate level rises above 26 mEq/L.
Test-Taking Strategy: Knowing that a pH of 7.34 is acidotic allows you to eliminate
options 2 and 4 first. From the remaining options, knowing that a metabolic condition
exists when the bicarbonate follows the same up or down pattern as the pH, helps you to
choose option 3 over option 1. Review the procedure for interpreting arterial blood gases
if you had difficulty with this question.
1986. A client with Guillain-Barré syndrome has been asking many questions about the
condition, and the nursing staff feels that the client is very discouraged about her
condition. It is important for the nurse to include which of the following information in
discussions with the client?
1. Maximum paralysis occurs within 48 hours following diagnosis
2. Paralysis occurs proximally to distally
3. With maximum rehabilitation, function is regained within 3 months
4. Generally, the vast majority of people recover from this condition
Answer: 4
Rationale: The vast majority of clients with Guillain-Barré syndrome recover from the
paralysis because it affects peripheral nerves that have the capacity to remyelinate.
Maximum paralysis can take up to 4 weeks to develop. Paralysis progresses distally to
proximally. Rehabilitation can take from 6 months to 2 years.
because they present very restricted time frames. From the remaining options, eliminate
option 2 because paralysis progresses distally to proximally. One way to remember the
progression of paralysis with Guillain-Barré is that it moves from the “Ground to the
Brain.” Review the characteristics associated with this syndrome if you had difficulty
with this question.
1987. A client with myasthenia gravis is being discharged on pyridostigmine bromide

(Mestinon). The nurse provides the client with medication instructions and makes which
statement to the client?
1. “Take the medication on an empty stomach.”
2. “Take the medication before activities such as eating or work.”
3. “Tonic water with quinine and the use of antacids improve the effect of the
medication.”
4. “It is not important when you take the medication, as long as you take the exact
amount prescribed.”
Answer: 2
Rationale: Pyridostigmine bromide (Mestinon) is an anticholinesterase that is used to
improve muscle strength in the client with myasthenia gravis. Taking the medication
before activities such as working or eating helps lessen fatigue and dysphagia and
improves muscle strength. The medication should be taken with food. Clients should
avoid quinine, antacids, magnesium, and morphine sulfate and its derivatives, because
these medications can reverse the action of the pyridostigmine bromide and increase
weakness. The medication should be taken regularly and on time to prevent fluctuating
blood levels, which can cause weakness.
Test-Taking Strategy: Use the process of elimination. Using general guidelines related to
medication administration will assist in eliminating options 3 and 4. From the remaining
options, recalling that muscle weakness is a major problem with the disease will direct
you to option 2. Review this medication if you had difficulty with this question.
Content Area: Pharmacology
Philadelphia: W.B. Saunders, pp. 857, 859.
1988. A nurse is caring for a client with type 1 diabetes mellitus who is hyperglycemic.
Which nursing diagnosis noted on the plan of care would the nurse consider first, when
planning care for this client?
1. Deficient Knowledge
2. Potential for Impaired Urinary Elimination
3. Potential for Imbalanced Nutrition
4. Deficient Fluid Volume

