NURSING MISC PRACTICE EXAM QUESTIONS AND ANSWERS GRADED A+ GUARANTEED SUCCESS NEW UPDATED, Exams of Nursing

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1. A nurse is instilling an otic solution into the adult client’s left ear. The nurse avoids doing which of the following as part of this procedure? Options: A) Warming the solution to room temperature B) Placing the client in a side-lying position with the ear facing up C) Pulling the auricle backward and upward D) Placing the tip of the dropper on the edge of the ear canal Correct Answer is: D Explanation : The dropper is not allowed to touch any object or any part of the client’s skin. The solution is warmed before use. The client is placed on the side with the affected ear upward. The nurse pulls the auricle backward and upward and instills the medication by holding the dropper about 1 cm above the ear canal.
2. Levothyroxine sodium (Synthroid) is administered to a hospitalized child with congenital hypothyroidism. The child vomits 10 minutes after administration of the dose. The most appropriate nursing action is to: Options: A) Repeat the prescribed dose B) Give two doses of the prescribed medicine on the next day C) Contact the physician immediately D) Hold the dose for today Correct Answer is: A Explanation : Levothyroxine sodium (Synthroid) is the medication of choice for hypothyroidism. The most

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significant factor adversely affecting the eventual intelligence of children born with congenital hypothyroidism is inadequate treatment. Therefore, compliance with the medication regimen is essential. If the infant or child vomits within 1 hour of taking medication, the dose should be administered again. 3 A client diagnosed as having catatonic excitement has been pacing rapidly non-stop for several hours and is not eating or drinking. The nurse recognizes that in this situation: Options: A) There is an urgent need for physical and medical control B) There is an urgent need for restraint C) There is a need to encourage verbalization of feelings D) The client will soon become catatonic stuporous Correct Answer is: A Explanation : Catatonic excitement is manifested by a state of extreme psychomotor agitation. Clients urgently require physical and medical control because they are often destructive and violent to others, and their excitement can cause them to injure themselves or to collapse from complete exhaustion. Options 2, 3, and 4 are incorrect. 4A 52-year-old male client is seen in the physician’s office for a physical examination after experiencing unusual fatigue over the last several weeks. The client’s height is 5 feet, 8 inches, and weight is 220 pounds. Vital signs are temperature 98o F orally, pulse 86 beats per minute, and respirations 18 breaths per minute. The blood pressure (BP) is 184/100 mmHg. Random blood glucose is 122 mg/dL. Which of the following questions should the nurse ask the client first? Options: A) Do you exercise regularly? B) Are you considering trying to lose weight? C) Is there a history of diabetes mellitus in your family?

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D) When was the last time you had your blood pressure checked?

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Correct Answer is: D Explanation : The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The client is over weight, which is a contributing risk factor. The client’s nonmodifiable risk factors are age and gender. Because the client present with several risk factors, the nurse places priority of attention on the client’s major modifiable risk factors. 5A client tells the nurse about a pattern of getting a strong urge to void, which of followed by incontinence before the client can get to the bathroom. The nurse formulates which of the following nursing diagnoses for this client? Options: A) Reflex Urinary Incontinence B) Stress Urinary Incontinence C) Urge Urinary Incontinence D) Total Urinary Incontinence Correct Answer is: C Explanation : Urge incontinence occurs when the client has urinary incontinence soon after experiencing urgency. Reflex incontinence occurs when incontinence occurs at rather predictable rimes that correspond to when a certain bladder volume is attained. Stress incontinence occurs when the client voids in increments that are less than 50 mL and has increased abdominal pressure. Total incontinence occurs when there is an unpredictable and continuous loss of urine. 6A pregnant client is receiving rehabilitative services for alcohol abuse. The nurse would provide supportive care by: Options: A) Encouraging the client to participate in care and identifying supportive strategies that are helpful B) Avoiding discussion of the alcohol problem and recovery with the client C) Minimizing communication with supportive family members

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D) Encouraging the client to stop counseling once the infant is born

