Practice Exam 3 and Rationales
This chapter is from the book
This chapter is from the book
This chapter is from the book
Editor's Note: You may also be interested in newer versions of this book and related titles:
- NCLEX-RN Practice Questions, 2nd Edition (print version)
- NCLEX-RN Practice Questions, Adobe Reader, 2nd Edition (eBook version)
- NCLEX-RN Exam Cram, 2nd Edition (print version)
- NCLEX-RN Exam Cram, Adobe Reader, 2nd Edition (eBook version)
- NCLEX Exam Prep (print version)
A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?
Body temperature of 99°F or less
Toes moved in active range of motion
Sensation reported when soles of feet are touched
Capillary refill of < 3 seconds
A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?
Side-lying with knees flexed
Knee-chest
High Fowler's with knees flexed
Semi-Fowler's with legs extended on the bed
A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
Taking hourly blood pressures with mechanical cuff
Encouraging fluid intake of at least 200mL per hour
Position in high Fowler's with knee gatch raised
Administering Tylenol as ordered
Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
Peaches
Cottage cheese
Popsicle
Lima beans
A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.
Adjust the room temperature
Give a bolus of IV fluids
Start O2
Administer meperidine (Demerol) 75mg IV push
The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
Roast beef, gelatin salad, green beans, and peach pie
Chicken salad sandwich, coleslaw, French fries, ice cream
Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
Pork chop, creamed potatoes, corn, and coconut cake
Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
A family vacation in the Rocky Mountains
Chaperoning the local boys club on a snow-skiing trip
Traveling by airplane for business trips
A bus trip to the Museum of Natural History
The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?
Palpate the spleen
Take the blood pressure
Examine the feet for petechiae
Examine the tongue
An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?
Conjunctiva of the eye
Soles of the feet
Roof of the mouth
Shins
The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
BP 146/88
Respirations 28 shallow
Weight gain of 10 pounds in 6 months
Pink complexion
The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
"I will drink 500mL of fluid or less each day."
"I will wear support hose when I am up."
"I will use an electric razor for shaving."
"I will eat foods low in iron."
A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?
The client collects stamps as a hobby.
The client recently lost his job as a postal worker.
The client had radiation for treatment of Hodgkin's disease as a teenager.
The client's brother had leukemia as a child.
An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?
The abdomen
The thorax
The earlobes
The soles of the feet
A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?
"Have you noticed a change in sleeping habits recently?"
"Have you had a respiratory infection in the last 6 months?"
"Have you lost weight recently?"
"Have you noticed changes in your alertness?"
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
Oral mucous membrane, altered related to chemotherapy
Risk for injury related to thrombocytopenia
Fatigue related to the disease process
Interrupted family processes related to life-threatening illness of a family member
A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?
Sexual dysfunction related to radiation therapy
Anticipatory grieving related to terminal illness
Tissue integrity related to prolonged bed rest
Fatigue related to chemotherapy
A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor:
Platelet count
White blood cell count
Potassium levels
Partial prothrombin time (PTT)
The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80, It will be most important to teach the client and family about:
Bleeding precautions
Prevention of falls
Oxygen therapy
Conservation of energy
A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client?
Place the client in Trendelenburg position for postural drainage
Encourage coughing and deep breathing every 2 hours
Elevate the head of the bed 30°
Encourage the Valsalva maneuver for bowel movements
The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
Measure the urinary output
Check the vital signs
Encourage increased fluid intake
Weigh the client
A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
Place the client in a sitting position with the head hyperextended
Pack the nares tightly with gauze to apply pressure to the source of bleeding
Pinch the soft lower part of the nose for a minimum of 5 minutes
Apply ice packs to the forehead and back of the neck
A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is:
Blood pressure
Temperature
Output
Specific gravity
A client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?
Glucometer readings as ordered
Intake/output measurements
Sodium and potassium levels monitored
Daily weights
A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be?
Obtain a crash cart
Check the calcium level
Assess the dressing for drainage
Assess the blood pressure for hypertension
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
Impaired physical mobility related to decreased endurance
Hypothermia r/t decreased metabolic rate
Disturbed thought processes r/t interstitial edema
Decreased cardiac output r/t bradycardia
The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?
Report muscle weakness to the physician.
Allow six months for the drug to take effect.
Take the medication with fruit juice.
Ask the doctor to perform a complete blood count before starting the medication.
The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:
Utilize an infusion pump
Check the blood glucose level
Place the client in Trendelenburg position
Cover the solution with foil
The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?
Blood pressure of 126/80
Blood glucose of 110mg/dL
Heart rate of 60bpm
Respiratory rate of 30 per minute
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
Replenish his supply every 3 months
Take one every 15 minutes if pain occurs
Leave the medication in the brown bottle
Crush the medication and take with water
The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
Macaroni and cheese
Shrimp with rice
Turkey breast
Spaghetti
The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
Feet
Neck
Hands
Sacrum
The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:
Phlebostatic axis
PMI
Erb's point
Tail of Spence
The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
Question the order
Administer the medications
Administer separately
Contact the pharmacy
The best method of evaluating the amount of peripheral edema is:
Weighing the client daily
Measuring the extremity
Measuring the intake and output
Checking for pitting
A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:
Overnight stays by family members is against hospital policy.
