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NGN RN COMPREHENSIVE PREDICTOR EXAM 2024| 180 QUESTIONS AND VERIFIED ANSWERS AND EXPLANATIONS (TYPED VERSION)
Typology: Exams
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Question 1:
A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?
A. Perform the procedure twice each day. B. Hold the hand flat to perform percussions on the child. C. Administer a bronchodilator after the procedure. D. Perform the procedure prior to meals.
Explanation
A. Incorrect. Postural drainage is usually performed multiple times a day, usually three to four times, to effectively mobilize respiratory secretions. B. Incorrect. Percussions are typically performed using cupped hands to create vibrations. Holding the hand flat would not produce the desired effect. C. Correct. Administering a bronchodilator after postural drainage helps open the airways, facilitating easier breathing and the removal of mucus. D. Incorrect. Postural drainage is commonly performed before meals to prevent the risk of vomiting and aspiration.
Question 2:
A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?
A. Maintain eye contact with the newborn during feedings. B. Swaddle the newborn with his legs extended. C. Minimize noise in the newborn's environment. D. Administer naloxone to the newborn.
Explanation
A. Incorrect. While maintaining eye contact during feedings is generally beneficial for bonding, it's not a specific intervention for managing neonatal abstinence syndrome.
B. Incorrect. Swaddling a newborn with extended legs might be uncomfortable, as newborns with neonatal abstinence syndrome can experience increased muscle tone and jitteriness. C. Correct. Newborns with neonatal abstinence syndrome can be hypersensitive to stimuli, including noise. Minimizing noise in the environment helps reduce stress and overstimulation. D. Incorrect. Naloxone is not typically administered to newborns with neonatal abstinence syndrome. The syndrome is managed through supportive care, gradually reducing exposure to the substance.
Question 3:
A nurse is admitting a client to a medical-surgical unit. When performing medication reconciliation for the client, which of the following actions should the nurse take?
A. Include any adverse effects of the medications the client might develop. B. Exclude nutritional supplements from the list of medications the client reports. C. Encourage the client to make his own list after he returns to his home. D. Compare new prescriptions with the list of medications the client reports.
Explanation
A. Incorrect. While adverse effects are important to consider, the primary purpose of medication reconciliation is to ensure accurate and up-to-date medication information.
B. Incorrect. Nutritional supplements and over-the-counter medications should be included in the medication reconciliation process to provide a comprehensive overview of the client's medication regimen.
C. Incorrect. The nurse is responsible for accurately reconciling the client's medications during the admission process. Encouraging the client to create a list later may lead to inaccuracies.
D. Correct. Comparing new prescriptions with the client's reported medication list helps identify any discrepancies or potential interactions, ensuring safe and effective medication administration.
Question 4:
A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?
A. "The child usually has an aura prior to onset."
B. "This type of seizure can be mistaken for daydreaming." C. "This type of seizure lasts 30 to 60 seconds." D. "This type of seizure has a gradual onset."
Explanation
A. Incorrect. Absence seizures typically do not have an aura. They are characterized by a sudden and brief loss of awareness without warning.
B. Correct. Absence seizures often involve a brief period of staring and decreased responsiveness. They can indeed be mistaken for daydreaming, as they are not as dramatic as other types of seizures.
C. Incorrect. Absence seizures are usually very brief, lasting only a few seconds (often less than 10 seconds), rather than 30 to 60 seconds.
D. Incorrect. Absence seizures have a sudden and abrupt onset, not a gradual one. They occur without warning and without a preceding aura.
Question 5:
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
A. Reinforce orientation to time, place, and person. B. Allow the client to choose among a variety of activities each day. C. Give the client one simple direction at a time. D. Establish eye contact when communicating with the client. E. Refute the client's delusions using logic.
Explanation
A. Correct. Reinforcing orientation to time, place, and person helps ground the client in reality, even if their memory is impaired.
B. Correct. Allowing the client to choose activities empowers them and helps maintain a sense of control.
C. Correct. Providing one simple direction at a time helps prevent confusion and frustration for clients with dementia.
D. Correct. Establishing eye contact while communicating can enhance the client's focus and understanding.
E. Incorrect. It's generally not effective to try to refute a client's delusions using logic.
Redirecting or validating their feelings might be more appropriate.
Question 6:
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
A. Bleeding gums
B. Faintness upon rising C. Swelling of the face D. Urinary frequency
Explanation
A. Incorrect. Bleeding gums can be a common finding during pregnancy due to hormonal changes, but they are not typically considered a serious concern unless severe.
B. Correct. Faintness upon rising can be a sign of orthostatic hypotension, which can be a concern during pregnancy and should be reported to the provider.
