The correct answer is A: Household pets 46. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider? A)   Slurred speech B)   Incontinence C)   Muscle weakness D)   Rapid pulse The correct answer is A: Slurred speech 47. A 3 year-old child is brought to the clinic by his grandmother to be seen for “scratching his bottom and wetting the bed at night.” Based on these complaints, the nurse would initially assess for which problem? A)   Allergies B)   Scabies C)   Regression D)   Pinworms The correct answer is D: Pinworms 48. A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care,what is the most important action by the nurse? A)   Investigating the client’s insurance coverage for home IV antibiotic therapy B)   Determining if there are adequate hand washing facilities in the home C)   Assessing the client’s ability to participate in self care and/or the reliability of a caregiver D)   Selecting the appropriate venous access device The correct answer is C: Assessing the client'’s ability to participate in self care and/or the reliability of a caregiver 49. The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse? A)  “Folic acid should be taken before and after conception.” B)  “Multivitamin   supplements          are     recommended       during pregnancy.”   C)  “A well balanced diet promotes normal fetal development.” D) “Increased dietary iron improves the health of mother and fetus.” The correct answer is A: “Folic acid should be taken before and after conception.” 50. A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse? A)   Telfa dressing with antibiotic ointment B)   Moist sterile non adherent dressing C)   Dry sterile dressing that is occlusive D)   Sterile occlusive pressure dressing The correct answer is B: Moist sterile non adherent dressing 51. A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation,which of the following is most important to prevent lead poisoning? A)  Use ready-to-feed commercial infant formula B)  Boil the tap water for 10 minutes prior to preparing the formula C)  Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled “lead free” to mix the formula The correct answer is C: Let tap water run for 2 minutes before adding to concentrate 52. A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The most appropriate intervention for this client is A)   Position client in upright position while eating B)   Place client on a clear liquid diet C)   Tilt head back to facilitate swallowing reflex D)   Offer finger foods such as crackers or pretzels The correct answer is A: Position client in upright position while eating 53. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, “I will receive tissue from… A)   a tissue bank.” B)   a pig." C)   my thigh." D)   synthetic skin." The correct answer is C: my thigh." 54. The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? A)   Risk for dehydration B)   Ineffective airway clearance C)   Altered nutrition D)   Risk for injury The correct answer is B: Ineffective airway clearance 55. A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to A)   Promote the client’s comfort B)   Reduce the drying time C)   Decrease irritation to the skin D)   Improve venous return The correct answer is D: Improve venous return 56. During the initial home visit a nurse is discussing the care of a newly diagnosed client with Alzheimer’s disease with family members. Which of these interventions would be most helpful at this time? A)  Leave a book about relaxation techniques B)  Write out a daily exercise routine for them to assist the client to do C)  List actions to improve the client’s daily nutritional intake D) Suggest communication strategies The correct answer is D: Suggest communication strategies 57. The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to A)   Maintain previous calorie intake B)   Keep a candy bar available at all times C)   Reduce carbohydrates intake to 25% of total calories D)   Keep a regular schedule of meals and snacks The correct answer is D: Keep a regular schedule of meals and snacks 58. The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby’s record and expect which immunization to be most associated to the findings in the infant? A)   DTaP B)   Hepatitis B C)   Polio D)   H. Influenza The correct answer is A: DTaP 59. The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A)   Donating blood B)   Using public bathrooms C)   Unprotected sex D)   Touching a person with AIDS The correct answer is C: Unprotected sex 60. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the unlicensed assistive personnel (UAP)? A client with A)   Difficulty swallowing after a mild stroke B)   an order of enemas until clear prior to colonoscopy C)   an order for a post-op abdominal dressing change D)   transfer orders to a long term facility The correct answer is B: an order of enemas until clear prior to colonoscopy 61. A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: ”My child seems to have problems in learning to count and recognizing basic colors.” Based on this data, the nurse suspects that the child is most likely showing the effects of which problem? A)   Congenital abnormalities B)   Chronic toxoplasmosis C)   Fetal alcohol syndrome D)   Lead poisoning The correct answer is C: Fetal alcohol syndrome 62. The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately? A)  Prolonged inspiration with each breath B)  Expiratory wheezes that are suddenly absent in 1 lobe C)  Expectoration of large amounts of purulent mucous D)  Appearance of the use of abdominal muscles for breathing The correct answer is B: Expiratory wheezes that are suddenly absent in one lobe 63. The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best? A)  Fish sticks, french fries, banana, cookies, milk B)  Ground beef patty, lima beans, wheat roll, raisins, milk