1. Which contraindication should the nurse assess for prior to giving a child immunizations?
A) Mild cold symptoms
B) Chronic asthma
C) Depressed immune system
D) Allergy to eggs
The correct answer is C: Depressed immune system
Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations
2. Included
in teaching the client with tuberculosis taking INH about follow-up
home care, the nurse should emphasize that a laboratory appointment for
which of the following lab tests is critical?
A) Liver function
B) Kidney function
C) Blood sugar
D) Cardiac enzymes
The correct answer is A: Liver function
INH
can cause hepatocellular injury and hepatitis. This side effect is
age-related and can be detected with regular assessment of liver
enzymes, which are released into the blood from damaged liver cells.
3. Which client is at highest risk for developing a pressure ulcer?
A) 23 year-old in traction for fractured femur
B) 72 year-old with peripheral vascular disease, who is unable to walk without assistance
C) 75 year-old with left sided paresthesia and is incontinent of urine and stool
D) 30 year-old who is comatose following a ruptured aneurysm
The correct answer is C: 75 year-old client with left sided paresthesia and is incontinent of urine and stool
Risk
factors for pressure ulcers include: immobility, absence of sensation,
decreased LOC, poor nutrition and hydration, skin moisture,
incontinence, increased age, decreased immune response. This client has
the greatest number of risk factors.
4. A
client complains of some discomfort after a below the knee amputation.
Which action by the nurse is appropriate to do initially?
A) Conduct guided imagery or distraction
B) Ensure that the stump is elevated for the initial day
C) Wrap the stump snugly in an elastic bandage
D) Administer opioid narcotics as ordered
The correct answer is B: Ensure that the stump is elevated for the initial day
The
priority is to elevate the stump, preventing pressure caused by pooling
of blood and thus minimizing the pain. Without this measure, a firm
elastic bandage, opioid narcotics, or guided imagery will have little
effect. The opioid would be given for severe pain.
5. A
nurse is caring for a client who had a closed reduction of a fractured
right wrist followed by the application of a fiberglass cast 12 hours
ago. Which finding requires the nurse’s immediate attention?
A) Capillary refill of fingers on right hand is 3 seconds
B) Skin warm to touch and normally colored
C) Client reports prickling sensation in the right hand
D) Slight swelling of fingers of right hand
The correct answer is C: Client reports prickling sensation in the right hand
Prickling
sensation is an indication of compartment syndrome and requires
immediate action by the nurse. The other findings are normal for a
client in this situation.
6. What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention?
A) Set good examples themselves
B) Protect their child from outside influences
C) Make sure their child understands all the safety rules
D) Discuss the consequences of not wearing protective devices
The correct answer is A: Set good examples themselves
Preschool
years is the time for parents to begin emphasizing safety education as
well as providing protection. Setting a good example themselves is
crucial because of the imitative behaviors of pre-schoolers; they are
quick to notice discrepancies between what they see and what they are
told.
7. A
client with a fractured femur has been in Russell’s traction for 24
hours. Which nursing action is associated with this therapy?
A) Check the skin on the sacrum for breakdown
B) Inspect the pin site for signs of infection
C) Auscultate the lungs for atelectasis
D) Perform a neurovascular check for circulation
The correct answer is D: Perform a neurovascular check for circulation
While
each of these is an important assessment, the neurovascular integrity
is most associated with this type of traction. Russell’s traction is
Buck’s traction with a sling under the knee.
8. The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action?
A) Periorbital edema
B) Dizziness spells
C) Lethargy
D) Shortness of breath
The correct answer is B: Dizziness spells
Cardiac
dysrhythmias may cause a transient drop in cardiac output and decreased
blood flow to the brain. Near syncope refers to lightheartedness,
dizziness, temporary confusion. Such "spells" may indicate runs of
ventricular tachycardia or periods of asystole and should be reported
immediately.
9. A
client who is 12 hour post-op becomes confused and says: “Giant sharks
are swimming across the ceiling.” Which assessment is necessary to
adequately identify the source of this client's behavior?
A) Cardiac rhythm strip
B) Pupillary response
C) Pulse oximetry
D) Peripheral glucose stick
The correct answer is C: Pulse oximetry
A
sudden change in mental status in any post-op client should trigger a
nursing intervention directed toward further respiratory evaluation.
Pulse oximetry would be the initial assessment. If available, arterial
blood gases would be better. Acute respiratory failure is the sudden
inability of the respiratory system to maintain adequate gas exchange
which may result in hypercapnia and/or hypoxemia. Clinical findings of
hypoxemia include these finding which are listed in order of initial to
later findings: restlessness, irritability, agitation, dyspnea,
disorientation, confusion, delirium, hallucinations, and loss of
consciousness. While there may be other factors influencing the
client''s findings, the first nursing action should be directed toward
oxygenation issues. Once respiratory or oxygenation issues are ruled out
then significant changes in glucose would be next to evaluate
10. A
client returns from surgery after an open reduction of a femur
fracture. There is a small bloodstain on the cast. Four hours later, the
nurse observes that the stain has doubled in size. What is the best
action for the nurse to take?
A) Call the health care provider
B) Access the site by cutting a window in the cast
C) Record the findings in the nurse's notes only
D) Outline the spot with a pencil and note the time and date on the cast
The correct answer is D: Outline the spot with a pencil and note the time and date on the cast
This
is a good way to assess the amount of bleeding over a period of time.
The bleeding does not appear to be excessive and some bleeding is
expected with this type of surgery. The bleeding should also be
documented in the nurse’s notes.
11. The
parents of a toddler ask the nurse how long their child will have to
sit in a car seat while in the automobile. What is the nurse’s best
response to the parents?
12.