C. Incorrect. Mild swelling of the face can also occur during pregnancy, but significant or sudden swelling might be a sign of a condition like preeclampsia.
D. Incorrect. Urinary frequency is a common symptom of pregnancy due to increased pressure on the bladder from the growing uterus.
Question 7:
A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practical nurse?
A. Perform a sterile dressing change for a client who has an abdominal wound. B. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus. C. Perform an admission assessment for a client who is scheduled for surgery. D. Complete the Glasgow Coma Scale for a client who has an evolving stroke.
Explanation
A. Correct. Performing a sterile dressing change falls within the scope of practice for a licensed practical nurse (LPN).
B. Incorrect. Discharge teaching often involves complex information and considerations, which are typically better suited for a registered nurse.
C. Incorrect. An admission assessment requires comprehensive assessment skills that are typically performed by registered nurses.
D. Incorrect. Completing assessments related to complex neurological changes, such as the Glasgow Coma Scale for a stroke, is typically within the scope of a registered nurse.
Question 8:
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?
A. Provide oral hygiene care. B. Administer an antiemetic medication. C. Replace the NG tube. D. Evaluate the functioning of the suction device.
Explanation
A. Correct. Providing oral hygiene care is the first priority after a client has vomited to prevent complications and ensure their comfort.
B. Incorrect. While administering an antiemetic medication might be considered, providing oral hygiene care to the client is the immediate priority.
C. Incorrect. Replacing the NG tube is not typically the first action to take after a client vomits. Addressing oral hygiene and assessing the client's condition comes first.
D. Incorrect. Evaluating the functioning of the suction device is important, but addressing the client's immediate comfort and preventing complications take precedence.
Question 9:
A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?
A. Apply the largest cuff available. B. Place the arm above the level of the client's heart. C. Deflate the cuff quickly. D. Use the palpatory method to determine blood pressure.
Explanation
A. Incorrect. Avoiding the issue by scheduling the nurses to have fewer shifts together might not address the underlying conflict and could lead to resentment.
B. Incorrect. To auscultate blood pressure accurately, it's essential to follow proper positioning and technique, which typically involves having the client's arm at heart level. Placing the arm above heart level can lead to falsely lower blood pressure readings.
C. Incorrect. While promising more equitable assignments is important, addressing the conflict directly and encouraging collaboration is a more proactive approach.
D. Using the palpatory method, the nurse can feel for the radial pulse while slowly deflating the blood pressure cuff. This helps estimate the systolic blood pressure when Korotkoff sounds are challenging to hear. It provides a rough estimate until clear sounds can be heard and ensures accurate blood pressure measurement.
Question 10:
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
A. Use gestures to convey meaning. B. Speak slowly when talking to the interpreter. C. Speak directly to the client. D. Pause in the middle of sentences.
Explanation
A. Incorrect. While some gestures can be helpful in communication, they might not always convey complex medical information accurately.
B. Incorrect. Speaking slowly might not necessarily enhance understanding, especially if the client's primary language is different from the nurse's.
C. Correct. When using an interpreter, the nurse should address the client directly and speak as if they are having a direct conversation with the client.
D. Incorrect. Pausing in the middle of sentences can disrupt the flow of communication and might not facilitate understanding.
Question 11:
A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take?
A. Encourage rural residents to focus health spending on tertiary health interventions. B. Launch a media campaign to increase awareness about industrial pollution. C. Have a nurse from outside the community provide health lectures at the county hospital. D. Provide anticipatory guidance classes to parents through public schools.
Explanation
A. Incorrect. Encouraging a focus on tertiary health interventions might not address the preventive health needs of the population.
B. Incorrect. While raising awareness about industrial pollution is important, it might not be the primary focus of a public health program in a rural area.
C. Incorrect. Utilizing a nurse from outside the community might not be the most effective approach for understanding the specific health needs and context of the local population.
D. Correct. Providing anticipatory guidance classes to parents through public schools is a community-based preventive approach that can address the health needs of families and children in the area.
Question 12:
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?
A. Clamp the catheter tubing for 30 min. B. Obtain a urine specimen for culture and sensitivity. C. Initiate continuous bladder irrigation. D. Administer a fluid bolus.
Explanation
A. Incorrect. Clamping the catheter tubing might not be necessary in this situation and could potentially cause urinary retention.
B. Correct. Dark yellow urine can be an indication of concentrated urine or blood in the urine. Obtaining a urine specimen for culture and sensitivity can help identify any infection or other issues.
C. Incorrect. Continuous bladder irrigation might be indicated for specific situations, such as after certain surgeries, but it is not the first-line intervention based solely on the description provided.
