221) Answer
B. Urine concentration

Rationale
•ADH concentrates the urine by reabsorbing water in the renal tubule aquaporins.
•Sodium reabsorption and potassium excretion is the responsibility of aldosterone.v

220) Answer
A. Administering I.V. therapy


Rationale
•Administering I.V. fluids and medication is USUALLY beyond the scope of an LPN. The LPN must have special training in order to administer I.V. fluids.
•The other options are all within the scope of an LPN.

219) Answer
B. Check the PCA pump to verify that the settings are correct

Rationale
•After stabilizing the patient from opioid toxicity, the nurse should verify that the patient was receiving the correct dosage. The ordered dosage was safe for an adult patient, so the error may have been programming the PCA pump.
•Requesting that the PCA be discontinued or that the dosage be lowered is not appropriate until the nurse investigates the reason for opioid toxicity.

218) ANSWER
A) Cefoxitan (Mefoxin)

RATIONALE
A disulfiram-like effect is associated with certain drugs, including metronidazole (Flagyl). Onset is usually within 15-30 minutes of ingestion of alcohol, but can occur up to 72 hours after Flagyl has been discontinued. The reaction lasts approximately 20-30 minutes but can remain up to 24 hours. The core issue of the question is knowledge of which drugs can cause a disulfiram-like reaction when used with alcohol. Use specific nursing knowledge and the process of elimination to make a selection.

217) ANSWER
C) Sodium bicarbonate, to make the client alkalotic so the potassium will shift into the ECF

RATIONALE
Sodium bicarbonate will temporarily alkalinize the plasma, causing the potassium to move into the cells. NS is an isotonic solution, and therefore will not cause fluid or electrolyte shifting. Calcium gluconate is given to blunt the effects on the myocardium; it does not decrease the serum K level. Insulin and dextrose are given to decrease K levels by increasing K uptake at the cellular level. A critical word is acidosis. Recall that potassium is increased in acidosis to direct you to option 3, in which alkalosis is the goal of treatment.

216) ANSWER
C) Chronic impairment of brain functioning

RATIONALE
The behaviors described in this situation are characteristic of clients with dementia, which is a possible late consequence of AIDS. The nurse should understand that the occurrence of symptoms indicates progression of the AIDS illness and that care should be planned accordingly. Option 1 is incorrect because an individual can live with dementia for some time before death occurs, either from AIDS or another cause. Option 2 is incorrect because the situation describes behaviors that are characteristic of the chronic progressive decline that is seen in persons with dementia. Option 4 is incorrect because the particular pattern of behaviors that is described are not particularly associated with the side effect profile of drugs used to control AIDS. Review usual progression patterns of AIDS. Recognize that the client and significant others have a right to know what is happening.

215) ANSWER
B) ST elevations

RATIONALE
ST elevations indicate immediate myocardial injury; ST depressions indicate myocardial ischemia; a Q wave forms several days after a myocardial infarction; a U wave is a sign of hypokalemia. Omit options 3 and 4 as not reflective of the acute phase of myocardial injury. Recall that ST elevations reflect injury.

214) ANSWER
C) Isoproterenol (Isuprel)

RATIONALE
Terbutaline, pirbuterol, and metaproterenol are all beta 2 stimulants. Isoproterenol stimulates beta 1 and beta 2 receptors, and therefore should not be used with clients with tachydysrhythmias. In order to answer this question, recall knowledge of beta 1 and beta 2 stimulants and their effects on the heart. Use the process of elimination, and exclude those medications of the same category, to be led to the correct choice.

213) ANSWER
D) Acetaminophen (Tylenol)



RATIONALE
Medications such as acetaminophen (Tylenol) are highly metabolized by the liver and should be avoided. Other such drugs are barbiturates and sedatives. Options 1 and 2 are ordered to decrease the ammonia level, and option 3 may be ordered for pain. Omit options 1 and 2 as these are commonly used to reduce ammonia. Demerol is the better option for pain.

