NURSING PRACTICE EXAM AND RATIONALES

1. A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty
a) Expressing feelings of low self-worth
b) Expressing anger toward others
c) Discussing remorse and guilt for actions
d) Displaying dependence on others
Answers: B. Expressing anger toward others
Explanation. A suicidal client will have difficulty expressing anger toward others. A suicidal client frequently expresses feelings of low self-worth, feelings of remorse and guilt, and a dependence on others; therefore, answers A, C and D are incorrect.

2. A client receiving HydroDIURIL (hydrochlorothiazide) is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:
a) Pear
b) Apple
c) Orange
d) Banana
Answers: C. Banana
Explanation. Pear, Apple and Orange contain lower amount of potassium compared to Banana which contains 450mg K+ while the apple contains 165mg K+, the apple contains 165mg K+.and the orange contains 235mg K+.

3. The nurse is caring for a client following removal of the thyroid. Immediately post-op, the nurse should:
a) Encourage the client to turn her head side to side, to promote drainage of oral secretions
b) Maintain the client in a supine position with sandbags placed on either side of the head and neck
c) Maintain the client in a semi-Fowler’s position with the head and neck supported by pillows
d) Encourage the client to cough and breathe deeply every 2 hours, with the neck in a flexed position
Answers: C. Maintain the client in a semi-Fowler’s position with the head and neck supported by pillows
Explanation. Client should be placed in semi-Fowler’s position following a thyroidectomy to decrease swelling that would place pressure on the airway. All others are incorrect because they would increase the chances of post-operative complications that include bleeding, airway obstruction and swelling. Professional assignment writing help “Nursing practice exam and rationales” Meet the team that makes it all possible.

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4. A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer?
a) Dairy products
b) Luncheon meats
c) Carbonated beverages
d) Refined sugars
Answers: B. Luncheon meats
Explanation. Luncheon meats contain preservatives such as nitrites that have been linked to gastric cancer while A, C and D are not correct as they don’t increase the risk of gastric cancer.

5. A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client’s record, the nurse could expect to find:
a) A History of consistent employment
b) A below-average intelligence
c) An expression of remorse for his actions
d) A history of cruelty to animals
Answer: D. A history of cruelty to animals.
Explanation. A history of cruelty to people and animals, truancy, setting fires, and lack of guilt or remorse are associated with a diagnosis of conduct disorder in children, which becomes a diagnosis of antisocial personality disorder in adults. Answer A is incorrect because the client with antisocial personality disorder does not hold consistent employment. Answer B is incorrect because the IQ is usually higher than average. Answer C is incorrect because of a lack of guilt or remorse for wrong-doing.

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6. The licensed vocational nurse may not assume the primary care for a client:
a) In the fourth stage of labor
b) Two days post-appendectomy
c) With bipolar disorder
d) With a venous access device
Answers: D. With a venous access device
Explanation. The licensed Professional assignment writing help “Nursing practice exam and rationalesMeet the team that makes it all possible. vocational nurse may not assume primary care of the client with a central venous access device. The licensed vocational nurse may care for the client in labor, the client post-operative client, and the client with bipolar disorder; therefore, answers A, B, and C are incorrect.

7. The physician has ordered dressings with mafenide acetate (Sulfamylon) cream for a client with full-thickness burns of the hands and arms. Before dressing changes, the nurse should give priority to:
a) Checking the adequacy of urinary output
b) Administering pain medication
c) Requesting a daily complete blood count
d) Obtaining a blood glucose by finger stick
Answers: B. Administering pain medication
Explanation. Sulfamylon (mafenide acetate) produces a painful sensation when applied to the burn wound; therefore, the client should receive pain medication before dressing changes. Answers A, C and D do not pertain to dressing changes for the client with burns, so they are incorrect.

8. The nurse is teaching a group of parents about gross motor development of the toddler. Which behavior is an example of the normal gross motor skill of a toddler?
a) She can copy a horizontal line.
b) She can build a tower of eight blocks.
c) She can broad-jump.
d) She can pull a toy behind her.
Answers: D. She can pull a toy behind her.
Explanation. According to the Denver Developmental Screening Test, the child can pull a toy behind her by age 2 years. Answers A, B and C are not accomplished until ages 4–5 years; therefore, they are incorrect.

