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2. Correct Answer: 2. Rationale: A licensed practical nurse works under the direction of a registered nurse. A registered nurse can delegate the task of acquiring basic information from the client to a licensed practical nurse, but the registered nurse is responsible for ensuring that the admission database is complete. The registered nurse is responsible for identifying nursing diagnoses and developing the initial plan of care for preventing, reducing, or resolving the nursing diagnoses. The registered nurse delegates implementation of the plan of care to the licensed practical nurse and encourages the licensed practical nurse to make future contributions to the initial care plan. Category of Client
Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
Chapter 4
1. Correct Answer: 2. Rationale: The highest priority for client care is
relief of labored breathing. Breathing is a basic physiologic need. Feeling powerless affects the need for security. Family support is an issue that affects the need for love and belonging. Issues of self-esteem follow the others in the list. Category of Client Need: Safe, Effective
Care Environment; Step in the Nursing Process: Planning.
2. Correct Answer: 4. Rationale: Initial examination by a family practice physician is the rst step in primary care. The family practice physician may then refer the client for secondary or tertiary care. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
Chapter 3
1. Correct Answer: 4. Rationale: The first step when a nurse suspects another of stealing narcotics is to report the information to the immediate nursing supervisor. Providing specific observations and facts is important. Once the information is validated, the nursing supervisor is responsible for proceeding with other possible legal and ethical actions. It is unethical to damage the character of a colleague by discussing the situation prematurely. Category of Client Need:
Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
3. Correct Answer: 2. Rationale: A referral to a home health nursing organization before discharge helps to maintain health care from an acute care agency to home care without appreciable interruption. The other three organizations are examples of insurance plans for facilitation of third party payers of health care. Category of Client Need:
Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
Chapter 5
1. Correct Answer: 3. Rationale: Primary prevention involves eliminating the potential for an illness. Stress-management techniques help to reduce the release of norepinephrine and epinephrine and promote normal blood pressure. Blood pressure assessment is a secondary preventive measure that provides a means for early diagnosis. It is premature to give a client information about medications before a diagnosis is made. Teaching about the hazards of hypertension can motivate a client to implement measures to reduce health risks but offering the client a tool, like methods for stress management, is best. Category of
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APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions feelings of the clients statement. The nurse avoids any emotional support or involvement by offering to arrange contact with the surgeon. Giving advice and disagreeing with the client are nontherapeutic forms of communication. Client Need: Psychosocial Integrity; Step in the
Nursing Process: Implementation.
Client Need: Health Promotion and Maintenance; Step in the Nursing Process: Planning.
2. Correct Answer: 1. Rationale: According to Holmes and Rahes Social Readjustment Rating Scale, death of a spouse is the most stressful event a person experiences. The other examples are signicant stressors but less intense than the death of a spouse. Category of
Client Need: Health Promotion and Maintenance; Step in the Nursing Process: Assessment.
3. Correct Answer: 4. Rationale: Denial is a coping mechanism in which a person rejects objective information and believes something else is true. Denial protects the ego from dealing with threatening information. Somatization is a coping mechanism in which a person manifests an emotional stressor via a physical disorder or symptom. Regression is manifested by behaving in a manner characteristic of a younger age. Displacement involves expressing ones anger toward something or someone unlikely to retaliate. Category of Client Need:
Psychosocial Integrity; Step in the Nursing Process: Assessment.
3. Correct Answer: 2. Rationale: The nurse performs the role of educator by providing explanations to a client who is unfamiliar with hospital equipment. Explanations are best in simple, understandable terms. Once informed, the client has a basis for interpreting and coping with what are unique experiences. The client is unlikely to understand what the name of a heart rhythm implies. Administering a tranquilizer or distracting the client with a magazine does not help to prevent a similar fearful response if the situation recurs. Client Need: Psychosocial
Integrity; Step in the Nursing Process: Implementation.
Chapter 6
1. Correct Answer: 4. Rationale: Determining a clients food preferences forms the basis for menu planning and dietary selections within the prescribed restrictions of the clients therapeutic diet. Incorporating cultural preferences, if they exist, promotes the potential for compliance with a diet. Although the trends in the clients blood glucose level and knowledge of drug therapy are important, they are secondary to preparation for diet teaching. Once he or she has identied the clients food preferences, the nurse personalizes the exchange list by emphasizing the allowed amounts of those foods that the client is accustomed to eating. Category of Client Need: Health Promotion
and Maintenance; Step in Nursing Process: Planning.
2. Correct Answer: 2. Rationale: Clients who have retained their Asian culture will feel most comfortable if the nurse maintains a distance just beyond arms reach. People from non-Anglo cultures often nd physical closeness with strangers to be discomforting. Touch also may provoke anxiety; it is important to explain when and how a client will be touched if that is necessary. A position within the doorway to the room is too distant during an interview regardless of the clients culture.
Category of Client Need: Psychosocial Integrity; Step in Nursing Process: Implementation.
Chapter 8
1. Correct Answer: 1. Rationale: Before the nurse can proceed with
teaching, he or she should assess the childs height and weight to determine if the child is within norms for his or her age group. Another pertinent assessment is determining if the child has any food allergies or health problems affected by food. A food pyramid is a useful guideline for normal, healthy nutrition, but serving sizes require modication for a child especially if he or she is underweight or overweight. It is inappropriate for the nurse to plan 1 weeks menus without knowing what the mother usually prepares for the family and the budget for purchasing groceries. Recipes are the mothers personal choice and various cookbooks are available from resources other than the nurses own collection. Category of Client Need: Health Promotion and Maintenance; Step in the Nursing Process: Assessment.