D. Incorrect. Administering a fluid bolus might not be necessary unless there are other signs of dehydration or fluid imbalance.
Question 13:
A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
A. Beneficence B. Autonomy C. Fidelity D. Veracity
Explanation
A. Correct. Beneficence refers to the ethical principle of doing good and taking actions that promote the well-being and best interests of the client. Sitting with the client to provide comfort aligns with this principle.
B. Incorrect. Autonomy relates to respecting the client's right to make decisions about their own care and treatment.
C. Incorrect. Fidelity pertains to keeping promises and maintaining trust in the nurse-client relationship.
D. Incorrect. Veracity involves truthfulness and honesty in communication with clients, particularly in providing accurate information about their care and condition.
Question 14:
A nurse is caring for a female client who requests a contraceptive diaphragm. Which of the following actions should the nurse take first?
A. Document the client's level of understanding about potential adverse effects. B. Teach the client how to insert the diaphragm. C. Determine the client's knowledge about diaphragm use. D. Supervise return demonstration of diaphragm use.
Explanation
A. Incorrect. Documenting the client's understanding of adverse effects is important, but ensuring the client's knowledge about diaphragm use is the first step.
B. Incorrect. Teaching the client how to insert the diaphragm can be an important step, but first, it's essential to assess the client's existing knowledge.
C. Correct. Before proceeding with teaching or other actions, it's important to determine the client's baseline understanding of diaphragm use.
D. Incorrect. Supervising the return demonstration is important but should come after the client's knowledge level is assessed.
Question 15:
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
A. Encourage the client to watch television. B. Sit with the client to provide a sense of security. C. Administer a dose of atomoxetine to decrease anxiety. D. Teach the client how to meditate.
Explanation
A. Incorrect. Encouraging the client to watch television might not provide the calming presence and support needed during a panic attack.
B. Correct. Sitting with the client and providing a sense of security can help them feel more grounded and supported during the panic attack.
C. Incorrect. Atomoxetine is not typically used to treat acute panic attacks. It's a medication used for attention deficit hyperactivity disorder (ADHD).
D. Incorrect. Teaching the client how to meditate might be beneficial in the long term, but during an acute panic attack, the client may not be receptive to learning new techniques.
Question 16:
A nurse inadvertently administered 160 mg of valsartan PO to a client who was scheduled to receive 80 mg. Which of the following actions is the priority for the nurse to take?
A. Evaluate the client for orthostatic hypotension. B. Check the client for nasal congestion. C. Obtain the client's laboratory results.
D. Monitor the client's urine output.
Explanation
A. Correct. The priority is to assess the client for any adverse effects of the medication, such as a drop in blood pressure, which can result in orthostatic hypotension.
B. Incorrect. Nasal congestion is not typically associated with an overdose of valsartan.
C. Incorrect. While obtaining laboratory results might be necessary, it is not the priority action in this situation.
D. Incorrect. Monitoring urine output is important, but assessing for potential complications related to the overdose takes precedence.
Question 17:
A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include?
A. "Documentation of sensitive material is performed by the charge nurse." B. You will be given access to the medical records of every client in the facility. C. You will be asked to change your password once per year. D. "Information Technology will install a firewall to secure client information."
Explanation
A. Incorrect. Documentation of sensitive material might have designated personnel, but this information does not need to be limited to the charge nurse.
B. Incorrect. Access to medical records should be limited to those with a need for that information, not every nurse in the facility.
C. Correct. Regularly changing passwords helps maintain the security of the computerized documentation system.
D. Incorrect. While a firewall is an important security measure, it is not the primary responsibility of the nurse to install it.
Question 18:
A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?
A. Educate the family to avoid sharing personal belongings. B. Ensure the state health department has been notified. C. Administer antitoxin. D. Assess for skin necrosis.
Explanation
A. Correct. Lyme disease is primarily transmitted through ticks. Educating the family to avoid sharing personal belongings can help prevent the spread of ticks.
B. Incorrect. While notifying the state health department about communicable diseases is important, it might not be the nurse's immediate action in this situation.
C. Incorrect. Antitoxin is not used for treating Lyme disease. Lyme disease is caused by a bacterium, not a toxin.
D. Incorrect. Skin necrosis is not a common manifestation of Lyme disease. The primary symptoms include fever, fatigue, headache, and a characteristic skin rash known as erythema migrans.
Question 19:
A nurse is caring for a client who has experienced a stroke and is moving in with their adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
A. Minimize open discussion regarding the changes to avoid embarrassment. B. Decrease socialization with extended relatives until roles are identified. C. Encourage authoritative communication from the adult child. D. Implement firm but flexible boundaries in their relationship.
