NCLEX PRACTICE QUESTIONS ANSWER PART - 02 ANSWERS AND RATIONALES
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ANSWERS and Rationales
101. Answer A is correct.
If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins,bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, an alphaadrenergic blocking agent. Answers B, C, and D are not related to the question.
102. Answer D is correct. Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, vertigo, headache, visual disturbances, and confusion. Answers A, B, and C are not related to the use of quinidine.
103. Answer B is correct. Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of ventricular contractions. It is not used for atrial arrhythmias; thus, answer A is incorrect. Answers C and D are incorrect because it slows the heart rate, so it is not used for heart block or brachycardia.
104. Answer A is correct. Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities, making answer B incorrect. Answer C is incorrect because nitroglycerine should not be rubbed into the skin, and answer D is incorrect because the medication should be covered with a prepared dressing made of a thin paper substance, not gauze.
105. Answer B is correct. A persistent cough might be related to an adverse reaction to Captoten. Answers A and D are incorrect because tinnitus and diarrhea are not associated with the medication. Muscle weakness might occur when beginning the treatment but is not an adverse effect; thus, answer C is incorrect.
106. Answer A is correct. Lasix should be given approximately 1mL per minute to prevent hypotension. Answers B, C, and D are incorrect because it is not necessary to be given in an IV piggyback, with saline, or through a filter.
107. Answer B is correct. The antidote for heparin is protamine sulfate. Cyanocobalamine is B12, Streptokinase is a thrombolytic, and sodium warfarin is an anticoagulant. Therefore, answers A, C, and D are incorrect.
108. Answer A is correct. The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy is not radioactive because he travels to the radium department for therapy, and the radiation stays in the department. The client in answer B does pose a risk to the pregnant nurse. The client in answer C is radioactive in very small doses. For approximately 72 hours, the client should dispose of urine and feces in special containers and use plastic spoons and forks. The client in answer D is also radioactive in small amounts, especially upon return from the procedure.
109. Answer A is correct.
The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed. In answer B, the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hyperthyroidism or myxedema, and poses no risk to others or himself.
110. Answer C is correct.
Assault is defined as striking or touching the client inappropriately, so a nurse assistant striking a client could be charged with assault. Answer A, negligence, is failing to perform care for the client. Answer B, a tort, is a wrongful act committed on the client or their belongings. Answer D, malpractice, is failure to perform an act that the nurse assistant knows should be done, or the act of doing something wrong that results in harm to the client.
111. Answer D is correct.
The licensed practical nurse cannot start a blood transfusion, but can assist the registered nurse with identifying the client and taking vital signs. Answers A, B, and C are duties that the licensed practical nurse can perform.
112. Answer B is correct.
The vital signs are abnormal and should be reported to the doctor immediately. Answer A, continuing to monitor the vital signs, can result in deterioration of the client’s condition. Answer C, asking the client how he feels, would supply only subjective data. Involving the LPN, in Answer D, is not the best solution to help this client because he is unstable.
113. Answer B is correct.
Thalasemia is a genetic disorder that causes the red blood cells to have a shorter life span. Frequent blood transfusions are necessary to provide oxygen to the tissues. Answer A is incorrect because fluid therapy will not help; answer C is incorrect because oxygen therapy will also not help; and answer D is incorrect because iron should be given sparingly because these clients do not use iron stores adequately.
114. Answer B is correct.
Cystic fibrosis is a disease of the exocrine glands. The child with cystic fibrosis will be salty. A sweat test result of 60meq/L and higher is considered positive. Answers A, C, and D are incorrect because these test results are within the normal range and are not reported on the sweat test.
115. Answer A is correct.
A meningomylocele is an opening in the spine. The nurse should keep the defect covered with a sterile saline gauze until the defect can be repaired. Answer B is incorrect because the child should be placed in the prone position. Answer C is incorrect because feeding the child slowly is not necessary. Answer D is not correct because this is not the priority of care.
