Nursing Interventions in Pediatric and Skilled Nursing: Best Practices, Exams of Nursing

Download Nursing Interventions in Pediatric and Skilled Nursing: Best Practices and more Exams Nursing in PDF only on Docsity! KAPLAN TRAINER EXAM LATEST EXAM QUESTIONS AND CORRECT ANSWERS | ALREADY GRADED A+ | LATEST UPDATE 2024 | VERIFIED ANSWERS A young adult patient constantly seeks attention from the nurses, stomping away from the nurses' station and pouting when requests are refused. Which of the following responses by the nurse is MOST appropriate? 1. Encourage the patient to establish trust with one staff person with whom therapeutic interventions should occur. 2. Give the patient unsolicited attention when the patient is exhibiting acceptable behaviors. 3. Ignore the patient when the patient exhibits attention-seeking behavior. 4. Rotate the staff so that the patient will learn to relate to more than one nurse. ------CORRECT ANSWER---------------Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) staff should use a consistent undivided approach (2) correct—reward non-attention-seeking behaviors by giving the patient unsolicited attention (3) remain nonjudgmental, carry out limit-setting (4) staff should use a consistent undivided approach Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) staff should use a consistent undivided approach (2) correct—reward non-attention-seeking behaviors by giving the patient unsolicited attention (3) remain nonjudgmental, carry out limit-setting (4) staff should use a consistent undivided approach ------CORRECT ANSWER---------------Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) tube would be irrigated with normal saline after the position of the tube was evaluated (2) correct—to confirm placement, nurse should aspirate and test the pH of the aspirate; results should be 0 to 4 (3) does not assess status of nasogastric tube (4) does not assess status of nasogastric tube A middle-aged woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician's office a month later for a routine checkup, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery? 1. "I have been helping my family deal with their feelings about the surgery." 2. "I have been having difficulty coping with the surgery and cry frequently." 3. "I have been unable to leave the house or talk to my friends about the surgery." 4. "I am doing just great since the surgery and have gone back to work at my job." ------CORRECT ANSWER---------------Strategy: Think about each answer choice. Does it describe an expected response to a crisis situation? (1) will not be able to help others this soon after surgery The nurse cares for clients on a medical/surgical unit and determines that several situations need to be addressed. Which of the following situations should the nurse attend to FIRST? 1. An angry daughter is threatening to sue the hospital because her confused mother fell out of bed during the previous shift. 2. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week. 3. The physician calls the unit to ask the nurse to obtain a client's latest serum electrolyte results from the lab. 4. The husband of a client reports to the nurse that his wife's nose began bleeding after she returned from radiation therapy. ------CORRECT ANSWER---------------Strategy: Determine the least stable situation (1) important issue that needs to be addressed after tending to the client who is bleeding (2) patients take priority over personnel issues (3) can be delegated to another staff member (4) correct—should assess client to determine amount and cause of bleeding A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority? 1. Administer oxygen. 2. Turn her to the right side. 3. Provide adequate hydration. 4. Start antibiotics. ------CORRECT ANSWER---------------Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not a priority (2) not a priority (3) correct—adequate hydration is a priority for any client with sickle cell crisis (4) not a priority A client diagnosed with a peptic ulcer has a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the nurse should caution the client about which of the following? 1. Sit up for at least 30 minutes after eating. 2. Avoid fluids between meals. 3. Increase the intake of high-carbohydrate foods. 4. Avoid eating large meals that are high in simple sugars and liquids. ------ CORRECT ANSWER---------------Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client should recline for 30 minutes after eating (2) fluids should be given between meals (3) intake of carbohydrates should be reduced along with highly spiced foods (4) correct—basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates The nurse is assigned to work with the parents of a child diagnosed with mental retardation. Which of the following should the nurse include in the care plan for the parents? 1. Interpret the grieving process for the parents. 2. Discuss the reality of institutional placement. 3. Assist the parents in making decisions and long-term plans for the child. 4. Perform a family assessment to assist in the planning of intervention. --- ---CORRECT ANSWER---------------Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) inappropriate before the assessment; action can be taken only when the circumstances are known (2) inappropriate before the assessment; action can be taken only when the circumstances are known (3) inappropriate before the assessment; action can be taken only when the circumstances are known (4) correct—assessment; this will help the nurse to know where the family is in regard to grieving, coping, etc. The nurse should explain to a client that glipizide (Glucotrol) is effective for diabetics who 1. can no longer produce any insulin. 2. produce minimal amounts of insulin. 3. are unable to administer their injections. 4. have a sustained decreased blood glucose. ------CORRECT ANSWER-- -------------Strategy: Think about each answer choice. (1) type 1 insulin-dependent diabetic is unable to produce insulin (2) correct—oral hypoglycemic agents are administered to type 2 (non- insulin-dependent) clients who are able to produce minimal amounts of insulin (3) type 1 diabetics who cannot administer their injections need alternate plans to be made for them to receive the injection from a family member (4) Glucotrol is administered for an increase in blood glucose 4. Codeine phosphate (Paveral). ------CORRECT ANSWER--------------- Strategy: Think about the action of each medication. (1) contains aspirin, contraindicated for persons with bleeding disorders (2) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders (3) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders (4) correct—analgesic used for moderate to severe pain The parents of a 1-month-old boy bring their son to the clinic for evaluation of a possible developmental dysplasia of the right hip. The nurse should observe for which of the following? 1. Limited adduction of the right leg. 2. Uneven gluteal fold and thigh creases. 3. Increase in length of the right limb. 4. Internal rotation of the right leg. ------CORRECT ANSWER--------------- Strategy: Think about each answer choice. (1) will see limited abduction (2) correct—folds and creases will be longer and deeper on affected side (3) will be decrease in limb length (4) may or may not see internal rotation The nurse administers terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. Which of the following actions should the nurse take FIRST? 1. Withhold the medication. 2. Decrease the dose by half. 3. Administer the medication. 4. Wait 15 minutes, and then recheck the rate. ------CORRECT ANSWER-- -------------Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires validation? No. Determine the outcome of each answer choice. (1) correct—maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness, tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on blood pressure (2) should never change a prescribed dosage of medication (3) should not be given with a high pulse rate (4) assessment; maternal tachycardia is a side effect of Brethine; medication should be withheld The nurse supervises the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room. 2. The staff removes a toy from the child's bed and takes it to the nurse's station. 3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack. 4. The staff uses standard precautions. ------CORRECT ANSWER----------- ----Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—contact precautions required for diapered or incontinent clients (2) do not remove toys from room, possibly contaminated (3) diet should be high in carbohydrates and protein and low in fat (4) contact precautions required in addition to standard precautions The nurse prepares to administer an injection of haloperidol decanoate (Haldol D) to a client. Which of the following actions by the nurse is MOST appropriate? 1. Massage the injection site. 2. Give deep IM in a large muscle mass. 3. Use a 2 inch 25 gauge needle. 4. Administer the medication in divided doses. ------CORRECT ANSWER-- -------------Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should not be done because medication is very irritating to subcutaneous tissue (2) correct—medication is very irritating to subcutaneous tissue (3) should use a 2 inch 21 gauge needle (4) should administer in single dose; patient should lie in recumbent position for one-half hour after administration of IM haloperidol decanoate The young adult is brought to the ED after a MVA. A closed head injury with suspected subdural hematoma is diagnosed. The client is alert and answers questions appropriately and reports a severe headache. The nurse questions which order? 