36) ANSWER
c. “What you’re asking me to do is unacceptable.”

RATIONALE
These clients often try to manipulate the nurse to get special privileges or make exceptions to the rules on their behalf. By informing the client directly when actions are inappropriate, the nurse helps the client learn to control unacceptable behaviors by setting limits. By sitting down to talk about the request, the nurse is telling the client there’s room for negotiating when there is none.

35) ANSWER

A) Mild

RATIONALE

Mild anxiety motivates one to action ,such as learning or making changes. Higher levels of anxiety tends to blur the individual’s perceptions and interference with functioing.

34) ANSWER

A) "Oxygen saturation is only assessed by analyzing the PaO₂."

Explanation

The PaO₂ is not the only determinant used to assess oxygen saturation. Oxygen saturation reflects the total oxygen concentration that is carried on the hemoglobin molecule. There is a relationship observed between the PaO₂ and SaO₂ indicating safe and dangerous levels as the PaO₂ level drops. Options 2, 3, and 4 are consistent with the concept of SaO₂. The critical words are lack of understanding. This is a negative-response question, indicating that three of the options are correct statements. Recognize that options 2, 3, and 4 are true statement about oxygenation and eliminate them.

33) ANSWER

B) Relief of diarrhea

Explanation

The most common use of bilberry is the relief of simple diarrhea. Other known uses are the prevention and treatment of eye disorders, such as diabetic retinopathy, night blindness, macular degeneration, glaucoma, and cataracts. It is also used in the treatment of diabetes mellitus, as an antioxidant and the possible treatment of varicose veins and hemorrhoids. The other options are incorrect. In this question note that all of the options, except the correct response, have multiple conditions in the string.

32) ANSWER

C. Sexual dysfunction

RATIONALE

•Escitalopram is a selective serotonin reuptake inhibitor (SSRI).

•Common SSRI side effects include sexual dysfunction, nausea, diarrhea, headache, dizziness, dry mouth, and weight gain, drowsiness, and insomnia.

31)ANSWER

C. Return of circulation distal to the burn

RATIONALE

•Escharotomies are performed when circumferential burns compromise circulation to the extremity.

•An incision is made down the affected extremity to relieve pressure caused by edema. The depth of the incision is limited to the eschar tissue.

•Reduced edema is an outcome of escharotomies, but edema alone does not require an escharotomy.

30)ANSWER

A. Weakness and fatigue

RATIONALE

•Erythropoietin is synthesized in the renal cortex. A decrease in production related to CRF leads to anemia, manifesting as weakness and fatigue. Dyspnea, pallor, malaise, and poor concentration are also common symptoms of anemia.

•Nausea is not associated with anemia.

•Intercostal retractions, cyanosis, and hypercapnia are generally related to problems with ventilation and perfusion.

29 )ANSWER

D. Positive Epstein-Barr virus antibody test

RATIONALE

•Epstein Barr virus antibody test is used to confirm diagnosis if the Monospot test is negative and the patient has symptoms of mononucleosis.

•The Monospot test, or heterophile antibody test, is a quick test used for mononucleosis, but it may produce false negatives.

•Mononucleosis is usually caused by the Epstein-Barr virus and causes severe fatigue and malaise. Swollen tonsils and lymph nodes, stomach ache, and flu like symptoms are generally present.

•Leukocytosis and lymphocytosis are indicative of infection, but not specific to mononucleosis.

28)ANSWER

B) Pain with urination

Explanation

Balanitis, or inflammation of the foreskin and prepuce, would cause edema and pain of the penile glans, leading to dysuria. Option 1 is inappropriate for balanitis; a urethral discharge (option 3) may occur in gonorrhea; back pain (option 4) could indicate many diseases, but not balanitis. Omit option 1 as this could not occur in a female. Use the process of elimination to work through the other options.

27)ANSWER

D) the condition causes a reduction of gamma globulin in the body.

Explanation

Nephrotic syndrome involves the loss of protein in the urine. Gamma globulins, which help the body fight infections, are proteins. Skin that is not clean and dry is more prone to breakdown, which could lead to infection. The child is oliguric and therefore does not urinate frequently. The only restrictions on the child’s intake are fluid and perhaps sodium. There is no electrolyte deficiency. The core issue of the question is the ability to relate gamma globulin deficiency in nephrotic syndrome to situations that increase risk of infection, such as unclean or moist skin. Use nursing knowledge and the process of elimination to make a selection.

