NCLEX-RN Quiz Part 7 (301-375)

NO.301 A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:

A.            Demand that she relax

B.            Ask what is the problem

C.            Stand or sit next to her

D.            Give her something to do

NO.302 A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated 5 cm, effaced 85%, and the fetus's head is at 0 station. She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects:

A.            Hypertension

B.            Hypotension

C.            Hypoglycemia

D.            Hyperglycemia Answer: B Explanation:

NO.303 A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:

A.            Potassium-rich foods

B.            Tryptophan

C.            Tyramine

D.            Saturated fats Answer: C Explanation:

NO.304 A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at:

A. 9:30 AM

B. 10:30 AM

C. 12 noon

D. 4:00 PM

NO.305 A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect:

A.            Compensated respiratory acidosis

B.            Normal blood gases

C.            Uncompensated metabolic acidosis

D.            Uncompensated respiratory acidosis

NO.306 As a nurse works with an adolescent with cystic fibrosis, the nurse begins to notice that he appears depressed and talks about suicide and feelings of worthlessness. This is an important factor to consider in planning for his care because:

A.            It may be a bid for attention and an indication that more diversionary activity should be planned for him

B.            No threat of suicide should be ignored or challenged in any way

C.            He needs to be observed carefully for signs that his depression has been relieved

D.            He needs to be confronted with his feelings and forced to work through them

NO.307 As a postoperative cholecystectomy client completes tomorrow's dinner menu, the nurse knows that one of the following meal choices will best provide the essential vitamin(s) necessary for proper tissue healing?

A.            Liver, white rice, spinach, tossed salad, custard pudding

B.            Fish fillet, carrots, mashed potatoes, butterscotch pudding

C.            Roast chicken, gelatin with sliced fruit

D.            Chicken breast fillet in tomato sauce, potatoes, mustard greens, orange and strawberry slices

NO.308 A 64-year-old client is admitted to the hospital with benign prostatic hypertrophy (BPH). He has a history of adult-onset diabetes and hypertension and is scheduled to undergo a resection of the prostate. When recording his health history, the nurse asks about his chief complaint. The most serious symptom that may accompany BPH is:

A.            Acute urinary retention

B.            Hesitancy in starting urination

C.            Increased frequency of urination

D.            Decreased force of the urinary stream

NO.309 A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2

hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to:

A.            Provide cathartic action within the colon

B.            Reduce the risk of wound infection from anaerobic bacteria

C.            Relieve the client's concern regarding possible infection

D.            Reduce the risk of intraoperative fever

NO.310 A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse's first action would be to:

A.            Call the physician immediately and give dopamine IM

B.            Turn her on her left side and recheck her blood pressure in 5 minutes

C.            Administer oxytocin (Pitocin) immediately and increase the rate of IV fluids

D.            Increase the rate of IV fluids and start O2 by mask

NO.311 A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would:

A.            Discuss the disease process and the importance of the medication in prevention of symptoms.

B.            Inform the client that additional side effects are to be expected and need not be reported.

C.            Discuss the importance of getting blood drawn weekly to determine medication therapeutics.

D.            Inform the client to cease taking the medication when all psychotic symptoms have cleared.

NO.312 A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.

What tests should the nurse anticipate?

A.            Reticulocyte count, creatinine phosphokinase (CPK)

B.            Aspartate transaminase, alanine transaminase

C.            Sedimentation rate, WBC count

D.            Lactic dehydrogenase, CPK

NO.313 In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:

A.            Explain the side effects of the medication

B.            Discuss the danger of overmedication

C.            Distribute written material to supplement verbal instructions

D.            Explore the client's perception regarding medication therapy

NO.314 A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:

A.            Place her under the radiant warmer

B.            Dry her with blankets

C.            Place her to her mother's breast

D.            Place her on a heated pad

NO.315 Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder?

A.            Playing cards with other clients

B.            Working crossword puzzles

C.            Playing tennis with a staff member

D.            Sewing beads on a leather belt

NO.316 A postoperative prostatectomy client is preparing for discharge from the hospital the next morning. The nurse realizes that additional instructions are necessary when he states:

A.            "If I drink 10 to 12 glasses of fluids each day, that will help to prevent any clot formation in my urine."

B.            "The isometric exercises will help to strengthen my perineal muscles and help me control my urine."

C.            "If I feel as though I have developed a fever, I will take a rectal temperature, which is the most accurate."

