Topic included related to nursing concept.
1. A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:
A. Depression and suicidal ideation
B. Tachycardia and diarrhea
C. Muscle cramping and abdominal pain
D. Tachycardia and euphoric mood
2. During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
A. Right breech presentation
B. Right occiput anterior presentation
C. Left sacral anterior presentation
D. Left occipital transverse presentation
3. The primary physiological alteration in the development of asthma is:
A. Bronchiolar inflammation and dyspnea
B. Hypersecretion of abnormally viscous mucus
C. Infectious processes causing mucosal edema
D. Spasm of bronchial smooth muscle
4. A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
A. Serve high-calorie foods she can carry with her
B. Encourage her appetite by sending out for her favorite foods
C. Serve her small, attractively arranged portions
D. Allow her in the unit kitchen for extra food whenever she pleases
5. To maintain Bryant’s traction, the nurse must make certain that the child’s:
A. Hips are resting on the bed, with the legs suspended at a right angle to the bed
B. Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
C. Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed
D. Hips and legs are flat on the bed, with the traction positioned at the foot of the bed
6. Which action by the nurse indicates understanding of herpes zoster?
A. The nurse covers the lesions with a sterile dressing.
B. The nurse wears gloves when providing care.
C. The nurse administers a prescribed antibiotic.
D. The nurse administers oxygen.
7. The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab for them to collect the blood:
A. 15 minutes after the infusion
B. 30 minutes before the infusion
C. 1 hour after the infusion
D. 2 hours after the infusion
8. The client using a diaphragm should be instructed to:
A. Refrain from keeping the diaphragm in longer than 4 hours
B. Keep the diaphragm in a cool location
C. Have the diaphragm resized if she gains 5 pounds
D. Have the diaphragm resized if she has any surgery
9. The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client’s statements indicates the need for additional teaching?
A. “I’m wearing a support bra.”
B. “I’m expressing milk from my breast.”
C. “I’m drinking four glasses of fluid during a 24-hour period.”
D. “While I’m in the shower, I’ll allow the water to run over my breasts.”
10. Damage to the VII cranial nerve results in:
A. Facial pain
B. Absence of ability to smell
C. Absence of eye movement
11. A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication may:
A. Cause diarrhea
B. Change the color of her urine
C. Cause mental confusion
D. Cause changes in taste
12. Which of the following tests should be performed before beginning a prescription of Accutane?
A. Check the calcium level
B. Perform a pregnancy test
C. Monitor apical pulse
D. Obtain a creatinine level
13. A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
A. Limit the client’s activity
B. Encourage a high-carbohydrate diet
C. Utilize an incentive spirometer to improve respiratory function
D. Encourage fluids
14. A client is admitted for an MRI. The nurse should question the client regarding:
B. A titanium hip replacement
C. Allergies to antibiotics
D. Inability to move his feet
15. The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?
A. Changes in vision
C. Urinary frequency
D. Changes in skin color
16. The nurse should visit which of the following clients first?
A. The client with diabetes with a blood glucose of 95mg/dL
B. The client with hypertension being maintained on Lisinopril
C. The client with chest pain and a history of angina
D. The client with Raynaud’s disease
17. A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:
A. Once per day in the morning
B. Three times per day with meals
C. Once per day at bedtime
D. Four times per day
18. Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?
A. The lens controls stimulation of the retina.
B. The lens orchestrates eye movement.
C. The lens focuses light rays on the retina.
D. The lens magnifies small objects.
19. A client who has glaucoma is to have miotic eye drops instilled in both eyes. The nurse knows that the purpose of the medication is to:
A. Anesthetize the cornea
B. Dilate the pupils
C. Constrict the pupils
D. Paralyze the muscles of accommodation
20. A client with a severe corneal ulcer has an order for Gentamycin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?
