NCLEX Practice Questions — Set 48
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
When planning home care for the child with Legg-Calv-Perthes disease, what should be the primary focus for family teaching?
Show answer and rationale
Correct answer: A. Management of the corrective appliance.
Because most of the child’s care takes place at home, the primary focus of family teaching would be on the care and management of the corrective device. Devices such as an abduction brace, a leg cast, or a harness sling are used to protect the affected joint while revascularization and bone healing occur. As long as the child is eating a well-balanced diet, there is no need for an intake of protein-rich foods. The parents can encourage range of motion in the unaffected leg, but motion in the affected leg is limited until it heals. Once therapy has been initiated, pain is usually not a problem. The key is management of the corrective device.
At the 2-week well-child visit a parent states, "My baby seems to keep his head tilted to the right." The nurse should further assess the:
Show answer and rationale
Correct answer: A. Sternocleidomastoid muscle.
The parent is describing symptoms consistent with torticollis, or wry neck syndrome. With this musculoskeletal disorder, the sternocleidomastoid muscle shortens causing the infant to drop the head toward the affected muscle and tilt the chin upward in the opposite direction. Frequently, a lump may be felt in the affected muscle. Palpating the fontanel is done to assess neurologic status, not musculoskeletal status. Torticollis does not involve the cervical vertebrae or trapezius muscle.
An adolescent tells the nurse that the area below his knee has been hurting for several weeks. The nurse should obtain history information about participation in which of the following?
Show answer and rationale
Correct answer: D. Soccer.
The adolescent’s problem should alert the nurse to the possibility of Osgood-Schlatter disease. This disease, found primarily in boys 10 to 15 years of age and in girls 8 to 13 years of age, occurs when the infrapatellar ligament of the quadriceps muscle is not well anchored to the tibial tubercle. Excessive activity of the quadriceps muscle results in microtrauma, which causes swelling and pain. Track, soccer, and football commonly produce this condition. Osgood-Schlatter disease is self-limited and usually responds to rest and application of ice.
An adolescent is on the football team and practices in the morning and afternoon before school starts for the year. The temperature on the field has been high. The school nurse has been called to the practice field because the adolescent is now reporting that he has muscle cramps, nausea, and dizziness. Which of the following actions should the school nurse do first?
Show answer and rationale
Correct answer: B. Move the adolescent to a cool environment.
The adolescent is most likely experiencing heat exhaustion or heat collapse, which are common after vigorous exercise in a hot environment. Symptoms result from loss of fluids and include nausea, vomiting, dizziness, headache, and thirst. Treatment consists of moving the adolescent to a cool environment and giving cool liquids. Cool liquids are easier to drink than cold liquids. Taking the adolescent’s temperature would be appropriate once these actions have been completed. However, the adolescent’s temperature is likely to be normal or only mildly elevated. The water in a swimming pool would be too cool, possibly causing the adolescent to shiver and thus raising his temperature.
During a developmental screening, the nurse finds that a 3-year-old child with cerebral palsy has arrested social and language development. The nurse tells the family:
Show answer and rationale
Correct answer: D. "I need to refer you for more developmental testing."
It is important to identify primary developmental delays in children with cerebral palsy and to prevent secondary and tertiary delays. The arrested development is worrisome and requires further investigation. It is possible the lack of development indicates hearing loss or may be a sign of autism. The brain damage caused by cerebral palsy is not progressive. The brain of a young child is quite plastic; assuming the child’s development has peaked at age 3 would be a serious mistake. The therapy plan will need to be modified, but a better understanding of the underlying problem will lead to the greatest chance of creating a successful therapy plan.
A child with spastic cerebral palsy is to begin botulinum toxin type A (Botox) injections. Which treatment goals should the health care team set for the child related to Botox?
Show answer and rationale
Correct answer: B. All of the above
Botox injections can be used to improve many aspects of quality of life for the child with cerebral palsy. The injections can help decrease pain from spasticity. Injections improve motor status by reducing rigidity and allowing for more effective physical therapy to improve range of motion. Decreased spasms enhance self-esteem. Improved motor status facilitates the ability to provide some aspects of care, especially transfers. Botox does not significantly affect nutritional status or speech.
The nurse judges that the mother understands the term cerebral palsy when she describes it as a term applied to impaired movement resulting from which of the following?
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Correct answer: D. Nonprogressive brain damage caused by injury.
The term cerebral palsy (CP) refers to a group of nonprogressive disorders of upper motor neuron impairment that result in motor dysfunction due to injury. In addition, a child may have speech or ocular difficulties, seizures, hyperactivity, or cognitive impairment. The condition of congenital malformed blood vessels in the ventricles is known as arteriovenous malformations. Viral infection and metabolic imbalances do not cause CP.
The parent of a child with spastic cerebral palsy and a communication disorder tells the nurse, "He seems so restless. I think he is in pain." The nurse should:
Show answer and rationale
Correct answer: A. Administer the pain medication that is prescribed to be given as needed and assess the response.
The parent is the child’s primary care provider and may be very in tune to subtle changes in the child’s behavior. If the parent thinks the child is in pain, it is very likely to be so. The nurse should administer the pain medication and evaluate if the medication affected the child’s behavior. The FLACC scale may be difficult to interpret when the child has spasticity. The FACES scale requires self-report. The primary health care provider should be contacted regarding the change in behavior only if other available interventions are unsuccessful.
The mother asks the nurse whether her child with hemiparesis due to spastic cerebral palsy will be able to walk normally because he can pull himself to a standing position. Which of the following responses by the nurse would be most appropriate?
Show answer and rationale
Correct answer: A. "It’s difficult to predict, but his ability to bear weight is a positive factor."
