Nursing Exam Questions and Answers, Exams of Nutrition

Download Nursing Exam Questions and Answers and more Exams Nutrition in PDF only on Docsity! NACE PN TO RN (A NEW UPDATED VERSION) LATEST 2024-2025 EXAM ALL 100 ACTUAL EXAM QUESTIONS AND WELL ELABORATED ANSWERS To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following? - CORRECT ANSWER>>CORRECT ANSWER: Organs The purpose of deep palpation, in which the nurse indents the client's skin approximately 1-1/2", is to assess underlying organs and structures such as the kidneys and spleen. Skin turgor, hydration, and temperature can be assessed using light touch or light palpation. A client is brought to the emergency department and the physician determines he has gastrointestinal (GI) bleeding. In planning for his care, which of the following would be first priority? - CORRECT ANSWER>>The CORRECT ANSWER is: assessment of vital signs Vital sign assessment would be the priority nursing intervention. This would provide an indication of the amount of blood loss that has occurred and also provide a baseline by which to monitor the progress of treatment. The other answers (b, c, and d) are important but not priority actions. When providing instructions to the adolescent regarding physical development of her body, the RN should do all of the following EXCEPT - CORRECT ANSWER>>CORRECT ANSWER: Discuss the importance of avoiding social events in order to stay out of trouble. Socialization is very important to teenagers and is a normal part of their development. The other answers (b, c, and d) are all accurate instructions and discussions for the adolescent regarding development. The nurse is developing discharge plans for a 65-year-old client. The discharge plans indicate the client will be discharged home with home health nursing care. The nurse provides the home health agency with details regarding the needs of the patient. The nurse made which of the following to the home health agency? - CORRECT ANSWER>>CORRECT ANSWER: A referral. A referral is recommending home care services or giving information to an home care service regarding the client and the client's needs. Typically the sources of referral to a home care agency are family members, nurses, physicians, social workers, discharge planners or therapists. Which of the following is the normal serum electrolyte level for magnesium? - CORRECT ANSWER>>CORRECT ANSWER: 1.6 to 2.4 mEq/L The school nurse is approached by a mother who explains that her kindergarten child is constantly scratching the perianal area and that the area is irritated. The RN understands that she should instruct the mother to obtain a rectal specimen by a tape test and that the mother should obtain the specimen when? - CORRECT ANSWER>>The CORRECT ANSWER is: in the morning, when the child awakens Visualization of pinworms by means of a tape test is necessary for the diagnosis. Transparent tape is lightly touched to the anus and then applied to a slide for microscopic examination. The best specimen is obtained as the child awakens, before toileting or bathing. A 20-year-old patient is admitted to the hospital with respiratory failure. He's intubated, given oxygen, and is coughing with copious secretions in his lungs. What should be done first? - CORRECT ANSWER>>CORRECT ANSWER: Suction the lungs The first priority is to make sure the client's airways are clear and that he can breathe. The other choices can be addressed after ensuring the client can breathe. A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and intervention, what would be the MOST desirable outcome? - CORRECT ANSWER>>CORRECT ANSWER: The student accepts a referral to a substance abuse counselor. All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor. The RN is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse use to dilute this medication? - CORRECT ANSWER>>Normal saline (0.9%) solution. Phenytoin (Dilantin) should be administered by injection into a large vein by intermittent intravenous infusion. Normal saline (0.9%) solution is the preferred solution. Dextrose should be avoided because of medication precipitation. Of the following, which is the normal range of respiration rate, in breaths per minute, for an adult? - CORRECT ANSWER>>12-20 30-45 breaths per minute is the normal range for an 3-6 month old babies. 