2. Correct Answer: 2. Rationale: Directly observing the clients performance is the best method for evaluating if he or she learned the information. The client may correctly describe the importance of performing breathing exercises, yet not actually perform the skill. The client may say he or she is performing the exercises even if this is untrue. Monitoring the respiratory rate is not the best technique for determining if, when, and how often the client is performing the exercises because the rate changes in response to many variables such as current level of activity and oxygenation status. Category of Client Need: Physiological
Integrity; Step in the Nursing Process: Evaluation.
Chapter 7
1. Correct Answer: 1. Rationale: Paraphrasing is a therapeutic communication technique by which the nurse lets the client know empathetically that he or she has understood both the content and the
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Chapter 9
1. Correct Answer: 2. Rationale: Publicly identifying the names of clients violates their right to condentiality. The number of clients assigned to each nursing team member depends on the persons knowledge and experience and the clients acuity level. Posting the names of staff demonstrates respect for the right of clients to know who is managing their care. The Kardex is a resource that the nurse and members of the nursing team use frequently for current information about clients. Category of Client Need: Safe, Effective Care Environment;
Step in the Nursing Process: Implementation.
is not likely to create sufcient exercise to signicantly alter the pulse rate; therefore, a 15-minute delay is not necessary. Blood pressure can be assessed in a lying, sitting, or standing position. To evaluate trends in blood pressure, all measurements are taken consistently on the same arm and body position. Category of Client Need: Physiological
Integrity; Step in the Nursing Process: Data Collection.
2. Correct Answer: 1. Rationale: Inserting information on a record that suggests the documentation was entered earlier is legally problematic because it could be interpreted as falsifying a record. If the writer recalls information omitted earlier, the best practice is to identify the time the note is being written and write late entry for [insert date and time]. . . . Misspelled words, a color of ink that is contrary to the agencys documentation policy, and failure to identify ones title are practices that require improvement but they are not as serious to cases involving a lawsuit. Category of Client Need: Safe, Effective Care
Environment; Step in the Nursing Process: Implementation.
2. Correct Answer: 2. Rationale: Shivering takes place at the onset of a fever as a physiologic measure for assisting the hypothalamus to reach a higher set point. Covering the client provides comfort and shortens the period of chilling. Once the temperature reaches a plateau, the extra covers can be removed. Fluid replacement and facilitating evaporation with adequate circulation of environmental air are appropriate when diaphoresis occurs in the later phase of a fever. Rest conserves energy to compensate for an elevated metabolic rate caused by the fever, but it is not the most important nursing action in response to shivering. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.
3. Correct Answer: 3. Rationale: A thready pulse, also classied as a 1+ pulse, is one that is not easily felt and disappears with slight pressure. A normal pulse is easily felt and disappears when moderate pressure is applied. A weak pulse is stronger than a thready pulse and disappears with light pressure. Although the pulsation may be difcult to detect, the term diminished is not a standard descriptive term.
Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
Chapter 10
1. Correct Answer: 2. Rationale: Under the privacy and security components added to the Health Insurance Portability and Accountability Act (HIPAA), a healthcare institution must protect clients health information. Permission must be obtained before sharing health information with any third party. When interacting directly with a client, it is respectful to use the clients surname unless permission has been given otherwise. A clients surname is not used in public locations like an elevator or cafeteria. When communicating with staff, referring to a client by a room number disregards the clients unique identity. All medical records, which are kept condential, contain both the clients name and medical record number. Category of Client Need:
Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
2. Correct Answer: 3. Rationale: The federal Patient Self-determination Act ensures clients right to have advance directives declaring their wishes regarding life-sustaining treatment. If a client has not prepared a document of this nature, the nurse provides information and an accompanying form with which to do so. Social security numbers are not medically necessary. A clients Medicare status and information about health insurance are important for collecting third-party payment for health care, but the information is obtained by personnel in the admitting or business ofce of the health care agency. Category of
Client Need: Safe Effective Care Environment; Step in Nursing Process: Implementation.
Chapter 12
1. Correct Answer: 3. Rationale: If a cough is productive, it is important to document the color, odor, amount, and viscosity of sputum raised. Other data that may help the physician make a diagnosis include the onset, duration, precipitating factors, and relief measures that relate to the cough. The clients family history may or may not correlate with the clients current condition. The clients heart rate may be elevated if his or her temperature is elevated or oxygenation status is compromised, but a focused assessment of the heart rate is less critical than is the characteristics of sputum. Measures the client is using to manage his or her cough are helpful, but the characteristics of the sputum are more signicant for the diagnostic process. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
3. Correct Answer: 2. Rationale: Anxiety is usually manifested via sympathetic nervous system stimulation. Of the four choices, restlessness and disturbed sleep correlate most with anxiety. Being quiet and withdrawn, eating less than expected, and missing family members suggests depression or loneliness. Category of Client Need: Psychosocial
Integrity; Step in the Nursing Process: Data Collection.
