Med Surg V2 PN HESI, OB HESI, Pediatrics HESI PN Review, Maternity NCLEX PN
47. A nurse is caring for a client who is having an allergic reaction to a blood transfusion. In what order should the nurse provide care for this client? 1. Stop the transfusion. 2. Send the blood bag and blood slip to the blood bank. 3. Keep the vein open with normal saline solution. 4. Administer an antihistamine as directed.
1,3,4,2
53. While assessing a neonate 30 minutes after birth, the nurse observes that the child has a short neck covered with webbing. The nurse should further assess the client for: 1. Genetic deviations. 2. Cleft palate. 3. Potter's syndrome. 4. Neural tube defects.
3. Potter's syndrome.
This is a dark streak down the midline of the abdomen that may appear as the uterus is enlarging. The LPN correctly describes this to the pregnant woman as?
LINEA NIGRA
Family centered nursing care for women and newborn focuses on which of the following? A. Assisting individuals and families achieve their optimal health B. Diagnosing and treating problems promptly C. Preventing further complications from developing D. Conducting nursing research to evaluate clinical skills
A
32. Which of the following indicates that a 5-month-old weighing 15 lb (6.8 kg) and being treated for dehydration has a normal urine output? The urine output is: 1. 1 to 2 mL/kg/h. 2. 3 to 5 mL/kg/h. 3. 6 to 8 mL/kg/h. 4. 10 to 12 mL/kg/h.
1. 1 to 2 mL/kg/h.
The hormone responsible for the development of the ovum during the menstrual cycle is? A. estrogen B. progesterone C. follicle stimulating hormone (Correct Answer) D. leutenizing hormone (Your Answer)
C
The LPN is preparing to administer Solu-medrol 40 mg mixed in 150 mL of sodium chloride via intravenous piggyback. The medication is to be administered over 30 minutes. Using the tubing with a drop factor of 15 ggts/mL, what would the LPN calculate the rate to be in drops per minute? A. 40 B. 50 C. 75 D. 150
C
44. A primary care provider is calling the pediatric unit and asking the nurse to go into the electronic medical record (EMR) for test results of a fellow pediatrician. How should the nurse respond to this request? 1. Identify if the caller is the primary care provider of record or has a need to know. 2. Access the EMR and give the primary care provider the test results. 3. Decline to give the primary care provider the information requested. 4. Determine whether the nurse can access the EMR.
1. Identify if the caller is the primary care provider of record or has a need to know.
33. The nurses in the neonatal intensive care unit are not identifying important clinical changes in the clients that need to be documented. The unit director should initiate which of the following actions? Select all that apply. 1. Identify the problem at a staff meeting without placing blame on any individual or group. 2. Ask the unit staff to develop a plan that they think will work for the unit members. 3. Ask an experienced nurse to spend time reorienting newer staff members. 4. Collaborate with the staff development educator to develop a plan. 5. Ask the neonatologist to give a presentation about assessing newborns.
1,2,4
55. The nursing staff on the antepartal unit has Depo Lupron and Depo Provera in the pharmacy for their clients. The nursing staff observed that the vials are similar in size and shape and could be confused. In order to promote client safety, the nursing staff should take which of the following actions? Select all that apply. 1. Petition the pharmacy to relocate one drug away from the other product. 2. Move the drugs to a new position within the medication administration system during the night shift. 3. Communicate concerns, measures to remedy, and final decisions to all staff. 4. Leave repositioning of drugs to pharmacy staff to resolve. 5. Collaborate with pharmacy staff to develop a location that works well for both groups.
1,3,5
28. A young adult has been bitten by a human, and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client for: 1. An injection of tetanus toxoid. 2. An application of a corticosteroid cream. 3. Closure of the wound with sutures. 4. Testing for tuberculosis.
1. An injection of tetanus toxoid.
41. A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Physician prescriptions include the following: oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/min. The nurse should first: 1. Increase the oxygen flow rate from 2 to 4 L/min. 2. Call the physician immediately. 3. Provide reassurance to the client. 4. Obtain a sample for arterial blood gas analysis.