There is no need for him to stay because staffing is adequate.
His wife will rest much better knowing that he is at home.
Visitation is limited to 30 minutes when the implant is in place.
The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
Roast beef sandwich, potato chips, pickle spear, iced tea
Split pea soup, mashed potatoes, pudding, milk
Tomato soup, cheese toast, Jello, coffee
Hamburger, baked beans, fruit cup, iced tea
The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
"I will make sure I eat breakfast within 10 minutes of taking my insulin."
"I will need to carry candy or some form of sugar with me all the time."
"I will eat a snack around three o'clock each afternoon."
"I can save my dessert from supper for a bedtime snack."
The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:
New parents need time to learn how to hold the baby.
The umbilical cord needs time to separate.
Newborn skin is easily traumatized by washing.
The chance of chilling the baby outweighs the benefits of bathing.
A client with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:
Treat iron-deficiency anemia caused by chemotherapeutic agents
Create a synergistic effect that shortens treatment time
Increase the number of circulating neutrophils
Reverse drug toxicity and prevent tissue damage
A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:
Hib titer
Mumps vaccine
Hepatitis B vaccine
MMR
The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:
30 minutes before meals
With each meal
In a single dose at bedtime
30 minutes after meals
A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
Call security for assistance and prepare to sedate the client.
Tell the client to calm down and ask him if he would like to play cards.
Tell the client that if he continues his behavior he will be punished.
Leave the client alone until he calms down.
When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:
Check the client for bladder distention
Assess the blood pressure for hypotension
Determine whether an oxytocic drug was given
Check for the expulsion of small clots
A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:
Pneumonia
Reaction to antiviral medication
Tuberculosis
Superinfection due to low CD4 count
The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?
Diabetes
Prinzmetal's angina
Cancer
Cluster headaches
The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes:
Pain on flexion of the hip and knee
Nuchal rigidity on flexion of the neck
Pain when the head is turned to the left side
Dizziness when changing positions
The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:
Agnosia
Apraxia
Anomia
Aphasia
The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
Chronic fatigue syndrome
Normal aging
Sundowning
Delusions
The client with confusion says to the nurse, "I haven't had anything to eat all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?
"You know you had breakfast 30 minutes ago."
"I am so sorry that they didn't get you breakfast. I'll report it to the charge nurse."
"I'll get you some juice and toast. Would you like something else?"
"You will have to wait a while; lunch will be here in a little while."
The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug?
Urinary incontinence
Headaches
Confusion
Nausea
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
Document the finding
Report the finding to the doctor
Prepare the client for a C-section
Continue primary care as prescribed
A client with a diagnosis of HPV is at risk for which of the following?
Hodgkin's lymphoma
Cervical cancer
Multiple myeloma
Ovarian cancer
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
Syphilis
Herpes
Gonorrhea
Condylomata
A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
Venereal Disease Research Lab (VDRL)
Rapid plasma reagin (RPR)
Florescent treponemal antibody (FTA)
Thayer-Martin culture (TMC)
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
Elevated blood glucose
Elevated platelet count
Elevated creatinine clearance
Elevated hepatic enzymes
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow.
The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?
Magnesium sulfate 4gm (25%) IV
Brethine 10mcg IV
Stadol 1mg IV push every 4 hours as needed prn for pain
Ancef 2gm IVPB every 6 hours
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of this data is:
The infant is at low risk for congenital anomalies.
The infant is at high risk for intrauterine growth retardation.
The infant is at high risk for respiratory distress syndrome.
The infant is at high risk for birth trauma.
Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
Crying
Wakefulness
Jitteriness
Yawning
The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
Decreased urinary output
Hypersomnolence
Absence of knee jerk reflex
Decreased respiratory rate
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:
Place her in Trendelenburg position
Decrease the rate of IV infusion
Administer oxygen per nasal cannula
Increase the rate of the IV infusion
A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
Alteration in nutrition
Alteration in bowel elimination
Alteration in skin integrity
Ineffective individual coping
The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
Inspection of the abdomen for enlargement
Bimanual palpation for hepatomegaly
Daily measurement of abdominal girth
Assessment for a fluid wave
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis?
Alteration in cerebral tissue perfusion
Fluid volume deficit
Ineffective airway clearance
Alteration in sensory perception
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
Likes to play football
Drinks several carbonated drinks per day
Has two sisters with sickle cell tract
Is taking acetaminophen to control pain
The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
Allow the client to keep the fruit
Place the fruit next to the bed for easy access by the client
Offer to wash the fruit for the client
Tell the family members to take the fruit home
The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse's action should be to:
Place the client in Trendelenburg position
Increase the infusion of Dextrose in normal saline
Administer atropine intravenously
Move the emergency cart to the bedside
The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
Order a chest x-ray
Reinsert the tube
Cover the insertion site with a Vaseline gauze
Call the doctor
A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
Assess for signs of abnormal bleeding
Anticipate an increase in the Coumadin dosage
Instruct the client regarding the drug therapy
Increase the frequency of neurological assessments
Which selection would provide the most calcium for the client who is 4 months pregnant?