Chapter 11
1. Correct Answer: 3. Rationale: To obtain an accurate oral temperature, the assessment is delayed 30 minutes after the client has consumed hot or cold beverages or food. Unless the client is taking medication that affects heart rate, has a slow or irregular pulse, or the radial pulse is difcult to assess, there is no reason to obtain an apical-radial rate. Eating
2. Correct Answer: 2. Rationale: There is more than one correct description for how breast self-examination is performed, but all include palpating the breasts from the outer margins toward the nipple. Category
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3. Correct Answer: 4. Rationale: Changes in pupil response indicate increasing intracranial pressure. The other assessments are appropriate, but they do not provide the most critical information about the clients neurologic status. Category of Client Need: Physiological
Integrity; Step in Nursing Process: Data Collection.
3. Correct Answer: 2. Rationale: Maintaining or gaining weight is the best evidence that a clients nutritional needs are being met. The client could remain alert yet be malnourished. Because eating food is both an emotional as well as physical phenomenon, well-nourished, satiated people may feel hungry when they see, smell, or think about food. The clients tolerance of pain may increase with improved nutrition, but it is not the best criterion for determining the outcome of a nutritional regimen. Category of Client Need: Physiological Integrity; Step in Nursing Process: Evaluation.
5. Correct Answer: 2. Rationale: A Snellen chart is used to test far vision. Clients stand 20 feet from the chart and are asked to read letters that progressively become smaller. A Jaeger chart requires that the client read various sizes of print and is used to test near vision. Ishihara plates are used to test color vision. A tangent screen is used to assess the peripheral visual eld. This test requires that the client indicate when he or she sees a stimulus in his peripheral vision. Category of Client
Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.
5. Correct Answer: 3. Rationale: Red meat, liver, and egg yolk are good
dietary sources of iron. Dairy products are low in iron, but high in calcium. Citrus fruits are high in vitamin C. Yellow vegetables like carrots and squash are a source of vitamin A. Category of Client Need: Health
Promotion & Maintenance; Step in Nursing Process: Implementation.
Chapter 15 Chapter 13
1. Correct Answer: 1. Rationale: An anesthetic is not administered to
clients undergoing a sigmoidoscopy. Clients can eat lightly before a sigmoidoscopy. A exible sigmoidoscope is used more commonly than one that is rigid. The sigmoidoscope is inserted through the anus and traverses the rectum to the sigmoid area of the lower bowel. Clients can take medications that do not interfere with the test ndings prior to a sigmoidoscopy. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Evaluation.
3. Correct Answer: 1. Rationale: Douching in the days before obtaining a specimen for a Pap test interferes with accurate test results because it removes cervical cells. None of the other instructions is necessary before a pelvic examination and Pap test. Category of Client Need:
Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
Chapter 14
1. Correct Answer: 1. Rationale: When the mucous membrane of the
oral cavity is inamed, it is best to eliminate foods that are acidic, salty, spicy, dry, or very hot. Other than tomato soup, none of the other foods has these characteristics. Category of Client Need: Physiological
Integrity; Step in Nursing Process: Implementation.
3. Correct Answer: 1. Rationale: A unit of packed blood cells contains similar numbers of blood cells in less uid volume. A unit of packed red blood cells is prepared by removing approximately two-thirds of the plasma from 1 unit of whole blood. Administration of packed red blood cells is preferred for clients who need a blood transfusion but for whom additional water within the circulatory system is hazardous. Typically the candidate for packed blood cells is someone prone to excess uid volume. Packed red blood cells pose the same risk for an allergic transfusion reaction as whole blood. Neither a transfusion of packed red blood cells nor whole blood stimulates the bone marrow to produce more red blood cells. Category of Client Need: Health promotion/maintenance; Step
in the Nursing Process: Implementation.
2. Correct Answer: 2. Rationale: Chewing food thoroughly helps the bolus to descend through the esophagus. Restricting dietary intake to baby food is unnecessary and could contribute to constipation. Drinking liquids helps to keep the mouth moist. Liquids are thickened if a client has weakness or paralysis of the tongue or pharynx. Eliminating dairy products will not promote the ability to swallow. Category of
APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions indications of a problem with the administration of the blood rather than a reaction to the blood. Category of Client Need: Physiological
Integrity; Step in the Nursing Process: Data Collection.
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of etiologies may cause. Carbon monoxide is an odorless gas. The pulse rate may be rapid and irregular with carbon monoxide poisoning, but this finding is not as specific as cherry-red skin. Category of
Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
Chapter 16
1. Correct Answer: 3 Rationale: Hair conditioner is not recommended for those infected with head lice because it coats the hair and protects the nits (eggs) attached to shafts of hair. Pediculocide shampoos are effective, but some contain strong neurotoxic or carcinogenic chemicals that may be harmful for clients who are pregnant, nursing, younger than 2 years, or who have open wounds, epilepsy, or asthma. Manual removal with a ne-toothed combing tool is best for removal of nits and live lice. The water temperature is of no consequence as long as it is not so hot as to burn the scalp. Category of Client Need:
Health Promotion and Maintenance; Step in the Nursing Process: Evaluation.
Chapter 17
1. Correct Answer: 3. Rationale: Keeping the bed in low position while making an occupied bed predisposes to muscle strain and back injury. Loosening the linen, wearing gloves to avoid contact with blood or body uids, and rolling the client to the far side are appropriate actions. Category of Client Need: Safe, Effective Care Environment;
Step in the Nursing Process: Evaluation.
