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Question # 1
A 60-year-old client has undergone a nerve-sparing prostatectomy and has been advised by his physician that he may not recover normal sexual functioning. The client is very concerned about this and asks the nurse for more information. Which of the following information should the nurse include? Select all that apply.
A. Retrograde ejaculation may occur. B. Recovery rates vary but can take up to a year or more. C. If sexual functioning is going to return, it will do so within a month. D. Attempts at sexual intercourse are usually avoided for 1 month after surgery. E. Anxiety can interfere with sexual functioning. F. Other forms of sexual intimacy are more important than sexual intercourse.
Answer: A, B, D, E
Explanation:
The nurse should give this patient the following information:
•Retrograde ejaculation may occur.
•Recovery rates vary but can take up to a year or more.
•Attempts at sexual intercourse are usually avoided for 1 month.
•Anxiety can interfere with sexual functioning.
•The client may want to explore other forms of sexual intimacy even though these are not likely as important to
the client as sexual intercourse at this time.
Question # 2
A client with epilepsy is taking phenytoin. What long-term effects should the nurse advise the client can occur with prolonged administration of phenytoin? Select all that apply.
A. Gingival hypertrophy B. Hirsutism C. Hypertrophy of facial subcutaneous tissue D. Dementia E. Anemia
Answer: A, B, C
Explanation:
The long-term effects of prolonged use of phenytoin include a condition referred to as "Dilating
facies," which is characterized by gingival hypertrophy, hirsutism, and hypertrophy of facial subcutaneous
tissue. Clients must be advised to maintain good dental care. Additionally, clients may develop osteoporosis, so
supplementary vitamin D is usually advised. Clients with low levels of albumin (usually associated with renal
disease or malnutrition) may have more severe effects.
Question # 3
A client is hospitalized in a long-term care facility because of Alzheimer's disease. The client is incontinent of urine and feces. The nurse has delegated incontinent care to unlicensed assistive personnel (UAP). How frequently should the nurse advice that the UAP check the client for dryness?
A. Every 2 hours B. Every hour C. When the client appears restless D. Before meals and at bedtime
Answer: A
Explanation:
If a client with Alzheimer's disease is incontinent of urine and feces and incontinent care has been
delegated to UAP. then the LIAP should be advised to check the client for dryness on a regular schedule of every
2 hours. Eating and drinking often trigger urination and/or bowel movements, so scheduling checks after
meals is advisable. However, if the client appears restless or pulls at their clothing at other times. the UAP
should check for dryness then as well.
Question # 4
A client is receiving an opioid per patient-controlled analgesia (PCA) pump to control postoperative pain; however, when the nurse assesses the client, she finds the client is pale and hypertensive with a respiratory rate of 6 breaths per minute. The PCA pump record shows that the limit for maximum dosage was set far too high, resulting in an overdose. The client is very somnolent and barely responsive. What interventions should the nurse anticipate? Select all that apply
A. Immediately stop the infusion. B. Discontinue the PCA pump. C. Administer naloxone per standing orders. D. Administer supplementary oxygen. E. File an incident report.
Answer: A, C, D, E
Explanation:
In this scenario, the nurse should immediately stop the infusion. The nurse should also
administer naloxone per standing order (or immediately consult the physician to obtain the order). Because
the respirations are so slow, supplementary oxygen will generally be administered. Because an error occurred
in setting the parameters of dosage on the PCA an incident report must be filed.
Question # 5
If teaching a client to use a metered-dose inhaler (MDI) without a spacer, how far away from the mouth should the nurse advise the client that the inhaler be positioned when administering a dose of inhaled medication?
A. The inhaler should be enclosed within the clients’ lips. B. The inhaler should be immediately outside of the client's lips. C. The inhaler should be 1-2 inches away from the client's lips. D. The inhaler should be 3—4 inches away from the client's lips.