Explanation
A. Incorrect. Open discussion is important to address the changes and challenges resulting from the stroke. Avoiding discussions might hinder effective communication and problem-solving.
B. Incorrect. Socialization with extended relatives can provide valuable support during this transition and should not be decreased without reason.
C. Incorrect. Authoritative communication might not be suitable for all family dynamics.
Effective communication should be respectful and tailored to the specific needs and preferences of the individuals involved.
D. Correct. Implementing firm but flexible boundaries allows for a healthy balance between support and maintaining the client's independence and autonomy.
Question 20:
A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
A. Administer a cathartic suppository 30 min prior to scheduled defecation times. B. Encourage a maximum fluid intake of 1,500 mL per day. C. Increase the amount of refined grains in the client's diet. D. Provide the client with a cold drink prior to defecation.
Explanation
A. Correct. Administering a cathartic suppository can help stimulate bowel movement and facilitate a bowel-training program, particularly for individuals with altered bowel function due to spinal cord injury.
B. Incorrect. Adequate fluid intake is important, but limiting fluid intake is not typically recommended for clients with spinal cord injuries.
C. Incorrect. Refined grains are not specifically indicated for promoting bowel function. A balanced diet with sufficient fiber is more appropriate.
D. Incorrect. Providing a cold drink prior to defecation might not have a significant impact on bowel function and is not a commonly recommended intervention.
Question 21:
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
A. Hypotension B. Weight loss C. Polyuria D. Hematuria
Explanation
A. Incorrect. Acute glomerulonephritis can cause fluid retention and hypertension, rather than hypotension.
B. Incorrect. Weight gain might occur due to fluid retention rather than weight loss.
C. Incorrect. Decreased urine output, not polyuria, is a common finding in acute glomerulonephritis.
D. Correct. Hematuria (blood in the urine) is a classic sign of acute glomerulonephritis, reflecting inflammation and damage to the glomeruli in the kidneys.
Question 22:
A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?
A. Release the tourniquet. B. Retract the stylet. C. Flush the catheter with saline. D. Advance the catheter into the vein.
Explanation
A. Incorrect. Releasing the tourniquet is a step that can be taken after advancing the catheter into the vein.
B. Incorrect. Retracting the stylet at this point could disrupt the position of the catheter and cause leakage or damage.
C. Incorrect. Flushing the catheter with saline is an appropriate step after ensuring the catheter is correctly placed in the vein.
D. Correct. After noting a blood return in the flashback chamber, the next step is to advance the catheter into the vein to ensure proper placement for intravenous access.
Question 23:
A nurse is teaching a client who has rheumatoid arthritis about illness management. Which of the following instructions should the nurse include in the teaching?
A. Administer biological response modifiers to prevent infection. B. Take a hot shower in the morning to decrease stiffness. C. Cluster physical activities during the day. D. Apply cold packs directly on the skin of the affected joints.
Explanation
A. Incorrect. Biological response modifiers are medications used to treat autoimmune diseases like rheumatoid arthritis, not to prevent infection.
B. Incorrect. While warmth can help alleviate joint stiffness, a hot shower might not be appropriate for everyone, and excessive heat can exacerbate inflammation for some individuals.
C. Correct. Clustering physical activities during the day helps manage energy levels and minimize joint strain for clients with rheumatoid arthritis.
D. Incorrect. Cold packs can help reduce inflammation and pain, but they should be applied with a cloth barrier to protect the skin from direct contact.
Question 24:
A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?
A. Initiate airborne precautions. B. Monitor for the development of Koplik spots. C. Administer aspirin to the client. D. Isolate the client from staff who are pregnant.
Explanation
A. Incorrect. Rubella is not transmitted via airborne routes. Droplet precautions are typically not required for rubella.
B. Incorrect. Koplik spots are a characteristic of measles, not rubella.
C. Incorrect. Aspirin administration is contraindicated in adolescents with viral infections due to the risk of Reye's syndrome.
D. Correct. Rubella is a teratogenic virus that can cause birth defects in pregnant women who are exposed to the virus. Isolation from pregnant staff members is important to prevent potential transmission.
Question 25:
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?
A. Offer small amounts of clear liquids 6 hr following surgery. B. Give cromolyn nebulized solution every 8 hr. C. Apply a warm compress to the operative site once daily. D. Administer analgesics on a scheduled basis for the first 24 hr.
Explanation
A. Incorrect. Clear liquids are usually introduced slowly and progressively, but 6 hours postoperative might be too soon for this intervention.
B. Incorrect. Cromolyn nebulized solution is used to prevent asthma symptoms triggered by certain factors, not for postoperative care.
C. Incorrect. Applying a warm compress to the operative site might not be appropriate for the immediate postoperative period, especially in the case of appendicitis.
