As I prepare to take the NCLEX in a couple months, I went searching online for NCLEX CAT adaptive style test. I stumbled upon this site by accident and what a lovely mistake that accident was. I took the free try CAT on the home page of the website and loved how the questions were worded and the overall format of the website. At that moment I knew I was going to register for this amazing product. As I explored around the website and checked out the daily NCLEX questions on the Facebook page I knew this was going to be a good thing. Before this program I was killing myself going through old medical surgical nursing textbooks and finding every NCLEX question possible, but there was only one problem these questions was all pre-programmed nothing was adaptive truly like the NCLEX is, with that along it makes all the other website truly inferior to this one. The website truly looks good, format is easy on computer and on mobile, I’d like to see more practice questions, but that’s one of the reasons I’m writing this is to unlock a free premium membership as we know nursing school wallets are tight with very little money to spare.

Things I was doing before this website, was a lot of dry reading in a textbook.

Kaplan Strategies book – I suggest to read this when you need a run through of the topics and after comprehensive review. Because this book will help you prepare how to answer questions and eliminate choices to get to the correct answer.

Hurst - This is by far the funniest and coolest book I have read about nursing. If my books in college especially med surg were written like it in college, I bet lessons would have not been so hard to understand. I believe Aunt Marlene did a great job in explaining Pharmacology in a nutshell.

Saunders - for comprehensive review, this is the book to read and understand by heart. It explained each disease process in simple and in a concise manner. Of course it is not that compete as it could be, but whenever I had more questions about a topic, I try to look for other books for details.

PDA – great for practicing and knowing what to expect in NCLEX. Questions here were formulated the way NCLEX questions are given. Raw, simple but definitely tricky.

Kaplan review – I wasn’t able to finish watching the videos because I felt I could learn more in reading Saunders than watching the videos. The videos, aside from being so long, felt like everything was mooshed together. I mostly used the qbank and qtrainers to gauge myself in areas I needed to improve with. The questions were definitely harder in Kaplan.

I started to answer 25 questions a day for 2 weeks and progressed to 75 questions a day on my 3rd week before I started feeling like these really aren’t adaptive and so I went on the lookout for an adaptive style NCLEX questions and I found this site, and I’m so glad that I did. This site will be one I go and tell all my friends about.

You, What’s your story?

Happy Nurse Week!!!

2. C. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

3. A. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

4. A. Normal ICP is 0-15 mm Hg.

5. A. A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia. Phenytoin doesn’t cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure.

6. C. The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there’s damage to the posterior pituitary.

7. D. The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The frontal lobe primarily functions to regulate thinking, planning, and judgment. The occipital lobe functions regulate vision. The parietal lobe primarily functions with sensory function.

8. C. The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The frontal lobe regulates thinking, planning, and judgment, and the occipital lobe is primarily responsible for vision function. The temporal lobe regulates memory.

9. D. Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

10. A. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae.

11. C. Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.

12. B. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

13. A. Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski’s sign, and positive Kernig’s sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig’s sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.

14. C. The client’s innate responses to pain are directed initially toward escaping from the source of pain. Variations in individuals’ tolerance and perception of pain are apparent only in conscious clients, and only conscious clients are able to employ distraction to help relieve pain.

15. B. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent overstressing the child, any treatments should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.

16. A. DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.

17. B. Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. The meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumonococcus. A chronically draining ear is frequently also found.

18. A.B and D. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

19. B. A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels.

20. C. A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.

a. Vomiting continues
b. Intracranial pressure (ICP) is increased
c. The client needs mechanical ventilation
d. Blood is anticipated in the cerebralspinal fluid (CSF)

2. A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?

a. To reduce intraocular pressure
b. To prevent acute tubular necrosis
c. To promote osmotic diuresis to decrease ICP
d. To draw water into the vascular system to increase blood pressure

3. A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?

a. Urine output increases
b. Pupils are 8 mm and nonreactive
c. Systolic blood pressure remains at 150 mm Hg
d. BUN and creatinine levels return to normal

4. Which of the following values is considered normal for ICP?

a. 0 to 15 mm Hg
b. 25 mm Hg
c. 35 to 45 mm Hg
d. 120/80 mm Hg

5. Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?

a. Ataxia and confusion
b. Sodium depletion
c. Tonic-clonic seizure
d. Urinary incontinence

6. Which of the following signs and symptoms of increased ICP after head trauma would appear first?

a. Bradycardia
b. Large amounts of very dilute urine
c. Restlessness and confusion
d. Widened pulse pressure

7. Problems with memory and learning would relate to which of the following lobes?

a. Frontal
b. Occipital
c. Parietal
d. Temporal

8. While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be dysfunctional?

a. Frontal
b. Occipital
c. Parietal
d. Temporal

9. The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?

a. Sternal rub
b. Pressure on the orbital rim
c. Squeezing the sternocleidomastoid muscle
d. Nail bed pressure

10. The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

a. Side-lying, with legs pulled up and head bent down onto the chest
b. Side-lying, with a pillow under the hip
c. Prone, in a slight Trendelenburg’s position
d. Prone, with a pillow under the abdomen.