24-32 is normal for a toddler, and 20-24 for a small child. The average breath rate drops with age and levels off during adolescence, to approximately 12-20 breaths per minute. Which of the following is the generic name for Nizoral? - CORRECT ANSWER>>Ketoconazole. Isotretinoin is the generic name for Accutane. Nystatin is the generic name for Mycostatin and Flucinonide, a generic name for Lidex. Which of the following is not a goal for a client with social phobia? - CORRECT ANSWER>>CORRECT ANSWER: Use suppression. A client needs concrete goals to pursue. These goals might include managing fear in groups, verbalizing feelings in stressful situations, and developing a plan for stressful situations. Suppression, or avoidance of thoughts and feelings, would be very counterproductive to a person with social phobia. A client has had pain in the right leg for 3 weeks. The nurse understands that the MOST LIKELY effect of this pain is? - CORRECT ANSWER>>CORRECT ANSWER: The disruption of sleep. Pain can have many effects on the human body. Clients with acute pain may have a decrease in appetite, decrease in fluid intake, nausea, vomiting and disruption in sleep. Which of the following is the sixth provision of the Code of Ethics for Nurses? - CORRECT ANSWER>>CORRECT ANSWER: "The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action." Which of the following is a brand name for Rabeprazole? - CORRECT ANSWER>>CORRECT ANSWER: Aciphex. Aciphex is a brand name for Rabeprazole. Carafate is a brand name for Sucralfate and azulfidine for Sulfasalazine. Zantac is Ranitidine. Which of the following is MOST likely a characteristic found with individuals who are diagnosed with borderline personality disorder? - CORRECT ANSWER>>The CORRECT ANSWER is: identity disturbance. Individuals with borderline personality have an identity disturbance where the individual has difficulty keeping a stable mood and self image. Characteristics of personality disorders are unpredictable behavior, impulsiveness, and irritability. Timidness, social discomfort and fear of negative feedback are not typical with borderline personality but are found in individuals diagnosed with avoidant personality disorder. The nurse at the family planning clinic has performed teaching on oral contraceptives. The nurse knows that the teaching has been effective when one of the clients responds: - CORRECT ANSWER>>CORRECT ANSWER: "I can't take 'the pill' if I have gallbladder disease." Oral contraceptive is contraindicated in women with gallbladder disease and those who are heavy smokers. There is not an age specification. Menstrual flow is decreased with the use of oral contraceptives. Which of the following clinical signs would the nurse expect to see in a child with respiratory depression? - CORRECT ANSWER>>CORRECT ANSWER: Shallow breathing. Respiratory depression is the breaths per minute that are less than 12 breaths per minute in a child who is two years of age and younger. Respiratory depression is one of the complications associated with opioids (for example morphine, codeine, Demerol, Oxycodone), which are a common analgesic given to client's after surgery or to treat a severe injury. Children who experience respiration depression exhibit clinical signs such as shallow breathing, sleepiness and small pupils. Which of the following blood transfusion reactions is a rare, but severe reaction in which the donated blood type is not compatible with that of the patient? - CORRECT ANSWER>>CORRECT ANSWER: Hemolytic A hemolytic transfusion reaction is a serious complication that occurs when the red blood cells that were given during a transfusion are destroyed by the person's immune system. An allergic transfusion reaction is usually due to a patient's sensitivity to the plasma proteins of the donor's blood. A febrile transfusion reaction is caused by the incompatibility of leukocytes. A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stool to look like which of the following? - CORRECT ANSWER>>CORRECT ANSWER: Black and tarry. Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes in the blood. Vomitus associated with upper GI tract bleeding is commonly described as coffee ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding. A client is scheduled to have a blood transfusion. The client asks the nurse, "What types of diseases are transmitted through blood transfusions?" The nurse should respond that there is a low risk of contracting diseases through blood transfusions. However, a possible illness is which of the following? - CORRECT ANSWER>>CORRECT ANSWER: CytomegalovirusBlood borne diseases and diseases that are transmitted through a transfusion are Hepatitis B, Hepatitis C, HIV, Cytomegalovirus and Malaria, to name a few. Also, the nurse should assure the client that the transmission of these diseases is low since blood banks have rigorous screening procedures to test blood. In which of the following stages of reaction toward stress does a body increase in hormone levels in order to mobilize for a fight? - CORRECT ANSWER>>CORRECT ANSWER: Alarm. During the exhaustion stage, the body becomes "exhausted" because it did not positively respond to the stress. The body undergoes many physiological changes such as taking more air into the lungs in order to prepare for fight or flight during the resistance stage. In a client with acute hepatitis, the nurse assesses the client's aspartate aminotransferase (AST) range on the