NCLEX PRACTICE QUESTIONS PART - 09 ANSWERS AND RATIONALES...
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Answers and Rationales
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1. Answer B is correct.
The nurse should check the client’s immunization record to determine the date of the last tetanus immunization. The nurse should question the client regarding allergies to medications before administering medication; therefore, answer A is incorrect. Answer C is incorrect because a sling, not a spint, should be applied to imimobilize the arm and prevent dependent edema. Answer D is incorrect because pain medication would be given before cleaning and dressing the wound, not afterward.
2. Answer D is correct.
Watery vaginal discharge and painless bleeding are associated with endometrial cancer. Frothy vaginal discharge describes trichomonas infection; thick, white vaginal discharge describes infection with candida albicans; and purulent vaginal discharge describes pelvic inflammatory disease. Therefore, answers A, B, and C are incorrect.
3. Answer A is correct. Stereotactic surgery destroys areas of the brain responsible for intractable tremors. The surgery does not increase production of dopamine, making answer B incorrect. Answer C is incorrect because the client will continue to need medication. Serotonin production is not associated with Parkinson’s disease; there-fore, answer D is incorrect.
4. Answer D is correct.
The client with AIDS should not drink water that has been sitting longer than 15 minutes because of bacterial contamination. Answer A is incorrect because ice water is not better for the client. Answer B is incorrect because juices should not replace water intake. Answer C is not an accurate statement.
5. Answer B is correct.
The finding that differentiates interstitial cystitis from other forms of cystitis is the absence of bacteria in the urine. Answer A is incorrect because symptoms that include burning and pain on urination characterize all forms of cystitis. Answer C is incorrect because blood in the urine is a characteristic of interstitial as well as other forms of cystitis. Answer D is an incorrect statement because females are affected more often than males.
6. Answer B is correct. Approximately 99% of males with cystic fibrosis are sterile due to obstruction of the vas deferens. Answers A, C, and D are incorrect because most males with cystic fibrosis are incapable of reproduction.
7. Answer B is correct.
Infants under the age of 2 years should not be fed honey because of the danger of infection with Clostridium botulinum. Answers A, C, and D are not related to the situation; therefore, they are incorrect.
8. Answer C is correct.
Children with autistic disorder engage in ritualistic behaviors and are easily upset by changes in daily routine. Changes in the environment are usually met with behaviors that are difficult to control. Answers A, B, and D are incorrect because they do not focus on autistic disorder.
9. Answer A is correct.
The degree of pulmonary involvement is the greatest determinant in the prognosis of cystic fibrosis. Answers B, C, and D are affected by cystic fibrosis; however, they are not major determinants of the prognosis of the disease.
10. Answer A is correct. Decreased blood pressure and increased pulse rate are associat-ed with bleeding and shock. Answers B, C, and D are within normal limits; thus, incor-rect.
11. Answer D is correct.
Early decelerations during the second stage of labor are benign and are the result of fetal head compression that occurs during normal contractions. No action is necessary other than documenting the finding on the flow sheet. Answers A, B, and C are interventions for the client with late decelerations, which reflect ureteroplacental insufficiency.
12. Answer B is correct.
The client’s statement that meat should be thoroughly cooked to the appropriate temperature indicates an understanding of the nurse’s teaching regard-ing food preparation. Undercooked meat is a source of toxoplasmosis cysts. Toxoplasmosis is a major cause of encephalitis in clients with AIDS. Answer A is incor-rect because fresh-ground pepper contains bacteria that can cause illness in the client with AIDS. Answer C is an incorrect choice because cheese contains molds and yogurt contains live cultures that the client with AIDS must avoid. Answer D is incorrect because fresh fruit and vegetables contain microscopic organisms that can cause illness in the client with AIDS.
13. Answer D is correct.
The client taking isoniazid should have a negative sputum culture within 3 months. Continued positive cultures reflect noncompliance with therapy or the development of strains resistant to the medication. Answers A, B, and C are incorrect because there has not been sufficient time for the medication to be effective.
14. Answer D is correct.
Lyme’s disease is transmitted by ticks found on deer and mice in wooded areas. The people in answers A and B have little risk of the disease. Veterinarians are exposed to dog ticks, which carry Rocky Mountain Spotted Fever, so answer C is incorrect.
