Feuer Nursing Review

NCLEX®-RN
Test Taking Strategies Booklet

2019 Edition
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Copyright © 2019 by Feuer Nursing Review.
All rights reserved. This book or any portion thereof
may not be reproduced or used in any manner whatsoever
without the express written permission of the publisher
except for the use of brief quotations in a book review.

Printed in the United States of America

First Printing, 2019

www.feuernursingreview.com
 Test Taking Strategies Booklet

Most students experience some level of anxiety when taking exams. A good NCLEX®-RN
review will decrease your anxiety, boost your self-confidence, give you focus and increase
your sense of being in control in addition to offering the most up to date content and test
questions.

After completing the Feuer Nursing Review you will be able to identify your areas of
strength as well as your areas of weaknesses and follow an organized, systematic and
realistic plan of study, which will maximize your time, effort and performance.

Knowing what to study, how to read/answer questions, how to study, and how to control
anxiety are factors that will influence how you perform on the exam.

3 Factors To Consider For Best Performance On The NCLEX®

1 What To Study?
2 How To Study?
3 How To Control Test Anxiety?

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Understanding the NCLEX® Test Plan and how to read/answer questions are critical factors
for NCLEX® Success.

The Test Plan: The NCLEX-RN Test Plan is developed by the National Council of State
Board of Nursing (NCSBN). It is based on:

1. Legal scope of nursing practice – It is described in the Nurse Practice Act for each
state. It guides and governs Nursing practice.
2. Practice Analysis – Nursing activities performed by newly licensed registered nurses.
It outlines content/knowledge that entry-level nurses must know to be considered
minimally competent, to perform safely and effectively as a newly, entry-level nurse.

2019 NCLEX®-RN Test Plan

Distribution of Content

Percentage of Items from each

Client Needs
Category/Subcategory

Safe and Effective Care Environment

§ Management of Care 17-23%

§ Safety and Infection Control 9-15%

Health Promotion and Maintenance 6-12%

Psychosocial Integrity 6-12%

Physiological Integrity

§ Basic care and Comfort 6-12%

§ Pharmacological Therapies 12-18%

§ Reduction of Risk Potential 9-15%

§ Physiological Adaptation 11-17%

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Safe and Effective Care Environment

§ Management of care (17-23%)
Priorities in patient care, concepts of management, delegation, confidentiality,
legal/ethical practice, client rights, informed consent, advance directives,
collaboration with multidisciplinary team
§ Safety and Infection Control (9-15%)
Prevention of accidents, errors, emergency response plans, ergonomic principles,
handling biohazardous materials, home and equipment safety, standard
precautions, asepsis, restraints, safety devices

Health Promotion and Maintenance (6-12%)

Aging process and developmental stages, ante/intra/postpartum/newborn care, high
risk behaviors, health promotion/disease prevention, principles of teaching and
learning, techniques of physical assessment

Psychosocial Integrity (6-12%)

Mental health concepts, therapeutic communication, coping strategies, end of life

care, chemical dependency, behavioral intervention/crisis, grief/loss, cultural,
religious/spiritual needs

Physiological Integrity

§ Basic Care and Comfort (6-12%)

Assistive devices, positioning, mobilization, nutrition, elimination, non-
pharmacological comfort measures
§ Pharmacological and Parenteral Therapies (12-18%)
Medication administration, side effects/contraindications, blood administration,
IV/parenteral therapy, central venous access devices, dosage calculation, pain
management, total parenteral nutrition
§ Reduction of Risk Potential (9-15%)
Pathophysiology, diagnostic tests/lab values, potential for alteration in body
systems, potential for complications of tests and procedures, assessment of
specific systems, pre and/or post-op education
§ Physiological Adaptation (11-17%)
Alteration in body systems, nursing procedures, pathophysiology, fluids and
electrolyte imbalances, medical emergencies, hemodynamics, unexpected
response to therapies

The chart above is only a summary of the nursing content you will be tested on the NCLEX®-
RN.

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Integrated Processes: The following concepts are integrated throughout the exam content.
The following processes are fundamental to providing effective nursing care:
§ Caring – essence of nursing; treating clients with respect and dignity is vital to
nursing practice
§ Communication – use of therapeutic communication addresses client’s feelings,
concerns, fears, etc.
§ Documentation – provides information regarding client’s health status and the care
given by health care professionals

Nursing Process

1. Assessment – The nurse gathers data to identify actual and potential health
problems. Database includes subjective and objective data.

2. Analysis – The nurse summarizes, interprets the assessment data and formulates
nursing diagnosis. Answering analysis questions requires an understanding of
principles of physiology, pathophysiology and application of critical thinking skills.

3. Planning – In this step, the nurse sets priorities, determines goals and develops
the plan of care in collaboration with other health care professionals. The
expected goals provide with direction in the selection of nursing interventions
and determine the criteria for evaluation. Answering planning questions requires
that the nurse give priority to actual problems over potential ones.

4. Implementation – The nurse completes nursing interventions required to reach

the desired goals. During this step, the nurse teaches, counsels, manages client
care, documents care provided and client responses. Some of these actions are
independent; (NO MD order is required) others do require a physician’s order.
Remember that on the NCLEX exam, your answer should be based on the ideal
situation where you have only one client and all the necessary resources, time and
supplies readily available. This is not always the case in reality.

5. Evaluation – Even though this is the final step of the nursing process, evaluation
is a continuous process which serves to compare the actual outcomes with
expected ones and determines the need to change the plan of care. Often these
evaluation questions are written in a false response format. For instance, the
question may ask for a client statement that reflects incorrect information related
to a particular issue.

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§ Teaching and Learning: Before any teaching/learning takes place, the nurse must
assess if the client is ready and motivated to learn.

Factors to consider:
1. Client’s learning needs
2. Client’s existing knowledge of the particular information
3. Physical and cognitive abilities.
4. Client’s age, education and developmental level
5. Assorted teaching methods and teaching tools. Client’s learning is evaluated
by observing the client’s performance of assigned task.

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NCLEX®-RN Test Questions: Test questions on the NCLEX address different levels of
cognitive abilities. Most of the questions you will find on the exam are written at the analysis
and application level.

Levels of Cognitive Abilities

Application Questions – tests whether or not you can apply newly learned information to a
particular clinical scenario. It requires the ability to prioritize information, concepts or
principles. It is a part of the Nursing process. You must determine which client data requires
immediate action to take.

Background Stem

Case or Scenario Question

A 55-year old client is admitted to the Which of the following actions would be most
telemetry unit with atrial fibrillation. appropriate for the nurse to take?
When preparing to administer the
Answers
prescribed digoxin (Lanoxin) 0.125 mg,
p.o., stat, the nurse auscultates an 1. Withhold the digoxin and notify the
irregular heart rhythm with an apical rate health care provider that the client has
of 92. an irregular heart rhythm.
2. Withhold the digoxin and recheck the
heart rate and rhythm in one hour.
3. Administer the digoxin and notify the
health care provider that the client has
an irregular heart rhythm.
4. Administer the digoxin and document
the heart rate and rhythm.

Correct answer is choice 4. In this example, you must have knowledge regarding the action of
digoxin, required client assessment prior to administration of digoxin, and then decide which
nursing action would be appropriate based on this knowledge and client data.

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Analysis Questions – tests whether you can identify critical from non-critical information. It
requires you to break down information into smaller components to get the correct
response. You must examine cause and effect relationships.

Background Stem

Case or Scenario Question

The nurse is caring for a 55-year-old Which of the following actions would be most
client on a telemetry unity. The client’s appropriate for the nurse to take?
electrocardiogram (ECG) rhythm strip is
Answers
illustrated below. The client has
prescriptions for the following 1. Withhold the digoxin and notify the
medications: Digoxin 0.125 mg, p.o. health care provider that the client has
daily; Furosemide 20 mg, p.o., b.i.d.; an irregular heart rhythm.
and Maalox 30 cc, p.r.n. It is 8:00 am. 2. Withhold the digoxin and recheck the
heart rate and rhythm in one hour.
3. Administer the digoxin and notify the
health care provider that the client has
an irregular heart rhythm.
4. Administer the digoxin and document
the heart rate and rhythm.

Correct answer is choice 4. In this example, you must recognize atrial fibrillation from an ECG
rhythm strip, the pathophysiology and clinical manifestations of atrial fibrillation, the
appropriate medical treatment for this problem, and the actions/possible interactions of
multiple medications the client is receiving.

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Types of Questions: You will be required to respond to questions in a variety of formats.

These formats may include:
1. Standard four option multiple choice – Requires that you select one response
from four different options. These type of questions represent the majority of
questions on the exam.
2. Multiple response or Select All That Apply (SATA) – Requires that you select one
or more than one response.
3. Fill-in-the-blank – Requires that you type in number(s) in a calculation question.
4. Hot spot items – Asks you to identify one or more area(s) on a picture or graphic.
5. Chart/exhibit – You will be presented with a scenario and will need to read the
information in the chart to answer the problem.
6. Ordered response – Asks that you place the options in a numerical or
chronological order.
7. Audio format – You will be presented an audio clip and asked to wear
headphones to listen and choose the option that applies. Example: lung sounds,
heart sounds
8. Graphic options – You will be presented with graphics instead of text for the
answer choices and asked to select the appropriate graphic answer.

Note: Any of these questions, including standard multiple choice may include charts,
tables or graphic images.

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§ Single-Response Multiple Choice

1. Background – It is a client-based scenario providing information about the client that
you need to answer the question, Pay attention to information about the client’s age,
family status and health status.
2. Stem (question) – Presents the problem to solve. The stem may be written as a direct
question such as “Which nursing intervention receives the highest priority?” or an
incomplete sentence such as “The nurse should…”. As you answer the questions,
relate the answer to the background information.
3. Options (answers) – These are possible responses to the stem. Each stem has one
correct option and three incorrect options or distractors.

Background Stem

Case or Scenario Question

How would the nurse interpret these
When reviewing the arterial blood gas results findings?
of a client, the nurse notes the following
results: Answers
1. Metabolic acidosis
pH 7.25 2. Metabolic alkalosis
CO2 41 mmHg 3. Respiratory acidosis
HCO3 17 mEq/L
4. Respiratory alkalosis

Choice 1 is correct. A pH of 7.25 is low and indicates acidosis. A CO2 (respiratory)

level of 41 is within normal range. An HCO3 (metabolic) level of 17 is low and indicates
acidosis. Therefore, the client’s arterial blood gas results indicate metabolic acidosis.
Choices 2, 3, and 4 are incorrect as they indicate a different arterial blood gas analysis.

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§ Multiple Response – You must select all that apply in this type of question. The options
are preceded by square boxes and you can check more than one box.

Which of the following are signs of readiness Correct answers: 1, 2, 4 & 7

for toilet training? Select all that apply. Additional signs of readiness include:
Ø Regularity in elimination.
ü 1. Able to remove clothing.
Ø The ability to walk and sit still.
ü 2. Desire to please the caregiver.
Ø The ability to communicate the
3. Awakening in the morning with a
need to defecate and urinate.
dry diaper.
ü 4. Caregivers have time and energy The caregiver or parent must:
to invest. Ø Be able to recognize signs of
5. Able to release safety latch on readiness.
toilet cover. Ø Have the time and energy to
6. Caregivers have small toys to invest (absence of other
serve as rewards. stressors)
ü 7. Able to recognize urges to
defecate and urinate.
8. Able to dress self.

The correct options are 1, 2 4 & 7. You must answer all correctly to get the question
right. No partial credit is given.

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§ Fill-in the Blank – Used for medication calculation, IV flow rate, intake & output record
questions. A calculator will be provided on the computer.

The order reads: Give acetaminophen 10mg/kg PO to a 44lb child.

How many mg should the nurse administer?

Answer: mg Correct answer: 200mg

44lbs ÷ 2.2 = 20kgs
20kg x 10mg/kg=200mg

Type only a number as your answer, including a decimal point if appropriate. If rounding
is necessary, perform the rounding at the end of the calculation. If directions indicate
that abbreviations are not acceptable, do not use them.

§ Hot Spot-Picture – “click” on the correct area with your mouse.

Anterior superior
iliac spine
Injection site
Greater trochanter
Iliac crest of femur

Identify the landmark where the nurse would administer a ventrogluteal injection.
Plan an X on the spot.

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§ Chart (exhibit) – Physician order, nurses note or lab sheet

A nurse reviews a female client’s medical record prior to medication

administration. The following information is available:

Labs: Value:
Calcium 10.4 mg/dL
Potassium 3.1 mEq/L
Sodium 141 mEq/L
Magnesium 2.1 mEq/L
Hemoglobin 13.8 g/dL
Hematocrit 44 %
White Blood Cell Count 19,200 per microliter

Vitals: Value:
Temperature (oral) 98.8o F
Pulse 52 bpm
Respirations 16 bpm
Blood Pressure 122/80 mmHg

Based on these results, which medication(s) will the nurse plan to hold?
Select all that apply.

1. Metoprolol
2. Potassium
3. Furosemide
4. Alprazolam
5. Vancomycin

Choice 3 is correct. The nurse will hold the client’s furosemide as the client’s
potassium level is low. Administering furosemide will likely result in a further
reduction in the client’s potassium level.
Choice 1 is incorrect as there is no need to hold the client’s metoprolol as the
client’s blood pressure is within a normal range. Holding the metoprolol will
likely result in a hypertensive state for the client.
Choice 2 is incorrect as the client’s potassium level is low.
Choice 4 is incorrect as there is no indication to hold this anti-anxiety
medication.
Choice 5 is incorrect as the client’s white blood cell count is elevated,
indicating a need for antibiotic therapy.

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§ Drag and Drop/Ordered Response Item

The floor nurse receives morning report and prepares to assess and assign the
clients. List in order of priority how the nurse will perform these assignments.

1. Client on an IV dobutamine drip and the pump is alarming.

2. Client preparing for discharge and the spouse is at the bedside.

3. Client with a chest tube to suction one-day post pneumothorax.

4. Client in wrist restraints on the bed with a sitter in the room.

5. Client from the ER three hours ago with a diagnosis of R/O acute
abdomen.

Correct order of priority:

1
1. Client on an IV dobutamine drip and the pump is alarming.
5
2. Client preparing for discharge and the spouse is at the bedside.

2
3. Client with a chest tube to suction one-day post pneumothorax.
4
4. Client in wrist restraints on the bed with a sitter in the room.

3
5. Client from the ER three hours ago with a diagnosis of R/O acute
abdomen.

Correct answers are choices 1, 3, 5, 4 and 2 respectively. A pump with a

continuous drip infusing vasoactive meds that is alarming is a priority. A one-day-
old chest tube is the second priority because it ultimately involves airway
assessment and is a current client admitted to the hospital. The client that is a new
admission is a rule out diagnosis and if positive signs of an acute abdomen were
present, the client would have gone to the ICU or even the OR. The nurse needs to
admit this client. The client with wrist restraints has a sitter but a nursing
assessment needs to occur. The discharged client can wait for instructions because
he is stable.

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§ Graphic Options

The nurse knows that which picture below is of a clinical manifestation primarily associated
with Lyme disease?

1. 2. 3. 4.

Choice 3 is correct. A classic clinical manifestation for Lyme disease is a bull’s eye rash
(erythema migrans). Choice 1 is incorrect as this rash on the client’s elbow is more
consistent with psoriasis. Choice 2 is incorrect as the butterfly rash on the client’s face is a
clinical manifestation of systemic lupus erythematosus (SLE). Choice 4 is incorrect as this
rash is consistent with hand-foot-mouth disease.

CONTENT AREAS
Safe and Effective Care and Environment
• Management of Care

The triage nurse is assessing clients arriving to the emergency department. Which client
will the nurse prioritize as requiring emergency care first?

1. A 44-year-old male client with a stab injury to the chest.

2. A 12-year-old male client with a suspected broken leg.
3. A 77-year-old female client recently discharged from the hospital with heart
failure.
4. A 56-year-old female client with clinical manifestations of a cerebral vascular
accident.

Rationale:
Choice 1 is correct. The nurse is aware that injury to the chest is a priority for triaging
clients in the emergency department. This client should be seen first.
Choice 2 is incorrect as a broken bone is a non-urgent situation.
Choice 3 is incorrect as there is no identified life-threatening or acute injury with this client.
Choice 4 is incorrect as a suspected CVA does not receive more priority over a traumatic
chest injury.

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• Safety and Infection Control

In order to best prevent nosocomial infections, the nurse should wash his/her hands under
which conditions? Select all that apply.

1. Immediately after removing gloves

2. Before and after eating
3. Between clean and dirty procedures on the same client
4. Before and after direct contact with client secretions
5. Before and after using the toilet

Rationale:
Choices 1, 2, 3, 4, and 5 are all correct. All of these choices are an integral part of an
infection control program and the prevention of nosocomial infections.

Health Promotion and Maintenance

A pregnant client arrives to the clinic for a 10 week prenatal exam. Which of the following
clinical findings would be considered abnormal?

1. Dark brown vertical line down her abdomen.

2. White, non-malodorous vaginal discharge.
3. Intermittent cramping that begins in the back and radiates to the abdomen
4. Increase fullness of the breasts.

