NCSBN TEST BANK - for the NCLEX-RN & NCLEX-PN, Updated 2022, Complete Questions & Answers, Exams of Nursing

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NCSBN TEST BANK - for the NCLEX-RN & NCLEX-

PN, Updated 2021, Complete Questions & Answers

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Question 1

T h e nu r s e i s a s s e ss i ng a 4 ye ar- o l d f o r p o ss i b l e r h e u m a ti c f eve r. W h i c h o f t h e f o l l o w i ng w o u l d t h e nu r s e s u s p e c t i s r e l at e d t o t h i s d i agn o s i s?

A) D iagn o s i s o f c h i cke np ox s i x mo n t h s a g o

B) Exposure to strep throat in daycare last month

C) Tr e at m e n t f o r e ar i n f e ct i o n t w o mo n t h s ag o

D) Ep i s o d e o f f ung al s k i n i n f e c t i o n l a s t w eek

R eview Information : T h e co rr e ct an s w e r i s : B ) E x p o s u r e t o s tr e p t h r o at i n d ay c ar e las t mon t h.

E v i d e n c e s upp o rt s a s tr o ng r e l at i o n s h i p b e t w ee n i n f e ct i o n w i t h Gro up A s tr e p t oco cc i and sub s e qu e n t r h e um at i c f eve r ( u s u al l y w i t h i n 2 - 6 w eek s ). T h e r e f o r e , t h e h i s t o r y o f p l ay m at e s r ecove r i ng f r om s tr e p t h r o at w o u l d i nd ic a t e t h at t h e c h il d d iagn o s e d w i t h r h e um at i c f eve r mo s t like l y a l s o had s tre p t h r oa t. S o me t ime s , s u c h an in f e ct i o n h as n o c li n i c al s y mp t om s.

Question

W h e n t h e nu r s e b eco me s aw ar e o f f ee li ng r e l u ct an t t o i n t e r act w i t h a man i pu l at i ve c li e n t , t h e B ES T a c t i o n by the nurse is to

A) Discuss the feeling of rel uctance with an objective peer or supervi sor

B) L i m i t co nt a ct s w i t h t h e c li e n t t o avo i d r e i n f o r c i ng t h e man i pu lat i ve b e h av i o r

C) C o n f r o n t t h e c l i e n t r e g ar d i ng t h e n e g at i ve e ff e c t s o f h i s / h e r b e h av i o r o n o t h e r s

D) D eve l o p a b e h av i o r mo d ifi c a ti o n p l an t h at w ill p r o mo t e mo r e f un c t i o n al b e h av i o r

R eview Information : T h e co rr e ct an s w e r i s : A ) D i s c u ss t h e f ee li ng o f r e l u c t anc e w i t h an o b j e c t i ve p ee r o r s up e r v i s o r.

T h e nu r s e w h o i s ex p e r i e n c i ng s tr e ss i n t h e t h e r a p e u t i c r e l at i o n s h i p can g ai n o b j e c t i v i t y t h r o ugh s up e r v i s i o n. T h e nu r s e m u s t at t e mpt t o d i s cove r at t i t ud e s and f ee li ng s i n t h e s e l f t h at i n f l u e n c e t h e nu r s e - c li e n t r e l at i o n s h i p.

Question 3

A c li e n t i s b e i ng tr ea t e d f o r p ar an o i d s c h i zo phr e n i a. W h e n t h e c li e n t b e c a m e l o ud a nd b o i s t e r o u s , t h e nu r s e i mm e d i at e l y p l a c e d h i m i n s e c l u s i o n as a p r e c au ti o n ar y m eas ur e. T h e c li e n t w illi ng l y com p li e d. T h e nu r s e 's act i o n

A) May result in charges of unlawful seclusion and restraint

B) L eave s t h e nu r s e v u l n e r ab l e f o r c h a r g e s o f as s au l t and b a tt e r y

C) Was app r o p r iat e i n v i e w o f t h e c li e n t's h i s t o r y o f v i o l e n ce

D) Was n e c e ssar y t o m ai n t a i n t h e t h e r a p e u t i c m ili e u o f t h e un i t

R eview Information : T h e co rr e ct an s w e r i s : A ) May r e s u l t i n c h ar g e s o f un l aw f u l s e c l u s i o n and r e s tr ai n t.

S e c l u s i o n s h o u l d o n l y b e u s e d w h e n t h e r e i s an i mm e d i at e t hr e at o f v i o l e n c e o r t h r ea t e n i ng b e h av i o r.

Question 4

A c. W h at d o c um e n t s h o u l d b e i n gu i d i ng t h e car e o f t h i s c li e n t?

A) C li e n t S e l f D e t e r m i n at i o n A c t

B) P h y s i c i an ' s tr ea t me n t or d e r s

C) Advance Directives.

D) C li n i c al Pa t h w ay p r o t oco l s

R eview Information : T h e co rr e ct an s w e r i s : C ) A d v an c e D i r e ct i ve s. T h i s d o c u me n t s p e c if i e s t h e c li e n t's w i s h e s

Question

Yo u ar e t h e o f a h e al t h car e t e am t h at co n s i s t s o f o n e li c e n s e d p r act i c al / vo cat i o n al nu r s e , o n e nu r s i ng as s i s t an t , a nu r s i ng s t ud e n t a nd yo u r s e l f. To w h o m i s i t app r o p r i at e t o as s i gn co mp l e t e car e f o r

A) Yourself

B) T h e nu r s i ng s t ud e n t

C) T h e li c e n s e d vo c a t i o n a l nu r s e

D) T h e nu r s i ng as s i s t an t

R eview Information : T h e co rr e ct an s w e r i s : A ) Yo u r s e l f.

W h il e t h e nu r s e m ay d e l e g at e a b e d b at h f o r a s t ab l e c li e n t , t h i s c ar e s h o u l d b e p e r f o r me d by an R N f o r a n e w ad m i ss i o n. On l y t ask s t h at d o n o t r e qu ir e i nd e p e nd e n t j udg m e n t s h o u l d b e d e l e g at e d.

3Question 6

A mo t h e r b r i ng s h e r t h e c li n i c , comp l a i n i ng t h at t h e c h il d s ee m s t o b e T h e nu r s e ex p e c t s t o f i nd w h i c h o f t h e f o ll o w i ng o n t h e i n i t i a l h i s t o r y and ph y s i c al as s e ss m e n t?

A) I n cr ease d t e mp e r at ur e and l e t h a r g y

B) Rash and restlessness

C) I n cr ease d s l ee p i ng and li s t l e ss n e ss

D) D i ar r h ea a nd p oo r s k i n t u r g o r

R eview Information : T h e co rr e ct an s w e r i s : B ) Ras h and r e s t l e ss n e ss.

Question 7

A s t h e nu r s e t ake s a h i s t o r y o f a 3 ye ar- o l d w i t h n e u r o b l a s t o m a , w h at comm e nt s b y t h e p ar e n t s r e qu i re f o ll o w - up and ar e co n s i s t e n t w i t h t h e d i agn o s i s?

A) " T h e c h il d h a s b ee n li s t l e ss and h as l o s t w e i gh t. "

B) " H e r u r i n e i s d a r k ye ll o w and s m al l i n amo un t s. "

C) "Clothes are becoming tighter across her abdomen." D+)

"We notice muscle weakness and some unsteadiness."

R eview Information : T h e co rr e ct an s w e r i s : C ) " C l o t h e s ar e b ecom i ng t i gh t e r a cr o ss h e r abd o me n. ".

On e o f t h e mo s t co mmo n s i gn s o f n e u r o b l as t o ma i s i n cr eas i ng abd om i n al g i rt h. T h e p a r e n t s '' r e p o rt t h at c l o t h i ng i s t i gh t i s s i gn ifi c an t , and s h o u l d b e f o ll o w e d b y add i t i o n a l as s e ss m e n t s.

Question

A 16 ye ar- o l d p r e s e n t s t o t h e e me r g e n c y d e p ar t me nt. T h e tr i a g e nu r s e fi nd s t h at t h i s t ee nag e r i s l e g a ll y marr i e d and s i gn e d t h e co n s e n t f o r m f o r tr e at m e n t. W h at w o u l d b e t h e app r o p r i at e I N I T I A L act i o n b y t h e nurse?

A) Re f u s e t o s ee t h e c li e n t un t il a p ar e n t o r l e g a l gu ar d i an c an b e co n t act e d

B) Wi t hh o l d tr e at m e n t unt il t e l e ph o n e co n s e n t can b e o b t ai n e d fr o m t h e s p o u s e

C) Re f e r t h e c li e n t t o a co mm un it y p e d iat r i c h o s p i t al e m e r g e n cy r oo m

D) Assess and treat in the same manner as any adult client

R eview Information : T h e co rr e ct an s w e r i s : D ) A ss e ss and tr ea t i n t h e s a m e man n e r as any adu l t c li e n t.

Mi n o r s may b eco me k n o w n as a n " e m anc i p at e d m i n o r " t h r ough marr i ag e , p r e gnan c y , h i gh s c h oo l g r adu at i o n , i nd e p e nd e n t li v i ng o r s e r v i c e i n t h e m ili t ar y. T h e r e f o r e , t h i s c li e n t , w h o i s mar r i ed , h a s t h e l e g a l capac i t y o f an adu l t.

Question

A n e w l y ad m i tt e d e l d e r l y c li e n t i s s eve r e l y d e h y d r at e d. W h e n p l ann i ng car e f o r t h i s c li e n t , w h i c h o n e o f t h e f o ll o w i ng i s a n app r o p r i at e t ask f o r an U n lic e n s e d A ss i s t i ve Pe r s o nn e l ( U A P )?