9. A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
a) Oral airway
b) Wire cutters
c) Pliers
d) Tracheostomy set
Answers: B. Wire cutters
Explanation. The client with a fractured mandible should keep a pair of wire cutters with him at all times to release the device in case of choking or aspiration. Answer A is incorrect because the wires would prevent insertion of an oral airway. Answer C is incorrect because it would be of no use in releasing the wires. Answer D is incorrect because it would be used only as a last resort in case of airway obstruction.

10. The nurse is to administer digoxin (Lanoxin) elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. The nurse should: Professional assignment writing help “Nursing practice exam and rationalesMeet the team that makes it all possible.

a. Record the heart rate and call the physician
b. Administer the medication and recheck the heart rate in 15 minutes
c. Hold the medication and recheck the heart rate in 30 minutes
d. Record the heart rate and administer the medication
Answers: D. Record the heart rate and administer the medication
Explanation: The infant’s apical heart rate is within the accepted range for administering the medication. Answers A, B, and C are incorrect because the apical heart rate is suitable for giving the medication.

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11. A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse’s explanation is based on the knowledge that lead poisoning is treated with:
a. Chelating agents
b. Gastric lavage
c. Antiemetics
d. Activated charcoal
Answer: A. Chelating agents
Explanation. Chelating agents are used to treat the client with poisonings from heavy metals such as lead and iron. Answers B and D are used to remove noncorrosive poisons; therefore, they are incorrect. Answer C prevents vomiting; therefore, it is an incorrect response.

12. An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are:
a. Elbow restraints
b. Full arm restraints
c. Wrist restraints
d. Mummy restraints
Answer: A. Elbow restraints
Explanation. The least restrictive restraint for the infant with cleft lip and cleft palate repair is elbow restraints. Answers B, C, and D are more restrictive and unnecessary; therefore, they are incorrect.

13. A client with glaucoma has been prescribed Timoptic (timolol) eyedrops. Timoptic should be used with caution in the client with a history of:
a. Diabetes
b. Gastric Professional assignment writing help “Nursing practice exam and rationalesMeet the team that makes it all possible. ulcers
c. Emphysema
d. Pancreatitis
Answer: C. Emphysem
Explanation. Beta blockers such as timolol (Timoptic) can cause bronchospasms in the client with chronic obstructive lung disease. Timoptic is not contraindicated for use in clients with diabetes, gastric ulcers, or pancreatitis; therefore, answers A, B, and C are incorrect.

14. An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client’s confusion by:
a. Assigning a nursing assistant to sit with him until he falls asleep
b. Allowing the client to room with another elderly client
c. Administering a bedtime sedative
d. Leaving a nightlight on during the evening and night shifts
Answer: D. Leaving a nightlight on during the evening and night shifts
Explanation. Leaving a nightlight on during the evening and night shifts helps the client remain oriented to the environment and fosters independence. Answers A and B will not decrease the client’s confusion. Answer C will increase the likelihood of confusion in an elderly client.

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15. Which of the following is a common complaint of the client with end-stage renal failure?
a. Weight loss
b. Itching
c. Ringing in the ears
d. Bruising
Answers: B. Itching
Explanation. Pruritis or itching is caused by the presence of uric acid crystals on the skin, which is common in the client with end-stage renal failure. Professional assignment writing help “Nursing practice exam and rationalesMeet the team that makes it all possible. Answers A, C and D are not associated with end-stage renal failure.

16. Which of the following medication orders needs further clarification?
a. Darvocet (propoxyphene) 65mg PO every 4–6 hrs. PRN
b. Mysoline (primidone) 250mg PO TID
c. Coumadin (warfarin sodium) 10mg PO
d. Premarin (conjugated estrogen) .625mg PO daily
Answers: C. Coumadin (warfarin sodium) 10mg PO
Explanation. There is no specified time or frequency for the ordered medication. Answers A, B, and D contain specified time and frequency, therefore they do not require further clarification.