212) ANSWER
A) The signs and symptoms of pulmonary edema

RATIONALE
Medications used to treat symptoms of multiple sclerosis have been noted to increase pulmonary edema, leading to chest pain and shortness of breath. Option 2 could increase risk of urinary tract infection. Option 3 is useful to avoid infection, but does not specifically relate to medication teaching. Option 4 could increase fatigue, if done to excess, and lead to exacerbation of symptoms. The core issue of the question is knowledge of essential teaching points for a client being treated with drug therapy for multiple sclerosis. Use specific nursing knowledge and the process of elimination to make a selection.

211) ANSWER
A) Gestational trophoblastic disease


RATIONALE
The client has three risk factors of molar pregnancy: Japanese background, brownish, "prune juice" vaginal bleeding, and the severe nausea and vomiting associated with excessive hCG found in trophoblastic disease. The client has only one symptom of hyperemesis; placenta previa presents with bright red bleeding; and there is no information suggestive of psychosis. The core issue of this question is a cluster of symptoms. Eliminate options 2 and 3 because they are characterized by one main symptom. Eliminate option 4 because no psychological symptoms are presented.

210) ANSWER
C) Vitamins A and D

RATIONALE
Clients who are taking cholestyramine (which is a bile resin) should be monitored for fat-soluble vitamin deficiencies (Vitamins A, D, E, and K), as the gastrointestinal side effects of the medication can lead to reduced absorption. Niacin, thiamine, folic acid, cyanocobalamin, and Vitamin C (options 1, 2, and 4) are all examples of water-soluble vitamins. The core issue of the question is knowledge that cholestyramine places the client at risk for deficiency of fat-soluble vitamins. Use the process of elimination and reason that this answer is correct because the action of cholestyramine is to bind onto cholesterol (fat) and prevent its absorption into the GI tract.

209) ANSWER
C) Ask him to choose a face on the Wong FACES pain rating scale.

RATIONALE
Pain management is a high priority following gastric surgery, and the nurse should use age-appropriate tools to assess for pain, such as the Wong FACES rating scale. A gastrostomy tube or nasogastric tube placed during surgery is kept in place to maintain gastric decompression. The child is kept NPO until bowel function returns. The use of a pH probe to measure gastric acidity is not necessary. The core issue of the question is knowledge of appropriate interventions in the first 24 hours following gastric surgery. Use knowledge that the gastric tube should not be manipulated or used for feeding to eliminate some options. Use nursing knowledge of routine postoperative care and the process of elimination to make a final selection.

208) ANSWER
A) Aminoglycoside antibiotics

RATIONALE
Nephrotoxicity can be caused by aminoglycoside antibiotics. This type of drug accumulates in tubular cells, eventually killing them. Options 2 and 3 are ototoxic, while option 4 is avoided in renal disease. Associate this drug category with nephrotoxicity.

207) ANSWER
C) Risk for injury related to disease state

RATIONALE
Because of their very fragile bones, children with OI experience countless fractures, and the prevention of injury takes highest priority in this child’s care. Pain would be important if a fracture actually occurs, but the key is prevention of fractures, making risk for injury more appropriate. Skin integrity impairment would also not be a concern unless a fracture actually occurred. Option 4 can be eliminated as the child is 4 years old and body image is not a great concern. Of the three remaining, choose the option that would be a concern throughout the care of this child.

206) ANSWER
A) These symptoms are consistent with an ulcer.

RATIONALE
This description of pain is consistent with ulcer pain. The pain is epigastric and is worse when the stomach is empty and is relieved by food. These symptoms are not common with cholelithiasis. Ordinary indigestion does not present with this clinical scenario. Associate pain relieved by food with ulcers.