1. Promethazine (Phenegran) 25 mg IM 3 h. 2. Morphine sulfate 10 mg IM q3 4h. 3. Docusate sodium (Colace) 50 mg PO bid. 4. Ranitidine (Zantac) 50 mg IVPB q12h. ------CORRECT ANSWER---------- -----Morphine sulfate 10 mg IM q3 4h. 1. Talk with the client about how the client is feeling 2. Instruct the nursing assistant to sit with the client while the client eats 3. Contacts the physician to obtain an order for an antacid 4. Evaluate the most recent vital signs recorded in the chart ------ CORRECT ANSWER---------------Talk with the client about how the client is feeling The nurse prepares a patient for a c-section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preop medication given before a c-section? 1. Contains a lower overall dosage of medication than is given before general surgery 2. Contains a lower amounts of sedatives and hypnotics than are given before general surgery 3. Contains lower amounts of narcotics than are given before general surgery 4. Contains medications similiar in type and dosages to those given before general surgery ------CORRECT ANSWER---------------Contains lower amounts of narcotics than are given before general surgery The nurse cares for patient placed in balanced suspension traction with a Thomas splint and Pearson attachment because of a fractured right femur. The nurse notes that the patient's left leg is externally rotated. The nurse should take which of the following actions? 1. Place a trochanter roll on the outer aspect of the thigh 2. Perform resistive range of motion of the left leg 3. Adduct and internally rotate the left leg 4. Instruct the patient to maintain the left leg in a neutral position ------ CORRECT ANSWER---------------Place a trochanter roll on the outer aspect of the the thigh The nurse prepares a 5-year-old child for surgery. The nurse notes that the child's parents are divorced and have joint legal custody. The informed consent for surgery has been signed by the mother. Which of the following actions by the nurse is BEST? 1. Notify the physician 2. Inform surgery 3. Contact the father to obtain consent 4. Continue the child's preop preparation ------CORRECT ANSWER---------- -----Continue the child's preop preparation The nurse cares for clients on the neurology unit. What is the MOST appropriate action for the nurse to take after noting that a client suddenly develops a fixed and dilated pupil? 1. Reassess in 5 minutes 2. Check the client's visual acuity 3. Lower the head of the client's bed 4. Contact the physician ------CORRECT ANSWER---------------Contact the physician A mother brings her 2-year-old to the pediatrician's office. Which of the following symptoms suggests to the nurse that the child has strabismus? 1. The child places his head close to the table when drawing 2. The child rubs his eyes frequently 3. The child closes one eye to see a poster on the wall 4. The child is unable to see objects in the periphery of his visual field ------ CORRECT ANSWER---------------The child closes one eye to see a poster on the wall The nurse administers morphine 6 mg IV push for a patient for postop pain. Following administration of the drug, the nurse observes the following: BP 100/68, pulse 68, respirations 8, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 1. Allow the client to sleep undisturbed 2. Administer oxygen via face mask or nasal prongs 3. Administer naloxone (Narcan) 4. Place epinephrine 1:1, 1,000 at the bedside ------CORRECT ANSWER--- ------------Administer naloxone (Narcan) The school nurse instructs a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates further teaching is necessary? 1. "The poison control center number is stored on all the phones in our house." 2. "I should induce vomiting if my child swallows lighter fluid." 3. "If I carry medication in my purse, it should be in a child-proof container." 4. "Proper storage is the key to poison prevention in the home." ------ CORRECT ANSWER---------------"I should induce vomiting if my child swallows lighter fluid." The nurse cares for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 1. Take the client to the dining room 1:1 supervision. 2. Inform the client that he may go to the dining room when he controls his behavior. 3. Hold the meal until the client is able to come out of seclusion. 4. Serve the meal to the client in the seclusion room. ------CORRECT ANSWER---------------Serve the meal to the client in the seclusion room Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of the body? 1. Encourage the patient o establish trust with one staff person with whom therapeutic interventions should occur 2. Give the patient unsolicited attention when the patient is exhibiting acceptable behaviors 3. Ignore the patient when the patient exhibits attention-seeking behavior 4. Rotate the staff so that the patient will learn to related to more than one nurse ------CORRECT ANSWER---------------Give the patient unsolicited attention when the patient is exhibiting acceptable behaviors After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions is MOST appropriate? 1. Irrigate the nasogastric tube with distilled water 2. Aspirate the gastric contents with a syringe 3. Administer an antiemetic medicine 4. Insert a new nasogastric tube ------CORRECT ANSWER--------------- Aspirate the gastric contents with a syringe A middle-aged woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician's office a month later for a routine checkup, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery? 1. "I have been helping my family deal with their feelings about the surgery." 2. "I have been having difficulty coping with the surgery and cry frequently." 3. "I have been unable to leave the house or talk to my friends about the surgery." 4. "I am doing just great since the surgery and have gone back to work at my job." ------CORRECT ANSWER---------------"I have been having difficulty coping with the surgery and cry frequently." The nurse cares for clients in outpatient surgery. The mother of a 4-year- old asks the nurse how to prepare her daughter for eye surgery. Which of the following statements by the nurse is BEST? 1. "Draw a picture of the eye to explain what will happen." 2. "Tell your daughter that the procedure will take 1 hour." 3. "Use dolls or puppets to explain how to get ready for surgery." 4. "Read an age-appropriate illustrated book about eye surgery to your daughter." ------CORRECT ANSWER---------------"Use dolls or puppets to explain how to get ready for surgery." A client at 32 weeks' gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, indicates a possible complication? 1. The client's urine test is positive for glucose and acetone 2. The client has 1+ pedal edema in both feet at the end of the day 3. The client complains of an increase in vaginal discharge 4. The client says that she feels pressure against her diaphragm when the baby moves ------CORRECT ANSWER---------------The client's urine test is positive for glucose and acetone A nurse cares for a client diagnosed with metastatic ovarian cancer admitted for nausea and vomiting. The healthcare provider orders parenteral nutrition (PN), a nutritional consult, and diet recall. Which is the BEST indication that the client's nutritional status has improved after 4 days? 1. The client eats most of the food served 2. The client has gained 1 pound since admission 3. The client's albumin level is 4.0 g/dL 4. The client's hemoglobin is 8.5 g/dL ------CORRECT ANSWER--------------- The client's albumin level is 4.0 g/dL The nurse cares for clients on a medical/surgical unit. The nurse determines several situations need to be addressed. In which order will the nurse address the situations? 1. The client's spouse reports the client's nose is bleeding 2. The healthcare provider asks the nurse to obtain the client's latest serum electrolytes 3. An angry child is threatening to sue the hospital because the confused parent fell out of bed 4. The nursing assistive personnel is 30 minutes late for the third time ------ CORRECT ANSWER---------------1, 3, 2, 4 A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority? 1. Administer oxygen 2. Turn her to the right side 3. Provide adequate hydration 4. Start antibiotics ------CORRECT ANSWER---------------Provide adequate hydration A client diagnosed with a peptic ulcer has a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the nurse should caution the client about which of the following? 1. Sit up for at least 30 minutes after eating 2. Avoid fluids between meals 3. Increase the intake of high-carbohydrate foods 4. Avoid eating large meals that are high in simple sugars and liquids ------ CORRECT ANSWER---------------Avoid eating large meals that are high in simple sugars and liquids 2. Uneven gluteal fold and thigh creases 3. Increase in length of the right limb 4. Internal rotation of the right leg ------CORRECT ANSWER--------------- Uneven gluteal fold and thigh creases The nurse administers terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. Which of the following actions should the nurse take FIRST? 1. Withhold the medication 2. Decrease the dose by half 3. Administer the medication 4. Wait 15 minutes, and then recheck the rate ------CORRECT ANSWER---- -----------Withhold the medication The nurse supervises the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room 2. The staff removes a toy from the child's bed and takes it to the nurse's station 3. The staff offers the child french fries and a vanilla milkshake for a mid afternoon snack 4. The staff uses standard precaution ------CORRECT ANSWER--------------- The child is placed in a private room The nurse prepares to administer an injection of haloperidol decanoate (Haldool D) to a client. Which of the following actions by the nurse is MOST appropriate? 1. Massage the injection 2. Give deep IM in a large muscle mass 3. Use a 2 inch 25 gauge needle 4. Administer the medication in divided doses ------CORRECT ANSWER---- -----------Give deep IM in a large muscle mass The nurse monitors a client's EKG strip and notes coupled premature ventricular contractions greater than 10 per minute. The nurse should expect to administer which of the following? 