11. A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:

a. A cerebral lesion
b. A temporal lesion
c. An intact brainstem
d. Brain death

12. The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?

a. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.
b. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
c. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.
d. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

13. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:

a. A positive Brudzinski’s sign
b. A negative Kernig’s sign
c. Absence of nuchal rigidity
d. A Glascow Coma Scale score of 15

14. A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to:

a. Tolerate the pain
b. Decrease the perception of pain
c. Escape the source of pain
d. Divert attention from the source of pain.

15. During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute?

a. Limiting conversation with the child
b. Keeping extraneous noise to a minimum
c. Allowing the child to play in the bathtub
d. Performing treatments quickly

16. Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?

a. Hemorrhagic skin rash
b. Edema
c. Cyanosis
d. Dyspnea on exertion

17. When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis?

a. Bladder infection
b. Middle ear infection
c. Fractured clavicle
d. Septic arthritis

18. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.

a. Head tilt
b. Vomiting
c. Polydipsia
d. Lethargy
e. Increased appetite
f. Increased pulse

19. A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis?

a. Cloudy CSF, decreased protein, and decreased glucose
b. Cloudy CSF, elevated protein, and decreased glucose
c. Clear CSF, elevated protein, and decreased glucose
d. Clear CSF, decreased pressure, and elevated protein

20. A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care?

a. No precautions are required as long as antibiotics have been started
b. Maintain enteric precautions
c. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics
d. Maintain neutropenic precautions

1.  ANSWER A. Anemia is defined as a decreased number of erythrocytes (red blood cells). Leukopenia is a decreased number of leukocytes (white blood cells). Thrombocytopenia is a decreased number of platelets. Lastly, granulocytopenia is a decreased number of granulocytes (a type of white blood cells).

2.  ANSWER C. Anemia stems from a decreased number of red blood cells and the resulting deficiency in oxygen and body tissues. Clotting factors, such as factor VIII, relate to the body’s ability to form blood clots and aren’t related to anemia, not is carbon dioxide of T antibodies.

3.  ANSWER C. The precursor to the RBC is the stem cell. B cells, macrophages, and T cells and lymphocytes, not RBC precursors.

4.  ANSWER A. Mild anemia usually has no clinical signs. Palpitations, SOB, and pallor are all associated with severe anemia.

5.  ANSWER B. In aplastic anemia, the most likely diagnostic findings are decreased levels of all the cellular elements of the blood (pancytopenia). T-helper cell production doesn’t decrease in aplastic anemia. Reed-Sternberg cells and lymph node enlargement occur with Hodgkin’s disease.

6.  ANSWER D. Preferably, ferrous gluconate should be taken on an empty stomach. Ferrous gluconae should not be taken with antacids, milk, or whole-grain cereals because these foods reduce iron absorption.

7.  ANSWER C. Hemophilia A results from a deficiency of factor VIII. Sickle cell disease is caused by a defective hemoglobin molecule. Christmas disease, also called hemophilia B, results in a factor IX deficiency.

8.  ANSWER C. Characteristic sickle cells tend to cause “log jams” in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of RBCs. The erythrocytes are sickle-shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.

9.  ANSWER D. Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborns hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin. The gene for sickle cell disease is transmitted at the time of conception, not passed through the placenta. Some hemoglobin S is produced by the fetus near term. The fetus produces all its own hemoglobin from the earliest production in the first trimester. Passive immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission of antibodies is important to protect the infant from various infections during early infancy.

10.  ANSWER C. For the child in a sickle cell crisis, pain is the priority nursing diagnosis because the sickled cells clump and obstruct the blood vessels, leading to occlusive and subsequent tissue ischemia. Although ineffective coping may be important, it is not the priority. Decreased cardiac output is not a problem with this type of vasoocclusive crisis. Typically, a sickle cell crisis can be precipitated by a fluid volume deficit or dehydration.

11.  ANSWER B. Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.

12.  ANSWERS A, B. Toddlers should have between 2 and 3 cups of milk per day and 8 ounces of juice per day. If they have more than that, then they are probably not eating enough other foods, including iron-rich foods that have the needed nutrients.

13.  ANSWER B. Potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron.

14.  ANSWER D. PTT measures the activity of thromboplastin, which is dependent on intrinsic clotting factors. In hemophilia, the intrinsic clotting factor VIII (antihemiphilic factor) is deficient, resulting in a prolonged PTT. Bleeding time reflects platelet function; the tourniquet test measures vasoconstriction and platelet function; and the clot retraction test measures capillary fragility. All of these are unaffected in people with hemophilia.

15.  ANSWER A. Bleeding into the joints in the child with hemophilia leads to pain and tenderness, resulting in restricted movement. Therefore, an early sign of hemarthrosis would be the child’s reluctance to move a body part. If the bleeding into the joint continues, the area becomes hot, swollen, and immobile—not cool, pale, and clammy. Ecchymosis formation around a joint would be difficult to assess. Instability of a long bone on passive movement is not associated with joint hemarthrosis.