A) O b t ai n a h i s t o r y o f f l u i d l o ss

B) Report output of less than 30 ml/hr

C) Mo n i t o r r e s p o n s e t o I V f l u i d s

D) C h eck s k i n t u r g o r eve r y f o u r h o u r s

R eview Information : T h e co rr e ct an s w e r i s : B ) Re p o rt o u t pu t o f l e ss t han 30 m l / h r.

W h e n d i r e ct i ng a U A P , t h e nu r s e m u s t comm un i c a t e c l e ar l y ab o u t ea c h d e l e g at e d t ask w i t h s p e c ifi c i n s tr u c t i o n s o n w h at m u s t b e r e p o rt e d. B ecau s e t h e R N i s r e s p o n s i b l e f o r a l l c ar e - r e l at e d d e c i s i o n s , o n l y i mp l em e nt at i o n t ask s s h o u l d b e a ss i gn e d b ecau s e t h ey d o n o t r e qu i r e i nd e p e nd e n t j udg men t.

Question 10

A c li e n t h as b ee n ad m i tt e d t o t h e C o r o n ar y C ar e U n i t w i t h a My o car d i a l I n f ar cti o n. W h ic h o f t h e f o ll o w i ng nu r s i ng d i agn o s i s s h o u l d h ave P R I O R I TY?

A) Pain related to ischemia

B) R i s k f o r al t e r e d e l im i n at i o n : co n s t i p a t i o n

C) R i s k f o r co m p li c at i o n : d y s r h y t hm i as

D) A n x i e t y

R eview Information : T h e co rr e ct an s w e r i s : A ) Pa i n r e l at e d t o i s c h e m i a.

Pai n i s r e l at e d t o i s c h em i a, a nd r eli e f o f p ai n w ill d ecr ease m yo car d i a l oxy g e n d em and s , r e duc e b l oo d p r e ss u r e and h e ar t r at e and r e li eve an x i e t y. Pa i n a l s o s t i m u l at e s t h e s y mp a t h e t i c n e r vo u s s y s t e m and i n c r ease d pr e l o ad , f u rt h e r i n c r eas i ng my oc a r d i al d e m and s.

Question 11

T h e nu r s e man ag e r w h o i s r e s p o n s i b l e f o r h i r i ng p r o f e ss i o n a l nu r s i ng s t a ff i s r e qu i r e d t o co mp l y w i t h t h e A m e r i c an s w i t h D i s ab ilit i e s A c t. T h e p r ov i s i o n s o f t h e l aw r e qu i r e t h e nu r s e man ag e r t o

A) Ma i n t a i n an e n v i r o nm e n t f r ee f r o m h a zar d s

B) P r ov i d e r easo n a b l e a c commo d at i o n s f o r d i s a b l e d i nd i v i du a l s

C) Mak e a ll n e c e ssar y a c co mmo d a t i o n s f o r d i s a b l e d i nd i v i du a l s

D) C o n s i d e r o n l y ph y s i c al d i s ab ili t i e s i n m ak i ng em p l oym e n t d e c i s i o n s

R eview Information : T h e co rr e ct an s w e r i s : B ) P r ov i d e r easo n a b l e a c co mmo d at i o n s f o r d i s ab l e d i nd i v i du al s.

T h e l aw i s d e s i gn e d t o p e rm i t p e r s o n s w i t h d i s ab ili t i e s acce ss t o j o b o pp o rt un i t i e s. E m p l oye r s m u s t ev al u at e an app li can t ' s a b ili t y t o p e r f o rm t h e j o b and n o t d i s c r i m i n at e o n t h e b as i s o f a d i s ab ili t y. E mp l oye r s al s o m u s t mak e " r easo nab l e a c co mmo d at i o n s.

Question 12

T h e mo t h e r o f a s c h oo l - ag e d c h il d i n a l o ng l e g c as t ask s t h e nu r s e h o w t o r e li eve i t c h i ng i n s i d e t h e cas t. W h i c h o f t h e f o ll o w i ng i s a pp r o p r i at e f o r t h e nu r s e t o s ugg e s t as a r em e d y?

A) S crat c h i ng t h e o u t s i d e o f t h e cas t v i g or o u s l y , app l y i ng p r e ss u r e ove r t h e ar ea

B) B l o w i ng a h ai r d r ye r o r h e at lamp o n t h e cast ove r t h e ar ea t h at i s i t c h i ng

C) U s i ng a l o ng , s mo o t h p i e c e o f w oo d t o g e n t l y s c r at ch t h e aff e ct e d ar ea

D) A pp l y i ng an i c e p ack ove r t h e ar ea o f t h e c as t t h at i s a ff e ct e d

R eview Information : T h e co rr e ct an s w e r i s : D ) A pp ly i ng a n i c e p ack ove r t h e ar ea o f t h e cas t t h at i s affected.

A pp l y i ng i c e i s a s a f e me t h o d o f r e l i ev i ng t h e i t c h i ng.

Question 13

W h i c h o f t h e f o ll o w i ng B ES T d e s c r i b e s t h e app li c at i o n o f t i m e m anag em e n t s tr at e g i e s i n t h e r o l e o f t h e nurse manager?

A) S che du li ng s taff e f fi c i e n t l y t o cove r c li e n t n ee d s

B) A ss u m i ng a f a i r s h ar e o f t h e c li e n t c ar e as a r o l e mo d e l

C) S e tt i ng d ai l y g oa l s t o p r i o r i t i z e w o r k

D) D e l e g at i ng t ask s t o r e du c e w o r k l o ad

R eview Information : T h e co rr e ct an s w e r i s : C ) S e tt i ng d a il y g o al s t o p r i o r i t i z e w o r k.

T i me man ag e me n t s tr at e g i e s m u s t i n c l ud e s e tt i ng p r i o r i t i e s a nd m ee t i ng g oa l s.

Question 14

T h e c li n i c nu r s e as s e ss e s a t o dd l e r w i t h a t e n t at i ve d i a gn o s i s o f n e u r o b l a s t o m a. S y mp t om s th e nu r s e o b s e r ve s t h at s ugg e s t t h i s p r o b l e m i n c l ud e

A) Ly mp h e d e m a and n e r ve p a l s y

B) H e ar i ng l o ss and at ax i a

C) H e ad ac h e s and vo m it i ng

D) A bd o m i n a l mas s and w eak n e ss

R eview Information : T h e co rr e ct an s w e r i s : D ) A bd o m i n a l mas s and w eak n e ss.

C li n i c al man i f e s t at i o n s o f n e u r o b l as t o m a i n c l ud e an i rr e gu l ar a bd o m i n a l m as s t h a t cr o ss e s t h e m i d li n e , w eak n e ss , p al l o r , a n o r ex i a, w e i gh t l o ss and i rr i t ab ilit y.

Question 15

A fift een yea r - ol d c li en t ha s been pl a c ed i n a Mil w aukee Br a c e. W h i c h one o f t he f oll o wi ng sta t e m en t s fr o m t he c lient ind i c at e s t he need f o r add iti onal t ea c h i ng?

A) " I will onl y have t o wea r t h i s f or s i x m on t h s ."

B) " I s houl d i n s pe c t m y sk i n da il y."

C) " The b r ac e will be w or n day and ni gh t ."

D) "I c an t ake i t off w hen I s ho w e r."

Review I nformat i on : The c orr e c t an s w er i s: A) " I w ill on l y have t o wea r th i s f or s ix m ont h s. ".

The br a c e m u st be w o r n l ong - t er m , u s ua ll y f o r 1 - 2 yea r s.

Question 16

The nu r se m anage r ha s been u s i ng a de c en tr a li z ed b l oc k sc hedu li ng p l an t o st a ff t he nu r s ing un it. H o w eve r , st a ff have a sked f o r m any c hange s and ex c ept i on s t o t he s c hedu l e ove r t he pa st f e w m on t h s. The m anage r c on s i de r s s el f- s c hedu li ng kno w ing t ha t

A) Qua li t y o f c are will im p r ove

B) St a ff t u r nover s hou l d de c r ea s e

C) Fl ex i bl e s c hedu li ng will o ccu r

D) Team m o r a l e will im pr ove

R eview Information : T h e co rr e ct an s w e r i s : D ) Te am mor a l e w ill i mp r ove.

N u r s e s ar e mo r e sat i s f i e d w i t h a u t o n o my and co n tr o l. T h e nu r s e m anag e r b ecom e s t h e f a c ili t at o r o f s c h e du li ng r at h e r t han t h e d e c i s i o n - mak e r o f t h e s c h e du l e.

Question 17

A c li e n t i s ad m itt e d t o t h e e me r g e n c y r oom f o ll o w i ng an ac ut e as t hm a at t a ck. W h i c h o f t h e f o ll o w i ng as s e ss m e n t s w o u l d b e ex p e ct e d b y t h e nu r s e?

A) D i ff u s e ex p i r at o r y w h ee z i ng

B) L oo s e , p r o du ct i ve co ugh

C) N o r e li e f f r o m i nh a l ant

D) Feve r and c h ill s

R eview Information : T h e co rr e ct an s w e r i s : A ) D i ff u s e ex p i r at o r y w h ee z i ng.

I n as t hm a , t h e a i r w ay s ar e n ar r o w e d - c r e at i ng d if f i c u l t y g e tt i ng ai r i n and a w h ee z i ng s o und.

