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C

Answers and Rationales for NCLEX-Style Review Questions

Chapter 2

1. Correct Answer: 3. Rationale: The first step in the nursing process is assessment. Data collection precedes determining needs, setting goals, and developing a plan for care. Category of Client Need:

Safe, Effective Care Environment; Step in the Nursing Process: Implementation. Need: Safe, Effective Care Environment; Step in the Nursing Process: Data Collection.

3. Correct Answer: 2. Rationale: An incident report is a tool for risk

management; it helps to determine measures for preventing potentially litigious incidents. It also is a tool that could be used in court in a nurse or health agency's defense. Fall precautions are implemented when the nurse determines that a client is at risk for falling; they are overdue after a fall. The nurse gives the nursing supervisor the written incident report; it is not a part of the client's medical record. The physician is informed of the incident, may examine the client, and determines if the client's family is notified. Category of Client Need:

Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

2. Correct Answer: 2. Rationale: A licensed practical nurse works under the direction of a registered nurse. A registered nurse can delegate the task of acquiring basic information from the client to a licensed practical nurse, but the registered nurse is responsible for ensuring that the admission database is complete. The registered nurse is responsible for identifying nursing diagnoses and developing the initial plan of care for preventing, reducing, or resolving the nursing diagnoses. The registered nurse delegates implementation of the plan of care to the licensed practical nurse and encourages the licensed practical nurse to make future contributions to the initial care plan. Category of Client

Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

Chapter 4

1. Correct Answer: 2. Rationale: The highest priority for client care is

relief of labored breathing. Breathing is a basic physiologic need. Feeling powerless affects the need for security. Family support is an issue that affects the need for love and belonging. Issues of self-esteem follow the others in the list. Category of Client Need: Safe, Effective

Care Environment; Step in the Nursing Process: Planning.

3. Correct Answer: 1. Rationale: Ineffective airway clearance reflects

a problem affecting breathing, a basic physiologic need. The remaining diagnoses affect other levels of Maslow's hierarchy. Ineffective coping affects needs of safety and security. Deficient diversional activity affects self-actualization. Interrupted family processes affect the need for love and belonging. Category of Client Need: Safe, Effective Care

Environment; Step in the Nursing Process: Implementation.

2. Correct Answer: 4. Rationale: Initial examination by a family practice physician is the first step in primary care. The family practice physician may then refer the client for secondary or tertiary care. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

Chapter 3

1. Correct Answer: 4. Rationale: The first step when a nurse suspects another of stealing narcotics is to report the information to the immediate nursing supervisor. Providing specific observations and facts is important. Once the information is validated, the nursing supervisor is responsible for proceeding with other possible legal and ethical actions. It is unethical to damage the character of a colleague by discussing the situation prematurely. Category of Client Need:

Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

3. Correct Answer: 2. Rationale: A referral to a home health nursing organization before discharge helps to maintain health care from an acute care agency to home care without appreciable interruption. The other three organizations are examples of insurance plans for facilitation of third party payers of health care. Category of Client Need:

Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

Chapter 5

1. Correct Answer: 3. Rationale: Primary prevention involves eliminating the potential for an illness. Stress-management techniques help to reduce the release of norepinephrine and epinephrine and promote normal blood pressure. Blood pressure assessment is a secondary preventive measure that provides a means for early diagnosis. It is premature to give a client information about medications before a diagnosis is made. Teaching about the hazards of hypertension can motivate a client to implement measures to reduce health risks but offering the client a tool, like methods for stress management, is best. Category of

2. Correct Answer: 3. Rationale: An advance directive is a written

statement identifying a competent person's wishes concerning end-oflife health care. The advance directive is valuable to the nurse and physicians because it will guide them in managing the client's care. Proof of insurance is important to the billing department of the health care agency. The client's date of birth and social security number may be useful to a social worker for determining if the client qualifies for Medicare or other services from social agencies. Category of Client

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APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions feelings of the client's statement. The nurse avoids any emotional support or involvement by offering to arrange contact with the surgeon. Giving advice and disagreeing with the client are nontherapeutic forms of communication. Client Need: Psychosocial Integrity; Step in the

Nursing Process: Implementation.

Client Need: Health Promotion and Maintenance; Step in the Nursing Process: Planning.

2. Correct Answer: 1. Rationale: According to Holmes' and Rahe's Social Readjustment Rating Scale, death of a spouse is the most stressful event a person experiences. The other examples are significant stressors but less intense than the death of a spouse. Category of

Client Need: Health Promotion and Maintenance; Step in the Nursing Process: Assessment.

2. Correct Answer: 3. Rationale: The best therapeutic nursing action

is to facilitate the client's discussion of his feelings. Reading literature on an emotional topic and thinking privately may help some people, but they are not as effective as verbalizing thoughts for most people. If the client requests a second opinion, the nurse should pursue it; however, it is inappropriate for the nurse to initiate the suggestion. Doing so is considered false reassurance because it implies that the nurse believes the present medical regimen is less than optimal and that other alternatives can change the outcome. Client Need: Psychosocial

Integrity; Step in the Nursing Process: Implementation.

3. Correct Answer: 4. Rationale: Denial is a coping mechanism in which a person rejects objective information and believes something else is true. Denial protects the ego from dealing with threatening information. Somatization is a coping mechanism in which a person manifests an emotional stressor via a physical disorder or symptom. Regression is manifested by behaving in a manner characteristic of a younger age. Displacement involves expressing one's anger toward something or someone unlikely to retaliate. Category of Client Need:

Psychosocial Integrity; Step in the Nursing Process: Assessment.

3. Correct Answer: 2. Rationale: The nurse performs the role of educator by providing explanations to a client who is unfamiliar with hospital equipment. Explanations are best in simple, understandable terms. Once informed, the client has a basis for interpreting and coping with what are unique experiences. The client is unlikely to understand what the name of a heart rhythm implies. Administering a tranquilizer or distracting the client with a magazine does not help to prevent a similar fearful response if the situation recurs. Client Need: Psychosocial

Integrity; Step in the Nursing Process: Implementation.

Chapter 6

1. Correct Answer: 4. Rationale: Determining a client's food preferences forms the basis for menu planning and dietary selections within the prescribed restrictions of the client's therapeutic diet. Incorporating cultural preferences, if they exist, promotes the potential for compliance with a diet. Although the trends in the client's blood glucose level and knowledge of drug therapy are important, they are secondary to preparation for diet teaching. Once he or she has identified the client's food preferences, the nurse personalizes the exchange list by emphasizing the allowed amounts of those foods that the client is accustomed to eating. Category of Client Need: Health Promotion

and Maintenance; Step in Nursing Process: Planning.

4. Correct Answer: 2. Rationale: 2. The nurse delegates tasks within

the nursing assistant's legal scope of job performance. Administering medications, collaborating with laboratory personnel about diagnostic test results, and performing physical assessments are nursing responsibilities. The nurse could delegate those to another licensed nurse or a nursing student who has demonstrated competencies in these skills.

Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

2. Correct Answer: 2. Rationale: Clients who have retained their Asian culture will feel most comfortable if the nurse maintains a distance just beyond arm's reach. People from non-Anglo cultures often find physical closeness with strangers to be discomforting. Touch also may provoke anxiety; it is important to explain when and how a client will be touched if that is necessary. A position within the doorway to the room is too distant during an interview regardless of the client's culture.

Category of Client Need: Psychosocial Integrity; Step in Nursing Process: Implementation.

Chapter 8

1. Correct Answer: 1. Rationale: Before the nurse can proceed with

teaching, he or she should assess the child's height and weight to determine if the child is within norms for his or her age group. Another pertinent assessment is determining if the child has any food allergies or health problems affected by food. A food pyramid is a useful guideline for normal, healthy nutrition, but serving sizes require modification for a child especially if he or she is underweight or overweight. It is inappropriate for the nurse to plan 1 week's menus without knowing what the mother usually prepares for the family and the budget for purchasing groceries. Recipes are the mother's personal choice and various cookbooks are available from resources other than the nurse's own collection. Category of Client Need: Health Promotion and Maintenance; Step in the Nursing Process: Assessment.

3. Correct Answer: 1. Rationale: Dark-blue pigmented areas, known

as Mongolian spots, are common on the lower back and buttocks of dark-skinned infants and children. The pigmentation tends to fade by the time a child is 5 years of age. The nurse who is unfamiliar with this normal physiologic variation may misinterpret it as a sign of physical abuse. This case does not warrant informing Child Protective Services or the physician. There is no justification for examining other children in the home for abuse. Category of Client Need: Safe, Effective Care

Environment; Step in Nursing Process: Implementation.