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Correct Answer is: A Explanation : The nurse provides supportive care by encouraging the client to participate in care. The nurse should not avoid discussing the client’s problem with the client, and communication with family members in important. Counselling needs to continue after the infant is born. 7A client in the second trimester of pregnancy is being assessed at the health care clinic. The nurse performing the assessment notes that the fetal heart rate is 100 beats per minute. Which nursing action would be most appropriate? Options: A) Document the findings B) Inform the mother that the assessment is normal and everything is fine C) Notify the physician D) Instruct the mother to return to the clinic in 1 week for reevaluation of the fetal heart rate Correct Answer is: C Explanation : The fetal heart rate should be between 120 to 160 beats per minute during pregnancy. A fetal heart rate of 100 beats per minute would require that the physician be notified and the client be further evaluated. Although the nurse would document the findings, the most appropriate nursing action is to notify the physician. Options 2 and 4 are inaccurate nursing actions. 8A client is admitted to the hospital with a diagnosis of a leaking cerebral aneurysm and is scheduled for surgery. The nurse implements which of the following during the preoperative period? Options: A) Encourages the client to be up at least twice per day B) Allows the client to ambulate to the bathroom C) Obtains a bedside commode for the client’s use D) Places the client on strict bed rest

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Correct Answer is: D Explanation : The client’s activity is kept to a minimum to prevent Valsalva maneuver. Clients often hold their breath and strain while pulling up to get out of bed. This exertion may cause a rise in blood pressure, which increases bleeding. Clients who have bleeding aneurysms in any vessel will have activity curtailed. Therefore, options 1, 2, and 3 are incorrect actions. 9A physician calls a nurse to obtain the daily laboratory results of a client receiving total parenteral nutrition (TPN). Which laboratory result would the nurse obtain from the client’s record because it would provide the most valuable information regarding the client’s status related to the TPN? Options: A) Serum electrolyte levels B) Arterial blood gas (ABG) levels C) White blood cell count (WBC) D) Complete blood cell count (CBC) Correct Answer is: A Explanation : TPN solutions contain amino acid and dextrose solutions, with electrolyte and trace elements added. The physician uses the electrolyte values to determine whether changes are needed in the composition of the TPN solutions that will be administered over the next 24 hours. This prevents the client from developing electrolyte imbalance, Options 2, 3, and 4 are not directly related to evaluating client status regarding TPN. 10A client who has episodes of bronchospasm and a history of tachydysrhythmias is admitted to the hospital. The nurse reviews the physician’s orders and contacts the physician to verify which medication, if prescribed by the physician? Options: A) Metaproterenol (Alupent) B) Albuterol (Proventil)

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C) Epinephrine (Primatene Mist) D) Salmeterol (servent)

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Correct Answer is: C Explanation : A client with a history of tachydysrhythmias should not be given bronchodilators that contain catecholamines, such as epinephrine and isoproterenol hydrochloride (Isuprel). Other sympathomimetics that are noncatecholamines should be used instead. These include metaproterenol, albuterol, and salmeterol. 11A client has a compulsive bed-making ritual in which the client makes and remakes a bed numerous times. The client often misses breakfast and some of the morning activities because of the ritual. Which nursing action would be most helpful? Options: A) Verbalize tactful, mild disapproval of the behavior B) Help the client to make the bed so that the task can be finished quicker C) Discuss the ridiculousness of the behavior D) Offer reflective feedback, such as “I see you have made your bed several times.” Correct Answer is: D Explanation : Verbalizing minimal disapproval would increase the client’s anxiety and reinforce the need to perform the ritual. Helping with the ritual is nontherapeutic and also reinforce the behavior. The client is usually aware of the irrationality (ridiculousness) of the behavior. Reflective feedback acknowledges the client’s behavior. 12An older client who has undergone internal fixation after fracturing a left hip as developed a reddened left heel. The nurse obtains which of the following as a priority item to manage this problem? Options: A) Bed cradle B) Sheepskin C) Trapeze

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D) Draw sheet

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Correct Answer is: B Explanation : The reddened heel results from pressure of the foot against the mattress. The nurse obtains a sheepskin, heel protectors, or an alternating pressure. The bed cradle will keep the linens off the client’s lower extremities but not assist in managing a reddened heel. A draw sheet and trapeze are of general use for this client but are not specific in dealing with the reddened heel. 13A nurse is caring for an infant following pyloromyotomy to treat hypertropic pyloric stenosis. The nurse places the infant in which position following surgery? Options: A) Flat on the unoperative side B) Flat on the operative side C) Prone with head of the bed elevated D) Supine with head of the bed elevated Correct Answer is: C Explanation : Following pyloromyotomy, the head of the bed is elevated and the infant is placed prone to reduce the risk of aspiration. Options 1, 2, and 4 are incorrect positions following this type of surgery. 14A mother if a child with mumps calls the health clinic to tell the nurse that the child has been lethargic and vomiting. The nurse most appropriately tells the mother: Options: A) To continue to monitor the child B) That lethargy and vomiting are normal manifestations of mumps C) To bring the child to the clinic to be seen by the physician D) That as long as there is no fever, there is nothing to be concerned about