Rationale:
Correct answer is Choice 3. Contractions that radiate from the back to the abdomen will cause
cervical dilation and are not normal at 10 weeks’ gestation.
Choice 1 is linea nigra which is a pigmentation that is normal during pregnancy. This is a
probable sign of pregnancy.
Choice 2 is called leukorrhea. Secretions of the vagina area increase during pregnancy due to
increased vascularization. These secretions are thick, white non-malodorous and acidic (pH 3.5-
6). This pH plays a role in preventing infections; however it also favors the growth of yeast
infections.
Choice 4 increase in the fullness of the breast is a normal and a probable sign of pregnancy.

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Psychosocial Integrity

A client diagnosed with bipolar disorder is exhibiting severe manic behaviors. The
psychiatrist prescribes lithium carbonate (Eskalith) and risperidone (Risperdal). The client’s
life partner asks about the need for the Risperdal. What should the nurse reply?

1. The Risperdal will help him sleep

2. The Risperdal and Eskalith are a good combination to decrease manic symptoms
3. The Risperdal will help calm your partner until the Eskalith reaches a therapeutic
blood level.
4. The Risperdal prevents the side effects of Eskalith

Rationale:
Correct answer is Choice 3. The nurse can educate the life partner that the Risperdal, which
is classified as an antipsychotic, will help calm the agitation and irritable behavior until the
Eskalith takes effect in 1-3 weeks. Choices 1 and 2 are true as the medication can have
sedative effects but it is not the primary action. Choice 4. It does not prevent side effects.

Basic Care and Comfort

Which gait-training technique is correct when teaching the client who has left leg weakness
to walk with a cane?

1. Placing the cane in the client’s left hand and moving the cane forward, followed by
moving the left leg one step forward.
2. Placing the cane in the client’s left hand and moving the cane forward, followed by
moving the right leg one step forward.
3. Placing the cane in the client’s right hand and moving the cane forward, followed
by moving the left leg one step forward.
4. Placing the cane in the client’s right hand and moving the cane forward, followed
by moving the right leg one step forward.

Rationale:
The correct answer is choice 3. After the cane in the right hand (stronger side) is moved
ahead, the cane and the stronger leg provide a stable base for movement of the weaker leg.
Placing the cane in the client’s left hand does not provide sufficient stability.
Choices 1, 2 & 4 could prove less reliable with respect to ambulation, and therefore be a
safety risk.

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Pharmacological and Parental Therapies

1. The nurse is preparing a dose of Tylenol for a 4-year-old 40-pound girl. The dosage
prescribed is 10 mg per kilogram, one time dose. The concentration of the
medication is 160 mg per 5 milliliters. How many milliliters should the nurse
administer?

Rationale:
Correct answer is 5.7 ml. The child’s weight must first be converted into kilograms: 40lbs.
divided by 2.2 is equal to 18.2 kilograms. 18.2 kg multiplied by 10mg is equal to 182 mg.
Available concentration: 160mg of Tylenol in 5ml equals 32mg per 1 ml. 182mg divided by
32 is equal to 5.7 ml.

2. A pregnant woman who is HIV positive is receiving Retrovir (zidovudine). The nurse
knows the clinical effects of retrovir is to:

1. Suppress the bone marrow activity.

2. Prevent viral replication.
3. Decrease the production of CD4 cells.
4. Increase the development of AIDS.

Rationale:
Correct answer is choice 2. Retrovir (Zidovudine) slows the progression of the disease
process by interfering with viral replication.
Choices 1, 3 & 4 are incorrect responses from treatment with Retrovir (Zidovudine).

Reduction of Risk Potential

A patient with a nasogastric tube gets a bolus feeding of 200 mL every 4 hours. Prior to
giving the bolus, the nurse aspirates a residual of 100 mL. After returning the residual to the
patient, the nurse should:

1. Give the 200 mL feeding.

2. Record the residual and give 100 mL of the feeding.
3. Document the residual and hold the feeding.
4. Position the patient in high-Fowler’s and give feeding.

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Rationale:
The correct answer is choice 3. Upon finding a large residual, the nurse should return the
residual to the patient, document the amount of the residual, and hold the feeding to avoid
possible aspiration. You would hold this feeding even if the client is repositioned in high-
Fowler’s because if aspiration exists, the threat for the client becomes pneumonia
development.

Physiological Adaption

When obtaining a health history on a child with suspected cystic fibrosis the nurse would be
most concerned with:

1. Recent strep throat that went untreated.

2. Peripheral cyanosis in the newborn period.
3. Two hospitalizations for pneumonia.
4. Vomiting after feedings.

Rationale:
Correct answer is 3. Frequent respiratory infection is a symptom of cystic fibrosis. The
respiratory mucous is excessively thick and difficult for the body to mobilize up the
respiratory tract. Other symptoms include: a history of meconium ileus, FTT and muscle
wasting, foul smelling, frothy stools, and salty tasting skin/sweat.
Choice 1, recent strept throat is associated with rheumatic fever and acute glomerular
nephritis.
Choice 2, peripheral cyanosis in the newborn period, also called acrocyanosis, is normal and
is not associated with any disorders.
Choice 4, vomiting after feeding is associated with GI obstruction, such as pyloric stenosis.

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Communication Questions: Communication questions will be presented in different clinical

scenarios: adult health, maternity & newborn, pediatrics or mental health area.

Guidelines:
1. Use therapeutic communication techniques for effective communication.
2. Avoid use of non-therapeutic communication techniques.
3. Focus on feelings, fears, concerns, anxieties from the client, the client’s family
member or hospital staff.
4. Keep in mind cultural differences – eye contact, physical gestures, touch and
language. Miscommunication may result from cultural differences in verbal and
non-verbal communication styles and patterns.

Sample Communication Question

The nurse would be most therapeutic using the following approach with the antisocial
patient:

1. Permissive and accepting

2. Distant and firm
3. Talking in a matter-of-fact way
4. Warm and engaging

Correct answer is 3. Being matter-of-fact reduces the untoward effects of

manipulation, such as flattery, seductiveness, or instilling guilt. It also reduces power
struggles.

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Sample Communication Question

A pregnant woman states she wants to leave her husband because he doesn’t
understand her moods. Which of the following would be the best response by the
nurse?

1. “Have you discussed this with him?”

2. “It seems like you’re making this decision alone.”
3. “It sounds like you and your husband are having some difficulties
understanding the problems caused by pregnancy.”
4. “Do you really want to leave him?”

Correct answer is 3. This answer demonstrates empathy to both partners. It also

allows the client to tell the nurse more about her feelings.

Priority Questions: Questions on prioritizing nursing actions can be challenging considering

that all the options presented are correct but you need to place them in the right sequence.

Stems found in priority questions:

1. What should the nurse do first?
2. Which nursing intervention receives the highest priority?
3. Which of the following actions should the nurse take initially?
4. Which of the following would be most important?
5. Which of the following interventions would be essential?

Factors to consider when establishing priorities:

1. Safety: A safety situation must be addressed immediately.

Example: A patient having an insulin reaction, allergic reaction or choking.
2. Timing: Some meds, blood levels, tests and vital signs are ordered at specific
times.
Example: Peak and trough blood levels for Gentamycin.
3. Interdependence of Events: You must know whether some task must occur before
the other task can take place.
Example: Checking fingerstick should be done prior to administering insulin.

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Steps in Decision Making Process:

1. Determine Status and Stability of each Patient: Take into consideration the disease
process, clinical setting, possible complications and lab test results. The nurse must
have knowledge of anatomy, physiology, pathophysiology, S/S of disease process,
drug actions, side effects and contraindications, normal lab values and medical
emergencies.
2. Decide What to Do First: You need to make a list of all the needs/problems of each
patient. The most immediate needs for the patients in the group should be
identified.

First Level Care Priorities:

§ Life threatening problems
Ø Acute Adrenal Crisis
Ø Acute Appendicitis
Ø Acute Upper GI Bleed
Ø Anaphylaxis
Ø Autonomic Dysreflexia
Ø Cardiac Tamponade
Ø Contrast Reaction
Ø Disseminated Intravascular Coagulation (DIC)
Ø Epiglotittis
Ø Hyperglycemia/Hypoglycemia
Ø Hyperkalemia/Hypokalemia
Ø Ischemic Stroke
Ø Lethal Dysrythmias
Ø Myxedema Coma
Ø Neuroleptic Malignant Syndrome
Ø Pacemaker Malfunction
Ø Perforated Peptic Ulcer
Ø Pulmonary embolism
Ø Retinal Tear
Ø Ruptured Ectopic pregnancy
Ø Shock
Ø Sickle Cell Crisis
Ø Stroke
Ø Subdural Hematoma

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Ø Tension Pneumothorax
Ø Thyroid Storm
Ø Transfusion Reaction
Ø Vesicant Extravasation
Ø Wound Dehiscence

§ Findings that indicate a worsening condition – Example: BUN of 40

§ Untreated medical problems threatening the patient’s health status – A
hypertensive patient with a high blood pressure reading who runs out of his
medication
§ Abnormal lab findings that require treatment – Example: High BUN, high ammonia
levels
§ Large fluid deficit or excess
§ Pain without any treatment orders
§ Acute change in vital signs – B/P 160/90 – 190/130
§ Administration of IV medications

Second Level Care Priorities: These are not life threatening. They are urgent events
that do not threaten life but could result in physical or emotional impairment.
§ Scheduled medications
§ Discharge teaching
§ Mental status changes
§ Acute pain relief
§ Acute urinary elimination
§ Risks for infection
§ Threats to safety and security

Third Level Care Priorities:

§ Comfort and hygiene
§ Physical mobility
§ Knowledge deficit
§ Family coping

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3. Decide What Needs to be Done: The nurse must decide what is urgent and what
can wait. She should ask herself this question, “If treatment or care is delayed, will
the patient suffer harm?”

1. Life threatening issues – A-B-C (airway, breathing, circulation)

2. Maslow’s Hierarchy of Needs

5
Self-Actualization

4 | Self-Esteem

3 | Love and Belonging

2 | Safety and Security

1 | Basic Physiological Needs

3. Safety – Fall prevention, safety devices, seizure precautions

4. Client priorities – Examples: Obtain informed consent prior to procedure, client
scheduled for diagnostic test, deadlines

Sample Priority Question

You have been assigned to care for a client who is S/P adrenalectomy. Which assessment would
be a priority?

1. Assess blood pressure.

2. Assess neurological status.
3. Assess urine output.
4. Assess for cyanosis.

Correct answer is 1. After an adrenalectomy, the nurse must monitor the patient for signs and
symptoms of impending shock. Shock can manifest as a drop in blood pressure, a weak, thread
pulse or a change in urinary output. It is important to remember that the patient’s pulse and
blood pressure may be unstable for up to 48 hours after surgery. Although a decrease in urine
output may be a sign of shock, it is usually precipitated by a fall in the patient’s blood pressure.
So choice 1 is correct and choice 3 would occur later. Choice 2 & 4 are not priority assessments.

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Sample Priority Question

Which of the following clients would the nurse assess first?

1. A one month old sleeping for six hours with a temperature of 38.5°C.
2. A six month old pulling on his ear.
3. A two year old with a temperature of 39°C playing with his mother.
4. A six-year-old who has a complaint of diarrhea for two days.

Correct answer is 1. A one month old with an elevated temperature needs to be evaluated for
sepsis. At one month the immune system is still immature and an infection in one body system
can easily spread to another, therefore it is important to do a more thorough evaluation of any
baby under three months old with a fever, also six hours of continuous sleeping is altered
behavior for a child this young. Choice 2 is a baby with a possible ear infection, Choice 3 is a
two year old with a fever, but who is demonstrating normal behavior. Choice 4 is a child who
can maintain his hydration status by taking PO fluids.

Delegating and Assignment Making Questions: The nurse must consider the roles of
available personnel and the tasks that can be legally delegated.

Principles of Delegation: Sources that provide guidelines for safe delegation.

§ The State Nurse Practice Act: provides legal definition of nursing practice and the
scope of practice for that state.
§ Institutional Policies and Procedures, Job Descriptions and Training. JCAHO
provides guidelines for institution standards.

5 Rights of Delegation that must be used when assigning care to others are:

1. Right person
2. Right task
3. Right circumstances
4. Right directions and communications
- 4 C’s: Clear, Concise, Correct, Complete
5. Right supervision and evaluation

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Factors to consider when delegating or assigning duties:

§ The potential for harm to the patient.
§ The patient’s medical condition.
§ The complexity of the task.
§ The unpredictability of the outcome
§ The nurse must decide the best use of available staff to provide safe, competent
and effective care for every client.

Room Assignment: Factors to consider when assigning room to patients.

§ Bed availability
§ Patient’s level of consciousness. If the patient appears confused he needs to be
placed close to the nurses’ station
§ Infectious diseases. The patient needs isolation or special precautions
§ Patient gender
§ Patient age
§ Special needs or equipment
§ Available staff

RN Scope of Practice: “The RN is prepared by education and clinical experience to

assess, diagnose, plan implement and evaluate nursing care in all settings” (NYSNA,
2007).
§ Performs complex procedures (Example: Developing the nursing care plan,
interpreting EKGs, starting IVs, sterile procedures, etc.).
§ Performs client/family teaching.
§ Directs and supervises care provided by LPNs and assisting personnel.
§ Appropriate assignment. Unstable patients with least predictable outcomes

LPN Scope of Practice: LPNs can provide care to medically stable patients with
established plans of care and predictable outcomes. The LPN is a dependent practitioner
who must practice under the direction of an RN, MD.
§ Collects data and reporting findings
§ Administer oral, subcutaneous, and intramuscular medications.
§ Start a peripheral IV infusion, administering plain IV solutions.
§ Administer subsequent doses of IV antibiotics.
§ Assist with identification of blood units for transfusion.
§ Changes dressings.
§ Irrigates wounds.
§ Monitor IV flow rate
§ Suctions tracheostomy
§ Performs urinary catheterization.

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Specific Activities Beyond LPN Scope of Practice

§ While LPNs cannot do patient assessments, they can do data collection.
§ LPNs cannot independently develop the nursing plan of care.
§ LPNs cannot administer IV chemotherapy. However, bladder instillation of
chemotherapy by LPNs is permissible.
§ LPNs cannot administer any medication (except saline and heparin flushes) by
direct IV push technique, or administer an IV fluid bolus for plasma volume
expansion, except in the care of patients with chronic renal hemodialysis.
§ LPNs cannot draw blood from any central line, remove a central line, re-
establish patency in a central line, or change dressings and/or heparin lock
caps in any central line. They cannot access or flush any venous chest or arm
port line device.
§ In home care/hospice, LPNs cannot administer initial IV doses of any
medication or be involved in any procedures involving central lines.
§ LPNs cannot do triage, case management or mental health counseling.
§ LPNs cannot administer a first dose of IV antibiotics.
§ LPNs cannot start a blood transfusion.
§ LPNs cannot monitor and administer parenteral nutrition.

Clinical Supervision
§ LPNs can delegate and supervise other LPNs in the delivery of care within the
LPNs legal scope of practice and level of competency.
§ LPNs can supervise assistive personnel in the delivery of care.
§ In long term care settings, an RN must be on site at least eight hours of the
day and immediately available by telephone at other times if professional
nursing care needs to be delivered.
§ When an LPN is delivering home care, an RN must be immediately available
by telephone.

UAP (Unlicensed Assistive Personnel) Job Description

UAPs may assist the RN/PN with activities that are not in the legally protected scope of
nursing practice. These health related activities do not require use of professional
judgment, critical thinking skills, or provision of skilled care. They can be completed
using standard procedures requiring no modification (NYSNA, 2007).

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Appropriate delegation: stable patients who need routine procedures with predictable
outcomes.

1. What you can Delegate

§ ADLs (feeding, drinking, ambulating, positioning, range of motion exercises,
grooming, toileting, dressing, care of nails, hair and skin)
§ Vital signs – the UAP is not qualified to evaluate the results
§ Clean dressing without assessment
§ Basic Intake & Output (I & O)
§ Oral suctioning and mouth care
§ Using glucometers
§ Assistance with braces and prosthesis
§ External catheter care
§ Specimen collection: urine and stool
§ Non nursing functions (transporting, cleaning, clerical work, answering the
telephone)
§ Collect, report and document simple data

2. What you cannot delegate

§ Initial nursing assessment
§ Determination of nursing diagnoses
§ Establishment of nursing care goals
§ Development of nursing plan of care
§ Evaluation of patient’s progress
§ Health counseling or teaching
§ Activities that require specialized nursing knowledge, skill or judgment

How to minimize your liability: Make sure you delegate a task the UAP is competent to
perform or you may be liable if his/her actions cause harm to the patient.

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Delegation Procedure: For effective delegation, the nurse utilizes the nursing process.
1. Assessment: The nurse determines what patient care is required – list of patient
needs.

2. Analysis: The nurse must analyze the level of care and complexity of each assigned
patient’s needs. Pertinent questions include:
§ Is the physical status of the patient expected to change?
§ What are the risks for complications?
§ Does the patient need routine care or care that requires advance assessment
skills?
§ Will there be adequate supervision available?
§ Is the staff properly trained and competent for specialized procedures that may
be needed?
The nurse who should perform specific aspects of care takes into consideration
the outcomes of the intervention.

3. Outcome Identification: The nurse develops outcomes for each of the patient’s
nursing diagnosis. He/she identifies tasks needed to achieve these outcomes and
selects the appropriate health care worker to perform these tasks.

4. Plan: In the planning phase, the nurse assigns patients to available staff. The nurse
uses the outcomes of the interventions to determine who should be performing the
specific aspect of care.

5. Implementation: In the implementation phase, the nurse communicates expectation

to health care workers.

