EXAM QUESTIONS AND CORRECT ANSWERS |ALREADY GRADED A+
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Course
MSSC CLA
Institution
MSSC CLA
EXAM QUESTIONS AND CORRECT ANSWERS |ALREADY GRADED A+
A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for
pain. Which organ function is most important for the nurse to monitor?
A. Cardiorespiratory.
B. Liver.
C. Sensory.
D. Kidney. - ANS B. Liver.
...
EXAM QUESTIONS AND CORRECT
ANSWERS |ALREADY GRADED A+
A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for
pain. Which organ function is most important for the nurse to monitor?
A. Cardiorespiratory.
B. Liver.
C. Sensory.
D. Kidney. - ANS B. Liver.
RATIONALE:
Acetaminophen and alcohol are both metabolized in the liver. This places the client at risk for
hepatotoxicity, so monitoring liver (A) function is the most important assessment because the
combination of acetaminophen and alcohol, even in moderate amounts, can cause potentially
fatal liver damage. Other non-narcotic analgesics, such as n onsteroidal anti-inflammatory drugs
(NSAIDs), are more likely to promote adverse renal effects (B). Acetaminophen does not place
the client at risk for toxic reactions related to (C or D).
The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a
scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse
implement?
A. Give intravenous (IV) calcium gluconate.
B. Withhold the drug and notify the healthcare provider.
C. Administer the dose as prescribed.
D. Recheck the vital signs in 30 minutes and then administer the dose. - ANS C. Administer the
dose as prescribed
RATIONALE:
Verapamil slows sinoatrial (SA) nodal automaticity, delays atrioventricular (AV) nodal
conduction, which slows the ventricular rate, and is used to treat atrial flutter, so (A) should be
,implemented, based on the client's heart rate and blood pressure. (B and C) are not indicated. (D)
delays the administration of the scheduled dose.
A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza.
Which categories of illness should the nurse develop goals for the client's plan of care?
A. One chronic and one acute illness.
B. Two acute illnesses.
C. One acute and one infectious illness.
D. Two chronic illnesses. - ANS A. One chronic and one acute illness
RATIONALE:
The plan of care should include goals that are specific for chronic and acute illnesses. Adultonset
diabetes is a life-long chronic disease, whereas influenza is an acute illness with a shortterm
duration (C). (A, B, and D) do not include the correct duration categories for this situation.
Following an emergency Cesarean delivery, the nurse encourages the new mother to
breastfeed her newborn. The client asks why she should breastfeed now. Which information
should the nurse provide?
A. Stimulate contraction of the uterus.
B. Initiate the lactation process.
C. Facilitate maternal-infant bonding.
D. Prevent neonatal hypoglycemia. - ANS A. Stimulate contraction of the uterus
RATIONALE:
When the infant suckles at the breast, oxytocin is released by the posterior pituitary to stimulates
the "letdown" reflex, which causes the release of colostrum, and contracts the uterus (C) to
prevent uterine hemorrhage. (A and B) do not support the client's need in the immediate period
after the emergency delivery. Although maternal-newborn bonding (D) is facilitated by early
breastfeeding, the priority is uterine contraction stimulation.
Which intervention should the nurse include in the plan of care for a female client with severe
,postpartum depression who is admitted to the inpatient psychiatric unit?
A. Restrict visitors who irritate the client.
B. Full rooming-in for the infant and mother
C. Supervised and guided visits with infant.
D. Daily visits with her significant other. - ANS C. Supervised and guided visits with infant
RATIONALE:
Structured visits (C) provide an opportunity for the mother and infant to bond and should be
facilitated and encouraged according to the client's pace of progress. (A) is unrealistic and may
not be safe for the baby or the client. (B) is an unrealistic expectation. Although daily visits may
provide support, the significant other may not be able to be there every day (D) based on other
family responsibilities.
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a
fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture.
Which action should be implemented to obtain a valid informed consent?
A. Obtain the permission of the custodial parent for the surgery.
B. Notify the non-custodial parent to also sign a consent form.
C. Instruct the client sign the consent before giving medications.
D. Obtain the signature of the client's stepfather for the surgery. - ANS A. Obtain the permission
of the custodial parent for the surgery.
RATIONALE:
The client is a minor and cannot legally sign his own consent unless he is an emancipated minor,
so the consent should be obtained from the guardian for this client, which is the custodial parent
(B). (A) is not a legal option. A stepparent is not a legal guardian for a minor unless the child has
been adopted by the stepparent (C). The non-custodial parent does not need to co-sign this form
(D).
During a client assessment, the client says, "I can't walk very well." Which action should the
nurse implement first?
, A. Predict the likelihood of the outcome.
B. Consider alternatives.
C. Choose the most successful approach.
D. Identify the problem. - ANS D. Identify the problem.
RATIONALE:
The sequential steps in problem-solving are to first identify the problem (B), then consider
alternatives (C), consider outcomes of the alternatives (D), predict the likelihood of the outcomes
occurring, and choose the alternative with the best chance of success (A)
The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced
nutrition: less than body requirements, related to mental impairment and decreased intake, as
evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6
months." Which short-term goal is best for this client?
A. Verbalize understanding of plan and of intention to eat meals.
B. Eat 50% of six small meals each day by the end of one week.
C. Meals prepared during hospitalization will be fed by the nurse.
D. Demonstrate progressive weight gain toward the ideal weight. - ANS B. Eat 50% of six small
meals each day by the end of one week.
RATIONALE:
Short-term goals should be realistic and attainable and should have a timeline of 7 to 10 days
before discharge. (A) meets those criteria. (B) is nurse-oriented. (C) may be beyond the
capabilities of a confused client. (D) is a long-term goal.
A male client is angry and is leaving the hospital against medical advice (AMA). The client
demands to take his chart with him and states the chart is "his" and he doesn' t want any more
contact with the hospital. How should the nurse respond?
A. This hospital does not need to keep it if you are leaving and not returning here.
B. Because you are leaving against medical advice, you may not have your chart.
C. The information in your chart is confidential and cannot leave this facility legally.
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