A. Allow 5 minutes between the two medications.
B. The medications may be used together.
C. The medications should be separated by a cycloplegic drug.
D. The medications should not be used in the same client.
21. The client with color blindness will most likely have problems distinguishing which of the following colors?
22. The client with a pacemaker should be taught to:
A. Report ankle edema
B. Check his blood pressure daily
C. Refrain from using a microwave oven
D. Monitor his pulse rate
23. The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:
24. Which of the following diet instructions should be given to the client with recurring urinary tract infections?
A. Increase intake of meats.
B. Avoid citrus fruits.
C. Perform pericare with hydrogen peroxide.
D. Drink a glass of cranberry juice every day.
25. The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
A. “I will make sure I eat breakfast within 2 hours of taking my insulin.”
B. “I will need to carry candy or some form of sugar with me all the time.”
C. “I will eat a snack around three o’clock each afternoon.”
D. “I can save my dessert from supper for a bedtime snack.”
26. The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?
A. The tube will allow for equalization of the lung expansion.
B. Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.
C. Chest tubes relieve pain associated with a collapsed lung.
D. Chest tubes assist with cardiac function by stabilizing lung expansion.
27. A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:
A. Mother’s educational level
B. Infant’s birth weight
C. Size of the mother’s breast
D. Mother’s desire to breastfeed
28. The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
A. The presence of scant bloody discharge
B. Frequent urination
C. The presence of green-tinged amniotic fluid
D. Moderate uterine contractions
29. The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions?
A. Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.
B. Duration is measured by timing from the end of one contraction to the beginning of the next contraction.
C. Duration is measured by timing from the beginning of one contraction to the end of the same contraction.
D. Duration is measured by timing from the peak of one contraction to the end of the same contraction.
30. The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
A. Maternal hypoglycemia
B. Fetal bradycardia
C. Maternal hyperreflexia
D. Fetal movement
31. A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?
A. Insulin requirements moderate as the pregnancy progresses.
B. A decreased need for insulin occurs during the second trimester.
C. Elevations in human chorionic gonadotrophin decrease the need for insulin.
D. Fetal development depends on adequate insulin regulation.
32. A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
A. Providing a calm environment
B. Obtaining a diet history
C. Administering an analgesic
D. Assessing fetal heart tones
33. A primigravida, age 42, is 6 weeks pregnant. Based on the client’s age, her infant is at risk for:
A. Down syndrome
B. Respiratory distress syndrome
C. Turner’s syndrome
D. Pathological jaundice
34. A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
A. Magnesium sulfate
B. Calcium gluconate
C. Dinoprostone (Prostin E.)
D. Bromocriptine (Parlodel)
35. A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:
A. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure
B. Stop the infusion of magnesium sulfate and contact the physician
C. Slow the infusion rate and turn the client on her left side
D. Administer calcium gluconate IV push and continue to monitor the blood pressure
36. Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?
A. An affected newborn has unaffected parents.
B. An affected newborn has one affected parent.
C. Affected parents have a one in four chance of passing on the defective gene.
D. Affected parents have unaffected children who are carriers.
37. A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:
A. Because it is a state law
B. To detect cardiovascular defects
C. Because of her age
D. To detect neurological defects
38. A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that:
A. There is no need to take thyroid medication because the fetus’s thyroid produces a thyroid-stimulating hormone.
B. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.
C. It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism.
D. Fetal growth is arrested if thyroid medication is continued during pregnancy.
39. The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse could expect to find:
A. An apical pulse of 100
B. An absence of tonus
C. Cyanosis of the feet and hands
D. Jaundice of the skin and sclera
40. A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for:
A. Supplemental oxygen
B. Fluid restriction
C. Blood transfusion
D. Delivery by Caesarean section
41. A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:
A. Increasing fluid intake
B. Limiting ambulation
C. Administering an enema
D. Withholding food for 8 hours
42. An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year?
A. 14 pounds
B. 16 pounds
C. 18 pounds
D. 24 pounds
43. A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:
A. Determines the lung maturity of the fetus
B. Measures the activity of the fetus
C. Shows the effect of contractions on the fetal heart rate
D. Measures the neurological well-being of the fetus
44. A full-term male has hypospadias. Which statement describes hypospadias?
A. The urethral opening is absent.
B. The urethra opens on the dorsal side of the penis.
C. The penis is shorter than usual.
D. The urethral meatus opens on the underside of the penis.
45. A gravida 3 para 2 is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
A. Alteration in coping related to pain
B. Potential for injury related to precipitate delivery
C. Alteration in elimination related to anesthesia
D. Potential for fluid volume deficit related to NPO status
46. The client with varicella will most likely have an order for which category of medication?
47. A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?
48. Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?