6. Evaluation: In the evaluation phase, the nurse compares outcomes with the plan of
care. If outcomes were not reached, the nursing care plan is examined, modified and
changed to meet the patient’s individual needs.

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Sample Delegation Question

The charge nurse is planning client assignment for the oncoming shift. One of the
nurses on this shift is a LPN. Select all the nursing activities that could safely be
assigned to the LPN.

1. Monitoring parenteral nutrition.

ü 2. Administering a subcutaneous injection of epoetin.
ü 3. Assisting with identification of blood units and blood transfusion.
4. Administering a first dose of antibiotic.
ü 5. Administering subsequent dose of antibiotic.
ü 6. Collecting data.

Correct answers are 2, 3, 5, & 6.

Sample Delegation Question

A RN is planning the client assignments for the evening shift. Which of these patients
should the nurse maintain direct care and not assign a certified nursing attendant?

1. A client with compound fracture of the leg requiring an x-ray.

2. A client with a stroke who was removed from the ventilator three days ago
and has requested a bath.
3. A client with chronic obstructive pulmonary disease (COPD) who is
complaining of shortness of breath.
4. A client with a history of hypertension who needs his blood pressure taken.

Correct answer is 3. This client will need to be assessed by an RN. Choices 1, 2, & 4,
the nursing assistant can competently and legally perform these tasks.

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Sample Delegation Question

A charge nurse is planning client assignments for the day shift. There is a RN, a LPN,
and a nursing assistant on the nursing team. Which client would the charge nurse
most appropriately assign to the RN?

1. A 34-year-old whose urine has tested positive for marijuana and cocaine
demanding pain medications. He threatens to sue if he doesn’t get some
immediately.
2. A 6-year-old girl brought in by her parents who suspect that she may have
ingested medications that belonged to her grandmother. She responds to
painful stimuli, has a BP of 80/50, HR 148, RR 10 (shallow and labored).
3. A 17-year-old boy, four days post open reduction-internal fixation who
needs his Foley removed.
4. A 45-year-old diabetic with cellulitis and stasis ulcers of the left lower leg
who needs wound care.

Correct answer is 2. This client is experiencing S/S of shock and needs to be closely
monitored and treated: IV fluids, vital signs, indwelling urinary catheter, blood
specimen, etc.

Pharmacology Questions
Remember these 8 principles when answering pharmacology questions.

1. Learn medications by classifications and be familiar with both generic and trade
names. On most occasions, the exam will only use generic medication names.
Identifying the classification will assist you in determining a medication’s action or
side effects.
- Ex: Aminoglycosides end in Mycin (Garamycin, Streptomycin, …) which have
ototoxic and nephrotoxic side effects.
- Other examples: Beta Blockers end in olol, anti-virals end in vir, anti-migraine
medications end triptan, ACE inhibitors end in pril, Lipid lowering drugs end
in statin.

2. Recognize the common side effects associated with each medication classification
and the appropriate nursing interventions.
- Ex: Anti-cholinergic medications cause dry mouth. Nursing intervention: suck
on sugar free hard candy.

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3. Read what the question is asking: therapeutic effect peak and trough, allergic
reaction, toxic effect, adverse effect.

4. Understand common drug to drug interactions, food interactions, drugs on empty

stomach.

- Clients on MAO Inhibitors should avoid foods with tyramine (hard cheeses, smoked
meats, chocolate). Clients on Warfarin should avoid foods with Vitamin K (green leafy
vegetables). Clients on antibiotics or statins should avoid grapefruit juice.
- Calcium can decrease the absorption of some antibiotics, such as tetracycline,
ciprofloxacin, or alendronate.
- Give antacids on an empty stomach because some medications need an acid
environment. Iron supplements are given on an empty stomach for best absorption.

5. 7 Rights of Safe Medication Administration

1. Right medication
2. Right client
3. Right dose
4. Right time
5. Right route
6. Right reason
7. Right documentation

6. Pediatrics and Medication Safety

- Dosages are based on size (BSA), weight. & age
- Children have immature kidneys/liver, and have smaller muscle size. They will need
less volume of medication.
- They have thinner skin and medication absorbs more rapidly

7. Pregnancy and Medication Safety

Avoid:
- Aspirin
- Acne medications: large doses of Vitamin A can cause birth defects and liver
toxicity
- Category X drugs: Studies have demonstrated fetal abnormalities, or there is
evidence of fetal risk. Ex: tetracyclines, ACE inhibitors, and most
antineoplastics.

8. Elderly and Medication Safety

- Be cautious of polypharmacy (the simultaneous use of multiple drugs by the elderly
to treat a single condition). The use of multiple medications contribute to cognitive
impairment, falls, and urinary incontinence.

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Test Taking Tips

1. Determine the number of days you have left before the exam.
2. Plan your study schedule based on the time you have available. A minimum of 2-5
weeks is recommended. We have included a 60 day study calendar for you at the end
of this chapter.
3. Decide the length of each day’s study session that will allow you to completely cover
all the material that needs to be learned (areas of weakness) as well as the material
that only needs to be reviewed (areas of strength).
4. Spend a minimum amount of time with math problems.
5. Do not memorize, it is a poor substitute for knowledge.
6. Your goal should be to understand and apply principles of nursing.
7. Begin studying the material you identified as your areas of weakness.
8. Start with 60-75 minutes blocks of time in a place, which is peaceful, quiet and free of
disruptions.
9. Divide the material into manageable tasks to avoid feeling overwhelmed.
10. Establish regular times for study when you are normally more awake and/or most
efficient.
11. Be consistent and stay focused.
12. Know your learning style. Decide what works best for you to study alone or in a
group, and if you are a visual or an auditory learner.

Guidelines
1. Assessment before intervention
2. Least invasive first
3. Take all possible relevant actions before calling the HCP
4. Set who to see first – most physiologically unstable and most at risk
5. Take into account client’s culture and spiritual beliefs

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Improving Your Memory: Design flash cards with information that is hard to remember or
understand. Example: Blood gases, Lab values, Acid Base Balance, Immunizations, guidelines
for delegation/prioritization of client care, disaster management, therapeutic communication
skills, etc.

Specific Test Taking Strategies:

§ Reading the question carefully is one of the most important aspects of successful test
taking. Take your time. Go at your own pace. Do not skip any options. Ask yourself,
“What is this question asking?” and “What is the expected response?”
§ Rephrase the question in your own words. Do not “read into” a question meaning
that is not intended and do not make a question more difficult than it is. If you do not
understand the question, try to figure it out. If, for example, the question is asking
about the fluid balance needs of a client with Diabetes Insipidus and you do not
remember what Diabetes Insipidus is then try to answer the question based on your
knowledge of principles of fluid balance.
§ Pay attention to key words. These words qualify what the question is asking as well as
limit the scope of the answer choice.
1. Early or late
2. Avoid/Refute
3. Understanding/lack of understanding
4. Needs reinforcement of the instructions
5. Ineffective, inadequate, inappropriate
6. Immediately, initial, first, best
7. Highest or lowest risk
8. Needs additional teaching
9. Most appropriate or least appropriate
10. Most likely or least likely
11. On the day of
12. After several days

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FEUER NURSING REVIEW 62 DAY STUDY CALENDAR

We created this study calendar to help you maximize your time, effort, and performance.
We suggest you use this calendar in conjunction with the FNR NCLEX® Online Review.

MEDICAL SURGICAL NURSING

Day Content Areas Quizzes
Day 1 Management of Care
• Prioritization
• Priority Quiz
• Delegation
• Legal Issues Quiz
• Leadership
• Management of Care Quiz
• Documentation
• Ethical & Legal Issues in Nursing

Day 2 Safety & Infection Control

• Standard Precautions
• Droplet Precautions
Day 3 Safety & Infection Control
• Safety Quiz
• Airborne Precautions
• Safety & Infection Control Quiz
• Contact Precautions
• Disaster Nursing Quiz
• Disaster Nursing

Fundamentals of Nursing
• Emergency Nursing Quiz
• Emergency Nursing
Day 4 Fundamentals of Nursing
• Fluids and Electrolytes
• Na
• K
Day 5 Fundamentals of Nursing
• Fluids and Electrolytes
• Ca
• Mg
Day 6 Fundamentals of Nursing
• Acid Base Balance • Fundamentals of Nursing Quiz
• Shock
Day 7
You deserve a rest day! Have fun with friends and family.

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Cardiac Disorders
• Cardiac Assessment
Day 8
• EKG Basics
• Dysrhythmias
Cardiac Disorders
• Angina vs MI
• Heart Failure
Day 9 • Cardiac Disorders Quiz
• Heart Surgery
• Vascular Disorders
• Cardiac Medications
Respiratory Disorders
• Respiratory Assessment
• Pneumonia
Day 10
• Tuberculosis
• COPD
• Respiratory Medications
Respiratory Disorders
• Asthma
• Chest Trauma
Day 11 • Respiratory Disorders Quiz
• Chest Tubes
• Tracheostomy
• Mechanical Ventilation
Gastrointestinal Disorders
• Gastrointestinal Assessment
• GERD
Day 12 • Peptic Ulcer
• Gastric Surgery
• Diverticular Disease
• Crohn’s vs. Ulcerative Colitis
Gastrointestinal Disorders
• Colostomy vs. Ileostomy
• Enteral Feeding
• Intestinal Tubes
Day 13
• Apendicitis
• Peritonitis
• Intestinal Obstruction
• Gastric Tubes
• Hernias

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Gastrointestinal Disorders
• Liver Function and Diagnostic Test
• Hepatitis
• Cirrhosis • Hepatic Quiz
Day 14 • Esophageal Varices • Gastrointestinal Disorders
• Cholelithiasis Quiz
• Pancreatic Cancer

Oncological Disorders
• Warning Signs of Cancer
• Guidelines for Early Cancer
Detection
• Oral Cancer
Day 15 • Lung Cancer
• Laryngeal Cancer
• Stomach Cancer
• Hodgkin’s Disease
• Breast Cancer

Oncological Disorders
• Cervical Cancer
• Endometrial Cancer
• Ovarian Cancer
Day 16 • Oncology Quiz
• Colorectal Cancer
• Oncological Emergencies
• Cancer Treatment

Endocrine Disorders
• Endocrine Assessment
• Addison’s vs. Cushing’s
Day 17 • Hypothyroidism vs.
Hyperthyroidism
• Hypoparathyroidism vs.
Hyperparathyroidism
Endocrine Disorders
Day 18 - Endocrine Disorders Quiz
• Diabetes Mellitus

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Renal Disorders
• Renal Assessment
• Acute vs. Chronic Renal Failure
Day 19
• Peritoneal Dialysis vs.
Hemodialysis
• CAPD
Renal Disorders
• Urinary Tract Infection
Day 20 • Renal Calculi
• Renal Disorders Quiz
• Benign Prostatic Hypertrophy
• Bladder Cancer/Ileal Conduit

Day 21 You deserve a rest day! Have fun with friends and family.

Musculoskeletal Disorders
• Osteoporosis
• Paget’s Disease
• Sprains
Day 22 • Carpal Tunnel Syndrome
• Fractures
• Acute Compartment Syndrome
• Fat Embolism Syndrome
• Cast Care
Musculoskeletal Disorders
• Traction
• Crutch Walking
• Total Knee Replacement
• Total Hip Replacement
• Musculoskeletal and
Day 23 Connective Tissue Disorders
Connective Tissue Quiz
• Lupus
• Gout
• Rheumatoid Arthritis vs.
Osteoarthritis
• Lyme Disease

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Eyes Disorders
• Cataracts
• Glaucoma
• Retinal Detachment
Day 24
• Macular Degeneration
• Care of Patient with Visual
Impairment

Ears Disorders
• Hearing Loss
• Meniere’s Disease • Eyes and Ears Disorders
Day 25
• Care of Patient with Hearing Quiz
Impairment

Neurological Disorders
• Neurological Assessment
• CVA/Stroke
Day 26 • Traumatic Brain Injury (TBI)
• Increased Intracranial Pressure
(IICP)

Neurological Disorders
• Spinal Cord Injury
• Autonomic Dysreflexia
Day 27
• Amyotrophic Lateral Sclerosis
(ALS)
• Guillain-Barré Syndrome (GBS)

You deserve a rest day! Eat healthy foods, drink plenty of water,
Day 28
meditate and sleep well.

Neurological Disorders
• Multiple Sclerosis (MS)
• Myasthenia Gravis (MG) • Neurological Disorders
Day 29
• Bell’s Palsy Quiz
• Parkinson’s Disease

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Integumentary Disorders
• Pressure Ulcers
• Burns
Day 30 • Herpes Zoster • Integumentary Quiz
• Psoriasis
• Latex Allergy

Medical Surgical Comprehensive Exam

Day 31

PHARMACOLOGY
Basic Principles of Pharmacology
• Medication Administration Pharmacology questions
• Basic Pharmacology are integrated throughout
Day 32
• Intravenous Route the PowerPoint
• Special Considerations presentation

Basic Principles of Pharmacology

• Major Drug Classifications
• Medications Affecting the
Autonomic Nervous System

Neurological Medications
Day 33 • Anticonvulsants
• Opioids and Analgesic
• NSAIDs
• Anti-Parkinson’s Agents
• Medications to treat Multiple
Sclerosis
Pharmacology questions
are integrated throughout
Neurological Medications
the PowerPoint
• Alzheimer’s Medications
presentation
• Antidepressants
• Mood stabilizing Drug
• Anti-Anxiety Medications
• Sleep Medications

Day 34
Cardiac Medications
• Diuretics
• Antihypertensives
• Calcium Channel Blockers
• Beta blockers
• Vasodilators
• Antidysrthymics

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• Statins
• Antianginals
• Nitroglycerin
• Anticoagulants

Anti Infectives
• Antimicrobials
• Antivirals

Respiratory Medications
• Antiasthmatics
Day 35 • Corticosteroids
• Mucolytics
Gastrointestinal Medications
• Antacids
• Histamine Antagonists
• Proton Pump Inhibitors

Pharmacology questions
Gastrointestinal Medications
are integrated throughout
• Antipeptics
the PowerPoint
• Antiemetics
presentation
• Antidiarrheals

Day 36
Endocrine Medications
• Insulin
• Oral Hypoglycemics
• Adrenal Agents
• Thyroid Replacements
Nutritional Supplements
• Herbal Supplements
• IV Therapy
Day 37
• Blood Transfusions
• Hyperalimentation
• Dosage Calculations

Day 38 Rest day! Relax and unwind!

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MATERNAL NEWBORN NURSING

Menstrual Cycle
• Menstrual Cycle

Day 39 Women’s Health

- Methods of Contraception
• Infertility

Women’s Health
• STDs • Women’s Health Quiz
Day 40
• Menstrual Cycle Disorders

Antepartum Nursing
• Pregnancy
• Antepartum Care
Day 41 • Maternal Screening Tests
• Screening Tests to Evaluate Fetal
Growth

Antepartum Nursing
• Complications During Pregnancy
• Antepartum Quiz
Day 42 • Abortion
• Ectopic Pregnancy

Intrapartum Nursing (L&D)

• Stages of Labor
Day 43 • Obstetric Procedures
• Anesthesia

Intrapartum Nursing (L&D)

• Intrapartial Concerns
• Fetal Distress
• Labor & Delivery Quiz
Day 44 • Prolapsed Umbilical Cord
• Amniotic Fluid Embolism
• Uterine Rupture
• Intra-Uterine Fetal Death
Postpartum Nursing Care
• Postpartum Infection
• Hemorrhage
• Post Partum Quiz
Day 45 • Newborn Assessment
• Newborn Implications
• Asphyxia
• Hypoglycemia

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• Premature Newborn
• Hyperbilirubinemia
• Small for Gestational age vs.
Large for Gestational age
• Post Mature Infant
• Breast milk vs. Formula
• OB drugs

Day 46 Maternal Newborn Nursing Comprehensive Exam

Rest Day! Maintain a balance between your work, studies, family and
Day 47
friends!
PEDIATRIC NURSING
Growth and Development of the
Infant
• Growth and Development of the
Infant
• Immunizations
• Nutrition
• Anticipatory Guidance
• Infancy Quiz
Day 48 • Toddler Quiz
Growth and Development of the
Toddler
• Growth and Development of the
Toddler
• Nutrition
• Toilet Training
• Issues Related to Hospitalization
• Anticipatory Guidance

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Growth and Development of the

Pre-schooler
• Growth and Development of the
• Pre-schooler
• Nutrition
• Issues Related to Hospitalization
• Anticipatory Guidance

Growth and Development of the

School Age
• Growth and Development of the • Preschool Quiz
School Age • School Age &
Day 49
• Nutrition Adolescence Quiz
• Issues Related to Hospitalization
• Anticipatory Guidance

Growth and Development of the

Adolescence
• Growth and Development of the
Adolescence
• Nutrition
• Issues Related to Hospitalization
• Anticipatory Guidance

Growth and Development

• Basic Pediatric Care
• Medication Administration
• Motor Vehicle Safety
• Basic Pediatric Care Quiz
Day 50 • Concept of Death
• Poisoning
• Child Abuse
• Pediatric Triage

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Cardiac Disorders
• Congenital Heart Defects
• Acquired Defects
• Rheumatic Fever
• Kawasaki’s Disease