1. Atropine sulfate (Atropine) IV 2. Isoproterenol (Isuprel) IV 3. Verapamil (Calan) IV 4. Lidocaine hydrochloride (Xylocaine) IV ------CORRECT ANSWER---------- -----Lidocaine hydrochloride (Xylocaine) IV The home care nurse visits a client with newly diagnosed type 1 diabetes. The healthcare provider's orders include a 1,200-calorie ADA diet, 15 units of intermediate-acting insulin before breakfast, and checking blood glucose QID. At 1700, the client performs a blood glucose analysis. The result is 50 mg/dL. The nurse observes for which information? 1. Confusion; cold, clammy skin; and an elevated pulse 2. Lethargy; hot, dry skin; rapid deep respirations 3. Alert and cooperative, blood pressure and pulse within normal limits 4. SOA, distended neck veins, and a bounding pulse of 96 ------CORRECT ANSWER---------------Confusion; cold, clammy skin; and an elevated pulse The nurse's INITIAL priority when managing a physically assaultive client is which of the following? 1. Restrict the client to the room 2. Place the client under one-to-one supervision 3. Restore the client's self-control and prevent further loss of control 4. Clear the immediate area of other clients to prevent harm ------ CORRECT ANSWER---------------Restore the client's self-control and prevent further loss of control The nurse observes an LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, indicates an understanding of proper technique? 1. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes 2. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing. 3. The nurse packs wet gauze into the incision without overlapping it onto the skin 4. The old dressing is saturated with sterile saline before it is removed ------ CORRECT ANSWER---------------The nurse packs wet gauze into the incision without overlapping it onto the skin The nurse assesses the development of a 3-month-old boy in the well-child clinic. Which of the following behaviors, if observed by the nurse, is UNEXPECTED? 1. The boy holds his head erect when sitting on the examination table 2. The boy tries to grasp a toy just out of reach 3. The boy turns his head to try to locate a sound 4. The boy smiles spontaneously when he sees his mother ------CORRECT ANSWER---------------The boy tries to grasp a toy just out of reach An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions is MOST beneficial in decreasing the client's pain during ambulation? 1. Perform passive ROM exercises before walking 2. Encourage partial weight bearing while ambulating 3. Immobilize the extremity between activities 1. Steadily increasing vital signs 2. Mild tremors and irritability 3. Decreased respirations and disorientation 4. Stomach distress and inability to sleep ------CORRECT ANSWER---------- -----Steadily increasing vital signs The nurse in the outpatient clinic instructs the mother of a school-aged child diagnosed with asthma how to prevent future asthmatic attacks. The nurse is MOST concerned if the mother states which of the following? 1. "My son plays the tube in the grade school band." 2. "My son loves to help his dad rake leaves." 3. "My son participates in after-school activities 3 days a week." 4. "My son walks 1 mile to school everyday with his friends." ------ CORRECT ANSWER---------------"My son loves to help his dad rake leaves." The nurse cares for a postcholecystectomy client who had the T-tube removed this morning. Two hours after removal of the T-tube, the nurse notes that the 4 x 4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions? 1. Remove the dressing, and replace it with a more absorbent dressing. 2. Collect a culture and sensitivity specimen of the drainage. 3. Observe the wound for dehiscence 4. Reinforce the dressing with an 8 x 10 dressing ------CORRECT ANSWER---------------Remove the dressing, and replace it with a more absorbent dressing. The nurse identifies which of the following is MOST likely to help the family of an emotionally disturbed client manage behaviors at home after discharge from inpatient treatment? 1. Refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups 2. Provide the family with pamphlets that describe the desired action and side effects of medications the client is taking 3. Tell the family that it is not their fault that the client behaves inappropriately 4. Involve the family in the assessment of the client when he/she is first admitted to the hospital ------CORRECT ANSWER---------------Refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups A child returns to the recovery room after a bronchoscopy. The nurse should position the client in which of the following positions? 1. Semi-Fowler's position 2. Prone with the head turned to the side 3. Head of the bed elevated 45 degrees with the neck extended 4. Supine with the head in the midline position ------CORRECT ANSWER--- ------------Semi-Fowler's position The nurse provides care for a client diagnosed with an abruptio placenta. Which is the priority nursing diagnosis for this client? 1. infection 2. Fetal demise 3. Altered tissue perfusion 4. Fluid volume deficit ------CORRECT ANSWER---------------Fluid volume deficit An elderly client returns to the room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include which of the following? 1. High-protein, low-residue diet 2. Position the client on unaffected side 3. Exercise the client's arms and legs 4. Encourage the client to cough and deep breathe ------CORRECT ANSWER---------------Encourage the client to cough and deep breathe The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse considers the assignments appropriate if the nursing assistant is assigned to care for which of the following clients? 1. A client diagnosed with Alzheimer's requiring assistance with feeding 2. A client diagnosed with osteoporosis complaining of burning on urination 3. A client diagnosed with scleroderma receiving a tube feeding 4. A client diagnosed with cancer who has Cheyne-Stokes respirations ----- -CORRECT ANSWER---------------A client diagnosed with Alzheimer's requiring assistance with feeding The client is admitted with a diagnosis of subdural hematoma and cerebral edema after a motorcycle accident. Which symptoms should the nurse expect to see initially? (Select all that apply) 1. Decreasing level of consciousness 2. Fine tremors of the extremities 3. Decerebrate posturing 4. Ipsilateral pupil dilation 5. Headache 6. Tonic/Clonic seizures ------CORRECT ANSWER---------------Decreasing level of consciousness, ipsilateral pupil dilation, & headache The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis. Which of the following observations is expected with scoliosis? 1. The girl's thoracic area is asymmetrical 2. The girl walks with a waddling gait 3. The girl's lower legs are edematous 1. Encourage the client to verbalize feelings 2. Assess for physical trauma 3. Provide privacy for the client during the interview 4. Help the client identify and mobilize resources and support systems. ----- -CORRECT ANSWER---------------Assess for physical trauma The client returns to the room following a myelogram. The nursing care plan should include which interventions? (Select all that apply) 1. Encourage oral fluid intake 2. Maintain prone position for 12 hours 3. Lie flat for several hours 4. Monitor vital and neurological signs 5. Encourage the client to ambulate after the procedure 6. Evaluate the client's distal pulses on the affected side. ------CORRECT ANSWER---------------Encourage oral fluid intake, lie flat for several hours, & monitor vital and neurological signs The nurse in the well-baby clinic observes a group of children. The nurse notes that one child is able to sit unsupported, play "peek-a-boo" with the nurse and is starting to say "mama" and "dada". The nurse determines the infant's behaviors are consistent with which of the following ages? 1. 5 months of age 2. 6 months of age 3. 9 months of age 4. 12 months of age ------CORRECT ANSWER---------------9 months of age The nurse performs triage on a group of clients in the ED. Which of the following clients should the nurse see FIRST? 1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can 2. A 19-year-old with a fever of 103.8 degrees who is able to identify her sister but not the place and time 3. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain 4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL ------CORRECT ANSWER---------------A 19-year-old with a fever of 103.8 degrees who is able to identify her sister but not the place and time The client develops right-sided heart failure. The nurse expects to observe which symptoms? (Select all that apply) 1. Increased respiration with exertion 2. Peripheral edema and anorexia 3. Polycythemia 4. Cough producing large amount of thick, yellow mucous 5. Twitching of extremities 6. Distended neck veins ------CORRECT ANSWER---------------Peripheral edema and anorexia, Polycythemia, & distended neck veins A client takes gemfibrozil. It is most important for the nurse to monitor which lab value? 1. Serum creatinine 2. Erythrocyte sedimentation rate (ESR) 3. Asparate aminotransferase (AST) 4. Arterial blood gases (ABG) ------CORRECT ANSWER--------------- Asparate aminotransferase (AST) The physician orders ranitidine hydrochloride (Zantac) 150 mg PO daily for the client. The nurse should advise the client the BEST time to take the medication is which of the following? 1. Prior to breakfast 2. With dinner 3. With food 4. At hour of sleep ------CORRECT ANSWER---------------At hour of sleep After a client has a positive Chlamydia trachoma's culture, the client and partner return for counseling. It is MOST important for the nurse to ask which of the following questions? 1. "Do you have contracts identify?" 