Question 18

T h e nu r s e man ag e r h e ars a ph y s i c i an l o ud l y c r i ti c i z i ng o n e o f t h e s taff nu r s e s i n t h e h e ar ing o f o t h e r s. T h e e m p l oyee d oe s n o t r e s p o nd t o t h e ph y s i c i an ' s co mp l a i nt s. T h e nu r s e man ag e r ' s FI R S T a c t i o n s h o u l d b e

A) Wal k up t o t h e ph y s i c i an and qu i e t l y ask t h at t h i s un acce p tabl e b e h av i o r s t o p

B) A ll o w t h e s taff nu r s e t o h a nd l e t h i s s i t u at i o n w i t h o u t i n t e r f e r e nc e

C) N o t i fy t h e N u r s i ng D i r e ct o r a nd Me d i c al S taff C h i e f o f a b r ee c h o f p r o f e ss i o n al co ndu c t

D) Re qu e s t an i mm e d i at e p r i va t e m ee t i ng w i t h t h e ph y s i c i an and s t a ff nu r s e

R eview Information : T h e co rr e ct an s w e r i s : D ) Re qu e s t an i mm e d i at e p r i v at e m ee t i ng w i t h t h e ph y s i c i an and staff nurse.

A ss e rt i ve commu n ic a t i o n r e s p e c t s t h e n ee d s o f al l p ar t i e s t o ex p r e ss t h e m s e l ve s , bu t n o t at t h e ex p e n s e o f o t h e r s. T h e nu r s e m anag e r n ee d s f i r s t t o p r o t e c t c l i e n t s and o t h e r s t a ff f r o m t h i s d i s p l ay and come t o t h e as s i s t an c e o f t h e nu r s e e mp l oyee.

Question 19

A c li e n t vo l un t ar il y ad m i t s h e r s e l f t o t h e h o s p i t al du e t o s u i c i d a l i d e at i o n. T h e c li e n t h as b ee n o n t h e un i t f o r t w o d ay s and i s n o w d e m and i ng t o b e r e l ease d. T h e MOS T app r o p r i at e a c t i o n i s f o r t h e nu r s e t o

A) Te ll t h e c li e n t t h at s h e c ann o t b e r e l ease d b e c au s e s h e i s s t ill s u i c i d al

B) I n f o rm t h e c li e n t t h at s h e can b e r e l ease d o n l y i f s h e s i gn s a n o s u i c i d e co n tr act

C) D i s c u ss w i t h t h e c li e n t t h e d e c i s i o n t o l eave and p r e p ar e f o r h e r d i s c h ar g e

D) I n s tr u ct h e r r e g ar d i ng h e r r i gh t t o s i gn o u t up o n r ece i p t o f t h e ph y s i c i an ' s d i s c h ar g e o r d e r

R eview Information : T h e co rr e ct an s w e r i s : C ) D i s c u ss w i t h t h e c li e n t t h e d e c i s i o n t o l eave a nd p r e p ar e f o r h e r d i s c h a r g e.

C li e n t s vo l un t ar il y a d m i tt e d t o t h e h o s p i t a l h ave a r i gh t t o d e m and and o b t ai n r e l ease. D i s c uss i ng t h e d e c i s i o n a ll o w s o pp o rt un i t y f o r o t h e r i n t e r ve n t i o n s.

Question 20

A c li e n t i s ad m itt e d w i t h i n f e ct i ve e nd o c a r d i t i s ( I E ). W h i c h s y mpt om w o u l d a l e rt t h e nu r s e t o a co mp li c at i o n o f t h i s co nd i t i o n?

A) Dyspnea

B) H e ar t m urm u r

C) Mac u l ar r as h

D) Hemorrhage

R eview Information : T h e co rr e ct an s w e r i s : B ) H e ar t m urm u r.

L ar g e , s o f t , r ap i d l y d eve l o p i ng ve g e t at i o n s at t a c h t o t h e h e ar t v al ve s. T h ey h ave a t e nd e n cy t o b r eak o ff , cau s i ng e mb o li a nd l eav i ng u l c e r at i o n s o n t h e v al ve l ea fl e t s. T h e s e e mb o li p r o du ce s y mp t o m s o f c a r d i a c mu rm u r , f eve r , an o r ex i a, m al a i s e a nd n e u r o l o g i c s e qu e l ae o f e mb o li. Fu rt h e r mo r e , t h e ve g e t at i o n s m ay tr ave l t o v ar i o u s o r gan s s u c h as s p l ee n , k i dn ey , co r o n ar y ar t e r y , b r a i n and l ung s and o b s tr u c t b l oo d fl o w.

Question 21

A nu r s e ad m i t s a p r e m a t u r e i n f an t w h o h as r e s p i r at o r y d i s tr e ss s y nd r o me. I n p l ann i ng c ar e , nu r s i ng a c t i o n s ar e b ase d o n t h e f ac t t h at t h e MOS T li ke l y c au s e o f t h i s p r o b l e m s t em s f r om t h e i n f an t ' s i nab ili t y t o

A) S t a b ili z e t h e r mo r e gu l at i o n

B) Ma i n t a i n al veo l ar s u r f a c e t e n s i o n

C) B e g i n n o r ma l pu l mo n ar y b l oo d fl o w

D) Re gu l at e i n tr aca r d i a c p r e ss u r e

R eview Information : T h e co rr e ct an s w e r i s : B ) Ma i n t a i n al veo l ar s u r f a c e t e n s i o n.

Re s p i r at o r y d i s tr e ss s y nd r o me i s p r i m ar il y a d i s ease r e l at e d t o d eve l o p m e n t a l d e l ay i n l ung m at u r at i o n. A l t h o ugh many f act o r s l ea d t o t h e d eve l o p me n t o f t h e p r o b l e m , t h e ce n tr al f ac t o r r el at e s t o t h e l a c k o f a n o r m al l y f un c t i o n i ng s u r f a c t ant s y s t e m du e t o i mm at u r it y i n l ung d eve l o p m e n t.

Question 22

A n 18 ye ar- o l d c li e n t i s ad m i tt e d t o i n t e n s i ve car e f r o m t h e e m er g e n cy r oom f o ll o w i ng a d i v i ng a cc i d e n t. T h e i n j u r y i s s u s p e c t e d t o b e at t h e l eve l o f t h e 2nd ce r v i c a l vert e b r ae. T h e nu r s e 's P R I OR I TY as s e ss m e n t s h o u l d b e

A) Re s p o n s e t o s t im u li

B) B l add e r co n tr o l

C) Re s p i r at o r y f un c t i o n

D) Mu s c l e w eak n e ss

Review Information : The correct answer is:

C ) Re s p i r at o r y f un c t i o n.

Sp i n a l i n j u r y at t h e C - 2 l eve l r e s u l t s i n qu a d r i p l e g i a. W h il e t h e c li e n t w ill ex p e r i e n c e a ll o f t h e p r o b l e m s i d e n t ifi e d , r e s p i r at o r y as s e ss m e n t i s a p r i o r i t y.

Question 23

T h e nu r s e i s c ar i ng f o r a c li e n t w h o w as s u c ce ss f u l l y r e s u s c i t at e d f r o m a pu l s e l e ss d y s r h y t h m i a. W hi c h o f t h e f o ll o w i ng as s e ss m e n t s i s CR I T I CA L f o r t h e nu r s e t o i n c l ud e i n t h e p lan o f c ar e?

A) H o u r l y u r i n e o u t pu t

B) W h i t e b l oo d co un t

C) B l oo d g l u co s e eve r y f o u r h o u r s

D) Te mp e r a t u r e eve r y t w o h o u r s

R eview Information : T h e co rr e c t an s w e r i s : A ) H o u r l y u r i n e o u t pu t.

C li e n t s w h o h ave had an e p i s o d e o f d e c r ease d g l o m e r u l ar p e r f u s i o n ar e at r i s k f o r p r e - r e n al f ai l u r e. T h i s i s cau s e d b y an y a bn o r mal d e c li n e i n k i dn ey p e r f u s i o n t h at r e du ce s g l o me r u l ar p e r f u s i o n. P r e - re n al f ai l u r e occu r s w h e n t h e e ff e ct i ve ar t e r i al b l oo d vo l u m e f a ll s. E xa m p l e s o f t h i s ph e n o me n a i n c l ud e a d r o p i n c i rc u l at i ng b l oo d vo l u m e as i n a c a r d i a c arr e s t s t at e o r i n l o w car d i ac p e r f u s i o n s t at e s s u c h a s co ng e s t i ve h e ar t f a il u r e as s o c i at e d w i t h a car d i o m yo p a t h y. C l o s e o b s e r v at i o n o f h o u r l y u r i n a r y o u t pu t i s n e c e ssar y f o r e ar l y d e t e ct i o n o f t h i s co nd i t i o n.

Question 24

T h e nu r s e ad m i tt i ng a 5 mo n t h - o l d w h o vo m i t e d n i n e t i m e s in t h e p as t s i x h o u r s s h o u l d o b s e r ve f o r s i gn s of

A) Me t ab o li c a c i d o s i s

B) Me t ab o li c al ka l o s i s

C) Re s p i r at o r y ac i d o s i s

D) Re s p i r at o r y al ka l o s i s

R eview Information : T h e co rr e ct a n s w e r i s : B ) Me t ab o li c a lk al o s i s.

Vo m i t i ng cau s e s l o ss o f a c i d f r o m t h e s t o mac h. P r o l o ng e d vo m i t i ng c an r e s u l t i n ex c e ss l o ss and l e ad t o me t a b o li c a lk al o s i s.