15. Answer B is correct. Children ages 18–24 months normally have sufficient sphincter control necessary for toilet training. Answer A is incorrect because the child is not developmentally capable of toilet training. Answers C and D are incorrect choices because toilet training should already be established.
16. Answer A is correct.
Large amounts of fluid and electrolytes are lost in the stools of the client with an ileostomy. The priority of nursing care is meeting the client’s fluid and electrolyte needs. Answers B and D do apply to clients with an ileostomy, but they are not the priority nursing diagnosis. Answer C does not apply to the client with an ileostomy and is, therefore, incorrect.
17. Answer B is correct.
Cobex is an injectable form of cyanocobalamin or vitamin B12. Increased Hgb levels reflect the effectiveness of the medication. Answers A, C, and D do not reflect the effectiveness of the medication; therefore, they are incorrect.
18. Answer C is correct. Behavior modification relies on the principles of operant condi-tioning. Tokens or rewards are given for appropriate behavior. Answers A and B are incorrect because they refer to techniques used to reduce anxiety, such as thought stopping and bioenergetic techniques, respectively. Answer D is incorrect because it refers to modeling.
19. Answer C is correct.
Small pieces of cereal promote chewing and are easily managed by the toddler. Pieces of hot dog, carrot sticks, and raisins are unsuitable for the tod-dler because of the risk of aspiration.
20. Answer C is correct. Complications of TPN therapy are osmotic diuresis and hypov-olemia. Answer A is incorrect because the intake and output would not reflect meta-bolic rate. Answer B is incorrect because the client is most likely receiving no oral flu-ids. Answer D is incorrect because the complication of TPN therapy is hypovolemia, not hypervolemia.
21. Answer D is correct.
L/S ratios are an indicator of fetal lung maturity. Answer A is incor-rect because it is the diagnostic test for neural tube defects. Answer B is incorrect because it measures fetal well-being. Answer C is incorrect because it detects circulating antibodies against red blood cells.
22. Answer A is correct.
By the third postpartum day, the fundus should be located 3 finger widths below the umbilicus. Answer B is incorrect because the discharge would be light in amount. Answer C is incorrect because the fundus is not even with the umbilicus at 3 days. Answer D is incorrect because the uterus is not enlarged.
23. Answer B is correct.
Rapid discontinuation of TPN can result in hypoglycemia. Answer A is incorrect because rapid infusion of TPN results in hyperglycemia. Answer C is incor-rect because TPN is administered through a central line. Answer D is incorrect because the infusion is administered with a filter.
24. Answer A is correct.
Kava-kava can increase the effects of anesthesia and post-opera-tive analgesia. Answers B, C, and D are not related to the use of kava-kava; therefore, they are incorrect.
25. Answer C is correct.
The maximum recommended rate of an intravenous infusion of potassium chloride is 5–10mEq per hour, never to exceed 20mEq per hour. An intravenous infusion controller is always used to regulate the flow. Answer A is incorrect because potassium chloride is not given IV push. Answer B is incorrect because the infusion time is too brief. Answer D is incorrect because the infusion time is too long.
26. Answer B is correct.
The normal platelet count is 150,000–400,000; therefore, the client is at high risk for spontaneous bleeding. Answer A is incorrect because the WBC is a low normal; therefore, overwhelming infection is not a risk at this time. The RBC is low, but anemia at this point is not life threatening; therefore, answer C is incorrect. Answer D is incorrect because the serum creatinine is within normal limits.
27. Answer A is correct.
The nurse should stop the infusion. The medication should be restarted through a new IV access. Answer B is incorrect because IV catheters are not to be flushed. Answer C is incorrect because a tourniquet would not be applied to the area. Answer D is incorrect because the IV should not be allowed to continue infusing because the medication is a vesicant and, in the event of infiltration, the tissue would be damaged or destroyed.
28. Answer B is correct.
The client will have a urinary catheter inserted to keep the blad-der empty during radiation therapy. Answer A is incorrect because visitors are allowed to see the client for short periods of time, as long as they maintain a distance of 6 feet from the client. Answer C is incorrect because the client is on bed rest. Side effects from radiation therapy include pain, nausea, vomiting, and dehydration; therefore, answer D is incorrect.
29. Answer C is correct.
The mother does not need to place an external heat source near the newborn. It will not promote healing, and there is a chance that the newborn could be burned, so the mother needs further teaching. Answers A, B, and D indicate correct care of the newborn who has been circumcised and are incorrect.