Answer: 4
Rationale: Hyperglycemia can develop into ketoacidosis in the client with type 1
diabetes mellitus. Polyuria develops as the body attempts to get rid of the excess glucose,
and the client will lose large amounts of fluid. Because glucose is hyperosmotic, fluid is
pulled from the tissue. Nausea and vomiting can occur as a result of hyperglycemia and
can lead to a loss of sodium and water. Water is also lost from the lungs in an attempt to
get rid of excess carbon dioxide. The severe dehydration that occurs can lead to
hypovolemic shock. Of the nursing diagnoses listed, fluid volume deficit is considered
first.
Test-Taking Strategy: Use the process of elimination and Maslow’s Hierarchy of Needs
theory. Eliminate options 2 and 3 first because they are potential rather than actual
problems. From the remaining options, select option 4 because it addresses a
physiological problem. Review care to the client with type 1 diabetes mellitus and
hyperglycemia if you had difficulty with this question.
Content Area: Delegating/Prioritizing
1989. When planning care for a woman with pregnancy-induced hypertension, the nurse
plans to encourage which maternal behavior?
1. Expression of hope for a positive outcome
2. Delaying preparations for finishing the nursery at home
3. Walking 1 to 2 miles daily
4. Anticipatory grieving
Answer: 1
Rationale: Hoping for a positive outcome is an appropriate coping mechanism. It is
important to support an expression of hope by a client with a high-risk pregnancy as long
as the hope is realistic (e.g., fetus is viable). Anticipatory grieving is not a positive
adaptation for this client. Grieving should begin when a loss occurs. Delaying nursery
preparations at home reflects an “expecting the worse” situation. Walking 1 to 2 miles
daily is contraindicated for a woman with pregnancy-induced hypertension.
Test-Taking Strategy: Focus on the client’s diagnosis. Eliminate option 3 because
walking 1 to 2 miles daily is much too strenuous. Next eliminate options 2 and 4 because
they indicate a negative outcome. Review the plan of care for a client with pregnancy-
induced hypertension if you had difficulty with this question.
Content Area: Maternity/Antepartum
Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-
newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 686.
1990. A woman with type 1 diabetes mellitus is in labor. Based on the knowledge of
insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn
infant who is most likely to have which complication?
1. Macrosomia
2. Hyperglycemia
3. Postmaturity syndrome
4. Anemia
Answer: 1
Rationale: Typically, infants of diabetic mothers are large for gestational age. Maternal
glucose crosses over the placenta to the fetus. The fetus is able to produce its own
insulin; therefore excessive body growth (macrosomia) results from high maternal
glucose levels. After birth, hypoglycemia may be a problem because the infant’s
pancreas continues to produce large amounts of insulin (hyperinsulinemia), which
quickly deplete the infant’s glucose supply. Infants of diabetic mothers are usually
delivered just before or at term because of an increased risk of ketoacidosis and
intrauterine fetal death after 36 weeks. Polycythemia, not anemia, is commonly
associated with infants of diabetic women.
Test-Taking Strategy: Use the process of elimination and recall that typically infants of
diabetic mothers are large for gestational age. This will direct you to option 1. Review
diabetes and pregnancy if you had difficulty with this question.
Content Area: Maternity/Postpartum
newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 855.
1991. A nurse is reviewing the medical record of a young female client who is suspected of
having systemic lupus erythematosus (SLE). Which of the following would the nurse
expect to note documented in the record that is related to this diagnosis?
1. Presence of two hemoglobin S genes in the blood cell report
2. Ascites noted in the abdomen
3. Recurrent emboli
4. Butterfly rash on cheeks and bridge of nose
Answer: 4
Rationale: SLE primarily occurs in females 10 to 35 years of age, and is a chronic
inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and
the bridge of the nose is a characteristic sign of SLE. Option 1 is found in sickle cell
anemia. Options 2 and 3 are found in many conditions, but are not usually noted in SLE.
Test-Taking Strategy: Focus on the issue—a manifestation of SLE. Recalling that a
butterfly rash on the cheeks and the bridge of the nose is a characteristic sign of SLE will
direct you to option 4. Review the signs and symptoms of systemic lupus erythematosus
(SLE) if you had difficulty with this question.