Question 25

A ch il d i s i n j u r e d o n t h e s c h oo l p l ay g r o und and a pp e ars t o h ave a f r a c t u r e d l e g. T h e FI R S T ac ti o n t h e s c h oo l nu r s e s h o u l d t ake i s

A) C al l f o r e me r g e nc y tr an s p o rt t o t h e h o s p i t al

B) I mmo b ili z e t h e li mb and j o i n t s a b ove and b e l o w t h e i n j u r y

C) A ss e ss t h e c h il d and t h e ex t e n t o f t h e i n j u r y

D) A pp l y co l d co mp r e ss e s t o t h e i n j u r e d ar ea

R eview Information : T h e co rr e ct an s w e r i s : C ) A ss e ss t h e c h il d and t h e ex t e n t o f t h e i n j u r y.

W h e n app ly i ng t h e nu r s i ng p r o c e ss , as s e ss m e n t i s t h e f i r s t s t e p i n p r ov i d i ng c ar e. T h e 5 " P s " o f vas c u l ar i mp a i rm e n t c an b e u s e d as a gu i d e ( p a i n , pu l s e , p a ll o r , p ar e s t h e s i a, p ar a l y s i s ).

Question 26

A s t h e nu r s e i n t e r v i e w s t h e p ar e n t s o f a c h il d w i t h as t hm a, it i s a P R I OR I TY t o a s k ab o u t

A) H o u s e h o l d p e t s

B) N e w f u r n i t ur e

C) L e ad b ase d p a i n t

D) P l a n t s s u c h a s c a c t u s

R eview Information : T h e co rr e ct an s w e r i s : A ) H o u s e h o l d p e t s.

A n i m al dand e r i s a ve r y co mmo n a ll e r g e n a ff e ct i ng p e r s o n s w i t h as t hm a. Ot h e r tr i gg e r s may i n c l ud e p o ll e n s , car p e t i ng a nd h o u s e h o l d du s t.

Question 27

A n 80 ye ar- o l d c li e n t w as ad m itt e d w i t h a d i agn o s i s o f p o ss i b l e ce r e b r al vas c u l ar a cc i d e n t. B l oo d p r e ss u r e h as r ang e d f r om 180 / 110 t o 160 / 100. O ve r t h e p as t s eve r a l h o u r s , t h e nu r s e n o t e d i n c r eas i ng l e t h ar g y. W h i c h o f t h e f o ll o w i ng as s e ss m e n t s s h o u l d t h e nu r s e r e p o rt I MMED I AT E LY t o t h e ph y s i c i an?

A) S l u rr e d s p ee c h

B) I n co nt i n e n c e

C) Mu s c l e w eak n e ss

D) R ap i d pu l s e

R eview Information : T h e co rr e ct a n s w e r i s : A ) S l u rr e d s p ee c h.

C hang e s i n s p eech p at t e r n s and l eve l o f co n s c i o u s can b e i nd i c a t o r s o f co n t i nu e d i n t e rc r an i al b l ee d i ng. Tr ea tme nt o p t i o n s may c hang e b ase d o n f u rt h e r d i a gn o s t i c t e s t s.

Question 28

A 3 ye ar- o l d c h il d i s b r o ugh t t o t h e c li n i c b y h i s g r and mo t h e r t o b e s ee n f o r " s c r at ch i ng h i s b o tt om and w e tt i ng t h e b e d at n i gh t. " B ase d o n t h e s e co mp l ai n t s , t h e nu r s e w o u l d I N I T I A LLY as s e ss f o r

A) A ll e r g i e s

B) H y p e r act i v i t y

C) Re g r e ss i o n

D) P i n w o rm s

R eview Information : T h e co rr e ct an s w e r i s : D ) P i n w o r m s.

S i gn s o f p i n w o r m i n f e ct i o n i n c l ud e i n t e n s e p e r i an a l i t c h i ng , p oo r s l ee p p a tt e r n s , g e n e r al i rr i ta b ili t y , r e s t l e ss n e ss , b e d - w e tt i ng , d i s tr act i b ili t y and s h o rt at t e n t i o n s pan.

Question 29

A 72 ye ar- o l d c li e n t w i t h o s t eo my e li t i s r e qu i r e s a s i x w eek co u r s e o f i n tr ave n o u s an t i b i o t i c s. I n p l ann i ng f o r h o me c ar e , t h e MOS T i m p o rt an t act i o n b y t h e nu r s e i s

A) I n ve s t i g at i ng t h e c li e n t ' s i n s u r an c e cove r ag e f o r h o m e I V an t i b i o t i c t h e r ap y

B) D e t e rm i n i ng i f t h e r e ar e ad e qu at e hand w as h ing f ac ilit i e s i n t h e h o me

C) A ss e ss i ng t h e c li e n t's ab ili t y t o p ar t i c i pat e i n s e l f car e and / o r t h e r e li a b il i t y o f a c a r e g i ve r

D) S e l e c t i ng t h e app r o p r i at e ve n o u s a c ce ss d ev i c e

R eview Information : T h e co rr e ct an s w e r i s : C ) A ss e ss i ng t h e c li e n t '' s ab ili t y t o p ar t i c i p at e i n s e l f c ar e and / o r t h e r e li ab ili t y o f a car e g i ve r.

T h e co gn i t i ve ab ili t y o f t h e c li e n t as w e ll as t h e av ai l ab ili t y a nd r e li a b ili t y o f a c ar e g i ve r m u s t b e a ss e ss e d t o d e t e rm i n e i f h o me car e i s a f eas i b l e o p t i o n.

Question 30

T h e mo t h e r o f a ch il d w i t h a n e u r a l t ub e d e f e c t ask s t h e nu r s e w h at s h e can d o t o d e c r ease t h e c han c e s o f h av i ng an o t h e r b a b y w i t h a n e u r a l t ub e d e f e c t. T h e B ES T r e s p o n s e b y t h e nu r s e i s

A) " Fo li c a c i d s h o u l d b e t ake n b e f o r e and af t e r co n ce pti o n. "

B) " Mu l ti v i t ami n s upp l e me n t s ar e r ecomm e nd e d du r i ng pr e gnan c y. "

C) " A w e ll b al an ce d d i e t p r omot e s n o r ma l f e t al d eve l o p m e n t. "

D) " I n c r ease d d i e t ar y i r o n i m p r ove s t h e h e al t h o f mo t h e r and f e t u s. "

R eview Information : T h e co rr e c t an s w e r i s : A ) " Fo li c ac i d s h o u l d b e t ake n b e f o r e and af t e r co n c e p ti o n. ".

T h e A m e r ic an A cade my o f Pe d i at r i c s r ecomm e nd s t h at a ll c h il db e ar i ng w o m e n i n cr ease f o li c ac i d f r om d i e t ar y s o u r ce s a nd / o r s upp l e me n t s. T h e r e i s ev i d e n c e t h at i n cr ease d a m o un t s o f f o li c a c i d p r eve n t s n e u r al tube defects.

Question 31

T h e nu r s e i s c ar i ng f o r a n e w b o r n w i t h a n e u r a l t ub e d e f e c t. T h e B ES T cove r i ng f o r t h e l e s i o n i s

A) Te l f a d r e ss i ng w i t h an t i b i o t i c o i n tm e nt

B) Mo i s t s t e r il e n o nadh e r e n t d r e ss i ng

C) D r y s t e r il e d r e ss i ng

D) S t e r il e o cc l u s i ve p r e ss u r e d r e ss i ng

R eview Information : T h e co rr e ct a n s w e r i s : B ) M o i s t s t e r il e n o nadh e r e n t d r e ss i ng.

B e f o r e s u r g i c a l c l o s u r e t h e s ac i s p r eve n t e d f r o m d r y i ng b y t h e app li c at i o n o f a s t e r il e , mo i s t , n o nadh e r e n t d r e ss i ng ove r t h e d e f e c t. D r e ss i ng s ar e ch ang e d f r e qu e n t l y t o kee p t h e m mo i s t.

Question 32

A nu r s e i s p r ov id i ng a p ar e n t i ng c l as s t o i nd i v i du al s liv i ng i n a co mmu n it y o f o l d e r h o m e s. I n d i s c u ss i ng f o r m u l a p r e p arat i o n , w h i c h o f t h e f o ll o w i ng i s mo s t i mp o rt ant t o p r eve n t l ea d p o i s o n i ng?

A) U s e r e ad y - t o - f ee d co mme r c i a l i n f an t f o rm u l a

B) B o il t h e t a p w at e r f o r 10 m i nu t e s p r i o r t o p r e p ar i ng t h e f o r m u l a

C) L e t t a p w at e r r un f o r 2 m i nu t e s b e f o r e add i ng t o co n ce n tr a t e

D) B u y b o tt l e d w at e r l ab e l e d " l e ad f r ee " t o m i x t h e f o r m u l a

R eview Information : T h e co rr e ct an s w e r i s : C ) L e t t a p w at e r r un f o r 2 m i nu t e s b e f o r e add i ng t o concentrate.

U s e o f l e ad - co n t ami n at e d w at e r t o p r e p ar e f o r mu l a i s a m aj o r s o u r c e o f p o i s o n i ng i n i n f an t s. D r i n k i ng w a t e r m ay b e co n t am i n at e d b y l e ad f r o m o l d l e ad p i p e s o r l ea d s o l d e r u s e d i n s ea li ng w at e r p i p e s. L e tt i ng t a p w at e r r un f o r s eve r a l m i nu t e s w ill d i m i n i s h t h e l e ad co n tami n at i o n.

Question 33

A c li e n t i s ad m itt e d t o t h e r e hab ili t at i on un i t f o ll o w i ng a CVA and m il d d y s phag i a. T h e MOS T app r o p r i at e i n t e r ve n t i o n f o r t h i s c li e n t i s

A) Po s i t i o n c li e n t i n up r i gh t p o s i t i o n w h il e e at i ng

B) P l a c e c li e n t o n a c l e ar li qu i d d i e t

C) Til t h e ad b ack t o f a c ili t at e s w al l o w i ng r e f l ex

D) O ff e r f i ng e r f oo d s s u c h as cr acke r s o r p r e t z e l s

R eview Information : T h e co rr e ct an s w e r i s : A ) Po s i t i o n c li e n t i n up r i gh t p o s i t i o n w h il e e at i ng.