2. "What is your understanding regarding how chlamydia is transmitted?" 3. "Do you have questions about the culture and its validity?" 4. "Do you have allergies to the medications?" ------CORRECT ANSWER--- ------------"What is your understanding regarding how chlamydia is transmitted?" A client diagnosed with bipolar disorder receives haloperidol (Haldol) 2 mg PO TID. The client tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge?" 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication." ------CORRECT ANSWER---------------"You are experiencing a side effect of Haldol." An elderly client returns from surgery after a hysterectomy due to cancer, and there is an order for anti embolism stockings. Which of the following should the nurse include when instructing the client about wearing the support stockings?" 1. "Wear the stockings when your legs cramp." 2. "Wear the stockings during your hospitalization." 3. "Put the stockings on prior to going to bed." A 4-month-old child is admitted with a tentative diagnosis of meningitis. To confirm the diagnosis, a lumbar puncture is ordered. While assisting the physician with the procedure, it is MOST important for the nurse to take which of the following actions? 1. Appropriately restrain the child 2. Instruct the parents about the procedure 3. Provide support to the child 4. Elevate the head of the bed ------CORRECT ANSWER--------------- Appropriately restrain the child A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses. The client's history indicates an onset of menses at age 14, para 2 gravid 2, and regular periods every 28 to 30 days. The client is divorced and works full-time as a bank teller. The nurse identifies the MOST probable cause of the client's symptom is which of the following? 1. Emotional trauma and stress 2. Onset of menopause 3. Presence of uterine fibroids 4. Possible tubal pregnancy ------CORRECT ANSWER---------------Onset of menses The nurse cares for a child several hours after the application of a hip spica cast. The patient turns on the call list and complains of pain in the left foot. Which of the following actions should the nurse take FIRST? 1. Elevate the left leg on two pillows 2. Palpate the cast for warmth and wetness 3. Administer pain medication as ordered 4. Check the blanching signs on both feet ------CORRECT ANSWER--------- ------Check the blanching sign on both feet The nurse cares for clients in the skilled nursing facility. In which order does the nurse see the clients? 1. The client admitted for a stroke whose prescription for warfarin expired two days ago 2. The client who has dysuria and foul-smelling, cloudy, dark amber urine 3. The client diagnosed with immunosuppression and who has not received an influence immunization 4. The client who received IV morphine and is transferred with an order for acetaminophen with codeine ------CORRECT ANSWER---------------1, 4, 2, 3 An extremely agitated client receives haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. It is MOST important for the nurse to take which of the following actions? 1. Monitor BP every 30 minutes 2. Remain at the client's side to provide reassurance 3. Tell the client the name of the medication and its effects 4. Assess for anticholinergic effects of the medication ------CORRECT ANSWER---------------Monitor BP every 30 minutes The newborn infant of an HIV-positive mother is admitted to the nursery. The nurse should include which of the following in the plan of care? 1. Standard precautions 2. Testing for HIV 3. Transfer to an acute care nursing facility 4. Place the infant in isolation ------CORRECT ANSWER--------------- Standard precautions The nurse cares for a client receiving IV antibiotics for 4 days. Which of the following should cause the nurse to be concerned about post infusion phlebitis? 1. Tenderness at the IV site 2. Increased swelling at the insertion site 3. Reddened area or red streaks at the site 4. Leaking of fluid around the IV catheter ------CORRECT ANSWER---------- -----Reddened area or red streaks at the site The nurse counsels an elderly client who comes to the outpatient clinic for a routine examination. The history indicates the client takes a laxative tablet twice a day and a laxative suppository once a day. The nurse should suspect which of the following about the client? 1. The client has an anal fixation resulting from recent loss of a spouse 2. The client is depressed because of alterations in intestinal absorption and excretion 3. The client is experiencing excessive concern with body function because of physical changes 4. The client has regressed because of a fear of losing the ability to have bowel movements ------CORRECT ANSWER---------------The client is experiencing excessive concern with body function because of physical changes The nurse performs discharge teaching for a client diagnosed with Addison's disease. It is MOST important for the nurse to instruct the client about which of the following? 1. Signs and symptoms of infection 2. Fluid and electrolyte balance 3. Seizure precautions 4. Steroid replacement ------CORRECT ANSWER---------------Steroid replacement The nurse care plans for a client on bed rest. To promote evening rest and sleep for this client, it is MOST important for the nurse to take which of the following actions? 1. Provide privacy 2. Give back rubs at bedtime 3. Assist with a bath every day 4. Encourage daytime activities ------CORRECT ANSWER--------------- Encourage daytime activities Which nursing intervention is a priority in preventing complications after a cesarean birth? 1. Turn, cough, and deep breathe 2. Limit fluid intake 3. Supply a high-carbohydrate diet 4. Evaluate skin integrity ------CORRECT ANSWER---------------Turn, cough, and deep breathe The nurse cares for a client just returning to the post surgical unit following abdominal surgery for cancer of the colon. It is MOST appropriate for the nurse to take which of the following actions? 1. Determine the stage of loss and grief 2. Analyze the quality and quantity of pain 3. Instruct the client to cough and deep breathe 4. Ask the client to lift his head off the pillow ------CORRECT ANSWER------ ---------Ask the client to list his head off the pillow A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parents would be that the client: 1. Acknowledges willing participation in an incestuous relationship 2. Re-establishes a trusting relationship with his/her other parent 3. Verbalizes that he/she is not responsible for the sexual abuse 4. Describes feelings of anxiety when speaking about sexual abuse ------ CORRECT ANSWER---------------Verbalizes that he/she is not responsible for the sexual abuse A patient is returned to the room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration 2. Calcium glutinate for IV administration 3. Tracheostomy setup 4. Suction equipment ------CORRECT ANSWER---------------Potassium chloride for IV administration The nurse knows that the client diagnosed with drug-induced Cushing's syndrome should FIRST be instructed about which of the following? 1. Compression fractures from increased calcium excretion 2. Decreased resistance to stress 3. The schedule for gradual withdrawal of the drug 4. Changes in secondary sex characteristics ------CORRECT ANSWER----- ----------The schedule for gradual withdrawal of the drug Which of the following is a correct instruction by the nurse to the parent of a 4-year-old client regarding collecting a specimen to be tested for pinworms? 1. Collect the specimen 30 minutes after the child falls asleep at night 2. Save a portion of the child's first stool of the day and take it to the physician's office immediately 3. Collect the specimen in the early morning with a piece of Scotch tape touched to the child's anus 4. Feed the child a high-fat meal, and then save the first stool following the meal ------CORRECT ANSWER---------------Collect the specimen in the early morning with a piece of Scotch tape touched to the child's anus The client is being discharged with sublingual nitroglycerin. Which information should the nurse give to the client? 1. Take the medication 5 minutes after the pain has started 2. Stop taking the medication if a stinging sensation is absent 3. Take the medication on an empty stomach 4. Avoid abrupt changes in posture ------CORRECT ANSWER--------------- Avoid abrupt changes in posture The nurse provides care for a client who has a positive cytomegalovirus (CMV) titer. Which is the MOST appropriate action for the nurse to take while caring for the client? 1. Instruct the client to wear a mask when outside the room 2. Wear eyewear when emptying a urinary drainage bag 3. Place the client in a private room 4. Keep the client's door shut at all times ------CORRECT ANSWER---------- -----Wear eyewear when emptying a urinary drainage bag A 13-year-old male diagnosed with muscular dystrophy develops nocturne. The client wants to know about external catheters. The nurse should base the response on which of the following statements? 1. The catheter can be removed during the day 2. External catheters are uncomfortable 3. The catheter would drain into a bag at the bedside or on the wheelchair 4. The external condom catheter is easy to apply ------CORRECT ANSWER---------------The catheter can be removed during the day The nurse cares for clients on the medical/surgical unit. The nurse identifies which of the following clients is MOST at risk for developing herpes zoster? 1. A 19-year-old with a broken tibia in Buck's traction 2. A 50-year-old with a diabetic foot ulcer 3. A 62-year-old heart transplant with suspected rejection 4. An 84-year-old with chronic obstructive pulmonary disease ------ CORRECT ANSWER---------------A 62-year-old heart transplant with suspected rejection The nurse cares for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient in which of the following positions? 