1.Answer D is correct. Methotrexate is a folic acid antagonist. Leucovorin is the drug given for toxicity to this drug. It is not used to treat iron-deficiency anemia, create a synergistic effects, or increase the number of circulating neutrophils. Therefore, answers A, B, and C are incorrect.
2.Answer B is correct. The client who is allergic to dogs, eggs, rabbits, and chicken feathers is most likely allergic to the rubella vaccine. The client who is allergic to neomycin is also at risk. There is no danger to the client if he has an order for a TB skin test, ELISA test, or chest x-ray; thus, answers A, C, and D are incorrect.
3.Answer B is correct. Zantac (rantidine) is a histamine blocker that should be given with meals for optimal effect, not before meals. However, Tagamet (cimetidine) is a histamine blocker that can be given in one dose at bedtime. Neither of these drugs should be given before or after meals, so answers A and D are incorrect.
4.Answer C is correct. The proximal end of the double-barrel colostomy is the end toward the small intestines. This end is on the client’s right side. The distal end, as in answers A, B, and D, is on the client’s left side.
5.Answer A is correct. If the nurse checks the fundus and finds it to be displaced to the right or left, this is an indication of a full bladder. This finding is not associated with hypotension or clots, as stated in answer B. Oxytoxic drugs (Pitocin) are drugs used to contract the uterus, so answer C is incorrect. It has nothing to do with displacement of the uterus. Answer D is incorrect because displacement is associated with a full bladder, not vaginal bleeding.
6.Answer C is correct. Clients with an internal defibrillator or a pacemaker should not have an MRI because it can cause dysrhythmias in the client with a pacemaker. If the client has a need for oxygen, is claustrophobic, or is deaf, he can have an MRI, but provisions such as extension tubes for the oxygen, sedatives, or a signal system should be made to accommodate these problems. Therefore, answers A, B, and D are incorrect.
7.Answer C is correct. A 6-month-old is too old for the colorful mobile. He is too young to play with the electronic game or the 30-piece jigsaw puzzle. The best toy for this age is the cars in a plastic container, so answers A, B, and D are incorrect.
8.Answer C is correct. The client with polio has muscle weakness. Periods of rest throughout the day will conserve the client’s energy. A hot bath can cause burns; however, a warm bath would be helpful, so answer A is incorrect. Strenuous exercises are not advisable, making answer B incorrect. Visual disturbances are directly associated with polio and cannot be corrected with glasses; therefore, answer D is incorrect.
9.Answer B is correct. The client with a protoepisiotomy will need stool softeners such as docusate sodium. Suppositories are given only with an order from the doctor, Methergine is a drug used to contract the uterus, and Parlodel is an anti-Parkinsonian drug; therefore, answers A, C, and D are incorrect.
10.Answer C is correct. Total Parenteral Nutrition is a high-glucose solution. This therapy often causes the glucose levels to be elevated. Because this is a common complication, insulin might be ordered. Answers A, B, and D are incorrect. TPN is used to treat negative nitrogen balance; it will not lead to negative nitrogen balance. Total Parenteral Nutrition can be managed with oral hypoglycemic drugs, but it is difficult to do so. Total Parenteral Nutrition will not lead to further pancreatic disease.
11.Answer B is correct. The client who is 10 weeks pregnant should be assessed to determine how she feels about the pregnancy. It is too early to discuss preterm labor, too late to discuss whether she was using a method of birth control, and after the client delivers, a discussion of future children should be instituted. Thus, answers A, C, and D are incorrect.
12.Answer A is correct. The best IV fluid for correction of dehydration is normal saline because it is most like normal serum. Dextrose pulls fluid from the cell, lactated Ringer’s contains more electrolytes than the client’s serum, and dextrose with normal saline will also alter the intracellular fluid. Therefore, answers B, C, and D are incorrect.
13.Answer A is correct. A thyroid scan uses a dye, so the client should be assessed for allergies to iodine. The client will not have a bolus of fluid, will not be asleep, and will not have a urinary catheter inserted, so answers B, C, and D are incorrect.
14.Answer B is correct. RhoGam is used to prevent formation of Rh antibodies. It does not provide immunity to Rh isoenzymes, eliminate circulating Rh antibodies, or convert the Rh factor from negative to positive; thus, answers A, C, and D are incorrect.
15.Answer B is correct. A client with a fractured foot often has a short leg cast applied to stabilize the fracture. A spica cast is used to stabilize a fractured pelvis or vertebral fracture. Kirschner wires are used to stabilize small bones such as toes and the client will most likely have a cast or immobilizer, so answers A, C, and D are incorrect.
16.Answer A is correct. Iridium seeds can be expelled during urination, so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answers B, C, and D are incorrect.
17.Answer C is correct. Immunosuppressants are used to prevent antibody formation. Antivirals, antibiotics, and analgesics are not used to prevent antibody production, so answers A, B, and D are incorrect.
18.Answer A is correct. Before cataract removal, the client will have Mydriatic drops instilled to dilate the pupil. This will facilitate removal of the lens. Miotics constrict the pupil and are not used in cataract clients. A laser is not used to smooth and reshape the lens; the diseased lens is removed. Silicone oil is not injected in this client; thus, answers B, C, and D are incorrect.
19.Answer C is correct. Placing simple signs that indicate the location of rooms where the client sleeps, eats, and bathes will help the client be more independent. Providing mirrors and pictures is not recommended with the client who has Alzheimer’s disease because mirrors and pictures tend to cause agitation, and alternating healthcare workers confuses the client; therefore, answers A, B, and D are incorrect.
20.Answer C is correct. A Jackson-Pratt drain is a serum-collection device commonly used in abdominal surgery. A Jackson-Pratt drain will not prevent the need for dressing changes, reduce edema of the incision, or keep the common bile duct open, so answers A, B, and D are incorrect. A t-tube is used to keep the common bile duct open.
21.Answer C is correct. The infant who is 32 weeks gestation will not be able to control his head, so head lag will be present. Mongolian spots are common in African American infants, not Caucasian infants; the client at 32 weeks will have scrotal rugae or redness but will not have vernix caseosa, the cheesy appearing covering found on most full-term infants. Therefore, answers A, B, and D are incorrect.
22.Answer A is correct. Hematuria in a client with a pelvic fracture can indicate trauma to the bladder or impending bleeding disorders. It is not unusual for the client to complain of muscles spasms with multiple fractures, so answer B is incorrect. Dizziness can be associated with blood loss and is nonspecific, making answer C incorrect. Nausea, as stated in answer D, is also common in the client with multiple traumas.
23.Answer C is correct. The client’s statement "They are trying to kill me" indicates paranoid delusions. There is no data to indicate that the client is hearing voices or is intoxicated, so answers A and D are incorrect. Delusions of grandeur are fixed beliefs that the client is superior or perhaps a famous person, making answer B incorrect.
24.Answer B is correct. Because the nurse is unaware of when the bottle was opened or whether the saline is sterile, it is safest to obtain a new bottle. Answers A, C, and D are not safe practices.
25.Answer C is correct. Infants with an Apgar of 9 at 5 minutes most likely have acryocyanosis, a normal physiologic adaptation to birth. It is not related to the infant being cold, experiencing bradycardia, or being lethargic; thus, answers A, B, and D are incorrect.