30. Answer D is correct.
A sputum specimen for culture and sensitivity should be obtained before the antibiotic is administered to determine whether the organism is sensitive to the prescribed medication. A routine urinalysis, complete blood count and serum electrolytes can be obtained after the medication is initiated; therefore, Answers A, B, and C are incorrect.
31. Answer A is correct. Ginkgo interacts with many medications to increase the risk of bleeding; therefore, bruising or bleeding should be reported to the doctor. Photosensitivity is not a side effect of ginkgo; therefore, answer B is incorrect. Answer C is incorrect because the FDA does not regulate herbals and natural products. The client does not need to take additional vitamin E, so answer D is incorrect.
32. Answer B is correct. The client should be well hydrated before and during treatment to prevent nephrotoxicity. The client should be encouraged to drink 2,000–3,000mL of fluid a day to promote excretion of uric acid. Answer A is incorrect because it does not prevent nephrotoxicity. Answer C is incorrect because the intake and output should be recorded hourly. Answer D is incorrect because it refers to ototoxicity, which is also an adverse side effect of the medication but is not accurate for this stem.
33. Answer A is correct.
The client who is colonized with MRSA will have no symptoms associated with infection. Answer B is incorrect because the client is more likely to develop an infection with MRSA following invasive procedures. Answer C is incorrect because the client should not be placed in the room with others. Answer D is incorrect because the client can colonize others, including healthcare workers, with MRSA.
34. Answer B is correct.
The therapeutic range for vancomycin is 1025mcg/mL. Answer A is incorrect because the range is too low to be therapeutic. Answers C and D are incorrect because they are too high.
35. Answer A is correct. Pseudomembranous colitis resulting from infection with Clostridium difficile produces diarrhea containing blood, mucus, and white blood cells. Answers B, C, and D are incorrect because they are not specific to infection with Clostridium difficile.
36. Answer C is correct. Pyridoxine (vitamin B6) is usually administered with INH (isoni-azid) in order to prevent nervous system side effects. Answers A, B, and D are not associated with the use of INH; therefore, they are incorrect choices.
37. Answer A is correct. Factors associated with the development of Legionnaires’ dis-ease include immunosuppression, advanced age, alcoholism, and pulmonary disease. Answer B is incorrect because it is associated with the development of SARS. Answer C is associated with food-borne illness, not Legionnaires’ disease, and answer D is not related to the question.
38. Answer B is correct.
The client can check the inhaler by dropping it into a container of water. If the inhaler is half full, it will float upside down with onefourth of the contain-er remaining above the water line. Answers A, C, and D do not help determine the amount of medication remaining.
39. Answer C is correct. Following a nephrolithotomy, the client should be positioned on the unoperative side. Answers A, B, and D are incorrect positions for the client follow-ing a nephrolithotomy.
40. Answer A is correct. The client with sickle cell crisis and sequestration can be expect-ed to have signs of hypovolemia, including decreased blood pressure. Answer B is incorrect because the client would have dry mucus membranes. Answer C is incorrect because the client would have increased respirations because of pain associated with sickle cell crisis. Answer D is incorrect because the client’s blood pressure would be decreased.
41. Answer D is correct. The first sign of latex allergy is usually contact dermatitis, which includes swelling and itching of the hands. Answers A, B, and C can also occur but are not the first signs of latex allergy.
42. Answer A is correct. The nurse caring for the client with disseminated herpes zoster (shingles) should use airborne precautions as outlined by the CDC. Answer B is incor-rect because precautions are needed to prevent transmission of the disease. Answer C and D are incorrect because airborne precautions are used, not contact or droplet pre-cautions.
43. Answer B is correct. Acticoat, a commercially prepared dressing, should be mois-tened with sterile water. Answers A and C are incorrect because Acticoat dressings remain in place up to 5 days. Answer D is incorrect because normal saline should not be used to moisten the dressing.
44. Answer A is correct. The presence of a white or gray dot (a cat’s eye reflex) in the pupil is associated with retinoblastoma, a highly malignant tumor of the eye. The nurse should report the finding to the physician immediately so that it can be further evaluated. Simply recording the finding can delay diagnosis and treatment; therefore, answer B is incorrect. Answer C is incorrect because it is not a variation of normal. Answer D is incorrect because the presence of the red reflex is a normal finding.