1. Increase the oxygen flow rate from 2 to 4 L/min.
52. A child with sickle cell crisis is being discharged. As part of discharge teaching to prevent further crisis, the nurse advises the parent to do which of the following? 1. Encourage the child to drink lots of liquids. 2. Take the child's temperature every morning. 3. Weigh the child every day. 4. Offer the child a high-protein diet.
1. Encourage the child to drink lots of liquids.
37. The nurse is assessing an infant diagnosed with bacterial meningitis. The nurse should ask the parent if the infant has which of the following? Select all that apply. 1. Fever. 2. Vomiting. 3. Diarrhea. 4. Poor feeding. 5. Abdominal pain.
1. Fever. 2. Vomiting. 4. Poor feeding.
45. A client is at risk for development of metabolic alkalosis because of persistent vomiting. The nurse should assess the client specifically for: 1. Irritability. 2. Hyperventilation. 3. Diarrhea. 4. Edema.
1. Irritability.
21. The nurse should assess the child with nephrotic syndrome for which of the following? Select all that apply. 1. Normal blood pressure. 2. Generalized edema. 3. Normal serum lipid levels. 4. No red blood cells in the urine. 5. Elevated streptococcal antibody titers.
1. Normal blood pressure. 2. Generalized edema. 4. No red blood cells in the urine.
7. A mother who is breast-feeding and has known food sensitivities is asking the nurse what foods she should avoid in her diet. The nurse should advise her to avoid which foods? Select all that apply. 1. Shellfish. 2. Eggs. 3. Peanuts. 4. Beef. 5. Lamb.
1. Shellfish. 2. Eggs. 3. Peanuts.
16. When witnessing an adult client's signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply. 1. That there was adequate disclosure of information. 2. That the client understood the information. 3. That there was voluntary consent on the client's part. 4. That the client has full awareness of the potential complications. 5. That the client's relative, spouse, or legal guardian was present.
1. That there was adequate disclosure of information. 2. That the client understood the information. 3. That there was voluntary consent on the client's part. 4. That the client has full awareness of the potential complications.
9. After the client has a temporary pacemaker inserted, the nurse should verify that which of the following has been documented? 1. The client's cardiovascular status. 2. The client's emotional state. 3. The type of sedation used. 4. Pacemaker rate, type, and settings.
1. The client's cardiovascular status.
27. The client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for which of the following? Select all that apply. 1. Vertigo. 2. Tinnitus. 3. Nausea. 4. Ataxia. 5. Hearing loss.
1. Vertigo. 3. Nausea. 4. Ataxia.
2. A client at a follow-up appointment after having a miscarriage 2 weeks previously yells at the nurse, "How could God do this to me? I've never done anything wrong." Which of the following responses by the nurse would be most appropriate at this time? 1. "God can handle your anger. It's okay." 2. "I know you are angry. It's so hard to lose your baby." 3. "It isn't God's fault. It was an accident." 4. "You're a strong person. You will get through this."
2. "I know you are angry. It's so hard to lose your baby."
15. A client asks the nurse why it is necessary to complete an advance directive on admission to the hospital. The nurse's best response is which of the following? 1. "This will provide a substitute for informed discussion with your primary care provider." 2. "It is your chance to make your wishes known if you ever become incapable of making your own decisions." 3. "Your primary care provider will make the best decisions for you in an emergency." 4. "Are you worried that extraordinary means will be taken if you are dying?"
2. "It is your chance to make your wishes known if you ever become incapable of making your own decisions."
20. A client with asthma asks the nurse if she should use her salmeterol inhaler when she exercises and experiences wheezing and shortness of breath. The nurse's best response is which of the following? 1. "Yes, use the inhaler immediately for these symptoms." 2. "No, this drug is a maintenance drug, not a rescue inhaler." 3. "Use the inhaler 5 minutes before you exercise to prevent the wheezing." 4. "This inhaler is for allergic rhinitis, not asthma."
2. "No, this drug is a maintenance drug, not a rescue inhaler."