The nurse needs to respond honestly to the mother. Most children with hemiparesis due to spastic cerebral palsy are able to walk because the motor deficit is usually greater in the upper extremity. There is no need to refer the mother to the primary health care provider. The age at which the mother walked may be important to elicit, but this does not influence when the child will walk. The will to walk is important, but without neurologic stability the child may be unable to do so.
The nurse assesses the family’s ability to cope with the child’s cerebral palsy. Which action should alert the nurse to the possibility of their inability to cope with the disease?
Show answer and rationale
Correct answer: C. Limiting interaction with extended family and friends.
Limited interaction or lack of interaction with friends and family may lead the nurse to suspect a possible problem with the family’s ability to cope with others’ reactions and responses to a child with cerebral palsy. Learning measures to meet the child’s physical needs demonstrates some understanding and acceptance of the disease. Requesting teaching about the disease suggests curiosity or a desire for understanding, thus demonstrating the family dealing with the situation. Participating in social media may serve as a form of support and can be a healthy coping mechanism.
A nurse is making an initial visit to a family with a 3-year-old child with early Duchenne’s muscular dystrophy. Which of the following findings is expected when assessing this child?
Show answer and rationale
Correct answer: D. Difficulty riding a tricycle.
Usually the first clinical manifestations of Duchenne’s muscular dystrophy include difficulty with typical age-appropriate physical activities such as running, riding a bicycle, and climbing stairs. Contractures of the large joints typically occur much later in the disease process. Occasionally enlarged calves may be noted, but they are not typical findings in a child with Duchenne’s muscular dystrophy. Muscular atrophy and development of small, weak muscles are later signs.
The nurse observes as a child with Duchenne’s muscular dystrophy attempts to rise from a sitting position on the floor. After attaining a kneeling position, the child "walks" his hands up his legs to stand. The nurse documents this as which of the following?
Show answer and rationale
Correct answer: D. Gower’s sign.
With Gower’s sign, the child walks the hands up the legs in an attempt to stand, a common approach used by children with Duchenne’s muscular dystrophy when rising from a sitting to a standing position. Galeazzi’s sign refers to the shortening of the affected limb in congenital hip dislocation. Goodell’s sign refers to the softening of the cervix, considered a sign of probable pregnancy. Goodenough’s sign refers to a test of mental age.
When developing the plan of care for a child with early Duchenne’s muscular dystrophy, which of the following nursing goals is the priority?
Show answer and rationale
Correct answer: A. Maintaining function of unaffected muscles.
The guilt that mothers of children with muscular dystrophy commonly experience usually results from the fact that the disease is genetic and the mother transmitted the defective gene. Although many children die from the disease, the disease is considered chronic and progressive. As the disease progresses, the child becomes more dependent. However, guilt typically stems from the knowledge that the mother transmitted the disease to her son rather than the dependency of the child. The disease onset is usually gradual, not sudden.
When interacting with the mother of a child who has Duchenne’s muscular dystrophy, the nurse observes behavior indicating that the mother may feel guilty about her child’s condition. The nurse interprets this behavior as guilt stemming from which of the following?
Show answer and rationale
Correct answer: A. The terminal nature of the disease.
Muscular dystrophy is a progressive disease. Children who are affected by this disease usually are unable to walk independently by age 9 to 11 years. There is no effective treatment for childhood muscular dystrophy. Although children who remain active are able to avoid wheelchair confinement for a longer period, activity does not prevent disease progression.
A 16-month-old child is seen in the clinic for a checkup for the first time. The nurse notices that the toddler limps when walking. Which of the following would be appropriate to use when assessing this toddler for developmental dysplasia of the hip?
Show answer and rationale
Correct answer: B. Trendelenburg’s sign.
In a toddler, weight bearing causes the pelvis to tilt downward on the unaffected side instead of upward as it would normally. This is Trendelenburg’s sign, and it indicates developmental dysplasia of the hip. Ortolani’s maneuver is used during the neonatal period to assess developmental dysplasia of the hip in infants. With the infant quiet, relaxed, and lying on the back, the hips and knees are flexed at right angles. The knees are moved to abduction and pressure is exerted. If the femoral head moves forward, then it is dislocated. Barlow’s maneuver is used to assess developmental dysplasia of the hip in infants. As the femur is moved into or out of the acetabulum, a "clunk" is heard, indicating dislocation. Adam’s position is used to evaluate for structural scoliosis. The child bends forward with feet together and arms hanging freely or with palms together.
The nurse teaches the parents of an infant with developmental dysplasia of the hip how to handle their child in a Pavlik harness. Which of the following is most appropriate?
Show answer and rationale
Correct answer: C. Fitting the diaper under the straps.
The Pavlik harness is worn over a diaper. Knee socks are also worn to prevent the straps and foot and leg pieces from rubbing directly on the skin. For maximum results, the infant needs to wear the harness continuously. The skin should be inspected several times a day, not every other day, for signs of redness or irritation. Lotions and powders are to be avoided because they can cake and irritate the skin.
When developing the teaching plan for parents using the Pavlik harness with their child, what should be the nurse’s initial step?
Show answer and rationale
Correct answer: B. Determining the parents’ knowledge about the device.
Assessing the learner’s knowledge level is the initial step in any teaching plan to promote the maximum amount of learning. This assessment also provides the nurse with a starting point for teaching. Assessing coping strategies can provide important information to the development of the teaching plan but is not the initial step. Giving parents written instructions or a list of community resources is appropriate once the parents’ knowledge level has been determined and teaching has begun.
When teaching the family of an older infant who has had a spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar?
Show answer and rationale
Correct answer: B. It adds strength to the cast.
The abduction bar is incorporated into the cast to increase the cast’s strength and maintain the legs in alignment. The bar cannot be removed or adjusted, unless the cast is removed and a new cast is applied. The bar should never be used to lift or turn the client, because doing so may weaken the cast.