1992. A client with a diagnosis of congestive heart failure is preparing for discharge to
home from the hospital. The nurse determines that the client is ready for discharge to
home if the client can:
1. Verbally describe the daily medications, doses, and times to be administered
2. Get the prescriptions filled
3. Be self-sufficient at home without any help
4. Independently dress and put on support hose
Answer: 1
Rationale: Medication therapy is an essential part of the therapeutic regimen for treating
heart failure. The client must have a clear understanding of which medications to take
and when to take them. Options 2 and 4 can be carried out with the assistance of
someone else. Option 3 may not be realistic for this client.
Test-Taking Strategy: Use the process of elimination. Note the client’s diagnosis and the
issue of the question—that the client is ready for discharge. Eliminate option 3 first
because it is unrealistic. Next, eliminate options 2 and 4 because they can be
accomplished by others or with the assistance of others. Remember, it is a priority that
the client understands the medication regimen. Review home care instructions for the
client with heart failure if you had difficulty with this question.
1993. A nurse notes that a client’s urinalysis report contains a notation of positive red
blood cells (RBCs). The nurse interprets that this finding is unrelated to which of the
following items that is part of the client’s medical record?
1. Diabetes mellitus
2. Concurrent anticoagulant therapy
3. History of kidney stones
4. History of recent blow to the right flank
Answer: 1
Rationale: Hematuria can be caused by trauma to the kidney, such as with blunt trauma
to the lower posterior trunk or flank. Kidney stones can cause hematuria as they scrape
the endothelial lining of the urinary system. Anticoagulant therapy can cause hematuria
as a side effect. Diabetes mellitus does not cause hematuria, although it can lead to renal
failure from prerenal causes.
Test-Taking Strategy: Use the process of elimination noting the key word unrelated. This
word indicates a false response question and that you need to select the condition that is
not a cause of hematuria. Begin to answer this question by eliminating options 2 and 4,
which are most likely to cause RBCs in the urine. From the remaining options, recalling
that the scraping of the stones against mucosa could cause minor trauma and bleeding
will direct you to option 1. Review the causes of RBCs in the urine if you had difficulty
with this question.
1994. A client with acute glomerulonephritis had a urinalysis sent to the laboratory. The
report reveals that there is hematuria and proteinuria present in the urine. The nurse
interprets that these results are:
1. Consistent with glomerulonephritis
2. Inconsistent with glomerulonephritis
3. Unclear, and no conclusion can be drawn
4. Indicative of impending renal failure
Answer: 1
Rationale: Gross hematuria and proteinuria are the cardinal signs of glomerulonephritis.
The urine may be small in volume, dark or smoky in color from the hematuria, and foamy
from the proteinuria. Concurrent serum studies would reveal elevated blood urea
nitrogen level, creatinine level, C-reactive protein level, and antistreptolysin O titer.
Test-Taking Strategy: Use the process of elimination. Noting the diagnosis of the client
and recalling that the presence of hematuria and proteinuria in the urine is abnormal will
direct you to option 1. Review the findings in glomerulonephritis if you had difficulty
with this question.
Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical
nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1210.
1995. A young female client with acute pyelonephritis is scheduled for a voiding
cystourethrogram. The nurse determines that this client would most likely benefit from
increased support and teaching about the procedure because:
1. Radiopaque contrast is injected into the bloodstream with a syringe
2. Radioactive material is injected into the bladder with a syringe
3. The client must lie on an x-ray table in a cold, barren room
4. The client must void while the micturition process is filmed
Answer: 4
Rationale: Having to void in the presence of others can be very embarrassing for clients,
and may actually interfere with the client’s ability to void. The nurse teaches the client
about the procedure to try to minimize stress from lack of preparation, and gives the
client encouragement and emotional support. Screens may be used in the radiology
department to try to provide an element of privacy during this procedure.
Test-Taking Strategy: Begin to answer this question by eliminating options 1 and 2, since
the contrast material is inserted into the bladder by means of a catheter. From the
remaining options, note the key words young female client in the question and recall that
the client has to void to allow filming of the movement of urine through the lower urinary
tract. This will assist in directing you to the correct option. Review this diagnostic test if
1996. A nurse is caring for a client with a suspected diagnosis of aplastic anemia. Which
of the following tests would the nurse anticipate to be performed to confirm the
diagnosis?
1. Bone marrow aspiration
2. Complete blood count
3. Sickle cell screen
4. Schilling test
Answer: 1
Rationale: A bone marrow aspiration will identify aplastic anemia and will identify
pancytopenia, a deficiency in erythrocytes, leukocytes, and thrombocytes. A Schilling
test is diagnostic for pernicious anemia. A sickle cell screen is diagnostic for sickle cell
anemia. A complete blood count will identify anemia but may not identify the specific
type.
Test-Taking Strategy: Use the process of elimination and note the key word confirm.
Recalling that anemias originate in the bone marrow will direct you to option 1. Option 1
is the only option that mentions the bone marrow. Review the diagnostic tests for aplastic
anemia if you had difficulty with this question.
Content Area: Adult Health/Oncology
1997. During inspection of a client’s skin, the nurse notes redness and an abrasion-type
wound on the sacrum area. The nurse determines that this finding is indicative of a:
1. Stage 1 pressure ulcer
Answer: 2
Rationale: In a stage 1 pressure ulcer, the skin is intact, and the area is red and does not
blanch with external pressure. In a stage 2 pressure ulcer, the skin is not intact, and the
ulcer is superficial and may appear as an abrasion, blister, or shallow crater. In stage 3,
skin loss is full-thickness, and there is a deep crater-like appearance. In stage 4, skin loss
is full-thickness with extensive destruction, tissue necrosis, or damage to muscle, bone, or
supporting structures.
Test-Taking Strategy: Use the process of elimination. Remembering that in stage 1 the
skin is intact and that the skin disruption worsens as the stage number increases will
assist in directing you to the correct option. If you had difficulty with this question,
review the characteristics of pressure ulcers.
1998. A client who has undergone a cardiac catheterization using the right femoral
approach is returned to the nursing unit. Thirty minutes later, the client complains of
numbness and tingling of the right foot. The pedal pulse is weak, and the foot is pale.
The nurse notifies the registered nurse (RN) immediately because these symptoms are
consistent with:
1. Femoral artery thrombus or hematoma
2. Local allergic reaction to the contrast dye
3. Right sciatic nerve damage
4. Early massive infection at the catheter insertion site
Answer: 1
Rationale: Adverse changes such as numbness and tingling, coolness, pallor, cyanosis, or
sudden loss of peripheral pulses indicate serious circulatory impairment and are reported
to the RN immediately, who will then contact the physician. Allergic reaction to the dye
is a systemic problem, not a local one. The data in the question are not consistent with
sciatic pain. Infection does not become apparent this quickly.
and circulation—to answer the question. Noting that the signs and symptoms in the
question indicate a circulatory problem will direct you to option 1. Review the
complications associated with a cardiac catheterization if you had difficulty with this
question.
1999. A client admitted to the hospital with coronary artery disease complains of
dyspnea at rest. The nurse determines that which of the following items would be of
most help to the client?