16.  ANSWER A. Because factor VIII concentrate is derived from large pools of human plasma, the risk of hepatitis is always present. Clinical manifestations of hepatitis include yellowing of the skin, mucous membranes, and sclera. Use of factor VIII concentrate is not associated with constipation, abdominal distention, or puffiness around the eyes.

17.  ANSWER C. A diagnosis is established based on a complete blood count, examination for sickled red blood cells in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, and increased reticulocyte count, and the presence of nucleated red blood cells. Increased reticulocyte counts occur in children with sickle cell disease because the life span of their sickled red blood cells is shortened.

18.  ANSWER C. Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 ½ to 2 times the daily requirement to prevent dehydration.

19.  ANSWER D. The results of a CBC in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

20.  ANSWER D. Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Hemophilia is inherited in a recessive manner via a genetic defect on the X-chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX.

a. Erythrocytes
b. Granulocytes
c. Leukocytes
d. Platelets

2. A client with anemia may be tired due to a tissue deficiency of which of the following substances?

a. Carbon dioxide
b. Factor VIII
c. Oxygen
d. T-cell antibodies

3. Which of the following cells is the precursor to the red blood cell (RBC)?

a. B cell
b. Macrophage
c. Stem cell
d. T cell

4. Which of the following symptoms is expected with hemoglobin of 10 g/dl?

a. None
b. Pallor
c. Palpitations
d. Shortness of breath

5. Which of the following diagnostic findings are most likely for a client with aplastic anemia?

a. Decreased production of T-helper cells
b. Decreased levels of white blood cells, red blood cells, and platelets
c. Increased levels of WBCs, RBCs, and platelets
d. Reed-Sternberg cells and lymph node enlargement

6. A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan?

a. “Take the medication with an antacid.”
b. “Take the medication with a glass of milk.”
c. “Take the medication with cereal.”
d. “Take the medication on an empty stomach.”

7. Which of the following disorders results from a deficiency of factor VIII?

a. Sickle cell disease
b. Christmas disease
c. Hemophilia A
d. Hemophilia B

8. The nurse explains to the parents of a 1-year-old child admitted to the hospital in a sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following?

a. Autoimmune reaction complicated by hypoxia
b. Lack of oxygen in the red blood cells
c. Obstruction to circulation
d. Elevated serum bilirubin concentration.

9. The mothers asks the nurse why her child’s hemoglobin was normal at birth but now the child has S hemoglobin. Which of the following responses by the nurse is most appropriate?

a. “The placenta bars passage of the hemoglobin S from the mother to the fetus.”
b. “The red bone marrow does not begin to produce hemoglobin S until several months after birth.”
c. “Antibodies transmitted from you to the fetus provide the newborn with temporary immunity.”
d. “The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth.”

10. Which of the following would the nurse identify as the priority nursing diagnosis during a toddler’s vasoocclusive sickle cell crisis?

a. Ineffective coping related to the presence of a life-threatening disease
b. Decreased cardiac output related to abnormal hemoglobin formation
c. Pain related to tissue anoxia
d. Excess fluid volume related to infection

11. A mother asks the nurse if her child’s iron deficiency anemia is related to the child’s frequent infections. The nurse responds based on the understanding of which of the following?

a. Little is known about iron-deficiency anemia and its relationship to infection in children.
b. Children with iron deficiency anemia are more susceptible to infection than are other children.
c. Children with iron-deficiency anemia are less susceptible to infection than are other children.
d. Children with iron-deficient anemia are equally as susceptible to infection as are other children.

12. Which statements by the mother of a toddler would lead the nurse to suspect that the child has iron-deficiency anemia? Select all that apply.

a. “He drinks over 3 cups of milk per day.”
b. “I can’t keep enough apple juice in the house; he must drink over 10 ounces per day.”
c. “He refuses to eat more than 2 different kinds of vegetables.”
d. “He doesn’t like meat, but he will eat small amounts of it.”
e. “He sleeps 12 hours every night and take a 2-hour nap.”

13. Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia?

a. Rice cereal, whole milk, and yellow vegetables
b. Potato, peas, and chicken
c. Macaroni, cheese, and ham
d. Pudding, green vegetables, and rice

14. The physician has ordered several laboratory tests to help diagnose an infant’s bleeding disorder. Which of the following tests, if abnormal, would the nurse interpret as most likely to indicate hemophilia?

a. Bleeding time
b. Tourniquet test
c. Clot retraction test
d. Partial thromboplastin time (PTT)

15. Which of the following assessments in a child with hemophilia would lead the nurse to suspect early hemarthrosis?

a. Child’s reluctance to move a body part
b. Cool, pale, clammy extremity
c. Eccymosis formation around a joint
d. Instability of a long bone in passive movement

16. Because of the risks associated with administration of factor VIII concentrate, the nurse would teach the client’s family to recognize and report which of the following?

a. Yellowing of the skin
b. Constipation
c. Abdominal distention
d. Puffiness around the eyes

17. A child suspected of having sickle cell disease is seen in a clinic, and laboratory studies are performed. A nurse checks the lab results, knowing that which of the following would be increased in this disease?