The mother asks the nurse about using a car seat for her toddler who is in a hip spica cast. The nurse should tell the mother:
Show answer and rationale
Correct answer: C. "You will need a specially designed car seat for your toddler."
The toddler in a hip spica cast needs a specially designed car seat. The one that the mother already has will not be appropriate because of the need for the car seat to accommodate the cast and abductor bar.
The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they state:
Show answer and rationale
Correct answer: B. "I should use a pillow to elevate my child’s foot as he sleeps."
Elevating the extremity at different points during the day is helpful to prevent edema, but pillows should not be used in the crib because they increase the risk of sudden infant death syndrome (SIDS). A change in the color of the toes is a sign of impaired circulation and requires medical evaluation. Children typically need a series of 5 to 10 casts to correct the deformity. Infants with club feet still need frequent holding like any other newborn.
After teaching the parents of an infant with clubfoot requiring application of a plaster cast how to care for the cast, which of the following statements would indicate that the parents have understood the teaching?
Show answer and rationale
Correct answer: A. "We will check the color and temperature of the toes of the casted leg frequently."
A cast that is too tight can cause a tourniquet effect, compromising the neurovascular integrity of the extremity. Manifestations of neurovascular impairment include pain, edema, pulselessness, coolness, altered sensation, and inability to move the distal exposed extremity. The toes of the casted extremity should be assessed frequently to evaluate for changes in neurovascular integrity. Wetting a plaster cast with water and soap softens the plaster, which may alter the cast’s effectiveness. There is no reason to elevate the casted extremities when a child with clubfoot is being treated with nonsurgical measures. The legs would be elevated if swelling were present. Petals, which are applied to cover the rough edges of the cast, are to be left in place to minimize the risk for skin irritation from the cast edges.
The parents of a child just diagnosed with juvenile idiopathic arthritis (JIA) tell the nurse that the diagnosis frightens them because they know nothing about the prognosis. What should the nurse include when teaching the parents about the disease?
Show answer and rationale
Correct answer: A. Half of affected children recover without joint deformity.
In half of the children diagnosed with JIA, recovery occurs without joint deformity. Approximately one-third of the children will continue to have the disease into adulthood, and approximately one-sixth will experience severe, crippling deformities.
The mother of a 4-year-old child with juvenile idiopathic arthritis (JIA) is worried that her child will have to stop attending preschool because of the illness. Which of the following responses by the nurse would be most appropriate?
Show answer and rationale
Correct answer: C. "Your child should be encouraged to attend school, but he’ll need extra time to work out early morning stiffness."
Socialization is important for this preschool-age child, and activity is important to maintain function. Because children with JIA commonly experience most problems in the early morning after arising, they need more time to "warm up." Adverse effects may or may not occur. The child’s normal routine needs to be maintained as much as possible. Although splints and braces may be needed, they are worn during periods of rest, not activity, to maintain function.
A preschool-age child with juvenile idiopathic arthritis (JIA) has become withdrawn, and the mother asks the nurse what she should do. Which of the following suggestions by the nurse would be most appropriate?
Show answer and rationale
Correct answer: C. Encourage the mother to be supportive and understanding of the child.
Because the child is dealing with grief and loss associated with a chronic illness, parents need to be supportive and understanding. The child needs to feel valued and worthwhile. Introducing the child to others of the same age who also have JIA most probably would be ineffective because preschoolers are developmentally egocentric. Although the child needs to feel valued, the mother’s spending more time with the child and less time with her other children is inappropriate because the child with JIA may experience secondary gain from the illness if the family interaction patterns are altered. Also, this action reinforces the child’s withdrawal behavior. Psychological counseling is not needed at this time because the child’s reaction is normal.
Nonsteroidal anti-inflammatory drugs are the first choice in treating a child with juvenile idiopathic arthritis. Which adverse effects should the nurse include in the teaching plan for the parents?
Show answer and rationale
Correct answer: A. All of the above
Adverse effects from nonsteroidal anti-inflammatory drugs include abdominal pain, blood in stool, and reduced clotting ability. Weight gain is common with corticosteroids. Folic acid deficiency is associated with methotrexate therapy.
What should the nurse include when developing the teaching plan for the parents of a child with juvenile idiopathic arthritis who is being treated with naproxen (Naprosyn)?
Show answer and rationale
Correct answer: A. The nurse should be called before giving the child any over-the-counter medications.
The first group of drugs typically prescribed is the nonsteroidal anti-inflammatory drugs, which include naproxen. Naproxen is included in only a few over-the-counter medications but aspirin is in several. The family should check with the nurse before giving any over-the-counter medications. Once therapy is started, it takes hours or days for relief from pain to occur. However, it takes 3 to 4 weeks for the anti-inflammatory effects to occur, including reduction in swelling and less pain with movement. The missed dose will need to be made up to maintain the serum level and to maintain therapeutic effectiveness of the drug.
A 10-year-old has 5 lb (2.27 kg) of Buck’s extension traction on his left leg. The nurse should assess the child for which of the following?
Show answer and rationale
Correct answer: A. All of the above
Buck’s traction provides a skin traction that keeps the extremity in straight alignment and can be observed by noting a straight line formed between the shoulder, hips, and knees. The rope must be intact to maintain the prescribed traction from the weights. The correct amount of traction must be maintained to keep the fractured femur in correct alignment. Because the client is in a recumbent position, the nurse should also inspect the skin on the back and buttocks for integrity. The nurse should not remove the client’s wraps and boot unless she has a primary health care provider’s prescription to do so.
A 14-year-old has just had a plaster cast placed on his lower left leg. To provide safe cast care, the nurse should:
Show answer and rationale
Correct answer: D. Use only the palms of the hand when handling the cast.