Reconciliation Act (1987), which applies to the use of restraints in longterm care facilities, and most healthcare agency policies, the nurse must obtain a medical order for using a restraint. The order must be renewed every 24 hours thereafter. It is good judgment to report the need to restrain a client to the nursing supervisor who may temporarily send additional personnel to assist with the care of clients. Sedatives are considered a form of chemical restraint that may further jeopardize the clients safety. There may be a charge for a restraint, but failure to do so does not compromise the legality of their use. Category of Client Need:
Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
Chapter 19
1. Correct Answer: 2. Rationale: Asking the client to rate the pain using a numeric scale helps the nurse to assess its intensity. The nurse can use the rating scale later to evaluate the effectiveness of any painrelieving interventions used. Noting whether or not the client can stop moving is not the best assessment technique because a cooperative client may make an effort to stop moving despite the continuation of severe pain. Perspiration is a physiologic sign that may accompany pain. Because other factors can trigger perspiration, however, its presence or absence is not the best assessment. Administering an analgesic is an intervention, not a form of assessment. Category of Client Need:
Physiological Integrity; Step in the Nursing Process: Data Collection.
Chapter 18
1. Correct Answer: 2. Rationale: Carbon monoxide diffuses and binds with hemoglobin more readily than oxygen. It causes a victims skin to appear cherry red. Eye medication could cause dilated pupils or this could be an ominous sign of brain anoxia, which any number
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APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions than maintaining intact skin. Supporting the breasts and applying warm compresses will provide comfort but will have no effect on preventing the transmission of microorganisms elsewhere. Category of
Client Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.
4. Correct Answer: 2. Rationale: It is best to control pain before it escalates. When pain is intense, relief is more difcult to achieve. Administering pain-relieving drugs on a routine schedule rather than when it becomes absolutely necessary can reduce peaks and valleys of pain. The goal is to keep a terminal client comfortable yet not dull his or her consciousness or ability to communicate. To avoid potentially lethal side effects, there must be time enough between doses for the drug to be metabolized and excreted; therefore, giving the medication on demand is not appropriate. Asking the physician to order a high dose may be premature. Doses of opioid medications are titrated upward as tolerance develops. Category of Client Need: Physiological Integrity; Step in
the Nursing Process: Implementation.
2. Correct Answer: 3. Rationale: Using individual bath linen and performing frequent handwashing are techniques for preventing the transmission of infectious microorganisms that may be present in eye secretions. Eating a nutritious diet and using sunglasses to lter ultraviolet light are healthful behaviors, but they are unrelated to the clients disorder. The use of aspirin is not contraindicated; in fact, a mild analgesic may relieve some of the clients discomfort. Category of Client
Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.
Chapter 20
1. Correct Answer: 2. Rationale: Of the choices provided, restlessness is the most indicative sign of early hypoxia. Blood loss is expected; if it is profuse or prolonged, it may eventually affect the red blood cells oxygen-carrying capacity. Clients with compromised oxygenation are more likely to manifest tachycardia than an irregular heart rhythm. Thirst is a sign of uid volume decit. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
4. Correct Answer: 1. Rationale: A client who is immunosuppressed is at high risk for infection. Handwashing is the best technique for reducing the spread of microorganisms. The clients needs must be met and that is never circumvented because the client is immunosuppressed. Maintaining adequate nourishment and assessing blood pressure are components of good nursing care; however, these actions are not as critical in relation to the problem of immunosuppression. Category of
Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.
3. Correct Answer: 2. Rationale: The reservoir bag of a partial rebreathing mask should remain partially lled during inspiration. If the bag collapses completely, the equipment may be faulty. The nurse should report this information to the respiratory therapy department. The mask has been applied properly if it covers the mouth and nose and the strap ts the head snugly. Moisture is likely to accumulate because the oxygen is humidied. This is not signicant information to report. The nurse can temporarily wipe the moisture away and reapply the mask. Category of Client Need: Physiological Integrity;
Step in the Nursing Process: Implementation.
5. Correct Answer: 3. Rationale: Respiratory infections are most commonly spread to a susceptible host through droplet transmission. There may be organisms on inadequately sterilized dental instruments, but these are more likely to transmit a bloodborne infection when a clients gums (gingiva) are traumatized during dental procedures. Generally only immunosuppressed clients acquire opportunistic infections from their own microorganisms. Category of Client
Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.
Chapter 22
1. Correct Answer: 4. Rationale: Gloves are the most important personal protective item in this situation. Nurses wear gloves whenever there is a possibility for contact with body uids or blood. Because the nurse must hold the container, the hands need protection. In addition to the gloves, it is acceptable to don any or all of the other items. To avoid being splashed or sprayed, the nurse may choose to wear a face shield and cover gown. The nurse bases the choice of additional items on his or her judgment as to the potential for contact with blood or body uid by some other means such as splashing into the eyes, nose, or mouth, or onto the uniform. Category of Client Need: Safe, Effective
Care Environment; Step in the Nursing Process: Implementation.