Answer: C
Explanation:
If teaching a client to use a metered-dose inhaler without A spacer, the inhaler should be positioned 1—2
inches away from the client's lips for administration of a dose of inhaled medication. The client should be
advised to exhale and then to deliver a dose while breathing in slowly for about 5 seconds. followed by holding
the breath for 10 seconds before exhaling. If an adult has difficulty with coordinating breathing and delivering
of a dosage or holding the inhaler at the correct distance. then a spacer should be used. Children should also
use a spacer.
Question # 6
Following procurement of organs from a standard criteria donor (donor younger than 50 years who suffered brain death), within what time period should the heart and lungs be transplanted?
A. 4-6 hours B. 8—12 hours C. 24 hours D. 36 hours
Answer: A
Explanation:
Following procurement of organs from a standard criteria donor (donor younger than 50 years who
suffered brain death), the heart and lungs should be transplanted within 4—6 hours, liver and pancreas within
12 hours. and the kidney within 24 hours. Organ and tissue recovery is carried out in the operating room with
members of the recovery team present and transportation to the recipient available. The corneas and skin can
be harvested for up to 2 hours After death and bone up to 36 hours. Heart valves can be harvested up to 72
hours after death.
Question # 7
If a six-year-old child has influenza with a fever and cough, which statements by the child's caregiver suggest a need for education? Select all that apply
A. "If his fever gets too high, I'll give him a bath in cold water." B. "I try to offer him plenty of liquids." C. "Sipping hot lemonade seems to help relieve his cough." D. "I've been giving him baby aspirin to lower his fever." E. "I alternate giving him acetaminophen and ibuprofen for this fever."
Answer: A, D
Explanation:
If a 6-year-old child has influenza with a fever and cough, the statements by the child's caregiver
that suggest a need for information include:
• "If his fever gets too high, I'll give him a bath in cold water": This could lower the child's fever too
quickly. If the child's fever is high (>102 ?F or 39 ?C), then the child may be bathed with lukewarm
water.
• "I've been giving him baby aspirin to lower his fever": Children should not be administered any type of
salicylate for viral infections because this places the child at risk for developing Reye syndrome, which
can cause progressive encephalopathy, liver failure, and death.
Question # 8
A client has an open draining wound infected with MRSA and is on contact precautions. If the nurse is entering the room to care for the client, when are gloving and gowning necessary?
A. When the nurse has direct contact with the wound or drainage B. When the nurse has direct contact with the clients’ body, wound, or drainage C. When the nurse enters the room for any type of patient or environmental contact D. When drainage is not contained by a dressing
Answer: C
Explanation:
If a client is on contact precautions because of a MRSA infection and has an open, draining wound, the
nurse should glove and gown whenever entering the room for any type of patient or environmental contact.
MRSA can be spread from the client to surfaces, such as the bedrails or bedside table. Upon leaving the room,
the gloves and gown should be removed and placed into a receptacle near the door and inside of the client's
room.
Question # 9
A neonate has severe congenital abnormalities that make death imminent. The NICU team believes that further attempts at treatment or feeding are not warranted and that palliative care only should be provided, When speaking with the parents about this, which of the following is the best approach?
A. Tell the parents that the team suggests that all food and treatment will be withheld. B. Tell the parents that the team suggests a change in care plan to focus on comfort measures. C. Tell the parents that any further efforts at treatment are futile, as the infant is dying. D. Tell the parents that the best thing is to let nature take its course.
Answer: B
Explanation:
If a neonate has severe congenital abnormalities, death is imminent, and the NICU team feels that no
further attempts at treatment or feeding are warranted, the best approach is to tell the parents that the team
suggests a change in care plan to focus on comfort measures. The nurse should avoid such phrases as
"stopping" or "withdrawing" treatment or feeding because these terms may make the parents feel as though
they are starving or killing their infant, although the exact plan for care should be explained.
