Nursing Practice Scenarios: Questions & Answers, Exams of Nursing

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Question & Answers 2024

Which of the following is a manifestation of autism:

• Strict adherence to routines
• Excessive anxiety when seperated from parents - Correct Answers ✅trict adherence to routines. Excessive anxiety is a manifestation of seperation anxiety disorder Which of the following is appropriate teaching for the rhomberg test?
• I will be checking on you with your eyes open and once with them closed
• You will place your hands and hold your hands on your hips - Correct Answers ✅- I will be checking on you with your eyes open and once with them closed How will the feet be positioned in proximity to one another during the romberg test? - Correct Answers ✅Feet will be together

Question & Answers 2024

The nurse should be standing across the room or near the patient during the performance of a romberg test? - Correct Answers ✅Close- due to risk of fall A client with new terminal cancer would like to go home with loved ones. Which of the following should the nurse do?

• Explain the process of leaving the facility against medical advice
• Make a referral for social services - Correct Answers ✅Make a referral for social services. The client isn't leaving against medical advice. In adults, the goal for oxygen therapy is to keep O2 > what %? - Correct Answers ✅ 95 For clients with increased ICP, should care be clustered or spaced apart? - Correct Answers ✅Spaced apart. Clustering their care would increase stress which can increase ICP. Should clients with increased ICP be supine? - Correct Answers ✅No. Elevate HOB to promote blood return away from the heart

Question & Answers 2024

A client who is receiving mechanical ventilation is at risk for what blood pressure alteration? - Correct Answers ✅Hypotension due to increased chest pressure and decreased blood return to the heart Which of the following is an adverse effect of PEEP?

• Tension pneumothorax
• Atelectasis - Correct Answers ✅Tension pneumothorax PEEP is used to prevent atelectasis by strengthening gas exchange Clients who are receiving home therapy oxxygen should wear cotton or synthetic / woolen fabric? - Correct Answers ✅Cotton fabrics. Synthetic or woolen fabrics can create static electricity, which increases risk for fire. Which of the two lubricants can be used for clients receiving oxygen therapy?

Question & Answers 2024

• Petroleum
• Water-soluble - Correct Answers ✅Water soluble Petroleum is flammable when near oxygen How often should oxygen equipment functionality be tested? - Correct Answers ✅Once a day Which of the following should be done prior to administering a bolus NG tube feeding
• Review the medical record for previous x-ray verification of placement
• Aspirate contents from the tube and verify the pH level - Correct Answers ✅- Aspirate contents from the tube and verify the pH level Which of the following is priority for a client who had abdominal surgery 24hr ago
• Assist with deep breathing and coughing

Question & Answers 2024

• Monitor the incision site for findings of infection - Correct Answers ✅- Assist with deep breathing and coughing Which of the following is an adverse reaction to propranolol?
• Hypertension
• Tachycardia
• Wheezing - Correct Answers ✅Wheezing What kind of BP cuff should you use for clients with sickle cell anemia - automatic or manual? - Correct Answers ✅Manual - use alternatives to monitoring BP due to the clients increased risk of venous occlusion Which of the following is an adverse effect of amitriptyline?
• DIarrhea
• Frequent urination

Question & Answers 2024

• Blurred vision - Correct Answers ✅Blurred vision Frequent urination, or urinary retention, is an adverse effect of amitriptyline? - Correct Answers ✅Urinary retention Diarrhea, or constipation, is an averse effect of amitriptyline? - Correct Answers ✅Constipation? Which task can be delegated to an AP?
• Measure the client's daily wt
• Assess the client's vital signs - Correct Answers ✅measure the daily weight Vital signs are considered part of the assessment A nurse is preparing to administer insulin to a client via a pen device. What should they do?
• Hold the insulin pen perpendicular to the client's skin to inject the medication

Question & Answers 2024

• Hold the pen device for 3 seconds after injecting the insulin - Correct Answers ✅- Hold the insulin pen perpendicular to the client's skin to inject the medication The pen should be held for 6 - 10 seconds to insure the insulin has been received How many seconds should an insulin pen remain injected in the client to ensure the insulin has been received?
• 3 - 5 seconds
• 6 - 10 seconds - Correct Answers ✅6 to 10 seconds For a client who is postoperative following a laparoscopic cholecystectomy, the nurse should anticipate prescriptions for the client to apply (Heat / cold) for abdominal pain related to carbon dioxide retention? - Correct Answers ✅Heat How often should a client who is immunosuppressed and have a continuous IV infusion have their mouth monitored? - Correct Answers ✅Q8H for manifestations of infection - such as sores or lesions

Question & Answers 2024

How often is WBC checked for immunosupressed clients - Correct Answers ✅Q24H How often should the IV tubing be changed for a client who is immunosuppressed? - Correct Answers ✅Q24H Dry, coarse hair is a manifestation of ___thyroidism - Correct Answers ✅hypo Bradycardia is a manifestation of ___thyroidism - Correct Answers ✅hypo Tremors are a manifestation of ___thyroidism - Correct Answers ✅hyper tachycardia is a manifestation of ___thyroidism - Correct Answers ✅hyper Diaphoresis is a manifestaiton of ___thyroidism - Correct Answers ✅hyper