1. Placing an oxygen cannula at the bedside for use if needed
2. Performing continuous monitoring of oxygen saturation
3. Elevating the head of the bed to at least 45 degrees
4. Providing a walker to aid in ambulation
Answer: 3
Rationale: The management of dyspnea is generally directed toward alleviating the
cause. Symptom relief may be achieved or at least aided by placing the client at rest with
the head of bed elevated. In severe cases, supplemental oxygen is used. Monitoring of
oxygen saturation detects early complications but does not help the client. Likewise,
placing an oxygen cannula at the bedside for use would not help the client.
Test-Taking Strategy: Use the process of elimination. The words “of most help to the
client” direct you to look for the item that is going to have the best immediate effect from
the client’s perspective. Therefore eliminate options 1, 2, and 4 first. Review nursing
measures for the client with dyspnea if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2002). Medical surgical nursing: Critical
2000. The nurse prepares to administer erythromycin base (Ilotycin) ophthalmic

ointment to a newborn infant immediately after delivery. The nurse understands that this
ointment:
1. Is more irritating to the newborn’s eyes than silver nitrate drops
2. Must be administered at room temperature to prevent side effects
3. Is staining to the infant’s skin and must be wiped off immediately
4. Is effective in protecting the newborn from both Neisseria gonorrhoeae and
chlamydia
Answer: 4
Rationale: Erythromycin (Ilotycin) is effective in protecting the newborn from both
Neisseria gonorrhoeae and chlamydia. It is less irritating to the newborn’s eyes than
silver nitrate, does not stain, and may be administered at any safe temperature.
Test-Taking Strategy: Focus on the name of the medication. Recalling that this
medication is an antibiotic and that it is administered to the newborn in the immediate
postdelivery period will direct you to option 4. Review the action of this medication if
Content Area: Maternity/Intrapartum
newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 552, 972.