1. With the client's neck in a midline position and the head of the bed elevated 30 degrees 2. Side-lying with the client's head extended and the bed flat 3. In high Fowler's position with the client's head maintained in a neutral position 4. In semi-Fowler's position with the client's head turned to the side ------ CORRECT ANSWER---------------With the client's neck in a midline position and the head of the bed elevated 30 degrees A client at the health clinic asks the nurse is a "flu shot" should be obtained. Which health history factors are reasons for the client to receive the influenza vaccine? (Select all that apply) 1. The client is 69-years-old 2. The client plays poke with a group every week 3. The client volunteers at a preschool 4. The client lives with two large dogs 5. The client and sibling share an apartment 6. The client had bronchitis twice last year ------CORRECT ANSWER-------- -------The client is 69-years-old, the client plays poker with a group every week, the client volunteers at a preschool, & the client had bronchitis twice last year The nurse cares for clients in the pediatric clinic. The mother of a child calls the nurse to say that after administering Dimetane-DC cough syrup to her child, her child becomes very excitable and restless. Which of the following actions by the nurse is MOST appropriate? 1. Report the child's behavior to the physician to alert the physician to the potential need for a change in medication 2. Instruct the mother to administer half the ordered amount in all future doses to limit this behavioral response 3. Instruct the mother to give the child a glass of warm milk to dilute any medication left in the stomach 4. Chart the client's response to the medication, and alert the staff about the mother's phone call ------CORRECT ANSWER---------------Report the child's behavior to the physician to alert the physician to the potential need for a change in medication A young adult asks the nurse in the AIDS clinic what to do for the multiple small, painless purplish-brown spots on the right leg and ankle. The nurse should instruct the client to take which of the following actions? 1. Clean the spots carefully with soap and warm water twice a week, and cover them with a sterile dressing 2. Clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine), and leave them open to the air 3. Shower daily using a mild soap from a pump dispenser, and pat the skin dry 4. Soak in a warm tub three times a day, and rub the spots with a washcloth ------CORRECT ANSWER---------------Shower daily using a mild soap from a pump dispenser, and pat the skin dry The nurse knows which of the following observations is indicative of chronic cocaine use? 1. Nasal septum disruption 2. Lack of coordination 3. Constricted pupils 4. Craving for sweets and carbohydrates ------CORRECT ANSWER---------- -----Nasal septum disruption Which of the following statements should the nurse make to a client who is going to self-administer continuous ambulatory peritoneal dialysis (CAPD) at home? 1. "Check your weight daily." 2. "Maintain clean technique at all times during the procedure." 3. "Milk the catheter to encourage extra fluid to be removed from the abdomen." 4. "Eat a well-balanced, low-protein diet." ------CORRECT ANSWER---------- -----"Check your weight daily." Which of the following nursing interventions is MOST important for a client diagnosed with rheumatoid arthritis? 1. Provide support to flexed joints with pillows and pads 2. Position the client on the abdomen several times a day 3. Massage the inflamed joints with creams and oils 4. Assist the client with heat application and ROM exercises ------ CORRECT ANSWER---------------Assist the client with heat application and ROM exercises A nonstress test is scheduled for a client at 34 weeks' gestation who developed hypertension, periorbital edema, and proteinuria. Which of the A client receives parenteral nutrition (PN). To determine the client's tolerance of this treatment, the nurse should assess which physiological sign? 1. A significant increase in pulse rate 2. A decrease in diastolic BP 3. Temperature in excess of 98.6 4. Urine output of at least 30 mL/hr ------CORRECT ANSWER--------------- Urine output of at least 30 mL/hr The visiting nurse instructs a client how to use esophageal speech following a total laryngectomy. Which of the following actions, if performed by the client, indicates teaching is effective? 1. The client swallows air and then eructates it while forming words with his mouth 2. The client places a battery-powered device against the side of his neck 3. The client places a finger over the tracheostomy, forcing air up through the vocal cords 4. The client covers the stoma in the tracheoesophageal fistula and moves his lips ------CORRECT ANSWER---------------The client swallows air and then eructates it while forming words with his mouth The nurse cares for a client who has just returned to his room after a scleral buckling procedure was completed to repair a detached retina. Which of the following is the MOST important nursing action? 1. Remove reading material to decrease eyestrain 2. Ask the client if he is nauseated 3. Assess color of drainage from the affected eye 4. Maintain sterility during Q3H saline eye irrigations ------CORRECT ANSWER---------------Ask the client is he is nauseated A 4-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105 degrees. The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding indicates an increase in intracranial pressure? 1. Positive Babinski 2. High-pitched cry 3. Bulging posterior fontanels 4. Pinpoint pupils ------CORRECT ANSWER---------------High-pitched cry A client tells the nurse, "I have taken acetaminophen every day for 5 months." The nurse is MOST concerned by which lab result? 1. Aspartate aminotransferase (AST) 60 units/L and alanine aminotransferase (ALT) 48 units/L 2. Hemoglobin (Hgb) 16.2 g/dL and hematocrit (Hct) 46% 3. White blood cell count (WBC) 7,000/mm 4. Blood urea nitrogen (BUN) 11 mg/dL ------CORRECT ANSWER------------ ---Aspartate aminotransferase (AST) 60 units/L and alanine aminotransferase (ALT) 48 units/L The nurse teaches a well-baby class to a group of parents with toddlers. The nurse should encourage the parents to do which of the following? 1. Exercise their children daily 2. Use a playpen whenever possible 3. Provide a safe play area for their children 4. Teach their children noncompetitive activities ------CORRECT ANSWER- --------------Provide a safe play area for their children A 2-year-old is admitted to the pediatric unit with numerous bruises, a fractured left humerus, and several lacerations with unexplained origin. The nurse identifies which of the following as a priority nursing action? 1. Report the findings to the child protection agency 2. Share this information with other health care professionals 3. Document this information in the chart 4. Share the information with the pediatric social worker ------CORRECT ANSWER---------------Report the findings to the child protection agency An elderly patient is admitted to the hospital for treatment of a fractured femur. The patient's spouse tells the nurse that the patient has become very hard of hearing. The nurse might expect the patient to exhibit which of the following characteristics? 1. The patient prefers to be left alone 2. The patient appears suspicious of strangers 3. The patient communicates best in writing 4. The patient's speech is difficult to understand ------CORRECT ANSWER- --------------The patient appears suspicious of strangers The nurse cares for a client with type 1 diabetes. The client receives nasal oxygen at 4 L/min. The student nurse reports that the client has pulled out the nasogastric tube and is picking at the bed covers. The client's BP is 150/90 and pulse is 90. Which of the following actions by the nurse is MOST appropriate? 1. Obtain a pulse oximetry reading 2. Apply soft wrist restraints 3. Reorient the client to person and place 4. Determine the client's blood glucose level ------CORRECT ANSWER------ ---------Obtain a pulse oximetry reading To maintain client safety, the nurse should have which of the following equipment readily available when inserting an Ewald tube? 1. Suction equipment 2. BP cuff 1. Severe cravings, depression, fatigue, hypersomnia 2. Depression, disturbed sleep, restlessness, disorientation 3. N/V, tachycardia, coarse tremors, seizures 4. Runny nose, yawning, fever, muscle and joint pain, diarrhea ------ CORRECT ANSWER---------------Runny nose, yawning, fever, muscle and joint pain, diarrhea The nurse cares for a 26-year-old woman immediately after delivery of 8-lb, 4-oz baby girl. The patient's history indicates that she was diagnosed with type 1 diabetes at age 12. The nurse expects which of the following changes to occur in the patient? 1. The blood sugar will fall because of a sudden decrease in insulin requirements 2. The blood sugar will rise because of a rapid decrease in circulating insulin 3. The blood sugar will gradually rise because of a decreased level of metabolic stress 4. The blood sugar will gradually fall because of a decrease in food intake - -----CORRECT ANSWER---------------The blood sugar will fall because of a sudden decrease in insulin requirements When caring for a client with a nursing diagnosis of rape trauma syndrome, acute phase, the nurse should consider which of the following the MOST important initial goal for the client? 1. Within 3 to 5 months, the client will state that the memory of the event is less vivid and distressing 2. The client will indicate a willingness to keep a follow-up appointment with a rape crisis counselor 3. The client will be able to describe the results of the physical examination that was completed in the emergency room 4. The client will begin to express her reactions and feelings about the assault before leaving the emergency room ------CORRECT ANSWER------- --------The client will begin to express her reactions and feelings about the assault before leaving the emergency room The nurse leads an in-service education class on legal issues. The nurse identifies which of the following acts constitutes battery? 