15. Key: C Client Need: Reduction of Risk Potential
C. Inflammation and swelling of the epiglottis can cause respiratory difficulties.
A. Epinephrine has not been proven effective in the treatment of epiglottitis.
B. A mist tent is not essential but may assist with treating epiglottis.
D. Tongue depressors are not essential at the bedside for this child.
16. Key: D Client Need: Physiologic Adaptation
D. A positive test for glucose may indicate the presence of cerebrospinal fluid.
A. The nurse should not pack the nares of a patient with a head injury.
B. The drainage is clear and does not require a culture and sensitivity.
C. Nasal suctioning should not be undertaken in the patient with a suspected head injury.
17. Key: A Client Need: Management of Care
A. If the individual is responsive, CPR may not be necessary. This action should be carried out first.
B. Responsiveness should be determined first.
C. Compressions should not be started until responsiveness and breathing are determined.
D. Responsiveness should be established first followed by breathing.
18. Key: B Client Need: Safety and Infection Control
B. Expectoration of mucus requires deep coughing rather than “spitting”.
A. Deep coughing is required to produce a sputum specimen.
C. Mucus collection does not have to occur at night.
D. Liquids may facilitate expectoration of mucus.
19. Key: D Client Need: Health Promotion and Maintenance
D. Control of blood glucose can decrease associated risks of gestational diabetes.
A. Daily exercise, such as walking, is recommended.
B. Diet should be tailored to the individual and provide sufficient calories for pregnancy.
C. Weight gain should be individualized, however, 4.4 lbs/month is high.
20. Key: A Client Need: Psychosocial Integrity
A. Fighting against restraints may compromise circulation.
B. Taking the patient to the bathroom would require release of all restraints, which is not an appropriate option.
C. Withholding food and fluid is not an appropriate treatment option.
D. Orienting to reality will not necessarily decrease fighting against restraints.
21. Key: B Client Need: Basic Care and Comfort
B. A quiet, pleasant atmosphere is conducive to eating.
A. Patients respond best to small frequent feedings.
C. Smooth-textured foods may be comforting but will not necessarily improve appetite.
D. Fluid intake between bites may create fullness more quickly and decrease appetite.
22. Key: D Client Need: Pharmacological and Parenteral Therapies
D. Nerve and blood cells need Vitamin B12 to function normally. A decrease in tingling in the feet would indicate a positive outcome of therapy.
A. Joint involvement is seen in sickle cell anemia.
B. Hearing is not affected in pernicious anemia.
C. Vision is not affected in pernicious anemia.
23. Key: C Client Need: Reduction of Risk Potential
C. A normal elimination pattern indicates that telescoping of bowel has been remedied.
A. Cessation of vomiting may be a result of treatment, but the best indicator of treatment effectiveness is normal elimination pattern.
B. Reduction of abdominal girth may be a result of treatment, but the best indicator of treatment effectiveness is normal elimination pattern.
D. A soft, non-tender abdomen may be a result of treatment, but the best indicator of treatment effectiveness is normal elimination pattern.
24. Key: C Client Need: Physiologic Adaptation
C. Washing hands before each catheter insertion is appropriate for home catheterization. It is a clean, rather than sterile, procedure.
A & B. Self-catheterization is a clean, rather than a sterile, procedure.
D. The catheter should be left in place until the bladder is emptied.
25. Key: A Client Need: Management of Care
A. The wound should be covered and kept moist.
B. Pressure should not be placed on an eviscerated bowel.
C. Finding should be reported after covering the wound and checking the patient’s vital signs.
D. Wound should be covered with a saline dressing. Hydrogen peroxide is too caustic for irrigating fluid.
26. Key: A Client Need: Safety and Infection Control
A. The dosage of Demerol is high. The normal range is 50–150 mg. This order should be questioned.
B, C & D. Valium and Phenergan are both appropriate for preoperative sedation. Atropine is appropriate for preoperative decrease in secretions. The dose listed is appropriate
27. Key: B Client Need: Health Promotion and Maintenance
B. Feeding pattern will provide information about weight loss/gain in infants.
A. Using another scale will not help to accurately interpret results.
C. Record of bowel movements is not the most important aspect of assessment.
D. Measurement of abdominal girth will not give information about weight loss.
28. Key: D Client Need: Psychosocial Integrity
D. Patients and families can meet to share what they have been experiencing, which helps all members to cope.
A. Patients respond better to family therapy, psychotherapy and support groups.
B. Patients with anorexia nervosa often enjoy reading about food preparation and preparing food but do not eat the food.
C. The focus should be on overall proper nutrition.
29. Key: D Client Need: Basic Care and Comfort
D. The patient has right-sided paralysis. The patient’s left side is not paralyzed and he is able to chew on that side.
A. The patient should not be fed using a syringe. This increases the possibility of aspiration.
B. There is an increased risk for aspiration since the patient has right-sided paralysis.
C. Position of the nurse is not relevant to food placement.
30. Key: B Client Need: Pharmacological and Parenteral Therapies
B. Maternal use of Accutane has been known to cause severe birth defects.
A. Hypertension is not a side effect of Accutane.
C. Treatment is usually given for 4 to 5 months. If a second course of therapy is needed, it should not be initiated until at least 8 weeks after completion of the first course. Experience has shown that clients may continue to improve while off Accutane.
D. Weekly blood tests are not required.
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