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Correct Answer is: C

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Explanation : Mumps generally affects the salivary glands but can also affect multiple organs. The most common complication is septic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. The child should be seen be the physician. 15A nurse is reviewing the physician’s orders for a child admitted to the hospital with vaso-occlusive pain crisis from sickle cell anemia. Which of the following physician orders would the nurse question? Options: A) Intravenous fluids B) Supplemental oxygen C) Bed rest D) Meperidine hydrochloride (demerol) for pain Correct Answer is: D Explanation : Meperidine hydrochloride is contraindicated for ongoing pain management because of the increased risk of seizures associated with the use of the medication. Management for sever pain generally includes the use of strong narcotic analgesics such as morphine sulfate or hydromorphone (Dilaudid). These medications are usually most effective when given as a continuous infusion or at regular intervals around the clock. Options 1, 2 and 3 are appropriate prescriptions for treating vaso- occlusive pain crisis. 16A nurse is caring for an infant with laryungomalacia (congenital laryngeal stridor). Which position would the nurse place the infant in to decrease the incidence of stridor? Options: A) Supine B) Supine with the neck flexed C) Prone D) Prone with the neck hyperextended

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Correct Answer is: D

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Explanation : The prone position with the neck hyper extended improves the child’s breathing. Options 1,2 and 3 are not appropriate positions. 17A nurse in the newborn nursery prepares to admit a newborn infant with spina bifida, meningomyelocele type. Which nursing action is most important in the care for this infant? Options: A) Monitoring blood pressure B) Monitoring specific gravity of the urine C) inspecting the anterior fontanel for bulging D) Monitoring temperature Correct Answer is: C Explanation : Intracranial pressure is complication associated with spina bifida. A sign of intracranial pressure in the newborn infant with spina bifida is a bulging anterior fontanel. The newborn infant is at risk for infection before the surgical procedure and closure of the gibbus, and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is most important. A normal saline dressing is placed over the affected site to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of skin integrity at the site. Blood pressure is difficult to assess during the newborn period, and it is not the best indicator of infection or a potential complication. Urine concentration is not well developed in the newborn stage of development. 18On assessment of a child, a nurse notes that the child’s genitals are swollen. The nurse suspects that the child is being sexually abused. Which action by the nurse is of primary importance? Options: A) Document the child’s physical findings B) Report the case in which the abuse is suspected C) Refer the family to appropriate support groups D) Assist the family in identifying resources and support systems

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Correct Answer is: B Explanation : The primary legal responsibility of the nurse when child abuse is suspected is to report to the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documentation of assessment findings, assisting the family, and referring the family to appropriate resources and support groups is important, the primary legal responsibility is to report the case. 19A nurse is planning care for an infant with a diagnosis of encephalocele located in the occipital area. Which item would the nurse use to assist in positioning the child to avoid pressure on the encephalocele? Options: A) Sheep skin B) Foam half donut C) Feather pillows D) Sand bags Correct Answer is: B Explanation : The infant is positioned to avoid pressure on the lesion. If the encephalocele is in the occipital area, a foam half donut may be useful in positioning to prevent this pressure. A sheepskin, feather pillow, or sandbag will not protect the enecephalocele from pressure. 20A nurse is caring for a child with a head injury. On review of the record, the nurse notes that the physician has documented that the physician has documented decorticate posturing. On assessment of the child, the nurse notes extension of the upper extremities and internal rotation of the upper arm and wrist. The nurse also notes that the lower extremities are noted at the knees and feet. Based on these findings, which of the following is the appropriate nursing action? Options: A) Document the findings B) Continue to monitor for posturing of the child C) Attempt to flex the child’s lower extremities