205) ANSWER
C) Increasing hoarseness

RATIONALE
Guillain-Barré syndrome is an ascending paralysis. While the child will have increasingly less muscle tone in the extremities, the hoarseness could indicate involvement in the muscles of respiration. Serious concern is raised when the respiratory muscles are affected. Sometimes mechanical ventilation is indicated. Tingling is a common sign of Guillain-Barré and not related to respiratory distress. Consider which option can have serious implications. Knowledge of Guillain-Barré as an ascending paralysis would indicate that hoarseness would be an impending sign of difficulty.

204) ANSWER
B) Edema.

RATIONALE
Edema is the major clinical symptom of nephrosis. The child may gain twice his or her normal weight in severe cases. Nephrosis is a urinary condition, so look first for the options related to urinary function. That would eliminate the rash, leaving hematuria, dehydration, and edema. Body fluid is involved in dehydration and edema, which are opposites. If the kidneys aren’t working effectively, there will be problems eliminating fluid.

203) ANSWER
A) Sertraline is most often taken as a morning dose.
E) It is possible that sexual side effects will occur.


RATIONALE
The nurse should know that one of the common side effects of sertraline (Zoloft) is insomnia. Therefore, most clients are given sertraline (Zoloft) early in the day. Sexual side effects to sertraline (Zoloft) and other SSRIs are common. One way to decrease the likelihood of noncompliance is to inform the client that prompt reporting of such side effects can lead to corrective treatment measures. It is important for the nurse to know that diarrhea is a much more common side effect to sertraline (Zoloft) than is constipation (option 2). It is vital for the nurse to know that all persons taking sertraline (Zoloft) or other SSRIs should be taught to recognize early symptoms of possible central serotonin syndrome (option 3). Such symptoms include sudden onset fever, sweating, and extrapyramidal side effects (EPS). The development of central serotonin syndrome is a rare medical emergency, but the client will need intensive medical treatment because the mortality rate is very high. The nurse should teach the client that while some reduction in symptoms may occur in a relatively short period of time, it may be several weeks before full therapeutic effects are realized (option 4). Without this knowledge, clients often become discouraged and think that the medication is ineffective. Translate the statements of the nurse into medical terminology and then determine if each option is related to a known side effect of sertraline (Zoloft). .

202) ANSWER
B) An elevated TSH and decreased T4 levels

RATIONALE
In hypothyroidism, the thyroid gland does not produce thyroxine (T4), despite being stimulated by the pituitary gland (TSH, thyroid-stimulating hormone) to do so. Elevated TSH and T4 levels are seen with secondary hyperthyroidism caused by excessive TSH production by the pituitary. A decreased TSH and elevated T4 are seen with primary hyperthyroidism. Decreased TSH and T4 levels are seen in hypothyroidism secondary to insufficient pituitary secretions. The question requires knowledge of pituitary and thyroid hormone functions. Recall the negative feedback loop of the endocrine system. Eliminate options 1 and 4 because there is an increased T4 level, which would not be seen with primary hypothyroidism.

201) Answer
C. Prevent internal rotation of the affected hip


Rationale
•After a total hip replacement, the affected leg should be abducted and externally rotated to prevent dislocation.
•Slight hip flexion is ok, but flexion should not exceed 90 degrees.

200) ANSWER
C) Fecal impaction.

RATIONALE
Fecal impaction causes a diarrhea that has rapid onset. Diarrhea caused by anal incontinence (option 2) often occurs twice a day, and the stool caused by malabsorption (option 1) would be foul-smelling, fatty and pale. Diarrhea caused by food poisoning (option 4) would occur hours after ingestion of food, typically accompanied by severe nausea and vomiting. Review the assessment information for diarrhea that occurs in clients who are near the end of life. The incorrect options do not provide sufficient or correct explanations. Use nursing knowledge and the process of elimination to make a selection.

199) Answer
B. A nurse who recently discharged two patients


Rationale
•After discharging two patients, the nurse is free to take on additional patient assignments.
•A patient with no visitors can still require frequent monitoring and assessment.
•A complex dressing change requires time from the nurse, leaving her unable to admit a new patient.
•A patient with multiple GI bleeds requires frequent assessment.