26)ANSWER

D) A client who was admitted 3 days ago with multiple trauma

Explanation

Catabolism refers to processes involving the release of energy in order to restore body dynamics and is seen in clients undergoing acute periods of starvation and/or traumatic injury. The client in option 4 has the most severe triggering condition for catabolism. The client in option 1 would undergo catabolism, but this is a short-term event compared to option 4. The clients in options 2 and 3 are in an anabolic pattern of metabolism representing growth states and new tissue development. Option 4 is more comprehensive than the other options offered.

25) ANSWER

C) The level of the symphysis pubis

Explanation

By the 12th week of gestation, the uterus should have increased in size to be palpable at the symphysis pubis. Factors affecting this finding include abnormal fetal growth or the presence of a multiple gestation. To answer this question correctly, you must be familiar with expected physiological changes during pregnancy. Use nursing knowledge and the process of elimination to make your selection.

24) ANSWER      

D) Measure the abdominal girth.

Explanation

The first meconium stool should be passed within the first 24 hours after birth; if not, the abdominal girth should be measured to evaluate distention and the possibility of obstruction. The presence of anal fissures will not prevent the passage of a meconium stool (option 1). Notifying the physician will not provide more information (option 2). Increasing the amount of feedings will not provide more information, and if there is an obstruction, will complicate that problem (option 3). Note the key words not and first 36 hours. This tells you that there is a problem with the infant s gastrointestinal status. From there, make a selection that gathers more assessment data. Eliminate option 1 as obviously incorrect. Eliminate option 3 because increased feedings would not be given if a problem were suspected. Choose option 4 over 2 because a physician is called when there is a composite set of data, not one assessment item.

23) ANSWER

C) Follow prescribed weight loss plan.

Explanation

A client diagnosed with Pickwickian syndrome is typically clinically obese and has hypoventilation symptoms. A realistic goal is to establish a weight loss plan because it will help to improve breathing, relieve respiratory symptoms, and decrease the workload placed on both the heart and lungs. Option 1 is incorrect because maintaining the client's current weight will not help to improve clinical symptoms. Option 2 is incorrect as increasing caloric intake will further contribute to weight gain and affect respiratory status. Although the use of increased fluids may be helpful to thin secretions, the client with Pickwickian syndrome does not present with thick secretions, but rather has disturbances with sleep apnea. Critical words are Pickwickian syndrome and most realistic. Recall aspects of this syndrome to be directed to option 3.

22)  ANSWER

B) Severe facial acne

Explanation

Oral contraceptives can reduce acne; result in signs and symptoms of early pregnancy, including chloasma; and accelerate the progress of gallbladder disease. Birth control pills do not provide protection against STIs that can result in PID. This question is actually asking about secondary uses of oral contraceptives. Eliminate option 1 first because it is the least plausible. Eliminate options 3 and 4 next because they are aggravated by the use of oral contraceptives.

21 )ANSWER

C) "I should eat 4 to 6 servings of food high in calcium."

Explanation

Long-term corticosteroid therapy can cause Cushing's syndrome. To prevent the osteoporosis associated with Cushing's syndrome, clients should eat diet high in calcium. Extra corticosteroids over the long term can cause weight gain and increased hair on the body. These clients are at risk for gastrointestinal bleeding and should avoid taking aspirin. Use the process of elimination to find the one correct answer.

20 ANSWER 

B) How the pain affects the client's daily life.

Explanation

Chronic pain is multidimensional, often without an identifiable cause and not responsive to conventional treatment. By asking how/if the pain interferes with the client's daily activities, the nurse will obtain information about the impact the pain has on the person's quality of life. Recognize that the question is asking about planning care. Reference to interruption of daily life and activities is a hint to the correct response.

19) ANSWER 

D) Cimetidine (Tagamet)

Explanation

Cimetidine decreases metabolism of beta blockers, phenytoin, procainamide, quinidine, benzodiazepines, metronidazole, tricyclic antidepressants, and warfarin, leading to increased risk of drug toxicity. Ranitidine, famotidine, and nizatidine are histamine blockers that are newer than cimetidine, and have fewer side effects. The core issue of the question is knowledge of histamine antagonists that are highest in side or adverse effects. Specific medication knowledge is needed to answer the question. Use medication knowledge and the process of elimination to make a selection.