A granola bar
A bran muffin
A cup of yogurt
A glass of fruit juice
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?
The nurse places a sign over the bed not to check blood pressure in the right arm.
The nurse places a padded tongue blade at the bedside.
The nurse inserts a Foley catheter.
The nurse darkens the room.
A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child's mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?
Ask the mother to leave while the blood transfusion is in progress
Encourage the mother to reconsider
Explain the consequences without treatment
Notify the physician of the mother's refusal
A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
Hypovolemia
Laryngeal edema
Hypernatremia
Hyperkalemia
The nurse is evaluating nutritional outcomes for an elderly client with bulimia. Which data best indicates that the plan of care is effective?
The client selects a balanced diet from the menu.
The client's hemoglobin and hematocrit improve.
The client's tissue turgor improves.
The client gains weight.
The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
Pain beneath the cast
Warm toes
Pedal pulses weak and rapid
Paresthesia of the toes
The client is having an arteriogram. During the procedure, the client tells the nurse, "I'm feeing really hot." Which response would be best?
"You are having an allergic reaction. I will get an order for Benadryl."
"That feeling of warmth is normal when the dye is injected."
"That feeling of warmth indicates that the clots in the coronary vessels are dissolving."
"I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing."
The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?
The nursing assistant wears gloves while giving the client a bath.
The nurse wears goggles while drawing blood from the client.
The doctor washes his hands before examining the client.
The nurse wears gloves to take the client's vital signs.
The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client's ECT has been effective?
The client loses consciousness.
The client vomits.
The client's ECG indicates tachycardia.
The client has a grand mal seizure.
The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep
Scrape the skin with a piece of cardboard and bring it to the clinic
Obtain a stool specimen in the afternoon
Bring a hair sample to the clinic for evaluation
The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?
Treatment is not recommended for children less than 10 years of age.
The entire family should be treated.
Medication therapy will continue for 1 year.
Intravenous antibiotic therapy will be ordered.
The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
The client receiving linear accelerator radiation therapy for lung cancer
The client with a radium implant for cervical cancer
The client who has just been administered soluble brachytherapy for thyroid cancer
The client who returned from placement of iridium seeds for prostate cancer
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
The client with Cushing's disease
The client with diabetes
The client with acromegaly
The client with myxedema
The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
Negligence
Tort
Assault
Malpractice
Which assignment should not be performed by the licensed practical nurse?
Inserting a Foley catheter
Discontinuing a nasogastric tube
Obtaining a sputum specimen
Starting a blood transfusion
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?
Continuing to monitor the vital signs
Contacting the physician
Asking the client how he feels
Asking the LPN to continue the post-op care
Which nurse should be assigned to care for the postpartal client with preeclampsia?
The RN with 2 weeks of experience in postpartum
The RN with 3 years of experience in labor and delivery
The RN with 10 years of experience in surgery
The RN with 1 year of experience in the neonatal intensive care unit
Which information should be reported to the state Board of Nursing?
The facility fails to provide literature in both Spanish and English.
The narcotic count has been incorrect on the unit for the past 3 days.
The client fails to receive an itemized account of his bills and services received during his hospital stay.
The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.
The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
Call the Board of Nursing
File a formal reprimand
Terminate the nurse
Charge the nurse with a tort
The home health nurse is planning for the day's visits. Which client should be seen first?
The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube
The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
The 50-year-old with MRSA being treated with Vancomycin via a PICC line
The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis
The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury
The client who arrives with a large puncture wound to the abdomen and the client with chest pain
The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?
The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.
The child should be allowed to instill his own eyedrops.
The mother should be allowed to instill the eyedrops.
If the eye is clear from any redness or edema, the eyedrops should be held.
The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?
"It is okay to give my child white grape juice for breakfast."
"My child can have a grilled cheese sandwich for lunch."
"We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch."
"For a snack, my child can have ice cream."
A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?
Ask the parent/guardian to leave the room when assessments are being performed.
Ask the parent/guardian to take the child's favorite blanket home because anything from the outside should not be brought into the hospital.
Ask the parent/guardian to room-in with the child.
If the child is screaming, tell him this is inappropriate behavior.
Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
Remove the mold and clean every week.
Store the hearing aid in a warm place.
Clean the lint from the hearing aid with a toothpick.
Change the batteries weekly.