39. A 7-year-old child is admitted to the hospital with acute rheumatic fever. When discussing long-term care for the child with the parents, the nurse should teach them that a necessary part of this care is: 1. Physical therapy. 2. Antibiotic therapy. 3. Psychological therapy. 4. Anti-inflammatory therapy.
2. Antibiotic therapy.
19. A 2-month-old infant is at risk for an ileus after surgery to correct intussusception. Which of the following should be included in a focused assessment for this complication? Select all that apply. 1. Measurement of urine specific gravity. 2. Assessment of bowel sounds. 3. Characteristics of the first stool. 4. Measurement of gastric output. 5. Bilirubin levels.
2. Assessment of bowel sounds. 3. Characteristics of the first stool. 4. Measurement of gastric output.
31. A client with chronic obstructive pulmonary disease is bedridden at home and gets little exercise. The nurse should assess the client for which of the following? 1. Increased sodium retention. 2. Increased calcium excretion. 3. Increased insulin use. 4. Increased red blood cell production.
2. Increased calcium excretion.
46. Which of the following should first alert the nurse that a child is hemorrhaging after a tonsillectomy? 1. Mouth breathing. 2. Frequent swallowing. 3. Requests for a drink. 4. Increased pulse rate.
2. Frequent swallowing.
25. The nurse is watching two siblings, ages 7 and 9 years, verbally arguing over a toy. The nurse has counseled the parent before about how to handle this situation. The nurse should judge that the teaching has been effective when the parent does which of the following? 1. Tells the siblings to stop arguing and shake hands. 2. Ignores the arguing and continues what she is doing. 3. Tells the children they will be punished when they go home. 4. Says they will not go out to lunch now since they have argued.
2. Ignores the arguing and continues what she is doing.
38. Which of the following nursing interventions would best accomplish the goal of preventing atelectasis and pneumonia in a postoperative client? 1. Administering oxygen therapy as needed to maintain adequate oxygenation. 2. Offering pain medication before having the client deep-breathe and use incentive spirometry. 3. Encouraging the client to cough, deep-breathe, and turn in bed once every 4 hours. 4. Forcing fluids to 2,000 mL every 24 hours.
2. Offering pain medication before having the client deep-breathe and use incentive
26. A client is diagnosed with genital herpes, (herpes simplex virus type 2, or HSV-2). The nurse should instruct the client that: 1. Using occlusive ointments may decrease the pain from the lesions. 2. Reducing stressful life events may decrease the incidence of herpetic outbreaks. 3. There are no effective drug therapies to manage herpes symptoms. 4. Herpes is transmitted to partners only when lesions are weeping.
2. Reducing stressful life events may decrease the incidence of herpetic outbreaks.
42. A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation? 1. Use a cool air vaporizer with plain water. 2. Use saline nose drops and then a bulb syringe. 3. Blow into the child's mouth to clear the infant's nose. 4. Administer a nonprescription vasoconstrictive nose spray
2. Use saline nose drops and then a bulb syringe.
30. A mother who is visibly upset tells the nurse she wants to take her child home because the child is dying. Which of the following would be the nurse's best response? 1. "I know how you feel, but the medication will make your child feel better." 2. "I can't let you do this without calling your physician first." 3. "Can you tell me why you want to take your child home now?" 4. "I can imagine how hard this is for you, but it's not what's best for the child."
3. "Can you tell me why you want to take your child home now?"
10. The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent states which of the following? 1. "I can lay my child flat and feed that way." 2. "I'll raise my child's head up and leave the hips and legs on a pillow." 3. "I can borrow a special feeding table to use." 4. "It will take two of us, one to hold and one to feed."
3. "I can borrow a special feeding table to use."
6. A worried mother confides in the nurse that she wants to change primary care providers because her infant is not getting better. The best response by the nurse is which of the following? 1. "This doctor has been on our staff for 20 years." 2. "I know you are worried, but the doctor has an excellent reputation." 3. "You always have an option to change. Tell me about your concerns." 4. "I take my own children to this doctor."
3. "You always have an option to change. Tell me about your concerns."
51. During the clinical breast examination, which of the following is a normal finding? 1. Pronounced unilateral venous pattern. 2. Peau d'orange breast tissue. 3. Long-term, bilateral nipple inversion. 4. Breast tissue that is darker than the areolae.