a. Platelet count
b. Hematocrit level
c. Reticulocyte count
d. Hemoglobin level

18. A clinic nurse instructs the mother of a child with sickle cell disease about the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions?

a. Infection
b. Trauma
c. Fluid overload
d. Stress

19. Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia?

a. An elevated hemoglobin level
b. A decreased reticulocyte count
c. An elevated RBC count
d. Red blood cells that are microcytic and hypochromic

20. A pediatric nurse health educator provides a teaching session to the nursing staff regarding hemophilia. Which of the following information regarding this disorder would the nurse plan to include in the discussion?

a. Hemophilia is a Y linked hereditary disorder
b. Males inherit hemophilia from their fathers
c. Females inherit hemophilia from their mothers
d. Hemophilia A results from a deficiency of factor VIII

View Answers and Rationale

1. ANSWER A. Fever, chills, hemoptysis, dyspnea, cough, and pleuric chest pain are the common symptoms of pneumonia, but elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response.
2. ANSWER D. The most common feature of all types of pneumonia is an inflammatory pulmonary response to the offending organism or agent. Atelectasis and brochiectasis indicate a collapse of a portion of the airway that doesn’t occur with pneumonia. An effusion is an accumulation of excess pleural fluid in the pleural space, which may be a secondary response to pneumonia.
3. ANSWER A. Based on the client’s history and symptoms, acute asthma is the most likely diagnosis. He’s unlikely to have bronchial pneumonia without a productive cough and fever and he’s too young to have developed COPD or emphysema.
4. ANSWER C. Inspiratory and expiratory wheezes are typical findings in asthma. Circumoral cyanosis may be present in extreme cases of respiratory distress. The nurse would expect the client to have a decreased forced expiratory volume because asthma is an obstructive pulmonary disease. Breath sounds will be “tight” sounding or markedly decreased; they won’t be normal.
5. ANSWER C. Intrinsic asthma doesn’t have an easily identifiable allergen and can be triggered by the common cold. Asthma caused be emotional reasons is considered to be in the extrinsic category. Extrinsic asthma is caused by dust, molds, and pets; easily identifiable allergens. Mediated asthma doesn’t exist.
6. ANSWER B. Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow. Beta-adrenergic blockers aren’t used to treat asthma and can cause bronchoconstriction. Inhaled or oral steroids may be given to reduce the inflammation but aren’t used for emergency relief.
7. ANSWER B. The client is having an acute asthma attack and needs to increase oxygen delivery to the lung and body. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. First resolve the acute phase of the attack ad how to prevent attacks in the future. It may not be necessary to place the client on a cardiac monitor because he’s only 19-years-old, unless he has a past medical history of cardiac problems.
8. ANSWER C. Because of his extensive smoking history and symptoms, the client most likely has chronic obstructive bronchitis. Clients with ARDS have acute symptoms of and typically need large amounts of oxygen. Clients with asthma and emphysema tend not to have a chronic cough or peripheral edema.
9. ANSWER C. Clients with chronic obstructive bronchitis appear bloated; they have large barrel chests and peripheral edema, cyanotic nail beds and, at times, circumoral cyanosis. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amounts of oxygen. Clients with asthma don’t exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic (a state of ill health, malnutrition, and wasting).
10. ANSWER D. Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer”. Clients with ARDS are usually acutely short of breath. Clients with asthma don’t have any particular characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.
11. ANSWER D. These are classic signs and symptoms of a client with emphysema. Clients with ARDS are acutely short of breath and require emergency care; those with asthma are also acutely short of breath during an attack and appear very frightened. Clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.
12. ANSWER D. It’s highly recommended that clients with respiratory disorders be given vaccines to protect against respiratory infection. Infections can cause these clients to need intubation and mechanical ventilation, and it may be difficult to wean these clients from the ventilator. The vaccines have no effect on bronchodilation or respiratory care.
13. ANSWER A. Exercise can improve cardiovascular fitness and help the client tolerate periods of hypoxia better, perhaps reducing the risk of heart attack. Most exercise has little effect on respiratory muscle strength, and these clients can’t tolerate the type of exercise necessary to do this. Exercise won’t reduce the number of acute attacks. In some instances, exercise may be contraindicated, and the client should check with his physician before starting any exercise program.
14. ANSWER A. Reducing fluid volume reduces the workload of the heart, which reduces oxygen demand and, in turn, reduces the respiratory rate. It may also reduce edema and improve mobility a little, but exercise tolerance will still be harder to clear airways. Reducing fluid volume won’t improve respiratory function, but may improve oxygenation.
15. ANSWER D. In emphysema, the wall integrity of the individual air sacs is damaged, reducing the surface area available for gas exchange. Very little air movement occurs in the lungs because of bronchiole collapse, as well. In ARDS, the client’s condition is more acute and typically requires mechanical ventilation. In asthma and bronchitis, wheezing is prevalent.
16. ANSWER C. Clients with emphysema breathe when their oxygen levels drop to a certain level; this is known as the hypoxic drive. They don’t take a breath when their levels of carbon dioxide are higher than normal, as do those with healthy respiratory physiology. If too much oxygen is given, the client has little stimulus to take another breath. In the meantime, his carbon dioxide levels continue to climb, and the client will pass out, leading to a respiratory arrest.
17.ANSWER D. Respiratory infection in clients with a respiratory disorder can be fatal. It’s important that the client understands how to recognize the signs and symptoms of an impending respiratory infection. It isn’t appropriate for the wife to listen to his lung sounds, besides, you can’t purchase stethoscopes from Wal-Mart. If the client has signs and symptoms of an infection, he should contact his physician at once.
18.ANSWER A. Atelectasis develops when there’s interference with the normal negative pressure that promotes lung expansion. Clients in the postoperative phase often splint their breathing because of pain and positioning, which causes hypoxia. It’s uncommon for any of the other respiratory disorders to develop.
19. ANSWER D. Using an incentive spirometer requires the client to take deep breaths and promotes lung expansion. Chest physiotherapy helps mobilize secretions but won’t prevent atelectasis. Reducing oxygen requirements or placing someone on mechanical ventilation doesn’t affect the development of atelectasis.
20. ANSWER A. Inhaled beta-adrenergic agents help promote bronchodilation, which improves oxygenation. I.V. beta-adrenergic agents can be used but have to be monitored because of their greater systemic effects. They’re typically used when the inhaled beta-adrenergic agents don’t work. Corticosteriods are slow-acting, so their use won’t reduce hypoxia in the acute phase.