5. Correct Answer: 1. Rationale: Until the lung has expanded, the uid
in the water-seal chamber rises and falls with respirations, which is called tidaling. There should be 2 cm of water in the water-seal chamber at all times; if it is lower, the nurse must add water. Continuously bubbling uid is an indication that the drainage system may have a leak. Drainage from the chest is usually dark red blood. Category of Client
Need: Physiological Integrity; Step in the Nursing Process: Evaluation.
Chapter 21
1. Correct Answer: 3. Rationale: Cleaning with soap and water is one
of the best methods for reducing the transmission of microorganisms. Eating more sources of protein is a healthful measure but less specic
APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions to latex. It is unsafe to work unprotected when there is a potential for contact with blood or body uids that contain blood. Category of
Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
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if they are positively resolved, the clients rehabilitation will be delayed if he or she develops contractures and immobile joints. Category of Client Need: Physiological integrity; Step in the Nursing Process: Planning.
4. Correct Answer: 2. Rationale: Inuenza is transmitted by droplet infection. Avoiding crowded places reduces the numbers of people to whom a susceptible person is exposed. All the other suggestions are good health practices, but none is as denitive as avoiding crowds. Category of Client Need: Health Promotion/Maintenance Step in the Nursing Process: Implementation.
Chapter 23
1. Correct Answer: 2. Rationale: A Sims position is best used for procedures involving the rectum and lower gastrointestinal tract. A lithotomy position is used for cystoscopy and vaginal examination. A supine position facilitates assessment of structures on the anterior of the body. Fowlers position is used for many reasons, one of which is improving ventilation. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
4. Correct Answer: 2. Rationale: The length of time the client used the
machine provides additional documentation of the clients response to treatment. Inspecting and documenting the appearance of the wound, the drainage on the dressing, and the presence and quality of arterial pulses are important data to record; however, this information is more pertinent to general physical assessment ndings. Category of Client
Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
5. Correct Answer: 1. Rationale: A stress ECG demonstrates the extent to which the heart tolerates and responds to the additional demands placed on it during exercise. The hearts ability to continue adapting is related to the adequacy of blood supplied to the myocardium through the coronary arteries. If the client develops chest pain, dangerous cardiac rhythm changes, or signicantly elevated blood pressure, the diagnostic testing is stopped. Category of Client Need: Health Promotion/
Maintenance; Step in the Nursing Process: Implementation.
Chapter 25
1. Correct Answer: 4. Rationale: The nurse holds and supports a wet cast with the palms of the hands. Using the ngers is likely to cause indentations in the cast. The inward dents create pressure areas on the underlying tissue. After application of the cast, it dries while supported on a soft surface. A wet cast on a hard surface can become attened.
Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.
4. Correct Answer: 4. Rationale: A trochanter roll helps to prevent external rotation of the hip. It will not prevent adduction, abduction, or exion. Category of Client Need: Physiological Integrity Step in
the Nursing Process: Implementation.
2. Correct Answer: 2. Rationale: Fiberglass casts have several advantages, one of which is that they tend to weigh less than plaster casts. Fiberglass casts dry more quickly, are more durable, and are less likely to soften if they become wet. They are no less exible or less restrictive than plaster casts. The major disadvantage is that they are more expensive than casts made of plaster of Paris. Category of Client
Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.
Chapter 24
1. Correct Answer: 2. Rationale: A client performs isometric exercises by tensing and releasing muscles. They do not involve any appreciable movement of a joint. The quadriceps muscles are on the anterior of the thigh. All the other options in this item describe isotonic exercises that involve joint movement. Category of Client Need: Health Promotion/
Maintenance; Step in the Nursing Process: Evaluation.
2. Correct Answer: 3. Rationale: The long-term outcomes following a stroke often are determined by aggressive nursing efforts to maintain musculoskeletal function. Rehabilitation begins on admission with functional positioning, active and passive exercise, and early physical and occupational therapy. Managing bowel and bladder elimination will not have the same effects as the development of musculoskeletal deformities. Helping the client cope with changes in body image and grieving are appropriate nursing responsibilities. But even
3. Correct Answer: 3. Rationale: The nurse assesses circulation in an extremity by performing the blanching test to determine capillary rell time. After releasing pressure on the nailbed, the color normally returns within 2 to 3 seconds. The nurse also performs this assessment on the opposite extremity. If the capillary rell time is similar in both extremities, the cast or tissue swelling is not a factor. Asking if the cast feels heavy or palpating it to feel the temperature are not techniques for assessing circulation. Determining if there is space between the cast and the skin is not a totally reliable assessment technique. If the circulation is impaired because of compartment syndrome, there may still be room to insert a nger at the margins of the cast. Category of
Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
4. Correct Answer: 4. Rationale: Purulent drainage is sometimes referred to as pus. This drainage is a collection of uid containing white blood cells and pathogens. White blood cells indicate that the body is attempting to destroy and remove infecting microorganisms. Serous drainage is clear; it is made up of plasma or serum. Bloody drainage indicates trauma. Mucoid
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Chapter 26
1. Correct Answer: 1. Rationale: In a three-point partial weight-bearing
gait, the client advances the weaker leg and walker together. He uses his hands to support most of the weight while lifting and advancing the stronger leg. Category of Client Need: Health Promotion/
Maintenance; Step in the Nursing Process: Evaluation.