18 ANSWER 

D) Muscle weakness

Explanation

The normal calcium level is 9.0-11.0 mg/dL, making this client hypercalcemic. Muscle weakness is a key feature of hypercalcemia due to alterations in excitable membranes. This occurs as a complication in some clients with cancer. Peaked T waves, muscle spasm, and increased gastric motility are signs of hyperkalemia. The core issue of the question is knowledge of electrolyte imbalance (hypercalcemia in this case) and the associated manifestations. Recall that calcium plays a key role in nervous system function to help guide you to the correct option.

17 ANSWER 

C) Urgency with urination

Explanation

Postpartum clients are at risk for urinary tract infections related to urinary retention after delivery. The risk is increased if the client has been catheterized during labor, delivery, or postpartum. Signs of a urinary tract infection include urgency, burning, and frequency of urination. The other answers are normal and do not require immediate attention. The key focus of the question is time-related postpartal risk; the greatest risk at this time is urinary retention and subsequent infection. Eliminate option 1 because it is too early for breastfeeding problems. Eliminate option 2 because this could be related to dehydration at this time. Eliminate option 4 because this describes the normal psychological adaptation that commonly occurs at days 2-3 postpartum for the majority of women.

16) ANSWER

A) The liver produces about 1,000 mL of bile per day.

Explanation

The liver produces between 700 and 1,000 mL of bile a day. The gallbladder stores and concentrates bile and then releases it when stimulated, but is not an essential structure. Recall that the role of the gallbladder is to store and concentrate, not to produce bile.

15)

ANSWER

C) AIDS dementia complex

Explanation

AIDS dementia complex involves cognitive, behavioral, and motor deficits and is a common central nervous system complication of untreated HIV. Along with the above symptoms, apathy, confusion, hallucinations, personality changes, unsteady gait, leg tremors, impaired handwriting, and mental slowing will occur. This question requires knowledge about AIDS dementia.

14)ANSWER B) Pain.

Explanation

Pain usually does not accompany ruptured varices. The increased venous pressure and gastric acid causes the rupture, which is usually followed by bleeding. Hypertension, melena, and high ammonia levels are all expected. Eliminate options 1, 3, and 4 as commonly associated with ruptured varices.

13)ANSWER C  "Dimetane-DC is an opioid antitussive that contains codeine."

Explanation

Dimetane-DC is an opioid antitussive that contains codeine, affecting the cough center directly and suppressing the central nervous system. Dextromethorphan is a nonopioid antitussive that suppresses the cough reflex directly by affecting the cough center. Recall the difference between the letters DM and DC after a medication. DC would indicate that codeine is in the medication. Use of this knowledge will lead to the only correct option, 4. DM after a medication name does not refer to a narcotic in the medication. This will allow you to eliminate the other three options.

12)ANSWER B) Atropine sulfate (generic)

Explanation

The client is exhibiting signs of cholinergic toxicity, and atropine is the antidote. Phytonadione or vitamin K (option 1) is the antidote to warfarin (Coumadin). Oxybutinin is indicated for use as a urinary antispasmodic. Epinephrine is used to treat severe hypersensitivity reactions (anaphylaxis). Use the process of elimination, focusing on the critical words abdominal pain and difficulty breathing. After determining that the client is experiencing adverse or toxic effects of the medication, choose the option that is an anticholinergic drug, which will treat the cholinergic symptoms.

11) ANSWER A)Allow the client adequate time to carry out the rituals.

Explanation

Ritualistic behaviors are related to heightened anxiety. The compulsive behaviors increase in intensity and/or frequency as the anxiety level escalates. The nurse should allow the client to complete the ritual in as reasonable and timely a manner as possible. Interrupting or stopping the ritual will increase anxiety, which in turn will increase the client's need to engage in the ritual. Exploring childhood experiences (option 2) cannot be expected to bring about reductions in anxiety or ritualistic behavior. Clients who display compulsive behaviors need support and encouragement to manage their daily lives by modifying the environment and allowing time for the behaviors. Assigning solitude (option 3) cannot be expected to decrease the client’s need for the ritual. What causes the client to have a need to perform the ritual is not from the actual environment. Hence, remaining in the room will not necessarily decrease the urge to recheck and recheck compulsively. The nurse should recognize that the client's motivations for the rechecking arise from within the psyche and are not related to environmental events (option 4). While keeping others out of the room may spare the client from feelings of embarrassment, it will not necessarily decrease the compulsive behavior. Look beyond the rechecking behavior to what is thought to be underlying, or causing, it.