2. Correct Answer: 2. Rationale: Directly observing the client's performance is the best method for evaluating if he or she learned the information. The client may correctly describe the importance of performing breathing exercises, yet not actually perform the skill. The client may say he or she is performing the exercises even if this is untrue. Monitoring the respiratory rate is not the best technique for determining if, when, and how often the client is performing the exercises because the rate changes in response to many variables such as current level of activity and oxygenation status. Category of Client Need: Physiological

Integrity; Step in the Nursing Process: Evaluation.

4. Correct Answer: 2. Rationale: When a cultural practice is not

unsafe or potentially injurious to the client, it is best to incorporate the client's belief system along with the scientific regimen for treatment. Implying that the client's cultural practices are not beneficial is an example of ethnocentrism. The tribal elder has not claimed to be a physician; rather, he or she is performing a ritual with a long cultural tradition. Category of Client Need: Psychosocial Integrity; Step in

Nursing Process: Implementation.

Chapter 7

1. Correct Answer: 1. Rationale: Paraphrasing is a therapeutic communication technique by which the nurse lets the client know empathetically that he or she has understood both the content and the

3. Correct Answer: 1. Rationale: Using dolls or puppets as a teaching

aid is the most appropriate strategy for a preschooler's cognitive ability. Pamphlets and diagrams are too abstract for a child of this age. The preschooler might confuse use of a videotape as a form of entertainment rather than personal instruction. Category of Client Need: Safe,

Effective Care Environment; Step in the Nursing Process: Planning.

APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions

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Chapter 9

1. Correct Answer: 2. Rationale: Publicly identifying the names of clients violates their right to confidentiality. The number of clients assigned to each nursing team member depends on the person's knowledge and experience and the clients' acuity level. Posting the names of staff demonstrates respect for the right of clients to know who is managing their care. The Kardex is a resource that the nurse and members of the nursing team use frequently for current information about clients. Category of Client Need: Safe, Effective Care Environment;

Step in the Nursing Process: Implementation.

is not likely to create sufficient exercise to significantly alter the pulse rate; therefore, a 15-minute delay is not necessary. Blood pressure can be assessed in a lying, sitting, or standing position. To evaluate trends in blood pressure, all measurements are taken consistently on the same arm and body position. Category of Client Need: Physiological

Integrity; Step in the Nursing Process: Data Collection.

2. Correct Answer: 1. Rationale: Inserting information on a record that suggests the documentation was entered earlier is legally problematic because it could be interpreted as falsifying a record. If the writer recalls information omitted earlier, the best practice is to identify the time the note is being written and write "late entry for [insert date and time]. . . ." Misspelled words, a color of ink that is contrary to the agency's documentation policy, and failure to identify one's title are practices that require improvement but they are not as serious to cases involving a lawsuit. Category of Client Need: Safe, Effective Care

Environment; Step in the Nursing Process: Implementation.

2. Correct Answer: 2. Rationale: Shivering takes place at the onset of a fever as a physiologic measure for assisting the hypothalamus to reach a higher set point. Covering the client provides comfort and shortens the period of chilling. Once the temperature reaches a plateau, the extra covers can be removed. Fluid replacement and facilitating evaporation with adequate circulation of environmental air are appropriate when diaphoresis occurs in the later phase of a fever. Rest conserves energy to compensate for an elevated metabolic rate caused by the fever, but it is not the most important nursing action in response to shivering. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

3. Correct Answer: 3. Rationale: A thready pulse, also classified as a 1+ pulse, is one that is not easily felt and disappears with slight pressure. A normal pulse is easily felt and disappears when moderate pressure is applied. A weak pulse is stronger than a thready pulse and disappears with light pressure. Although the pulsation may be difficult to detect, the term "diminished" is not a standard descriptive term.

Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

Chapter 10

1. Correct Answer: 2. Rationale: Under the privacy and security components added to the Health Insurance Portability and Accountability Act (HIPAA), a healthcare institution must protect clients' health information. Permission must be obtained before sharing health information with any third party. When interacting directly with a client, it is respectful to use the client's surname unless permission has been given otherwise. A client's surname is not used in public locations like an elevator or cafeteria. When communicating with staff, referring to a client by a room number disregards the client's unique identity. All medical records, which are kept confidential, contain both the client's name and medical record number. Category of Client Need:

Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

4. Correct Answer: 3. Rationale: According to the American Heart

Association, the length of the bladder of a blood pressure cuff should be at least 80% and up to 100%. A blood pressure cuff bladder that measures 40% or 60% of the forearm is an inaccurate size for assessing blood pressure. A cuff whose bladder measures 100% is the maximum size and is therefore appropriate to use, but it is not the minimum standard. Category of Client Need: Physiological Integrity; Step in the

Nursing Process: Data Collection.

5. Correct Answer: 2. Rationale: Orthostatic or postural hypotension

is a drop in blood pressure that results in lightheadedness, dizziness, and even syncope (fainting) when a client with circulatory problems, dehydration, or using a diuretic, antihypertensive, or other drug assumes an upright position. Rising gradually provides time for baroreceptors to stimulate increased blood flow to the brain to prevent or reduce symptoms. Increasing fluid intake, if not contraindicated, is more appropriate than limiting fluid intake. Remaining on bedrest is unnecessary and may cause problems associated with inactivity. Ambulating is not contraindicated but should be temporarily postponed until the client is no longer experiencing symptoms. Category

of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Planning.

2. Correct Answer: 3. Rationale: The federal Patient Self-determination Act ensures clients' right to have advance directives declaring their wishes regarding life-sustaining treatment. If a client has not prepared a document of this nature, the nurse provides information and an accompanying form with which to do so. Social security numbers are not medically necessary. A client's Medicare status and information about health insurance are important for collecting third-party payment for health care, but the information is obtained by personnel in the admitting or business office of the health care agency. Category of

Client Need: Safe Effective Care Environment; Step in Nursing Process: Implementation.

Chapter 12

1. Correct Answer: 3. Rationale: If a cough is productive, it is important to document the color, odor, amount, and viscosity of sputum raised. Other data that may help the physician make a diagnosis include the onset, duration, precipitating factors, and relief measures that relate to the cough. The client's family history may or may not correlate with the client's current condition. The client's heart rate may be elevated if his or her temperature is elevated or oxygenation status is compromised, but a focused assessment of the heart rate is less critical than is the characteristics of sputum. Measures the client is using to manage his or her cough are helpful, but the characteristics of the sputum are more significant for the diagnostic process. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

3. Correct Answer: 2. Rationale: Anxiety is usually manifested via sympathetic nervous system stimulation. Of the four choices, restlessness and disturbed sleep correlate most with anxiety. Being quiet and withdrawn, eating less than expected, and missing family members suggests depression or loneliness. Category of Client Need: Psychosocial

Integrity; Step in the Nursing Process: Data Collection.

Chapter 11

1. Correct Answer: 3. Rationale: To obtain an accurate oral temperature, the assessment is delayed 30 minutes after the client has consumed hot or cold beverages or food. Unless the client is taking medication that affects heart rate, has a slow or irregular pulse, or the radial pulse is difficult to assess, there is no reason to obtain an apical-radial rate. Eating

2. Correct Answer: 2. Rationale: There is more than one correct description for how breast self-examination is performed, but all include palpating the breasts from the outer margins toward the nipple. Category

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APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions

Client Need: Health Promotion & Maintenance; Step in Nursing Process: Implementation.

of Client Need: Health Promotion/Maintenance; Step in the Nursing Process Implementation.

3. Correct Answer: 4. Rationale: Changes in pupil response indicate increasing intracranial pressure. The other assessments are appropriate, but they do not provide the most critical information about the client's neurologic status. Category of Client Need: Physiological

Integrity; Step in Nursing Process: Data Collection.

4. Correct Answer: 1. Rationale: The S1 heart sound is heard best by

auscultating the apical area, which is at the fifth intercostal space in the left midclavicular line. The S2 heart sound is best heard at the second intercostal space to the right of the sternum. The examiner may hear a splitting of the S1 and S2 heart sounds with the stethoscope in the other locations. Category of Client Need: Physiological Integrity; Step in

the Nursing Process: Data Collection.

3. Correct Answer: 2. Rationale: Maintaining or gaining weight is the best evidence that a client's nutritional needs are being met. The client could remain alert yet be malnourished. Because eating food is both an emotional as well as physical phenomenon, well-nourished, satiated people may feel hungry when they see, smell, or think about food. The client's tolerance of pain may increase with improved nutrition, but it is not the best criterion for determining the outcome of a nutritional regimen. Category of Client Need: Physiological Integrity; Step in Nursing Process: Evaluation.