The wet plaster cast should be handled using only the palms of the hands to prevent indentations of the cast surface. Petaling a cast should be done only when the edges of the cast are rough and are causing irritation to the client’s skin. The nurse should not keep the child in the same position until the cast is dry. Doing so would prohibit proper toileting and elimination and would produce undue pressure on the coccyx. The cast typically emits heat as it dries, so notifying a primary health care provider is not necessary in this instance. If needed, a fan can be used to circulate the room air.
A 9-year-old is given morphine for postoperative pain. As the nurse is assessing the client for pain 4 hours later, his mother leaves the room and the child begins to cry. The nurse’s initial assessment of the child’s pain is that he is:
Show answer and rationale
Correct answer: A. Less tolerant of pain because he is upset.
Emotional or physical stress lowers a person’s tolerance of pain. The mother’s presence may have distracted him and when she left it caused him to focus on the pain he was having. Crying does not automatically indicate pain. The nurse must further assess the client for pain. Although an analgesic was given 4 hours before, pain may be present.
A 13-year-old is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, the nurse should do which of the following?
Show answer and rationale
Correct answer: B. Verify that the site, side, and level are marked.
As part of a surgery safety checklist, the nurse must verify that the site, side, and level are marked. Pointing to the area is not sufficient identification of the surgery site. The nurse must verify the form has been signed by reviewing the form. The surgeon holds primary responsibility for explaining the risks of surgery.
A child is admitted with a fracture of the femur and placed in skeletal traction. What should the nurse assess first?
Show answer and rationale
Correct answer: B. The pull of traction on the pin.
Skeletal traction applies the pull directly to the skeletal structure by tongs, pin, or wire. The nurse should assess the pull of the traction on the pin first. This is critical to the success of the traction. Once this is assessed, then the pin sites are assessed for signs of infection. The dressings would be examined after the pull of the traction, neurovascular status, and pin sites were assessed. The Ace wrap is used to anchor skin traction nonadherent straps, not skeletal traction.
A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts. It is too early for pain medication. The nurse should:
Show answer and rationale
Correct answer: B. Assess the feet for signs of neurovascular impairment.
The nurse should assess the client frequently for signs of neurovascular impairment of the feet, such as pallor, coldness, numbness, or tingling. Pillows are not placed under the buttocks because the pillows would alter the alignment of the traction. Weights provide traction and should not be removed. Pulleys help to maintain optimal alignment of the traction and therefore should be left alone.
The nurse in the emergency department is caring for a 3-year-old child with a fractured humerus. The child is crying and screaming, "I hate you." Which of the following would be most appropriate?
Show answer and rationale
Correct answer: C. Reassure the parents that this normal behavior under the circumstances.
Explaining to the parents that this is a normal reaction under the circumstances is most appropriate. The child’s outburst is related to the child’s fears of the unknown. The child is scared and anxious and needs the parents for support. Asking the parents to wait outside would only add to the child’s fear and anxiety. The reaction is normal for a child her age and does not usually call for a change in staff assignments. Asking the parents to discipline their child for her behavior is inappropriate. The nurse needs to handle the situation.
After a plaster cast has been applied to the arm of a child with a fractured right humerus, the nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the mother agrees to seek medical advice if the child experiences which of the following?
Show answer and rationale
Correct answer: B. Inability to extend the fingers on the right hand.
Inability to extend the fingers of the involved arm may indicate neurologic impairment caused by pressure on soft tissue. It is not unusual for a child to vomit after experiencing a traumatic injury. It may take up to 72 hours for a plaster cast to dry. Until the cast dries, the dampness causes the sensation of coolness. The cast will seem heavy until the child adjusts to the extra weight. The child may exhibit fussiness (such as whining, crying or clinging) as a result of numerous causes, such as placement of the cast, the hospital experience, or pain. These reactions are normal and do not warrant medical advice.
The nurse should teach the mother of a child who has a new cast for a fractured radius to do which of the following for the first few days at home?
Show answer and rationale
Correct answer: A. Have the child refrain from strenuous activities.
For the first few days after application of a plaster or fiberglass cast, the child should not engage in strenuous activities, to minimize swelling that would cause the cast to become too tight. Use of a hair dryer to complete the drying of the cast is not encouraged because the hair dryer only dries the outside of the cast. Movement and sensation of the fingers need to be checked several times a day for the first few days. Typically, the mother would be instructed to administer acetaminophen every 4 to 6 hours, not every 8 to 12 hours, for discomfort.
While assessing a 3-year-old child who has had an injury to the leg, has pain, and refuses to walk, the nurse notes that the child’s left thigh is swollen. What should the nurse do next?
Show answer and rationale
Correct answer: C. Assess the neurologic status of the toes.
Because the nurse suspects a possible fracture based on the child’s presentation, assessing the neurologic and circulatory status of the toes, the tissues distal to the fracture, is important. Soft tissue contusions, which accompany femur fractures, can result in severe hemorrhage into the tissue and subsequent circulatory and neurologic impairment. Once this information has been obtained, vital signs can be assessed and the nurse can notify the primary health care provider and report the findings. In fractures, circulation impairment will occur distal to the injury.
Anticipating that a 3-year-old child in traction will have need for diversion, what should the nurse offer the child?
Show answer and rationale
Correct answer: C. Hand puppets.
Hand puppets would enable a 3-year-old child in traction to act out feelings within the constraints imposed by the traction. A 3-year-old needs creative play. The video game would make the child too active in bed and does not meet the child’s developmental need for creative play. Blocks would be more appropriate for a younger child. Marbles are unsafe at this age because they can be swallowed.
The parents of a child who requires skeletal traction are unable to visit their child for more than 1 hour a day because there are five other children at home and both parents work outside of the home. The nurse recognizes expressions of guilt in both parents. To help alleviate this guilt, the nurse should make which of the following remarks?