198) ANSWER
D) Calcium channel blocker

RATIONALE
Verapamil and diltiazem, of all the calcium channel blockers, have the greatest effect on the AV node to slow the heart rate. Additional drug effects are slowing of the ventricular rate in atrial fibrillation or flutter, and conversion of supraventricular tachycardia (SVT) to a normal sinus rhythm (NSR). Knowing that one of the actions of calcium channel blockers slows the heart rate will assist in selecting option 4. If this was difficult, review the effects of each listed classification.

197) Answer
A. Brain tumor

Rationale
•Assessment findings for a patient with a brain tumor include headache that becomes worse in the morning and with straining and stooping, vomiting, papilledema, seizures, changes in mental status, and altered vision.
•A patient with meningitis has fever, headache, nuchal rigidity, Kernig’s signs and Brudzinski’s signs.
•There can be no skull fracture since there was no history of head trauma.
•A patient with encephalitis can manifest headache, fever, vomiting, and menigeal signs due the inflammation of the brain caused by a virus.

196) ANSWER
C) pH 7.49; PaCO2 36; HCO3- 30; PaO2 90

RATIONALE
Clients who take potassium-wasting diuretics, such as Lasix, are at risk for developing hypokalemia and metabolic alkalosis. Options 1 and 2 are incorrect because they reflect an acidotic state. Option 1 is a respiratory acidosis and option 2 is a respiratory acidosis with partial compensation. Option 4 is incorrect because the primary disturbance is a respiratory alkalosis due to the increased PaCO2 level. Critical words are furosemide and potassium level of 3.2. Recognize the drug is a potassium-wasting diuretic that contributes to metabolic alkalosis. Determine that options 1 and 2 reflect acidosis, and eliminate them. Option 4 is respiratory in nature, so eliminate it.

195)Answer
A. Dysuria and mucopurulent penile discharge

Rationale
•Assessment findings characteristic of urethritis are dysuria, mucopurulent penile discharge, and frequent urination.
•Hematuria suggests traumatic injury or increased permeability of the glomerulus.

194) Answer

A. pH 7.28 PCO2 60 HCO3 26

Rationale

•Because the patient went some time without breathing, PCO2 will be elevated due to retention, causing respiratory acidosis. The bicarb level is normal because the kidneys have not had time to compensate.



Respiratory Acidosis:
•Respiratory system is the cause, for ex. hypoventilation
•Increase in PCO2, decrease in pH
•Compensation – Kidneys reabsorb Bicarb (HCO3)

Metabolic Acidosis:
•Caused by loss of bicarb or a build up of acids, for ex. lactic acidosis, diarrhea, renal failure, ketones, ammonium intoxication. Not caused by respiration.
•HCO3 decreases, pH decreases
•Compensation – hyperventilation to eliminate CO2

Respiratory Alkalosis:
•Caused by excessive ventilation
•Decrease in PCO2, increase in pH
•Compensation – Kidneys excrete HCO3

Metabolic Alkalosis
•Acid (H+) lost from emesis, diuretics. Retention of HCO3 from medications, hyperaldosteronism
•Increase in HCO3, Increase in pH
•Compensation – Respiratory centers are not stimulated, this leads to hypoventilation and CO2 retention

193) Answer
B. Tandem mass spectrometry
Rationale
•All newborns receive a heel stick to test the serum for several metabolic disorders. The tandem mass spectrometry can measure the levels of several amino acids to confirm the presence of PKU.
•The Guthrie test was once used to measure serum phenylalanine levels, but has been replaced with tandem mass spectrometry.
•Liver enzyme analysis can be done to measure the activity of phenylalanine hydroxylase, but this is generally not done.
•Urinalysis can detect ketones in the urine of a child with PKU, however, this does not confirm the diagnosis.