• Pediatric Cardiac
Gastrointestinal Disorders
Disorders Quiz
• Gastroenteritis
Day 51 • Gastrointestinal
• Failure to Thrive (FTT)
Disorders Quiz
• Cleft Lip vs. Cleft Palate
• Intussusception
• Hirschsprung’s Disease
• PKU
• Celiac Disease
• Pinworms

Respiratory Disorders
• Croup
• Epiglottitis
• Foreign Body Aspiration
• Tonsillectomy
• Asthma
• Cystic Fibrosis
• Respiratory Disorders
Quiz
Hematological Disorders
Day 52 • Peds Renal Disorders
• Leukemia
Quiz
• Sickle Cell Anemia
• Iron Deficiency Anemia
• Hemophilia

Renal Disorders
• Nephrotic Syndrome
• Acute Glomerulonephritis (AGU)

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Neurological Disorders
• Meningitis
• Hydrocephalus
• Spina bifida
• Myelomeningocele
• Peds Neurological
• Cerebral Palsy
Disorders Quiz
• Down’s Syndrome
• Musculoskeletal
Day 53 • Autism
Disorders Quiz
• Lead Poisoning

Musculoskeletal Disorders
• Congenital Hip Dysplasia
• Scoliosis
• Juvenile Rheumatoid Arthritis

Day 54 Pediatric Nursing Comprehensive Exam

PSYCHIATRIC NURSING
Nurse Client Relationship
• Therapeutic vs. Non Therapeutic
Communication
Day 56 • Legal and Ethical Aspects
• Charge Duties
• Theories of Personality

Nurse Client Relationship

• Anxiety and Defense Mechanisms
• Grief Response
• Nurse-Client, Legal &
Day 57 • Boundaries and Limit Setting
Ethical Quiz
• Crisis Intervention
• Abuse and Family Violence

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Anxiety Disorders
• Obsessive Compulsive Disorder
(OCD)
• Anxiety Disorders Quiz
Day 58 • Post-Traumatic Stress Disorder
(PTSD)
• Anti-Anxiety Medications

Schizophrenia
• Schizophrenia
Day 59
• Antipsychotics

Mood Disorders
• Depression
• Suicide
• Schizophrenia & Mood
Day 60 • Anti-Depressant Medications
Disorders Quiz
• Mania
• Anti-Manic Medications

Personality Disorders
• Anti-Social Personality
• Borderline Personality

Neurocognitive Disorders
• Substance Abuse
• Addictions
• Personality Disorders
• Alcoholism
Quiz
Day 61 • Nursing Care of the patient using
• Neurocognitive & Eating
Opioids, Stimulants, and CNS
Disorders
Depressants
• Delirium
• Dementia
• Alzheimer’s

Eating Disorders
• Anorexia vs. Bulimia

Day 62 Psychiatric Nursing Comprehensive Exam

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Preparing to take the NCLEX® can produce a great deal of anxiety. You may be thinking
that there is a lot of content that you need know and that you do not know the best way to
study. It is normal to feel overwhelmed and scared. Having a positive mindset, a structured
plan with goals and steps, and maintaining control and balance will decrease your test
anxiety and help you gain a sense of control to reach your goal.

Mild anxiety can be a motivating factor and doesn’t interfere with your ability to think
clearly, concentrate and overall performance. However, high levels of anxiety will interfere
with concentration and make it difficult or impossible to answer questions correctly. Some
relaxation techniques include guided imagery, breathing exercises and positive self-
talk/affirmations.

You can consciously choose to change your negative thoughts and beliefs at any time and by
doing so; you can manage your level of anxiety. It is important that you stop negative
thinking before it lowers your self-confidence. You need to become aware of your internal
dialogue or self-talk you have with yourself. Set aside time to focus on everything positive in
your life. Reflect on your strengths and past successes. Do not dwell on your past mistakes.
Recognize that the mistake doesn’t define who you are.

Small goals and small steps taken daily will move you forward over time and boost your self-
confidence crucial to succeed on your exam. It is also important to reflect on past
accomplishments.

Replace negative self-talk for positive or empowering self-talk.

Challenges are made to

This is difficult. Replace overcome.

negative self-talk to…

I will do the best I can.
I cannot do that.

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“The NCLEX® is a challenging exam that you can conquer with a positive mindset,
the right study tools and support system. You are an intelligent, capable and
driven student who completed nursing school while juggling work and family
responsibilities. This is a major accomplishment in your life! Give yourself credit for
your efforts and achievements. We are here for you to guide and support you until
you pass your test. Good luck on your exam and much success in your Nursing
career.”

Angelica Feuer RN, BSN, MSN

President
Feuer Nursing Review

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References

National Council of State Boards of Nursing: Test Plan for the National Council Licensure
Examination for Registered Nurses (effective date April 2019)

National Council of State Boards of Nursing Online, www.ncsbn.org

Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 14th Edition, Philadelphia 2017
Lippincott Williams & Wilkins

Potter & Perry: Fundamentals of Nursing, 9th Edition (2017)

Wong’s Essentials of Pediatric Nursing, 10th Edition (2017)

Varcarolis’ Foundations of Psychiatric Mental Health Nursing, 8th Edition (2017)

Resources

http://www.pearsonvue.com/nclex/NCLEX_Tutorial.msi
https://www.ncsbn.org/1213.htm
https://www.ncsbn.org/testplans.htm
https://www.ncsbn.org/1216.htm
https://www.ncsbn.org/nclex-faqs.htm

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Feuer NCLEX®-RN Comprehensive Exam

Select the best answer/answers for each question

1. A 12-year-old child is brought to the 3. A home health nurse is planning for the
Emergency Department with a compound morning patient assignments. Which one
fracture of the left femur from a of the following clients should the home
skateboarding accident. The child is health nurse visit first?
anxious, asking for his parents and in pain
(5/10). Vital signs are BP 86/60, HR 122, 1. A 50-year-old with C. Difficile
RR 26, Temperature 99°F. Which of the being treated with
following orders should a nurse implement metronidazole (Flagyl).
first? 2. A 6-month-old discharged one
week ago with pneumonia that
1. Oxygen via nasal cannula: is being treated with
titrate to keep oxygen azithromycin (Zithromax).
saturations > 93% 3. A 30-year-old with
2. Normal Saline IV bolus 500 mL exacerbation/flare-up of
X1 multiple sclerosis being treated
3. Morphine Sulfate 5mg IVP Q3 with dimethyl fumarate
hours (Tecfidera).
4. Ceftriaxone 750mg IV Q12 4. A 65-year-old who had a
hours gastrectomy 2 weeks ago
status-post gastric feeding tube
2. The nurse is working in the triage area insertion.
of the emergency department and four
patients approach the triage desk at the 4. An average-size male client has right-
same time. Prioritize the order in which sided hemiparesis. The nurse helps this
the nurse will assess these patients: client to ambulate by:

1. A 3-year-old child with 1. Standing at his left side and

inconsolable high pitched cry, holding his arm.
high fever, headache, and 2. Standing at his left side and
nuchal rigidity. holding one arm around his waist.
2. A 55-year-old man with 3. Standing at his right side and
diaphoresis complaining of left holding his arm.
anterior crushing chest pain. 4. Standing at his right side and
3. A 15-year-old with a broken holding one arm around his waist.
wrist having a radial pulse with
no deformity.
4. A 35-year-old woman
complaining of upper
abdominal pain and vomiting
green bile emesis.

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5. A nurse is providing a 40-year-old 7. A female client presents for a complete

postpartum client instruction on the self- gynecological exam. During the history
breast exam (SBE). Place the following taking portion of the visit, the client
steps in the correct order: discloses to the nurse that she hasn’t had
a Pap smear since the birth of her son 5
1. Watch in the mirror as you clasp years ago. As part of your client
your hands behind your head and education, you educate the client on the
press your hands forward. importance of regular Pap smears. Which
2. “Stand in the mirror, look for of the following states the
discharge from the nipple, recommendation based on the current
dimpling or puckering. screening guidelines of the American
3. Lie flat on your back with your left Cancer Society? Select all that apply.
arm over your head and a pillow
under your shoulder. Use the 1. You should have a Pap smear
“strip” method up and down. every 3 years until you reach
4. Raise your left arm, use 3-4 fingers the age of 30.
of your right hand to feel your 2. You should not be tested for
breast firmly HPV unless it is needed after an
5. Press your hands on your hips and abnormal Pap test result.
bend lightly as you pull your 3. You should have an annual Pap
shoulders and elbows forward. smear if you have an immune
deficiency disease.
4. You should get you first Pap
6. A The nurse is caring for a patient in smear at 21 or when sexually
preterm labor at 30 weeks’ gestation. The active.
nurse receives orders to administer two 5. After the age of 30 Pap smears
doses of betamethasone 12 mg are recommended every 5
intramuscularly. The nurse knows that the years.
purpose of administering this drug to the 6. Women who have had a total
patient is which of the following? hysterectomy should stop
receiving Pap smears unless the
1. To stimulate fetal surfactant hysterectomy was for the
production. treatment of cervical pre-
2. To suppress uterine contractions. cancerous cells was done for
3. To reduce tachycardia associated the treatment.
with terbutaline administration.
4. To stimulate maternal respiratory
status.

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8. A pregnant client arrives to the clinic for 11. An 8-year-old just had surgery for
a 10 week prenatal exam. Which of the appendicitis. He is very concerned that he
following clinical findings would be might die. The nurse knows that a child in
considered abnormal? this age group understands death as:

1. Dark brown vertical line down 1. A personification, such as a

her abdomen. ghost or bogeyman.
2. White, non-malodorous vaginal 2. A reversible condition.
discharge. 3. A punishment for evil behavior.
3. Intermittent cramping that 4. A universal event that will occur
begins in the back and radiates at some time to all living things.
to the abdomen
4. Increase fullness of the breasts.
12. A nurse is planning a nutrition class for
parents. In making a list of acceptable
9. Several babies are in the waiting room foods for babies during the first year of
of a pediatrician’s office. Which one life, which of the following should be
would the nurse be most concerned included? Select all that apply.
about?
1. Half-inch cubes of tender beef.
1. A 2-month-old with significant 2. Pureed bananas.
head lag. 3. Whole milk.
2. A 4-month-old that cannot turn 4. Infant oatmeal cereal.
over. 5. Half strength orange juice.
3. A 6-month-old who wants to 6. Pureed and seeded
nurse frequently. strawberries.
4. A 9-month-old who fell forward 7. Boiled and chopped string
and did not put out his arms. beans.

10. The nurse is preparing a dose of

Tylenol for a 4-year-old 40-pound girl. The
dosage prescribed is 10 mg per kilogram,
one time dose. The concentration of the
medication is 160 mg per 5 milliliters. How
many milliliters should the nurse
administer?

_________________________

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13. A client is admitted to an inpatient 15. Planning care for a client who is
psychiatric unit with a diagnosis of diagnosed with bipolar disorder-manic
obsessive-compulsive disorder. The client episode requires prioritizing expected
describes intensive rituals surrounding his outcomes. Choose the correct order of
ADLs. What is an expected outcome the priorities related to expected outcome.
nurse might see after the first week of
hospitalization? a. Maintains nutritional status
b. Interacts appropriately with peers
1. The client will exchange one c. Remains free from injury
ritual for an alternative healthy d. Sleeps 6 to 8 hours a night
coping activity
2. The client will only engage in 1. c, a, d, b
his rituals in preparation for 2. b, a, c, d
sleep. 3. a, d, b, c
3. The client will set his alarm to 4. d. a. c. b
get up earlier than usual to
complete his rituals before the 16. A client diagnosed with bipolar
day’s unit activities begin. disorder is exhibiting severe manic
4. The client will attend at least behaviors. The psychiatrist prescribes
three groups by day three. lithium carbonate (Eskalith) and
risperidone (Risperdal). The client’s life
14. A recently admitted client has been partner asks about the need for the
diagnosed with major depressive disorder Risperdal. What should the nurse reply?
with suicidal ideations with a plan to kill
himself. What is the first intervention the 1. The Risperdal will help him
nurse should perform? sleep
2. The Risperdal and Eskalith are a
1. Encourage the client to remain good combination to decrease
out of his room and visible on manic symptoms
the unit. 3. The Risperdal will help calm
2. Place the client on one-to-one your partner until the Eskalith
observation for safety reaches a therapeutic blood
3. Teach the client strategies to level.
change his pattern of thinking 4. The Risperdal prevents the side
4. Set realistic goals for the client effects of Eskalith
to increase his self-esteem

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17. When attempting to intermittently permission to tube feed him that

catheterize a male client with spinal cord amount.
injury, the nurse meets resistance to 2. Be alert to his need for laxatives
catheter insertion. Which intervention and stool softeners to prevent
should the nurse take first? constipation.
3. Place suction in the room for the
1. Withdraw the catheter and start eventual dyspnea and choking he
over. will experience.
2. Ask the patient to take a deep 4. Place an air pressure mattress, turn
breath. and position the patient every 2
3. Ask the patient to bear down and hours, and keep his skin dry and
hold his breath. clean to prevent breakdown.
4. Ask that the patient to lie on the
right side. 20. After a patient expiration, the nurse is
preparing to perform postmortem care.
18. A nurse has just begun to digitally The client’s body is:
remove a fecal impaction from a patient.
The nurse should stop the procedure 1. Placed on a transport stretcher and
immediately and take corrective action if covered with a sheet for removal
the patient’s: to the morgue or funeral home.
2. Washed with the family’s
1. Blood pressure increases from assistance, if they are present and
110/84 to 118/88 mm Hg. wish to help; dressed in clean
2. Pulse rate decreases from 78 to 52 pajamas or hospital gown; and
beats/min. positioned in the bed for the family
3. Respiratory rate increases from 16 to say their last goodbyes.
to 24 breaths/min. 3. Washed, placed in a shroud with
4. Temperature increases from 98.8° identification attached to the big
to 99.0° F. toe or ankle and the outside of the
shroud, viewed by the family for
19. An 87-year-old Hindu client who is their last goodbyes, and quickly
terminally ill has been unable to maintain transported to the morgue on a
good nutrition because of nausea and stretcher.
anorexia and has lost a great deal of 4. Placed in a shroud with all
weight. He is now unable to change his equipment or tubing left in place
position in bed and needs frequent and the head lowered, to await
perineal care because of urinary pick-up by the funeral home.
incontinence. The nurse planning his care
would most importantly:

1. Coax him to eat high-calorie, high-

fat supplements and, if he is unable
to consume at least 3000
calories/day, request the doctor’s

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21. The doctor is performing an 3. Decrease the production of CD4

amniocentesis on the client at 16 weeks’ cells.
gestation to detect genetic anomalies. 4. Increase the development of AIDS.
Which statement indicates the nurse
understands the proper instructions for 24. A Type 2 diabetic client who is diet
the client having an amniocentesis at 16 controlled is pregnant. The client asks a
weeks’ gestation? nurse what impact this will have on her
diabetes. The nurse’s best response
1. Prior to ultrasound exam and would be: Select all that apply.
amniocentesis, the client should
empty the bladder. 1. “Insulin will not be required.”
2. After the ultrasound exam and the 2. “Insulin will definitely be required.”
amniocentesis, the client should 3. “You are at no greater risk than a
not void for the amniocentesis. non-diabetic client since you are
3. The ultrasound exam will be done diet controlled.”
at least eight hours prior to the 4. “Your glucose will be closely
amniocentesis. evaluated and you may or may not
4. The amniocentesis cannot be done need insulin.”
prior to 20 weeks’ gestation 5. “Type 2 diabetics do not have a
need for insulin in pregnancy if
22. A nurse is caring for a client diagnosed they have been well controlled
with placenta previa. Which of the with diet prior to pregnancy”
following intervention would help prevent 6. “Pregnancy has no effect on type 2
complications for the fetus? Select all that diabetics”
apply.
25. A 7-year-old with a fractured femur is
1. Strict bed rest in skeletal traction. He asks the nurse for
2. Frequent sonograms a toy. Which toy should the nurse bring to
3. Administration of corticosteroids the child?
4. Avoid sexual intercourse
5. Frequent vaginal exams 1. A video.
6. The client will only need 2. A simple card game.
interventions if the client is 3. A 150-piece puzzle.
experiencing heavy bleeding 4. A stacking toy.

23. A pregnant woman who is HIV positive

is receiving Retrovir (zidovudine). The
nurse knows the clinical effects of Retrovir
is to:

1. Suppress the bone marrow activity.

2. Prevent viral replication.

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26. Which of the following physical injuries 4. With baby supine, sudden neck
are NOT associated with suspicion of child extension results in extension and
maltreatment? Select all correct answers. flexion of all extremities.

1. Spiral fractures. 29. When assessing a client for risk of

2. Scalp laceration. suicide, which statement would the nurse
3. Sock-like burn. see as most appropriate?
4. Bruising on the extremities.
5. Bruising in various stages of 1. The nurse asks a direct question,
healing. “Have you ever thought about
6. Greenstick fractures. killing yourself?”
7. Scald burn to the shoulder. 2. The nurse asks the client to rate his
8. Bruising on the trunk. mood on a scale of 1 to 10.
3. The nurse asks the client, “Do you
27. Which of the following statements by a have a plan for how you will kill
mother of a 1-month-old would indicate yourself?”
that she understands the safety needs of 4. The nurse asks the client “How
her infant? long have you been feeling
depressed?”
1. I will put the crib rails up fully.
2. I will put gates at the top and 30. A client is admitted to the psychiatric
bottom of the stairs. unit in a manic state and is diagnosed with
3. I will not leave the infant alone in bipolar I. What is the best approach for
the crib. staff to consider when interacting with this
4. I will keep the mobile at least 36 client?
inches above the mattress.
1. Explain the unit rules and set firm
limits on the client’s manic
behavior
28. Which of the following best describes 2. Redirect the client to spend time in
the asymmetric tonic neck reflex? his room to decrease external
stimulation
1. With baby supine, turn the head to 3. Use a calm unemotional approach
one side, the arm and leg on that when interacting with the client-
side will extend and the extremities low expressed emotion (low EE)
on the opposite side flex. 4. Encourage client to engage in all
2. With baby supine, turn the head to scheduled unit groups
one side, the body will turn in the
same direction, so that the head
and body are realigned.
3. With the baby held vertically, the
sole of the foot is touched on a
tabletop; the foot flexes, extends
then touches the surface.