Show answer and rationale
Correct answer: A. "It’s important that you visit even for 1 hour."
Stressing the importance of the parents’ visiting when they can helps to alleviate the guilt they feel. It allows the parents to feel that they are doing what they can. Acknowledging the guilt gives the parents an opportunity to talk about it but does not help alleviate it. Comparing the parents with other parents does not alleviate guilt feelings. The parents need reinforcement that what they are doing is appropriate. Suggesting that the parents take turns visiting implies that they should feel guilty because they may not be doing all they could.
The child in a new hip spica cast seems to be adjusting to the cast, except that after each meal the child tells the nurse that the cast is too tight. Which of the following should the nurse plan to do?
Show answer and rationale
Correct answer: C. Offer smaller, more frequent meals.
A hip spica cast encircles the abdomen. When the child eats a large meal, abdominal pressure increases, causing the cast to feel tight. Therefore, the nurse should plan to offer smaller, more frequent meals to minimize abdominal distention. If the child’s appetite were decreased in conjunction with a feeling of fullness, the nurse might suspect that the child was becoming constipated and plan to use laxatives or a higher-fiber diet. A mechanical soft diet is indicated when the child has difficulty chewing food adequately. Giving the child more fruits and grains would contribute to abdominal distention and problems with the cast tightness after eating.
The nurse is helping a family plan for the discharge of their child, who will be going home in a spica cast. Which of the following points of information should be most important for the nurse to consider?
Show answer and rationale
Correct answer: B. The child’s bedroom is on the second floor.
The child with a hip spica cast who is going home and has a bedroom on the second floor of the home needs to have the bed moved to an area that is more central to family life. Negotiating a flight of steps at least twice a day (on awakening in the morning and before going to bed at night) with a child in a hip spica cast would be difficult and most likely dangerous. Because the child in a hip spica cast will need to use a bedpan or urinal, the bathrooms can be on any floor. Because the family is involved in the discharge, the 16-year-old sister should be taught appropriate care along with the rest of the family. The child can be carried up and down the three steps to the house the few times necessary after discharge.
The nurse is measuring a child for crutches. What should the nurse consider?
Show answer and rationale
Correct answer: D. Both of the above
To ensure proper fit of crutches, the child’s elbow flexion should be 20 degrees, and the area above the top of the crutch to the child’s axilla should be 1 to 1 1/2 inches (2.5 to 3.8 cm). The type of gait, weight of the child, and use of stairs are not factors in the measurement.
During the initial assessment of a child admitted to the pediatric unit with osteomyelitis of the left tibia, when assessing the area over the tibia, which is an expected finding?
Show answer and rationale
Correct answer: D. Increased warmth.
Findings associated with osteomyelitis commonly include pain over the area, increased warmth, localized tenderness, and diffuse swelling over the involved bone. The area over the affected bone is red.
A child is to receive IV antibiotics for osteomyelitis. Before the initial dose of antibiotics can be given, the nurse confirms that a blood sample for which of the following tests has been drawn?
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Correct answer: A. Culture.
Cultures are used to determine exactly what organism is causing the inflammation. From the culture, sensitivities to various antibiotics may be determined. If the antibiotics are given before obtaining the culture, the antibiotics may inhibit the growth of the organism in the culture medium. This may lead to a delay in the most appropriate treatment. Unless a child has a known renal problem, baseline creatinine levels are not typically needed. However, levels may be needed during treatment depending on the medication. A complete blood count (CBC) with hemoglobin and white blood cell count is typically prescribed for any suspected infection, but these tests do not identify the causative organism.
The nurse is caring for a child with osteomyelitis who will be receiving high-dose intravenous antibiotic therapy for 3 to 4 weeks. What should the nurse plan to monitor?
Show answer and rationale
Correct answer: A. Urine specific gravity.
Long-term, high-dose antibiotic therapy can adversely affect renal, hepatic, and hematopoietic function. Urine specific gravity would provide valuable information about the kidneys’ ability to concentrate or dilute urine, thereby suggesting renal impairment. Blood glucose levels reveal how well the client’s body is using glucose. Thrombin times reveal information about the clotting mechanism. Urine glucose levels reveal information about the body’s use and excretion of glucose.
To meet the developmental needs of an 8-year-old child who is confined to home with osteomyelitis, what should the nurse include in the care plan?
Show answer and rationale
Correct answer: C. Encouraging the child to communicate with schoolmates.
Encouraging contact with schoolmates allows the school-age child to maintain and develop socialization with peers, an important developmental task of this age group. Although having family visits and interacting with the child are important, they do not meet the child’s developmental needs. Talking to the child about his interests is important, but encouraging contact with schoolmates is crucial to maintain and develop socialization with peers.
A child with newly diagnosed osteomyelitis has nausea and vomiting. The parent wishes to give the child ginger snaps to help control the nausea. The nurse should tell the parent:
Show answer and rationale
Correct answer: D. "You can try them and see how he does."
Some clients find ginger snaps help relieve nausea. Ginger, in small doses such as would be found in the cookies, has few side effects. There is no reason that the parent should not try this dietary intervention; however, the nurse must monitor the client’s response. If the child has a diet as tolerated prescription, there is no need for an additional prescription. Ultimately, the child may need an antiemetic medication, but dietary strategies are often successful in treating vomiting related to osteomyelitis. Making a universal statement disregarding home remedies is not a client-centered approach.
When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?
Show answer and rationale
Correct answer: B. Bend forward at the waist with arms hanging freely.
Scoliosis, a lateral deviation of the spine, is assessed by having the client bend forward at the waist with arms hanging freely, then looking for lateral curvature of the spine and a rib hump. The other positions will not reveal the deviation of the spine.