A. Avoid exercise because it fatigues the joints.
B. Take prescribed anti-inflammatory medications with meals.
C. Alternate hot and cold packs to affected joints.
D. Avoid weight-bearing activity.
49. A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?
A. Meperidine 100 mg IM q 4 hours PRN pain
B. Mylanta 30 ccs q 4 hours via NG
C. Cimetidine 300 mg PO q.i.d.
D. Morphine 8 mg IM q 4 hours PRN pain
50. The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
A. Hallucinogenic drugs create both stimulant and depressant effects.
B. Hallucinogenic drugs induce a state of altered perception.
C. Hallucinogenic drugs produce severe respiratory depression.
D. Hallucinogenic drugs induce rapid physical dependence.
Answers and Rationale
1. Answer: B. Tachycardia and diarrhea.Barbiturates create a sedative effect. When the client stops taking barbiturates, he will experience tachycardia, diarrhea, and tachypnea. Answer A is incorrect even though depression and suicidal ideation go along with barbiturate use; it is not the priority. Muscle cramps and abdominal pain are vague symptoms that could be associated with other problems. Tachycardia is associated with stopping barbiturates, but euphoria is not.
2. Answer: A. Right breech presentation. If the fetal heart tones are heard in the right upper abdomen, the infant is in a breech presentation. If the infant is positioned in the right occiput anterior presentation, the FHTs will be located in the right lower quadrant, so answer B is incorrect. If the fetus is in the sacral position, the FHTs will be located in the center of the abdomen, so answer C is incorrect. If the FHTs are heard in the left lower abdomen, the infant is most likely in the left occiput transverse position, making answer D incorrect.
3. Answer: D. Spasm of bronchial smooth muscle. Asthma is the presence of bronchial spasms. This spasm can be brought on by allergies or anxiety. Answer A is incorrect because the primary physiological alteration is not inflammation. Answer B is incorrect because there is the production of abnormally viscous mucus, not a primary alteration. Answer C is incorrect because infection is not primary to asthma.
4. Answer: A. Serve high-calorie foods she can carry with her. The client with mania is seldom sitting long enough to eat and burns many calories for energy. Answer B is incorrect because the client should be treated the same as other clients. Small meals are not a correct option for this client. Allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed, so answer D is incorrect.
5. Answer: B. Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
Bryant’s traction is used for fractured femurs and dislocated hips. The hips should be elevated 15° off the bed. Answer A is incorrect because the hips should not be resting on the bed. Answer C is incorrect because the hips should not be above the level of the body. Answer D is incorrect because the hips and legs should not be flat on the bed.
6. Answer: B. The nurse wears gloves when providing care. Herpes zoster is shingles. Clients with shingles should be placed in contact precautions. Wearing gloves during care will prevent transmission of the virus. Covering the lesions with a sterile gauze is not necessary, antibiotics are not prescribed for herpes zoster, and oxygen is not necessary for shingles; therefore, answers A, C, and D are incorrect.
7. Answer: B. 30 minutes before the infusion. A trough level should be drawn 30 minutes before the third or fourth dose. The times in answers A, C, and D are incorrect times to draw blood levels.
8. Answer: B. Keep the diaphragm in a cool location The client using a diaphragm should keep the diaphragm in a cool location. Answers A, C, and D are incorrect. She should refrain from leaving the diaphragm in longer than 8 hours, not 4 hours. She should have the diaphragm resized when she gains or loses 10 pounds or has abdominal surgery.