45. Answer B is correct. Stage II indicates that multiple lymph nodes or organs are involved on the same side of the diaphragm. Answer A refers to stage I Hodgkin’s lymphoma, answer C refers to stage III Hodgkin’s lymphoma, and answer D refers to stage IV Hodgkin’s lymphoma.
46. Answer B is correct. The client taking methotrexate should avoid multivitamins because multivitamins contain folic acid. Methotrexate is a folic acid antagonist. Answers A and D are incorrect because aspirin and acetaminophen are given to relieve pain and inflammation associated with rheumatoid arthritis. Answer C is incorrect because omega 3 and omega 6 fish oils have proven beneficial for the client with rheumatoid arthritis.
47AIIMS DELHI STAFF NURSE EXAM PAPERS. Answer C is correct. Fried foods are not permitted on a low-residue diet. Answers A, B, and D are all allowed on a low-residue diet and, therefore, are incorrect.
48. Answer C is correct. The client with cirrhosis and abdominal ascites requires addi-tional protein and calories. (Note: if the ammonia level increases, protein intake should be restricted or eliminated.) Answer A is incorrect because the client needs a low-sodium diet. Answer B is incorrect because the client does not need to increase his intake of potassium. Answer D is incorrect because the client does not need additional fat.
49. Answer B is correct. The most common symptom reported by clients with multiple sclerosis is double vision. Answers A, C, and D are not symptoms commonly reported by clients with multiple sclerosis, so they are wrong.
50. Answer A is correct. Common sources of E. coli are undercooked beef and shellfish. Answers B, C, and D are incorrect because they are not sources of E. coli.
51. Answer B is correct. St. John’s wort has properties similar to those of monoamine oxidase inhibitors (MAOI). Eating foods high in tryramine (example: aged cheese, chocolate, salami, liver) can result in a hypertensive crisis. Answer A is incorrect because it can relieve mild to moderate depression. Answer C is incorrect because use of a sunscreen prevents skin reactions to sun exposure. Answer D is incorrect because St. John’s wort should not be used with MAOI antidepressants.
52. Answer A is correct. Foods high in purine include dried beans, peas, spinach, oat-meal, poultry, fish, liver, lobster, and oysters. Answers B, C, and D are incorrect because they are low in purine. Other sources low in purine include most vegetables, milk, and gelatin.
53. Answer D is correct. The nurse should tell the client to avoid bearing weight on the axilla when using crutches because it can result in nerve damage. Answer A is incor-rect because the finger width between the axilla and the crutch is appropriate. Answer B is incorrect because the client should bear weight on his hands when ambulating with crutches. Answer C is incorrect because it describes the correct use of the four-point gait.
54. Answer A is correct. By writing down her suspicions, the nurse leaves herself open for a suit of libel, a defamatory tort that discloses a privileged communication and leads to a lowering of opinion of the client. Defamatory torts include libel and slander. Libel is a written statement, whereas slander is an oral statement. Thus, answer B is incorrect because it involves oral statements. Malpractice is an unreasonable lack of skill in performing professional duties that result in injury or death; therefore, answer C is incorrect. Negligence is an act of omission or commission that results in injury to a person or property, making answer D incorrect.
55. Answer B is correct. The client with bulimia is prone to tooth erosion and dental caries caused by frequent bouts of self-induced vomiting. Answers A, C, and D are findings associated with anorexia nervosa, not bulimia, and are incorrect.
56. Answer B is correct. Antacids should not be taken within 2 hours of taking digoxin; therefore, the nurse needs to do additional teaching regarding the client’s medication. Answers A, C, and D are true statements indicating that the client understands the nurse’s teaching, so they are incorrect. 301
57. Answer A is correct. Fever, sore throat, and weakness need to be reported immediate-ly. Adverse reactions to Thorazine include agranulocytosis, which makes the client vul-nerable to overwhelming infection. Answers B, C, and D are expected side effects that occur with the use of Thorazine; therefore, it is not necessary to notify the doctor immediately.
58. Answer C is correct. The anterior approach for cervical discectomy lends itself to covert bleeding. The nurse should pay particular attention to bleeding coming from the mouth. Answer A is incorrect because bleeding will be obvious on the surgical dressing. Answer B is incorrect because complaints of neck pain are expected and will be managed by the use of analgesics. Answer D is incorrect because swelling in the posterior neck can be expected. The nurse should observe for swelling in the anterior neck as well as changes in voice quality, which can indicate swelling of the airway.