Question # 10
A client has increasing pain in both hands. On examination, the nurse notes that the metatarsophalangeal and proximal interphalangeal joints are enlarged and swollen, swan-neck deformity is evident, and the fingers on both hands show ulnar deviation. These findings are consistent with which of the following disorders?
A. Osteoarthritis B. Rheumatoid arthritis C. Gouty arthritis D. Psoriatic arthritis
Answer: B
Explanation:
If a client has bilateral pain, enlarged and swollen metatarsophalangeal and proximal interphalangeal
joints, swan-neck deformity, and ulnar deviation, these signs and symptoms are consistent with rheumatoid
arthritis (RA), an autoimmune disorder that results in inflammation and damage to the joints. R.A may also
affect other organs of the body. Clients typically experience periods when the disease exacerbates and
symptoms worsen. Treatment includes NSAIDs, analgesics, disease-modifying antirheumatic drugs (DMARDs),
and biologics.
Question # 11
If a client with psoriasis is to begin NB-UVB phototherapy, how long should the initial treatment be?
A. 30 seconds to 1 minute B. 1-2 minutes C. 5-10 minutes D. 15-20 minutes
Answer: B
Explanation:
If a client with psoriasis is to begin NB-UVB phototherapy, the initial treatment is 1—2 minutes long with
the time increased gradually by 10—15% until the optimal duration is reached. Treatments are usually done 3
times weekly to a maximum of 20—30 treatments. The phototherapy dosage is adjusted so that only slight
erythema occurs during treatment. If the dose is too high, the client may experience marked erythema or
burns.
Question # 12
A client with prostate cancer has been given the option of various treatments and asks the nurse for advice. Which of the following is the most appropriate response?
A. "Let’s discuss the different options and how you feel about them." B. "I can't help you to make a decision about your treatment." C. "You need to discuss this decision with your physician." D. "I would choose surgery if I were in your position."
Answer: A
Explanation:
If a client with prostate cancer has been given the option of various treatments and asks the nurse for
advice. the most appropriate response is: "Let's discuss the different options and how you feel about them."
The nurse must avoid trying to directly influence the client's choice; however, since the client asked for advice,
this is a good opportunity for the client to express feelings and concerns about the diagnosis and treatment.
Additionally, talking through the options may help the client reach an independent decision.
Question # 13
A client has had a recent below-knee (BK) amputation of the right leg because of a traumatic injury. After removing the elastic wrap, which the client had applied, the nurse notes an unusual pattern of swelling. Which of the following is the most likely reason for this observation?
A. Wound infection B. Impaired circulation to the stump C. Incorrect wrap technique D. Bleeding into the tissues
Answer: C
Explanation:
If a client has had a recent BK amputation of the right leg and the nurse notes an unusual pattern of
swelling after removing the elastic wrap, which the client had applied. the most likely reason for this observation is incorrect wrap technique in which the pressure from the wrap is uneven. The nurse should
point out the swelling and discuss the reasons. demonstrating the correct wrap procedure and then observing
the client rewrap the stump.
Question # 14
If a client is to have a nasogastric (NG) tube inserted for intermittent feedings, which of the following is an appropriate task to delegate to unlicensed assistive personnel?
A. Inserting the NG tube B. Verifying tube position C. Administering tube feedings D. Reposition a displaced NG tube
Answer: C
Explanation:
If a client is to have a nasogastric tube inserted for intermittent feedings, an appropriate task to delegate
to unlicensed assistive personnel (UAP) is the administering of the tube feedings if the person has been trained
in doing so. However, an RN or LVN /LPN must verify the tube position first because this cannot be delegated to
UAP. LIAP cannot insert or reposition a displaced NG tube. LIAP can be advised to monitor the client's condition
and to report any changes in condition, such as dyspnea or nausea.
Question # 15
An older client has been sleeping poorly at night, and her daughter states that the client has always loved music and suggests that listening to music might relax the client. Which type of music is most likely to help the client relax?