116. Answer D is correct. Absent femoral pulses indicates coarctation of the aorta. This defect causes strong bounding pulses and elevated blood pressure in the upper body, and low blood pressure in the lower extremities. Answers A, B, and C are incorrect because they are normal findings in the newborn.
117. Answer D is correct. Clostrium dificille is primarily spread through the GI tract, resulting from poor hand washing and contamination with stool containing clostridium dificille. Answers A, B, and C are incorrect because the mode of transmission is not by sputum, through the urinary tract, or by unsterile surgical equipment.
118. Answer A is correct. The first client to be seen is the one who recently returned from surgery. The other clients in answers B, C, and D are more stable and can be seen later.
119. Answer D is correct. Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect. Answers A, B, and C are white blood cells and have nothing to do with this medication.
120. Answer C is correct. The client taking antabuse should not eat or drink anything containing alcohol or vinegar. The other foods in answers A, B, and D are allowed.
121. Answer A is correct. The client with unilateral neglect will neglect one side of the body. Answers B, C, and D are not associated with unilateral neglect.
122. Answer D is correct. Because the client is immune suppressed, foods should be served in sealed containers, to avoid food contaminants. Answer B is incorrect because of possible infection from visitors. Answer A is not necessary, but the utensils should be cleaned thoroughly and rinsed in hot water. Answer C might be a good idea, but alcohol can be drying and can cause the skin to break down.
123. Answer A is correct. Identifying oneself as a nurse without a license defrauds the public and can be prosecuted. A tort is a wrongful act; malpractice is failing to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. Therefore, answers B, C, and D are incorrect.
124. Answer B is correct. The client with the appendectomy is the most stable of these clients and can be assigned to a nursing assistant. The client with bronchiolitis has an alteration in the airway; the client with periorbital cellulitis has an infection; and the client with a fracture might be an abused child. Therefore, answers A, C, and D are incorrect.
125. Answer B is correct. The first action the nurse should take is to report the finding to the nurse supervisor and follow the chain of command. If it is found that the pharmacy is in error, it should be notified, as stated in answer A. Answers C and D, notifying the director of nursing and the Board of Nursing, might be necessary if theft is found, but not as a first step; thus, these are incorrect for this question.
126. Answer B is correct. The best client to transport to the postpartum unit is the 40year-old female with a hysterectomy. The nurses on the postpartum unit will be aware of normal amounts of bleeding and will be equipped to care for this client. The clients in answers A and D will be best cared for on a medical-surgical unit. The client with depression in answer C should be transported to the psychiatric unit.
127. Answer D is correct. The fresh peach is the lowest in sodium of these choices. Answers A, B, and C have much higher amounts of sodium.
128. Answer B is correct. The client with congestive heart failure who is complaining of nighttime dyspnea should be seen because airway is number one in nursing care. In answers A, C, and D, the clients are more stable. A brain attack in answer A is the new terminology for a stroke.
129. Answer D is correct. Xerostomia is dry mouth, and offering the client a saliva substitute will help the most. Eating hard candy in answer A can further irritate the mucosa and cut the tongue and lips. Administering an analgesic might not be necessary; thus, answer B is incorrect. Splinting swollen joints, in answer C, is not associated with xerostomia.
130. Answer A is correct. The client with Alzheimer’s disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living. The clients in answers B, C, and D are less stable and should be attended by a registered nurse.
131. Answer A is correct. Frequent rest periods help to relax tense muscles and preserve energy. Answers B, C, and D are incorrect because they are untrue statements about cerebral palsy.
132. Answer D is correct.
A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea. Answers A, B, and C are incorrect because these cultures do not test for gonorrhea.
133. Answer D is correct. After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet. Stool softeners will be included in the plan of care, to avoid constipation. Later, a high-fiber diet, in answer A, is encouraged, but this is not the first diet after surgery. Answers B and C are not diets for this type of surgery.
134. Answer C is correct. A sitz bath will help with swelling and improve healing. Ice packs, in answer D, can be used immediately after delivery, but answers A and B are not used in this instance.