After teaching the family of a child with scoliosis who needs to wear a Boston brace, which of the following activities, if stated by the child and family as occasions appropriate for removal of the brace, indicates successful teaching?
Show answer and rationale
Correct answer: C. When bathing, for about 1 hour per day.
One of the most effective spinal braces for correcting scoliosis, the Boston brace should be worn for at least 16 to 23 hours a day, except when carrying out personal hygiene measures.
A 14-year-old is being screened for scoliosis. Which of the following statements about scoliosis screening is true?
Show answer and rationale
Correct answer: A. The girl is assessed standing and bending forward.
Screening is done with the child wearing minimal clothing, standing and bending forward. The examination should be done on girls aged 10 to 12 years old, so a diagnosis can be made early and the scoliosis can be treated with exercises or bracing. Only underwear should be worn for the examination so that symmetry of the shoulders and hips can be observed. If the deviation on the scoliometer is <20 degrees, no treatment is indicated. The child does not need to refrain from eating prior to this test.
A 10-year-old with scoliosis has to wear a brace. The nurse should develop a teaching plan with the client to include which of the following instructions?
Show answer and rationale
Correct answer: A. Wear a form-fitting, sleeveless T-shirt under the brace.
A form-fitting, sleeveless T-shirt can be worn under the brace to prevent skin irritation and collect perspiration. Braces are worn 23 hours each day. Lotions may cause irritation and should not be used. The skin under the brace should be bathed daily to help prevent irritation from the brace. The brace can be removed for bathing so all the skin can be bathed.
A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today, but had to cancel the appointment when the child became ill. The nurse should:
Show answer and rationale
Correct answer: D. Arrange for the pump to be refilled in the hospital.
To prevent a baclofen withdraw, pump refills are scheduled several days before anticipated low-volume alarms. The nurse should make it a high priority to have the pump refilled as soon as possible. Discontinuing baclofen suddenly can result in a high fever, muscle rigidity, change in level of consciousness, and even death. Waiting until the child leaves the hospital for a refill may lead to a low dose or withdraw. Waiting for the low-volume alarm puts the client at risk because medication and team members who can refill the pump may not be readily available under all circumstances.
Which procedures can the nurse working on a pediatric floor safely delegate to the licensed practical nurse (LPN)?
Show answer and rationale
Correct answer: D. Both of the above
In general, LPNs may perform skills related to feeding, oral medication administration, and activities of daily living, such as insertion of a hearing aid. Refilling a baclofen pump constitutes administering an intrathecal medication and is beyond the scope of practice for LPNs in most areas. Some institutions allow LPNs to give IV push medicines; however, special training is required. Communicating with the primary health care provider would require discussion of the client’s assessments and evaluations, which fall under the RN scope of practice.
A 4-year-old male presents to the emergency room. His father tearfully reports that his son was on his shoulders in the driveway playing when he began to fall. When the child began to fall, the father grabbed him by the leg, swinging him toward the grass to avoid landing on the pavement. As the father swung his son, the child hit his head on the driveway and twisted his right leg. After a complete examination, it is determined that the child has a skull fracture and a spiral fracture of the femur. Which of the following actions should the nurse take?
Show answer and rationale
Correct answer: A. Record the father’s story in the chart.
The father’s story is consistent with the injuries incurred by the child; therefore, the nurse should document the cause of injury. There is no need to restrict the father’s visitation because the injuries sustained by the child are consistent with the explanation given. The police only need to be notified if there is suspicion of child abuse. The injuries incurred by this child appear to be accidental. There is no need to refer the father for parenting classes. The father appears to be upset about the accident and will not likely repeat such reckless behavior. However, the nurse should educate the father regarding child safety.
A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What is the highest priority for nursing management of this client at this time?
Show answer and rationale
Correct answer: B. Reduce pain and myocardial oxygen demand.
Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.
A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip?
Show answer and rationale
Correct answer: C. Blood pressure is 88/46.
Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range.
The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse should first:
Show answer and rationale
Correct answer: C. Assess for changes in vital signs.
Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left midclavicular line. The murmur worsens during expiration and in the supine or left-side position. Vital sign changes will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function.
A client with acute chest pain is receiving IV morphine sulfate. Which of the following results are intended effects of morphine?
Show answer and rationale
Correct answer: B. All of the above
Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme-inhibitor drugs, not morphine, may help to prevent ventricular remodeling.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?
Show answer and rationale
Correct answer: B. Confusion, urine output 15 mL over the last 2 hours, orthopnea.
A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema, and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation, there is a loss of atrial kick, but the blood pressure and heart rate are stable.
The nurse notices that a client’s heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first:
Show answer and rationale
Correct answer: B. Take the client’s blood pressure.
The nurse should first assess the client’s tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if Atropine is needed. If the client is symptomatic, Atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.
A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as:
Show answer and rationale
Correct answer: B. Heart rate irregular with S3.
An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve.
When administering a thrombolytic drug to the client who is experiencing a myocardial infarction (MI) and who has premature ventricular contractions, the expected outcome of the drug is to:
Show answer and rationale
Correct answer: A. Dissolve clots.
Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage.
The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm on the monitor .The nurse should:
Show answer and rationale
Correct answer: D. Assess the client for changes in the rhythm.
The client is experiencing a single PVC. PVCs are characterized by a QRS of longer than 0.12 second and by a wide, notched, or slurred QRS complex. There is no P wave related to the QRS complex, and the T wave is usually inverted. PVCs are potentially serious and can lead to ventricular fibrillation or cardiac arrest when they occur more than 6 to 10 in an hour in clients with myocardial infarction. The nurse should continue to monitor the client and note if the PVCs are increasing. It is not necessary to notify the physician or call the rapid response team at this point. Lidocaine is not indicated from the data on this ECG.
A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following prescriptions from the health care provider should the nurse verify before implementing?