A. Classical music B. Jazz C. Single instrument music (guitar, piano) D. The client's favorite music
Answer: D
Explanation:
In this scenario, the nurse should ask about the client's favorite music. Tastes in music are very
individual. For example. while classical music may seem relaxing to some, others may find it boring or
irritating. If the client is not in a private room. then the client should use earphones.
Question # 16
A client is to be discharged 48 hours after a normal vaginal delivery of an infant with no laceration or episiotomy. Which of the following danger signs should the client be advised to report to her physician? Select all that apply.
A. Temperature higher than 38 ?C (100.4 ?F) B. Difficulty urinating C. Swelling, redness, or pain in one or both legs D. Fatigue E. Foul-smelling vaginal discharge
Answer: A, B, C, E
Explanation:
When a client is discharged 48 hours after delivery of an infant. the client should be apprised
of danger signs that could indicate infection or other complications, Constant fatigue, although debilitating, is
usually normal so soon after delivery. Danger signs include:
•Temperature higher than 38 ?C (100.4 ?F)
•Difficulty urinating
•Swelling, redness, or pain in one or both legs
•Increased vaginal bleeding or foul vaginal discharge
•Swelling, masses, or red streaks in the breasts or bleeding nipples
•Blurred vision, persistent headache
•Depression, overwhelming feeling of sadness
Question # 17
The nurse is assessing an older adult. The client does not appear to always understand the questions, sometimes answering incorrectly, and stares at the nurse's mouth rather than the nurse's eyes when the nurse is speaking. The client answers in an unusually loud voice. Which of the following impairments should the nurse suspect?
A. Hearing impairment B. Cognitive impairment C. Vision impairment D. Anxiety
Answer: A
Explanation:
Clients who are hearing impaired often are reluctant to say so but may try to compensate by reading
lips. Because their hearing of their own voice may also be impaired, they may speak more loudly than usual.
Even clients who are quite adept at lip reading may misunderstand some words, resulting in answering
incorrectly. If A client appears to have hearing impairment. the nurse should ask the client directly if he or she
is having trouble hearing the nurse and ask how to best communicate.
Question # 18
If the nurse is teaching a group of clients about risk factors for diabetes mellitus, type 2, the nurse should include which of the following? Select all that apply
A. Obesity B. Hypertension and/or heart disease C. 45 years or older D. Caucasian race E. Family history of diabetes mellitus, type 2
Answer: A, B, C, E
Explanation:
If the nurse is teaching a group of clients about risk factors for diabetes mellitus, type 2, the nurse should include
•High level of LDL cholesterol or low level of HDL cholesterol and high level of triglycerides
•History of polycystic ovarian syndrome
Question # 19
A client with rheumatoid arthritis tells the nurse that she is having increasing difficulty cooking, cleaning, and attending to activities of daily living. Which of the following referrals is the most appropriate?
A. An occupational therapist B. A physical therapist C. A home health agency D. An assisted-living facility
Answer: A
Explanation:
Because this client faces many challenges in the home environment, the most appropriate referral is to
an occupational therapist. The occupational therapist (OT) can meet with the client to determine her goals and
may observe her carrying out activities of daily living (ADLs) to evaluate her abilities and deficits. After words,
the OT can advise her about modifications needed in the home environment and assistive devices so she can
remain independent for as long as possible.
Question # 20
When determining whether or not a client is a candidate for restraints, which of the following would be considered an appropriate reason for a restraint?
A. Current dangerous behavior B. A history of falls C. A recent violent attack on a staff member D. Refusal to cooperate with treatment
Answer: A
Explanation:
When determining whether or not A client is a candidate for restraints, only current behavior should be
considered. If the client currently poses a danger to others or to self and no other reasonable alternative exists,
then restraints may be considered. Restraints cannot be applied as a preventive measure for such things as a
previous violent attack against a staff member or a history of falls. There must be evidence of current risk
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