135. Answer B is correct. The best way to evaluate pain levels is to ask the client to rate his pain on a scale. In answer A, the blood pressure, pulse, and temperature can alter for other reasons than pain. Answers C and D are not as effective in determining pain levels.
136. Answer C is correct. The client is experiencing compensated metabolic acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be the inverse of the CO2 and bicarb levels. This means that if the pH is low, the CO2 and bicarb levels will be elevated. Answers A, B, and D are incorrect because they do not fall into the range of symptoms.
137. Answer B is correct. The registered nurse is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor; therefore, answers A, C, and D are incorrect.
138. Answer C is correct. Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. This allows for accurate bleeding times to be drawn in the morning. Therefore, answers A, B, and D are incorrect.
139. Answer C is correct. Covering both eyes prevents consensual movement of the affected eye. Answer A is incorrect because the nurse should not attempt to remove the object from the eye because this might cause trauma. Rinsing the eye, as stated in answer B, might be ordered by the doctor, but this is not the first step for the nurse. Answer D is not correct because often when one eye moves, the other also moves.
140. Answer A is correct. To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the shin might abrade the area. Answer C is incorrect because washing with hot water will vasodilate and increase absorption. The patches should be applied to areas above the waist, making answer D incorrect.
141. Answer B is correct. The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity. The client will be positioned sitting up or leaning over an overbed table, making answer A incorrect. The client is usually awake during the procedure, and medications are not commonly instilled during the procedure; thus answers C and D are incorrect.
142. Answer A is correct. Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic crises. Furosemide (answer B) is a diuretic; Prostigmin (answer C) is the treatment for myasthenia gravis; and Promethazine (answer D) is an antiemetic, antianxiety medication. Thus, answers B, C, and D are incorrect.
143. Answer D is correct. The first exercise that should be done by the client with a mastectomy is squeezing the ball. Answers A, B, and C are incorrect as the first step; they are implemented later.
144. Answer D is correct. The mothers in answers A, B, and C all require RhoGam and, thus, are incorrect. Answer D is the only mother who does not require a RhoGam injection.
145. Answer A is correct. Answer A, AST, is not specific for myocardial infarction. Troponin, CK-MB, and Myoglobin, in answers B, C, and D, are more specific, although myoglobin is also elevated in burns and trauma to muscles.
146. Answer B is correct. The client who says he has nothing wrong is in denial about his myocardial infarction. Rationalization is making excuses for what happened, projection is projecting feeling or thoughts onto others, and conversion reaction is converting a psychological trauma into a physical illness; thus, answers A, C, and D are incorrect.
147. Answer C is correct. When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. Answers A, B, and D are not directly related to the question and are incorrect.
148. Answer B is correct.
A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. Answers A, C, and D will not prevent the client from being able to care for himself and, thus, are incorrect.
149. Answer C is correct. Lactulose is administered to the client with cirrhosis to lower ammonia levels. Answers A, B, and D are incorrect because they do not have an effect on the other lab values.
150. Answer B is correct.
If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting the finding, as stated in answer A, as not enough; straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not urine at all. However, the physician might order a white blood cell count.
151. Answer B is correct. The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first. In answer A, the 10 year old with lacerations has superficial bleeding. The client in answer C with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The client in answer D with the dislocated elbow can be seen later as well.
152. Answer A is correct. The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet. The client with Crohn’s disease in answer B will be up to the bathroom frequently; the client with pylonephritis in answer C has a kidney infection and will be up to urinate frequently. The client in answer D with bronchitis will be coughing and will disturb any roommate.
153. Answer C is correct. The client should not be instructed to do the Valsalva maneuver during central venous pressure reading. If the nurse tells the client to perform the Valsalva maneuver, he needs further teaching. Answers A, B, and D are incorrect because they indicate that the nurse understands the correct way to check the CVP.
154. Answer D is correct. The most critical client should be assigned to the registered nurse; in this case, that is the client 2 days post-thoracotomy. The clients in answers A and B are ready for discharge, and the client in answer C who had a splenectomy 3 days ago is stable enough to be assigned to a PN.