Question & Answers 2024

Weight loss is an manifestation of ___thyroidism - Correct Answers ✅hyper insomnia is a manifestation of ____thyroidism - Correct Answers ✅hyper Exophythalmia is a manifestation of ___thyroidism - Correct Answers ✅Hyperthyroidism Periorbital edema is a manifestation of ___thyroidism - Correct Answers ✅Hypothyroidism Can you listen to the apical pulse while palpating the radial pulse in a newborn - Correct Answers ✅No, this is used to detect pulse deficits in an adult Is it sterile technique to pick up and pour solutions with the palm of the hand covering bottle labels - Correct Answers ✅No Sterile items should be how many inches away from the sterile drape? - Correct Answers ✅1in

Question & Answers 2024

What kind of pH condition can occur in a pregnant client who is loosing excessive weight - Correct Answers ✅Metabolic acidosis Select all that is true- "I will breastfeed my baby on a schedule of every 4 hours" "I will bathe my baby every day" "I will place my baby on her stomach for sleeping" "I will cover my baby's body when I wash her hair." "I will use the bulb syringe first in her mouth and then in her nose." - Correct Answers ✅"I will cover my baby's body when I wash her hair." "I will use the bulb syringe first in her mouth and then in her nose." The client should respond to the newborn's cues for feeding at least ___ to ___ times per 24 hours - Correct Answers ✅8 - 12

Question & Answers 2024

Are strict feeding schedules adequate for a newborn's nutrition - Correct Answers ✅nope, should be feeding them at least eight times every 24hrs, or every3 hours. Which should be suctioned first with a bulb syringe- the newborn's nose or mouth - Correct Answers ✅Mouth first, then the nose In an intestinal obstruction, should urine out be monitored? - Correct Answers ✅Yes. A manifestation of intestinal obstruction is dehydration. Assess bowel sounds at least twice daily for peristalsis return Which of the following is an adverse effect of epinepherine?

• CP
• Tinnitus - Correct Answers ✅Chest pain, due to increase cardiac workload and oxygen demand = angina Which of the following should be decreased in a client with Crohn's?
• Protein

Question & Answers 2024

• Potassium
• Fiber - Correct Answers ✅Fiber Fiber will reduce diarrhea. Which of the following are foods high in tyramine?
• Brocolli
• Yogurt
• Pepperoni pizza
• Cream cheese
• Bologna sandwhich - Correct Answers ✅Broccoli, yogurt, and cream cheese

Question & Answers 2024

Which of the following is appropriate for a continuous passive motion machine?

• Turn off during mealtime
• Store the CPM under the bed when not in use
• Maintain the client's affected hip in an externally rotated position - Correct Answers ✅- Turn off during mealtime How should the affected limb be aligned when its using a continuous passive motion machine? - Correct Answers ✅Neutral alignment Can a client adjust the settings on a continuous passive motion device?
• Correct Answers ✅No, only the PT can muscle tetany - Correct Answers ✅Spasms or rapid contractions A client who takes clozapine and risperidone abdruptly stops taking their rX and ends up with neuroleptic malignant syndrome.

Question & Answers 2024

The client should or should not be given their antipsychotic meds? - Correct Answers ✅Hold the antipsychotic meds. Is carpet or tile a worse source of allergens - Correct Answers ✅Carpet is a source of allergens Which of the following is appropriate for a client with crutches who is non weight bearing:

• Use a 3 point gait
• advance the affected leg first when talking upstairs - Correct Answers ✅- Use a 3 point gait Which of the following is appropriate for a client with crutches who is non weight bearing
• advance the affected leg first when talking upstairs
• advance the unaffected leg first when talking upstairs - Correct Answers ✅- advance the unaffected leg first when talking upstairs

Question & Answers 2024

A client has continuous heparin and has doses of warfarin. The lab values were aPTT 98, INR 1.8. Which should the RN do?

• Prepare to administer vitamin K
• Withold the heparin infusion
• Withold the warfarin - Correct Answers ✅Withold the heparin infusion The expected value for aPTT for heparin infusion is 60 - 80. Which of the following is expected for a client with COPD?
• Decrease in Anteroposterior diameter of the chest
• pH 7.31 - Correct Answers ✅pH 7. Due to their increased CO2. There will be an increase in AP diameter, not decrease

Question & Answers 2024

The anteroposterior diameter of the chest will increase or decrease with COPD? - Correct Answers ✅increase Which of the following are manifestations of ovarian cancer?