4. Correct Answer: 3. Rationale: A clear liquid diet includes fat-free

bouillon, tea or coffee, flavored gelatin, fruit ices, carbonated beverages like ginger ale, and some clear fruit juices like apple and grape. Honey and sugar also may be used. No milk or milk products are permitted.

Category of Client Need: Physiological Integrity; Step in Nursing Process: Implementation.

5. Correct Answer: 2. Rationale: A Snellen chart is used to test far vision. Clients stand 20 feet from the chart and are asked to read letters that progressively become smaller. A Jaeger chart requires that the client read various sizes of print and is used to test near vision. Ishihara plates are used to test color vision. A tangent screen is used to assess the peripheral visual field. This test requires that the client indicate when he or she sees a stimulus in his peripheral vision. Category of Client

Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.

5. Correct Answer: 3. Rationale: Red meat, liver, and egg yolk are good

dietary sources of iron. Dairy products are low in iron, but high in calcium. Citrus fruits are high in vitamin C. Yellow vegetables like carrots and squash are a source of vitamin A. Category of Client Need: Health

Promotion & Maintenance; Step in Nursing Process: Implementation.

Chapter 15 Chapter 13

1. Correct Answer: 1. Rationale: An anesthetic is not administered to

clients undergoing a sigmoidoscopy. Clients can eat lightly before a sigmoidoscopy. A flexible sigmoidoscope is used more commonly than one that is rigid. The sigmoidoscope is inserted through the anus and traverses the rectum to the sigmoid area of the lower bowel. Clients can take medications that do not interfere with the test findings prior to a sigmoidoscopy. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Evaluation.

1. Correct Answer: 1. Rationale: To evaluate trends in weight that may

reflect deficient or excess fluid volumes, the nurse weighs the client at the same time daily using the same scale each time. The amount of clothing is similar at each weighing. If the time of weighing is consistent, the amount of food or liquids that the client has been consuming is not likely to vary considerably. It is important to collaborate with the client, but obtaining the weight is not omitted or postponed for frivolous reasons. Category of Client Need: Physiological Integrity; Step in the

Nursing Process: Planning.

2. Correct Answer: 2. Rationale: Anything containing metal is removed

before a chest x-ray. The metal object may be misinterpreted as diseased tissue. Fasting is not required before a chest x-ray. No contrast dye is given before or during a chest x-ray. Analgesia (pain medication) is not usually necessary because there is no discomfort from the chest x-ray itself. Category of Client Need: Safe, Effective Care Environment;

Step in the Nursing Process: Planning.

2. Correct Answer: 1. Rationale: Soy sauce is high in sodium and,

therefore, is restricted on a low-sodium diet. Lemon juice and onion powder (not salt) can be used liberally. Maple syrup is not restricted for its sodium content but may be limited if the client needs to lose weight. Category of Client Need: Health Promotion/Maintenance;

Step in the Nursing Process: Evaluation.

3. Correct Answer: 1. Rationale: Douching in the days before obtaining a specimen for a Pap test interferes with accurate test results because it removes cervical cells. None of the other instructions is necessary before a pelvic examination and Pap test. Category of Client Need:

Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

Chapter 14

1. Correct Answer: 1. Rationale: When the mucous membrane of the

oral cavity is inflamed, it is best to eliminate foods that are acidic, salty, spicy, dry, or very hot. Other than tomato soup, none of the other foods has these characteristics. Category of Client Need: Physiological

Integrity; Step in Nursing Process: Implementation.

3. Correct Answer: 1. Rationale: A unit of packed blood cells contains similar numbers of blood cells in less fluid volume. A unit of packed red blood cells is prepared by removing approximately two-thirds of the plasma from 1 unit of whole blood. Administration of packed red blood cells is preferred for clients who need a blood transfusion but for whom additional water within the circulatory system is hazardous. Typically the candidate for packed blood cells is someone prone to excess fluid volume. Packed red blood cells pose the same risk for an allergic transfusion reaction as whole blood. Neither a transfusion of packed red blood cells nor whole blood stimulates the bone marrow to produce more red blood cells. Category of Client Need: Health promotion/maintenance; Step

in the Nursing Process: Implementation.

4. Correct Answer: 4. Rationale: A person with A, Rh-positive blood

type would have an incompatibility reaction if transfused with AB, Rhpositive blood. Type O is referred to as the universal donor. In an emergency, anyone can receive type O blood. People who are Rh positive can receive compatible blood types that are either Rh positive or Rh negative. The reverse is not true; in other words, a person who is Rh negative should never be given Rh-positive blood. Category of Client Need:

Physiological Integrity; Step in the Nursing Process: Implementation.

2. Correct Answer: 2. Rationale: Chewing food thoroughly helps the bolus to descend through the esophagus. Restricting dietary intake to baby food is unnecessary and could contribute to constipation. Drinking liquids helps to keep the mouth moist. Liquids are thickened if a client has weakness or paralysis of the tongue or pharynx. Eliminating dairy products will not promote the ability to swallow. Category of

5. Correct Answer: 2. Rationale: Hypotension is one sign of a serious

blood transfusion reaction. In a serious transfusion reaction, urine production is decreased. Swelling and pale skin at the infusion site are

APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions indications of a problem with the administration of the blood rather than a reaction to the blood. Category of Client Need: Physiological

Integrity; Step in the Nursing Process: Data Collection.

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of etiologies may cause. Carbon monoxide is an odorless gas. The pulse rate may be rapid and irregular with carbon monoxide poisoning, but this finding is not as specific as cherry-red skin. Category of

Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

Chapter 16

1. Correct Answer: 3 Rationale: Hair conditioner is not recommended for those infected with head lice because it coats the hair and protects the nits (eggs) attached to shafts of hair. Pediculocide shampoos are effective, but some contain strong neurotoxic or carcinogenic chemicals that may be harmful for clients who are pregnant, nursing, younger than 2 years, or who have open wounds, epilepsy, or asthma. Manual removal with a fine-toothed combing tool is best for removal of nits and live lice. The water temperature is of no consequence as long as it is not so hot as to burn the scalp. Category of Client Need:

Health Promotion and Maintenance; Step in the Nursing Process: Evaluation.

2. Correct Answer: 3. Rationale: A restraint alternative is one in

which the client can release himself or herself independently. A restraint that fastens behind the client does not facilitate being released without the assistance of another person. Restraints or restraint alternatives may both be made from cloth or nylon. Although it is beneficial to communicate with the client and family in an effort to maintain safety and promote cooperation, their use may be implemented as a nursing decision. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

3. Correct Answer: 4. Rationale: Falls, more than any other injury,

are the most common accident that older adults experience. Although older adults experience poisonings from incorrect self-administration of medication or inability to read labels, thermal burns, and electrical shock, the incidence of these types of injuries is less than those that result from falls. Category of Client Need: Safe, Effective Care

Environment; Step in the Nursing Process: Implementation.

2. Correct Answer: 2. Rationale: Psoriasis is characterized by areas of

redness covered with silvery scales. Areas affected usually include the elbows, knees, and scalp, although other areas also are affected. No other choice is a characteristic description of psoriasis. Category of

Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

4. Correct Answer: 1. Rationale: If an alert person has ingested an

excessive amount of a non-caustic, non-corrosive, non-petroleum substance, the first step in preventing complications is to induce vomiting. Notifying emergency medical services, who will transport the client, is subsequently prudent. Personnel in the emergency department may perform lavage and administer activated charcoal. Emergency department personnel will notify the client's personal physician following treatment. The administration of an antacid generally is not indicated in poisonings. Category of Client Need: Physiological Integrity; Step

in the Nursing Process: Implementation.

3. Correct Answer: 1. Rationale: Soaking or immersing in water with

substances like oatmeal or cornstarch relieves itching. Rough fibers, like wool, irritate the skin and contribute to itching. Bathing or showering frequently with soap removes skin oils and adds to or causes itching. Rubbing the skin creates skin irritation and contributes to itching and skin discomfort. Category of Client Need: Physiological Integrity; Step

in the Nursing Process: Implementation.

5. Correct Answer: 1. Rationale: According to the Omnibus Budget

Chapter 17

1. Correct Answer: 3. Rationale: Keeping the bed in low position while making an occupied bed predisposes to muscle strain and back injury. Loosening the linen, wearing gloves to avoid contact with blood or body fluids, and rolling the client to the far side are appropriate actions. Category of Client Need: Safe, Effective Care Environment;

Step in the Nursing Process: Evaluation.