2. Correct Answer: 3. Rationale: A cane is always held on the uninvolved side. By doing so, the client can transfer or redistribute body weight from the painful joint to the hand with the cane when taking a step. Covering the top with a rubber cap, wearing supportive shoes, and maintaining good posture are all appropriate techniques when using a cane. Category of Client Need: Health Promotion/Maintenance; Step
in the Nursing Process: Evaluation.
4. Correct Answer: 1. Rationale: Once preoperative medication is given, the side rails are raised and the client is instructed to remain in bed. Elimination and oral hygiene are accomplished prior to giving the preanesthetic drugs. A narcotic makes it difcult for the client to remain alert during attempts to teach leg exercises. Category of Client
Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
3. Correct Answer: 2. Rationale: The hip of a client who has undergone a total hip replacement (arthroplasty) is maintained in a position of abduction. If the client exes the hip more than 90 or adducts the hip, the prosthetic femoral head may become dislocated. A triangular foam wedge generally is kept between the clients legs while in bed.
Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.
5. Correct Answer: 3. Rationale: A dropping blood pressure frequently suggests that the client is going into shock. A systolic pressure of 90 to 100 mm Hg indicates shock is approaching. Below 80 mm Hg, shock is present. Other signs of shock include a rapid, thready pulse; pale, cold, and clammy skin; rapid respirations; a falling body temperature; restlessness; and a decreased level of consciousness. Category
of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
4. Correct Answer: 3. Rationale: Almost immediately after surgery, the nurse encourages a client to lift up using the trapeze because the muscles that most need strengthening prior to ambulating with crutches are those in the arms, neck, shoulders, chest, and back. The client also may squeeze rubber balls and perform arm push-ups. Doing arm push-ups involves placing the palms at on the bed and raising the buttocks. Balancing between parallel bars occurs later in rehabilitation. Standing and transferring maintain strength and tone of lower leg muscles, but they are not subjected to as much physical work as the muscles in the upper body. Category of Client Need: Physiological Integrity; Step in
the Nursing Process: Planning.
Chapter 28
1. Correct Answer: 2. Rationale: An open drain relies on gravity to
remove exudates, which the dressing then absorbs. The lithotomy, recumbent, and Trendelenberg positions do not promote the collection of wound drainage near the abdominal drain. Category of
Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.
5. Correct Answer: 3. Rationale: If crutches are measured and tted appropriately, there is room for at least two ngers between the axillae and the axillary bars of the crutches. Prolonged pressure under the arm affects circulation or impairs nerve function, resulting in permanent paralysis. All of the other observations are indications that the crutch length and the position of the handgrips are correct. Category of
Client Need: Physiological Integrity; Step in the Nursing Process: Evaluation.
Chapter 27
1. Correct Answer: 4. Rationale: To reduce the potential for infection,
hair is shaved after the client is transferred from the nursing unit to the surgical department. Shaving the night before facilitates colonization of microorganisms within skin abrasions. If the skin preparation is performed on the nursing unit, it is better to do so before administering sedation and after a shower. Category of Client Need: Safe, Effective
Care Environment; Step in the Nursing Process: Planning.
4. Correct Answer: 2. Rationale: Wet-to-dry dressings provide a means for debriding the ulcerated areas of necrotic tissue. Although covering impaired skin reduces the entrance of microorganisms, absorbs drainage,
APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions and protects the skin, they are not the primary reasons for use. Category
of Client Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.
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Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
5. Correct Answer: 3. Rationale: The appearance of pink tissue indicates the formation of granulation tissue, which consists of capillaries and brous collagen that seals and nourishes the tissue. Increased drainage suggests that cellular death is continuing or the wound is infected. Relief of discomfort is a positive sign; however, some ulcers are not severely painful even in the acute stage. White or black wound margins suggest an extension of cell death. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Evaluation.
2. Correct Answer: 4. Rationale: The client should not restrict uid intake, which potentially can lead to uid imbalance. Concentrated urine also is more likely to foster renal stone formation. Inadequate uid intake does contribute to constipation, but that is not the main reason to discourage the incontinent client from limiting uid intake. Although the client is invested in achieving the desired goal, it is unsafe to encourage uid restriction as a means of reaching the expected outcome. Category of Client Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.
Chapter 29
1. Correct Answer: 4. Rationale: The distance from the nose (N) to the
earlobe (E) to the xiphoid process (X) is called the NEX measurement. It is used to determine the approximate distance to the stomach. None of the other landmarks are correct for approximating the length for nasogastric tube insertion. Category of Client Need: Safe, Effective
Care Environment; Step in the Nursing Process: Implementation.
bottom of the catheter prevents irritation to the urinary meatus and promotes drainage of urine. Lubrication is not appropriate because it interferes with maintaining the catheter in place. External catheters are similar to latex condoms; they stretch to t. Therefore, measuring the penis is unnecessary. The foreskin of an uncircumcised male is never left in a retracted position because it could have a tourniquet effect and interfere with circulation of blood to the tissue. Category of Client Need:
Physiological Integrity; Step in the Nursing Process: Implementation.