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31. A client with borderline personality 33. An older adult client with HTN,
disorder asks to meet with a nurse. What hypercholesterolemia, diabetes mellitus,
is the best approach for the nurse to use and renal failure is in need of a CAT scan
when developing a therapeutic with IV contrast. The nurse anticipates that
relationship with this client? which laboratory test will be ordered by
the primary care provider (PCP) prior to
1. Maintain a clear, firm, consistent the CAT scan?
yet empathic approach when
addressing client concerns. 1. Blood urea nitrogen
2. Avoid addressing problematic 2. Serum albumin
behaviors utilizing the behavioral 3. Serum electrolytes
approach of “extinction” 4. White blood cell count
3. Use confrontation to address client
behaviors in an effort to set clear 34. The nurse is preparing to position a
limits on what is expected, client for a bedside thoracentesis. Which
acceptable behavior. of the following diagrams best represents
4. Encourage client to set parameters correct positioning for this procedure?
for when and what can be
discussed with the nurse.

32. What findings should a nurse be alert

for in a client with bulimia nervosa? Select
all that apply. 1.

1. Severe electrolyte imbalance

2. Damaged tooth enamel
3. Amenorrhea
2.
4. Intestinal obstruction
5. Esophageal tears and gastric
rupture
6. Aspiration pneumonia
3.

4.

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35. The nurse is working at a school where 37. An adolescent client is 37 week
several students have bee sting allergies. pregnant and is admitted on the
Which action should be included in the antepartum unit with a diagnosis of
plan of care for these students in the Pregnancy induced Hypertension (PIH).
event of a bee sting? Her blood pressure is 190/110, she has
generalized edema, 3+ proteinuria and
1. Administer the student’s EpiPen has gained 8 lbs. in the last week. She is
subcutaneously if respiratory complaining of nausea and a pounding
distress or wheezing is noted. headache. The priority nursing
2. Repeat administration of the intervention for this client would be:
student’s EpiPen in 15 minutes
until symptoms are relieved or until 1. Give Labetalol.
emergency medical services (EMS) 2. Prevent seizure activity.
arrives. 3. Maintain strict I&O.
3. Call EMS (911) only if the student’s 4. Induce labor.
symptoms are not relieved after
administration of the EpiPen. 38. While a client is receiving Magnesium
4. Diphenhydramine (Benadryl) sulfate (MgSO4 ) the client develops
should be administered respiratory depression and loss of her
immediately after the bite to deep tendon reflexes. The primary
prevent an anaphylactic reaction. nursing intervention is:

36. Which of the following statements 1. Notify the primary care provider.
reflects a nurse’s need for further 2. Discontinue the Magnesium sulfate
instructions regarding an incident report? infusion (MgSo4).
3. Place the client on her left side.
1. “I hope this incident report will 4. Administer calcium gluconate.
help determine a way to help
prevent falls.”
2. “Risk management will want to
review the incident report on the
client’s fall.”
3. “I put the incident report on the
client’s fall in his chart as soon as I
was finished.”
4. “I need to review the guidelines
before I fill out this incident report
regarding the client’s fall.”

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39. Which of the following clients would 42. An 8-month-old with croup requires
the Charge Nurse delegate to the RN to humidified oxygen. Which is the most
see first? appropriate method of delivery
considering the child’s age and diagnosis?
1. A 40 week gestation laboring client
that is currently on the EFM 1. Mist tent.
(electronic fetal monitor) that is 2. Oxyhood.
having early decelerations 3. Face mask.
2. A 39 week gestation laboring client 4. Nasal cannula.
whose water broke and has
meconium stained amniotic fluid 43. Which of the following orders
3. A 12 week gestation antepartum would the nurse expect to implement for a
client that is reporting feeling child during a severe asthma attack with
excessive nausea progressive respiratory distress?
4. A 41 week gestation laboring client
that is in the latent phase of labor 1. Clear liquid diet and encourage PO
that is requesting an epidural intake.
2. Small amount of soft foods at
40. A nurse enters a client’s room in the frequent intervals.
Labor and Delivery (L&D) suite and notes 3. Regular diet as tolerated.
late decelerations on the monitor. The 4. NPO with IV at maintenance rate.
nurse’s first action would be to:
44. When obtaining a health history on a
1. Call the primary care provider child with suspected cystic fibrosis the
2. Place the client in Trendelenburg. nurse would be most concerned with:
3. Place the client on the left side and
administer O2 of 3L or more. 1. Recent strep throat that went
4. Increase the client’s intravenous untreated.
fluids. 2. Peripheral cyanosis in the newborn
period.
41. In assessing a 3-year-old with diarrhea 3. Two hospitalizations for
and moderate dehydration the nurse pneumonia.
would expect to find: 4. Vomiting after feedings.

1. Dry oral mucosa, decreased urine

output.
2. Urine specific gravity of 1.020 and
large ketones.
3. Sunken fontanel, listlessness.
4. Sunken eyes, lethargy.

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45. Sociopathic features of behavior 47.Mary, a high school sophomore, is

appear to be built into an individual’s prescribed Adderall (amphetamine and
entire personality. Which of the following dextroamphetamine) for attention-deficit
statements most clearly depict the disorder (ADD). She has noticed that since
dominant characteristics of an antisocial she has been taking the medication, she
patient? has no appetite and has lost 5 pounds in
the past month. What instruction should
1. When the sociopath is confronted the nurse provide to Mary about when to
about behavior acts, which are take the medication?
unacceptable to society, there is an
obvious display of real concern and 1. “Take the medication at bedtime”
sensitivity to the social effects of 2. “Take the medication after
his deeds breakfast/lunch and not at
2. Typically, the sociopath is bedtime”
affectionate, sharing, grateful and 3. “When you feel hungry you will
group oriented eat”
3. These persons are so deficient in 4. “If you don’t feel hungry, skip a
emotional control and normal dose of the medication”
feeling responses that they are
insensitive to consequences, and 48. A client with a diagnosis of
fail to profit from experience or schizophrenia is being treated with the
punishment antipsychotic medication Clozaril, daily.
4. They continuously seek an Which assessment by the nurse requires
emotional outlet but only with immediate follow-up?
regard for rational, acceptable
conduct, or the feelings and 1. Weight gain of 10 lbs. over past 30
interests of other persons days
2. Client’s complaint of increased
46. A client is seen in the outpatient clinic salivation
for follow-up after his recent 3. Increase in blood pressure over the
hospitalization for severe depression. He past week
has been treated with a serotonin 4. Temperature of 101ºF
norepinephrine reuptake inhibitor (SNRI)
antidepressant. The nurse teaches the
client about the serotonin syndrome,
which includes (Select all that apply):

1. Change in mental status,

confusion, flushing
2. Diarrhea, lethargy
3. Myoclonus (muscle twitching)
4. Elevated temperature 103◦-105◦
5. Constricted pupils

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49. When a nurse enters a patient’s room, 51. A postoperative client enters the post
he discovers that there are smoke and anesthesia care unit and blood studies are
flames coming from the patient’s bed done. The client’s serum potassium level is
covers. The patient is sitting next to the 2.9 mEq/L. IV potassium infusion is
bed. After evacuating the patient, the ordered by the Primary Care Provider.
next step is to: Pharmacy sends a 250 ml IV bag of
dextrose in water with 40 mEq of
1. Close the door to the room to potassium to be infused over 1 hour. What
confine the fire. potential complications must the nurse
2. Remove the patient from the room monitor for?
to a safe place.
3. Extinguish the flames with an 1. Institute seizure precautions.
appropriate extinguisher. 2. Monitor ECG readings.
4. Activate the fire alarm system 3. Draw liver enzyme levels.
immediately. 4. Elevate the head of the bed.

50. A client exhibits the posturing

illustrated below. Which statements 52. A nurse is preparing to administer 0.25
regarding this posturing are true? Select mg of alprazolam (Xanax) po. The
all that apply. pharmacy provides Xanax 0.5 mg po.
Which procedure regarding preparation of
this medication delivery is correct?

1. Obtain 2 pills to administer to the

client.
2. Have a nurse witness the wasting
of ½ of the pill.
3. Keep the extra half of the pill in the
client’s room to administer at the
1. “This posturing indicates damage next dosage time.
to the client’s brain stem.” 4. Discard the extra half of the pill in
2. “This client is at risk for respiratory the nearest wastebasket.
failure.”
3. “This client may be experiencing
bleeding into the brain.”
4. “This type of posturing is the most
critical.”
5. “This type of posturing is called
decorticate posturing.”

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53. A nurse is caring for a primigravida in 2. A 41-year-old G2 P1001 client who

labor who suddenly has spontaneous is post-partum day 0 with history of
rupture of membranes (SROM). The nurse pre-eclampsia on MgSO4.
notes that the fetal heart rate suddenly 3. An 18-year-old G1 P0 client who is
drops to 86 after SROM. The most Postpartum day 1 with a history of
appropriate initial nursing intervention prolonged rupture of membranes
would be to: and a temperature of 102.3°F on IV
antibiotic therapy.
1. Open up the intravenous line. 4. A 28-year-old G8 P6016 client who
2. Place the client in a knee to chest is post-partum day 1 and post D&C
position. for retained placental fragments,
3. Apply 10 liters of oxygen via mask. with small amount rubra lochia and
4. Call for an emergency cesarean a firm fundus at U/U.
section.
56. A neonate is born and the nurse
54. In teaching a client about the onset of assigns an Apgar score of 8 at 1 minute
labor, a nurse should include which of the and 9 at 5 minutes. This score indicates
following in the teaching plan? Select all the neonate most likely:
that apply.
1. Required some resuscitation.
1. “You should go to the hospital as 2. Had flaccid muscle tone.
soon as contractions begin.” 3. Heart rate was less than 100.
2. “You should wait to go to the 4. Had acrocyanosis.
hospital until the contractions are 3
minutes apart.” 57. Which of the following scenarios
3. “If your membranes rupture you would most likely precipitate a crisis in a
should take a warm bath.” patient with sickle cell anemia?
4. “Bloody vaginal discharge is a sign
of impending labor.” 1. A 3-month-old infant with 10%
5. “If your membranes rupture you dehydration.
should go to the hospital” 2. A 4-year-old boy with painful
abdominal cramps and intermittent
55. On a postpartum unit there are 2 diarrhea.
LPN’s, 1 RN, and 2 Nursing Assistants. 3. A 6-year-old girl with a
Which of the following client would be temperature of 102.5 and
most appropriate to assign to the vomiting.
unlicensed personnel? 4. A 12-year-old girl with her first
menstrual period.
1. A 27-year-old G2 P1001 client who
is post cesarean section day three,
is ambulatory and vital signs are
stable.

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58. A 7-year-old has been admitted with a 61. A 75 year old client arrives on the unit.
diagnosis of R/O Acute The diagnosis is Major Neurocognitive
Glomerulonephritis. During the history, Disorder, Alzheimer’s. She is described as
the nurse is concerned when the mother having “sundown syndrome.” The nurse
states that the child: should expect that the client will:

1. Had chicken pox 2 weeks ago. 1. Become hyper alert in the evening.
2. Has a history of urinary tract 2. Evidence extreme lethargy at
infections. night.
3. Had a sore throat 3 weeks ago. 3. Manifest increased confusion and
4. Is allergic to eggs. agitation in the evening and at
night.
59. A 6-year-old with Pneumocystis Carinii 4. Complain of chronic fatigue
Pneumonia secondary to AIDS is admitted throughout the day.
on the unit. The most appropriate 2
bedded room assignment for this child 62. Repression is a defense mechanism.
would be with: Which of the following would the nurse
recognize as an example of repression?
1. An 8-year-old with a fractured
femur and skeletal traction. 1. A woman who was physically
2. A neonate with pyloric stenosis. assaulted 5 years ago does not
3. A 7-year-old with leukemia. remember the assault.
4. A 3-year-old with AIDS. 2. A woman who enters the hospital
to deliver her baby and is informed
60. A 4-year-old child asks when his that the baby is dead. The woman
mother is coming back. The mother has does not believe the results of the
told you that she will return at 1:00pm. ultrasound.
The best response would be: 3. A young woman who was abused
by her alcoholic father graduates
1. Your mom will be back when the college with a degree in Alcohol
big hand on my watch points to Counseling.
one. 4. A woman who is unhappy in her
2. Your mom will be back when you job tells others that she has the
wake up from your nap. best job in the world.
3. Your mom will be back after you
have lunch.
4. Your mom will be back before your
bath.

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63. A client has been prescribed

Clonazepam (klonopin) for symptoms of
generalized anxiety disorder. The nurse
educates the client about the risks of
overdosing on the medication for which
potential situation?

1. Taking the medication before

meals. __________________________
2. Combining the medication with
alcohol use. 66. A client presents to the acute care
3. Eating a diet rich in aged cheese. setting with a pressure ulcer. The nurse
4. Taking the medication only for notes that the area is nonblanchable and
sleep enhancement. erythematous and could also be described
using the picture below. The nurse
64. A client comes to the emergency room correctly documents the pressure ulcer as
with severe diarrhea, blurred vision, and which of the following?
tinnitus. He reports he has been taking
lithium 1200mg po daily for over a year.
What interpretation should the nurse
make of these symptoms?

1. Symptoms indicate that the client

has not been taking his lithium and
is experiencing withdrawal
symptoms 1. Stage 0
2. Symptoms indicate that the client 2. Stage 1
has contracted a stomach flu 3. Stage 2
3. Symptoms indicate that the client 4. Stage 3
has developed lithium toxicity
4. Symptoms indicate that the client 67. Twelve hours after a total
has developed a tolerance for the thyroidectomy, the client develops stridor
prescribed dose. on exhalation. Which is the nurse’s priority
intervention?
65. The nurse is preparing a dose of
methotrexate for a client with psoriasis. 1. Reassuring the client that the voice
The primary healthcare provider has change is temporary.
prescribed methotrexate 15 mg IM 2. Documenting the finding and
weekly. Using the pharmacy label assess the client hourly.
provided below, calculate one dose of this 3. Hyperextending the client’s neck.
medication. 4. Calling for emergency assistance.

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68. The nurse is assessing a client who has 71. A neonate receiving phototherapy is
undergone a transurethral resection of the having dark green stools and the urine is
prostate (TURP). Which assessment finding slightly green. The nurse is aware that this
requires immediate action by the nurse? is an indication that the:

1. Client passes small blood clots 1. Phototherapy is having a desired

after catheter removal. outcome.
2. Client experiences urinary 2. The neonate may have an
frequency after catheter removal. infection.
3. Client experiences bleeding 24 3. Phototherapy lights are too close
hours post-surgery. to the abdomen.
4. Client has the urge to void 4. The neonate is receiving too much
continuously while catheter is phototherapy.
inserted.
72. A newborn being discharged from the
69. Which of the following neonatal well-baby nursery is being given a follow-
assessments would the nurse considered up appointment to return for
abnormal in a full term male? immunizations. The baby would be
scheduled to return in:
1. Cyanosis of hands and feet.
2. Small white patches on the face. 1. 2 weeks
3. Hemorrhagic areas in the sclera. 2. 2 months
4. Urinary meatus on the dorsal 3. 3 weeks
aspect of the penis. 4. 3 months

70. A nurse is attempting to elicit the 73. During the assessment of a 7-month-
Moro reflex in an infant. Which of the old, which of the following would most
following would best describe the Moro likely indicate a neurological problem?
reflex?
1. Crying when a stranger holds the
1. Stimulating the side of the infant’s child.
mouth until the infant opens his 2. Inability to hold a bottle.
mouth. 3. Presence of the parachute reflex.
2. Turning the infant’s head to one 4. Presence of the moro reflex.
side and flexion of the arm on the
opposite side.
3. Extension and abduction of the
arms into a “C” formation.
4. Hyperextension and fanning of the
toes.