D. Correct. Administering analgesics on a scheduled basis helps manage postoperative pain and provides effective pain relief, promoting comfort and recovery.
Question 26:
A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
A. Acetaminophen B. Ibuprofen C. Naproxen sodium D. Aspirin
Explanation
A. Correct. Acetaminophen can be taken concurrently with enoxaparin without significant interactions or increased bleeding risk.
B. Incorrect. Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with caution in combination with anticoagulants due to an increased risk of bleeding.
C. Incorrect. Naproxen sodium, like other NSAIDs, should be used cautiously with anticoagulants due to potential interactions and bleeding risk.
D. Incorrect. Aspirin is an anticoagulant itself and can increase the risk of bleeding when taken with enoxaparin.
Question 27:
A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?
A. "Participate in range-of-motion exercises." B. "Place a pillow under your knees while in bed." C. "Remain on bed rest for 24 hours following the procedure." D. "Use an incentive spirometer every 4 hours."
Explanation
A. Correct. Participating in range-of-motion exercises helps prevent circulation problems and joint stiffness that can result from prolonged immobility after surgery.
B. Incorrect. While elevating the knees can help reduce strain on the lower back, this might not specifically promote circulation.
C. Incorrect. Prolonged bed rest can lead to decreased circulation and increased risk of complications such as deep vein thrombosis (DVT).
D. Incorrect. While using an incentive spirometer is important for preventing respiratory complications, it might not specifically address circulation issues.
Question 28:
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
A. Hold the bottle in the center of the sterile field when pouring the solution. B. Place sterile gauze over areas of spilled solution within the sterile field. C. Hold the irrigation solution bottle with the label facing away from the palm of the hand. D. Remove the cap and place it sterile-side up on a clean surface.
Explanation
A. Incorrect. The bottle should be held outside the sterile field while pouring the solution.
B. Incorrect. If any spillage occurs on the sterile field, it is best to discard the contaminated items and set up a new sterile field.
C. Correct. Holding the bottle with the label facing away from the palm helps prevent potential contamination of the sterile solution by avoiding contact between the hand and the bottle's label.
D. Incorrect. When removing the cap, it should be held with the sterile side down, not up, to prevent contamination.
Question 29:
A nurse is caring for a client who is receiving penicillin G via intermittent IV piggyback. Which of the following actions should the nurse take?
A. Infuse the medication over 10 min. B. Check the client for a sulfa allergy. C. Refrigerate the medication after reconstitution. D. Instruct the client to notify the provider if diarrhea develops.
Explanation
A. Correct. Penicillin G should be infused over a recommended time to prevent adverse effects and ensure proper administration.
B. Incorrect. Checking for a sulfa allergy is not relevant to the administration of penicillin, as sulfa and penicillin are different types of antibiotics.
C. Incorrect. Refrigeration is not typically required for penicillin G after reconstitution.
D. Incorrect. While notifying the provider about adverse effects is important, infusing the medication over the appropriate time is a more immediate nursing action.
Question 30:
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
A. "What are the voices telling you?" B. "Have you taken your medication today?" C. "I realize the voices are real to you, but I don't hear anything." D. "How long have you been hearing the voices?"
Explanation
A. While exploring the content of the voices is important, the priority is to assess if the client has taken their medication as prescribed, as it could affect their symptomatology.
B. Correct. The priority response is to assess if the client has taken their antipsychotic medication, as noncompliance with medication can contribute to auditory hallucinations and other symptoms.
C. While offering empathy is important, addressing medication compliance takes priority in this situation.
D. Asking about the duration of the voices can provide useful information, but ensuring medication compliance is the priority in this context.
Question 31:
A nurse is providing teaching about during administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?
A. "You can add the medication to a half-cup of your child's favorite juice." B. "Repeat the dose if your child vomits within 1 hour after taking the medication." C. "Limit your child's potassium intake while she is taking this medication." D. "Have your child drink a small glass of water after swallowing the medication."
Explanation
A. Incorrect. Adding medication to juice can mask the taste but might also decrease the effectiveness if the child does not consume all the juice.
B. Incorrect. Repeating a dose if vomiting occurs is not advisable without consulting a healthcare provider.
C. Incorrect. Limiting potassium intake is not relevant to medication administration for heart failure unless specifically instructed by a healthcare provider.
D. Correct. Having the child drink water after swallowing the medication helps ensure that the medication is fully swallowed and can enhance absorption.
Question 32:
A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching?
A. "I should replace any unused medication every 6 months." B. "I can crush the medication and mix it with applesauce." C. "I can store the medication in the refrigerator." D. "I should keep the medication in the original container."