59. Answer D is correct. The assessment suggests the presence of a diaphragmatic hernia. The newborn should be positioned on the left side with the head and chest elevated. This position will allow the lung on the right side to fully inflate. Supplemental oxygen for newborns is not provided by mask, therefore Answer A is incorrect. Answer B is incor-rect because bowel sounds would not be heard in the abdomen since abdominal con-tents occupy the chest cavity in the newborn with diaphragmatic hernia. Inserting a nasogastric tube to check for esophageal patency refers to the newborn with esophageal atresia; therefore, answer C is incorrect.
60. Answer B is correct. It takes 1–2 weeks for mood stabilizers to achieve a therapeutic effect; therefore, antipsychotic medications can also be used during the first few days or weeks to manage behavioral excitement. Answers A and D are not true statements and, therefore, are incorrect. Answer C is incorrect because the combination of medications will not allow for hypomania.
61. Answer D is correct. The nurse should first provide for the client’s safety, including protecting her from an embarrassing situation. Answer A is incorrect because it allows the client to continue unacceptable behavior. Answer B is incorrect because it does not stop the client’s behavior. Answer C is incorrect because it focuses on the other clients, not the client with inappropriate behavior.
62. Answer B is correct. According to the Denver Developmental Assessment, a 4-yearold should be able to state his first and last name. Answers A and C are expected abilities of a 5-year-old, and answer D is an expected ability of a 5- and 6-year-old.
63. Answer B is correct. The mother’s statement reflects the stress placed on her by her daughter’s chronic mental illness. Answer A is incorrect because there is no indication of ineffective family coping. Answer C is incorrect because it is not the most appropri-ate nursing diagnosis. Answer D is incorrect because there is no indication of altered parenting.
64. Answer B is correct. Clients with anorexia nervosa have problems with developing self-identity. They are often described by others as ―passive,‖ ―perfect,‖ and ―introverted.‖ Poor self-identity and low self-esteem lead to feelings of personal ineffectiveness. Answer A is incorrect because she will choose only low-calorie food items. Answer C is incorrect because the client with anorexia is restricted from exercising because it promotes weight loss. Placement in a private room increases the likelihood that the client will continue activities that prevent weight gain; therefore, answer D is incorrect.
65. Answer B is correct. The nursing assistant has skills suited to assisting the client with activities of daily living, such as bathing and grooming. Answer A is incorrect because the nurse should monitor the client’s vital signs. Answer C is incorrect because the client will have an induced generalized seizure, and the nurse should monitor the client’s response before, during, and after the procedure. Answer D is incorrect because staff does not remain in the room with a client in seclusion; only the nurse should monitor clients who are in seclusion.
66. Answer D is correct. Transderm Nitro is a reservoir patch that releases the medication via a semipermeable membrane. Cutting the patch allows too much of the drug to be released. Answer A is incorrect because the area should not be shaved; this can cause skin irritation. Answer B is incorrect because the skin is cleaned with soap and water. Answer C is incorrect because the patch should not be covered with plastic wrap because it can cause the medication to absorb too rapidly.
67. Answer A is correct. Cholinergic crisis is the result of overmedication with anticholinesterase inhibitors. Symptoms of cholinergic crisis are nausea, vomiting, diar-rhea, blurred vision, pallor, decreased blood pressure, and constricted pupils. Answers B, C, and D are incorrect because they are symptoms of myasthenia crisis, which is the result of undermedication with cholinesterase inhibitors.
68. Answer D is correct. The client should avoid eating American and processed cheeses, such as Colby and Cheddar, because they are high in sodium. Dried beans, peanut butter, and Swiss cheese are low in sodium; therefore, answers A, B, and C are incor-rect.
69. Answer C is correct. According to the Rule of Nines, the arm (9%) + the trunk (36%) = 45% TBSA burn injury. Answers A, B, and D are inaccurate calculations for the TBSA.
70. Answer A is correct. The client should void before the paracentesis to prevent acci-dental trauma to the bladder. Answer B is incorrect because the abdomen is not shaved. Answer C is incorrect because the client does not need extra fluids, which would cause bladder distention. Answer D is incorrect because the physician, not the nurse, would request an ultrasound, if needed.