192) Answer

A. Reposition every 2 hours

Rationale

•Bedrest increases the risk of developing pressure ulcers. To reduce this risk, the nurse should reposition the patient every two hours, provide a low-air-loss mattress, and promote the use of a trapeze.

•Elevating the head of bed may increase shear and friction.

•Promoting indepedence will prepare the patient for discharge.

•Fluid intake should be increased to reduce the risk of renal calculi formation.

191) Answer

D. Blurred vision

Rationale

•Bacitracin ointment commonly causes blurred vision, but is usually lasts only a few minutes.

•Amblyopia, or lazy eye, is not associated with the administration of medications.

•Diplopia, or double vision, is not associated with the use of bacitracin.

•Strabismus, a condition when the eyes are not properly aligned, is not associated with the use of bacitracin.

190) ANSWER

D) "My child needs an iron supplement."

RATIONALE

A child diagnosed with thalassemia who will receive multiple transfusions throughout life will need chelation therapy for excessive iron stores. An iron supplement would be inappropriate in this child. Consider which statements are appropriate for a child with thalassemia and eliminate those. That will leave only the response that indicates the need for more education.

189) ANSWER

D) Use a nitroglycerin (NTG) tablet before the activity.

RATIONALE

NTG can be taken as a preventive measure prior to activities that trigger angina. This is especially helpful with sexual activity or work-related activities that may need to be continued. Modifying such activities may be necessary, but cardiac clients should not become restricted by their condition and lead sedentary lifestyles. The question asks for a method of handling the precipitating event. Option 4 is the only option that provides a way of preventing the angina associated with exercise and stress.

188) ANSWER
D) Hard palate of the oral cavity

RATIONALE
Jaundice in the dark-skinned client can best be observed by assessing the hard palate. Normally, fat may be deposited in the layer beneath the conjunctivae that can reflect as a yellowish hue of the conjunctivae and the adjacent sclera in contrast to the dark periorbital skin. In these clients, palms and soles might appear jaundiced, but instead, calluses on the surface of their skin can make the skin appear yellow. Note that the question is referring to liver toxicity, which would appear as jaundice. Recall that assessment involves looking in the client s mouth for skin discoloration. If this was difficult, review alterations to physical assessment.

187) ANSWER
D) "My child will need to be home schooled to protect him from injury."

RATIONALE
Children with mild OI may be able to participate in sports, and many are able to participate in swimming. There are no current medications that stop this disease process. There are a variety of surgical procedures that may be done to help strengthen the bones; one is the insertion of intermedullary rods to provide for stability. The child with OI may participate in school, though care needs to be provided to protect this child from injury. The goal of treatment for all children is to promote growth and development. The one action that would limit growth and development would be home schooling.

186) ANSWER
C) The skin should always be tested for allergies by applying a small amount of oil to the area before treatment.

RATIONALE
Essential oils are distilled from flowers, roots, bark, leaves, wood, resins, citrus rinds, and more; the quality of essential oils varies. Many oils should be kept out of the sunlight and heat. Essential oils can be toxic and produce an allergic reaction in some individuals. Some essential oils are unsafe during pregnancy, so it is critical to contact the primary care provider prior to trying aromatherapy to determine which oils are safe and which are toxic. The core issue of the question is that essential oils can cause an allergic reaction in the client.

185) ANSWER
B) Inhalation of manganese dust

RATIONALE
Occupational exposure to the manganese can result from dust inhalation and can have profound neurological effects. The other options would not be applicable to this client. Critical words are mine and neurological problems. Note that options 2 and 3 contain the word inhalation, which correlates to confinement in a mind. Recall knowledge of manganese sources to be directed to option 2.

184) Answer

A. Exaggerated emotional response by the parents
B. Absent emotional response by the parents
D. Conflicting stories from the parents

Rationale

•Indications of child abuse include, but are not limited to, conflicting stories, exaggerated or absent emotional response by the parents, and a history inconsistent with the child’s developmental age.

•The parent’s appearance or use of inappropriate language are not indicators of abuse.