Explanation
A. Incorrect. Unused medication replacement might not be necessary every 6 months and depends on the expiration date of the medication container.
B. Incorrect. Dabigatran capsules should not be crushed or opened, as it can affect the medication's efficacy and increase the risk of bleeding.
C. Incorrect. Storing the medication in the refrigerator is not necessary for dabigatran.
D. Correct. Keeping the medication in the original container helps protect it from moisture and ensures proper identification and labeling.
Question 33:
A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?
A. Bisacodyl 10 mg rectal suppository B. Loperamide 4 mg PO C. Magnesium hydroxide 30 mL PO D. Famotidine 20 mg PO
Explanation
A. Correct. Bisacodyl is a stimulant laxative that can help stimulate bowel movement. It can be administered rectally to help relieve constipation.
B. Incorrect. Loperamide is an antidiarrheal medication and is not appropriate for constipation relief.
C. Incorrect. Magnesium hydroxide is a saline laxative and is often used for constipation relief, but it may not be the initial choice in the postpartum period due to potential electrolyte imbalances.
D. Incorrect. Famotidine is an H2 blocker used to reduce stomach acid and is not indicated for constipation relief.
Question 34:
A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?
A. Metallic taste in the mouth B. Excessive sweating C. Increased urinary frequency D. Dry cough
Explanation
A. Incorrect. A metallic taste in the mouth is not a common adverse effect of sertraline.
B. Correct. Excessive sweating (diaphoresis) is a potential adverse effect of sertraline and other selective serotonin reuptake inhibitors (SSRIs).
C. Incorrect. Increased urinary frequency is not commonly associated with sertraline.
D. Incorrect. A dry cough is not a known adverse effect of sertraline.
Question 35:
A nurse in a long-term care facility is providing care for a client who has been receiving donepezil. Which of the following findings indicates that the medication is effective?
A. Improved short-term memory B. Increased food intake C. Can perform ADLs independently D. Enhanced mood
Explanation
A. Correct. Donepezil is a medication used to treat Alzheimer's disease and is expected to improve cognitive function, including short-term memory.
B. Incorrect. Donepezil is not typically associated with changes in food intake.
C. Incorrect. While improved functional ability is a goal of treatment, performing ADLs independently might not be solely indicative of donepezil's effectiveness.
D. Incorrect. Donepezil is primarily focused on improving cognitive function rather than mood enhancement.
Question 36:
A nurse is planning to teach a client about taking prednisone. Which of the following instructions should the nurse include?
A. Take on an empty stomach. B. Schedule dosage at bedtime. C. Increase dietary calcium. D. Monitor for weight loss.
Explanation
A. Incorrect. Prednisone should be taken with food to help minimize gastrointestinal upset.
B. Incorrect. Prednisone is often prescribed as a single daily dose in the morning to coincide with the body's natural cortisol release.
C. Incorrect. While calcium supplementation might be necessary for some individuals on long-term prednisone therapy, it is not a primary instruction related to taking prednisone.
D. Correct. Monitoring for weight loss is important due to the potential for weight changes (both weight gain and weight loss) as a result of prednisone's effects on metabolism and appetite.
Question 37:
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?
A. A residual of 65 mL 1 hr postprandial B. Sitting in high-Fowler's position during the feeding C. A history of gastroesophageal reflux disease D. Receiving a high-osmolarity formula
Explanation
A. Correct. A large residual volume (greater than 50-100 mL) after feeding can indicate delayed gastric emptying and increases the risk of aspiration.
B. Incorrect. Sitting in high Fowler's position during feeding is actually a preventive measure against aspiration.
C. Incorrect. A history of gastroesophageal reflux disease increases the risk of reflux but does not directly correlate with aspiration risk.
D. Incorrect. The osmolarity of the formula might affect tolerance but is not directly related to aspiration risk.
Question 38:
A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which of the following actions should the nurse plan to take?
A. Measure gastric residual volumes every 4 hr. B. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication. C. Maintain the head of the bed at a 20° angle. D. Advance the rate of the feeding every 2 hr.
Explanation
A. Incorrect. Gastric residual volumes are typically measured every 4-6 hours during continuous enteral feedings to assess tolerance and prevent aspiration.
B. Correct. Flushing the NG tube with saline before and after medication helps ensure proper medication administration and prevents clogging.
C. Incorrect. The head of the bed should be elevated to a 30-45° angle to help prevent aspiration during enteral feedings.
D. Incorrect. The rate of the feeding should be advanced gradually to prevent overloading the client's gastrointestinal tract. This does not involve advancing the rate every 2 hours.
Question 39:
A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?