3. Correct Answer: 2. Rationale: Determining if the pH of uid aspirated from the tube is within the range of gastric pH helps to validate that the distal tip of the tube is located within the stomach. A portable x-ray is an accurate method, but the cost and unnecessary radiation exposure make it less appropriate unless the tube is a small diameter feeding tube. Liquids are never instilled until placement has been veried. Feeling for air is an unacceptable technique for determining placement. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
5. Correct Answer: 3. Rationale: When instructing a female client about collecting a clean-catch urine specimen, the nurse explains that the initial portion of the voided stream is discarded and a portion that follows is collected as the specimen. He or she instructs a female to cleanse the urethral area from front to back; males cleanse the penis using a circular motion. The specimen is collected in a sterile container. The antimicrobial agent is used for cleansing and is not mixed with the urine specimen. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
Chapter 31
1. Correct Answer: 1. Rationale: Long-term use of laxatives repeatedly subjects the bowel to artificial stimulation, causing it to become sluggish. Stool softeners are less harsh than laxatives; however, it is best to determine the cause of the constipation and treat the etiology with life-style changes rather than continue to rely on pharmaceutical interventions. Daily enemas are just as habituating as laxative abuse. Dilating the anal sphincter is not usually a technique for promoting bowel elimination. Category of Client Need: Health Promotion/
Maintenance; Step in the Nursing Process: Implementation.
5. Correct Answer: 2. Rationale: Clients with nasogastric tubes that connect to suction are generally NPO (nothing by mouth). The nurse can provide ice chips sparingly to keep a clients mouth moist but not in amounts that will cause an electrolyte imbalance. Giving water or other uids, which are subsequently removed from the stomach, is likely to dilute and deplete electrolyte levels. Category of Client Need:
Physiological Integrity; Step in the Nursing Process: Planning.
Chapter 30
1. Correct Answer: 1. Rationale: Although all the assessments are appropriate when caring for a client having problems with urinary elimination, the most important assessment in continence retraining is keeping a log of the clients pattern of urinary elimination. The nurse analyzes and uses recorded data to schedule toilet activities to initially correspond with the clients filling and emptying patterns.
3. Correct Answer: 1. Rationale: Activity promotes the movement of gas toward the anal sphincter where it can be released. Carbonated
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beverages can increase gas accumulation. Restricting food is inappropriate. It may prevent additional gas from forming, but it does not help to eliminate what is already present. Narcotic analgesics tend to slow peristalsis and contribute to the retention of stool and intestinal gas.
Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.
Chapter 33
1. Correct Answer: 3. Rationale: Tilting the head backward allows gravity and head positioning to locate and maintain the liquid nasal medication within the nasopharynx. Bending forward causes loss of medication before it can provide a therapeutic effect. None of the other prescribed positions help to distribute nasal medications where they are intended for use. Category of Client Need: Health Promotion/Maintenance;
Step in the Nursing Process: Implementation.
4. Correct Answer: 3. Rationale: Interrupting the instillation of the enema solution allows time for the bowel to adjust to the distention. Rapidly instilling the remaining solution may cause the client to lose control of elimination. Taking deep breaths or panting rather than holding the breath relieves some discomfort. To nish administering the remaining enema solution, the nurse needs to reinsert the withdrawn tip. Category of Client Need: Physiological Integrity; Step in
the Nursing Process: Implementation.
Chapter 32
1. Correct Answer: 4. Rationale: The abbreviation q.i.d. indicates that the drug must be administered four times a day. The abbreviation for once a day is q.d. The abbreviation for every other day is q.o.d. The abbreviation for three times a day is t.i.d. Category of
Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
D/H X Q = Amount to administer and accurately calculates that the amount to administer is 12 tablet. It is best if the tablet is scored to facilitate giving half of the prescribed amount, but devices can separate tablets into two portions. Generally if a 250 mg tablet of the prescribed drug is available, the pharmacist would most likely have provided that dose. There is no reason to consult the physician. The nurse may wish to use a drug reference to determine if other dosages of the drug are available, but this is not the best nursing action in this situation. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
4. Correct Answer: 1. Rationale: Liquid and ointment otic (ear) preparations are warmed to room temperature if they have been stored in a cool or cold area. Instilling cold medication into the ear is uncomfortable. Unless the dropper is grossly covered with obvious debris, it is not necessary to clean it routinely. There is no limit on the maximum volume instilled within the ear. The anatomic size of the ear canal and the prescribed dose of medication are guidelines for how much drug is administered. Category of Client Need: Physiological Integrity; Step
in the Nursing Process: Implementation.
3. Correct Answer: 2. Rationale: Asking the client to identify herself by name is the safest action. The nurse also obtains an identication bracelet and attaches it to the clients wrist as soon as possible. A confused client or one that is hearing impaired may respond, Yes, when asked if she is Anna Jones, whether that is true or not. Although a nursing assistant may know the identity of the client, the best choice is to have the client provide self-identification. Category of Client
Need: Safe, Effective Care Environment; Step in the Nursing Process: Data Collection.
Chapter 34
1. Correct Answer: 4. Rationale: The dorsogluteal site is located in the buttock. The hip is the location of the ventrogluteal site. The deltoid site is located in the arm. The vastus lateralis and rectus femoris are injection sites located in the thigh. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.
4. Correct Answer: 4. Rationale: Offering a few sips of water before administering medications helps to moisten the oral cavity and facilitates swallowing oral medications. Nurses never soften capsules by placing them in water before administration or tell the client to chew a capsule. Opening a capsule can cause the client to experience an unpleasant taste. Category of Client Need: Physiological Integrity;
Step in the Nursing Process: Implementation.