10) ANSWER  B)Decrease score on depression scale by one half.

Explanation

Option 2 is correct. This option is measurable, and the others are not. Statements of client outcomes should be written in specific measurable terms so that any nurse could determine outcome achievement or lack of achievement. This option indicates that a specific numerical comparison can be made. Options 1, 3, and 4 are incorrect. Each of them indicates the nurse's intention to bring about a change in the client's status, but not one of them is measurable. How does one measure "more" or "increase" without a standard of comparison? Recall basic elements of a well-written outcome statement, including its measurability.

9) ANSWER D)Check to see if the antibiotic is compatible with the continuous infusion.

Explanation

Before making a decision about how to infuse the antibiotic, the nurse should check compatibility of the antibiotic with the continuous IV solution. If the drug and the infusion were compatible, they would be run at the same time. If the drug and infusion were incompatible, the nurse would stop the infusion during the period of antibiotic administration and flush the line carefully before and after the antibiotic. It is always inadvisable to start a second IV site unless absolutely necessary. The other answers are incorrect. Omit options 1 and 2 as they call for an unnecessary stick. Omit option 3 as the flow rate is not addressed in the item and this does not answer the question.

8) ANSWER B)Squeeze the collection chamber.

Explanation

The nurse should squeeze the collecting chamber to reestablish negative pressure and suction to the device. The nurse then wipes the port with alcohol before closing to reduce the risk of infection. The tubing should always be free of kinks to prevent obstruction. The core issue of the question is which action by the nurse will reestablish suction to a Jackson Pratt wound-drainage device. Use nursing knowledge and the process of elimination to make a selection.

7)ANSWER C) "Any extra embryos can be frozen for implantation later."

Explanation

In vitro fertilization usually creates multiple embryos, of which up to four are implanted. Cryopreservation of excess embryos is common, and they can be implanted at a later date. The wording of this question guides you to look for a correct statement as the answer to the question. Evaluate each option as to whether it is true or false. The true statement is then the correct answer.

6) ANSWER:  C) Speak slowly in a low-pitched voice while facing the client

Explanation

For a client who is hearing impaired, speaking slowly in a low-pitched voice and facing the client will promote understanding of the message sent. Option 4 will not provide enough information to effectively care for the client. Options 1 and 2 may be appropriate if the client cannot hear at all. Notice that the scenario states that the client is "partially" hearing impaired. Select the option that adapts to the level of the client function.

5) Answer

C. Arterial blood gas

Rationale

•ABG levels should be assessed prior to any ventilation changes to establish a baseline. ABG levels are often ordered 1 hour after the changes to assess for improvement.

•Breath sounds and FiO2 requirements are important data, but do not neccesarily dictate ventilator settings or weaning.

•An echocardiogram does not help in the assessment of a patient’s respiratory status.

4) ANSWER C. Lactate

RATIONALE
•Lactate (or lactic acid) is elevated in sepsis due to low tissue perfusion and oxygenation. This causes the creation of energy through anaerobic metabolism, which forms lactic acid as a waste product.
•Sepsis is not associated with an increase in hemoglobin, platelets, or ammonia.

3) ANSWER  C. A-positive blood to an AB-negative patient

RATIONALE
•A hemolytic reaction occurs with a Rh or ABO incompatibility.
•Giving Rh-positive blood to an Rh-negative patient would cause a reaction, but giving Rh-negative blood to an Rh-positive patient is safe if there is an ABO compatibility.
•O-negative is the universal donor.
•AB patients can receive both A & B blood types, as long as there is a Rh compatibility.

2) ANSWER

C. Carbamazepine causes bone marrow suppression

RATIONALE

•Carbamazepine causes bone marrow suppression. In a patient with leukemia, bone marrow suppression is already a concern, and the use of carbamazepine could worsen her condition.

•Carbamazepine is approved for the use in children, and this is an accurate dose.

ANSWERS

1) Answer

A. Recent weight loss and febrile

Rationale

•Acute pancreatitis can cause an elevated temperature, weight loss, abdominal pain, nausea, & vomiting.

•The other options are not associated with pancreatitis.