3. Long-term, bilateral nipple inversion.
12. Forty-eight hours after a ventriculoperitoneal shunt placement, an infant is irritable and vomits a large amount. The assessment reveals a bulging fontanel. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with the recommendation for: 1. A dose of morphine (Astramorph). 2. A fluid bolus of normal saline. 3. A computerized tomography scan. 4. A dose of furosemide (Lasix).
3. A computerized tomography scan.
14. The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions? 1. Hospital-acquired pneumonia. 2. Hypovolemic shock. 3. Acute respiratory distress syndrome (ARDS). 4. Asthma.
3. Acute respiratory distress syndrome (ARDS)
54. A client has severe diarrhea that has lasted for 2 days. The nurse should now assess the client for: 1. Muscle spasms. 2. Thirst. 3. Arrhythmia. 4. Confusion.
3. Arrhythmia.
24. A nurse is assessing a client with a history of myocardial infarction who is in the surgical unit following a gastric resection. The client has chest pains. The nurse obtains the electrocardiogram (ECG) shown (see figure). What should the nurse do first? 1. Administer oxygen. 2. Inspect the client's incision. 3. Call the rapid response team. 4. Reposition the ECG electrodes.
3. Call the rapid response team.
29. A client 6 weeks postpartum is asking the nurse about taking progesterone (Depo-Provera) for birth control. Prior to discussing options, what should the nurse determine? Select all that apply. 1. If the client has a sexually transmitted disease. 2. How willing her husband is to have her take the drug. 3. If the woman is experiencing postpartum depression. 4. That the woman is not currently pregnant. 5. If the woman is breast-feeding.
3. If the woman is experiencing postpartum depression. 4. That the woman is not currently pregnant. 5. If the woman is breast-feeding.
13. The nursing staff has finished restraining a client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate outcomes? 1. Coordinate documentation of the incident. 2. Resolve negative feelings and attitudes. 3. Improve the use of restraint procedures. 4. Calm down before returning to the other clients.
3. Improve the use of restraint procedures.
18. After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next? 1. Evidence of ruptured membranes. 2. Viability status of the fetus. 3. Indications that contractions have ceased. 4. Fetal heart rate variability.
3. Indications that contractions have ceased.
22. A client is receiving spironolactone (Aldactone) for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which of the following nutritional modifications to prevent an electrolyte imbalance? 1. Increase intake of milk and milk products. 2. Restrict fluid intake to 1,000 mL/day. 3. Decrease foods high in potassium. 4. Decrease foods high in sodium.
3. Decrease foods high in potassium.
34. A 24-year-old client, diagnosed with acute osteomyelitis in the left leg, has acute pain in the leg that intensifies on movement. The client has a temperature of 101°F (38.3°C) and a reddened, warm area in the midcalf region over the shaft of the tibia. Based on this information, the nurse should do which of the following first? 1. Prepare the client for possible left lower leg amputation. 2. Instruct the client to keep the leg immobile. 3. Develop a plan for pain management. 4. Obtain a prescription for fluid replacement.
3. Develop a plan for pain management.
11. The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who: (Select all that apply.) 1. Requires monitoring of prothrombin time due to Coumadin (warfarin) therapy. 2. Needs additional instruction regarding preparation of food on a low-sodium diet. 3. Has episodes of vertigo that result in falls. 4. Has multiple sclerosis with an open, draining lesion on a foot. 5. Needs stronger lenses for glasses.
3. Has episodes of vertigo that result in falls. 4. Has multiple sclerosis with an open, draining lesion on a foot.
43. A nurse is assessing a client with metastatic lung cancer. The nurse should assess the client specifically for: 1. Diarrhea. 2. Constipation. 3. Hoarseness. 4. Weight gain.
3. Hoarseness.
50. A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours the tube has drained 2 L of fluid. The nurse should further assess the client for: 1. Hypermagnesemia. 2. Hypernatremia. 3. Hypokalemia. 4. Hypocalcemia.