Reconciliation Act (1987), which applies to the use of restraints in longterm care facilities, and most healthcare agency policies, the nurse must obtain a medical order for using a restraint. The order must be renewed every 24 hours thereafter. It is good judgment to report the need to restrain a client to the nursing supervisor who may temporarily send additional personnel to assist with the care of clients. Sedatives are considered a form of chemical restraint that may further jeopardize the client's safety. There may be a charge for a restraint, but failure to do so does not compromise the legality of their use. Category of Client Need:

Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

2. Correct Answer: 2. Rationale: Gloves are essential barrier garments

for avoiding contact with blood and body fluids. The nurse may choose to reuse any linen that is not soiled. A flat or fitted sheet can be used. The application of a blanket is based on the client's preference. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

Chapter 19

1. Correct Answer: 2. Rationale: Asking the client to rate the pain using a numeric scale helps the nurse to assess its intensity. The nurse can use the rating scale later to evaluate the effectiveness of any painrelieving interventions used. Noting whether or not the client can stop moving is not the best assessment technique because a cooperative client may make an effort to stop moving despite the continuation of severe pain. Perspiration is a physiologic sign that may accompany pain. Because other factors can trigger perspiration, however, its presence or absence is not the best assessment. Administering an analgesic is an intervention, not a form of assessment. Category of Client Need:

Physiological Integrity; Step in the Nursing Process: Data Collection.

3. Correct Answer: 2. Rationale: Duplicating sleep rituals facilitates

sleep. Hypnotic drugs may cause paradoxical excitement, interfere with REM sleep, and cause daytime drowsiness. Sleeping medication may be appropriate occasionally, but routine administration is discouraged. Exercise helps to relieve stress and promotes relaxation but when performed near bedtime, it may stimulate wakefulness. Schedules for retiring and rising from sleep should remain as consistent as possible. Category of Client Need: Physiological Integrity; Step in

the Nursing Process: Planning.

Chapter 18

1. Correct Answer: 2. Rationale: Carbon monoxide diffuses and binds with hemoglobin more readily than oxygen. It causes a victim's skin to appear cherry red. Eye medication could cause dilated pupils or this could be an ominous sign of brain anoxia, which any number

2. Correct Answer: 2. Rationale: Phantom pain, a phenomenon that

some who have an amputated limb experience, is a type of neuropathic pain. Referred pain is discomfort experienced in a location distant from the actual area of pathology. Visceral pain is discomfort arising from internal organs. Cutaneous pain is discomfort that originates at the skin level. Category of Client Need: Health promotion/

maintenance; Step in the Nursing Process: Implementation.

838

APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions than maintaining intact skin. Supporting the breasts and applying warm compresses will provide comfort but will have no effect on preventing the transmission of microorganisms elsewhere. Category of

Client Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.

3. Correct Answer: 2. Rationale: A client in acute pain is most likely

to have a rapid pulse rate, rapid respiratory rate, and rising blood pressure. Pain is least likely to influence body temperature. Category of

Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

4. Correct Answer: 2. Rationale: It is best to control pain before it escalates. When pain is intense, relief is more difficult to achieve. Administering pain-relieving drugs on a routine schedule rather than when it becomes absolutely necessary can reduce peaks and valleys of pain. The goal is to keep a terminal client comfortable yet not dull his or her consciousness or ability to communicate. To avoid potentially lethal side effects, there must be time enough between doses for the drug to be metabolized and excreted; therefore, giving the medication on demand is not appropriate. Asking the physician to order a high dose may be premature. Doses of opioid medications are titrated upward as tolerance develops. Category of Client Need: Physiological Integrity; Step in

the Nursing Process: Implementation.

2. Correct Answer: 3. Rationale: Using individual bath linen and performing frequent handwashing are techniques for preventing the transmission of infectious microorganisms that may be present in eye secretions. Eating a nutritious diet and using sunglasses to filter ultraviolet light are healthful behaviors, but they are unrelated to the client's disorder. The use of aspirin is not contraindicated; in fact, a mild analgesic may relieve some of the client's discomfort. Category of Client

Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.

3. Correct Answer: 4. Rationale: Swabbing the earlobes mechanically

removes microorganisms from the area. The use of alcohol, which is an antimicrobial agent, inhibits the growth of pathogens that may remain. Using quality metal, such as 14-carat gold, tends to reduce local inflammation resulting from hypersensitivity. Leaving the earrings in place temporarily and turning them facilitates the formation of a well-healed channel. Category of Client Need: Health Promotion/Maintenance;

Step in the Nursing Process: Implementation.

Chapter 20

1. Correct Answer: 2. Rationale: Of the choices provided, restlessness is the most indicative sign of early hypoxia. Blood loss is expected; if it is profuse or prolonged, it may eventually affect the red blood cells' oxygen-carrying capacity. Clients with compromised oxygenation are more likely to manifest tachycardia than an irregular heart rhythm. Thirst is a sign of fluid volume deficit. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

2. Correct Answer: 4. Rationale: Oxygen saturation is measured in

percent. The normal SpO2 is 95% to 100%. Oxygen that is dissolved in blood (SaO2) is measured by obtaining a specimen of arterial blood. The normal PaO2 is 80 to 100 mm Hg. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Evaluation.

4. Correct Answer: 1. Rationale: A client who is immunosuppressed is at high risk for infection. Handwashing is the best technique for reducing the spread of microorganisms. The client's needs must be met and that is never circumvented because the client is immunosuppressed. Maintaining adequate nourishment and assessing blood pressure are components of good nursing care; however, these actions are not as critical in relation to the problem of immunosuppression. Category of

Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

3. Correct Answer: 2. Rationale: The reservoir bag of a partial rebreathing mask should remain partially filled during inspiration. If the bag collapses completely, the equipment may be faulty. The nurse should report this information to the respiratory therapy department. The mask has been applied properly if it covers the mouth and nose and the strap fits the head snugly. Moisture is likely to accumulate because the oxygen is humidified. This is not significant information to report. The nurse can temporarily wipe the moisture away and reapply the mask. Category of Client Need: Physiological Integrity;

Step in the Nursing Process: Implementation.

5. Correct Answer: 3. Rationale: Respiratory infections are most commonly spread to a susceptible host through droplet transmission. There may be organisms on inadequately sterilized dental instruments, but these are more likely to transmit a bloodborne infection when a client's gums (gingiva) are traumatized during dental procedures. Generally only immunosuppressed clients acquire opportunistic infections from their own microorganisms. Category of Client

Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.

Chapter 22

1. Correct Answer: 4. Rationale: Gloves are the most important personal protective item in this situation. Nurses wear gloves whenever there is a possibility for contact with body fluids or blood. Because the nurse must hold the container, the hands need protection. In addition to the gloves, it is acceptable to don any or all of the other items. To avoid being splashed or sprayed, the nurse may choose to wear a face shield and cover gown. The nurse bases the choice of additional items on his or her judgment as to the potential for contact with blood or body fluid by some other means such as splashing into the eyes, nose, or mouth, or onto the uniform. Category of Client Need: Safe, Effective

Care Environment; Step in the Nursing Process: Implementation.

4. Correct Answer: 1. Rationale: Giving oxygen at greater than 3 L/min

to a client with chronic respiratory disease interferes with the brain's response to the hypoxic drive to breathe. The stimulus to breathe in a person with chronic obstructive lung disease, like emphysema, comes from low levels of oxygen rather than higher than normal levels of carbon dioxide. Administering high percentages of oxygen would depress the client's respiratory center. Category of Client Need: Physiological

Integrity; Step in the Nursing Process: Implementation.

5. Correct Answer: 1. Rationale: Until the lung has expanded, the fluid

in the water-seal chamber rises and falls with respirations, which is called "tidaling." There should be 2 cm of water in the water-seal chamber at all times; if it is lower, the nurse must add water. Continuously bubbling fluid is an indication that the drainage system may have a leak. Drainage from the chest is usually dark red blood. Category of Client

Need: Physiological Integrity; Step in the Nursing Process: Evaluation.