155. Answer D is correct. The most suitable roommate for the client with gastric reaction is the client with phlebitis because the client with phlebitis will not transmit any infection to the surgical client. Crohn’s disease clients, in answer A, have frequent stools and might transmit infections. The client in answer B with pneumonia is coughing and will disturb the gastric client. The client with gastritis, in answer C, is vomiting and has diarrhea, which also will disturb the gastric client.
156. Answer B is correct. The client having a mammogram should be instructed to omit deodorants or powders beforehand because these could cause a false positive reading. Answer A is incorrect because there is no need to restrict fat. Answer C is incorrect because doing a mammogram does not replace the need for self-breast exams. Answer D is incorrect because a mammogram does not require a higher dose of radiation than an x-ray.
157. Answer A is correct. The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction. Answers B, C, and D are incorrect because these answers indicate understanding by the nurse.
158. Answer A is correct. When the cadaver client is being prepared to donate an organ, the systolic blood pressure should be maintained at 70mmHg or greater, to ensure a blood supply to the donor organ. Answers B, C, and D are incorrect because these actions are not necessary for the donated organ to remain viable.
159. Answer A is correct. Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, answer B is incorrect. Answers C and D are incorrect because they do not relate to the question.
160. Answer C is correct. The client with laryngeal cancer has a potential airway alteration and should be seen first. The clients in answers A, B, and D are not in immediate danger and can be seen later in the day.
161. Answer B is correct. The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation. Changing the assignment in answer A might need to be done, but talking to the nursing assistant is the first step. Answer C is incorrect because discussing the incident with the family is not necessary at this time; it might cause more problems than it solves. Answer C is not a first step, even though initiating a group session might be a plan for the future.
162. Answer B is correct. The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it will be done by the charge nurse. Answers A, C, and D are incorrect because notifying the police is overreacting at this time, and monitoring or ignoring the situation is an inadequate response.
163. Answer D is correct. The best client to assign to the newly licensed nurse is the most stable client; in this case, it is the client with diverticulitis. The client receiving chemotherapy and the client with a coronary bypass both need nurses experienced in these areas, so answers A and B are incorrect. Answer C is incorrect because the client with a transurethral prostatectomy might bleed, so this client should be assigned to a nurse who knows how much bleeding is within normal limits.
164. Answer D is correct. Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client metastases, the client with chronic pain, or the client with cerebrospinal infections. Answers A, B, and C are incorrect because intravenous, rectal, and intramuscular injections are entirely different procedures.
165. Answer B is correct. Montgomery straps are used to secure dressings that require frequent dressing changes because the client with a cholecystectomy usually has a large amount of draining on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. This client is not at higher risk of evisceration than other clients, so answer A is incorrect. Montgomery straps are not used to secure the drains, so answer C is incorrect. Sutures or clips are used to secure the wound of the client who has had gallbladder surgery, so answer D is incorrect.
166. Answer B is correct. The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a Levine tube should be anticipated. Answers A and C are incorrect because blood pressures are not required every 15 minutes, and cardiac monitoring might be needed, but this is individualized to the client. Answer D is incorrect because there are no dressings to change on this client.
167. Answer B is correct. Oils can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. Answer A is incorrect because two baths per day is too frequent and can cause more dryness. Answer C is incorrect because powder is also drying. Rinsing with hot water, as stated in answer D, dries out the skin as well.
168. Answer A is correct.
If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate, but in this case, only one item is listed; therefore, answers B and C are incorrect. Shoe covers are not necessary, so answer D is incorrect.
169. Answer D is correct. Abnormal grieving is exhibited by a lack of feeling sad; if the client’s sister appears not to grieve, it might be abnormal grieving. She thinks the client might be suppressing feelings of grief. Answers A, B, and C are all normal expressions of grief and, therefore, incorrect.
170. Answer B is correct. Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers A, C, and D are not of particular significance in this case and, therefore, are incorrect.
171. Answer B is correct. The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior. Answers A, C, and D are not associated with hypernatremia and are, therefore, incorrect.