1. The nurse restrains an agitated, confused patient in the ED with a physician's order 2. The nurse chases a patient who tries to run away while outside for a walk 3. The nurse holds the arms of a manic patient who struck her while the nurse calls for assistance 4. The nurse administers an injection to a schizophrenic patient who refuses to take the medication by mouth because he believes it is poison --- ---CORRECT ANSWER---------------The nurse administers an injection to a schizophrenic patient who refuses to take the medication by mouth because he believes it is poison A young adult is involved in a motorcycle accident and is brought to the emergency room. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders? 1. "Promethazine (Phenergan) 25 mg IM 3 h." 2. "Morphine sulfate 10 mg IM q3 4h." 3. "Docusate sodium (Colace) 50 mg PO bid." 4. "Ranitidine (Zantac) 50 mg IVPB q12h." ------CORRECT ANSWER------- --------Strategy: "Question which of the following orders" indicates an incorrect order. (1) H1 receptor blocker, used as an antiemetic (2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure (3) stool softener, used for an immobilized patient (4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers The nurse returns to the desk and finds four phone messages to return. Which of the following messages should the nurse return FIRST? 1. A woman in the first trimester of pregnancy complains of heartburn. 2. A man complains of heartburn that radiates to the jaw. 3. A woman complains of hot flashes and difficulty sleeping. 4. A boy complains of knee pain after playing basketball. ------CORRECT ANSWER---------------Strategy: Determine the least stable client. (1) caused by reflux of gastric contents into esophagus, treatment is small, frequent meals, don't consume fluids with food, don't wear tight clothing (2) correct—indicates chest pain, needs to seek medical attention immediately (3) caused by menopause, treat with hormone replacement therapy (HRT) (4) should treat with rest and ice A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions? 1. Head of bed elevated 30-45°. 2. Head of bed elevated 60-90°. 3. Side-lying with head elevated 15°. 4. Lying flat with head turned to the left side. ------CORRECT ANSWER----- ----------Strategy: Remember the positioning strategy. (1) head of bed not elevated enough (4) not of primary importance in designing an effective behavior modification program A client received six units of regular insulin 3 hours ago. The nurse is MOST concerned if which of the following is observed? 1. Kussmaul respirations and diaphoresis. 2. Anorexia and lethargy. 3. Diaphoresis and trembling. 4. Headache and polyuria. ------CORRECT ANSWER---------------Strategy: "MOST concerned" indicates a complication. (1) Kussmaul respirations are signs of hyperglycemia (2) not indicative of hypoglycemia (3) correct—regular insulin peaks in 2 to 4 hours; indicates hypoglycemia; give skim milk (4) not indicative of hypoglycemia The nursing assistant reports to the nurse that a client who is 1 day postoperative after an angioplasty refuses to eat and states, "I just don't feel good." Which of the following actions by the nurse is BEST? 1. Talk with the client about how the client is feeling. 2. Instruct the nursing assistant to sit with the client while the client eats. 3. Contacts the physician to obtain an order for an antacid. 4. Evaluate the most recent vital signs recorded in the chart. ------ CORRECT ANSWER---------------Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is the assessment appropriate? Yes. (1) correct—assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias (2) assess cause of problem before implementing (3) assess cause of problem before implementing (4) more important to assess what is happening now The nurse prepares a patient for a cesarean section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section 1. contains a lower overall dosage of medication than is given before general surgery. 2. contains lower amounts of sedatives and hypnotics than are given before general surgery. 3. contains lower amounts of narcotics than are given before general surgery. 4. contains medications similar in type and dosages to those given before general surgery. ------CORRECT ANSWER---------------Strategy: Think about the action of the medications. (1) decreased dosage of narcotics are used (2) dosages of sedatives and hypnotics will be similar (3) correct—decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant (4) dosages of narcotics are reduced The nurse cares for patient placed in balanced suspension traction with a Thomas splint and Pearson attachment because of a fractured right femur. The nurse notes that the patient's left leg is externally rotated. The nurse should take which of the following actions? 1. Place a trochanter roll on the outer aspect of the thigh. 2. Perform resistive range of motion of the left leg. 3. Adduct and internally rotate the left leg. 4. Instruct the patient to maintain the left leg in a neutral position. ------ CORRECT ANSWER---------------Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee (2) exercise would not prevent future external rotation of the leg (3) adduction (add to midline of body) does not change external rotation, internal rotation is not beneficial, normal alignment is required (4) leg will externally rotate unless propped in proper alignment The nurse prepares a 5-year-old child for surgery. The nurse notes that the child's parents are divorced and have joint legal custody. The informed consent for surgery has been signed by the mother. Which of the following actions by the nurse is BEST? 1. Notify the physician. 2. Inform surgery. 3. Contact the father to obtain consent. 4. Continue the child's preoperative preparation. ------CORRECT ANSWER---------------Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no reason to notify the physician (2) no reason to call the OR (3) consent from either divorced parent is sufficient (4) correct—parent or legal guardian required to give informed consent prior to surgical procedure 4. "Proper storage is the key to poison prevention in the home." ------ CORRECT ANSWER---------------Strategy: "Further teaching is necessary" indicates an incorrect statement. (1) Appropriate action; terminate exposure to the poison and then contact poison control for further instructions (2) correct—vomiting contraindicated when child ingests hydrocarbons because of danger of aspiration (3) 'poison-proofs' the medication (4) store in locked cabinets The nurse cares for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 1. Take the client to the dining room with 1:1 supervision. 2. Inform the client that he may go to the dining room when he controls his behavior. 3. Hold the meal until the client is able to come out of seclusion. 4. Serve the meal to the client in the seclusion room. ------CORRECT ANSWER---------------Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should remain in the seclusion room (2) should have meal at regular time (3) should have meal at regular time (4) correct—should eat at regular time; remain in the seclusion room for client's safety Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of the body? 1. Counseling regarding problems of body image. 2. Maintain airborne precautions. 3. Maintain aseptic technique during procedures. 4. Encourage peers to visit on a regular basis. ------CORRECT ANSWER-- -------------Strategy: Think "Maslow." (1) psychosocial, not highest priority (2) physical, use standard precautions (3) correct—safety is a priority for the client who is at high risk for infection (4) psychosocial, important for an adolescent but is not highest priority The home health care nurse cares for a client diagnosed with type 1 diabetes. The client is maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past 2 days were 205 and 233 mg/dL. The nurse expects the physician to take which of the following actions? 1. Reduce the client's diet to 1,500 calorie ADA. 2. Order three additional units of NPH insulin at 10 P.M. 3. Order an additional 10 units of regular insulin at 8 P.M. 4. Eliminate the client's bedtime snack. ------CORRECT ANSWER------------ ---Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) diet should not be reduced (2) correct—dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia (3) peaks in 4 to 6 hours, would not prevent dawn phenomena (4) would adjust snack, not eliminate it After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a 5-year-old is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse 3 hours after admission, should be reported to the physician? 1. The client has slight edema of the eyelids. 2. There is clear fluid draining from the client's right ear. 3. There is some bleeding from the child's lacerations. 4. The client withdraws in response to painful stimuli. ------CORRECT ANSWER---------------Strategy: Think about how each answer choice relates to a head injury. (1) not priority (2) correct—indicates a rupture of meninges and presents a potential complication of meningitis (3) not priority (4) is not a change in assessment A psychiatric nurse is assigned to conduct an admission nursing history on a new client. The admission should include which of the following? 1. The nurse's opinion regarding the mental and emotional status of the client. 2. Data addressing the client's emotional state. 3. Data addressing a biopsychosocial approach, including a family system assessment. 