  1. The best diet for the client with Meniere’s syndrome is one that is:
    a) High in fiber
    b) Low in sodium
    c) High in iodine
    d) Low in fiber
    Answers: B. Low in sodium
    Explanation. A low-sodium diet is best for the client with Meniere’s syndrome. Answers A, C, and D do not relate to the care of the client with Meniere’s syndrome; therefore, they are incorrect.

 

  1. Which of the following findings is associated with right-sided heart failure?
    a) Shortness of breath
    b) Nocturnal polyuria
    c) Daytime oliguria
    d) Crackles in the lungs
    Answers: B. Nocturnal polyuria
    Explanation. A low-sodium diet is best for the client with Meniere’s syndrome. Answers A, C, and D do not relate to the care of the client with Meniere’s syndrome; therefore, they are incorrect.

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  1. An 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should:
    a) Place the probe on the child’s abdomen
    b) Recalibrate the oximeter at the beginning of each shift
    c) Apply the probe and wait 15 minutes before obtaining a reading
    d) Place the probe on the child’s finger
    Answers: D. Place the probe on the child’s finger
    Explanation. The pulse oximeter should be placed on the child’s finger or earlobe because blood flow to these areas is most accessible for measuring oxygen concentration. Answer A is incorrect because the probe cannot be secured to the abdomen. Answer B is incorrect because it should be recalibrated before application. Answer C is incorrect because a reading is obtained within seconds, not minutes.

 

  1. An infant with Tetralogy of Fallot is discharged with a prescription for lanoxin elixir. The nurse should instruct the mother to:
    a) Administer the medication using a nipple
    b) Administer the medication using the calibrated dropper in the bottle
    c) Administer the medication using a plastic baby spoon
    d) Administer the medication in a baby bottle with 1oz. of water
    Answers: B. Administer the medication using the calibrated dropper in the bottle
    Explanation. The medication should be administered using the calibrated dropper that comes with the medication. Answers A and C are incorrect because part or all of the medication could be lost during administration. Answer D is incorrect because part or all of the medication will be lost if the child does not finish the bottle.

 

  1. The client scheduled for electroconvulsive therapy tells the nurse, “I’m so afraid. What will happen to me during the treatment?” Which of the following statements is most therapeutic for Professional assignment writing help Nursing practice exam and rationalesMeet the team that makes it all possible. the nurse to make?“
    a) You will be given medicine to relax you during the treatment.”
    b) “The treatment will produce a controlled grand mal seizure.”
    c) “The treatment might produce nausea and headache.”
    d) “You can expect to be sleepy and confused for a time after the treatment.”
    Answer. A “You will be given medicine to relax you during the treatment.”
    Explanation. The client will receive medication that relaxes skeletal muscles and produces mild sedation. Answers B and D are incorrect because such statements increase the client’s anxiety level. Nausea and headache are not associated with ECT; therefore, answer C is incorrect

 

  1. Which of the following skin lesions is associated with Lyme’s disease?
    a) Bull’s eye rash
    b) Papular crusts
    c) Bullae
    d) Plaques

Answer. A, Bull’s eye rash
Explanation. Lyme’s disease produces a characteristic annular or circular rash sometimes described as a “bull’s eye” rash. Answers B, C, and D are incorrect because they are not symptoms associated with Lyme’s disease.

 

  1. Which of the following snacks would be suitable for the child with gluten-induced enteropathy?
    a) Soft oatmeal cookie
    b) Buttered popcorn
    c) Peanut butter and jelly sandwich
    d) Cheese pizza
    Answer B, Peanut butter and jelly sandwich
    Explanation. The client with gluten-induced enteropathy experiences symptoms after ingesting foods containing wheat, oats, barley, or rye. Corn or millet are substituted in the diet. Answers A, C, and D are incorrect because they contain foods that worsen the client’s condition.