Show answer and rationale
Correct answer: C. Metoprolol (Lopressor) 5 mg IV push.
Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability and a beta blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock.
Which of the following is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)? The client:
Show answer and rationale
Correct answer: D. Can perform personal self-care activities without pain.
By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program.
Which of the following is an expected outcome when a client is receiving an IV administration of furosemide?
Show answer and rationale
Correct answer: B. Increased urine output.
Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias.
A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of the following?
Show answer and rationale
Correct answer: D. Left end-diastolic pressure.
When wedged, the catheter is "pointing" indirectly at the left end-diastolic pressure. The pulmonary artery wedge pressure is measured when the tip of the catheter is slowing inflated and allowed to wedge into a branch of the pulmonary artery. Once the balloon is wedged, the catheter reads the pressure in front of the balloon. During diastole, the mitral valve is open, reflecting left ventricular end diastolic pressure. Cardiac output is the amount of blood ejected by the heart in 1 minute and is determined through thermodilution and not wedge pressure. Cardiac index is calculated by dividing the client’s cardiac output by the client’s body surface area, and is considered a more accurate reflection of the individual client’s cardiac output. Right atrial blood pressure is not measured with the pulmonary artery catheter.
After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. The expected outcome of this exercise is to:
Show answer and rationale
Correct answer: D. Prevent thrombophlebitis and blood clot formation.
Encouraging the client to move the legs while in bed is a preventive strategy taught to all clients who are hospitalized and on bed rest to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation.
Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction?
Show answer and rationale
Correct answer: C. Small, easily digested meals.
Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client’s needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be prescribed as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.
The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel (Plavix). The nurse should develop a teaching plan that includes which of the following points?
Show answer and rationale
Correct answer: C. All of the above
Plavix is generally well absorbed and may be taken with or without food; it should be taken at the same time every day and, while food may help prevent potential GI upset, food has no effect on absorption of the drug. Bleeding is the most common adverse effect of Plavix; the client must understand the importance of reporting any unexpected, prolonged, or excessive bleeding including blood in urine or stool. Increased bruising and bleeding gums are possible side effects of Plavix; the client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients that have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking Plavix.
Which client is at greatest risk for coronary artery disease?
Show answer and rationale
Correct answer: B. A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L).
The woman who is 65 years old, overweight, and has an elevated LDL is at greatest risk. Total cholesterol greater than 200 (11.1 mmol/L), LDL greater than 100 (5.5 mmol/L), HDL less than 40 (2.2 mmol/L) in men, HDL less than 50 (2.8 mmol/L) in women, men 45 years and older, women 55 years and older, smoking and obesity increase the risk of CAD. Atorvastatin reduces LDL and decreases risk of CAD. The combination of postmenopausal, obesity, and high LDL places this client at greatest risk.
A middle-aged adult with a family history of CAD has the following: total cholesterol 198 (11 mmol/L); LDL cholesterol 120 (6.7 mmol/L); HDL cholesterol 58 (3.2 mmol/L); triglycerides 148 (8.2 mmol/L); blood sugar 102 (5.7 mmol/L); and C-reactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why these medications are needed. Which is the best response by the nurse?
Show answer and rationale
Correct answer: B. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications prescribed."
CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, postmenopausal age, LDL above optimum levels, and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke. The blood sugar is within normal limits.
The client has been managing angina episodes with nitroglycerin. Which of the following indicate the drug is effective?
Show answer and rationale
Correct answer: B. Decreased chest pain.
Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation makes it easier for the heart to eject blood, resulting in decreased oxygen needs. Decreased oxygen demand reduces pain caused by heart muscle not receiving sufficient oxygen. While blood pressure may decrease ever so slightly due to the vasodilation effects of nitroglycerine, it is only secondary and not related to the angina the patient is experiencing. Increased blood pressure would mean the heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect of nitroglycerine.
Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to:
Show answer and rationale
Correct answer: B. Revascularize the blocked coronary artery.
The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and re-establish a blood supply to the area.
After the administration of t-PA, the nurse should:
Show answer and rationale
Correct answer: C. Observe the client for chest pain.
Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after administration of t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever.
When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?
Show answer and rationale
Correct answer: D. Cardiac arrhythmias.
Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue.
Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following contradictions to administering the drug?
Show answer and rationale
Correct answer: A. History of cerebral hemorrhage.
A history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not contraindications.
A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/min per nasal cannula. The nurse’s next action should be to:
Show answer and rationale
Correct answer: B. Start an IV infusion.
Advanced cardiac life support recommends that at least one or two IV lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the IV line.
Crackles heard on lung auscultation indicate which of the following?
Show answer and rationale
Correct answer: C. Fluid-filled alveoli.
Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.
Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which of the following measures would most likely help the client prevent this problem?
Show answer and rationale
Correct answer: D. Take a nitroglycerin tablet before climbing the stairs.
Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain free. Climbing the stairs early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode.
The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals would be best?
Show answer and rationale
Correct answer: D. Spaghetti with tomato sauce, salad, and coffee.
Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol.
The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include:
Show answer and rationale
Correct answer: B. Preventing fluid volume deficit.
Because the contrast medium used in PTCA acts as an osmotic diuretic, the client may experience diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium levels must be closely monitored because the client may develop hypokalemia due to the diuresis. Dyspnea would not be anticipated after this procedure. Maintaining adequate blood pressure control should not be a problem after the procedure. Increased myocardial contractility would be a goal, not decreased contractility.
Which of the following is not a risk factor for the development of atherosclerosis?
Show answer and rationale
Correct answer: A. Late onset of puberty.
Late onset of puberty is not generally considered to be a risk factor for the development of atherosclerosis. Risk factors for atherosclerosis include family history of atherosclerosis, cigarette smoking, hypertension, high blood cholesterol level, male gender, diabetes mellitus, obesity, and physical inactivity.