A. Banana slices B. Hot dog C. Grapes D. Popcorn
Explanation
A. Correct. Banana slices are a soft and easily manageable food that encourages a toddler's independence in eating. They can be easily held by the toddler and self-fed.
B. Incorrect. Hot dogs are a choking hazard due to their shape and texture, which can increase the risk of choking in young children.
C. Incorrect. Grapes are also a choking hazard for young children, as they can easily block the airway if not cut into small pieces.
D. Incorrect. Popcorn is a choking hazard due to its size, shape, and hardness. It should be avoided in young children.
Question 40:
A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
A. Pale and a 24-hr fluid deficit of 30 mL B. Sunken fontanels and dry mucous membranes C. Temperature 38°C (100.4°F) and pulse rate 124/min D. Decreased appetite and irritability
Explanation
A. Incorrect. A pale appearance and fluid deficit of 30 mL over 24 hours might require intervention but is not as critical as sunken fontanels and dry mucous membranes.
B. Correct. Sunken fontanels and dry mucous membranes are signs of dehydration, a potential complication of gastroenteritis. These findings should be reported to the provider for further evaluation and intervention.
C. Incorrect. A slightly elevated temperature and an increased pulse rate are common responses to infection and fever in infants.
D. Incorrect. Decreased appetite and irritability can be expected in infants with gastroenteritis and are not as concerning as signs of dehydration.
Question 41:
A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
A. Place a towel roll under the client's neck. B. Position a pillow under the client's knees. C. Apply an orthotic to the client's foot. D. Align a trochanter wedge between the client's legs.
Explanation
A. Incorrect. Placing a towel roll under the client's neck is a preventive measure to maintain proper cervical alignment, but it does not specifically address contracture prevention.
B. Correct. Positioning a pillow under the client's knees helps maintain the knee joint in a slightly flexed position, which can prevent contractures in the knee joint.
C. Incorrect. Applying an orthotic to the client's foot might be used to prevent foot drop but does not address contracture prevention in other areas of the body.
D. Incorrect. Aligning a trochanter wedge between the client's legs might help prevent external rotation of the hips but does not specifically address contracture prevention.
Question 42:
A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
A. Initiate seclusion protocol. B. Tell the client, "You seem to be very upset." C. Use a face shield with a mask when providing care to the client. D. Engage the panic alarm.
Explanation
A. Incorrect. Initiating seclusion protocol should only be done in situations where the safety of the client or others is at risk and after appropriate assessment and intervention.
B. Correct. Acknowledging the client's emotions and showing empathy can help defuse the situation and promote effective communication.
C. Incorrect. Using personal protective equipment (face shield with mask) is not necessary when interacting with an agitated client unless there is a specific infection control concern.
D. Incorrect. Engaging the panic alarm is not necessary in this situation, as it may escalate the client's agitation.
Question 43:
A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?
A. Drink 1.5 L of fluids each day. B. Take mineral oil at bedtime. C. Decrease insoluble fiber intake. D. Increase exercise activity.
Explanation
A. Correct. Opioid medications can cause constipation, and increasing fluid intake helps prevent dehydration and promotes bowel regularity.
B. Incorrect. While some laxatives or stool softeners might be recommended, mineral oil is generally not recommended due to its potential to interfere with the absorption of fat-soluble vitamins.
C. Incorrect. Increasing insoluble fiber intake, rather than decreasing it, can help prevent constipation.
D. Incorrect. While exercise is important for overall health, it might not have a significant impact on preventing constipation caused by opioid medications.
Question 44:
A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client's food tray?
A. Scrambled eggs and toast with milk B. Bacon and cheese quiche with milk C. Ham sandwich with milk D. Shrimp salad and tomato soup with milk
Explanation
A. Correct. Scrambled eggs and toast are generally kosher-friendly options. However, milk may not be suitable if the client keeps kosher dietary laws, as it cannot be mixed with meat in the same meal.
B. Incorrect. Bacon and cheese quiche contain pork (bacon), which is not kosher.
C. Incorrect. Ham is pork and is not considered kosher.
D. Incorrect. Shrimp and milk are not kosher foods.
Question 45:
A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
A. "You don't have to go through with the treatment." B. "Your doctor wouldn't have ordered this treatment unless it was necessary." C. "Most people who have this procedure feel better following the treatment." D. "It's okay to be nervous before this treatment."
Explanation
A. Correct. Informed consent means the client has the right to refuse treatment even after giving initial consent. The nurse should respect the client's autonomy and decision.
B. Incorrect. This statement does not respect the client's right to make decisions about her treatment.
C. Incorrect. While this statement might be true for some individuals, it does not address the client's current hesitation and does not respect her autonomy.
D. Incorrect. This statement does not address the client's expressed hesitation about the treatment.
Question 46:
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?