4. Specific data detailing the client's mental status. ------CORRECT ANSWER---------------Strategy: Think about each answer choice. (1) depends on opinions that are not based on a complete assessment (4) correct—lidocaine is the drug of choice for frequent premature ventricular contractions (PVC) occurring in excess of 6 to 10 per minute; for coupled PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia The home care nurse visits a client with newly diagnosed type 1 diabetes. The physician orders include 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the client perform a blood sugar analysis. The result is 50 mg/dL. The nurse should observe for which of the following? 1. Confusion; cold, clammy skin; and an elevated pulse. 2. Lethargy; hot, dry skin; rapid deep respirations. 3. Alert and cooperative, blood pressure and pulse within normal limits. 4. Shortness of breath, distended neck veins, and a bounding pulse of 96. ------CORRECT ANSWER---------------Strategy: Determine the cause of each answer choice. (1) correct—symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL (2) symptoms of hyperglycemia, blood sugar above 110 mg/dL (3) normal appearance and vital signs (4) symptoms of fluid overload caused by heart failure, rapid infusion of IV fluids The nurse's INITIAL priority when managing a physically assaultive client is which of the following? 1. Restrict the client to the room. 2. Place the client under one-to-one supervision. 3. Restore the client's self-control and prevent further loss of control. 4. Clear the immediate area of other clients to prevent harm. ------ CORRECT ANSWER---------------Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) time out or room restriction might be a useful strategy before the client becomes assaultive; once client is assaultive, he/she may continue this behavior in his/her room without any redirection and support (2) may not stop assaultive behavior (3) correct—most important priority in the nursing management of an assaultive client is to maintain milieu safety by restoring the client's self- control; a quick assessment of situation, psychological intervention, chemical intervention, and possibly physical control are important when managing the physically assaultive client (4) is helpful but may not be realistic if the situation escalates quickly The nurse observes an LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, indicates an understanding of proper technique? 1. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes. 2. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing. 3. The nurse packs wet gauze into the incision without overlapping it onto the skin. 4. The old dressing is saturated with sterile saline before it is removed. ----- -CORRECT ANSWER---------------Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should clean from the center of wound to the outside using sterile equipment (2) dressings should be soaked before application (3) correct—if wet dressing touches skin, it could cause skin breakdown (4) should be removed dry so that wound debris and necrotic tissue are removed with old dressing The nurse assesses the development of a 3-month-old boy in the well-child clinic. Which of the following behaviors, if observed by the nurse, is UNEXPECTED? 1. The boy holds his head erect when sitting on the examination table. 2. The boy tries to grasp a toy just out of reach. 3. The boy turns his head to try to locate a sound. 4. The boy smiles spontaneously when he sees his mother. ------ CORRECT ANSWER---------------Strategy: Picture the infant. (1) expected at 3 months (2) correct—unexpected until 6 months of age (3) expected at 3 months of age (4) expected at 3 months of age An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions is MOST beneficial in decreasing the client's pain during ambulation? 1. Perform passive range-of-motion exercises before walking. 2. Encourage partial weight bearing while ambulating. 3. Immobilize the extremity between activities. 4. Restrict the amount of time and the distance the man walks. ------ CORRECT ANSWER---------------Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (4) symptoms should be reported to physician, antipyretic usually prescribed A client takes perphenazine (Trilafon) by mouth for 2 days and now displays the following: head turned to the side, neck arched at an angle, and stiffness and muscle spasms in neck. The nurse expects to give which of the following as a PRN medication? 1. Promazine (Sparine). 2. Biperiden (Akineton). 3. Thiothixene (Navane). 4. Haloperidol (Haldol). ------CORRECT ANSWER---------------Strategy: Think about each answer choice. (1) antipsychotic medication, would not relieve the side effects (2) correct—antiparkinsonian agent, used to counteract extrapyramidal side effects the client is experiencing (3) antipsychotic medication, would not relieve the side effects (4) antipsychotic medication, would not relieve the side effects The home care nurse instructs a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 1. The client should cover the mouth and nose when coughing or sneezing during the first 2 weeks of treatment. 2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease. 3. The family should support the client to help reduce feeling of low self- esteem and isolation. 4. The client will be required to take prescribed medication for 6 to 9 months. ------CORRECT ANSWER---------------Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) on airborne precautions during hospitalization; can send home with family because they are already exposed (2) not required (3) important, but not as important as taking medication (4) correct—necessary to take medication for 6 to 9 months Which of the following assessment findings indicates to the nurse the need for more sedation for a client withdrawing from alcohol dependence? 1. Steadily increasing vital signs. 2. Mild tremors and irritability. 3. Decreased respirations and disorientation. 4. Stomach distress and inability to sleep. ------CORRECT ANSWER-------- -------Strategy: Determine the cause of each answer choice and how it relates to alcohol withdrawal. (1) correct—indication that the client is approaching delirium tremens, which can be avoided with additional sedation (2) describes normal mild withdrawal symptoms (3) would contraindicate giving more sedation (4) describes expected symptoms of alcohol withdrawal, which will subside as the alcohol is excreted from the body The nurse in the outpatient clinic instructs the mother of a school-aged child diagnosed with asthma how to prevent future asthmatic attacks. The nurse is MOST concerned if the mother states which of the following? 1. "My son plays the tuba in the grade school band." 2. "My son loves to help his dad rake leaves." 3. "My son participates in after-school activities 3 days a week." 4. "My son walks 1 mile to school every day with his friends." ------ CORRECT ANSWER---------------Strategy: Think about what the words mean. (1) involves forced expiration; would not cause problems with asthma (2) correct—main cause of asthma is inhaled allergens (animal dander, mold, pollen, dust), would expose child to pollen and dust from leaves (3) school activities should be encouraged to help development (4) walking is good exercise; running could be a problem if he has exercise- induced asthma The nurse cares for a postcholecystectomy client who had the T-tube removed this morning. Two hours after removal of the T-tube, the nurse notes that the 4 × 4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions? 1. Remove the dressing, and replace it with a more absorbent dressing. 2. Collect a culture and sensitivity specimen of the drainage. 3. Observe the wound for dehiscence. 4. Reinforce the dressing with an 8 × 10 dressing. ------CORRECT ANSWER---------------Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? No. Determine the outcome of each implementation. (1) correct—expected that a stab wound will continue to drain until the wound seals; nurse should keep wound clean and dry (2) drainage described is bile, which is expected; no indication of infection (3) doesn't usually occur An elderly client returns to the room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include which of the following? 1. High-protein, low-residue diet. 2. Position client on unaffected side. 3. Exercise the client's arms and legs. 4. Encourage the client to cough and deep breathe. ------CORRECT ANSWER---------------Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) diet should be high residue to prevent constipation due to inactivity (2) may be positioned on affected side after incision heals (3) foot flexion exercises should be done every hour to prevent complications (4) correct—prevents respiratory complications due to immobility following surgery The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse considers the assignments appropriate if the nursing assistant is assigned to care for which of the following clients? 1. A client diagnosed with Alzheimer's requiring assistance with feeding. 2. A client diagnosed with osteoporosis complaining of burning on urination. 3. A client diagnosed with scleroderma receiving a tube feeding. 4. A client diagnosed with cancer who has Cheyne-Stokes respirations. ---- --CORRECT ANSWER---------------Strategy: Assign to nursing assistants clients with standard, unchanging procedures. (1) correct—standard, unchanging procedure (2) requires assessment; should assign to an RN (3) stable patient with expected outcome; should assign to an LPN/LVN (4) unstable patient, requires assessment and nursing judgment; should assign to an RN A client is admitted diagnosed with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? 1. Unequal and dilated pupils. 2. Decerebrate posturing. 3. Grand mal seizures. 