(PLACE FIGURE HERE (Fig. 20) For Q#1901)

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PN~CD~Questions~1901-2000 - 1

Comprehensive Review CD Questions 1901-2000

{PLACE FIGURE HERE (Fig. 20) for Q#1901}

{PLACE FIGURE HERE (Fig. 20) for Q#1901}

3. Situational Low Self Esteem related to changes in personal appearance

{PLACE FIGURE HERE (Fig. 21). For Q#1907}

{PLACE FIGURE HERE (Fig. 21). For Q#1907}

1909. A nurse is performing nasotracheal suctioning of the secretions of a client. The

4. Skin color becomes cyanotic

Content Area: Pharmacology

1915. A client has undergone fluoroscopy-assisted aspiration biopsy of a chest lesion.

procedures (4th ed.). Philadelphia: W.B. Saunders, p. 238.

1916. A client with acquired immunodeficiency syndrome (AIDS) has difficulty

1918. A client has received instructions on self-management of peritoneal dialysis. The

{PLACE FIGUREs HERE (Figs. 22-25). For Q#1919}

{PLACE FIGUREs HERE (Figs. 22-25). For Q#1919}

Content Area: Adult Health/Cardiovascular

1921. A postgastrectomy client is at high risk for hyperglycemia related to uncontrolled

{PLACE FIGURE HERE (FIG. 26) for Q#1922}

Integrated Process: Nursing Process/Data Collection

{PLACE FIGURE HERE (FIG. 26) for Q#1922}

{PLACE FIGURE HERE (Fig. 27) for Q#1925}

{PLACE FIGURE HERE (Fig. 27) for Q#1925}

1926. A nurse is monitoring the respiratory status of a client following insertion of a

1. The chest compressions are given at a depth of 1.5 to 2 inches

Integrated Process: Nursing Process/Evaluation

1932. The client with acquired immunodeficiency syndrome (AIDS) is experiencing

1. There are no expected side effects associated with ECT

Rationale: Clients generally increase activity by beginning a simple walking program,

Content Area: Adult Health/Endocrine

1946. Which nursing measure would be most effective in preventing complications in a

1947. An older client with advanced Alzheimer’s disease is placed in balanced

Recalling the effects of cognitive impairment, skeletal traction, analgesics, immobility,

1949. A nurse is collecting data on a client with a diagnosis of hypothyroidism. Which

1955. A client with suspected Guillain-Barré syndrome has a lumbar puncture

3. Higher than normal, supporting the diagnosis of Guillain-Barré

1956. The client is scheduled for an endoscopic retrograde cholangiopancreatography

{PLACE FIGURE HERE (Fig. 28). For Q#1957}

{PLACE FIGURE HERE (Fig. 28). For Q#1957}

Client Needs: Safe, Effective Care Environment

fludrocortisone acetate causes sodium retention and increased urinary potassium

{PLACE FIGURE HERE (Fig. 29). For Q#1963}

{PLACE FIGURE HERE (Fig. 29). For Q#1963}

Integrated Process: Nursing Process/Planning

or akinesia (freezing or no movement). Having these individuals imagine lines on the

1. Repositioning self from side to side

client is exhibiting decerebrate posturing. The nurse understands that decerebrate

Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing

2. Unexpected, and indicates a deficit of hydrogen ions in the bloodstream

Louis: Mosby, p. 184.

Content Area: Adult Health/Endocrine

Integrated Process: Nursing Process/Data Collection

1987. A client with myasthenia gravis is being discharged on pyridostigmine bromide

4. Deficient Fluid Volume

Content Area: Adult Health/Immune

most help to the client?

2000. The nurse prepares to administer erythromycin base (Ilotycin) ophthalmic

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