D.            "I do not plan to do any heavy lifting until I visit my doctor again."

NO.317 After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following:

A.            Cold stress

B.            Cyanosis

C.            Respiratory distress syndrome

D.            Seizures

NO.318 Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20 years old. It is characterized by an absence of, or marked decrease in, circulating insulin. When teaching a newly diagnosed diabetes client, the nurse includes information on the functions of insulin:

A.            Transport of glucose into body cells and storage of glycogen in the liver

B.            Glycogenolysis and facilitation of glucose use for energy

C.            Glycogenolysis and catabolism

D.            Catabolism and hyperglycemia

NO.319 A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner describes the limp as a "Trendelenburg gait." This gait is characteristic of:

A.            Scoliosis

B.            Dislocated hip

C.            Fractured femur

D.            Fractured pelvis

NO.320 Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is:

A.            70 mg/dL and 120 mg/dL

B.            100 mg/dL and 200 mg/dL

C.            40 mg/dL and 130 mg/dL

D.            90 mg/dL and 200 mg/dL

NO.321 A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:

A.            Tell the physician her concerns

B.            Report her suspicions to the authorities

C.            Talk to the child's father

D.            Confront the child's mother

NO.322 An 18-month-old child has been playing in the garage. His mother brings him to a nurse's home complaining of his mouth being sore. His lips and mouth are soapy and white, with small ulcerated areas beginning to form. The child begins to vomit. His pulse is rapid and weak. The nurse suspects that the child has:

A.            Inhaled gasoline fumes

 B.           Ingested a caustic alkali

C.            Eaten construction chalk

D.            Lead poisoning

NO.323 Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should:

A.            Check airway, feeling for amount of air exchange noting rate, depth, and quality of respirations

B.            Obtain pulse and blood pressure readings noting rate and quality of pulse

C.            Reassure the client that his surgery is over and that he is in the recovery room

D.            Review physician's orders, administering medications as ordered

NO.324 A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the client is:

A.            Having a heart attack

B.            Wanting attention from the nurses

C.            Suffering from complete upper airway obstruction

D.            Hyperventilating

NO.325 The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure?

A.            "Some say this feels like a pinch or a bug bite. You tell me what it feels like."

B.            "This is going to hurt a lot; close your eyes and hold my hand."

C.            "This is a terrible procedure, so don't look."

D.            "This will hurt only a little; try to be a big boy."

NO.326 A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, "I can't stay still at night. I toss and turn and can't fall asleep." The nurse suspects that she may be experiencing:

A.            Akathisia

B.            Akinesia

C.            Dystonia

D.            Opisthotonos

NO.327 A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:

A.            Warmed solution helps keep the body temperature maintained within a normal range during instillation

B.            Warmed solution helps dilate the peritoneal blood vessels

 C.           Warmed solution decreases the risk of peritoneal infection

D.            Warmed solution promotes a relaxed abdominal muscle

NO.328 The nurse would expect to include which of the following when planning the management of the client with Lyme disease?

A.            Complete bed rest for 6-8 weeks

B.            Tetracycline treatment

C.            IV amphotericin B

D.            High-protein diet with limited fluids

NO.329 A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?

A.            Head of bed elevated 30 degrees on nonoperative side

B.            Head of bed elevated 30 degrees on operative side

C.            Bed flat on operative side

D.            Bed flat on nonoperative side

NO.330 A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:

A.            "I don't see your mother in the room. Let's talk about how you're feeling."

B.            "OK, I'll come back later when you're feeling more like taking your medicine."

 

C.            "She may be here, but I can't see her."

D.            "Why don't you finish talking to her, and I'll wait."

NO.331 A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:

A.            Oxytocin

B.            Magnesium sulfate (MgSO4)

C.            Ampicillin

D.            Tetracycline

NO.332 A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to:

A.            Respiratory acidosis

B.            Respiratory alkalosis

C.            Metabolic acidosis

D.            Metabolic alkalosis

NO.333 The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:

A.            Prolonged bed rest

 B.           The client's maintaining a semi-Fowler position

C.            Cerebral hypoxia

D.            IV fluids of 2.5-3 liters in 24 hours

NO.334 A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing response is to:

A.            Administer methergine IM

B.            Remove the retained placental fragments

C.            Assist the client to the bathroom and provide cues to stimulate urination

D.            Massage the fundus until firm

NO.335 The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:

A.            Infected

B.            Not healing

C.            Necrotic

D.            Healing

NO.336 A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, "I just couldn't take it anymore." The nurse's best response to this disclosure would be:

A.            "You shouldn't do things like that, just tell someone you feel bad."

B.            "Tell me more about what you couldn't take anymore."

C.            "I'm sure you probably didn't mean to kill yourself."

D.            "How long have you been in the hospital."

NO.337 A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?