9. Answer: C. “I’m drinking four glasses of fluid during a 24-hour period.” Mothers who plan to breastfeed should drink plenty of liquids, and four glasses is not enough in a 24-hour period. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle-feed, so answer A is incorrect. Expressing milk from the breast will stimulate milk production, making answer B incorrect. Allowing the water to run over the breast will also facilitate “letdown,” when the milk begins to be produced; thus, answer D is incorrect.
10. Answer: A. Facial pain. The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. The auditory nerve is responsible for hearing loss and tinnitus, eye movement is controlled by the Trochlear or C IV, and the olfactory nerve controls smell; therefore, answers B, C, and D are incorrect.
11. Answer: B. Change the color of her urine. Clients taking Pyridium should be taught that the medication will turn the urine orange or red. It is not associated with diarrhea, mental confusion, or changes in taste; therefore, answers A, C, and D are incorrect. Pyridium can also cause a yellowish color to skin and sclera if taken in large doses.
12. Answer: B. Perform a pregnancy test. Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. Calcium levels, apical pulse, and creatinine levels are not necessary; therefore, answers A, C, and D are incorrect.
13. Answer: D. Encourage fluids. Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. Limiting activity is not necessary, nor is eating a high-carbohydrate diet. Use of an incentive spirometer is not specific to clients taking Acyclovir; therefore, answers A, B, and C are incorrect.
14. Answer: A. Pregnancy. Although there are no evidence to suggest MRI scans can pose a risk during pregnancy, it is considered precaution to not perform MRI during pregnancy, particularly in the first three months. This is particularly the case during the first trimester of pregnancy, as organogenesis takes place during this period. The concerns in pregnancy are the same as for MRI in general, but the fetus may be more sensitive to the effects—particularly to heating and to noise. Clients with a titanium hip replacement can have an MRI. No antibiotics are used with this test and the client should remain still only when instructed, so answers C and D are not specific to this test.
15. Answer: D. Changes in skin color. Clients taking Amphotericin B should be monitored for liver, renal, and bone marrow function because this drug is toxic to the kidneys and liver, and causes bone marrow suppression. Jaundice is a sign of liver toxicity and is not specific to the use of Amphotericin B. Changes in vision are not related, and nausea is a side effect, not a sign of toxicity; nor is urinary frequency. Thus, answers A, B, and C are incorrect.
16. Answer: C. The client with chest pain and a history of angina.The client with chest pain should be seen first because this could indicate a myocardial infarction. The client in answer A has a blood glucose within normal limits. The client in answer B is maintained on blood pressure medication. The client in answer D is in no distress.
17. Answer: B. Three times per day with meals. Pancreatic enzymes should be given with meals for optimal effects. These enzymes assist the body in digesting needed nutrients. Answers A, C, and D are incorrect methods of administering pancreatic enzymes.
18. Answer: C. The lens focuses light rays on the retina. The lens allows light to pass through the pupil and focus light on the retina. The lens does not stimulate the retina, assist with eye movement, or magnify small objects, so answers A, B, and D are incorrect.
19. Answer: C. Constrict the pupils Miotic eye drops constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm. They do not anesthetize the cornea, dilate the pupil, or paralyze the muscles of the eye, making answers A, B, and D incorrect.
20. Answer: A. Allow 5 minutes between the two medications. When using eyedrops, allow 5 minutes between the two medications; therefore, answer B is incorrect. These medications can be used by the same client but it is not necessary to use a cycloplegic with these medications, making answers C and D incorrect.
21. Answer: B. Violet. Clients with color blindness will most likely have problems distinguishing violets, blues, and green. The colors in answers A, C, and D are less commonly affected.
22. Answer: D. Monitor his pulse rate.The client with a pacemaker should be taught to count and record his pulse rate. Answers A, B, and C are incorrect. Ankle edema is a sign of right-sided congestive heart failure. Although this is not normal, it is often present in clients with heart disease. If the edema is present in the hands and face, it should be reported. Checking the blood pressure daily is not necessary for these clients. The client with a pacemaker can use a microwave oven, but he should stand about 5 feet from the oven while it is operating.