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
Body image disturbance
Impaired verbal communication
Risk for aspiration
Pain
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
High fever
Nonproductive cough
Rhinitis
Vomiting and diarrhea
The nurse is caring for a client admitted with epiglottis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
Intravenous access supplies
A tracheostomy set
Intravenous fluid administration pump
Supplemental oxygen
A 25-year-old client with Grave's disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?
Bradycardia
Decreased appetite
Exophthalmos
Weight gain
The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?
Ham sandwich on whole-wheat toast
Spaghetti and meatballs
Hamburger with ketchup
Cheese omelet
The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?
Notify the physician
Recheck the O2 saturation level in 15 minutes
Apply oxygen by mask
Assess the child's pulse
A gravida III para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy?
Fetal heart tones 160bpm
A moderate amount of straw-colored fluid
A small amount of greenish fluid
A small segment of the umbilical cord
The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make?
"We have a name picked out for the baby."
"I need to push when I have a contraction."
"I can't concentrate if anyone is touching me."
"When can I get my epidural?"
The client is having fetal heart rates of 90–110bpm during the contractions. The first action the nurse should take is:
Reposition the monitor
Turn the client to her left side
Ask the client to ambulate
Prepare the client for delivery
In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:
A painless delivery
Cervical effacement
Infrequent contractions
Progressive cervical dilation
A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
Anticipate the need for a Caesarean section
Apply the fetal heart monitor
Place the client in Genu Pectoral position
Perform an ultrasound exam
A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
The cervix is closed.
The membranes are still intact.
The fetal heart tones are within normal limits.
The contractions are intense enough for insertion of an internal monitor.
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primagravida as she completes the early phase of labor?
Impaired gas exchange related to hyperventilation
Alteration in placental perfusion related to maternal position
Impaired physical mobility related to fetal-monitoring equipment
Potential fluid volume deficit related to decreased fluid intake
As the client reaches 8cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?
The baby is asleep.
The umbilical cord is compressed.
There is a vagal response.
There is uteroplacental insufficiency.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
Notify her doctor
Start an IV
Reposition the client
Readjust the monitor
Which of the following is a characteristic of a reassuring fetal heart rate pattern?
A fetal heart rate of 170–180bpm
A baseline variability of 25–35bpm
Ominous periodic changes
Acceleration of FHR with fetal movements
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
The bladder fills more rapidly because of the medication used for the epidural.
Her level of consciousness is such that she is in a trancelike state.
The sensation of the bladder filling is diminished or lost.
She is embarrassed to ask for the bedpan that frequently.
A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:
Estrogen levels are low.
Lutenizing hormone is high.
The endometrial lining is thin.
The progesterone level is low.
A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:
Age of the client
Frequency of intercourse
Regularity of the menses
Range of the client's temperature
A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?
Intrauterine device
Oral contraceptives
Diaphragm
Contraceptive sponge
The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy?
Painless vaginal bleeding
Abdominal cramping
Throbbing pain in the upper quadrant
Sudden, stabbing pain in the lower quadrant
The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?
Hamburger pattie, green beans, French fries, and iced tea
Roast beef sandwich, potato chips, baked beans, and cola
Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea
Fish sandwich, gelatin with fruit, and coffee
The client with hyperemesis gravidarum is at risk for developing:
Respiratory alkalosis without dehydration
Metabolic acidosis with dehydration
Respiratory acidosis without dehydration
Metabolic alkalosis with dehydration
A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
Elevated human chorionic gonadatropin
The presence of fetal heart tones
Uterine enlargement
Breast enlargement and tenderness
The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
Hypoglycemic, small for gestational age
Hyperglycemic, large for gestational age
Hypoglycemic, large for gestational age
Hyperglycemic, small for gestational age
Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?
Weight gain should be reported to the physician.
An alternate method of birth control is needed when taking antibiotics.
If the client misses one or more pills, two pills should be taken per day for 1 week.
Changes in the menstrual flow should be reported to the physician.
The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
Diabetes
Positive HIV
Hypertension
Thyroid disease
A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse's first action should be to:
Assess the fetal heart tones
Check for cervical dilation
Check for firmness of the uterus
Obtain a detailed history
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
Her contractions are 2 minutes apart.
She has back pain and a bloody discharge.
She experiences abdominal pain and frequent urination.
Her contractions are 5 minutes apart.
The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
Low birth weight
Large for gestational age
Preterm birth, but appropriate size for gestation
Growth retardation in weight and length
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
Within 72 hours of delivery
Within 1 week of delivery
Within 2 weeks of delivery
Within 1 month of delivery
After the physician performs an amniotomy, the nurse's first action should be to assess the:
Degree of cervical dilation
Fetal heart tones
Client's vital signs
Client's level of discomfort
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client's cervix is 5cm dilated with 75% effacement. Based on the nurse's assessment the client is in which phase of labor?