A.            High fever, tachycardia, stupor, renal failure

B.            Lip smacking, chewing, blinking, lateral jaw movements

C.            Photosensitivity, orthostatic hypotension, dry mouth

D.            Constipation, blurred vision, drowsiness

NO.338 A client has developed congestive heart failure secondary to his myocardial infarction. Discharge diet instructions should emphasize the reduction or avoidance of:

A.            Fresh vegetables and fruit

B.            Canned vegetables and fruit

C.            Breads, cereals, and rice

D.            Fish

NO.339 Which of the following nursing actions is essential to prevent drug-resistant tuberculosis?

A.            Monitor liver function.

B.            Monitor renal function.

C.            Assess knowledge of respiratory isolation.

D.            Monitor compliance with drug therapy.

NO.340 A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the "tension-building phase," the nurse might expect the client to describe which of the following?

A.            Promises of gifts that her husband made to her

B.            Acute battering of the client, characterized by his volatile discharge of tension

C.            Minor battering incidents, such as the throwing of food or dishes at her

D.            A period of tenderness between the couple

NO.341 During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:

A.            Dyskinesia

B.            Akathisia

C.            Echopraxia

D.            Echolalia

NO.342 The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms:

A.            Fever, runny nose, and hyperactivity

B.            Changes in breathing pattern, moodiness, fatigue, and edema of eyes

C.            Fatigue, dark circles under the eyes, changes in breathing pattern, glassy eyes, and moodiness

D.            Fever, cough, paleness, and wheezing

NO.343 A post-lung surgery client is placed on a chest tube drainage system. When explaining to the family how the system works, the nurse states that the water-seal bottle of a three-bottle chest drainage system serves which of the following purposes?

A.            Collection bottle for drainage

B.            Pressure regulator

C.            Preventing accumulation of blood around the heart

D.            Preventing air from entering the chest upon inspiration

NO.344 A client delivered a stillborn male at term. An appropriate action of the nurse would be to:

A.            State, "You have an angel in heaven."

 B.           Discourage the parents from seeing the baby.

C.            Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time.

D.            Reassure the parents that they can have other children.

NO.345 On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:

A.            Gently massage the uterus until firm, express any clots, and note the amount and character of lochia

B.            Catheterize the client and reassess the uterus

C.            Begin IV fluids and administer oxytocic medication

D.            Administer analgesics as ordered to relieve discomfort

NO.346 A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?

A.            Books with colorful pictures

B.            Music

C.            Riding toys

D.            Puppets

NO.347 A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, "I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?'' The RN could suggest which one of the following?

A.            Push-ups

B.            Jumping jacks

C.            Leg lifts

D.            Kegel exercises

NO.348 A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication:

A.            Dissolves any clots already formed in the arteries

B.            Prevents the conversion of prothrombin to thrombin

C.            Interferes with the synthesis of vitamin K-dependent clotting factors

D.            Stimulates the manufacturing of platelets

NO.349 An 8-year-old child comes to the physician's office complaining of swelling and pain in the knees. His mother says, "The swelling occurred for no reason, and it keeps getting worse." The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history?

A.            A decreased urinary output and flank pain

B.            A fever of over 103F occurring over the last 2-3 weeks

C.            Rashes covering the palms of the hands and the soles of the feet

D.            Headaches, malaise, or sore throat

NO.350 A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?

A.            Always allow the most vocal person to state the problem first.

B.            Encourage the mother to speak for the children.

C.            Interpret immediately what seems to be going on within the family.

D.            Allow family members to assume the seats as they choose.

NO.351 A client has been diagnosed with thrombophlebitis. She asks, "What is the most likely cause of thrombophlebitis during my pregnancy?" The nurse explains:

A.            Increased levels of the coagulation factors and a decrease in fibrinolysis

B.            An inadequate production of platelets

C.            An inadequate intake of folic acid during pregnancy

D.            An increase in fibrinolysis and a decrease in coagulation factors

NO.352 Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?

A.            Increased PaCO2

B.            Decreased PaO2

C.            Increased HCO3

D.            Decreased base excess

NO.353 A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion:

A.            The risks of exposure of the visitor to infectious organisms is great.

B.            Hospital regulations mandate that everyone in the facility adhere to appropriate codes.

C.            The client is at extreme risk of acquiring infections.

D.            Adherence to the guidelines are the latest Centers for Disease Control and Prevention recommendations on use of protective apparel.

NO.354 A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that:

A.            Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices

B.            Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods

C.            It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily

D.            He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds. Milk intake should be limited to 1 qt/day

NO.355 A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to

other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?