23. Answer: A. 1900. Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m., or 1 The times in answers B, C, and D are too early in the day.
24. Answer: D. Drink a glass of cranberry juice every day..Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria does not grow freely in acidic urine. Increasing intake of meats is not associated with urinary tract infections, so answer A is incorrect. The client does not have to avoid citrus fruits and peri care should be done, but hydrogen peroxide is drying, so answers B and C are incorrect.
25. Answer: C. “I will eat a snack around three o’clock each afternoon.” NPH insulin peaks in 8–12 hours, so a snack should be offered at that time. NPH insulin onsets in 90–120 minutes, so answer A is incorrect. Answer B is untrue because NPH insulin is time released and does not usually cause sudden hypoglycemia. Answer D is incorrect, but the client should eat a bedtime snack.
26. Answer: B. Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.Chest tubes work to reinflate the lung and drain serous fluid. The tube does not equalize expansion of the lungs. Pain is associated with collapse of the lung, and insertion of chest tubes is painful, so answers A and C are incorrect. Answer D is true, but this is not the primary rationale for performing chest tube insertion.
27. Answer: D. Mother’s desire to breastfeed. Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level, the infant’s birth weight, and the size of the mother’s breast have nothing to do with success, so answers A, B, and C are incorrect.
28. Answer: C. The presence of green-tinged amniotic fluid. Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. The presence of scant bloody discharge is normal, as are frequent urination and moderate uterine contractions, making answers A, B, and D incorrect.
29. Answer: C. Duration is measured by timing from the beginning of one contraction to the end of the same contraction. Duration is measured from the beginning of one contraction to the end of the same contraction. Answer A refers to frequency. Answer B is incorrect because we do not measure from the end of one contraction to the beginning of the next contraction. Duration is not measured from the peak of the contraction to the end, as stated in D.
30. Answer: B. Fetal bradycardia. The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia, maternal hyperreflexia, or fetal movement; therefore, answers A, C, and D are incorrect.
31. Answer: D. Fetal development depends on adequate insulin regulation.Fetal development depends on adequate nutrition and insulin regulation. Insulin needs increase during the second and third trimesters, insulin requirements do not moderate as the pregnancy progresses, and elevated human chorionic gonadotrophin elevates insulin needs, not decreases them; therefore, answers A, B, and C are incorrect.
32. Answer: A. Providing a calm environment. A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures. Obtaining a diet history should be done later, and administering an analgesic is not indicated because there is no data in the stem to indicate pain. Therefore, answers B and C are incorrect. Assessing the fetal heart tones is important, but this is not the highest priority in this situation as stated in answer D.
33. Answer: A. Down syndrome. The client who is age 42 is at risk for fetal anomalies such as Down syndrome and other chromosomal aberrations. Answers B, C, and D are incorrect because the client is not at higher risk for respiratory distress syndrome or pathological jaundice, and Turner’s syndrome is a genetic disorder.
34. Answer: C. Dinoprostone (Prostin E.)The client with a missed abortion will have induction of labor. Prostin E. is a form of prostaglandin used to soften the cervix. Magnesium sulfate is used for preterm labor and preeclampsia, calcium gluconate is the antidote for magnesium sulfate, and Pardel is a dopamine receptor stimulant used to treat Parkinson’s disease; therefore, answers A, B, and D are incorrect. Pardel was used at one time to dry breast milk.
35. Answer: A. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure. The client’s blood pressure and urinary output are within normal limits. The only alteration from normal is the decreased deep tendon reflexes. The nurse should continue to monitor the blood pressure and check the magnesium level. The therapeutic level is 4.8–9.6mg/dL. Answers B, C, and D are incorrect. There is no need to stop the infusion at this time or slow the rate. Calcium gluconate is the antidote for magnesium sulfate, but there is no data to indicate toxicity.