Active
Latent
Transition
Early
A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:
Teaching the mother to provide tactile stimulation
Wrapping the newborn snugly in a blanket
Placing the newborn in the infant seat
Initiating an early infant-stimulation program
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
Checking for cervical dilation
Placing the client in a supine position
Checking the client's blood pressure
Obtaining a fetal heart rate
The nurse is aware that the best way to prevent post- operative wound infection in the surgical client is to:
Administer a prescribed antibiotic
Wash her hands for 2 minutes before care
Wear a mask when providing care
Ask the client to cover her mouth when she coughs
The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
Pain
Disalignment
Cool extremity
Absence of pedal pulses
The nurse knows that a 60-year-old female client's susceptibility to osteoporosis is most likely related to:
Lack of exercise
Hormonal disturbances
Lack of calcium
Genetic predisposition
A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant's traction. Which finding by the nurse indicates that the traction is working properly?
The infant no longer complains of pain.
The buttocks are 15° off the bed.
The legs are suspended in the traction.
The pins are secured within the pulley.
A client with a fractured hip has been placed in Buck's traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
Utilizes a Steinman pin
Requires that both legs be secured
Utilizes Kirschner wires
Is used primarily to heal the fractured hips
The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
Serum collection (Davol) drain
Client's pain
Nutritional status
Immobilizer
Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse's teaching?
"I must flush the tube with water after feedings and clamp the tube."
"I must check placement four times per day."
"I will report to the doctor any signs of indigestion."
"If my father is unable to swallow, I will discontinue the feeding and call the clinic."
The nurse is assessing the client with a total knee replacement 2 hours post-operative. Which information requires notification of the doctor?
Bleeding on the dressing is 3cm in diameter.
The client has a temperature of 6°F.
The client's hematocrit is 26%.
The urinary output has been 60 during the last 2 hours.
The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?
The client has traveled out of the country in the last 6 months.
The client's parents are skilled stained-glass artists.
The client lives in a house built in 1
The client has several brothers and sisters.
A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?
High-seat commode
Recliner
TENS unit
Abduction pillow
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
Administer oxygen via nasal cannula
Have narcan (naloxane) available
Prepare to administer blood products
Prepare to do cardioresuscitation
Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell's traction?
16-year-old female with scoliosis
12-year-old male with a fractured femur
10-year-old male with sarcoma
6-year-old male with osteomylitis
A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?
Take the medication with milk.
Report chest pain.
Remain upright after taking for 30 minutes.
Allow 6 weeks for optimal effects.
A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse:
Handles the cast with the fingertips
Petals the cast
Dries the cast with a hair dryer
Allows 24 hours before bearing weight
The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?
"It will be alright for your friends to autograph the cast."
"Because the cast is made of plaster, autographing can weaken the cast."
"If they don't use chalk to autograph, it is okay."
"Autographing or writing on the cast in any form will harm the cast."
The nurse is assigned to care for the client with a Steinmen pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
Assisting the LPN with opening sterile packages and peroxide
Telling the LPN that clean gloves are allowed
Telling the LPN that the registered nurse should perform pin care
Asking the LPN to clean the weights and pulleys with peroxide
A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?
Check the bowel sounds
Assess the blood pressure
Offer pain medication
Check for swelling
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
Russell's traction
Buck's traction
Halo traction
Crutchfield tong traction
A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?
"Use of the CPM will permit the client to ambulate during the therapy."
"The CPM machine controls should be positioned distal to the site."
"If the client complains of pain during the therapy, I will turn off the machine and call the doctor."
"Use of the CPM machine will alleviate the need for physical therapy after the client is discharged."
A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
Palms rest lightly on the handles
Elbows are flexed 0°
Client walks to the front of the walker
Client carries the walker
When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
Attempt to replace the cord
Place the client on her left side
Elevate the client's hips
Cover the cord with a dry, sterile gauze
The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?
The tube will allow for equalization of the lung expansion.
Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.
Chest tubes relieve pain associated with a collapsed lung.
Chest tubes assist with cardiac function by stabilizing lung expansion.
A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:
Mother's educational level
Infant's birth weight
Size of the mother's breast
Mother's desire to breastfeed
The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
The presence of scant bloody discharge
Frequent urination
The presence of green-tinged amniotic fluid
Moderate uterine contractions
The nurse is measuring the duration of the client's contractions. Which statement is true regarding the measurement of the duration of contractions?
Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.
Duration is measured by timing from the end of one contraction to the beginning of the next contraction.
Duration is measured by timing from the beginning of one contraction to the end of the same contraction.
Duration is measured by timing from the peak of one contraction to the end of the same contraction.
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
Maternal hypoglycemia
Fetal bradycardia
Maternal hyperreflexia
Fetal movement
A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?
Insulin requirements moderate as the pregnancy progresses.
A decreased need for insulin occurs during the second trimester.
Elevations in human chorionic gonadotrophin decrease the need for insulin.
Fetal development depends on adequate insulin regulation.
A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
Providing a calm environment
Obtaining a diet history
Administering an analgesic
Assessing fetal heart tones
A primigravida, age 42, is 6 weeks pregnant. Based on the client's age, her infant is at risk for:
Down syndrome
Respiratory distress syndrome
Turner's syndrome
Pathological jaundice
A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
Magnesium sulfate
Calcium gluconate
Dinoprostone (Prostin E.)