A n up r i gh t p o s i t i o n f ac ili t at e s p r o p e r c h e w i ng and s w al l o w i ng.

Question 34

T h e nu r s e ex p l ai n s a n au t o g r af t t o a c li e n t s c h e du l e d f o r ex ci s i o n o f a s k i n t u mo r. T h e nu r s e k n o w s t h e c li e n t und e r s t and s t h e p r oce dur e w h e n t h e c li e n t s ay s , " I w ill r e c e i ve t i ss u e f r o m

A) a t i ss u e ban k. "

B) a p i g. "

C) m y t h i gh. "

D) s y n t h e t i c s k i n. "

R eview Information : T h e co rr e ct an s w e r i s : C ) m y t h i gh. ".

A u t o g r af t s ar e d o n e w i t h t i ss u e tr an s p l a n t e d f r om t h e c li e n t ''s o w n s k i n.

Question 35

T h e nu r s e i s c ar i ng f o r a n e w b o r n w i t h tr ac h eoe s o phag e al f i s t u l a. W h ic h o f t h e f o ll o w i ng nu r s i ng d i agn o s e s i s a P R I OR I TY?

A) R i s k f o r d e h y d r at i o n

B) I n e ff e c t i ve ai r w ay c l e ar an c e

C) A l t e r e d nu tr it i o n

D) R i s k f o r i n j u r y

R eview Information : T h e co rr e ct an s w e r i s : B ) I n e ff e ct i ve ai r w ay c l e ar an ce.

T h e mo s t co mmo n f o rm o f T E F i s o n e i n w h i c h t h e p r ox i m a l e s o phag ea l s e g m e n t t e rm i n at e s i n a b li nd p o u c h and t h e d i s t a l s e g m e n t i s co nn e ct e d t o t h e tr ac h ea o r p r im ar y b r o n c hu s b y a s h o rt f i s t u l a at o r n e ar t h e b i f u r c at i o n. T hu s , a p r i o r i t y i s ma i n t ai n i ng a n o p e n a i r w ay , p r eve n t i ng a s p i r at i o n. O t h e r nu r s i ng d i agn o s e s ar e t h e n add r e ss e d.

Question 36

A c li e n t h as b ee n h o s p i t a li z e d a ft e r an a u t o mo b il e acc i d e nt. A f u ll l e g cas t w as a pp li e d i n t h e e m e r g e n cy r oo m. T h e MOS T i m p o rt ant r easo n f o r t h e nu r s e t o e l eva t e t h e c as t e d l e g i s t o

A) P r o mot e t h e c li e n t' s co m f o rt

B) Re du c e t h e d r y i ng t i m e

C) D e cr ease i rr it at i o n t o t h e s k i n

D) I mp r ove ve n o u s r e t u r n

R eview Information : T h e co rr e ct a n s w e r i s : D ) I mpr ove ve n o u s r e t u r n.

E l ev at i ng t h e l e g b o t h i m p r ove s ve n o u s r e t u r n and r e du ce s s w e lli ng.

Question 37

A nu r s e i s w o r k i ng w i t h f am il y m emb e r s o f a n e w l y d i agn o s e d c li e n t w i t h A l z h e im e r's d i s ease. W h ic h o f t h e f o ll o w i ng i n t e r ve n t i o n s i s MOS T h e l p f u l?

A) Teac h i ng r e l ax at i o n t ech n i qu e s

B) I mp l e m e nt i ng a d ai l y exe r c i s e r o u t i n e

C) I mp r ov i ng d ai l y nu tr it i o n a l i n t ake

D) Sugg e s t i ng co mm un i c at i o n s tr at e g i e s

R eview Information : T h e co rr e ct a n s w e r i s : D ) Sugg e s t i ng comm un i c at i o n s tr at e g i e s.

S i n ce A l z h e i m e r'' s d i s ease i s a p r o g r e ss i ve c h r o n i c ill n e ss t h at g r e at l y c h al l e ng e s car e g i ve r s , t h e nu r s e can b e o f g r e at e s t a ss i s t an c e i n h e l p i ng f am il y t o i d e n t i fy l a nguag e ch ang e s , and s e l e ct ve r b al and n o n ve r b a l commun i c at i o n s tr at e g i e s t o m i n im i ze ab e rr an t b e h av i o r.

Question 38

T h e nu r s e i s t each i ng a c li e n t w i t h n o n - i n s u li n d e p e nd e n t d iab e t e s m e lli t u s ab o u t t h e p r e s c r i b e d d i e t. T h e nu r s e s h o u l d t each t h e c li e n t t o

A) Ma i n t a i n p r ev i o u s cal o r i e i n t ake

B) Kee p a can d y b ar ava il ab l e at al l t i m e s

C) Re du c e car b o h y d r a t e s i n t ake t o 25 % o f t o t a l c al o r i e s

D) K ee p a r e gu l ar s c h e du l e o f m ea l s a nd s n ack s

R eview Information : T h e co rr e ct a n s w e r i s : D ) Kee p a r e gu l ar s c h e du l e o f m ea l s and s n acks.

C u rr e n t l y , ca l o r i e - co n tr o ll e d d i e t s w i t h s tr i ct m e al p l an s ar e r ar e l y s ugg e s t e d f o r c li e n t s w h o h ave d i a b e t e s. Tr y t o i n co r p o r at e s c h e du l e o r f oo d c hang e s i n t o c li e n t s '' ex i s t i ng d i e t ar y p at t e r n s. H e l p c li e n t s l e ar n t o r e ad l ab e l s and i d e n t i fy s p e c if i c can n e d f oo d s , f r o z e n e n tr ee s , o r o t h e r f oo d s w h i c h ar e a c ce p t a b l e and t h o s e w h i c h s h o u l d b e avo i d e d.

Question 39

T h e mo t h e r o f a t w o mo n t h - o l d b a b y c al l s t h e nu r s e at a w e ll - b a b y c li n i c t w o d ay s af t e r t h e fi r s t D TaP i mm un i zat i o n. Sh e r e p o rt s t h at t h e b a b y f ee l s ve r y w ar m , h as cr i e d i n co n s o l a b l y f o r a s l o ng as t hr ee h o u r s , and h as had s eve r al s h ak i ng s p e ll s. T h e r e s p o n s e o f t h e nu r s e s h o u l d b e t o

A) i n s tr u c t t h e mo t h e r t o c al l 911 f o r an a m bu l an ce t o tr an s p o rt t h e i n f a n t

B) s ugg e s t t h at t h e s e ar e ex p e ct e d r ea c t i o n s and t o b e g i n eve r y 4 h o u r a n t i p y r e t i c s

C) t e ll t h e mo t h e r t o t ake t h e i n fan t im me d i at e l y t o t h e n e ar e s t e m e r g e n cy r oo m

D) g i ve i n s tr u ct i o n s t o b r i ng t h e i n f an t t o t h e c li n i c n o w

R eview Information : T h e co rr e ct an s w e r i s : A ) i n s tr u c t t h e mo t h e r t o cal l 911 f o r an a m bu lan c e t o tr an s p o rt t h e i n f a n t

T h e ex h i b i t e d f i nd i ng s o f t h e i n f a n t i nd i c at e a s eve r e r e act i o n t o t h e i mm un izat i o n s. I mme d iat e at t e n t i o n i s n ee d e d & an amb u lanc e w i t h tra i n e d s t a ff n ee d s t o tr an s p o rt b e c au s e o f t h e r i s k o f g r and ma l s e i z u r e s f r om p o t e n t i a l e n c e ph a l o p at h y w h i c h i s a cr i t i c a l r e act i o n. T h e mo t h e r w o u l d n ee d t o b e i n s tr u c t e d af t e r t h i s ac u t e r e act i o n t o i n f o r m t h e p r ov i d e r o f t h i s r ea c t i o n t o t h e fi r s t d o s e o f D TaP. B ase d o n t h e n ee d and r i s k i n vo l ve d t o t h e i n f an t , t h e h ea l t h car e p r ov i d e r m ay d e c i d e t h at f u rt h e r D TaP i mm un i zat i o n s ar e co n tr ai nd ic at e d f o r li f e. T h e c li n i c nu r s e w o u l d n ee d t o d ocu me n t i n t h e n o t e s f o r t h i s i n f an t : t h e i n s tr u c t i o n s g i ve n , f i nd i ng s r e p o rt e d b y t h e mo t h e r and s p e c if i c f o ll o w - up n ee d s f o r t h e n ex t c li n i c v i s i t i n r e l at i o n t o t eac h i ng and ev alu at i o n o f t h e o u t co m e o f t h i s eve n t.

Question 40

T h e nu r s e i s t each i ng a c l as s o n H I V p r eve n t i o n. W h ic h o f t h e f o ll o w i ng s h o u l d b e e m ph as ized as i n c r eas i ng ri s k?

A) D o n at i ng b l oo d

B) U s i ng pub li c b at h r oo ms

C) Unprotected sex

D) To u c h i ng a p e r s o n w i t h A ID S

R eview Information : T h e co rr e ct an s w e r i s : C ) U np r o t e c t e d s ex.

B e c au s e H I V i s s p r e ad t h r o ugh ex p o s u r e t o b o d il y f l u i d s , unp r o t e ct e d i n t e r co u r s e and s h ar e d d r ug p ar aph e r n a li a r ema i n t h e h i gh e s t r i s k f o r i n f e c t i o n.