4. Decreased level of consciousness. ------CORRECT ANSWER-------------- -Strategy: All answers are assessments. Determine how each relates to increased intercranial pressure. (1) indicates brainstem damage (2) late sign of brainstem damage (3) late sign of increased intracranial pressure (4) correct—may be confused and stuporous The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis. Which of the following observations is expected with scoliosis? 1. The girl's thoracic area is asymmetrical. 2. The girl walks with a waddling gait. 3. The girl's lower legs are edematous. 4. The girl has a protruding sternum. ------CORRECT ANSWER--------------- Strategy: Determine the significance of each answer choice and how it relates to scoliosis. (1) correct—thoracic area becomes noticeably distorted (2) seen with hip dislocation (3) seen with circulatory or inflammatory processes (4) seen with pigeon breast, or pectus carinatum A client in the ICU is given procainamide HCl (Pronestyl) slowly by IV push. The nurse should withhold the next dose if which of the following is observed? 1. Presence of premature ventricular contractions. 2. Occurrence of severe hypotension. 3. Recurring paroxysmal atrial tachycardia. 4. A sedimentation rate of 10. ------CORRECT ANSWER--------------- Strategy: Determine the cause of each answer choice and how it relates to Pronestyl. (1) procainamide is given to treat premature ventricular contractions or atrial tachycardia (2) correct—severe hypotension or bradycardia are signs of an adverse reaction to this medication (3) procainamide is given to treat premature ventricular contractions or atrial tachycardia (4) lab value is within normal limits A client diagnosed with AIDS is seen in the emergency room with complaints of mouth pain, difficulty swallowing, and a white discharge in the back of the throat. The nurse expects the physician to order which of the following? 1. Metronidazole (Flagyl) 7.5 mg/kg q6h. 2. Ketoconazole (Nizoral) 200 mg daily. 3. Trimethoprim-sulfamethoxazole (Bactrim) 800 mg PO q12h. 4. "Take another deep breath, hold it, and then cough deeply." ------ CORRECT ANSWER---------------Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—most effective way of deep breathing and coughing, dilates airway and expands lung surface area (2) should splint incision before coughing to reduce discomfort and increase efficiency (3) partial answer, should take three deep breaths before coughing (4) implies coughing routine is adequate, incision needs to be splinted The nurse in a psychiatric emergency room cares for a client who is a victim of interpersonal violence. The INITIAL priority of the nurse is which of the following? 1. Encourage the client to verbalize feelings. 2. Assess for physical trauma. 3. Provide privacy for the client during the interview. 4. Help the client identify and mobilize resources and support systems. ---- --CORRECT ANSWER---------------Strategy: Think "Maslow." (1) psychosocial, priority is physical injury (2) correct—physical, victim may have physical trauma and concealed injuries; assessment is of utmost importance so that the client's physiologic integrity is maintained (3) psychosocial, done concurrently as the nurse is assessing for physical injury (4) psychosocial, priority is physical injury A client returns to his room following a myelogram. The nursing care plan should include which of the following? 1. Encourage oral fluid intake. 2. Maintain the prone position for 12 hours. 3. Encourage the client to ambulate after the procedure. 4. Evaluate the client's distal pulses on the affected side. ------CORRECT ANSWER---------------Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of the implementations. (1) correct—implementation; fluids should be encouraged to facilitate dye excretion and to maintain normal spinal fluid (2) implementation; clients are not placed in the prone position (3) implementation; bed rest is maintained for several hours after the test (4) assessment; an extremity was not used for injection of the dye The nurse in the well-baby clinic observes a group of children. The nurse notes that one child is able to sit unsupported, play "peek-a-boo" with the nurse and is starting to say "mama" and "dada". The nurse determines the infant's behaviors are consistent with which of the following ages? 1. 5 months of age. 2. 6 months of age. 3. 9 months of age. 4. 12 months of age. ------CORRECT ANSWER---------------Strategy: Picture each infant. (1) unable to sit unsupported until 8 months (2) unable to sit unsupported until 8 months (3) correct—can pull self up and assume a sitting position at 8 months, can say few words (4) would be able to say three to five words in addition to dada and mama The nurse in the outpatient clinic instructs a client diagnosed with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, indicates to the nurse that teaching is effective? 1. The client advances the cane 18 inches in front of the foot with each step. 2. The client holds the cane in the left hand. 3. The client advances the right leg, then the left leg, and then the cane. 4. The client holds the cane with elbows flexed 60°. ------CORRECT ANSWER---------------Strategy: "Teaching is effective" indicates a correct behavior. (1) should advance cane 6-10 inches with body weight on both legs (2) correct—should hold cane on strong side, widens base of support, reduces stress on affected side (3) should advance cane, weaker leg, stronger leg (4) should flex no more than 30° The nurse performs triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? 1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can. 2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time. 3. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain. 4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL. ------CORRECT ANSWER---------------Strategy: Identify the least stable client. After a client has a positive Chlamydia trachomatis culture, the client and partner return for counseling. It is MOST important for the nurse to ask which of the following questions? 1. "Do you have contacts to identify?" 2. "What is your understanding regarding how chlamydia is transmitted?" 3. "Do you have questions about the culture and its validity?" 4. "Do you have allergies to the medications?" ------CORRECT ANSWER-- -------------Strategy: "MOST important" indicates that this is a priority question. (1) may be part of follow-up (2) correct—means of transmission of chlamydia may or may not have been made clear to both partners; nurse should assess this first; is a sexually transmitted disease (3) most cultures used today have few false positives (4) would be done later in the nursing assessment A client diagnosed with bipolar disorder receives haloperidol (Haldol) 2 mg PO tid. The client tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge?" 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication." ------CORRECT ANSWER---------------Strategy: The topic of the question is unstated. (1) hallucinations usually not seen with patients with bipolar disorder; seen with psychotic disorders (2) assumption that patient just wants attention (3) correct—side effects include galactorrhea (excessive or spontaneous flow of milk), lactation, gynecomastia (excessive growth of male mammary glands) (4) indicates a side effect, not effectiveness of medication Strategy: The topic of the question is unstated. (1) hallucinations usually not seen with patients with bipolar disorder; seen with psychotic disorders (2) assumption that patient just wants attention (3) correct—side effects include galactorrhea (excessive or spontaneous flow of milk), lactation, gynecomastia (excessive growth of male mammary glands) (4) indicates a side effect, not effectiveness of medication ------CORRECT ANSWER---------------Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antiembolism stockings should be worn to prevent any discomfort and to increase the blood flow (2) correct—stockings should be worn the entire time that client is in the hospital; should be removed for baths and replaced after the skin is dry, and before the client gets out of bed (3) stockings should be worn during the day and when client is nonambulatory (4) stockings should be applied before getting out of bed A client is scheduled for a left lower lobectomy. The physician orders diazepam (Valium) 2 mg IM for anxiety. The nurse determines the medication is appropriate if the client displays which of the following symptoms? 1. Agitation and decreased level of consciousness. 2. Lethargy and decreased respiratory rate. 3. Restlessness and increased heart rate. 4. Hostility and increased blood pressure. ------CORRECT ANSWER-------- -------Strategy: Determine if the answer choice relates to Valium. (1) more indicative of preoperative complications, should be reported before medications are given (2) more indicative of preoperative complications, should be reported before medications are given (3) correct—observation most indicative for antianxiety drugs is restlessness and increase in heart rate due to circulating catecholamines (fight or flight) (4) hostility may be treated best by ventilating feelings A client diagnosed with multiple sclerosis (MS) is at 39 weeks' gestation. The client is admitted to the labor and delivery unit in active labor. The client's vital signs are BP 127/72; pulse 72 bpm; cervix is 4 cm dilated; FHT 124 bpm; moderate contractions are 4 minutes apart. The nurse should anticipate the need for which of the following? 1. Prepare to administer IV Pitocin to the client. 2. A reduction in the amount of pain medication administered. 3. Check the client's blood pressure every 5 minutes. 4. Prepare an isolette for the infant. ------CORRECT ANSWER--------------- Strategy: Answers are a mix of assessments and implementations. Does the assessment make sense? No. Determine the outcome of each intervention. (1) uterine contractions not affected by MS