2. Correct Answer: 2. Rationale: Before removing the gloves, the nurse

unfastens the waist closure located at the front of the cover gown. If there is no front waist closure, the nurse removes the gloves; after handwashing, he or she removes the mask and unfastens the tie of the gown at the neckline. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

Chapter 21

1. Correct Answer: 3. Rationale: Cleaning with soap and water is one

of the best methods for reducing the transmission of microorganisms. Eating more sources of protein is a healthful measure but less specific

3. Correct Answer: 4. Rationale: Vinyl gloves may be substituted for

latex gloves; because they are more permeable, two pairs should be worn (see Chapter 21). Neither rinsing the gloves with tap water nor applying petroleum-based ointment will eliminate an allergic reaction

APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions to latex. It is unsafe to work unprotected when there is a potential for contact with blood or body fluids that contain blood. Category of

Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

839

if they are positively resolved, the client's rehabilitation will be delayed if he or she develops contractures and immobile joints. Category of Client Need: Physiological integrity; Step in the Nursing Process: Planning.

4. Correct Answer: 2. Rationale: Influenza is transmitted by droplet infection. Avoiding crowded places reduces the numbers of people to whom a susceptible person is exposed. All the other suggestions are good health practices, but none is as definitive as avoiding crowds. Category of Client Need: Health Promotion/Maintenance Step in the Nursing Process: Implementation.

3. Correct Answer: 4. Rationale: The machine is used primarily to

restore full ROM. Clients with joint replacement surgery are reluctant to exercise the operative joint because of pain. Exercise tones and strengthens muscles and relieves dependent swelling by promoting venous circulation; however, these are considered secondary benefits. It is appropriate for the nurse to administer a prescribed analgesic before the client uses the machine. Category of Client Need: Health Promotion/

Maintenance; Step in the Nursing Process: Implementation.

Chapter 23

1. Correct Answer: 2. Rationale: A Sims' position is best used for procedures involving the rectum and lower gastrointestinal tract. A lithotomy position is used for cystoscopy and vaginal examination. A supine position facilitates assessment of structures on the anterior of the body. Fowler's position is used for many reasons, one of which is improving ventilation. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

4. Correct Answer: 2. Rationale: The length of time the client used the

machine provides additional documentation of the client's response to treatment. Inspecting and documenting the appearance of the wound, the drainage on the dressing, and the presence and quality of arterial pulses are important data to record; however, this information is more pertinent to general physical assessment findings. Category of Client

Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

2. Correct Answer: 2. Rationale: A Fowler's position promotes

abdominal wound drainage via gravity. Neither a lithotomy, supine, or Trendelenberg position promotes the collection of wound drainage in the abdominal area. Category of Client Need: Physiological Integrity

Step in the Nursing Process: Implementation.

3. Correct Answer: 2. Rationale: To facilitate turning a client, it is

helpful if the client flexes a knee prior to rolling onto his or her side. Holding one's breath may increase discomfort if it is accompanied by bearing down. It is difficult to turn a client who is curled up in a ball. Turning a client like a log is appropriate in cases when the spine has been fused, but it is not appropriate for most clients who have had surgery. Category of Client Need: Physiological Integrity; Step in the

Nursing Process: Planning.

5. Correct Answer: 1. Rationale: A stress ECG demonstrates the extent to which the heart tolerates and responds to the additional demands placed on it during exercise. The heart's ability to continue adapting is related to the adequacy of blood supplied to the myocardium through the coronary arteries. If the client develops chest pain, dangerous cardiac rhythm changes, or significantly elevated blood pressure, the diagnostic testing is stopped. Category of Client Need: Health Promotion/

Maintenance; Step in the Nursing Process: Implementation.

Chapter 25

1. Correct Answer: 4. Rationale: The nurse holds and supports a wet cast with the palms of the hands. Using the fingers is likely to cause indentations in the cast. The inward dents create pressure areas on the underlying tissue. After application of the cast, it dries while supported on a soft surface. A wet cast on a hard surface can become flattened.

Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

4. Correct Answer: 4. Rationale: A trochanter roll helps to prevent external rotation of the hip. It will not prevent adduction, abduction, or flexion. Category of Client Need: Physiological Integrity Step in

the Nursing Process: Implementation.

5. Correct Answer: 3. Rationale: A trapeze is an item that allows the

client to help move and lift himself or herself. Encouraging the client to participate actively helps to maintain muscular strength and reduces the effort the nurse must provide when moving and positioning the client. A bed cradle is used to keep linen off the lower extremities. A bed board is used to support the client's spine. Lower side rails promote safety. Category of Client Need: Physiological Integrity; Step in the

Nursing Process: Implementation.

2. Correct Answer: 2. Rationale: Fiberglass casts have several advantages, one of which is that they tend to weigh less than plaster casts. Fiberglass casts dry more quickly, are more durable, and are less likely to soften if they become wet. They are no less flexible or less restrictive than plaster casts. The major disadvantage is that they are more expensive than casts made of plaster of Paris. Category of Client

Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.

Chapter 24

1. Correct Answer: 2. Rationale: A client performs isometric exercises by tensing and releasing muscles. They do not involve any appreciable movement of a joint. The quadriceps muscles are on the anterior of the thigh. All the other options in this item describe isotonic exercises that involve joint movement. Category of Client Need: Health Promotion/

Maintenance; Step in the Nursing Process: Evaluation.

2. Correct Answer: 3. Rationale: The long-term outcomes following a stroke often are determined by aggressive nursing efforts to maintain musculoskeletal function. Rehabilitation begins on admission with functional positioning, active and passive exercise, and early physical and occupational therapy. Managing bowel and bladder elimination will not have the same effects as the development of musculoskeletal deformities. Helping the client cope with changes in body image and grieving are appropriate nursing responsibilities. But even

3. Correct Answer: 3. Rationale: The nurse assesses circulation in an extremity by performing the blanching test to determine capillary refill time. After releasing pressure on the nailbed, the color normally returns within 2 to 3 seconds. The nurse also performs this assessment on the opposite extremity. If the capillary refill time is similar in both extremities, the cast or tissue swelling is not a factor. Asking if the cast feels heavy or palpating it to feel the temperature are not techniques for assessing circulation. Determining if there is space between the cast and the skin is not a totally reliable assessment technique. If the circulation is impaired because of compartment syndrome, there may still be room to insert a finger at the margins of the cast. Category of

Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

4. Correct Answer: 4. Rationale: Purulent drainage is sometimes referred to as pus. This drainage is a collection of fluid containing white blood cells and pathogens. White blood cells indicate that the body is attempting to destroy and remove infecting microorganisms. Serous drainage is clear; it is made up of plasma or serum. Bloody drainage indicates trauma. Mucoid

840

APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions

drainage is sticky, transparent, and released from mucous membranes.

Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

2. Correct Answer: 4. Rationale: The nurse obtains permission from

a minor's parent or guardian. Minors cannot give legal consent under most circumstances. If permission is obtained over the telephone, at least two people must hear the verbal consent and co-sign as witnesses to what they heard. Category of Client Need: Safe, Effective Care

Environment; Step in the Nursing Process: Implementation.

5. Correct Answer: 3. Rationale: To maintain countertraction, the

client's foot must never press against the foot of the bed. If this is observed, the nurse helps to pull the client back toward the head of the bed. The weights must always hang free rather than rest on the floor or bed. The body must be in alignment with the pull of the traction. The traction rope must move freely within the groove of the pulley. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

3. Correct Answer: 4. Rationale: Jewelry is removed preoperatively,

itemized, identified, and locked in a secure area. Another alternative is to give the client's valuables to a member of the family. The nurse has a responsibility to document in the client's record the items that were taken and how they are being kept secure. Some agencies give the client a receipt for his property. If a client asks that a wedding ring be left on, the nurse can secure it to the finger or hand with tape or a strip of gauze. To reduce a reservoir of microorganisms, it is best to remove and safeguard the ring. The ring is subject to theft if left in the bedside stand. Security guards usually are not responsible for safekeeping of personal valuables. Category of Client Need: Safe, Effective Care

Environment; Step in the Nursing Process: Implementation.

Chapter 26

1. Correct Answer: 1. Rationale: In a three-point partial weight-bearing

gait, the client advances the weaker leg and walker together. He uses his hands to support most of the weight while lifting and advancing the stronger leg. Category of Client Need: Health Promotion/

Maintenance; Step in the Nursing Process: Evaluation.

2. Correct Answer: 3. Rationale: A cane is always held on the uninvolved side. By doing so, the client can transfer or redistribute body weight from the painful joint to the hand with the cane when taking a step. Covering the top with a rubber cap, wearing supportive shoes, and maintaining good posture are all appropriate techniques when using a cane. Category of Client Need: Health Promotion/Maintenance; Step

in the Nursing Process: Evaluation.