Question 41

A 6 ye ar- o l d c h il d i s s ee n f o r t h e f i r s t t i m e i n t h e c li n i c. U p o n as s e ss m e n t , t h e nu r s e f i nd s t h at t h e c h il d h as s h o rt p al p e b r al fi ss u r e s , t h i nn e d upp e r li p , and h y p o p l as t i c ph iltr um o f t h e upp e r li p. T h e mo t h e r s t at e s t h at t h e c h il d s ee m s t o h ave p r o b l e m s i n l e ar n i ng t o co un t and r eco gni z i ng b as i c col o r s. B a s e d o n t h i s d at a, t h e nu r s e s u s p e ct s t h at t h e c h il d i s M O S T li ke l y s h o w i ng t h e e ff e c t s o f

A) C o ng e n i t al a bn o r mal i t i e s

B) C h r o n i c t oxo p lasm o s i s

C) Fe t a l a lco h o l s y nd r o m e

D) L e ad p o i s o n i ng

R eview Information : T h e co rr e ct an s w e r i s : C ) Fe t a l a l co h o l s y nd r o m e.

Majo r f e at u r e s o f f e t al a l c o h o l s y nd r o me co n s i s t o f f ac i a l a nd as s o c i at e d ph y s i c al f e at u r e s , s u c h a s s h o rt p a l p e b r a l fi ss u r e , h y p o p l as t i c ph il tr um , t h i nn e d upp e r li p , s h o rt , up t u r n e d n o s e. B e h av i o r a l p r o b l e m s , co gn i t i ve i m p airme nt and p s y c h o s o c i al d e fi c i t s ar e al s o as s o c i at e d w i t h t h i s s y nd r o me.

Question 42

T h e nu r s e i s p e r f o rm i ng t h e ad m i ss i o n as s e ss m e n t o f a c li e n t w i t h an ac u t e e p i s o d e o f as t h m a. W h i c h o f t h e f o ll o w i ng as s e ss m e n t s w o u l d t h e nu r s e an t i c i p at e f ind i ng?

A) P r o l o ng e d i n s p i r at i o n

B) E x p i r at o r y w h eeze s

C) E x p e c t o r at i ng l ar g e amo un t s o f pu r u l e n t m uco u s

D) Lethargy

R eview Information : T h e co rr e ct an s w e r i s : B ) E x p i r at o r y w h eeze s.

A s t h m a i s c h aract e r i z e d b y ex p i r at o r y w h ee z e s cau s e d b y o b s tr u c t i o n o f t h e a i r w ay s. W h eez e s ar e a h i gh p i t c h e d m u s i c al s o und s p r o du c e d b y a i r mo v i ng t h r o ugh n ar r o w e d a i r w ay s. C li e n t s o f t e n a ss o c i at e w h ee z e s w i t h t h e f ee li ng o f t i gh t n e ss i n t h e che s t.

Question 43

T h e nu r s e i s p l a nn i ng a m e al p l a n t h at w o u l d p r ov i d e t h e mo s t ir o n f o r a c h il d w i t h an e m i a. W h ic h o f t h e f o ll o w i ng d i nn e r me nu s w o u l d b e B ES T?

A) Fi s h s t i c k s , f r e n c h f r i e s , banan a, cook i e s , m ilk

B) Gro und b ee f p at t y , li m a b e an s , w h ea t r o ll , r a i s i n s , m il k

C) C h i cke n nugg e t s , m a c ar o n i, p eas , can t al o up e , m il k

D) Pe anu t bu tt e r and j e ll y s and w ic h , app l e s li c e s , m il k

R eview Information : T h e co rr e ct a n s w e r i s : B ) Gro und b ee f p a tt y , li m a b e an s , w h e at r o ll, r a i s i n s , m il k.

I r o n r i c h f oo d s i n c l ud e r e d me at , fi s h , e gg yo l k s , g r ee n l e af y ve g e t ab l e s , l e gu m e s , w h o l e g r a i n s , d r i e d f r u i t s s u c h as r ai s i n s. T h i s d i nn e r i s t h e b e s t cho i c e , h i gh i n i r o n and i s app r o p r i at e f o r a t o dd l e r.

Question 44

A t e n yea r- o l d c l i e n t i s r ecove r i ng f r om a s p l e n e ct o my f o ll o w i ng a tr aum at i c i n j u r y. T h e c li e n t s l ab o r at o r y r e s u l t s s h o w a h emo g l o b i n o f 9 g / d L and a h em at o c r i t o f 28 p e rc e n t. T h e B ES T app r oach f o r t h e nu r s e t o use is to

A) L i m i t m ilk a nd m il k p r o du ct s

B) En c o u r ag e b e d a c t i v i t i e s and g a m e s

C) P l an nu r s i ng c ar e ar o und l e ng t h y r e s t p e r i o d s

D) P r omot e a d i e t r i c h i n i r o n

R eview Information : T h e co rr e ct an s w e r i s : C ) P l an nu r s i ng c ar e ar o und l e ng t h y r e s t p e r i o d s.

T h e i n i t i al p r i o r i t y f o r t h i s c li e n t i s r e s t du e t o t h e i nab ili t y o f r e d b l oo d c e ll s t o car r y oxy g e n.

Question 45

T h e nu r s e p l ann i ng c a r e f o r a 12 ye ar- o l d c h il d w i t h s i c k l e ce ll d i s ease i n a vaso - o cc l u s i ve c r i s i s o f t h e e l b o w s h o u l d i n c l ud e w h i c h o n e o f t h e f o ll o w i ng a s a P R I O R I TY?

A) L i m i t fl u i d s

B) C li e n t co n tr o ll e d an a l g e s i a

C) C o l d co mp r e ss e s t o e l b o w

D) Pas s i ve r ang e o f mo t i o n exe r c i s e

R eview Information : T h e co rr e ct a n s w e r i s : B ) C li e n t co n tr o ll e d a n al g e s i a.

Man ag e me n t o f a c r i s i s i s d i r e c t e d t o w ar d s s upp o rt i ve and s y m p t om at i c tr e at m e nt. T h e p r i o r i t y o f car e i s p a i n r e l i e f. I n a 12 yea r- o l d c h il d , c li e n t co n tr o l l e d an a l g e s i a p r o mo t e s m ax i m um com f o rt.

Question 46

A s t h e nu r s e p r ov i d e s d i s c h ar g e t each i ng t o t h e p ar e n t s o f a 15 mo n t h- o l d ch il d w i t h K a w asak i D i s ea s e w h o h a s r ece i ve d imm un o g l o bu li n t h e r ap y , w h i c h o n e o f t h e f o ll o w i ng i n s tr u c t i o n s w o u l d b e MOS T a pp r o p r i at e?

A) H i gh d o s e s o f a s p i r i n w ill b e co n t i nu e d f o r s o m e t i m e

B) C o mp l e t e r e c ove r y i s ex p e ct e d w i t h i n s eve r al d ay s

C) A ct i ve r a ng e o f mo t i o n exe rc i s e s s h o u l d b e d o n e f r e qu e n t l y

D) T h e m eas l e s , m u mp s and r ub e ll a vacc i n e s h o u l d b e d e l aye d

R eview Information : T h e co rr e ct a n s w e r i s : D ) T h e meas l e s , mump s and r ub e ll a vacc i n e s h o u l d b e d e l aye d.

D i sc h a r g e i n s tr u c t i o n s f o r a c h il d w i t h K aw asak i D i s ease s h o u l d i n c l ud e i mm un o g l o bu li n t h e rap y m ay i n t e r f e r e w i t h t h e b o d y '' s ab ili t y t o f o rm a pp r o p r i at e a m o un t s o f an t i b o d i e s and li ve i mm un izat i o n s s h o u l d b e d e l aye d.

Question 47

T h e nu r s e i s g i v i ng i n s tr u ct i o n s t o t h e p ar e n t s o f a ch il d w i t h C y s t i c Fi b r o s i s. T h e nu r s e w o u l d e m ph asi z e t h at pan c r e at i c e n z ym e s s h o u l d b e t ake n

A) Once each day

B) T h r ee t i me s d ai l y af t e r m ea l s

C) Wi t h eac h me al o r s n ack

D) E ac h t im e car b o h y d r at e s ar e e at e n

R eview Information : T h e co rr e ct an s w e r i s : C ) W i th ea c h me al o r s n a c k.

Pan c r ea t i c e n zy me s s h o u l d b e t ake n w i t h ea c h m e al and eve r y s n a c k t o a ll o w f o r d i g e s t i o n o f a ll f oo d s t h a t are eaten.

Question 48

T h e nu r s e i s a s s e ss i ng an e i gh t mo nt h - o l d i n f a n t w i t h a m al f un cti o n i ng ve n tr i c u l o p e r i t o n e al s hun t. W h i c h o n e o f t h e f o ll o w i ng man i f e s t a t i o n s w o u l d t h e i n f a n t b e MOS T li ke l y t o ex h i b i t?

A) Lethargy

B) I rr i t ab ilit y

C) N e g at i ve M o r o

D) D e p r e ss e d f o n t an e l

R eview Information : T h e co rr e ct an s w e r i s : B ) I rr i t a b ilit y. S i gn s o f II C P ( i n c r ease d i n tr acr an ia l p r e ss u r e ) i n i n f a n t s i n c l ud e bu l g i ng f o n t an e l, i n s t a b ili t y , h i gh - p i t c h e d cr y , and cr i e s w h e n h e l d. V i t a l s i gn c hang e s i n c l ud e pu l s e t h at i s v ar i a b l e , i. e. , r ap i d , s l o w and b o und i ng , o r f ee b l e. Re s p i r at i o n s ar e mo r e o ft e n s l o w , d ee p , and i rr e gu l ar.