a. Altered mental status and dehydration
b. fever and chills
c. Hemoptysis and dyspnea
d. Pleuretic chest pain and cough

2. Which of the following pathophysiological mechanisms that occurs in the lung parenchyma allows pneumonia to develop?

a. Atelectasis
b. Bronchiectasis
c. Effusion
d. Inflammation

3. A 7-year-old client is brought to the E.R. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and a nonproductive cough. He recently had a cold. From his history, the client may have which of the following?

a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema

4. Which of the following assessment findings would help confirm a diagnosis of asthma in a client suspected of having the disorder?

a. Circumoral cyanosis
b. Increased forced expiratory volume
c. Inspiratory and expiratory wheezing
d. Normal breath sounds

5. Which of the following types of asthma involves an acute asthma attack brought on by an upper respiratory infection?

a. Emotional
b. Extrinsic
c. Intrinsic
d. Mediated

6. A client with acute asthma showing inspiratory and expiratory wheezes and a decreased expiratory volume should be treated with which of the following classes of medication right away?

a. Beta-adrenergic blockers
b. Bronchodilators
c. Inhaled steroids
d. Oral steroids

7. A 19-year-old comes into the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should be taken first?

a. Take a full medication history
b. Give a bronchodilator by neubulizer
c. Apply a cardiac monitor to the client
d. Provide emotional support to the client.

8. A 58-year-old client with a 40-year history of smoking one to two packs of cigarettes a day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema

9. The term “blue bloater” refers to which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema

10. The term “pink puffer” refers to the client with which of the following conditions?

a. ARDS
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema

11. A 66-year-old client has marked dyspnea at rest, is thin, and uses accessory muscles to breathe. He’s tachypneic, with a prolonged expiratory phase. He has no cough. He leans forward with his arms braced on his knees to support his chest and shoulders for breathing. This client has symptoms of which of the following respiratory disorders?

a. ARDS
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema

12. It’s highly recommended that clients with asthma, chronic bronchitis, and emphysema have Pneumovax and flu vaccinations for which of the following reasons?

a. All clients are recommended to have these vaccines
b. These vaccines produce bronchodilation and improve oxygenation.
c. These vaccines help reduce the tachypnea these clients experience.
d. Respiratory infections can cause severe hypoxia and possibly death in these clients.

13. Exercise has which of the following effects on clients with asthma, chronic bronchitis, and emphysema?

a. It enhances cardiovascular fitness.
b. It improves respiratory muscle strength.
c. It reduces the number of acute attacks.
d. It worsens respiratory function and is discouraged.

14. Clients with chronic obstructive bronchitis are given diuretic therapy. Which of the following reasons best explains why?

a. Reducing fluid volume reduces oxygen demand.
b. Reducing fluid volume improves clients’ mobility.
c. Restricting fluid volume reduces sputum production.
d. Reducing fluid volume improves respiratory function.

15. A 69-year-old client appears thin and cachectic. He’s short of breath at rest and his dyspnea increases with the slightest exertion. His breath sounds are diminished even with deep inspiration. These signs and symptoms fit which of the following conditions?

a. ARDS
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema

16. A client with emphysema should receive only 1 to 3 L/minute of oxygen, if needed, or he may lose his hypoxic drive. Which of the following statements is correct about hypoxic drive?

a. The client doesn’t notice he needs to breathe.
b. The client breathes only when his oxygen levels climb above a certain point.
c. The client breathes only when his oxygen levels dip below a certain point.
d. The client breathes only when his carbon dioxide level dips below a certain point.

17. Teaching for a client with chronic obstructive pulmonary disease (COPD) should include which of the following topics?

a. How to have his wife learn to listen to his lungs with a stethoscope from Wal-Mart.
b. How to increase his oxygen therapy.
c. How to treat respiratory infections without going to the physician.
d. How to recognize the signs of an impending respiratory infection.