4. Correct Answer: 1. Rationale: Once preoperative medication is given, the side rails are raised and the client is instructed to remain in bed. Elimination and oral hygiene are accomplished prior to giving the preanesthetic drugs. A narcotic makes it difficult for the client to remain alert during attempts to teach leg exercises. Category of Client

Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

3. Correct Answer: 2. Rationale: The hip of a client who has undergone a total hip replacement (arthroplasty) is maintained in a position of abduction. If the client flexes the hip more than 90° or adducts the hip, the prosthetic femoral head may become dislocated. A triangular foam wedge generally is kept between the client's legs while in bed.

Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

5. Correct Answer: 3. Rationale: A dropping blood pressure frequently suggests that the client is going into shock. A systolic pressure of 90 to 100 mm Hg indicates shock is approaching. Below 80 mm Hg, shock is present. Other signs of shock include a rapid, thready pulse; pale, cold, and clammy skin; rapid respirations; a falling body temperature; restlessness; and a decreased level of consciousness. Category

of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

4. Correct Answer: 3. Rationale: Almost immediately after surgery, the nurse encourages a client to lift up using the trapeze because the muscles that most need strengthening prior to ambulating with crutches are those in the arms, neck, shoulders, chest, and back. The client also may squeeze rubber balls and perform arm push-ups. Doing arm push-ups involves placing the palms flat on the bed and raising the buttocks. Balancing between parallel bars occurs later in rehabilitation. Standing and transferring maintain strength and tone of lower leg muscles, but they are not subjected to as much physical work as the muscles in the upper body. Category of Client Need: Physiological Integrity; Step in

the Nursing Process: Planning.

Chapter 28

1. Correct Answer: 2. Rationale: An open drain relies on gravity to

remove exudates, which the dressing then absorbs. The lithotomy, recumbent, and Trendelenberg positions do not promote the collection of wound drainage near the abdominal drain. Category of

Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

2. Correct Answer: 3. Rationale: Soiled dressings are enclosed in a

receptacle or container, like the nurse's glove, to prevent the transmission of infectious microorganisms. A clean glove is used to remove soiled dressings. Tape is pulled toward the wound to prevent separating the healing edges. Wounds are always cleansed so as to carry microorganisms and debris away from the incision. Category of

Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

5. Correct Answer: 3. Rationale: If crutches are measured and fitted appropriately, there is room for at least two fingers between the axillae and the axillary bars of the crutches. Prolonged pressure under the arm affects circulation or impairs nerve function, resulting in permanent paralysis. All of the other observations are indications that the crutch length and the position of the handgrips are correct. Category of

Client Need: Physiological Integrity; Step in the Nursing Process: Evaluation.

3. Correct Answer: 1. Rationale: To establish negative pressure, the

nurse eliminates air and drainage from the bulb reservoir and caps the vent before releasing the squeezed bulb. A Jackson-Pratt drain is an example of a closed drainage device. The Jackson-Pratt device could drain by gravity, not negative pressure, if the drainage valve were left open. The nurse never fills the bulb reservoir with normal saline. The nurse secures the reservoir to the skin with tape; however, this is to prevent tension on the tubing and possibly pulling it from its insertion site. Category of Client Need: Safe, Effective Care Environment;

Step in the Nursing Process: Implementation.

Chapter 27

1. Correct Answer: 4. Rationale: To reduce the potential for infection,

hair is shaved after the client is transferred from the nursing unit to the surgical department. Shaving the night before facilitates colonization of microorganisms within skin abrasions. If the skin preparation is performed on the nursing unit, it is better to do so before administering sedation and after a shower. Category of Client Need: Safe, Effective

Care Environment; Step in the Nursing Process: Planning.

4. Correct Answer: 2. Rationale: Wet-to-dry dressings provide a means for debriding the ulcerated areas of necrotic tissue. Although covering impaired skin reduces the entrance of microorganisms, absorbs drainage,

APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions and protects the skin, they are not the primary reasons for use. Category

of Client Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.

841

Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

5. Correct Answer: 3. Rationale: The appearance of pink tissue indicates the formation of granulation tissue, which consists of capillaries and fibrous collagen that seals and nourishes the tissue. Increased drainage suggests that cellular death is continuing or the wound is infected. Relief of discomfort is a positive sign; however, some ulcers are not severely painful even in the acute stage. White or black wound margins suggest an extension of cell death. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Evaluation.

2. Correct Answer: 4. Rationale: The client should not restrict fluid intake, which potentially can lead to fluid imbalance. Concentrated urine also is more likely to foster renal stone formation. Inadequate fluid intake does contribute to constipation, but that is not the main reason to discourage the incontinent client from limiting fluid intake. Although the client is invested in achieving the desired goal, it is unsafe to encourage fluid restriction as a means of reaching the expected outcome. Category of Client Need: Health Promotion/Maintenance; Step in the Nursing Process: Implementation.

3. Correct Answer: 3. Rationale: Providing space between the penis and

Chapter 29

1. Correct Answer: 4. Rationale: The distance from the nose (N) to the

earlobe (E) to the xiphoid process (X) is called the NEX measurement. It is used to determine the approximate distance to the stomach. None of the other landmarks are correct for approximating the length for nasogastric tube insertion. Category of Client Need: Safe, Effective

Care Environment; Step in the Nursing Process: Implementation.

bottom of the catheter prevents irritation to the urinary meatus and promotes drainage of urine. Lubrication is not appropriate because it interferes with maintaining the catheter in place. External catheters are similar to latex condoms; they stretch to fit. Therefore, measuring the penis is unnecessary. The foreskin of an uncircumcised male is never left in a retracted position because it could have a tourniquet effect and interfere with circulation of blood to the tissue. Category of Client Need:

Physiological Integrity; Step in the Nursing Process: Implementation.

4. Correct Answer: 1. Rationale: Anchoring an indwelling retention

catheter to the male's abdomen eliminates pressure and irritation at the penoscrotal angle. Pressure in this area predisposes to fistula formation. The nurse passes the catheter and tubing over a client's leg to prevent obstruction of urinary drainage from compression of the tubing. It is appropriate to fasten the drainage tubing to the bed so that there is a straight line from the bed to the collection bag and to insert the catheter into a drainage collection bag. Neither of these nursing actions, however, prevents the formation of a penoscrotal fistula. Category of Client Need:

Physiological Integrity; Step in the Nursing Process: Implementation.

2. Correct Answer: 3. Rationale: Placing the chin to the chest helps to

direct a tube into the esophagus rather than the lower airway. The nurse gives the client water to sip to make breathing deeply difficult. A sniffing position is appropriate when first inserting the tube into a client's nose. Coughing occurs as a reflex if the tube enters the airway; it is a helpful sign that the tube must be raised from its present location.

Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

3. Correct Answer: 2. Rationale: Determining if the pH of fluid aspirated from the tube is within the range of gastric pH helps to validate that the distal tip of the tube is located within the stomach. A portable x-ray is an accurate method, but the cost and unnecessary radiation exposure make it less appropriate unless the tube is a small diameter feeding tube. Liquids are never instilled until placement has been verified. Feeling for air is an unacceptable technique for determining placement. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

5. Correct Answer: 3. Rationale: When instructing a female client about collecting a clean-catch urine specimen, the nurse explains that the initial portion of the voided stream is discarded and a portion that follows is collected as the specimen. He or she instructs a female to cleanse the urethral area from front to back; males cleanse the penis using a circular motion. The specimen is collected in a sterile container. The antimicrobial agent is used for cleansing and is not mixed with the urine specimen. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

4. Correct Answer: 2. Rationale: Slight bleeding, clear serum drainage,

or both (serosanguineous) is a normal finding that the nurse can expect immediately after insertion of a gastrostomy tube. Milky drainage suggests an infection; if it occurs after feedings have been initiated, it may indicate leakage of formula. Gastric secretions may appear green, especially if they are mixed with bile, but this finding is abnormal. Bright bloody drainage indicates arterial rather than darker venous or capillary bleeding. Category of Client Need: Physiological Integrity; Step

in the Nursing Process: Data Collection.

Chapter 31

1. Correct Answer: 1. Rationale: Long-term use of laxatives repeatedly subjects the bowel to artificial stimulation, causing it to become sluggish. Stool softeners are less harsh than laxatives; however, it is best to determine the cause of the constipation and treat the etiology with life-style changes rather than continue to rely on pharmaceutical interventions. Daily enemas are just as habituating as laxative abuse. Dilating the anal sphincter is not usually a technique for promoting bowel elimination. Category of Client Need: Health Promotion/

Maintenance; Step in the Nursing Process: Implementation.