laboratory test at 520 units. What should the nurse understand about this test value? - CORRECT ANSWER>>CORRECT ANSWER: The AST is elevated. In clients with acute hepatitis, liver disease and myocardial infarction, the aspartate aminotransferase (AST) is elevated. The normal range for this enzyme in the blood is 10 to 26 units per liter. In clients with acute hepatitis, the enzyme may be elevated four times above the normal range. The nurse who teaches nutrition at a community center is asked "how much water does a person need to drink daily". The nurse's best response would be: - CORRECT ANSWER>>The CORRECT ANSWER is two quarts. The average adult needs eight glasses, or two quarts, of water per day. The remaining answer choices are not correct. Experts now agree that schizophrenia develops as a result of interplay between biological disposition and the kind of environment a person is exposed to. However there are no medical tests that will diagnose schizophrenia. Pain has which of the following effects on respiratory rate? - CORRECT ANSWER>>CORRECT ANSWER: Increases. Pain will increase respiratory and heart functions. This can be counteracted with morphine if indicated. What hormone does the anterior pituitary produce? - CORRECT ANSWER>>CORRECT ANSWER: Follicle- stimulating hormone. The anterior pituitary regulates several physiological processes including stress, growth, and reproduction. Its regulatory functions are achieved through the secretion of various peptide hormones that act on target organs including the adrenal gland, liver, bone, thyroid gland, and gonads. The nurse is performing an assessment on a client who is complaining of pain in the abdomen. The nurse understands to do what? - CORRECT ANSWER>>CORRECT ANSWER: Use palpation at the end of the assessment only. When performing an assessment on the abdomen, the palpation of the abdomen should be performed last. The reason is the pressure placed on the abdominal wall along with the contents will affect the bowel sounds that are heard through auscultation. Which is the most numerous type of white blood cell (WBC)? - CORRECT ANSWER>>CORRECT ANSWER: Neutrophil. Neutrophil are the most numerous of the WBCs, comprising about 65%. Lymphocytes are the second most abundant. Eosinophils account for about 2%, while basophils are the least abundant. A female client is discharged from the hospital post delivery. The nurse escorts a mother and her newborn to the car. Which of the following approaches should the nurse instruct the new mother to place the newborn? - CORRECT ANSWER>>The CORRECT ANSWER is: in the back seat of the car with the car seat facing backwards. While regulations may vary from state to state, it is recommended that an infant up to 1 year of age use a rear facing car seat or longer until they outgrow it. The couple with the lowest risk of having a child with sickle cell disease is the one in which what is true? - CORRECT ANSWER>>CORRECT ANSWER: The father is HbA and the mother is HbS. If the father has normal hemoglobin (HbA) and the mother has sickle cell disease (HbS), the couple has a 0% chance of having a child with sickle cell disease. If both parents have sickle disease, the couple has a 100% chance of having a child with sickle cell disease. If the father has sickle cell disease and the mother has sickle cell trait (HbAS), the couple has a 50% chance of having a child with sickle cell disease. lf both parents have sickle cell trait, the couple has a 25% chance of having a child with sickle cell disease. You are reading the result of a Mantoux test on a 2-year- old child. The results indicate an area of induration that measures 10 mm. What do you interpret these results as? - CORRECT ANSWER>>The CORRECT ANSWER is: positive. Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age and in those with chronic illness or at high risk for environmental exposure to tuberculosis. For high risk groups, a reaction of 5mm or more is considered positive. A reaction of 15 mm or more is positive in children 4 years of age and older who have no risk factors. Of the following, which is the normal blood pressure range for an adolescent? - CORRECT ANSWER>>CORRECT ANSWER: 110-120/60-80 Which of the following theorists was mentally disturbed? - CORRECT ANSWER>>Gordon Allport, Hans Eysenck, and Raymond Cattell. NONE OF THE ABOVE A menopausal woman tells her nurse that she experiences discomfort from vaginal dryness during sexual intercourse, and asks, "What should I use as a lubricant?" The nurse should recommend: - CORRECT ANSWER>>CORRECT ANSWER: a water-soluble lubricant. A water-soluble jelly should be used. Petroleum jelly, body creams, and body lotions are not water soluble. Less-frequent intercourse is an inappropriate response. The nurse is teaching a client who drinks alcohol heavily about maintaining a healthy heart. The nurse should include which