A. "I can give you information about respite care if you are interested." B. "I am sure you're doing a great job taking care of your mother." C. "You should consider taking a sleeping pill before bed each night." D. "It is always difficult caring for someone who is terminally ill."
Explanation
A. Correct. Offering information about respite care provides the son with an option to take a break and get some rest while ensuring his mother's care is still managed by professionals.
B. Incorrect. While supportive, this statement does not offer a solution to the son's sleep deprivation.
C. Incorrect. Suggesting a sleeping pill might not address the underlying issue of the son's caregiving responsibilities.
D. Incorrect. While empathetic, this statement does not offer a practical solution or support for the son's situation.
Question 47:
A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings that requires follow-up care.
A. A client who received a Mantoux test 48 hr ago and has an induration B. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L C. A client who is scheduled for a colonoscopy and is taking sodium phosphate D. A client who is taking warfarin and has an INR of 1.8
Explanation
A.Induration after a Mantoux test is a common response and does not necessarily require follow-up care. B.A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L). C.Sodium phosphate is commonly used for bowel preparation before procedures like colonoscopy. D.Correct. An INR of 1.8 for a client on warfarin is below the therapeutic range (usually 2.0- 3.0 for most indications), indicating that the client's blood may not be adequately anticoagulated. This requires follow-up to adjust the warfarin dose.
Question 48:
A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet?
A. Canned black beans B. Cheese C. Fish D. Red meat
Explanation
A. Canned black beans are a good source of fiber and protein, but they are not specifically recommended for hypertension. B. Cheese is often high in saturated fat and sodium, which can contribute to hypertension and cardiovascular risk. C. Correct. Fish, especially fatty fish like salmon, mackerel, and trout, are rich in omega-3 fatty acids, which have been associated with cardiovascular benefits, including reducing blood pressure. D. Red meat is often high in saturated fat and is not typically recommended for individuals with hypertension.
Question 49:
A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?
A. INR B. Fibrinogen level C. aPTT D. Platelet count
Explanation
A. Correct. The International Normalized Ratio (INR) is used to monitor the effectiveness of warfarin therapy, which is commonly prescribed to prevent blood clotting. The INR provides information about the client's prothrombin time (PT) in relation to a standardized value. B. Fibrinogen level measures clotting potential but is not directly related to warfarin therapy monitoring. C. Activated Partial Thromboplastin Time (aPTT) is used to monitor other anticoagulants like heparin, not warfarin. D. Platelet count measures the number of platelets in the blood and is not specifically related to warfarin therapy monitoring.
Question 50:
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A. A client who is scheduled for a procedure in 1 hr B. A client who received a pain medication 30 min ago for postoperative pain C. A client who has 100 mL of fluid remaining in his IV bag D. A client who was just given a glass of orange juice for a low blood glucose level
Explanation
Answer is: A client who is scheduled for a procedure in 1 hr.
Explanation: The nurse should assess the client who is scheduled for a procedure in 1 hr first because this client may have a higher risk of complications or adverse outcomes from the procedure. The nurse should also monitor the client’s vital signs, pain level, and any signs of infection or bleeding before, during, and after the procedure. The nurse should also provide adequate preparation and education for the client regarding the procedure and its expected benefits and risks.
The other statements are wrong because:
A client who received a pain medication 30 min ago for postoperative pain may not need immediate assessment, unless there are signs of increased pain or other complications. The nurse can document the medication administration and observe the client’s response. A client who has 100 mL of fluid remaining in his IV bag may not need immediate assessment, unless there are signs of fluid overload or electrolyte imbalance. The nurse can monitor the client’s fluid intake and output, weight, blood pressure, pulse, temperature, and laboratory values. A client who was just given a glass of orange juice for a low blood glucose level may not need immediate assessment, unless there are signs of hypoglycemia or other complications. The nurse can check the client’s blood glucose level and provide appropriate treatment if needed.
Question 51:
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
A. Malaise B. Tinnitus C. Rhinorrhea D. Drooling
Explanation
A. Correct. Malaise, which is a general feeling of discomfort or unease, is a common manifestation of bacterial pneumonia in children. B. Tinnitus (ringing in the ears) is not a common manifestation of bacterial pneumonia. C. Rhinorrhea (runny nose) is not typically associated with bacterial pneumonia; it is more commonly seen in viral respiratory infections. D. Drooling is not a common manifestation of bacterial pneumonia.
Question 52:
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
A. Call in additional medical-surgical unit nursing care staff. B. Recommend to the provider specific acute care clients for discharge. C. Determine the medical needs of incoming clients through the emergency department. D. Act as a liaison between the facility and the media.