18. Which of the following respiratory disorders is most common in the first 24 to 48 hours after surgery?

a. Atelectasis
b. Bronchitis
c. Pneumonia
d. Pneumothorax

19. Which of the following measures can reduce or prevent the incidence of atelectasis in a post-operative client?

a. Chest physiotherapy
b. Mechanical ventilation
c. Reducing oxygen requirements
d. Use of an incentive spirometer

20. Emergency treatment of a client in status asthmaticus includes which of the following medications?

a. Inhaled beta-adrenergic agents
b. Inhaled corticosteroids
c. I.V. beta-adrenergic agents
d. Oral corticosteroids

21. Which of the following treatment goals is best for the client with status asthmaticus?

a. Avoiding intubation
b. Determining the cause of the attack
c. Improving exercise tolerance
d. Reducing secretions

22. Dani was given dilaudid for pain. She’s sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?

a. Asthma attack
b. Respiratory arrest
c. Be pissed about receiving Narcan
d. Wake up on her own

23. Which of the following additional assessment data should immediately be gathered to determine the status of a client with a respiratory rate of 4 breaths/minute?

a. Arterial blood gas (ABG) and breath sounds
b. Level of consciousness and a pulse oximetry value.
c. Breath sounds and reflexes
d. Pulse oximetry value and heart sounds

24. A client is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. The nurse would expect to PaCO2 to be which of the following values?

a. 15 mm Hg
b. 30 mm Hg
c. 40 mm Hg
d. 80 mm Hg

25. A client has started a new drug for hypertension. Thirty minutes after he takes the drug, he develops chest tightness and becomes short of breath and tachypneic. He has a decreased level of consciousness. These signs indicate which of the following conditions?

a. Asthma attack
b. Pulmonary embolism
c. respiratory failure
d. Rheumatoid arthritis

View Answers and Rationale

1. ANSWER A. FSH and LH, when stimulated by gonadotropin-releasing hormone from the hypothalamus, are released from the anterior pituitary gland to stimulate follicular growth and development, growth of the graafian follicle, and production of progesterone.
2. ANSWER B. Blood pumped by the embryo’s heart leaves the embryo through two umbilical arteries. Once oxygenated, the blood then is returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen and nutrients to the fetus.
3. ANSWER C. The fetal heart rate depends in gestational age and ranges from 160-170 BPM in the first trimester but slows with fetal growth to 120-160 BPM near or at term. At or near term, if the fetal heart rate is less than 120 or more than 160 BPM with the uterus at rest, the fetus may be in distress.
4. ANSWER C. Accurate use of Nagele’s rule requires that the woman have a regular 28-day menstrual cycle. Add 7 days to the first day of the last menstrual period, subtract three months, and then add one year to that date.
5. ANSWER B. Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies. T is term births, the number born at term (38-41 weeks). P is preterm births, the number born before 38 weeks gestation. A is abortions or miscarriages (included in gravida if before 20 weeks gestation; included in parity if past 20 weeks gestation). L is live births, the number of live births or living children. Therefore, a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 37 weeks, the number of preterm births is 1, and the number of term births is 0. The number of abortions is 0, and the number of live births is 1.
6. ANSWER B. The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160-170 BPM in the first trimester and slows with fetal growth, near and at term, the fetal heart rate ranges from 120-160 BPM. The other options are expected.
7. ANSWER A. In the early weeks of pregnancy the cervix becomes softer as a result of increased vascularity and hyperplasia, which causes the Goodell’s sign.
8. ANSWER C. Quickening is fetal movement and may occur as early as the 16th and 18th week of gestation, and the mother first notices subtle fetal movements that gradually increase in intensity. Braxton Hicks contractions are irregular, painless contractions that may occur throughout the pregnancy. A thinning of the lower uterine segment occurs about the 6th week of pregnancy and is called Hegar’s sign.
9. ANSWER D. Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and the examiner feels a gentle tap on the finger.
10. ANSWER A, D, E, and F. The probable signs of pregnancy include uterine enlargement, Hegar’s sign (softening and thinning of the uterine segment that occurs at week 6), Goodell’s sign (softening of the cervix that occurs at the beginning of the 2nd month), Chadwick’s sign (bluish coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at week 6), ballottement (rebounding of the fetus against the examiners fingers of palpation), Braxton Hicks contractions and a positive pregnancy test measuring for hCG. Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler) at 10-12 weeks and by nonelectronic device (fetoscope) at 20 weeks gestation, active fetal movements palpable by the examiner, and an outline of the fetus via radiography or ultrasound.
11. ANSWER A. Legs cramps occur when the pregnant woman stretches the leg and plantar flexes the foot. Dorsiflexion of the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting, and stops the cramping.
12. ANSWER D. The pregnant woman should be instructed to wash the breasts with warm water and keep them dry. The woman should be instructed to avoid using soap on the nipples and areola area to prevent the drying of tissues. Wearing a supportive bra with wide adjustable straps can decrease breast tenderness. Tight-fitting blouses or dresses will cause discomfort (especially on test days, even if you’re not pregnant. Yo.).
13. ANSWER A. Severe Preeclampsia can trigger disseminated intravascular coagulation (DIC; remember the Peds lecture?) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the M.D.
14. ANSWER A. Strict bed rest throughout the remainder of pregnancy is not required. The woman is advised to curtail sexual activities until the bleeding has ceased, and for 2 weeks following the last evidence of bleeding or as recommended by the physician. The woman is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The woman also should watch for the evidence of the passage of tissue.
15. ANSWER C. All pregnant women should be advised to do the following to prevent the development of toxoplasmosis. Women should be instructed to cook meats thoroughly, avoid touching mucous membranes and eyes while handling raw meat; thoroughly wash all kitchen surfaces that come into contact with uncooked meat, wash the hands thoroughly after handling raw meat; avoid uncooked eggs and unpasteurized milk; wash fruits and vegetables before consumption, and avoid contact with materials that possibly are contaminated with cat feces, such as cat litter boxes, sand boxes, and garden soil.
16. ANSWER C. If the client complains of a headache and blurred vision, the physician should be notified because these are signs of worsening Preeclampsia.
17. ANSWER C. Exercise is safe for the client with gestational diabetes and is helpful in lowering the blood glucose level.
18. ANSWER C. Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the physician or other health care provider needs to be notified, and continuation of the medication needs to be reassessed. A urinary output of 20 ml in a 30 minute period is adequate; less than 30 ml in one hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is WNL for a resting fetus.
19. ANSWER C. The immediate care during a seizure (eclampsia) is to ensure a patent airway. The other options are actions that follow or will be implemented after the seizure has ceased.
20. ANSWER A  and C. The three classic signs of preeclampsia are hypertension, generalized edema, and protenuria. Increased respirations are not a sign of preeclampsia.
21. ANSWER A. Rh incompatibility can occur when an Rh-negative mom becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the baby’s Rh positive blood can enter the maternal circulation, causing the woman’s immune system to form antibodies against Rh positive blood. Administration of Rho (D) immune globulin prevents the woman from developing antibodies against Rh positive blood by providing passive antibody protection against the Rh antigen.
22. ANSWER D. Magnesium toxicity can occur from magnesium sulfate therapy. Signs of toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden drop in the fetal heart rate and maternal heart rate and blood pressure. Therapeutic levels of magnesium are 4-7 mEq/L. Proteinuria of +3 would be noted in a client with preeclampsia.
23. ANSWER C. For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Magnesium sulfate is an anticonvulsant, not an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Ankle clonus indicated hyperrelexia and may precede the onset of eclampsia. Scotomas are areas of complete or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure.
24. ANSWER C, D, E, F, and G. When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.
25. ANSWER A. RhoGAM is given within 72 hours postpartum if the client has not been sensitized already.