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D) Notify the physician

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Correct Answer is: D Explanation : Decorticate posturing refers to flexion of the upper extremities and extension of the lower extremities. Plantar flexion of the feet may also be observed. Decerebrate posturing involves upper arm and wrist. The lower extremities will extend with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants physician notification. 21A child with a diagnosis of hepatitis b is being cared for at home. The mother of the child calls the health care clinic and tells the nurse that the jaundice seems to be worsening. The nurse makes which response to the mother? Options: A) The hepatitis may be spreading. B) You need to bring the child to the health care clinic to see the physician. C) The jaundice may appear to get worse before it resolves. D) It is necessary to isolate the child from the others. Correct Answer is: C Explanation : The parents should be instructed that jaundice may appear to get worse before it resolves. The parents of a child with hepatitis should also be taught the danger signs that could indicate a worsening of the child’s condition, specifically changes in neurological status, bleeding, and fluid retention. The statements in options 1,2, and 4 are incorrect. 22A nurse is preparing to suction a tracheotomy on an infant. The nurse prepares the equipment for the procedure and turns the suction to which setting? Options: A) 60 mmHg B) 90 mmHg

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C) 110 mmHg

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D) 120 mmHg Correct Answer is: B Explanation : The suctioning procedure for pediatric clients varies from that which is used in adults. Suctioning in infants and children requires the use of a smaller suction catheter and lower suction settings that in the adult. Suction settings for a neonate is 60 to 80 mmHg, for an infant is 80 to 100 mmHg, and for larger children is 100 to 120 mmHg. 23A nurse is caring for a client who begins to experience seizure activity while in bed. The nurse implements which action to prevent aspiration? Options: A) Loosens restrictive clothing B) Removes the pillow and raises the padded side rails C) Raises the head of the bed D) Positions the client on the side if possible, with the head flexed forward Correct Answer is: D Explanation : Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitates drainage of secretions, which could help prevent aspiration. The nurse would also remove restrictive clothing and the pillow, and raise the padded side rails, if present, but these actions would not decrease the risk of aspiration. Rather, they are general safety measures to use during seizure activity. The nurse would not raise the client’s head of bed. 24A client with a cerebrovascular accident (CVA) has episodes of coughing while swallowing liquids. The client has developed a temperature of 101oF, oxygen saturation of 91% (down from 98% previously), slight confusion, and noticeable dyspnea. The nurse would take which most appropriate action? Options: A) Administer a bronchodilator ordered on a prn basis

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B) Administer an acetaminophen (Tylenol) suppository

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C) Encourage the client to cough and deep breathe D) Notify the physician Correct Answer is: D Explanation : The client is exhibiting clinical signs and symptoms of aspiration, which include fever, dyspnea, decreased arterial oxygen levels, and confusion. Other symptoms that occur with this complication are difficulty in managing own saliva, or coughing or choking while eating. Because the client has developed a complication requiring medical intervention, the most appropriate action is to contact the physician 25A nurse is providing care to the client following a bone biopsy. Which action would the nurse take as part of aftercare for this procedure? Options: A) Keep the area in a dependent position B) Monitor vital signs once per day C) Monitor the site for swelling, bleeding, or hematoma formation D) Administer intramuscular narcotic analgiesics Correct Answer is: C Explanation : Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, or hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain usually indicates that complications arising. 26A nurse is caring for a client who is going to have an arthrogram using a contrast medium. Which action by the nurse is the highest priority? Options: A) Determining the presence of client allergies

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B) Telling the client that he will need to remain still during the procedure

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C) Asking if the client has any last-minute questions D) Telling the client to try to void before leaving the unit Correct Answer is: A Explanation : Because of the risk of allergy to contrast medium, the nurse place highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test and reminds the client about the need to remain still during the procedure. It is helpful to have the client void before the procedure for comfort. 27A nurse responds to a call bell and finds a client lying on the floor after a fall. The nurse suspects that the client’s arm may broken. The nurse takes which immediate action? Options: A) Tells the client that there is no permanent damage B) Immobilizes the arm C) Take a set of vital signs D) Calls the radiology department Correct Answer is: B Explanation : When a fracture is suspected, it is imperative that the area is splinted before the client moved. Emergency help should be called for if the client is external to a hospital. The nurse should remain with the client and provide realistic reassurance. The client would not told that there is no permanent damage. Vital signs would be taken, but this is not the immediate action. The physician (not the nurse) prescribes X-rays. 28A nurse in the post-partum unit checks a client’s temperature who delivered a healthy newborn infant 4 hours ago. The mother’s temperature is 100.8oF. The nurse provides oral hydration to the mother and encourages fluids. Four hours later, the nurse rechecks the temperature and notes that it is still 100.8oF. Which nursing action is most appropriate? Options:

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A) Notify the physician