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  1. A client with schizophrenia is receiving chlorpromazine (Thorazine) 400mg twice a day. An adverse side effect of the medication is:
    a) Photosensitivity
    b) Elevated temperature
    c) Weight gain
    d) Elevated blood pressure
    Answer B. Elevated temperature.
    Explanation. Neuroleptic malignant syndrome is an adverse reaction that is characterized by extreme elevations in temperature. Answers A and C are incorrect because they are expected side effects. Elevations in blood pressure are associated with reactions between foods containing tyramine and MAOI; therefore, answer D is incorrect.

 

  1. Which information should be given to the client taking phenytoin (Dilantin)?
    a) Taking the medication with meals will increase its effectiveness.
    b) The medication can cause sleep Nursing practice exam and rationalesMeet the team that makes it all possible disturbances.
    c) More frequent dental appointments will be needed for special gum care.
    d) The medication decreases the effects of oral contraceptives.
    Answer. C. More frequent dental appointments will be needed for special gum care.
    Explanation. Gingival hyperplasia is a side effect of phenytoin. The client will need more frequent dental visits. Answers A, B, and D do not apply to the medication; therefore, they are incorrect.

 

  1. A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client’s:
    a) Level of consciousness
    b) Gag reflex
    c) Urinary output
    d) Movement of extremities
    Answer, B. Gag reflex
    Explanation. The client’s gag reflex is depressed before having an EGD. The nurse should give priority to checking for the return of the gag reflex before offering the client oral fluids. Answer A is incorrect because conscious sedation is used. Answers C and D are not affected by the procedure; therefore, they are incorrect.

 

  1. Which instruction should be included in the discharge teaching for the client with cataract surgery?
    a) Over-the-counter eyedrops can be used to treat redness and irritation.
    b) The eye shield should be worn at night.
    c) It will be necessary to wear special cataract glasses.
    d) A prescription for medication to control post-operative pain will be needed.
    Answer B. The eye shield should be worn at night.
    Explanation. The eye shield should be worn at night or when napping, to prevent accidental trauma to the operative eye. Prescription eyedrops, not over-the-counter eyedrops, are ordered for the client; therefore, Answer A is incorrect. The client might or might not require glasses following cataract surgery; therefore, answer C is incorrect. Answer D is incorrect because cataract surgery is pain free.

 

  1. An 8-year-old is admitted with drooling, muffled phonation and a temperature of 102°F. The nurse should immediately notify the doctor because the child’s symptoms are suggestive of:
    a) Strep throat
    b) Epiglottitis
    c) Laryngotracheobronchitis
    d) Bronchiolitis
    Answer B. Epiglottitis
    Explanation. The child’s symptoms are consistent with those of epiglottitis, an infection of the upper airway that can result in total airway obstruction. Symptoms of strep throat, laryngotracheobronchitis, and bronchiolitis are different than those presented by the client; therefore, answers A, C, and D are incorrect.

 

  1. Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
    a) Offer the baby sterile water between feedings of formula
    b) Apply an emollient to the baby’s skin to prevent drying
    c) Wear a gown, gloves, and a mask while caring for the infant
    d) Place the baby on enteric isolation
    Answer A. Offer the baby sterile water between feedings of formula
    Explanation. Providing additional fluids will help the newborn eliminate excess bilirubin in the stool and urine. Answer B is incorrect because oils and lotions should not be used with phototherapy. Physiologic jaundice is not associated with infection; therefore, answers C and D are incorrect.

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  1. A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client’s plan of care?
    a) Weighing the client after she eats
    b) Having a staff member remain with her for 1 hour after she eats
    c) Placing high-protein foods in the center of the client’s plate
    d) Providing the client with child-size utensils
    Answer B. Having a staff member remain with her for 1 hour after she eats
    Explanation. Having a staff member remain with the client for 1 hour after meals will help prevent self-induced vomiting. Answer A is incorrect because the client will weigh more after meals, which can undermine treatment. Answer C is incorrect because the client will need a balanced diet and excess protein might not be well tolerated at first. Answer D is incorrect because it treats the client as a child rather than as an adult.