71. Answer C is correct. Rice cereal, mashed ripe bananas, and strained carrots are appropriate foods for a 6-month-old infant. Answer A is incorrect because the cocoa-flavored cereal contains chocolate and sugar, orange juice is too acidic for the infant, and strained meat is difficult to digest. Answer B is incorrect because graham crack-ers contain wheat flour and sugar. Pudding contains sugar and additives unsuitable for the 6-month-old. Answer D is incorrect because the white of the egg contains albu-min, which can cause allergic reactions.
72. Answer D is correct. A battery-operated CD player is a suitable diversion for the 9-year-old who is receiving oxygen therapy for asthma. He should not have an electric player while receiving oxygen therapy because of the danger of fire. Answer A is incor-rect because he does need diversional activity. Answer B is incorrect because there is no need for him to wear earphones while he listening to music. Answer C is incorrect because he can have items from home.
73. Answer A is correct. Maturational crises are normal expected changes that face the family. Entering nursery school is a maturational crisis because the child begins to move away from the family and spend more time in the care of others. It is a time of adjustment for both the child and the parents. Answers B, C, and D are incorrect because they represent situational crises.
74. Answer A is correct. The client with a history of phenylketonuria should not use Nutrasweet or other sugar substitutes containing aspartame because aspartame is not adequately metabolized by the client with PKU. Answers B and C indicate an under-standing of the nurse’s teaching; therefore, they are incorrect. The client needs to resume a low-phenylalanine diet, making answer D incorrect.
75. Answer D is correct. Duchenne’s muscular dystrophy is a sex-linked disorder, with the affected gene located on the X chromosome of the mother. Answer A is incorrect because the affected gene is not located on the autosomes. Overreplication of the X chromosomes in males is known as Klinefelter’s syndrome; therefore, answer B is incorrect. Answer C is incorrect because the disorder is not located on the Y chromo-some of the father.
76. Answer B is correct. The nurse and the client should work together to form a contract that outlines the amount of time he spends on a task. Answer A is incorrect because the client with a personality disorder will see no reason to change. The nurse should discuss his behavior and its effects on others with him, so answer C is incorrect. Answer D is incorrect because the client will not be able to set schedules and dead-lines for himself.
77. Answer A is correct. Zovirax (acyclovir) shortens the course of chickenpox; however, the American Academy of Pediatrics does not recommend it for healthy children because of the cost. Answer B is incorrect because it is the vaccine used to prevent chickenpox. Answer C is incorrect because it is the immune globulin given to those who have been exposed to chickenpox. Answer D is incorrect because it is an antihis-tamine used to control itching associated with chickenpox.
78. Answer A is correct. Sock and mitten burns, burns confined to the hands and feet, indicate submersion in a hot liquid. Falling into the tub would not have produced sock burns; therefore, the nurse should be alert to the possibility of abuse. Answer B and C are within the realm of possibility, given the active play of the school-aged child; therefore, they are incorrect. Answer D is within the realm of possibility; therefore, it is incorrect.
79. Answer B is correct. Assault is the intentional threat to bring about harmful or offen-sive contact. The nurse’s threat to give the medication by injection can be considered as assault. Answers A, C, and D do not relate to the nurse’s statement; therefore, they are incorrect.
80. Answer C is correct. A nephrostomy tube is placed directly into the kidney and should never be clamped or irrigated because of the damage that can result to the kidney. Answers A and B are incorrect because the first action should be to relieve pressure on the affected kidney. Answer D is incorrect because the tubing should not be irrigat-ed.
81. Answer D is correct. When the collection chambers of the Pleuravac are full, the nurse should prepare a new unit for continuing the collection. Answer A is incorrect because the unit is providing suction, so the amount of water does not need to be increased. Answer B is incorrect because the drainage is not to be removed using a syringe. Milking a chest tube requires a doctor’s order, and because the tube is draining in this case, there is no need to milk it, so answer C is incorrect.
82. Answer B is correct. The first action by the nurse is to stop the transfusion and main-tain an IV of normal saline. Answers A, C, and D are incorrect because they are not the first action the nurse would take.
83. Answer A is correct. Microwaving can cause uneven heating and ―hot spots‖ in the formula, which can cause burns to the baby’s mouth and throat. Answers B, C, and D are incorrect because the infant’s formula should never be prepared using a microwave.