point in her teaching? - CORRECT ANSWER>>CORRECT ANSWER: Use alcohol in moderation. Alcohol may be used in moderation as long as there are no other contraindications for its use. Having a diet high in cholesterol and saturated fat, and a sedentary lifestyle are all known risk factors for cardiac disease. The client should be encouraged to quit smoking, exercise three to four times per week, and consume a diet low in cholesterol and saturated fat. You are caring for a client with a chest tube. You enter the room and find that the client has turned onto the side of the tube and disconnected the tube accidentally from the machine but is still connected to the patient. The appropriate initial action is to: - CORRECT ANSWER>>The CORRECT ANSWER is: Place the tube in a bottle of sterile water. Once the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water and held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. The physician may be notified, but this is not the initial action necessary. Placing a dressing over the disconnection site will not prevent complications. Which of the following will MOST help an elderly, hearing impaired client admitted to the hospital? - CORRECT ANSWER>>Limit bedside conversation to that which directly pertains to the patient. This creates the least amount of auditory disturbance for the patient. Lots of noise can be upsetting to those with hearing impairments. Which of the following is the most common source of airway obstruction in an unconscious victim? - CORRECT ANSWER>>CORRECT ANSWER: The tongue. The muscles in many cases that control the tongue relax, causing the tongue to obstruct the airway. When this occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back in place. If a neck injury is suspected, the jaw-thrust maneuver must be performed. The nurse understands a child with HIV who is classified as Category C can have all except which of the following manifestations? - CORRECT ANSWER>>CORRECT ANSWER: anemia. The clinical manifestations that are seen with the category C classification of HIV include recurrent and multiple infections, encephalopathy, kaposi's sarcoma, lymphoma, cytomegalovirus, toxoplasmosis, and wasting syndrome. Anemia is a clinical manifestation of the Category B HIV classification. The nurse is talking with a woman who has been told she will never be able to bear children. The woman states, "I have decided to adopt a baby, because there are so many children in the world who need the kind of home I could provide a child." The nurse recognizes this woman is using what defense mechanism? - CORRECT ANSWER>>CORRECT ANSWER: compensation. Compensation is covering a weakness with a more desirable trait or behavior, such as replacing the desire to have children with adopting a child. Denial is avoiding unwanted realities by refusing to acknowledge they exist, such as the woman who refuses to accept that she is unable to bear children. Rationalization is justifying behavior Drinking enough fluid is the most important thing a person can do to prevent kidney stones. While the other foods will add nutrients to the diet, they do not address the development of further kidney stones. The nurse is providing dietary teaching for the parents of a child with celiac disease. This child should avoid what? - CORRECT ANSWER>>CORRECT ANSWER: Prepared puddings. A child with celiac disease must not consume food containing gluten and therefore should avoid prepared puddings, commercially prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley. The other choices do not contain gluten and are permitted when on a gluten free diet. The client is prescribed morphine. The client is experiencing urinary retention. The nurse understands the physician may order which of the following? - CORRECT ANSWER>>The CORRECT ANSWER is: a lowered dose of morphine. If the client experiences the side effect of urinary retention due to the morphine, the physician may order a change in the dose or a lowered dosing of morphine. Also, the physician may instruct the nurse to catharize the client. The remaining answer choices are incorrect as they are orders the physician may give for other conditions such as constipation. The nurse documents scalp edema that crosses the lines of the skull in the newborn as what? - CORRECT ANSWER>>CORRECT ANSWER: caput succedaneum. Since a caput succedaneum is just superficial and beneath the scalp, the swelling can cross the suture lines. Molding is overriding of the cranial plates, and cephalohematoma does not cross the suture lines, since it results when blood is trapped beneath the periosteum. Cranial distention is not a term used in newborn assessment. A 21-year-old female is diagnosed with dysthymic disorder. When obtaining a history from the female, what information should the nurse expect? - CORRECT ANSWER>>The CORRECT ANSWER is: irritability. In young adults and