Question 49

T h e nu r s e i s p e r f o rm i ng a ph y s i c al as s e ss m e n t o n a t o dd l e r. W h ic h o f t h e f o ll o w i ng s h o u l d b e t h e FI R S T a c t i o n?

A) Pe r f o rm tr aum at i c pr oce dur e s

B) U s e m i n im al ph y s i c a l co n t act

C) P r o c ee d f r om h e ad t o t oe

D) E x p l ai n t h e ex am i n d e t ai l

R eview Information : T h e co rr e ct a n s w e r i s : B ) U s e m i n im al ph y s i c al co n t ac t.

T h e nu r s e s h o u l d app r oa c h t h e t o dd l e r s l o w l y a nd u s e m i n im al ph y s i c a l co n t a ct i n i t i al l y s o a s t o g ai n t h e t o dd l e r '' s coo p e r a t i o n. B e f l ex i b l e i n t h e s e qu e n c e o f t h e exa m , a nd g i ve o n l y b r i e f s i mp l e ex p l an at i o n s j u s t p r i o r t o t h e a c t i o n.

Question 50

A c li e n t h as b ee n t e n t a t i ve l y d i agn o s e d w i t h Grave s ' d i s ease ( h y p e rt h y r o i d i s m ). W h i c h o f t h e f o ll o w i ng s y m p t om s n o t e d o n t h e i n i t i al nu r s i ng as s e ss m e n t i s ex p e c t e d?

A) Re c e n t w e i gh t g a i n

B) P h y s i c a l g r o w t h d e l ay

C) P r o tr ud i ng eye b a ll s

D) Sudd e n o n s e t o f i rr i t ab ilit y

R eview Information : T h e co rr e ct a n s w e r i s : C ) P r o tr ud i ng eye b al l s.

E xo ph t h al mo s o r p r o tr ud i ng eye b al l s i s a d i s t i n ct i ve ch aract e r i s t i c o f Grave s '' D i s ea s e.

Question 51

W h e n a ss e ss i ng a c li e n t ad m itt e d t o t h e h o s p i t a l f o r d i a b e t i c a c i d o s i s , w h i c h o f t h e f o ll o w i ng c li n i c al man i f e s t a ti o n s w o u l d t h e nu r s e ex p e c t?

A) A b l oo d p H l eve l ab ove 7. 5

B) A rt e r i al b l oo d P C O 2 a b ove 40

C) B l oo d p H l eve l b e l o w 7. 3

D) A rt e r i a l b l oo d P C O 2 b e l o w 10

R eview Information : T h e co rr e ct a n s w e r i s : C ) B l oo d p H l eve l b e l o w 7. 3.

I n t h e ab s e n c e o f i n s u li n , w h i c h f ac il i t at e s t h e tr an s p o rt o f g l u co s e i n t o t h e c e ll, t h e b o d y b r eak s d o w n f ats and p r o t e i n s t o s upp l y e n e r g y ke t o n e s , a b y - p r o du ct o f f at m e t ab o li s m. T h e s e a c cu m u l at e cau s i ng me t a b o li c ac i d o s i s ( p H < 7. 3 ).

Question 52

T h e nu r s e i s ex p l a i n i ng t h e p r o p e r u s e o f s y r up o f i p e c a c t o a g r o up o f p ar e n t s. Fo r w h i c h o f t h e f o ll o w i ng a cc i d e n t al p o i s o n i ng s i s t h e tr e at m e n t app r o p r i at e?

A) O ve n c l e an e r

B) D r ai n c l e an e r

C) Kerosene

D) C h e w a b l e v i t am i n s

R eview Information : T h e co rr e ct a n s w e r i s : D ) C h e w a b l e v i t am i n s.

O f t h e ab ove c h o i c e s , p o i s o n i ng w i t h v i t am i n s i s t h e o n l y c ase i n w h i c h i t i s saf e t o i ndu c e vo m it i ng w i t h s y r up o f i p ecac.

Question 53

A t w o ye ar- o l d c h il d i s b r o ugh t t o t h e p e d i at r i c i a n 's o f fi ce w i t h a c h i e f co mp l a i n t o f m il d d i arrh ea f o r t w o d ay s. N u tr i t i o n al co un s e li ng b y t h e nu r s e s h o u l d i n c l ud e w h i c h o n e o f t h e f o ll o w i ng s t at e me n t s?

A) P l a c e t h e c h il d o n c l e ar li qu i d s and g e l at i n f o r 24 h o u r s

B) C o n t i nu e w i t h t h e r e gu l ar d i e t a nd i n c l ud e o r al r e h y d r at i o n f l u i d s

C) G i ve bananas , app l e s , r i c e and t oas t as t o l e r at e d

D) P l ace N P O f o r 24 h o u r s , t h e n r e h y d r at e w i t h m il k a nd w a t e r

R eview Information : T h e co rr e ct an s w e r i s : B ) C o n t i nu e w i t h t h e r e gu l ar d i e t a nd i n c l ud e o r al r e h y d r at i o n fl u i d s.

C u rr e n t r ecomm e nd at i o n s f o r m il d t o mo d e r a t e d i ar r h ea ar e t o m ai n t a i n a n o r ma l d i e t w i t h re h y d r at i o n fl u i d s.

Question 54

T h e nu r s e i s t each i ng an e l d e r l y c li e n t h o w t o u s e MD I 's (m u lt i - d o s e i nh al e r s ). T h e nu r s e i s co n cer n e d t h at t h e c li e n t i s unab l e t o coo r d i n at e t h e r e l ease o f t h e me d i c at i o n w i t h t h e i nh a l at i o n ph ase. T h e nu r s e ' s B ES T r ecomm e nd at i o n f o r t h e c li e n t i s

A) N e bu li ze d tr ea t me n t s f o r h o me c ar e

B) A dd i ng a s p a c e r d ev i ce t o t h e MD I c an i s t e r

C) A s k i ng a f am il y mem b e r t o as s i s t t h e c li e n t w i t h t h e MD I

D) Re qu e s t a v i s i t i ng nu r s e t o f o ll o w t h e c li e n t at h o m e

R eview Information : T he co rr e ct an s w e r i s : B ) A dd i ng a s p ace r d ev i c e t o t h e MD I can i s t e r.

T h e m aj o r i t y o f pu l m o n ar y m e d ic a t i o n s f o r C O P D ar e d e li ve r e d b y inh a l at i o n. T h i s i s o ft e n p r e f e rr e d ove r o r a l adm i n i s tr at i o n b e c au s e a l o w e r d r ug d o s e i s n ee d e d and s y s t e m i c s i d e e ff e c t s ar e r e du ce d. I n add i t i o n , t h e o n s e t o f a c t i o n o f b r o n c h o d il at o r m e d i c a ti o n g i ve n v i a i nh a l at i o n i s f a s t e r.

Question 55

W h i c h o f t h e f o ll o w i ng m an i f e s t at i o n s o b s e r ve d b y t h e s c h oo l nu r s e co n fi r ms t h e p r e s e n c e o f p e d i c u l o s i s cap i t i s i n s t ud e n t s?

A) S c r at c h i ng t h e h ea d mo r e t han u s u al

B) F l ake s ev i d e n t o n a s t ud e n t ' s s h o u l d e r s

C) O va l p at t e r n o cc i p it al h ai r l o ss

D) W h it i s h ova l s p e c k s s t i c k i ng t o t h e h ai r

R eview Information : T h e co rr e ct an s w e r i s : D ) W h it i s h ov al s p e c k s s t i c k i ng t o t h e h ai r.

D iagn o s i s o f p e d i c u l o s i s cap i t i s i s mad e b y o b s e r v at i o n o f t h e w h i t e e gg s ( n i t s ) fi r m l y at t ache d t o t h e h a i r s h af t s. Tr e at me n t i n c l ud e s s h amp oo app li c a t i o n , s u c h as li ndan e f o r c h il d r e n ove r 2 ye ars o f ag e , and me ti c ul o u s co mb i ng and r emo v al o f a ll n i t s.

Question 56

W h e n p ar e n t s ca ll t h e e mer g e n c y r oom t o r e p o rt t h at a t o dd le r h as s w al l o w e d d r ai n c l e an e r , t h e nu r s e i n s tr u c t s t h em t o ca ll f o r e me r g e n c y tr an s p o rt t o t h e h o s p i t a l. W h il e w ait i ng f o r a n amb u l anc e , t h e B ES T a c t i o n t h e nu r s e w o u l d s ugg e s t t o t h e p ar e n t s i s

A) A dm i n i s t e r s y r up o f i p e c a c

B) O ff e r s m a ll amo un t s o f w at e r

C) H ave t h e c h il d d r i n k m ilk

D) Gi ve g i ng e r al e o r co l a

R eview Information : T h e co rr e ct an s w e r i s : B ) O ff e r s m a ll amo un t s o f w at e r.

S ma ll amo un t s o f w a t e r w ill d il u t e t h e co rr o s i ve s ub s t an c e p r i o r t o g as tri c l av ag e.

Question 57

A c li e n t i s s c h e du l e d f o r an I V P ( I n tr ave n o u s Pye l o g r a m ). W h ic h o f t h e f o ll o w i ng d at a f r o m t he c li e n t's h i s t o r y i nd i c a t e a p o t e n t i al h aza r d f o r t h i s t e s t?