Bromocrystine (Pardel)
A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:
Continue the infusion of magnesium sulfate while monitoring the client's blood pressure
Stop the infusion of magnesium sulfate and contact the physician
Slow the infusion rate and turn the client on her left side
Administer calcium gluconate IV push and continue to monitor the blood pressure
Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?
An affected newborn has unaffected parents.
An affected newborn has one affected parent.
Affected parents have a one in four chance of passing on the defective gene.
Affected parents have unaffected children who are carriers.
A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:
Because it is a state law
To detect cardiovascular defects
Because of her age
To detect neurological defects
A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse's response is based on the knowledge that:
There is no need to take thyroid medication because the fetus's thyroid produces a thyroid-stimulating hormone.
Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.
It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism.
Fetal growth is arrested if thyroid medication is continued during pregnancy.
The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse could expect to find:
An apical pulse of 100
An absence of tonus
Cyanosis of the feet and hands
Jaundice of the skin and sclera
A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client's need for:
Supplemental oxygen
Fluid restriction
Blood transfusion
Delivery by Caesarean section
A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:
Increasing fluid intake
Limiting ambulation
Administering an enema
Withholding food for 8 hours
An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year?
14 pounds
16 pounds
18 pounds
24 pounds
A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:
Determines the lung maturity of the fetus
Measures the activity of the fetus
Shows the effect of contractions on the fetal heart rate
Measures the neurological well-being of the fetus
A full-term male has hypospadias. Which statement describes hypospadias?
The urethral opening is absent.
The urethra opens on the dorsal side of the penis.
The penis is shorter than usual.
The urethra opens on the ventral side of the penis.
A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
Alteration in coping related to pain
Potential for injury related to precipitate delivery
Alteration in elimination related to anesthesia
Potential for fluid volume deficit related to NPO status
The client with varicella will most likely have an order for which category of medication?
Antibiotics
Antipyretics
Antivirals
Anticoagulants
A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?
Nitroglycerin
Ampicillin
Propranolol
Verapamil
Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?
Avoid exercise because it fatigues the joints.
Take prescribed anti-inflammatory medications with meals.
Alternate hot and cold packs to affected joints.
Avoid weight-bearing activity.
A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?
Meperidine 100mg IM q 4 hours PRN pain
Mylanta 30 ccs q 4 hours via NG
Cimetadine 300mg PO q.i.d.
Morphine 8mg IM q 4 hours PRN pain
The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
Hallucinogenic drugs create both stimulant and depressant effects.
Hallucinogenic drugs induce a state of altered perception.
Hallucinogenic drugs produce severe respiratory depression.
Hallucinogenic drugs induce rapid physical dependence.
A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:
Depression and suicidal ideation
Tachycardia and diarrhea
Muscle cramping and abdominal pain
Tachycardia and euphoric mood
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
Right breech presentation
Right occipital anterior presentation
Left sacral anterior presentation
Left occipital transverse presentation
The primary physiological alteration in the development of asthma is:
Bronchiolar inflammation and dyspnea
Hypersecretion of abnormally viscous mucus
Infectious processes causing mucosal edema
Spasm of bronchiolar smooth muscle
A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
Serve high-calorie foods she can carry with her
Encourage her appetite by sending out for her favorite foods
Serve her small, attractively arranged portions
Allow her in the unit kitchen for extra food whenever she pleases
To maintain Bryant's traction, the nurse must make certain that the child's:
Hips are resting on the bed, with the legs suspended at a right angle to the bed
Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed
Hips and legs are flat on the bed, with the traction positioned at the foot of the bed
Which action by the nurse indicates understanding of herpes zoster?
The nurse covers the lesions with a sterile dressing.
The nurse wears gloves when providing care.
The nurse administers a prescribed antibiotic.
The nurse administers oxygen.
The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab for them to collect the blood:
15 minutes after the infusion
30 minutes before the infusion
1 hour after the infusion
2 hours after the infusion
The client using a diaphragm should be instructed to:
Refrain from keeping the diaphragm in longer than 4 hours
Keep the diaphragm in a cool location
Have the diaphragm resized if she gains 5 pounds
Have the diaphragm resized if she has any surgery
The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client's statements indicates the need for additional teaching?
"I'm wearing a support bra."
"I'm expressing milk from my breast."
"I'm drinking four glasses of fluid during a 24-hour period."
"While I'm in the shower, I'll allow the water to run over my breasts."
Damage to the VII cranial nerve results in:
Facial pain
Absence of ability to smell
Absence of eye movement
Tinnitus
A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication may:
Cause diarrhea
Change the color of her urine
Cause mental confusion
Cause changes in taste
Which of the following tests should be performed before beginning a prescription of Accutane?