A) “Your child must use a care seat until he weighs at least 40 pounds."
B) The child must be 5 years of age to use a regular seat belt.
C) “Your child must reach a height of 50 inches to sit in a seat belt."
D) “The child can use a regular seat belt when he can sit still."
The correct answer is A: “Your child must use a care seat until he weighs at least 40 pounds."
A child should use a car seat until they weigh 40 pounds.
13. A
couple trying to conceive asks the nurse when ovulation occurs. The
woman reports a regular 32 day cycle. Which response by the nurse is
correct?
A) Days 7-10
B) Days 10-13
C) Days 14-16
D) Days 17-19
The correct answer is D: Days 17-19
Ovulation
occurs 14 days prior to menses. Considering that the woman''s cycle is
32 days, subtracting 14 from 32 suggests ovulation is at about the 18th
day.
14. A
4 year-old hospitalized child begins to have a seizure while playing
with hard plastic toys in the hallway. Of the following nursing actions,
which one should the nurse do first?
A) Place the child in the nearest bed
B) Administer IV medication to slow down the seizure
C) Place a padded tongue blade in the child's mouth
D) Remove the child's toys from the immediate area
The correct answer is D: Remove the child''s toys from the immediate area
Nursing
care for a child having a seizure includes, maintaining airway patency,
ensuring safety, administering medications, and providing emotional
support. Since the seizure has already started, nothing should be forced
into the child''s mouth and they should not be moved. Of the choices
given, first priority would be for safety
15. A
new nurse manager is responsible for interviewing applicants for a
staff nurse position. Which interview strategy would be the best
approach?
A) Vary the interview style for each candidate to learn different techniques
B) Use simple questions requiring "yes" and "no" answers to gain definitive information
C) Obtain an interview guide from human resources for consistency in interviewing each candidate
D) Ask personal information of each applicant to assure meeting of job demands
The correct answer is C: Obtain an interview guide from human resources for consistency in interviewing each candidate
An
interview guide used for each candidate enables the nurse manager to be
more objective in the decision making. The nurse should use resources
available in the agency before attempts to develop one from scratch
16. A
newborn delivered at home without a birth attendant is admitted to the
hospital for observation. The initial temperature is 35 degrees Celsius
(95 degrees Fahrenheit) axillary. The nurse recognizes that cold stress
may lead to what complication?
A) Lowered BMR
B) Reduced PaO2
C) Lethargy
D) Metabolic alkalosis
The correct answer is B: Reduced PaO2
Cold
stress causes increased risk for respiratory distress. The baby
delivered in such circumstances needs careful monitoring. In this
situation, the newborn must be warmed immediately to increase its
temperature to at least 36 degrees Celsius (97 degrees Fahrenheit).
17. The
nurse is teaching a parent about side effects of routine immunizations.
Which of the following must be reported immediately?
A) Irritability
B) Slight edema at site
C) Local tenderness
D) Temperature of 102.5 F
The correct answer is D: Temperature of 102.5 F
An
adverse reaction of a fever should be reported immediately. Other
reactions that should be reported include crying for > 3 hours,
seizure activity, and tender, swollen, reddened areas.
18. A
client asks the nurse to explain the basic ideas of homeopathic
medicine. The response that best explains this approach is that remedies
A) Destroy organisms causing disease
B) Maintain fluid balance
C) Boost the immune system
D) Increase bodily energy
The correct answer is C: Boost the immune system
The
practitioner treats with minute doses of plant, mineral or animal
substances which provide a gentle stimulus to the body''s own defenses
19. The
nurse is caring for a 1 year-old child who has 6 teeth. What is the
best way for the nurse to give mouth care to this child?
A) Using a moist soft brush or cloth to clean teeth and gums
B) Swabbing teeth and gums with flavored mouthwash
C) Offering a bottle of water for the child to drink
D) Brushing with toothpaste and flossing each tooth
The correct answer is A: Using a moist soft brush or cloth to clean teeth and gums
The
nurse should use a soft cloth or soft brush to do mouth care so that
the child can adjust to the routine of cleaning the mouth and teeth
20. At
a senior citizens meeting a nurse talks with a client who has diabetes
mellitus Type 1. Which statement by the client during the conversation
is most predictive of a potential for impaired skin integrity?
A) "I give my insulin to myself in my thighs."
B) "Sometimes when I put my shoes on I don't know where my toes are."
C) "Here are my up and down glucose readings that I wrote on my calendar."
D) "If I bathe more than once a week my skin feels too dry."
The correct answer is B: "Sometimes when I put my shoes on I don''t know where my toes are."
Peripheral
neuropathy can lead to lack of sensation in the lower extremities.
Clients do not feel pressure and/or pain and are at high risk for skin
impairment.
21. A
newborn is having difficulty maintaining a temperature above 98 degrees
Fahrenheit and has been placed in a warming isolette. Which action is a
nursing priority?
A) Protect the eyes of the neonate from the heat lamp
B) Monitor the neonate’s temperature
C) Warm all medications and liquids before giving
D) Avoid touching the neonate with cold hands
The correct answer is B: Monitor the neonate’s temperature
When
using a warming device the neonate’s temperature should be continuously
monitored for undesired elevations. The use of heat lamps is not safe
as there is no way to regulate their temperature. Warming medications
and fluids is not indicated. While touching with cold hands can startle
the infant it does not pose a safety risk.
22. The
nurse is caring for a client with extracellular fluid volume deficit.
Which of the following assessments would the nurse anticipate finding?
A) Bounding pulse
B) Rapid respirations
C) Oliguria
D) Neck veins are distended
The correct answer is C: Oliguria
Kidneys maintain fluid volume through adjustments in urine volume.
source: NCSBN
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