 

  1. According to Erickson’s stage of growth and development, the developmental task associated with middle childhood is:
    a) Trust
    b) Initiative
    c) Independence
    d) Industry
    Answer D. Industry
    Explanation. According to Erikson’s Psychosocial Developmental “Nursing practice exam and rationales” Meet the team that makes it all possible Theory, the developmental task of middle childhood is industry versus inferiority. Answer A is incorrect because it is the developmental task of infancy. Answer B is incorrect because it is the developmental task of the school-age child. Answer C is incorrect because it is not one of Erikson’s developmental stages.
  2. The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
    a) Tinnitus
    b) Nausea
    c) Ataxia
    d) Hypotension
    Answer B. Nausea
    Explanation. A side effect of bronchodilators is nausea. Answers A and C are not associated with bronchodilators; therefore, they are incorrect. Answer D is incorrect because hypotension is a sign of toxicity, not a side effect.

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  1. The 5-minute Apgar of a baby delivered by C-section is recorded as 9. The most likely reason for this score is:
    a) The mottled appearance of the trunk
    b) The presence of conjunctival hemorrhages
    c) Cyanosis of the hands and feet
    d) Respiratory rate of 20–28 per minute
    Answer C. Cyanosis of the hands and feet.
    Explanation. Although cyanosis of the hands and feet is common in the newborn, it accounts for an Apgar score of less than 10. Answer B suggests cooling, which is not scored by the Apgar. Answer B is incorrect because conjunctival hemorrhages are not associated with the Apgar. Answer D is incorrect because it is within normal range as measured by the Apgar.

 

  1. A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
    a) Periorbital edema
    b) Tenseness of the anterior fontanel
    c) Positive Babinski reflex
    d) Negative scarf sign
    Answer B. Tenseness of the anterior fontanel
    Explanation. Tenseness of the anterior fontanel indicates an increase in intracranial pressure. Answer A is incorrect because periorbital edema is not associated with meningitis. Answer C is incorrect because a positive Babinski reflex is normal in the infant. Answer D is incorrect because it relates to the preterm infant, not the infant with meningitis.

 

  1. A client with a bowel resection and returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suction is working properly?
    a) The client’s abdomen is soft.
    b) The client is able to swallow.
    c) The client has active bowel sounds.
    d) The client’s abdominal dressing is dry and intact.
    Answer A. The client’s abdomen is soft.
    Explanation. Nasogastric suction decompresses the stomach and leaves the abdomen soft and nondistended. Answer B is incorrect because it does not relate to the effectiveness of the NG suction. Answer C is incorrect because it relates to peristalsis, not the effectiveness of the NG suction. Answer D is incorrect because it relates to wound healing, not the effectiveness of the NG suction.

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  1. The nurse is teaching the client with insulin-dependent “Nursing practice exam and rationales” Meet the team that makes it all possible diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia?
    a) Tremulousness
    b) Slow pulse
    c) Nausea
    d) Flushed skin
    Answer A. Tremulousness
    Explanation. Tremulousness is an early sign of hypoglycemia. Answers B, C, and D are incorrect because they are symptoms of hyperglycemia.

37. Which of the following symptoms is associated with exacerbation of multiple sclerosis?
a) Anorexia
b) Seizures
c) Diplopia
d) Insomnia
Answer. C. Diplopia
Explanation. The most common sign associated with exacerbation of multiple sclerosis is double vision. Answers A, B, and D are not associated with a diagnosis of multiple sclerosis; therefore, they are incorrect.

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38. Which of the following conditions is most likely related to the development of renal calculi?
a) Gout
b) Pancreatitis
c) Fractured femur
d) Disc disease
Answer: Gout
Explanation. Gout and renal calculi are the result of increased amounts of uric acid. Answer B is incorrect because it does not contribute to renal calculi. Answers C and D can result from decreased calcium levels. Renal calculi are the result of excess calcium; therefore, answers C and D are incorrect.