Check the calcium level
Perform a pregnancy test
Monitor apical pulse
Obtain a creatinine level
A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
Limit the client's activity
Encourage a high-carbohydrate diet
Utilize an incentive spirometer to improve respiratory function
Encourage fluids
A client is admitted for an MRI. The nurse should question the client regarding:
Pregnancy
A titanium hip replacement
Allergies to antibiotics
Inability to move his feet
The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?
Changes in vision
Nausea
Urinary frequency
Changes in skin color
The nurse should visit which of the following clients first?
The client with diabetes with a blood glucose of 95mg/dL
The client with hypertension being maintained on Lisinopril
The client with chest pain and a history of angina
The client with Raynaud's disease
A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:
Once per day in the morning
Three times per day with meals
Once per day at bedtime
Four times per day
Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?
The lens controls stimulation of the retina.
The lens orchestrates eye movement.
The lens focuses light rays on the retina.
The lens magnifies small objects.
A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:
Anesthetize the cornea
Dilate the pupils
Constrict the pupils
Paralyze the muscles of accommodation
A client with a severe corneal ulcer has an order for Gentamycin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?
Allow 5 minutes between the two medications.
The medications may be used together.
The medications should be separated by a cycloplegic drug.
The medications should not be used in the same client.
The client with color blindness will most likely have problems distinguishing which of the following colors?
Orange
Violet
Red
White
The client with a pacemaker should be taught to:
Report ankle edema
Check his blood pressure daily
Refrain from using a microwave oven
Monitor his pulse rate
The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:
1900
1200
1000
0700
Which of the following diet instructions should be given to the client with recurring urinary tract infections?
Increase intake of meats.
Avoid citrus fruits.
Perform pericare with hydrogen peroxide.
Drink a glass of cranberry juice every day.
The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
"I will make sure I eat breakfast within 2 hours of taking my insulin."
"I will need to carry candy or some form of sugar with me all the time."
"I will eat a snack around three o'clock each afternoon."
"I can save my dessert from supper for a bedtime snack."
A client with pneumacystis carini pneumonia is receiving trimetrexate. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to:
Treat anemia.
Create a synergistic effect.
Increase the number of white blood cells.
Reverse drug toxicity.
A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question?
TB skin test
Rubella vaccine
ELISA test
Chest x-ray
The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:
30 minutes before meals
With each meal
In a single dose at bedtime
60 minutes after meals
A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:
Is the opening on the client's left side
Is the opening on the distal end on the client's left side
Is the opening on the client's right side
Is the opening on the distal right side
While assessing the postpartal client, the nurse notes that the fundus is displaced to the right. Based on this finding, the nurse should:
Ask the client to void
Assess the blood pressure for hypotension
Administer oxytocin
Check for vaginal bleeding
The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be done if the client has:
The need for oxygen therapy
A history of claustrophobia
A permanent pacemaker
Sensory deafness
A 6-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?
Colorful crib mobile
Hand-held electronic games
Cars in a plastic container
30-piece jigsaw puzzle
The nurse is preparing to discharge a client with a long history of polio. The nurse should tell the client that:
Taking a hot bath will decrease stiffness and spasticity.
A schedule of strenuous exercise will improve muscle strength.
Rest periods should be scheduled throughout the day.
Visual disturbances can be corrected with prescription glasses.
A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?
Dulcolax suppository
Docusate sodium (Colace)
Methyergonovine maleate (Methergine)
Bromocriptine sulfate (Parlodel)
A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is:
Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels.
Total Parenteral Nutrition cannot be managed with oral hypoglycemics.
Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.
Total Parenteral Nutrition leads to further pancreatic disease.
An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for a first check-up. To develop a teaching plan, the nurse should initially assess:
The client's knowledge of the signs of preterm labor
The client's feelings about the pregnancy
Whether the client was using a method of birth control
The client's thought about future children
An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?
.45 normal saline
Dextrose 1% in water
Lactated Ringer's
Dextrose 5% in .45 normal saline
The physician has ordered a thyroid scan to confirm the diagnosis. Before the procedure, the nurse should:
Assess the client for allergies
Bolus the client with IV fluid
Tell the client he will be asleep
Insert a urinary catheter
The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse understands that RhoGam is given to:
Provide immunity against Rh isoenzymes
Prevent the formation of Rh antibodies
Eliminate circulating Rh antibodies
Convert the Rh factor from negative to positive
The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?
Application of a short inclusive spica cast
Stabilization with a plaster-of-Paris cast
Surgery with Kirschner wire implantation
A gauze dressing only
A client with bladder cancer is being treated with iridium seed implants. The nurse's discharge teaching should include telling the client to:
Strain his urine
Increase his fluid intake
Report urinary frequency
Avoid prolonged sitting
Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?
Antivirals
Antibiotics
Immunosuppressants
Analgesics
The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:
Mydriatics to facilitate removal
Miotic medications such as Timoptic
A laser to smooth and reshape the lens
Silicone oil injections into the eyeball
A client with Alzheimer's disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?