2. Correct Answer: 1. Rationale: Pointing the toes inward reduces discomfort when giving an injection into the dorsogluteal site. Tightening muscles increases discomfort. Crossing the legs or exing the knees places the client in an awkward position and does not relieve discomfort. Category of Client Need: Physiological Integrity; Step in the
Nursing Process: Implementation.
3. Correct Answer: 1. Rationale: When administering an injection using the Z-track technique, the nurse pulls the tissue laterally until it is taut. He or she holds the tissue in that position during the injection as well. The nurse does not release the position of the tissue until after
APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions withdrawing the needle. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.
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barrier against skin contact and absorption. Avoiding powdered gloves prevents inhalation of the drug on particles of powder. Handwashing is appropriate before and after contact with a client, but it is not necessary to wash hands for 5 minutes. Distancing oneself from the client is important when the client is being treated with an implanted source of radiation, not chemotherapy. It is unnecessary to wear a high efciency air lter respirator when caring for a client receiving intravenous antineoplastic drugs. Category of Client Need: Safe, Effective
Care Environment; Step in the Nursing Process: Implementation.
Chapter 36
1. Correct Answer: 3. Rationale: When assessing a cough, the nurse determines if it is productive or nonproductive. If productive, it is important to document the color, odor, amount, and viscosity of sputum raised. Other data that may aid the physician in making a diagnosis include onset, duration, contributing factors, and relief measures that apply to the clients symptoms. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.
Chapter 35
1. Correct Answer: 2. Rationale: Whenever two medications are combined, the nurse must consult a reference to determine if the two drugs or the drug and solution are compatible. Some drug-drug and drugsolution combinations will cause a physical change such as a precipitate to form. Not all drugs are diluted before administration by intravenous bolus. When instilling an intravenous medication by bolus administration, the nurse interrupts the infusing solution for seconds at a time while instilling the drug through the port. Flushing a port with normal saline is unnecessary unless there may be a drug-drug or drug-solution interaction. Category of Client Need: Physiological Integrity; Step in
the Nursing Process: Implementation.
2. Correct Answer: 1. Rationale: Increased uid intake thins respiratory secretions. Increased moisture in inspired air through humidication also helps. Changing positions improves circulation and prevents pooling of respiratory secretions. A high-protein diet contributes to tissue growth and repair. Rest relieves fatigue and activity intolerance.
Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Planning.
3. Correct Answer: 4. Rationale: Obtaining a sputum specimen is easiest when the client first awakens in the morning or following an aerosol treatment. Secretions tend to accumulate in the respiratory tract during the night. Pooled secretions are more easily raised especially if the client is not fatigued from activity. Forced coughing after a meal can lead to vomiting. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Planning.
4. Correct Answer: 3. Rationale: The vent on a suction catheter is not occluded until after the catheter is fully inserted and being withdrawn. This reduces the potential for hypoxemia. Closing the vent before insertion or when just inside the inner cannula prolongs the time during which oxygen is removed from the airway. Coughing may or may not coincide with the proper time to occlude the vent. Therefore, it is not used as a criterion for this action. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.
Chapter 37
1. Correct Answer: 1. Rationale: A person with a stroke is at high risk
for choking and aspirating a bolus of food as a result of hemiparalysis (half-sided paralysis) of the muscles that control the face, tongue, and throat. People who have had a full mouth extraction do not have impaired swallowing; they initially receive liquids and soft or pureed foods that do not require chewing. A client with a biopsy of a tongue lesion also may receive a diet with modied texture but should not have signicantly impaired ability to chew or swallow food. The term facial cosmetic surgery is vague because it does not identify specically the extent of the procedure. Nevertheless, it is unlikely that this type of surgery would interfere with chewing or swallowing. Category of
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APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions The recovery position is used when breathing and circulation have been restored. Loosening a belt is unnecessary during resuscitation attempts. A rescuer gives two rescue breaths initially then administers a sequence of 15 chest compressions followed by two breaths when performing CPR. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.
2. Correct Answer: 2. Rationale: Products manufactured in or imported to the United States on or after January 1, 1995 must comply with the Child Safety Protection Act (CSPA). Before purchasing any toy, consumers should look for and heed the age recommendations identied. The greatest danger may be with homemade stuffed animals or dolls. The child is at risk for accidental choking with any toy that has small parts or pieces that can be broken off or separated. Soft, stuffed animals or dolls with buttons or plastic eyes are not as safe as those with painted or printed features. The gel in a teething ring, which is ultimately a semi-liquid, generally is sealed securely. A 6 month old is not capable of reaching the objects on a mobile provided it is suspended at an acceptable height above a crib. A ball less than 1 34 inches is a safety risk for a child younger than 3 years, but one that is 5 inches in diameter is generally safe. Category of Client Need: Health Promotion/Maintenance;
Step in the Nursing Process: Implementation.
Chapter 38
1. Correct Answer: 3. Rationale: Spontaneous breathing is related to
a functioning brain stem. Brain death is based on evidence that the whole brain including the brain stem is no longer functioning. Unresponsiveness is not the most conclusive criterion, although it supports the cluster of data suggesting neurological dysfunction. A client with a urine output less than 100 mL/24 hours is anuric, but the clients brain may not be permanently affected. Bilateral dilated pupils are more ominous than unequal pupils are. Category of Client Need: Physiological
Integrity; Step in the Nursing Process: Data Collection.