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74. A 2-year-old is in the supermarket with 77. A client with the diagnosis of
his mother and begins to have a tantrum Schizophrenia approaches the nurse and
because she won’t give him a lollipop. A states: “the cars, the stars, and Mars. It’s
nurse standing behind them on line might sad, it’s bad. The nurse understands this
suggest the following to the mother: as:

1. Give him the lollipop now and 1. Echolalia

explain to him after that next time 2. Neologisms
he wants something he should ask 3. Clang associations
for it nicely. 4. Ideas of reference
2. Scold the child and refuse his
request. 78. There are positive and negative
3. Ignore the child’s behavior. symptoms of Schizophrenia. Some of the
4. Pick the child up and comfort him, positive symptoms of Schizophrenia
but do not give him the lollipop. include:

75. A preschooler has begun to stutter 3 1. Bizarre behavior, hallucinations and

months after starting nursery school. The paranoia.
parents are concerned. What should the 2. Apathy, paranoia, amotivation
nurse recommend? 3. Bizarre behavior, apathy,
disorganized thoughts.
1. Always give the child plenty of 4. Anhedonia, hallucinations, apathy.
time to finish her thoughts.
2. Encourage the child to stop and 79. Neuroleptic Malignant Syndrome
repeat herself slowly. (NMS) is a potentially life threatening
3. Evaluate the child for speech complication of antipsychotic treatment.
therapy. What are the correct facts about NMS?
4. Take the child for psychological
counseling, as it may be an 1. Symptoms include hypotension,
indication of a serious problem. bradycardia and hyperthermia.
2. Symptoms include muscular
76. A child with PKU (Phenylketonuria) rigidity, confusion and
would have the following finding: hyperthermia.
3. Clients on Clozaril do not get
1. Musty smelling urine. NMS.
2. Shiny, foul smelling stool. 4. The onset of NMS is insidious.
3. Multiple café-au-lait spots.
4. Extra gluteal folds.

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80. An in-patient female client enters the 82. The nurse is preparing to administer a
dining room for dinner. She states that blood transfusion to a client. Put the
she has dressed up for expected visitors. following tasks in the correct order for
You observe that she is wearing a shirt administering a blood transfusion.
that is exposing her breasts. The nurse’s
best response would be: 1. Pick up the unit of blood from the
blood bank.
1. Ignore the client’s behavior and say 2. Insure patency of the intravenous
nothing. site.
2. Request that the client return to 3. Verify that the client has signed
her room with you and assist her in consent.
selecting more appropriate 4. Check the unit of blood with
clothing. another registered nurse at the
3. Tell the client to return to her room client’s bedside.
and change. 5. Begin infusing the blood.
4. Request that another staff member
manage the client. 83. The nurse is preparing to provide
tracheostomy care for a client. Put the
81. Which of the following clients are following tasks associated with
appropriate to assign to the LPN who will tracheostomy care in the proper order.
function under the supervision of the RN?
Select all the apply. 1. Put on sterile gloves
2. Replace the inner cannula.
1. A 70-year-old with congestive 3. Remove the soiled dressing.
heart failure and rheumatoid 4. Put on clean gloves.
arthritis with a feeding tube. 5. Replace tracheostomy ties.
2. A 55-year-old c/o abdominal 6. Remove the inner cannula.
distension who had 50ml of urine
output in the past 24 hours.
3. A 16-year-old admitted two days
ago with a tibial fracture and an
external fixator that require pin site
care.
4. A 45-year-old with a new ileostomy
who requires fitting of the
appliance and the first irrigation
procedure.
5. A 65-year-old status-post two days
GI tube placement, with a positive
(+) C. Difficile culture who needs
dressing changes to a pressure
ulcer on the coccyx.

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84. The nurse is teaching the client and 86. Which gait-training technique is
family how to do a colostomy irrigation. correct when teaching the client who has
Place the following activities in the order left leg weakness to walk with a cane?
in which they should be implemented:
1. Placing the cane in the client’s left
1. Wait about 45 minutes for bowel hand and moving the cane
to finish eliminating the irrigant forward, followed by moving the
and effluent. left leg one step forward.
2. Fill irrigation bag with 500-1000 mL 2. Placing the cane in the client’s left
of warmed tap water. hand and moving the cane
3. Allow water to enter the colon over forward, followed by moving the
5-10 minutes. right leg one step forward.
4. Put on a pair of clean gloves. 3. Placing the cane in the client’s
5. Hang bag at about shoulder right hand and moving the cane
height. forward, followed by moving the
6. Lubricate the cone with water left leg one step forward.
soluble lubricant and gently insert 4. Placing the cane in the client’s
tubing tip into ostomy. right hand and moving the cane
forward, followed by moving the
85. The nurse is providing discharge right leg one step forward.
teaching for a client following liver 87. The nurse is caring for a client with a
transplantation surgery. Which statement new onset of the following cardiac
indicates that additional teaching is dysrhythmia. The nurse anticipates that
needed? the primary healthcare provider will
prescribe which medication immediately?
1. “If I develop an infection, I should
stop taking my prednisone.”
2. “If I have tenderness in my
abdomen, I will call the physician.”
3. “I should avoid people who are ill
or who have an infection because I
1. Coumadin (warfarin)
am immunosuppressed now.”
2. Atropine (atropine sulfate)
4. “I should mix my cyclosporine
3. Heparin
exactly the way I was taught
4. Nitroglycerin
because it won't work as well if I
change the routine.”
88. When administering multiple inhalant
medications to one patient at the same
time, the last inhalant the nurse gives is:

1. Albuterol (Proventil).
2. Metaproterenol (Alupent).
3. Ipratropium (Atrovent).
4. Beclomethasone (Vanceril).

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89. A nurse has inserted a nasogastric 4. position the patient in high-

tube in a client and has obtained a sample Fowler’s and give feeding.
of gastric contents to measure the pH
level. The nurse determines that the pH 92. A client with diabetes is prescribed to
level of the contents obtained is 6. What take insulin glargine once daily and
action should the nurse take next? regular insulin four times daily. How will
the nurse teach the client to take these
1. Document the finding in the two medications when the first dose of
client’s medical record. regular insulin should be given at the
2. Notify the client’s primary same time of day as the insulin glargine
healthcare provider. dose?
3. Advance the nasogastric tube a
little further forward. 1. “Draw up and inject the insulin
4. Begin administering the client’s glargine first, and then draw up
tube feeding. and inject the dose of regular
insulin.”
90. When the nurse assesses that the level 2. “Draw up and inject the insulin
of chest tube drainage has not increased glargine first, wait 1 hour, and then
over the last 3 hours on a first day draw up and inject the dose of
postoperative thoracotomy patient, the regular insulin.”
nurse should initially: 3. “First draw up the dose of regular
insulin, and then draw up the dose
1. inform the charge nurse. of insulin glargine in the same
2. rearrange tubing to correct syringe, mix, and inject the two
dependent loops. insulins together.”
3. splint the patient with a pillow and 4. “First draw up the dose of insulin
coach to cough. glargine, and then draw up the
4. gently massage tube toward the dose of regular insulin in the same
collection bottle. syringe, mix, and inject the two
insulins together.”
91. A patient with a nasogastric tube gets
a bolus feeding of 200 mL every 4 hours.
Prior to giving the bolus, the nurse
aspirates a residual of 100 mL. After
returning the residual to the patient, the
nurse should:

1. give the 200 mL feeding.

2. record the residual and give 100
mL of the feeding.
3. document the residual and hold
the feeding.

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93. The nurse is calculating a client’s 6. “Cleanse the catheter with soap
intake and output (I and O) for the past 8 and water between each use.”
hours. What is the client’s intake, in mL, 7. “Store the catheter in a clean towel
based on the following consumption? or plastic bag between use.”

• 24 ounces of canned soda 96. The nurse is caring for a client with
• 500 mL of water diarrhea who has just been diagnosed
• 100 mL secondary intravenous with Clostridium difficile infection. Which
infusion nursing actions will help prevent the
• 12 ounces of juice spread of the infection to others? Select
• 240 mL of broth all that apply.

1. Cleaning hands with an alcohol-

___________________________ based gel before and after caring
for the client.
2. Washing hands thoroughly with
94. The probability of compartment antibacterial soap and water
syndrome in a patient with a side arm cast before and after caring for the
and traction is considered when the nurse client.
assesses: (Select all that apply.) 3. Placing the client in a private room
with contact isolation precautions.
1. warm, rosy fingers. 4. Wearing an isolation gown and
2. complaint of pain in hand and sterile gloves when providing care
fingers. for the client.
3. edema of fingers. 5. Ensuring that visitors and family
4. weak radial pulse. members do not share eating
5. tingling and numbness. utensils or dishes.
6. capillary refill less than 3 seconds. 6. Keeping a separate blood pressure
7. fingers warm to touch. cuff, stethoscope and thermometer
in the room for use with only the
95. The nurse is teaching the client about client.
self-catheterization in the home setting. 7. Cleaning nondisposable
Which instructions are applicable? Select equipment with bleach or
all that apply. disinfectant solution before use
with other clients
1. “Wash your hands before and after
self-catheterization.”
2. “Use a large-lumen catheter for
each catheterization.”
3. “Use lubricant on the tip of the
catheter prior to insertion.”
4. “Self-catheterize every 12 hours.”
5. “Use sterile gloves for the
procedure.”

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97. A client with a history of renal 99. Which intervention is most important
insufficiency is scheduled for a cardiac to teach the client who develops
catheterization. What will the nurse expect thrombocytopenia secondary to
to do for this client precatheterization? chemotherapy?
Select all that apply.
1. “Eat a low-bacteria diet.”
1. Assess laboratory results. 2. “Take your temperature daily.”
2. Administer acetylcysteine 3. “Use a soft-bristled toothbrush and
(Mucomyst). do not floss.”
3. Assess for allergies to iodine. 4. “Avoid using mouthwashes that
4. Keep the client NPO. contain alcohol.”
5. Assess pulses, marking them with
indelible ink. 100. An adult client is prescribed patient
6. Insert a central venous catheter. control analgesia (PCA) with morphine
7. Have the client sign a consent sulfate postoperatively for pain
form. management. What would the nurse
evaluate as being positive outcomes of
98. The nurse is caring for a female this intervention? Select all that apply.
patient who is concerned that she may be
at higher than normal risk of breast 1. Respiratory rate of 6 breaths/min.
cancer. Which of the following factors 2. Heart rate of 80 beats/minute.
identified by the patient place her at 3. Blood pressure 180/110 mm Hg.
higher than normal risk for development 4. Restlessness.
of breast cancer? 5. Absence of facial grimacing.
6. Verbalization of pain relief.
1. 60 years of age. 7. Ability to take deep breaths.
2. Used birth control pills for 25
years.
3. Breastfed two children.
4. Menopause at 48 years of age.

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Answers & Rationales

1. The correct answer is choice 2. Replacement fluid should be isotonic to restore circulating
blood volume. 0.9% NaCl is an appropriate option. Normal systolic blood pressure in
children between age 1-12 years is 90 +2 (age in years) so for this child 90 + 2 (12) = 90 +
24 = 114. The child is hypotensive and tachycardic.
Choice 1, the child is alert though anxious indicating good/sufficient oxygenation.
Choice 3, though he is in pain, the BP is too low to administer morphine.
Choice 4 will need antibiotics; but not first priority.

2. The correct sequence is 2,1,3,4.

Choice 2The 55-year-old man with diaphoresis complaining of left anterior crushing chest
pain may be experiencing an acute myocardial infarction. This is the priority patient with a
window for treatment time of approximately 60 – 90 minutes. If made to wait in the
emergency room triage, the patient may sustain irreparable myocardial injury which can lead
to death of the individual. This client needs to have immediate blood work consisting of
cardiac enzymes and an ECG to confirm an acute MI.
Choice 1, a 3-year-old child with inconsolable high pitched cry, high fever, headache, and
nuchal rigidity maybe indicative of meningitis. This is an example of a moderate-priority
patient. The window for treatment for this patient is greater than 90 minutes and therefore
not the correct answer. This patient will require multiple cultures to be collected (sputum,
urine, blood, etc). Once collected, targeted treatment can be administered.
Choices 3 & 4, the 35-year-old woman complaining of upper abdominal pain and vomiting
green bile emesis and the 15 year old patient with a broken wrist having a radial pulse with
no deformity are lower priority patients that require care and follow-up which is not as
emergent as the client with the crushing chest pain.

3. The correct answer is choice 3. The 30-year-old with exacerbation/flare-up of multiple

sclerosis is the only client on the patient assignment list who is experiencing an acute
episode, and therefore should be assessed by the home health nurse first. Multiple Sclerosis
signs and symptoms will vary with each individual; with the predominant signs and symptoms
being muscular. This could impede the client’s most basic needs (such as respiration) and
ADL.
Choices 1, 2 & 4 are all receiving (or have received) treatment for their conditions with no
obvious immediate episodic events occurring.

4. The correct answer is choice 4. The nurse provides support at the waist so the client’s
center of gravity remains midline.
Choices 1 & 3, the nurse should be on the client’s weaker side to assist him with ambulation.
The nurse should hold onto the client’s waist, not his arm. The nurse should hold onto the
client’s waist to help steady him in maintaining his center of gravity midline so that he does
not lose his balance and fall.
Choice 2, the nurse should be on client’s weaker side, not the stronger side.

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5. The correct sequence is choices 2,1,5, 4, & 3.

6. The correct answer is choice 1. Betamethasone is a glucocorticoid that is administered to

this patient to stimulate fetal surfactant production.

7. The correct answers is choices 1,2,3,4,6. The 2016 recommendation by the American
Cancer Society includes: Women ages 21-29 should have a Pap test every 3 years, HPV
testing should not be done unless it is needed after an abnormal Pap test result, Annual Pap
test are recommended if you have an HIV infection, had an organ transplant or long term
steroid use.
Choice 5 Women 30-65 should have a Pap test every 3 years or a Pap test combined with
HPV every 5 years.

8. Correct answer is choice 3. Contractions that radiate from the back to the abdomen will
cause cervical dilation and are not normal at 10 weeks’ gestation.
Choice 1 is linea nigra which is a pigmentation that is normal during pregnancy. This is a
probable sign of pregnancy.
Choice 2 is called leukorrhea. Secretions of the vagina area increase during pregnancy due
to increased vascularization. These secretions are thick, white non-malodorous and acidic
(pH 3.5-6). This pH plays a role in preventing infections; however it also favors the growth of
yeast infections.
Choice 4 increase in the fullness of the breast is a normal and a probable sign of pregnancy.

9. Correct answer is 4. This behavior describes the parachute reflex, which is not present at
birth and normally appears at 5 to 9 months of age. It is considered a protective reflex that
presents prior to walking.
Choice 1, head lag is normal in most infants when pulled to sit until age 4-6 months old.
Choice 2, rolling over is a milestone that is attained between 2½ months and 6 months.
Choice 3, infants may nurse more frequently during growth spurts and when needing
additional comfort.

10. Correct answer is 5.7 ml. The child’s weight must first be converted into kilograms: 40lbs.
divided by 2.2 is equal to 18.2 kilograms. 18.2 kg multiplied by 10mg is equal to 182 mg.
Available concentration: 160mg of Tylenol in 5ml equals 32mg per 1 ml. 182mg divided by
32 is equal to 5.7 ml.

11. Correct answer is 1.School age children often personify death.

Choice 2, preschoolers may perceive death as a temporary or reversible condition.
Choice 3, preschoolers may perceive death as a punishment. Preschoolers use magical and
egocentric thought.
Choice 4, death as a universal concept is typical of adolescent thought.

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12. Correct answers are 2, 4, and 7. Choice 2 is acceptable. Choice 4, all infant cereals
should be given to age 18 months as they are an excellent source of iron. Choice 7, most
strained soft fruits and vegetable can be introduced.
Choice 1, all meat should be finely chopped or ground to prevent choking.
Choice 3, breast milk or commercially prepared infant formula should be given until age one
year.
Choice 5, citrus fruits, along with strawberries, egg whites, seafood and peanut butter are
considered allergenic and should be avoided until after the first year of life. Additionally,
fruit drinks of any type provide little nutritional value and should not be encouraged.
Choice 6, strawberries, along with citrus fruits, egg whites, seafood and peanut butter are
considered allergenic and should be avoided until after the first year of life.

13. Correct answer is Choice 3. Encouraging the client to follow a structured plan as part of
his treatment. Allowing additional time for the rituals earlier in the day initially helps to
facilitate the client’s participation in the unit activities. The goal later on is to reduce the time
spent on the rituals and increase time spent in productive activities.
Choices 1, 2 and 4 are unrealistic for the first week of hospitalization as these are long
standing problems and will take time to see improvement.

14. Correct answer is Choice 2. Client safety is the most important intervention to initiate
first. Placing the client on 1:1 observation assures the client that his feelings are taken
seriously and any attempt to self-harm can be interrupted immediately.

Choice 1 does not address the safety concern adequately.

Choices 3 and 4 are interventions to be used as client is no longer suicidal and can engage in
treatment.

15. Correct answer is Choice 1. c, a, d, b. Safety is always the first priority, then adequate
nutritional intake and sleep. Interacting appropriately with peers is last. One of the greatest
concerns when a client is in a manic state involves preventing physical exhaustion,
dehydration.

16. Correct answer is Choice 3. The nurse can educate the life partner that the Risperdal,
which is classified as an antipsychotic, will help calm the agitation and irritable behavior until
the Eskalith takes effect in 1-3 weeks. Choices 1 and 2 are true as the medication can have
sedative effects but it is not the primary action. Choice 4. It does not prevent side effects.

17. The correct answer is choice 2. If resistance is met, the catheter should be twisted, and
the patient should be asked to take a deep breath, which relaxes the urinary sphincter.
Choice 1, withdrawing the catheter may cause more discomfort, and ultimately will need to
be reinserted.
Choice 3, the client bearing down and/or holding their breath will cause contracture of the
urinary sphincter.

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Choice 4, asking the patient to lie on their right side has no relevance to Foley
catheterization.