children, the symptoms noted with dysthymic disorder include irritability, depression, low self esteem, pessimism, and impaired social skills and social interactions. Talking excessively is more evident with children who have attention deficit hyperactivity disorder. Intense fear is associated with anxiety disorders. Further, compulsive behavior is not associated with individuals diagnosed with dysthymic disorder. The nurse is teaching accident prevention to the parents of a toddler. Which instruction is MOST appropriate for the nurse to tell the parents? - CORRECT ANSWER>>CORRECT ANSWER: Place locks on cabinets containing toxic substances. All household cleaners and poisons should be locked with childproof locks. The toddler's curiosity and the ability to climb and open doors and drawers makes poisoning a concern in this age group. Rollerblading is not an appropriate activity for toddlers. Toddlers lack the cognitive development to understand water safety. Pillows should not be placed in the crib of an infant to avoid suffocation; however, toddlers may use them. A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for which of the following? - CORRECT ANSWER>>CORRECT ANSWER: Fatigue and weakness. RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Nausea and vomiting may occur in CRF, but do not result from faulty RBC production. Dyspnea and cyanosis are associated with fluid excess, not CRF. Thrush, which signals fungal infection, and circumoral pallor which reflects decreased oxygenation, are not signs of CRF. Which of the following is a high risk factor for diabetes mellitus? - CORRECT ANSWER>>CORRECT ANSWER: Native American The highest risk factors include: Native Americans, obesity (BMI of 30 or higher), and an immediate family history (sibling or parent). African American and Hispanic populations are also at high risk. Which of the following patients would a nurse not administer Erythromycin to? - CORRECT ANSWER>>CORRECT ANSWER: A person with multiple sclerosis. An antibiotic is indicated if there is a possible infection. Multiple sclerosis is not characterized by infections. There are many rights the patient has when they are hospitalized. Which of the following is NOT a right to be considered with these patients? - CORRECT ANSWER>>The CORRECT ANSWER is: The right to bring their own personal protection devices and medications into a health care facility. The client is not allowed to bring weapons or medications into a health care facility as delegated by hospital rules, policies, and procedures. The other answers are all rights of the client. A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called what? - CORRECT ANSWER>>CORRECT ANSWER: Flight of ideas. Flight of ideas describes a thought pattern in which a client moves rapidly from one topic to the next with some connection. Looseness of association describes a pattern in which ideas lack an apparent logical connection to one another. Tangential thoughts seem to be related but miss the point. A client who talks around the subject and includes a lot of unnecessary information is exhibiting circumstantial thinking. The nurse is developing a plan of care for the client in a crisis state. When developing the plan, the nurse considers which of the following? - CORRECT ANSWER>>The CORRECT ANSWER is: A client's response to a crisis situation is individualized and what constitutes a crisis for one person may not constitute a crisis for another person. A crisis response can be described in similar terms, what constitute a crisis for one person may not constitute a crisis for another person because each person is unique. A crisis state does not mean that the person has an emotional or mental illness. The nurse is performing wound care. Which of the following practices violates surgical asepsis? - CORRECT ANSWER>>CORRECT ANSWER: Pouring solution onto a sterile field cloth. Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other choices are practices that help ensure surgical asepsis. The nurse assesses a child who is dehydrated. The child has lost 15% of his body weight. The nurse suspects what of the child? - CORRECT ANSWER>>The CORRECT ANSWER is the child has severe dehydration. When a child has lost 10% of his or her body weight during dehydration, this indicates the child has severe dehydration. Mild dehydration is indicated when the child has lost up to 5% of his or her body weight. Moderate dehydration is represented when the child has lost 6-9% of his or her body weight. After running several tests, Dr. Smith realizes that the microorganisms in his patient, Tom are rapidly multiplying. However, the microorganisms are not causing any damage. This multiplication of microorganisms is known as which of the following? - CORRECT ANSWER>>CORRECT ANSWER: Colonization. An infectious agent is an organism that can cause disease. A particulate respirator is a