84. Answer B is correct. HELLP syndrome is characterized by hemolytic anemia, elevated liver enzymes, and low platelet counts. Answers A, C, and D have no connection to HELLP syndrome, so they are incorrect.
85. Answer C is correct. Dark green, leafy vegetables; members of the cabbage family; beets; kidney beans; cantaloupe; and oranges are good sources of folic acid (B9). Answers A, B, and D are incorrect because they are not sources of folic acid. Meat, liver, eggs, dried beans, sweet potatoes, and Brussels sprouts are good sources of B12; pork, fish, and chicken are good sources of B6.
86. Answer B is correct. The client with preeclampsia should be kept as quiet as possible, to minimize the possibility of seizures. The client should be kept in a dimly lit room with little or no stimulation. The clients in answers A, C, and D do not require a private room; therefore, they are incorrect.
87. Answer B is correct. Myasthenia gravis is caused by a loss of acetylcholine receptors, which results in the interruption of the transmission of nerve impulses from nerve endings to muscles. Answer A is incorrect because it refers to multiple sclerosis. Answer C is incorrect because it refers to Guillain-Barre syndrome. Answer D is incor-rect because it refers to Parkinson’s disease.
88. Answer B is correct. Osmitrol (mannitol) is an osmotic diuretic, which inhibits reab-sorption of sodium and water. The first indication of its effectiveness is an increased urinary output. Answers A, C, and D do not relate to the effectiveness of the drug, so they are incorrect.
89. Answer B is correct. The client with a suspected subdural hematoma is more critical than the other clients and should be assessed first. Answers A, C, and D have more stable conditions; therefore, they are incorrect
90. Answer C is correct. When given within 8 hours of the injury, Solu-Medrol has proven effective in reducing cord swelling, thereby improving motor and sensory function. Answer A is incorrect because Solu-Medrol does not prevent spasticity. Answer B is incorrect because Solu-Medrol does not decrease the need for mechanical ventilation. Answer D is incorrect because Solu-Medrol is used to reduce inflammation, not used to treat infections.
91. Answer B is correct. The spinal fluid of a client with Guillain-Barre has an increased protein concentration with normal or near-normal cell counts. Answers A, C, and D are inaccurate statements; therefore, they are incorrect.
92. Answer A is correct. The child with laryngotracheobronchitis has inspiratory stridor and a harsh, ―brassy‖ cough. Answer B refers to the child with eppiglotitis, answer C refers to the child with bronchiolitis, and answer D refers to the child with asthma.
93. Answer D is correct. Hemarthrosis or bleeding into the joints is characterized by stiff-ness, aching, tingling, and decreased movement in the affected joint. Answers A, B, and C do not describe hemarthrosis, so they are incorrect.
94. Answer C is correct. The objective of therapy using aerosol treatments and chest per-cussion and postural drainage is to dilate the bronchioles and help loosen secretions. Answers A, B, and D are inaccurate statements, so they are incorrect.
95. Answer A is correct. Drooling of bright red secretions indicates active bleeding. Answer B is incorrect because the heart rate is within normal range for a 6-yearold. Answer C is incorrect because it indicates old bleeding. Answer D is incorrect because the child would have frequent, not infrequent, swallowing.
96. Answer A is correct. Cigarette smoking is the number one cause of bladder cancer. Answer B is incorrect because it is not associated with bladder cancer. Answer C is a primary cause of gastric cancer, and answer D is a cause of certain types of lung can-cer.
97. Answer A is correct. Cloudy or whitish dialysate returns should be reported to the doctor immediately because it indicates infection and impending peritonitis. Answers B, C, and D are expected with peritoneal dialysis and do not require the doctor’s atten-tion.
98. Answer C is correct. Nitroglycerin tablets should be used as soon as the client first notices chest pain or discomfort. Answer A is incorrect because the medication should be used before engaging in activity. Strenuous activity should be avoided. Answer B is incorrect because the medication should be used when pain occurs, not on a regular schedule. Answer D is incorrect because the medication will not prevent nocturnal angina.
99. Answer C is correct. The LDH and CK MB are specific for diagnosing cardiac damage. Answers A, B, and D are not specific to cardiac function; therefore, they are incorrect.
100. Answer A is correct. The school-age child (8 or 9 years old) engages in cooperative play. These children enjoy competitive games in which there are rules and guidelines for winning. Answers B and D describe peer-group relationships of the preschool child, and answer C describes peer-group relationships of the preteen.
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