39. Client with AIDS is admitted for treatment of wasting syndrome. “Nursing practice exam and rationales” Meet the team that makes it all possible Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
a) Thoroughly cooking all foods
b) Offering yogurt and buttermilk between meals
c) Forcing fluids
d) Providing small, frequent meals
Answer: Providing small, frequent meals.
Explanation. Providing small, frequent meals will improve the client’s appetite and help reduce nausea. Answer A is incorrect because it does not compensate for limited absorption. Foods and beverages containing live cultures are discouraged for the immune-compromised client; therefore, answer B is incorrect. Answer C is incorrect because forcing fluids will not compensate for limited absorption of the intestine.

40. The treatment protocol for a client with acute lymphocytic leukemia includes prednisone, methotrexate, and cimetadine. The purpose of the cimetadine is to:
a) Decrease the secretion of pancreatic enzymes
b) Enhance the effectiveness of methotrexate
c) Promote peristalsis
d) Prevent a common side effect of prednisone
Answer: Prevent a common side effect of prednisone
Explanation. A common side effect of prednisone is gastric ulcers. Cimetadine is given to help prevent the development of ulcers. Answers A, B, and C do not relate to the use of cimetadine; therefore, they are incorrect.

41. Which of the following meal choices is “Nursing practice exam and rationales” Meet the team that makes it all possible suitable for a 6-month-old infant?
a) Egg white, formula, and orange juice
b) Apple juice, carrots, whole milk
c) Rice cereal, apple juice, formula
d) Melba toast, egg yolk, whole milk
Answer. C. Rice cereal, apple juice, formula
Explanation. Rice cereal, apple juice, and formula are suitable foods for the 6-month-old infant. Whole milk, orange juice, and eggs are not suitable for the young infant; therefore, they are incorrect.

42. The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:
a) Rectus femoris muscle
b) Vastus lateralis muscle
c) Deltoid muscle
d) Dorsogluteal muscle
Answer: Vastus lateralis muscle
Explanation. The nurse should administer the injection in the vastus lateralis muscle. Answers A and C are not as well developed in the newborn; therefore, they are incorrect. Answer D is incorrect because the dorsogluteal muscle is not used for IM injections until the child is 3 years of age.

43. The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephotic syndrome. The nurse should:
a) Encourage the client to drink extra fluids
b) Request a low-protein diet for the client
c) Bathe the client using only mild soap and water
d) Provide additional warmth for swollen, inflamed joints
Answer: A. Encourage the client to drink extra fluids
Explanation. The client taking Cytoxan should increase his fluid intake to prevent hemorrhagic cystitis. Answers B, C, and D do not relate to the question; therefore, they are incorrect.

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44. The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?
a) Antabuse (disulfiram)
b) Romazicon (flumazenil)
c) Dolophine (methodone)
d) Ativan (lorazepam)
Answer: D. Ativan (lorazepam)
Explanation. Benzodiazepines are ordered for the client in alcohol withdrawal to prevent delirium tremens. Answer A is incorrect because it is a medication used in aversive therapy to maintain sobriety. Answer B is incorrect because it is used for the treatment of benzodiazepine overdose. Answer C is incorrect because it is the treatment for opiate withdrawal.

45. A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
a) 8 a.m.
b) 10 a.m.
c) 3 p.m.
d) 5 a.m.
Answer: 3 p.m.
Explanation. The client “Nursing practice exam and rationales” Meet the team that makes it all possible taking NPH insulin should have a snack midafternoon to prevent hypoglycemia. Answers A and B are incorrect because the times are too early for symptoms of hypoglycemia. Answer D is incorrect because the time is too late and the client would be in severe hypoglycemia.

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46. The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?
a) Alteration in comfort
b) Alteration in mobility
c) Alteration in skin integrity
d) Alteration in O2 perfusion
Answer: B. Alteration in mobility
Explanation. The client with a detached retina will have limitations in mobility before and after surgery. Answer A is incorrect because a detached retina produces no pain or discomfort. Answers C and D do not apply to the client with a detached retina; therefore, they are incorrect.