36. Answer: C. Affected parents have a one in four chance of passing on the defective gene. Autosomal recessive disorders can be passed from the parents to the infant. If both parents pass the trait, the child will get two abnormal genes and the disease results. Parents can also pass the trait to the infant. Answer A is incorrect because, to have an affected newborn, the parents must be carriers. Answer B is incorrect because both parents must be carriers. Answer D is incorrect because the parents might have affected children.
37. Answer: D. To detect neurological defects. Alpha fetoprotein is a screening test done to detect neural tube defects such as spina bifida. The test is not mandatory, as stated in answer A. It does not indicate cardiovascular defects, and the mother’s age has no bearing on the need for the test, so answers B and C are incorrect.
38. Answer: B. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy. During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. Answer A is incorrect because there could be a need for thyroid medication during pregnancy. Answer C is incorrect because the thyroid function does not slow. Fetal growth is not arrested if thyroid medication is continued, so answer D is incorrect.
39. Answer: C. Cyanosis of the feet and hands. Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. An apical pulse should be 120–160, and the baby should have muscle tone, making answers A and B incorrect. Jaundice immediately after birth is pathological jaundice and is abnormal, so answer D is incorrect.
40. Answer: A. Supplemental oxygen. Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief. Fluids are increased, not decreased. Blood transfusions are usually not required, and the client can be delivered vaginally; thus, answers B, C, and D are incorrect.
41. Answer: A. Increasing fluid intake. Before ultrasonography, the client should be taught to drink plenty of fluids and not void. The client may ambulate, an enema is not needed, and there is no need to withhold food for 8 hours. Therefore, answers B, C, and D are incorrect.
42. Answer: D. 24 pounds .By 1 year of age, the infant is expected to triple his birth weight. Answers A, B, and C are incorrect because they are too low.
43. Answer: B. Measures the activity of the fetus. A nonstress test is done to evaluate periodic movement of the fetus. It is not done to evaluate lung maturity as in answer A. An oxytocin challenge test shows the effect of contractions on fetal heart rate and a nonstress test does not measure neurological well-being of the fetus, so answers C and D are incorrect.
44. Answer: D. The urethral meatus opens on the underside of the penis. Hypospadias is a congenital abnormality in which the urethral meatus is on the underside of the penis.
45. Answer: A. Alteration in coping related to pain. Transition is the time during labor when the client loses concentration due to intense contractions. Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is incorrect. There is no data to indicate that the client has had anesthesia or fluid volume deficit, making answers C and D incorrect.
46. Answer: C. Antivirals. Varicella is chicken pox. This herpes virus is treated with antiviral medications. The client is not treated with antibiotics or anticoagulants as stated in answers A and D. The client might have a fever before the rash appears, but when the rash appears, the temperature is usually gone, so answer B is incorrect.
47. Answer: B. Ampicillin. Clients with chest pain can be treated with nitroglycerin, a beta blocker such as propranolol, or Verapamil. There is no indication for an antibiotic such as Ampicillin, so answers A, C, and D are incorrect.
48. Answer: B. Take prescribed anti-inflammatory medications with meals. Anti-inflammatory drugs should be taken with meals to avoid stomach upset. Answers A, C, and D are incorrect. Clients with rheumatoid arthritis should exercise, but not to the point of pain. Alternating hot and cold is not necessary, especially because warm, moist soaks are more useful in decreasing pain. Weight-bearing activities such as walking are useful but is not the best answer for the stem.
49. Answer: D. Morphine 8 mg IM q 4 hours PRN pain. Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphincter of Oddi. Meperidine, Mylanta, and Cimetidine are ordered for pancreatitis, making answers A, B, and C incorrect.
50. Answer: B. Hallucinogenic drugs induce a state of altered perception.Hallucinogenic drugs can cause hallucinations. Continuous observation is ordered to prevent the client from harming himself during withdrawal. Answers A, C, and D are incorrect because hallucinogenic drugs don’t create both stimulant and depressant effects or produce severe respiratory depression. However, they do produce psychological dependence rather than physical dependence.