Placing mirrors in several locations in the home
Placing a picture of herself in her bedroom
Placing simple signs to indicate the location of the bedroom, bathroom, and so on
Alternating healthcare workers to prevent boredom
A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:
Prevent the need for dressing changes
Reduce edema at the incision
Provide for wound drainage
Keep the common bile duct open
The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:
Mongolian spots
Scrotal rugae
Head lag
Vernix caseosa
The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?
Hematuria
Muscle spasms
Dizziness
Nausea
A client is brought to the emergency room by the police. He is combative and yells, "I have to get out of here. They are trying to kill me." Which assessment is most likely correct in relation to this statement?
The client is experiencing an auditory hallucination.
The client is having a delusion of grandeur.
The client is experiencing paranoid delusions.
The client is intoxicated.
The nurse is preparing to suction the client with a tracheotomy. The nurse notes a previously used bottle of normal saline on the client's bedside table. There is no label to indicate the date or time of initial use. The nurse should:
Lip the bottle and use a pack of sterile 4x4 for the dressing
Obtain a new bottle and label it with the date and time of first use
Ask the ward secretary when the solution was requested
Label the existing bottle with the current date and time
An infant's Apgar score is 9 at 5 minutes. The nurse is aware that the most likely cause for the deduction of one point is:
The baby is cold.
The baby is experiencing bradycardia.
The baby's hands and feet are blue.
The baby is lethargic.
The primary reason for rapid continuous rewarming of the area affected by frostbite is to:
Lessen the amount of cellular damage
Prevent the formation of blisters
Promote movement
Prevent pain and discomfort
A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that hemodialysis works by:
Passing water through a dialyzing membrane
Eliminating plasma proteins from the blood
Lowering the pH by removing nonvolatile acids
Filtering waste through a dialyzing membrane
During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?
Administer an antibiotic
Contact the physician for an order for immune globulin
Administer an antiviral
Tell the client that he should remain in isolation for 2 weeks
A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?
The client should be placed in a room with negative pressure.
Infection requires close contact; therefore, the door may remain open.
Transmission is highly likely, so the client should wear a mask at all times.
Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.
A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?
"The pain will go away in a few days."
"The pain is due to peripheral nervous system interruptions. I will get you some pain medication."
"The pain is psychological because your foot is no longer there."
"The pain and itching are due to the infection you had before the surgery."
A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the:
Head of the pancreas
Proximal third section of the small intestines
Stomach and duodenum
Esophagus and jejunum
The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:
Fruits
Salt
Pepper
Ketchup
A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:
Have a Protime done monthly
Eat more fruits and vegetables
Drink more liquids
Avoid crowds
The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to:
Perform the Valsalva maneuver as the catheter is advanced
Turn his head to the left side and hyperextend the neck
Take slow, deep breaths as the catheter is removed
Turn his head to the right while maintaining a sniffing position
A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:
Allergies to pineapples and bananas
A history of streptococcal infections
Prior therapy with phenytoin
A history of alcohol abuse
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
Using oil- or cream-based soaps
Flossing between the teeth
The intake of salt
Using an electric razor
The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:
Apply the new tie before removing the old one.
Have a helper present.
Hold the tracheotomy with the nondominant hand while removing the old tie.
Ask the doctor to suture the tracheostomy in place.
The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:
Turning the client to the left side
Milking the tube to ensure patency
Slowing the intravenous infusion
Notifying the physician
The infant is admitted to the unit with tetrology of falot. The nurse would anticipate an order for which medication?
Digoxin
Epinephrine
Aminophyline
Atropine
The nurse is educating the lady's club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence.
The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
Tire easily
Grow normally
Need more calories
Be more susceptible to viral infections
The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
Determine lung maturity
Measure the fetal activity
Show the effect of contractions on fetal heart rate
Measure the well-being of the fetus
The nurse is evaluating the client who was admitted 8 hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?
Instruct the client to push
Perform a vaginal exam
Turn off the Pitocin infusion
Place the client in a semi-Fowler's position
The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:
Atrial flutter
A sinus rhythm
Ventricular tachycardia
Atrial fibrillation
A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:
Be injected into the deltoid muscle
Be injected into the abdomen
Aspirate after the injection
Clear the air from the syringe before injections
The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:
Administer the medications together in one syringe
Administer the medication separately
Administer the Valium, wait 5 minutes, and then inject the Phenergan
Question the order because they cannot be given at the same time
A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:
Douche after intercourse
Void every 3 hours
Obtain a urinalysis monthly
Wipe from back to front after voiding
Which task should be assigned to the nursing assistant?
Placing the client in seclusion
Emptying the Foley catheter of the preeclamptic client
Feeding the client with dementia
Ambulating the client with a fractured hip
The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?
A tracheotomy set
A padded tongue blade
An endotracheal tube
An airway
The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:
Cats
Dogs
Turtles
Birds
Quick Check Answer Key
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D
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D
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D
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See diagram.
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D