18. The correct answer is choice 2. Stimulation of the sphincter may cause a vaso-vagal
response as evidenced by bradycardia, leading to a syncopal episode.
Choices 1, 3 & 4, slight increases in b/p (increase from 110/84 to 118/88 mmHg), respiratory
rate (increase from 16 to 24 rpm), and temp increase are still within normal range and to a
certain extent be somewhat expected.

19. The correct answer is choice 4. Weight loss, inactivity, poor nutritional intake, and
incontinence predispose this patient to the risk of impaired skin integrity. That would be
addressed by the actions in choice 4.
Choice 1, a terminally ill patient decreases his food and fluid intake as death approaches,
and a 3000-calorie/day goal is unrealistic, and tube feeding is not indicated as a patient
preference.
Choice 2, the patient may need laxatives, but with decreased intake, it would not be more
important than the skin breakdown prevention.
Choice 3, this is not necessary, placing suction in the room is not indicated.

20. The correct answer is choice 2. After death, if the family is present, they may wish to
provide their last act of care, assisting in washing the patient and saying their last goodbyes.
Choices 3 & 4, family would not view the body in the shroud, and tubing and equipment are
removed unless an autopsy is to be performed. The body is wrapped in a shroud and
identified before being moved to the morgue

21. Correct answer is choice 1. Prior to the ultrasound exam and amniocentesis the client
should empty their bladder to avoid puncturing the bladder with the needle used to obtain
the amniotic fluid sample during the procedure.
Choices 2 The client should not have a full bladder during the procedure to avoid puncturing
the bladder with the needle during aspiration of the amniotic fluid sample.
Choice 3. The amniocentesis is performed with the guided ultrasound to ensure accuracy of
the needle during aspiration of the fluid sample and to ensure fetal well-being
Choice 4. An amniocentesis is performed between 14-16 weeks for the testing of genetic
abnormalities.

22. Correct answers are choices 1 & 4. The management of placenta previa include bed rest
and avoiding trauma to the placenta via vaginal route. Hospitalization may be the best
method of ensuring both these options. While some cases of low-lying previa may be
managed on a more conservative basis, the RN must be aware that the best care would be
to ensure bed rest, avoiding all sexual intercourse and limiting vaginal exams.
Choice 2, frequent sonograms cannot prevent complications in the fetus
Choice 3, Corticosteroids are not indicated in placenta previa nor do they prevent
complications

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Choice 5 Frequent vaginal exams are not recommended because the risk of potential injury
is too great and can cause complications in the client who has a placenta previa
Choice 6 The client with a placenta previa will need specific interventions in order to ensure
client and fetal safety and to avoid complications during the pregnancy. These interventions
will be tailored to client’s needs based on the degree of the placenta previa and the amount
of bleeding the client is experiencing.

23. Correct answer is choice 2. Retrovir (Zidovudine) slows the progression of the disease
process by interfering with viral replication.
Choices 1, 3 & 4 are incorrect responses from treatment with Retrovir (Zidovudine).

24. Correct answer is choices 3 & 4. A slight decrease in insulin requirement occurs in the
first trimester then at around 24 weeks insulin resistance develops and the client may require
increased doses. All diabetics will be closely monitored and evaluated for changes in insulin
requirements, regardless of their prior status.
Choice 1 & 2. It is unknown if insulin will or will not be required during the pregnancy. This is
why close monitoring is important
Choice 5. It is not guaranteed that a client with type 2 diabetes will not need insulin during
their pregnancy
Choice 6. Clients will have a slight decrease in their insulin requirements during the first
trimester. Around 24 weeks insulin resistance develops and the client’s pre pregnancy
treatment of her type 2 diabetes may no longer be sufficient.

25. Correct answer is 2. Young school age children enjoy simple competitive games. A card
game would allow the child the opportunity to meet developmental milestones
Choice 1, a video is acceptable but is not the best choice as it does not address normal
school age developmental issues.
Choice 3, a 100-piece puzzle is too complex a task for most 7-year-olds and may be difficult
to complete based upon the child’s current physical restrictions.
Choice 4, this toy is appropriate for a very young child.

26. Correct answers are 2, 4, 6, and 7. Choice 2, scalp lacerations are common in young
children because of their relatively large head and unstable mobility. Choice 4, bruising on
the extremities is the typical location of accidental injury. Choice 6, greenstick fractures are
common in children resulting from relatively minor trauma and flexible bones. Choice 7,
accidental scald burns are most often found on the trunk of the children, obtained from
pulling hot liquid down onto themselves.
Choice 1, spiral fractures require a great amount of force to create.
Choice 3, sock-like burn without splash marks are typical of forced immersion burns.
Choice 5, bruising in various stages of healing is associated with abuse, as maltreatment is
not a one-time event.
Choice 8, bruising on the trunk is suspicious of maltreatment.

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27. Correct answer is 1. Putting the crib rails up fully is an appropriate safety measure for all
infants.
Choice 2, putting gates at the top and bottom of the stairs is not needed until the infant
near the point of mobility.
Choice 3, leaving the infant alone in the crib is a safe behavior.
Choice 4, a mobile for a 2-month-old should be at about 15 inches above the mattress in line
with the infant’s best visual acuity. The mobile should be removed by age 5 months for
safety.

28. Correct answer is 1. This describes the asymmetric tonic neck reflex, also called the
fencing reflex.
Choice 2, this describes neck righting or symmetrical tonic neck reflex, which presents after
the tonic neck reflex fades (5 months) and continues to about 9 months.
Choice 3, this is referred to as the placing reflex.
Choice 4, this describes the Moro reflex to a change in position. The same response can be
elicited with a loud noise.

29. Correct answer is Choice 1. Asking a direct question is generally the best approach to
assessing a suicidal client. By asking a specific question, it demonstrates that the nurse is
concerned about the client’s safety and it can facilitate further assessment questions that
require a more detailed answer. Most clients who are severely depressed have had thoughts
of ending their life.
Choice 2 is too indirect and impersonal.
Choices 3 & 4 are appropriate follow-up questions.

30. Correct answer is Choice 3. Clients who are in a manic state may demonstrate labile
mood swings, from calm to irritable to angry. Staff will be most effective in caring for this
client if they can maintain a low EE approach. EE refers to expressed emotion.
Choice 1 is incorrect as a manic client will not be able to absorb this information.
Choice 2 may be helpful if behavior becomes out of control but not as first step.
Choice 4, groups would be too overstimulating at this time.

31. Correct answer is Choice 1. Clients diagnosed with borderline personality disorder have
symptoms that demonstrate dysregulated emotional states. A consistent, clear, direct, and
firm approach sets the structure for the development of a therapeutic relationship and
allows for addressing any splitting or manipulative behavior. Empathy is the basis for all
client –staff interactions.
Choices 2, 3, and 4 are not most therapeutic approaches for this client as they may be
experienced by client as invalidating and devaluing.

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32. Correct answer is Choices: 1, 2, 3, and 5. Continuous bingeing and purging can result in
electrolyte imbalance, erosion of tooth enamel, absence of menses, and esophageal tears
and gastric rupture from frequent vomiting. Choices 4 & 6 are unlikely consequences.

33. The correct answer is choice 1. A common blood test, the blood urea nitrogen (BUN)
test reveals important information about how well your kidneys and liver are working and
reveal whether your urea nitrogen levels are higher than normal. If your kidneys are not
working well, the urea nitrogen will stay in the blood. This means that the patient who needs
IV contrast will have a difficult time removing the dye from their bloodstream if their kidneys
are not functioning properly. Normal blood contains 7-20 mg/dl of urea. If your BUN is more
than 20 mg/dL, your kidneys may not be working at full strength. Other possible causes of
an elevated BUN include dehydration and heart failure.
Choices 2, 3 & 4, serum albumin, serum electrolytes, and WBC count (although all are
diagnostic) do not provide the necessary priority information to ensure the patients safety
from toxicity.

34. The correct answer is choice 1. Choice 1 is correct for a thoracentesis because this
position allows the primary healthcare provider to access the client’s back for insertion of the
needle and drainage tubing.
Choice 2 is a semi-Fowler’s position which may be appropriate for a paracentesis.
Choice 3 is Sim’s position which is appropriate for an enema.
Choice 4 is the prone position.

35. The correct answer is choice 2. The epinephrine dose in the IM EpiPen will wear off after
about 15 minutes and an additional dose should be administered after 15 minutes while
waiting for EMS to arrive.
Choice 1, Epinephrine is never given subcutaneously. It is only given IM.
Choice 3, EMS should always be called should Epinephrine have to be administered.
Choice 4, although Benadryl is an antihistamine, it is not standard protocol and requires an
order from a Primary Care Provider.

36. The correct answer is choice 3. The report is confidential and separate from the client’s
medical record.
Choices 1, 2 & 4 reflect an appreciable understanding about incident reports, and therefore
cannot be the answer.

37. Correct answer is choice 2. This client is at risk for eclampsia, preventing seizure activity
would be a priority in caring for this client.
Choice 1. Labetalol may be ordered by the primary care provider but it would not be the 1st
priority.
Choice 3,.strict I&O is not necessary.
Choice 4. labor would never be induced with severe pre-eclampsia.

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38. Correct answer is choice 2. The primary nursing intervention is to first discontinue the
magnesium sulfate infusion because this client is exhibiting signs of magnesium sulfate
toxicity
Choice 1. Although notifying the primary care provider is important the infusion needs to be
stopped since the client already has toxicity
Choice 3. Turning the client on their left side is not an intervention for this client
Choice 4. Calcium gluconate is the antidote for magnesium sulfate toxicity and will be
administered after the infusion is stopped. When a client is on a magnesium sulfate infusion
there is ALWAYS an order to administer calcium gluconate in case toxicity should occur.

39. Correct answer is choice 2. The client who has ruptured membranes with meconium
stained fluid is the priority. The meconium stained fluid is indicative of fetal distress and
requires immediate attention.
All other choices are not a priority

40. Correct answer is choice 3. With late decelerations, there is utero-placental insufficiency.
Placing the mother on her left side and giving oxygen will help to perfuse the fetus better.
Choice 1, the primary care provider is called after the nurse repositions the client, places
oxygen on her and assesses whether the client late decelerations has been corrected.
Choice 2 placing the client in the Trendelenburg position is done when prolapsed cord is
noted.
Choice 4 increasing the client’s intravenous fluid is done when the mother’s blood pressure
drops.

41. Correct answer is 1.Moderate dehydration in a 3-year-old would also include a weight
loss of 6%, dry skin, sunken eyes, reduced tears, irritability, tachycardia and decreased pulse
quality.
Choice 2, a urine specific gravity of 1.020 is in the normal range. In moderate dehydration,
the urine specific gravity would be anticipated to be greater than 1.030.
Choice 3, one would be unable to assess the fontanel of a 3-year-old, as the fontanels are
closed by 18 months of age. In an infant, a soft fontanel is associated with moderate
dehydration and a sunken fontanel is associated with severe dehydration.
Choice 4, sunken eyes and poor skin turgor, along with clammy skin, parched mucous
membranes, sunken fontanel, lethargy, tachycardia, prolonged capillary refill and no urine
output are signs of severe dehydration.

42. Correct answer is 1. A mist tent is most appropriate as it offers the ability to deliver high
oxygen concentrations when the tent is sealed properly. More importantly, high levels of
humidification are created, which is most helpful to the child with croup. The size of this
oxygen delivery device allows relatively free movement of the child and play in the crib.
Choice 2, an oxyhood is a small oxygen delivery device, suited for small infants with limited
mobility.

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Choices 3 & 4, the facemask and nasal cannula offer minimal humidification and are often
bothersome to an older infant, who could frequently remove the devise from their face,
making both oxygen and humidification delivery ineffective.

43. Correct answer is 4. Fluid administration is important to liquefy respiratory secretions,

making them move more easily up and out of the respiratory tract. PO intake under the
described conditions is unsafe due to the risk of aspiration.

44. Correct answer is 3. Frequent respiratory infection is a symptom of cystic fibrosis. The
respiratory mucous is excessively thick and difficult for the body to mobilize up the
respiratory tract. Other symptoms include: a history of meconium ileus, FTT and muscle
wasting, foul smelling, frothy stools, and salty tasting skin/sweat.
Choice 1, recent strept throat is associated with rheumatic fever and acute glomerular
nephritis.
Choice 2, peripheral cyanosis in the newborn period, also called acrocyanosis, is normal and
is not associated with any disorders.
Choice 4, vomiting after feeding is associated with GI obstruction, such as pyloric stenosis.

45. A. Correct answer is Choice 3. They do not have the capacity to feel concern for others
or guilt. Therefore, learning from experience doesn’t take place.
Choice 1, is incorrect because the antisocial patient thinks rules don’t apply to him.
Choice 2 & 4, are incorrect because this patient is only concerned about his own needs, not
the needs of anyone else. His behavior is designed to get what he wants regardless of the
impact on others.

46. Correct answer is Choices 1, 2, 3, &4. Serotonin syndrome can occur if the client is taking
one or more SSRIs or SNRIs. Can occur also if client takes cough medicine with
dextromethorphan or medication containing tryptophan.
Choice 5, With serotonin syndrome pupils are dilated not constricted.

47. Correct answer is Choice 2. It is best to eat first before taking the medication as anorexia
can be a side effect of the stimulant properties of the medication.

Choice 1, Taking the medication at bedtime will cause sleep disturbance as it is a stimulant.
Choice 3, Stimulants decrease appetite.
Choice 4, Skipping a dose is not recommended as it goes against the purpose of treating
the attention deficit disorder and is never good advice. Clients who take stimulants may
experience weight loss and therefore should make all efforts at maintaining proper nutrition.

48. Correct answer is Choice 4. A temperature of 101 degrees F indicates an infectious

process. Agranulocytosis can be a side effect of clozapine (Clozaril). It reduces immunity and
the client is more susceptible to infection. The CBC is monitored on a scheduled basis.
Choices 1, 2, 3, can be side effects of the medication but a fever can be potentially life
threatening.

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49. The correct answer is choice 4. RACE is used as an acronym to respond to fire. “RACE”
represents:
Rescuing the patient from immediate danger
Activating the fire alarm system
Containing the fire by closing doors and windows
Extinguishing the flames with an appropriate extinguisher
After removing the client from harm, the next step in the sequence is activating the ALARM.

50. The correct answers are choices 1, 2, 3 & 4. This client is exhibiting decerebrate
posturing. As the most critical type of posturing, decerebrate posturing indicates severe
damage to the client’s brain stem. This damage is likely caused by bleeding into the brain.
The client is also at risk for respiratory failure as an effect of damage to the brain stem.

51. The correct answer is choice 2. A small drop in potassium usually doesn’t cause
symptoms. However, a big drop in the level can be life threatening. The question states
2.9mEq/L: this level of potassium puts the client at risk for cardiac dysrhythmias. In addition
the client is receiving a high dose K supplementation, in a small volume solution, over a short
time span. The nurse must monitor for cardiac irregularities.

52. The correct answer is choice 2. Xanax is a Schedule IV controlled substance and any
remaining medication not being administered must be wasted following organizational
protocol.
Choice 1 is incorrect as obtaining two pills to administer would be a dose of 1 mg, not the
prescribed 0.25 mg.
Choice 3 is incorrect as a controlled substance cannot simply be placed in a client’s room.
Choice 4 is incorrect as discarding a controlled substance in a wastebasket is not considered
wasting and is inappropriate.

53. Correct answer is choice 2. After spontaneous rupture of membranes (SROM) and if
there is a decrease in the fetal heart rate to the 80s a prolapsed cord is suspected. When a
prolapsed cord is suspected, the nurse must relieve the pressure off the umbilical cord.
Placing a client in the Trendelenburg and/or knee chest position will take pressure off the
cord, while the OR sets up for a Cesarean delivery.
Choice 1 opening up the IV line would be done if the client was hypotensive.
Choice 3 applying 10 liters of oxygen would be done for late and/or variable decelerations.
Choice 4, an emergency cesarean section is the next immediate priority. The pressure must
be taken off the cord first.

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54. Correct answers are choices 1, 4 & 5. Even if the contractions turn out to be false, it is
prudent for the RN to advise the client to have them checked out at the hospital. If the
client has ruptured her membranes she needs to go to the hospital because ruptured
membranes could place her at risk for infection . Choice 4 is correct but it also takes into
consideration that any vaginal bleed during pregnancy needs to be checked.
Choice 2 & 3 are incorrect

55. Correct answer is choice 1. A 27-year-old G2 P1001 client who is post cesarean section
day three, is ambulatory and vital signs are stable. All the other clients are in need of
assessment and nursing management due to medications and risk for complications.
Choices 2, 3, & 4 are incorrect. Only the first choice is stable and predictable in care
outcome.

56. Correct answer is choice 4. When an Apgar score is 8 or 9, it indicates that there was
some peripheral cyanosis, as this is the most likely cause of a less than perfect score.
Choices 1, 2 & 3 are other problems with the Apgar score.

57. Correct answer is 3. Both fever and vomiting are causes of body fluid loss. The ensuring
dehydration could likely precipitate sickling and crisis. Hypoxia and acidosis are other major
causes of sickling crises.
Choice 1, most infants less than 6 months of age do not experience a crisis. The amount of
HgbS is limited because of the presence of fetal hemoglobin (HgbF), which does not sickle
like the sickle cell hemoglobin (HgbS).
Choice 2, while abdominal pain is often a symptom of crisis, it does not precipitate crisis.
Dehydration is a precipitating factor but the intermittent diarrhea described in the scenario
would not lead to significant dehydration.
Choice 4, menses is not a precipitating factor for sickle cell crisis.