172. Answer A is correct. Radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, interferes with calcium and phosphorus regulation. Answer B has no significance to this case; answers C and D are more related to calcium only, not to phosphorus regulation.
173. Answer A is correct.
It is the responsibility of the physician to explain and clarify the procedure to the client, so the nurse should call the surgeon to explain to the client. Answers B, C, and D are incorrect because they are not within the nurse’s responsibility.
174. Answer B is correct.
It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect.
175. Answer C is correct.
If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. Reinserting the content should not be the action and will require that the client return to surgery; thus, answer A is incorrect. Answers B and D are incorrect because they not appropriate to this case.
176. Answer B is correct. Cancer in situ means that the cancer is still localized to the primary site. T stands for “tumor” and the IS for “in situ.” Cancer is graded in terms of tumor, grade, node involvement, and mestatasis. Answers A, C, and D pertain to these other classifications.
177. Answer B is correct.
A full bladder or bowel can obscure the visualization of the kidney ureters and urethra. Answer A is incorrect because there is no need to force fluids before the test. Answer C is incorrect because there is no need to withhold medication for 12 hours before the test. Answer D is incorrect because the client’s reproductive organs should not be covered.
178. Answer C is correct. The client with a fractured femur will be placed in Buck’s traction to realign the leg and to decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so answer A is incorrect. Ice might be ordered after repair, but not for the entire extremity, so answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, answer D is incorrect.
179. Answer C is correct.
A red, beefy tongue is characteristic of the client with pernicious anemia. Answer A, a weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in pernicious anemia. Numbness and tingling, in answer B, can be associated with anemia but are not particular to pernicious anemia. This is more likely associated with peripheral vascular diseases involving vasculature. In answer D, the hemoglobin is normal and does not support the diagnosis.
180. Answer B is correct. Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer C incorrect. Answer D is incorrect because the client can eat and drink following the test.
181. Answer C is correct. The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A.
182. Answer A is correct.
Suctioning can cause a vagal response, lowering the heart rate and causing bradycardia. Answers B, C and D can occur as well, but they are less likely.
183. Answer C is correct. The client with an internal defibrillator should learn to use any battery-operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers A, B, and D are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side, and fly in an airplane.
184. Answer A is correct.
A swelling over the right parietal area is a cephalhematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the suture line and is edema.
185. Answer A is correct. The client with a lung resection will have chest tubes and a drainage-collection device. He probably will not have a tracheostomy or Swanz Ganz monitoring, and he will not have an order for percussion, vibration, or drainage. Therefore, answers B, C, and D are incorrect.
186. Answer C is correct. The client with mouth and throat cancer will have all the findings in answers A, B, and D except the correct answer of diarrhea.
187. Answer D is correct.
A loss of 10% is normal due to meconium stool and water loss. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula; thus, answers A, B, and C are incorrect.
188. Answer C is correct. The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and D are allowed.
189. Answer D is correct. The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time.
190. Answer C is correct. The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation.
191. Answer C is correct. The least-helpful questions are those describing his usual diet. Answers A, B, and D are useful in determining the extent of disease process and, thus, are incorrect.
192. Answer C is correct. Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore answers A, B, and D are incorrect.
193. Answer D is correct. Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B, and C are not specific to this type of cancer and are incorrect.
194. Answer D is correct.
A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight. Answers A, B, and C therefore are incorrect.
195. Answer B is correct.
A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect. Wire cutters should be kept with the client who has wired jaws.
196. Answer C is correct. Fosamax should be taken with water only. The client should also remain upright for at least 30 minutes after taking the medication. Answers A, B, and D are not applicable to taking Fosamax and, thus, are incorrect.
197. Answer B is correct. The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases is of less priority.
198. Answer A is correct. The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question.
199. Answer B is correct. The only lab result that is abnormal is the potassium. A potassium level of 1.9 indicates hypokalemia. The findings in answers A, C, and D are not revealed in the stem.
200. Answer A is correct. Removal of the pituitary gland is usually done by a transphenoidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland.
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