a. FSH and LH are released from the anterior pituitary gland.
b. FSH and LH are secreted by the corpus luteum of the ovary
c. FSH and LH are secreted by the adrenal glands
d. FSH and LH stimulate the formation of milk during pregnancy.

2. A nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse accurately tells the client that fetal circulation consists of:

a. Two umbilical veins and one umbilical artery
b. Two umbilical arteries and one umbilical vein
c. Arteries carrying oxygenated blood to the fetus
d. Veins carrying deoxygenated blood to the fetus

3. During a prenatal visit at 38 weeks, a nurse assesses the fetal heart rate. The nurse determines that the fetal heart rate is normal if which of the following is noted?

a. 80 BPM
b. 100 BPM
c. 150 BPM
d. 180 BPM

4. A client arrives at a prenatal clinic for the first prenatal assessment. The client tells a nurse that the first day of her last menstrual period was September 19th, 2005. Using Nagele’s rule, the nurse determines the estimated date of confinement as:

a. July 26, 2006
b. June 12, 2007
c. June 26, 2006
d. July 12, 2007

5. A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year old child that was delivered at 37 weeks and tells the nurse that she doesn’t have any history of abortion or fetal demise. The nurse would document the GTPAL for this client as:

a. G = 3, T = 2, P = 0, A = 0, L =1
b. G = 2, T = 0, P = 1, A = 0, L =1
c. G = 1, T = 1. P = 1, A = 0, L = 1
d. G = 2, T = 0, P = 0, A = 0, L = 1

6. A nurse is performing an assessment of a primapira who is being evaluated in a clinic during her second trimester of pregnancy. Which of the following indicates an abnormal physical finding necessitating further testing?

a. Consistent increase in fundal height
b. Fetal heart rate of 180 BPM
c. Braxton hicks contractions
d. Quickening

7. A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of a Goodell’s sign. The nurse determines this sign indicates:

a. A softening of the cervix
b. A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus.
c. The presence of hCG in the urine
d. The presence of fetal movement

8. A nursing instructor asks a nursing student who is preparing to assist with the assessment of a pregnant client to describe the process of quickening. Which of the following statements if made by the student indicates an understanding of this term?

a. “It is the irregular, painless contractions that occur throughout pregnancy.”
b. “It is the soft blowing sound that can be heard when the uterus is auscultated.”
c. “It is the fetal movement that is felt by the mother.”
d. “It is the thinning of the lower uterine segment.”