5. Correct Answer: 2. Rationale: Clients with nasogastric tubes that connect to suction are generally NPO (nothing by mouth). The nurse can provide ice chips sparingly to keep a client's mouth moist but not in amounts that will cause an electrolyte imbalance. Giving water or other fluids, which are subsequently removed from the stomach, is likely to dilute and deplete electrolyte levels. Category of Client Need:

Physiological Integrity; Step in the Nursing Process: Planning.

2. Correct Answer: 1. Rationale: A client with a fecal impaction tends

to expel liquid stool around the hardened mass. Bad breath is not usually a sign of constipation or fecal impaction. If halitosis is chronic, the nurse should suspect dental disease, ineffective oral hygiene, or esophageal diverticula. Headaches have been anecdotally associated with constipation, but a relationship has not been proven scientifically. Loss of appetite may be either a cause or effect of impaired bowel elimination. Its presence does not necessarily indicate a fecal impaction.

Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

Chapter 30

1. Correct Answer: 1. Rationale: Although all the assessments are appropriate when caring for a client having problems with urinary elimination, the most important assessment in continence retraining is keeping a log of the client's pattern of urinary elimination. The nurse analyzes and uses recorded data to schedule toilet activities to initially correspond with the client's filling and emptying patterns.

3. Correct Answer: 1. Rationale: Activity promotes the movement of gas toward the anal sphincter where it can be released. Carbonated

842

APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions

beverages can increase gas accumulation. Restricting food is inappropriate. It may prevent additional gas from forming, but it does not help to eliminate what is already present. Narcotic analgesics tend to slow peristalsis and contribute to the retention of stool and intestinal gas.

Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

Chapter 33

1. Correct Answer: 3. Rationale: Tilting the head backward allows gravity and head positioning to locate and maintain the liquid nasal medication within the nasopharynx. Bending forward causes loss of medication before it can provide a therapeutic effect. None of the other prescribed positions help to distribute nasal medications where they are intended for use. Category of Client Need: Health Promotion/Maintenance;

Step in the Nursing Process: Implementation.

4. Correct Answer: 3. Rationale: Interrupting the instillation of the enema solution allows time for the bowel to adjust to the distention. Rapidly instilling the remaining solution may cause the client to lose control of elimination. Taking deep breaths or panting rather than holding the breath relieves some discomfort. To finish administering the remaining enema solution, the nurse needs to reinsert the withdrawn tip. Category of Client Need: Physiological Integrity; Step in

the Nursing Process: Implementation.

2. Correct Answer: 3. Rationale: Instilling vaginal medication before

bedtime aids in retaining the medication for a substantial time. If that is not possible, instruct the client to recline for 10 to 30 minutes afterward. The client should insert the applicator 2 to 4 inches within the vagina. The best position for instilling a vaginal drug is dorsal recumbent. Using gloves is a personal choice when self-administering vaginal medication. Gloves are required when a nurse administers vaginal medication into a client. Category of Client Need: Health Promotion/Maintenance;

Step in the Nursing Process: Implementation.

5. Correct Answer: 2. Rationale: A normal healthy stoma appears

bright red or pink because of its rich blood supply. If the stoma is light pink or dusky blue, the blood supply to the tissue is compromised. A tan stoma is atypical even in non-Caucasians; further assessments are necessary to determine the cause. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

3. Correct Answer: 4. Rationale: Eye drops and ointments are placed

in the exposed lower conjunctival sac. If placed on the cornea, they may cause discomfort and reflex blinking. Medication may be absorbed systemically when instilled at the inner canthus. Placing eye drops and ointments at the outer canthus makes it difficult to distribute them in the eye. Category of Client Need: Physiological Integrity; Step in the

Nursing Process: Implementation.

Chapter 32

1. Correct Answer: 4. Rationale: The abbreviation q.i.d. indicates that the drug must be administered four times a day. The abbreviation for once a day is q.d. The abbreviation for every other day is q.o.d. The abbreviation for three times a day is t.i.d. Category of

Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

2. Correct Answer: 3. Rationale: The nurse uses the formula

D/H X Q = Amount to administer and accurately calculates that the amount to administer is 1/2 tablet. It is best if the tablet is scored to facilitate giving half of the prescribed amount, but devices can separate tablets into two portions. Generally if a 250 mg tablet of the prescribed drug is available, the pharmacist would most likely have provided that dose. There is no reason to consult the physician. The nurse may wish to use a drug reference to determine if other dosages of the drug are available, but this is not the best nursing action in this situation. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

4. Correct Answer: 1. Rationale: Liquid and ointment otic (ear) preparations are warmed to room temperature if they have been stored in a cool or cold area. Instilling cold medication into the ear is uncomfortable. Unless the dropper is grossly covered with obvious debris, it is not necessary to clean it routinely. There is no limit on the maximum volume instilled within the ear. The anatomic size of the ear canal and the prescribed dose of medication are guidelines for how much drug is administered. Category of Client Need: Physiological Integrity; Step

in the Nursing Process: Implementation.

5. Correct Answer: 1. Rationale: Maintaining a position with the head

tilted to the side or a side-lying position, which was the body position at the time of medication administration, facilitates movement of the drug to the lowest area of the ear canal. Cotton is loosely inserted within the ear to collect drainage and any excess volume of medication. The eustachian tube does connect the middle ear with the pharynx; however, if the tympanic membrane is intact, blowing the nose does not displace the medication. The temperature of beverages does not affect the instilled ear drop(s). Category of Client Need: Physiological

Integrity; Step in the Nursing Process: Implementation.

3. Correct Answer: 2. Rationale: Asking the client to identify herself by name is the safest action. The nurse also obtains an identification bracelet and attaches it to the client's wrist as soon as possible. A confused client or one that is hearing impaired may respond, "Yes," when asked if she is Anna Jones, whether that is true or not. Although a nursing assistant may know the identity of the client, the best choice is to have the client provide self-identification. Category of Client

Need: Safe, Effective Care Environment; Step in the Nursing Process: Data Collection.

Chapter 34

1. Correct Answer: 4. Rationale: The dorsogluteal site is located in the buttock. The hip is the location of the ventrogluteal site. The deltoid site is located in the arm. The vastus lateralis and rectus femoris are injection sites located in the thigh. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

4. Correct Answer: 4. Rationale: Offering a few sips of water before administering medications helps to moisten the oral cavity and facilitates swallowing oral medications. Nurses never soften capsules by placing them in water before administration or tell the client to chew a capsule. Opening a capsule can cause the client to experience an unpleasant taste. Category of Client Need: Physiological Integrity;

Step in the Nursing Process: Implementation.

5. Correct Answer: 3. Rationale: Nurses never add oral medications

to a bag of tube feeding formula because doing so may delay the full dosage for a prolonged period as the formula instills. The other actions described are correct techniques when administering oral medications through a nasogastric feeding tube. Category of Client Need:

Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

2. Correct Answer: 1. Rationale: Pointing the toes inward reduces discomfort when giving an injection into the dorsogluteal site. Tightening muscles increases discomfort. Crossing the legs or flexing the knees places the client in an awkward position and does not relieve discomfort. Category of Client Need: Physiological Integrity; Step in the

Nursing Process: Implementation.

3. Correct Answer: 1. Rationale: When administering an injection using the Z-track technique, the nurse pulls the tissue laterally until it is taut. He or she holds the tissue in that position during the injection as well. The nurse does not release the position of the tissue until after

APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions withdrawing the needle. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

843

4. Correct Answer: 4. Rationale: When administering an intradermal

injection, the nurse inserts the needle between the layers of skin at approximately a 10- to 15-degree angle. He or she gives subcutaneous injections at either a 45- or 90-degree angle depending on the client's size. The nurse gives intramuscular injections at a 90-degree angle. It is incorrect to give any injection by inserting the needle at a 180-degree angle. Category of Client Need: Physiological Integrity; Step in the

Nursing Process: Implementation.

barrier against skin contact and absorption. Avoiding powdered gloves prevents inhalation of the drug on particles of powder. Handwashing is appropriate before and after contact with a client, but it is not necessary to wash hands for 5 minutes. Distancing oneself from the client is important when the client is being treated with an implanted source of radiation, not chemotherapy. It is unnecessary to wear a high efficiency air filter respirator when caring for a client receiving intravenous antineoplastic drugs. Category of Client Need: Safe, Effective

Care Environment; Step in the Nursing Process: Implementation.

5. Correct Answer: 3. Rationale: The client must take care to avoid

mixing the intermediate-acting insulin that contains an additive with the short-acting additive-free insulin. The additive-free insulin is always withdrawn first. The actions described in the other options are safe and appropriate for mixing two different types of insulin. Category of

Client Need: Health Promotion/Maintenance; Step in the Nursing Process: Evaluation.