• Urinary retention
• Abdominal bloating - Correct Answers ✅- Abdominal bloating Urinary frequency is a manifestation of ovarian cancer In ovarian cancer, urine would increase or decrease? - Correct Answers ✅increase Constipation or diarrhea is a manifestation of ovarian cancer - Correct Answers ✅constipation Which of the following clients are using dissociation as a defense mechanism?
• Client who was abused as an child describes the abuse as if it happened to someone else

Question & Answers 2024

• Client states they did not get a job promotion because the boss did not like them - Correct Answers ✅- Client who was abused as an child describes the abuse as if it happened to someone else Is an IV catheter indicated for a paracentesis? - Correct Answers ✅No. Remember to encourage the client to void first. The client should be positioned high fowlers, and they will be given a local anesthetic. Which of the following clients are using ratioanlzation as a defense mechanism?
• Client who was abused as an child describes the abuse as if it happened to someone else
• Client states they did not get a job promotion because the boss did not like them - Correct Answers ✅- Client states they did not get a job promotion because the boss did not like them Lab considerations for a client who is taking risperidone for schizophrenia? - Correct Answers ✅CBC for anemia, thrombocytopenia, leukocytosis, and leukopenia

Question & Answers 2024

Liver function for elevated AST or ALT Which of the following is an example of cost effective care?

• Delegate non nursing tasks to ancillary staff
• Assign dedicated equipment to each client's room - Correct Answers ✅- Delegate non nursing tasks to ancillary staff Assigning dedicated equipment to each client's room would only be indicated for clients who are on some sort of isolation precaution. A client who has superficial self-inflicted laceraitons on their forearms and has relationship problems is likely to have what disorder?
• Borderline
• Antisocial
• Histrionic

Question & Answers 2024

-Paranoid - Correct Answers ✅Borderline Which disorder tends to be manipulative, melodramatic, attention- seeking, and impulsive?

• Borderline
• Antisocial
• Histrionic -Paranoid - Correct Answers ✅Histrionic Which of the following disorders tend to be manipulative, deceitful, and antagonistic. Criminal behavior and substance use are associated with this disorder.
• Borderline
• Antisocial

Question & Answers 2024

• Histrionic -Paranoid - Correct Answers ✅Antisocial Which speech modification is when the speeker talks continuously with sudden, frequent topic changes?
• Tangenitality
• Flight of ideas
• Preservation - Correct Answers ✅Flight of ideas Which of the following is when the speaker does not continue to speak about the main topic but instead talks about subjects that do not relate to the main topic?
• Tangenitality
• Flight of ideas

Question & Answers 2024

• Preservation - Correct Answers ✅Tangenitality Which of the following is when the speaker repeats phrases over and over to avoid answering questions.
• Tangenitality
• Flight of ideas
• Preservation - Correct Answers ✅Preservation An O2 saturation of ___% is expected for a child who has croup - Correct Answers ✅ 92 What does sudden relief from appendicitis pain mean - Correct Answers ✅Peritonitis from a ruptured appendix Is bradycardia an expected finding of valproic acid? - Correct Answers ✅No Valproic acid - Correct Answers ✅Anticonvulsant

Question & Answers 2024

Which of the following is an indication of pulmonary edema

• Tachycardia
• Bradycardia - Correct Answers ✅Tachycardia Which of the following is an indication of pulmonary edema
• Flushed, dry skin Clammy, cyanotic skin - Correct Answers ✅Clammy, cyanotic skin Which of the following is an indication of pulmonary edema
• Crackles
• Wheezing - Correct Answers ✅Crackles

Question & Answers 2024

Chlorpromazine - Correct Answers ✅a drug that reduces the symptoms of schizophrenia by blocking dopamine D2 receptors. Therapeutic effect- decreased hallucinations Which should be reported to the provider of a patient who is taking captopril?

• Tinnitus
• Cough
• Polyuria
• Blurred vision - Correct Answers ✅Cough From Buildup of bradykinin in the lungs Which of the following places in a child should be assessed for hirchsprung disease?
• Eyes

Question & Answers 2024

• Chest
• Abdomen - Correct Answers ✅Abdomen The client will have distention and visible peristalsis, both which are manifestations of HD Hirchsprung disease - Correct Answers ✅Agonglionic megacolon A structural anomaly of the GI tract that is caused by lack of ganglionic cells in segments of the colon resulting in decreased motility and mechanical obstruction altruism - Correct Answers ✅unselfish regard for the welfare of others A pregnant client should wear a supportive or loose braw? - Correct Answers ✅supportive braw Will cortisone cream resolve hyperpigmentation in a pregnant client - Correct Answers ✅Nope

Question & Answers 2024

How should pregnancy-related back pain be relieved? - Correct Answers ✅Exercise, sleeping on a firm mattress, and low heeled shoes. Sleep on their side to promote placental perfusion Should you place pads in your baby's crib - Correct Answers ✅No, they increase the risk of suffocation Is overlapping of sutures in a vaginally delivered baby expected - Correct Answers ✅Yep Is transient strabismus an expected finding in a vaginally born newborn? If so, when should it poof? - Correct Answers ✅Yes. Poofs by 4 months Normal HR for newborn - Correct Answers ✅110 to 160 What lab value to monitor for heparin - Correct Answers ✅aPTT What lab value(s) to monitor for warfarin - Correct Answers ✅PT and INR