58. Correct answer is 3. AGN is often caused by the body’s response to infections with beta
hemolytic streptococcus which causes strept throat. Other infections may also be associated
with AGN but strept infections are most common precipitating cause. Identifying the
causative organism is helpful in diagnosis confirmation.

59. Correct answer is 1. This child has the most intact immune function and is not at risk for
an opportunistic infection such as pneumocystic carinii pneumonia.

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60. Correct answer is 3. This option offers the most stable point of reference for both the
child and nurse. Lunchtime is typically around noon for most children and meal delivery is
often at a standard time for each hospital unit.
Choice 1, telling time is a skill not mastered until early school age and does not offer the
child a stable reference point. Choice 2, most 4-year-old no longer nap, and all sleep
including naps are often disrupted in the hospital setting.
Choice 4, bath time may not be at a consistent time at home and at the hospital, making it a
less significant reference point in time.
61. Correct answer is Choice 3. Clients with Alzheimer’s are most oriented early in the day
and become increasingly more confused in the evening and as night approaches.

62. Correct answer is Choice 1. Repression is an unconscious mechanism which allows the
individual to “Forget” undesirable and unacceptable memories, thoughts, or feelings from
the conscious mind.
Choices 2, 3, & 4, are examples of defense mechanisms of denial, sublimation, and
rationalization respectively.

63. Correct answer is Choice 2. The effects of klonopin can be potentiated when alcohol is
added as both are central nervous system depressants causing possible respiratory
suppression, arrest and death. Choice 4, Medications should be taken as prescribed for
anxiety.
Choices 1 & 3, there are no dietary concerns with this medication.

64. Correct answer is Choice 3. The beginning signs of lithium toxicity include blurred vision,
severe diarrhea, tinnitus, ataxia and nausea/vomiting. The lithium should be held
immediately and lithium blood levels obtained. Client should be monitored for attainment of
therapeutic level.

65. The dose is 0.6 mL.

15 mg / 25 mg X 1 mL = 0.6 mL
or
15 mg / 250 mg X 10 mL = 0.6 mL

66. The correct answer is choice 2. This is an example of a Stage 1 pressure ulcer, which is
defined as an area of intact skin that is nonblanchable to touch and erythematous.
Choice 1, there is no Stage 0 in pressure ulcer definitions.
Choice 3, Stage 2 would require partial thickness skin loss.
Choice 4, Stage 3 would require full thickness skin loss.

67. The correct answer is choice 4. Stridor on exhalation is a cardinal clinical sign of
respiratory distress in clients who have had a total thyroidectomy, usually caused by
obstruction resulting from post-operative edema. One emergency nursing measure is to

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remove the surgical clips to relieve the pressure. Emergency intubation also may be
necessary by the Primary Care Provider.
Choices 1, 2 & 3 do not address the immediacy of this emergency situation. Should the
client’s condition go unaddressed, this may lead to occlusion of the airway and death of the
client.

68. The correct answer is choice 3. Transurethral resection of the prostate (TURP) is a type of
prostate surgery done to relieve moderate to severe urinary symptoms caused by an
enlarged prostate, a condition known as benign prostatic hyperplasia (BPH). The client who
undergoes a TURP is at risk for bleeding during the first 24 hours after surgery. After this
initial 24 hour period post-surgery, there should not be any bleeding noted.
Choices 1, 2 & 4 are all considered to be expected complications of the procedure. They will
resolve as the client continues to recover and the catheter is removed.

69. Correct answer is choice 4. The urinary meatus should be at the center of the glans
penis, otherwise it is considered hypospadia.
Choice 1 Cyanosis of the hands and feet is called acrocyanosis.
Choice 2, small tiny papules appearing on the face of a newborn are the result of unopened
sebaceous glands and they are called milia.
Choice 3 Hemorrhagic areas in the sclera can be the result of birth trauma.

70. Correct answer is choice 3. Extension and abduction of the extremities with formation of
a “C” by the thumb and forefinger is classic Moro reflex.
Choice 1 is the rooting reflex.
Choice 2 is tonic neck reflex.
Choice 4 is the Babinski reflex.

71. Correct answer is choice 1. When bilirubin is being excreted from the system, it will color
the stool and urine.
Choices 2, 3, & 4 are incorrect regarding the effect that the phototherapy is having on the
infant.

72. Correct answer is choice 2. The first immunization follow-up would be at 2 months. A 2-
week follow-up visit is only to identify any problems. If Hep B is to be given, the first dose is
at birth.
Choices 1, 3 & 4 are incorrect regarding the immunization schedule.

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73. Correct answer is 4. The moro reflex is a sign of CNS integrity in newborns, remains
active to age 3 months, when it begins to fade and disappears by age 6 months. Persistence
of such a reflex is associated with Cerebral Palsy (CP)
Choice 1, stranger anxiety can begin at this age and crying when separated from their
caregiver is normal. Both #1 and #2 are developmental milestones and such abnormalities
more directly point to developmental delay not necessarily neurological abnormalities.
Choice 2, holding a bottle is not considered a milestone, since breast-feed babies have
limited exposure to bottles.
Choice 3, the parachute reflex is a protective reflex in which the arms extend when falling
and typically presents at age 5-9 months.

74. Correct answer is 3. Ignoring the behavior decreases the importance of the event. The
child is not motivated by the parental response when having a temper tantrum in early
toddlerhood.

75. Correct answer is 1. Stuttering is a normal variation in early speech development.

Allowing the child adequate time to think and speak will allow the child to develop proper
speech patterns.

76. Correct answer is 1. The urine of a child with PKU will have a musty smell from the
inability to breakdown protein.
Choice 2, this is called steatorrhea and is associated with fat malabsorption as in celiac
disease.
Choice 3, multiple café-au-lait spots are associated with neurofibromatosis.
Choice 4, extra gluteal folds are a sign of congenital hip dysplasia.

77. Correct answer is Choice 3 clang associations. The client is using words that rhyme.
Choice 1, Echolalia is repeated words by the client to mirror the nurse.
Choice 2, Neologisms is a private understanding of a meaning of a word invented by the
client.
Choice 4, ideas of reference is a client’s belief that events in the environment have personal
meaning/significance to the client.

78. Correct answer is Choice 1. These behaviors are primarily associated with acute onset of
Schizophrenia.
Choice 2 is incorrect as apathy and amotivation are negative signs.
Choice 3 is incorrect as apathy is a negative sign.
Choice 4 is incorrect as apathy and anhedonia are negative signs.

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79. Correct answer is Choice 2. These are the typical symptoms of NMS which come on
quickly and are seen with the use of a number of antipsychotics including Clozaril.
Choice 1 is incorrect as all vital signs in NMS are elevated (labile blood pressure, tachycardia,
tachypnea, and hyperthermia).
Choice 3 is incorrect as there is a high incidence of NMS with the use of Clozaril.
Choice 4 NMS is not insidious (proceeds gradually), but rather proceeds quickly.

80. Correct answer is Choice 2. The client should be assisted in finding appropriate clothing
to preserve her dignity.
Choice 1 Unacceptable behavior should not be ignored.
Choice 3 The client should be assisted in finding appropriate clothing.
Choice 4 Nurses should never assign tasks to other staff that they are unwilling to assume
themselves.
81. The correct answers are choices 1, 3 & 5. A 70 year old with congestive heart failure
and rheumatoid arthritis with a feeding tube, the 16 year old admitted two days ago with a
tibial fracture and an external fixator that requires pin site care, and a 65 year old, two days
after GI tube placement, with a (+) C. Difficile culture who needs dressing changes to a
coccyx pressure ulcer; are all examples of clients who are stable and are not experiencing
signs of acute or potential acute illness. These patients are all examples of clients that one
may find in a long-term care facility such as a nursing home.
Choices 2 & 4 – A 55-year-old c/o abdominal distension who had 50 ml of urine output in the
past 24 hours is an example of a client that may require potential urgent care (the normal
urinary output in 24 hours should be 1500 mL to 2500 mL). Therefore this client should be
assessed and cared for by the RN. A 45 year old with a new ileostomy who requires fitting of
the appliance and the first irrigation procedure is also an example of a client requiring care
by the RN since the client has a NEW ileostomy requiring assessment; in need of the INITIAL
irrigation procedure.

82. The correct order is choices 3, 2, 1, 4 & 5 consecutively. The correct order is as follows:
Choice 3, verify that the client has signed consent. Without a signed consent, there is no
need to continue.
Choice 2, insure patency of the intravenous site. Client must have a working IV site before
blood is removed from the blood bank; otherwise, time will be wasted initiating IV access
while blood is sitting out of the refrigerator.
Choice 1, after consent has been verified and IV access is insured, the nurse should then pick
up the blood from the blood bank.
Choice 4, the nurse then will check the unit of blood with another registered nurse.
Choice 5, begin infusing the blood.

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83. The correct answer is 4, 3, 6, 1, 2 & 5 consecutively. The correct order for providing
tracheostomy care is as follows:
Choice 4, put on clean gloves in preparation for choice 3, removing the soiled dressing.
Choice 6, remove the inner cannula.
Choice 1, put on sterile gloves in preparation for choice 2, replacing/inserting an inner
cannula.
Choice 5, replace the tracheostomy ties.

84. The correct answers are choices 2, 4, 6, 5, 3 & 1 respectively. Filling irrigation bag with
500-1000 mL of warmed tap water does not require donning clean gloves. Gloves are
required prior to lubricating the cone and inserting tubing tip into ostomy site. Once
inserted, hanging bag at about shoulder height will facilitate infusion of the water into the
colon. A slow infusion (over 5 - 10 minutes) will help to decrease the abdominal discomfort
and cramping associated with colonic irrigations. Lastly, the clinician should wait about 45
minutes for the bowel to completely finish eliminating the irrigant and effluent.

85. The correct answer is choice 1. Immunosuppressive agents should not be stopped
without the consultation of the transplantation physician, even if an infection is present.
Stopping immunosuppressive therapy endangers the transplanted organ.
Choices 2, 3 & 4 demonstrate clear understanding of the post transplant protocol used to
help prevent transplanted organ rejection.

86. The correct answer is choice 3. After the cane in the right hand (stronger side) is moved
ahead, the cane and the stronger leg provide a stable base for movement of the weaker leg.
Placing the cane in the client’s left hand does not provide sufficient stability.
Choices 1, 2 & 4 could prove less reliable with respect to ambulation, and therefore be a
safety risk.

87. The correct answer is choice 3. The client is experiencing atrial fibrillation. This
dysrhythmia places the client at immediate risk of blood clots. Heparin should be
administered to prevent the formation of blood clots.
Choice 1, Coumadin will also decrease the risk of blood clots but does not start to work until
after a few days of therapy while Heparin works quickly.
Choice 2, Atropine is used for dysrhythmias such as symptomatic sinus bradycardia and
ventricular irritability.
Choice 4, Nitroglycerin relieves and prevents angina attacks. Dilates coronary arteries and
improves collateral flow to ischemic regions.

88. The correct answer is choice 4. Albuterol and metaproterenol are group 1 category
drugs and ipratropium is a group 2 category drug. Both group 1 and group 2 drugs are
given before group 3 category drugs.

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89. The correct answer is choice 2. The expected range of findings for gastric pH is 1-4. A
pH of 6 or higher is indicative of intestinal or pleural fluid from the bronchial tree. It is likely
that this nasogastric tube is not in the correct location and the primary healthcare provider
should be notified.
Choice 1 is incorrect as it does not address the probable incorrect location of the tube.
Choice 3 will likely push the tube further in the wrong direction.
Choice 4 places the client at risk for aspiration if the nasogastric tube is indeed located in
the client’s bronchial tree.

90. The correct answer is choice 2. Dependent loops can capture drainage and plug the
tube, not allowing any more drainage to leave the chest.
Choice 1, informing the charge nurse would be a task for the Nursing Assistant or
Unlicensed Assistive Personnel (UAP).
Choice 3, splinting and coughing is an intervention in preventing nosocomial pneumonia,
and not for facilitating chest tube drainage.
Choice 4, massaging the tube may be an acceptable intervention, only after dependent
loops have been corrected.

91. The correct answer is choice 3. Upon finding a large residual, the nurse should return the
residual to the patient, document the amount of the residual, and hold the feeding to avoid
possible aspiration. You would hold this feeding even if the client is repositioned in high-
Fowler’s because if aspiration exists, the threat for the client becomes pneumonia
development.

92. The correct answer is choice 1. Insulin glargine must not be diluted or mixed with any
other insulin or solution. It must be administered independent of other insulins. Mixing
results in an unpredictable alteration in the onset of action and time to peak action.
Choice 2, waiting 1 hour between insulins is not recommended.

93. Correct answer is 1920 mL. The conversion from ounces to mL is 1 ounce = 30 mL. 24
ounces of canned soda = 720 mL + 500 mL water + 100 mL secondary intravenous infusion
+ 360 mL (12 ounces = 360 mL) of juice + 240 mL of broth = 1920 mL total input.

94. The correct answers are choices 2, 3, 4 & 5. Compartment syndrome is a limb- and life-
threatening condition which occurs after an injury, when there is not a sufficient amount of
blood to supply the muscles and nerves with oxygen and nutrients because of the raised
pressure within the compartment such as the arm, leg or any enclosed space within the body
and leads to nerve damage because of the lack of blood supply. The severity of
compartment syndrome can be divided into acute, subacute, and chronic compartment
syndrome.
Choices 1, 6 & 7, warm, rosy fingers and capillary refill less than 3 seconds would be
assessed as signs of adequate perfusion.

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95. The correct answers are choices 1, 3, 6 & 7. Washing hands decreases self-
contamination, lubricant decreases trauma, and only clean technique is necessary in the
home (sterile technique in the hospital). Since the client will be using clean technique,
storing the catheter in a towel or plastic bag (once thoroughly dries) is an acceptable
storage modality.
Choice 2, a small-lumen catheter should be used to minimize trauma.
Choice 4, self-catheterization should be done every 6 to 8 hours depending on fluid intake,
and 12 hours leads to increased urinary retention, which leads to bacterial growth.

96. The correct answers are choices 2, 3, 5, 6 & 7. Alcohol-based hand gels have been
shown to be minimally effective at eradicating C. difficile, so hands should be washed with
an antibacterial soap before and after caring for the client. A private room setting would be
appropriate, as a semi-private setting would increase risk for transmission to other clients
within room.
Choice 4, an isolation gown is advisable, however sterile gloves are not needed when
providing basic care for clients in contact isolation with C. difficile infection. Having
dedicated equipment, supplies, utensils, etc. for the client would help minimize risk for
transmission to other individuals. Using a bleach solution (1 part bleach :: 10 parts water ) is
a typical solution that the nurse can use to properly disinfect surfaces for re-use items.

97. The correct answers are choices 1, 2, 3, 4, 5 & 7. If the client has renal disease, fluids and
Mucomyst may be given 12 to 24 hours prior to the procedure for renal protection. The
client should be assessed for lab results and allergies to iodine, including shellfish. The
contrast medium used during the catheterization contains iodine. The client needs to be
kept NPO to help minimize risk for aspiration. Vascular procedures should have client pulses
marked for ease in locating them after the procedure. Findings (laboratory and diagnostic)
need to be properly documented and the primary care provider and other members of the
health care team need to be notified of abnormal findings.
Choice 6, insertion of a Central Venous Access Device is not within the scope of practice of
the nurse. This CVAD can be inserted by the Cardiac Thoracic Surgeon, Vascular Surgeon,
etc. The specially certified RN or Advanced Practice Nurse can insert a PICC line.

98. The correct answer is choice 2. Hormonal risks for development of breast cancer include
use of birth control pills or hormone replacement therapy; early menarche (before 12 years
of age); late menopause (after 55 years of age); and first pregnancy after 30 years of age.
Nonhormonal risk factors include family history; lack of regular exercise; postmenopausal
obesity; increased use of alcohol; working the night shift; older than 65 years of age; no full-
term pregnancies; never breastfed; higher socioeconomic status; Jewish heritage; and two
or more first-degree relatives with breast cancer at an early age. alcohol; working the night
shift; older than 65 years of age; no full-term pregnancies; never breastfed; higher
socioeconomic status; Jewish heritage; and two or more first-degree relatives with breast
cancer at an early age.

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99. The correct answer is choice 3. Thrombocytopenia is defined as a decreased number of

platelets in the blood, which can result in poor blood clotting. Thrombocytopenia is usually
defined as less than 150,000 platelets per cubic millimeter of blood (normal platelet range is
150,000-400,000); although significant bleeding does not usually occur until the level drops
below 20,000. Since the client’s platelets are greatly decreased in number, this will increase
the client’s risk for prolonged bleeding in response to even minor injury, especially from
highly vascular areas, such as the gums.
Choices 1, 2 & 4, eating a low-bacteria diet, taking temperature daily, and avoiding alcohol
containing mouthwashes may be applicable depending upon a case-to-case patient basis,
but are not the priority generalized intervention applicable to ALL patients with
thrombocytopenia.

100. The correct answers are choices 2, 5, 6 & 7. Morphine is primarily used to treat both
acute and chronic severe pain. It is also used for pain due to myocardial infarction and for
advanced cancer. Morphine has also traditionally been used in the treatment of the acute
pulmonary edema. The objective and subjective signs as noted in the question options
indicate relief of pain and represent normal vital signs of which the nurse would be
assessing.

90 Feuer Nursing Review