As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug’s principal effects are produced by:
Show answer and rationale
Correct answer: B. Vasodilation of peripheral vasculature.
Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.
How should the nurse instruct the client with unstable angina to use sublingual nitroglycerin tablets when chest pain occurs? "Sit down and then
Show answer and rationale
Correct answer: C. take one tablet. If pain persists after 5 minutes call 911."
The nurse should instruct the client that correct protocol for using sublingual nitroglycerin involves immediate administration when chest pain occurs. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. The client should sit down and place the tablet under the tongue. If the chest pain is not relieved within 5 minutes, the client should call 911. Although some physicians may recommend taking a second or third tablet spaced 5 minutes apart and then calling for emergency assistance, it is not appropriate to take two tablets at once. Nitroglycerin acts within 2 to 3 minutes and the client should not wait 15 minutes to take further action. The client should call 911 to obtain emergency help rather than calling the physician.
A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to:
Show answer and rationale
Correct answer: A. Prevent thrombus formation.
Coumadin is an anticoagulant, which is used in the treatment of atrial fibrillation and decreased left ventricular ejection fraction (less than 20%) to prevent thrombus formation and release of emboli into the circulation. The client may also take other medication as needed to manage the heart failure. Coumadin does not reduce circulatory load or improve myocardial workload. Coumadin does not affect cardiac rhythm.
A client has a history of heart failure and has been furosemide (Lasix), digoxin (Lanoxin), and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of which of the following?
Show answer and rationale
Correct answer: A. Digoxin toxicity.
Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client’s history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.
The nurse should assess the client with left-sided heart failure for which of the following?
Show answer and rationale
Correct answer: C. All of the above
Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure. JVD and right upper quadrant pain along with ascites and edema are usually associated with congestion of the peripheral tissues and viscera in right-sided heart failure.
Which of the following sets of conditions is an indication that a client with a history of left-sided heart failure is developing pulmonary edema?
Show answer and rationale
Correct answer: D. Both of the above
Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia occurs due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated, depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.
An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. On admission which of the following should the nurse assess first?
Show answer and rationale
Correct answer: A. All of the above
Heart failure can be a result of several cardiovascular conditions, which will affect the heart’s ability to pump effectively. The body attempts to compensate through several neurohormonal mechanisms. Decreased cardiac output stimulates the aortic and carotid baroreceptors, which activates the sympathetic nervous system to release norepinephrine and epinephrine. This early response increases the heart rate and contractility. It also has some negative effects, including vasoconstriction of the skin, GI tract, and kidneys. Decreased renal perfusion (due to low CO and vasoconstriction) activates the renin-angiotensin-aldosterone process resulting in the release of antidiuretic hormone. This causes fluid retention in an attempt to increase blood pressure, therefore cardiac output. In the damaged heart, this causes fluid overload. There is no parasympathetic response. Decreased pulmonary perfusion can be a result of fluid overload or concomitant pulmonary disease.
In which of the following positions should the nurse place a client with heart failure who has orthopnea?
Show answer and rationale
Correct answer: D. Sitting upright (high Fowler’s position) with legs resting on the mattress
Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler’s position would be used if the client could not tolerate high Fowler’s position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate Trendelenburg’s position.
The major goal of nursing care for a client with heart failure and pulmonary edema is to:
Show answer and rationale
Correct answer: B. Increase cardiac output.
Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema.
Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug’s desired effect?
Show answer and rationale
Correct answer: C. 5 to 10 minutes.
After intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously.
The nurse teaches a client with heart failure to take oral furosemide in the morning. The primary reason for this is to help:
Show answer and rationale
Correct answer: A. Prevent sleep disturbances during the night.
When diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client’s sleep will not be disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night.
The nurse is teaching a client and his family about the client’s new diagnosis of hemochromatosis. Which of the following details should the nurse include?
Show answer and rationale
Correct answer: A. Men are at greater risk for hemochromatosis.
The nurse should teach the client and family that individuals who are heterozygous for hemochromatosis rarely develop the disease. Men and women are equally at risk for hemochromatosis, but men are diagnosed earlier because women do not usually have manifestations until menopause. Hemochromatosis is the most common genetic disorder in Canada and the United States. Individuals who are homozygous for hemochromatosis received a defective gene from each parent. Those with homozygous genes may develop the disease.
The nurse should assess the client for digoxin toxicity if serum levels indicate that the client has a:
Show answer and rationale
Correct answer: B. Low potassium level.
A low serum potassium level (hypokalemia) predisposes the client to digoxin toxicity. Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability. Sodium, glucose, and calcium levels do not affect digoxin or contribute to digoxin toxicity.
Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet?
Show answer and rationale
Correct answer: B. Tomato juice.
Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice.
A client receiving a loop diuretic should be encouraged to eat which of the following foods?
Show answer and rationale
Correct answer: A. All of the above
Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of food high in potassium. Angel food cake, yellow cake, and peppers are low in potassium.
When assessing an older adult, the nurse finds the apical impulse below the fifth intercostal space. The nurse should further assess the client for:
Show answer and rationale
Correct answer: D. Left ventricular enlargement.
A normal apical impulse is found over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.
A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action?
Show answer and rationale
Correct answer: A. The client has become more somnolent.
A complication of balloon valvuloplasty is emboli resulting in a stroke. The client’s increased drowsiness should be evaluated. Some degree of mitral regurgitation is common after the procedure. The oxygen status and urine output should be monitored closely, but do not warrant concern.
A client is scheduled for a cardiac catheterization. The nurse should do which of the following preprocedure tasks?
Show answer and rationale
Correct answer: C. All of the above
For clients scheduled for a cardiac catheterization it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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