Chapter 36

1. Correct Answer: 3. Rationale: When assessing a cough, the nurse determines if it is productive or nonproductive. If productive, it is important to document the color, odor, amount, and viscosity of sputum raised. Other data that may aid the physician in making a diagnosis include onset, duration, contributing factors, and relief measures that apply to the client's symptoms. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

Chapter 35

1. Correct Answer: 2. Rationale: Whenever two medications are combined, the nurse must consult a reference to determine if the two drugs or the drug and solution are compatible. Some drug-drug and drugsolution combinations will cause a physical change such as a precipitate to form. Not all drugs are diluted before administration by intravenous bolus. When instilling an intravenous medication by bolus administration, the nurse interrupts the infusing solution for seconds at a time while instilling the drug through the port. Flushing a port with normal saline is unnecessary unless there may be a drug-drug or drug-solution interaction. Category of Client Need: Physiological Integrity; Step in

the Nursing Process: Implementation.

2. Correct Answer: 1. Rationale: Increased fluid intake thins respiratory secretions. Increased moisture in inspired air through humidification also helps. Changing positions improves circulation and prevents pooling of respiratory secretions. A high-protein diet contributes to tissue growth and repair. Rest relieves fatigue and activity intolerance.

Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Planning.

2. Correct Answer: 4. Rationale: To determine if the IV catheter is

within the vein, the nurse aspirates with the plunger of the syringe containing the medication. The negative pressure created by pulling back the plunger causes blood to enter the distal end of the tubing, confirming that the catheter is still in the vein. Edema with or without a change in the rate of infusion indicates that the intravenous catheter is no longer in the vein but has become displaced within the interstitial space. Redness along the course of a vein indicates phlebitis. If the skin around an infusing IV solution feels cooler than adjacent skin areas, it could mean that the solution is infiltrating into the tissue; warmer skin than adjacent areas could mean that the client has phlebitis. Category of Client Need:

Physiological Integrity; Step in the Nursing Process: Implementation.

3. Correct Answer: 4. Rationale: Obtaining a sputum specimen is easiest when the client first awakens in the morning or following an aerosol treatment. Secretions tend to accumulate in the respiratory tract during the night. Pooled secretions are more easily raised especially if the client is not fatigued from activity. Forced coughing after a meal can lead to vomiting. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Planning.

4. Correct Answer: 3. Rationale: The vent on a suction catheter is not occluded until after the catheter is fully inserted and being withdrawn. This reduces the potential for hypoxemia. Closing the vent before insertion or when just inside the inner cannula prolongs the time during which oxygen is removed from the airway. Coughing may or may not coincide with the proper time to occlude the vent. Therefore, it is not used as a criterion for this action. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

5. Correct Answer: 2. Rationale: Airway suctioning should not extend

beyond 10 to 15 seconds. Some suggest holding one's own breath during suctioning to become aware of the air hunger the client is experiencing. Suctioning for too little time does not effectively clear the airway. Suctioning beyond 10 to 15 seconds causes hypoxemia. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

3. Correct Answer: 2. Rationale: Sterile normal saline generally is

used to flush a port of an intermittent infusion device before and after its use. Some agencies may continue to use a flush of heparin, although research shows that practice is necessary only for some types of central venous catheters. Bateriostatic water is hypotonic and may cause blood cells in the area to swell. Neither isopropyl alcohol nor hydrogen peroxide is used to flush an intermittent infusion device. Category of

Client Need: Physiological Integrity; Step in the Nursing Process: Implementation.

Chapter 37

1. Correct Answer: 1. Rationale: A person with a stroke is at high risk

for choking and aspirating a bolus of food as a result of hemiparalysis (half-sided paralysis) of the muscles that control the face, tongue, and throat. People who have had a full mouth extraction do not have impaired swallowing; they initially receive liquids and soft or pureed foods that do not require chewing. A client with a biopsy of a tongue lesion also may receive a diet with modified texture but should not have significantly impaired ability to chew or swallow food. The term "facial cosmetic surgery" is vague because it does not identify specifically the extent of the procedure. Nevertheless, it is unlikely that this type of surgery would interfere with chewing or swallowing. Category of

4. Correct Answer: 1. Rationale: Implanted central venous catheters

have the greatest protection against infection because they are sealed beneath the skin. Implanted catheters are designed for long-term use because they can sustain approximately 2000 punctures. They can remain in place for several years, but they eventually are removed. A dressing is applied only when the port is pierced and the catheter is being used. Category of Client Need: Health Promotion/Maintenance;

Step in the Nursing Process: Implementation.

5. Correct Answer: 4. Rationale: To avoid self-contamination while

administering an antineoplastic drug by intravenous instillation, the nurse wears one or two pairs of nonpowdered gloves, which provide a

844

APPENDIX C q Answers and Rationales for NCLEX-Style Review Questions The recovery position is used when breathing and circulation have been restored. Loosening a belt is unnecessary during resuscitation attempts. A rescuer gives two rescue breaths initially then administers a sequence of 15 chest compressions followed by two breaths when performing CPR. Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Implementation.

Client Need: Physiological Integrity; Step in the Nursing Process: Planning.

2. Correct Answer: 2. Rationale: Products manufactured in or imported to the United States on or after January 1, 1995 must comply with the Child Safety Protection Act (CSPA). Before purchasing any toy, consumers should look for and heed the age recommendations identified. The greatest danger may be with homemade stuffed animals or dolls. The child is at risk for accidental choking with any toy that has small parts or pieces that can be broken off or separated. Soft, stuffed animals or dolls with buttons or plastic eyes are not as safe as those with painted or printed features. The gel in a teething ring, which is ultimately a semi-liquid, generally is sealed securely. A 6 month old is not capable of reaching the objects on a mobile provided it is suspended at an acceptable height above a crib. A ball less than 1 3/4 inches is a safety risk for a child younger than 3 years, but one that is 5 inches in diameter is generally safe. Category of Client Need: Health Promotion/Maintenance;

Step in the Nursing Process: Implementation.

Chapter 38

1. Correct Answer: 3. Rationale: Spontaneous breathing is related to

a functioning brain stem. Brain death is based on evidence that the whole brain including the brain stem is no longer functioning. Unresponsiveness is not the most conclusive criterion, although it supports the cluster of data suggesting neurological dysfunction. A client with a urine output less than 100 mL/24 hours is anuric, but the client's brain may not be permanently affected. Bilateral dilated pupils are more ominous than unequal pupils are. Category of Client Need: Physiological

Integrity; Step in the Nursing Process: Data Collection.

3. Correct Answer: 3. Rationale: Inability to speak or make vocal sounds

indicates occlusion of the passageway between the upper and lower airway. The nurse also looks for the universal choking sign. Audible wheezing, ability to cough, and efforts to clear the throat are signs that suggest a partial airway obstruction. The Heimlich maneuver is recommended when airway obstruction is complete and the victim is conscious. If the victim is unconscious, the rescuer administers chest compressions. Category of Client Need: Physiological Integrity; Step in the Nursing Process: Data Collection.

2. Correct Answer: 2. Rationale: The bargaining stage is evidenced by

negotiating an extension to life to reach or accomplish some future event. Denial is a stage in which the terminal client refuses to believe valid information. Anger is a stage characterized by retaliation for feeling victimized. Depression occurs when the client is saddened by the inevitable end to life. When the client reaches the stage of acceptance, he or she is at peace with the finality of life. Category of Client Need:

Psychosocial Integrity; Step in the Nursing Process: Evaluation.

4. Correct Answer: 3. Rationale: After a quick initial assessment, the

nurse summons emergency service personnel. The nurse may delegate this task to others while implementing the next steps, which include early CPR followed by early cardiac defibrillation. When emergency service personnel arrive, they provide interventions considered advanced life support measures such as endotracheal intubation and emergency drug therapy. Category of Client Need: Physiological Integrity; Step in

the Nursing Process: Data Collection.

3. Correct Answer: 3. Rationale: Organ harvesting cannot occur

unless the deceased client's next of kin gives permission to do so. This is true even if the client signed an organ donor card prior to death. After obtaining permission from the next of kin, the organ procurement officer notifies the transplant team who will harvest and transport the organs. The client must be declared dead by standard medical criteria, but organ procurement cannot proceed based on this alone.

Category of Client Need: Safe, Effective Care Environment; Step in the Nursing Process: Planning.

5. Correct Answer: 3. Rationale: The nurse must ensure that no one

is touching the victim before administering the shock from the AED.

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