A.            "I understand you're depressed, but killing yourself is not a reasonable option."

B.            "We need to discuss this further, but right now let's complete these forms."

C.            "Don't do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one."

D.            "This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff."

NO.356 Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?

A.            Exudate

B.            Crust

C.            Edema

D.            Erythema

NO.357 Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?

A.            Fresh fruit

B.            A milkshake

C.            Saltine crackers and peanut butter

D.            A ham and cheese sandwich

NO.358 After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurse's appropriate response is:

A.            "No vegetable exchanges are allowed."

B.            "Corn and other starchy vegetables are considered to be bread exchanges."

C.            "Yes, you may exchange any vegetable for any other vegetable."

D.            "Yes, but only one-half ear is allowed."

NO.359 Before completing a nursing diagnosis, the nurse must first:

A.            Write goals and objectives

B.            Perform an assessment

C.            Plan interventions

D.            Perform evaluation

NO.360 A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking reflex. The nurse should suspect:

A.            Central nervous system damage

B.            Hypoglycemia

C.            Hyperglycemia

D.            These are normal newborn responses to extrauterine life

NO.361 A client is pregnant with her second child. Her last menstrual period began on January 15. Her expected date of delivery would be:

A.            October 8

B.            October 15

C.            October 22

D.            October 29

NO.362 A client returns to the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse needs to monitor will be:

A.            Chloride

B.            HCO3

C.            Potassium

D.            Sodium

NO.363 A client is pleased about being pregnant, yet states, "It is really not the best time, but I guess it will be OK." The nurse's assessment of this response is:

A.            Initial maternal-infant bonding may be poor.

B.            Client may have a poor relationship with her husband.

C.            This response is normal in the first trimester.

D.            This response is abnormal, to be re-evaluated at the next visit.

NO.364 On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:

A.            Normal involution

B.            A full bladder

C.            An infection pain

D.            A hemorrhage

NO.365 A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her?

A.            Respiratory rate of 16 breaths/min

B.            Pulse rate of 80 bpm

C.            Complaints of muscle aches

D.            A sore throat

NO.366 A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute

 

examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting

15 seconds. The nurse interprets this test to be:

A.            Nonreactive

B.            Reactive

C.            Positive

D.            Negative

NO.367 A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:

A.            Continue to monitor the foot

B.            Notify the physician immediately

C.            Reposition and reassess the foot

D.            Assure the client that his foot is fine

NO.368 An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?

A.            Water satiety

B.            Thirst

C.            Edema

D.            Diabetes insipidus

NO.369 A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the nurse's anger by using a condescending tone of voice with other clients and staff persons. Which ofthe following statements from the nurse would be most appropriate in acknowledging feelings regarding the client's behavior?

A.            "I feel angry when I hear that tone of voice."

B.            "You make me angry when you talk to me that way."

C.            "Are you trying to get me angry?"

D.            "Why do you treat me that way?"

NO.370 A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be:

A.            "You should ask your doctor about this."

B.            "Yes, increase your insulin by 1 U for each hour of practice because exercise causes the body to need more insulin."

C.            "No, do not increase your insulin. Exercise will not affect your insulin needs."

D.            "No, do not increase your insulin, but eating a snack prior to practice exercise will make insulin more effective and move more glucose into the cells."

NO.371 A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The nurse would expect him to be on which type of diet?

A.            High protein and high calorie

B.            High calorie and high carbohydrate

C.            Low-fat 2-g sodium diet

D.            High protein and high fat

NO.372 In cleansing the perineal area around the site of catheter insertion, the nurse would:

A.            Wipe the catheter toward the urinary meatus

B.            Wipe the catheter away from the urinary meatus

C.            Apply a small amount of talcum powder after drying the perineal area

D.            Gently insert the catheter another 12 inch after cleansing to prevent irritation from the balloon

NO.373 A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that:

A.            The test is inconclusive and should be repeated

B.            Further testing is needed

C.            The test is normal and the fetus is reacting appropriately

D.            The fetus is distressed

NO.374 When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill?

A.            Open discussion and understanding

B.            Play-acting out feelings in different roles

C.            Storytelling

D.            Drawing pictures

NO.375 A 33-year-old client was brought into the emergency room unconscious, and it is determined that surgery is needed. Informed consent must be obtained from his next of kin.

The sequence in which the next of kin would be asked for the consent would be:

A.            Parent, spouse, adult child, sibling

B.            Spouse, adult child, parent, sibling

C.            Spouse, parent, sibling, adult child

D.            Parent, spouse, sibling, adult child