A) Re fl ex i n co n t i n e n ce

B) A ll e r g i c t o s h e ll fi s h

C) C l au s tr o ph o b i a

D) H y p e rt e n s i o n

R eview Information : T h e co rr e ct an s w e r i s : B ) A ll e r g i c t o s h e ll fi s h. I t i s i m p o rt an t t o k n o w i f t h e c li e n t h as an al l e r g y t o i o d i n e o r s h e ll f i s h. I f t h e c li e n t d oe s , t h ey m ay h ave an al l e r g i c r e act i o n t o t h e I V P co n tr as t d ye i n j e c t e d du r i ng t h e p r o c e du r e.

Question 58

A h i gh s c h oo l nu r s e i s a d v i s i ng a c l as s o f un w e d p r e gn a n t s t ud e n t s t h at t h e M O S T i mp o rt ant a c t i o n t h ey can p e r f o r m t o d e li ve r a h e al t h y c h il d i s

A) Ma i n t a i n i ng g oo d nu tr i t i o n

B) S t ay i ng i n s c h oo l

C) Kee p i ng i n co n t act w i t h t h e c h il d ' s f at h e r

D) Ge tt i ng ad e qu at e s l ee p

R eview Information : T h e co rr e ct an s w e r i s : A ) Ma i n t a i n i ng g oo d nu tr i t i o n. N u r s e s can s e r ve a p ivo t a l r o l e i n p r ov i d ing nu tr i t i o n a l e du c at i o n and case m anag em e n t i n t e r ve n t i o n s. W e i gh t g a i n du r i ng p r e gnan c y i s o n e o f t h e s tr o ng e s t p r e d i ct o r s o f i n f an t b i rt h w e i gh t. Sp e c ifi c a ll y , t ee n s n ee d t o i n c r ease t he i r i n t ake o f p r o t e i n , v i t am i n s , and m i n e r a l s i n c l ud i ng i r o n. P r e gn a n t t ee n s w h o g ai n b e t w ee n 26 and 35 p o und s h ave t h e l o w e s t i n c i d e n c e o f l o w - b i rt h - w e i gh t bab i e s.

Question 59

T h e nu r s e i s p r e p ar i ng a hand o u t o n in f an t f ee d i ng t o b e d i s tr i bu t e d t o f am ili e s v i s i t i ng t h e c li n i c. W h i c h o f t h e f o ll o w i ng s h o u l d b e i n c l ud e d i n t h e t eac h i ng m a t e r i a l s?

A) S o li d f oo d s ar e i n tr o du ce d o n e at a t i m e b e g i nn i ng w i t h c er e al

B) Fi n e l y g r o und m ea t s h o u l d b e s t ar t e d e ar l y t o p r ov i d e i r o n

C) Egg w h i t e i s add e d e ar l y t o i n c r ease p r o t e i n i n t ake

D) S o li d f oo d s s h o u l d b e m i xe d w i t h f o rm u l a i n a b o tt l e

R eview Information : T h e co rr e ct an s w e r i s : A ) S o li d f oo d s ar e i n tr o du ce d o n e at a t i m e b e g i nn i ng w i t h cereal.

S o li d f oo d s s h o u l d b e a dd e d o n e at a t i me b e t w ee n 4 - 6 mo n t h s. I f t h e i n f an t i s ab l e t o t o l e r at e t h e f oo d , an o t h e r m ay b e add e d i n a w eek. I r o n f o rt ifi e d ce r e al i s t h e r ecomm e nd e d fi r s t f oo d.

Question 60

T h e nu r s e i s c ar i ng f o r a c li e n t w i t h s i ck l e cel l d i s ease w h o i s s c h e du l e d t o r ece i ve a un i t o f p acke d r e d b l oo d ce ll s. W h i c h o f t h e f o ll o w i ng i s a n app r o p r i at e ac t i on f o r t h e nu r s e w h e n ad m i n i s t e r i ng t h e i n f u s i o n?

A) S t o r i ng t h e p a c ke d r e d c e ll s i n t h e m e d i c i n e r e f r i g e r at o r w h il e s t ar t i ng I V

B) S l o w t h e r at e o f i n f u s i o n i f t h e c li e n t d eve l o p s f eve r o r c h i ll s

C) L i m i t t h e i n f u s i o n t i me o f ea c h o f t h e un i t t o a m ax i m um o f f o u r h o u r s

D) A ss e ss v i t al s i gn s eve r y 15 m i nu t e s t h r o ugh o u t t h e e n t ir e i n f u s i o n

R eview Information : T h e co rr e ct an s w e r i s : C ) L i m i t t h e i n f u s i o n t i m e o f ea c h o f t h e un i t t o a m ax i m um of four hours.

I n f u s e t h e s p e c if i e d amo un t o f b l oo d w i t h i n 4 h o u r s. I f t h e i n f u s i o n w ill excee d t h i s t i me , t h e b l oo d s h o u l d b e d i v i d e d i n t o app r o p r i at e l y s i z e d quan t i t i e s.

Question 61

A c li e n t w i t h a d o c u m e n t e d pu l m o n ar y e mb o li s m h as t h e f o ll o w i ng ar t e r i a l b l oo d g ase s : P O 2 - 70 mm hg , P C O2 - 32 mm hg , p H - 7. 45 , S a O 2 - 87%, H C O3 - 22. B ase d o n t h i s d at a, w h at i s t h e FI R S T nu r s i ng act i o n?

A) Rev i e w o t h e r l ab d at a

B) N o t i fy t h e ph y s i c i a n

C) A dm i n i s t e r oxy g e n

D) C a l m t h e c li e n t

R eview Information : T h e co rr e ct a n s w e r i s : C ) A d m i n i s t e r oxy g e n.

T h e c li e n t h as a l o w P C O2 du e t o i n c r ease d r e s p i r at o r y r at e f r o m t h e h y p oxe m i a a nd s i gn s o f r e s p i r at o r y al k al o s i s. I mm e d i at e i n t e r ve n t i o n i s i nd i c a t e d.

Question 62

A c li e n t d i a gn o s e d w i t h h e p at i t i s C d i s c u ss e s h i s h e al t h h i s t o r y w i t h t h e ad m i tt i ng nu r s e. T h e nu r s e s h o u l d r eco gni z e w h i c h o f t h e f o ll o w i ng as t h e MOS T i m p o rt ant d ata?

A) Re c e n t tr ave l t o C e n tr al A m e r i c a

B) I ng e s t i o n o f r aw s h e llf i s h l a s t w eek

C) Mu l t ip l e s ex p ar t n e r s

D) B l oo d tr an s f u s i o n 15 ye ars ag o

R eview Information : T h e co rr e ct a n s w e r i s : D ) B l oo d tr an s f u s i o n 15 ye ars ag o.

T h e c li e n t w h o w as tr an s f u s e d p r i o r t o b l oo d s c r ee n i ng f o r h e p at i t i s C may s h o w s y m p t om s m an y ye ars l at e r.

Question 63

A c li e n t i s r ecove r i ng f r o m a t h y r o i d e c t om y. W h il e mo n it o r i ng t h e c li e n t's i n i t i a l p o s t o p e r at i ve co nd i t i o n , w h i c h o f t h e f o ll o w i ng s h o u l d t h e nu r s e r e p o rt imm e d i at e l y?

A) Te t an y and p ar e s t h e s i a

B) M il d s tr i d o r a nd h o ars e n e s s

C) I rr i t ab ilit y and i n s o mn i a

D) Headache and nausea

Review Information : The correct answer is:

A ) Te t an y and p ar e s t h e s i a.

B e c au s e t h e p arat h y r o i d g land m ay b e d amag e d i n t h i s s u r g e r y , s eco nd ar y h y p oca l c em i a may o cc u r. S y mp t o m s o f h y p o p arat h y r o i d i s m i n c l ud e t e t an y , p a r e s t h e s i a, m u s c l e c r amp s and s e i z u r e s.

Question 64

A c li e n t i s ad m itt e d w i t h a r i gh t upp e r l o b e i n fil tr at e , and al s o t o r u l e o u t t ub e r c u l o s i s. T h e i s o l at i o n p r ecau t i o n s t h e nu r s e w o u l d i n s t i t u t e i n c l ud e

A) Po s i t i ve p r e ss u r e ve n t il at i o n

B) Go w n and g l ove s

C) Par t i c u l at e r e s p i r at o r m ask

D) B ar r i e r p r ecau t i o n s

R eview Information : T h e co rr e ct an s w e r i s : C ) Par t i c u l at e r e s p i r at o r m ask.

T i gh t fi tt i ng , h i gh - e f f i c i e n c y m ask s ar e r e qu i r e d w h e n c ar i ng f o r c li e n t s w h o h ave s u s p e c t e d comm un i c ab l e d i s ease o f t h e ai r b o r n e v ar i e t y.

Question 65

A c li e n t had 20 m g o f L as i x ( f u r o s e m i d e ) P O at 10 A M. W h i c h w o u l d b e e ss e n t i a l f o r t h e nu r s e t o i n c l ud e at t h e c hang e o f s h i f t r e p o rt?

A) T h e c li e n t l o s t 2 p o und s

B) T h e c li e n t ' s p o t as s i um l eve l i s 4 m Eq / li t e r.

C) T h e c li e n t ' s u r i n e o u t pu t w as 1500 cc i n fi ve h o u r s

D) T h e c li e n t i s t o r ece i ve a n o t h e r d o s e o f L as i x at 10 P M

R eview Informatio n : T h e co rr e ct an s w e r i s : C ) T h e c li e n t ' s u r i n e o u t pu t w as 1500 cc i n fi ve h o u r s.

A l t h o ugh al l o f t h e s e may b e co rr e ct i n f o r m at i o n t o i n c l ud e i n r e p o rt , t h e e ss e n t i al p i ece w o u l d b e t h e u r i n e o u t pu t.

Question 66