9. A nurse midwife is performing an assessment of a pregnant client and is assessing the client for the presence of ballottement. Which of the following would the nurse implement to test for the presence of ballottement?

a. Auscultating for fetal heart sounds
b. Palpating the abdomen for fetal movement
c. Assessing the cervix for thinning
d. Initiating a gentle upward tap on the cervix

10. A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

a. Uterine enlargement
b. Fetal heart rate detected by nonelectric device
c. Outline of the fetus via radiography or ultrasound
d. Chadwick’s sign
e. Braxton Hicks contractions
f. Ballottement

11. A pregnant client calls the clinic and tells a nurse that she is experiencing leg cramps and is awakened by the cramps at night. To provide relief from the leg cramps, the nurse tells the client to:

a. Dorsiflex the foot while extending the knee when the cramps occur
b. Dorsiflex the foot while flexing the knee when the cramps occur
c. Plantar flex the foot while flexing the knee when the cramps occur
d. Plantar flex the foot while extending the knee when the cramps occur.

12. A nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. The nurse tells the client to:

a. Avoid wearing a bra
b. Wash the nipples and areola area daily with soap, and massage the breasts with lotion.
c. Wear tight-fitting blouses or dresses to provide support
d. Wash the breasts with warm water and keep them dry

13. A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for:

a. Any bleeding, such as in the gums, petechiae, and purpura.
b. Enlargement of the breasts
c. Periods of fetal movement followed by quiet periods
d. Complaints of feeling hot when the room is cool

14. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement, if made by the client, indicates a need for further education?

a. “I will maintain strict bedrest throughout the remainder of pregnancy.”
b. “I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding.”
c. “I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad.”
d. “I will watch for the evidence of the passage of tissue.”

15. A prenatal nurse is providing instructions to a group of pregnant client regarding measures to prevent toxoplasmosis. Which statement if made by one of the clients indicates a need for further instructions?

a. “I need to cook meat thoroughly.”
b. “I need to avoid touching mucous membranes of the mouth or eyes while handling raw meat.”
c. “I need to drink unpasteurized milk only.”
d. “I need to avoid contact with materials that are possibly contaminated with cat feces.”

16. A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the Preeclampsia and the need to notify the physician?

a. Blood pressure reading is at the prenatal baseline
b. Urinary output has increased
c. The client complains of a headache and blurred vision
d. Dependent edema has resolved

17. A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes. Which statement if made by the client indicates a need for further education?

a. “I need to stay on the diabetic diet.”
b. “I will perform glucose monitoring at home.”
c. “I need to avoid exercise because of the negative effects of insulin production.”
d. “I need to be aware of any infections and report signs of infection immediately to my health care provider.”

18. A primagravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension (PIH). The nurse who is caring for the client is performing assessments every 30 minutes. Which assessment finding would be of most concern to the nurse?

a. Urinary output of 20 ml since the previous assessment
b. Deep tendon reflexes of 2+
c. Respiratory rate of 10 BPM
d. Fetal heart rate of 120 BPM

19. A nurse is caring for a pregnant client with Preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from Preeclampsia to eclampsia, the nurse’s first action is to:

a. Administer magnesium sulfate intravenously
b. Assess the blood pressure and fetal heart rate
c. Clean and maintain an open airway
d. Administer oxygen by face mask

20. A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)?

a. Elevated blood pressure
b. Negative urinary protein
c. Facial edema
d. Increased respirations

21. Rho (D) immune globulin (RhoGAM) is prescribed for a woman following delivery of a newborn infant and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following?

a. Being affected by Rh incompatibility
b. Having Rh positive blood
c. Developing a rubella infection
d. Developing physiological jaundice

22. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines the client is experiencing toxicity from the medication if which of the following is noted on assessment?

a. Presence of deep tendon reflexes
b. Serum magnesium level of 6 mEq/L
c. Proteinuria of +3
d. Respirations of 10 per minute

23. A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium therapy is effective if:

a. Ankle clonus in noted
b. The blood pressure decreases
c. Seizures do not occur
d. Scotoma’s are present

24. A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client.

a. Monitor maternal vital signs every 2 hours
b. Notify the physician if respirations are less than 18 per minute.
c. Monitor renal function and cardiac function closely
d. Keep calcium gluconate on hand in case of a magnesium sulfate overdose
e. Monitor deep tendon reflexes hourly
f. Monitor I and O’s hourly
g. Notify the physician if urinary output is less than 30 ml per hour.

25. In the 12th week of gestation, a client completely expels the products of conception. Because the client is Rh negative, the nurse must:

a. Admister RhoGAM within 72 hours
b. Make certain she receives RhoGAM on her first clinic visit
c. Not give RhoGAM, since it is not used with the birth of a stillborn
d. Make certain the client does not receive RhoGAM, since the gestation only lasted 12 weeks.

ANSWERS and RATIONALE on NCLEX Review on OB/GYN – Antepartum