3. Hypokalemia.
8. A widowed client who is receiving chemotherapy tells the nurse that he does not like to cook for himself. A community resource for this client is: 1. Hospice/palliative care association. 2. Home care/visiting nurses group. 3. Meals on Wheels. 4. Association for Retirees.
3. Meals on Wheels.
4. A 4-year-old child is admitted for a cardiac catheterization. Which of the following is most important to include as the nurse teaches this child about the cardiac catheterization? 1. A plastic model of the heart. 2. A catheter that will be inserted into the artery. 3. The parents. 4. Other children undergoing a catheterization.
3. The parents.
36. Long-term administration of gentamicin sulfate (Garamycin) to a client has been discontinued. The nurse should assess which of the following? 1. Hemoglobin level in 2 weeks. 2. White blood cell count in 2 weeks. 3. Vestibular check in 3 to 4 weeks. 4. Serum potassium level in 1 week.
3. Vestibular check in 3 to 4 weeks.
35. A client has undergone a vasectomy. The nurse instructs the client that he can begin having unprotected intercourse: 1. When desired because sterilization is immediate. 2. As soon as scrotal edema and tenderness resolve. 3. When the sperm count reflects sterilization. 4. After 6 to 10 ejaculations.
3. When the sperm count reflects sterilization.
The nurse is to administer chloramphenicol (Chloromycetin) 50 mg IV in 100 mL of dextrose 5% in water over 30 minutes. The infusion set administers 10 gtt/mL. At what flow rate (in drops per minute) should the nurse set the infusion? _______________ gtt/min.
33
3. A client who has been prescribed chemotherapy is worried and wants to take herbal treatments instead. The nurse's best response to the client is which of the following? 1. "You are making a mistake and placing your life in jeopardy." 2. "Herbal treatments are not approved by the government's regulatory agency." 3. "Herbal treatments have not been researched with cancer." 4. "Tell me about your concerns with chemotherapy."
4. "Tell me about your concerns with chemotherapy."
40. The nurse is assessing the perineal changes of a woman in the second stage of labor. The figure below represents which of the following perineal changes? 1. Anterior-posterior slit. 2. Oval opening. 3. Circular shape. 4. Crowning.
4. Crowning.
1. A primigravid client at 26 weeks' gestation asks the nurse what causes heartburn during pregnancy. The nurse should explain to the client that heartburn during pregnancy is usually caused by which of the following? 1. Increased peristaltic action during pregnancy. 2. Displacement of the stomach by the diaphragm. 3. Decreased secretion of hydrochloric acid. 4. Backflow of stomach contents into the esophagus.
4. Backflow of stomach contents into the esophagus.
17. A pregnant woman at 22 weeks' gestation is diagnosed with gonorrhea. The physician prescriptions doxycycline (Vibramycin). The nurse should first: 1. Instruct the client about the effects of the drug. 2. Make sure the record notes that the baby must receive eyedrops when born. 3. Have the physician add a single dose of ceftriaxone (Rocephin). 4. Discuss with the physician the need to change the prescription.
4. Discuss with the physician the need to change the prescription
5. A client has a reddened area over a bony prominence. The nurse finds a nursing assistant massaging this area. The nurse should: 1. Reinforce the nursing assistant's use of this intervention over the bony prominence. 2. Explain to the nursing assistant that massage is effective because it improves blood flow to the area. 3. Inform the nursing assistant that massage is even more effective when combined with the use of lotion. 4. Instruct the nursing assistant that massage is contraindicated because it decreases blood flow to the area.
4. Instruct the nursing assistant that massage is contraindicated because it decreases blood flow to the area.
49. A client claims to have a "special mission from God." The nurse incorporates this religious delusion of grandeur into the client's plan of care based on the understanding that the primary purpose of such a delusion is to provide which of the following? 1. Sexual outlet. 2. Comfort. 3. Safety. 4. Self-esteem.
4. Self-esteem.
23. A nurse is assessing a client who is receiving clozapine. The nurse reviews the chart below. What should the nurse do next? 1. Give the clozapine, and tell the client to lie down. 2. Withhold the clozapine, and tell the client to go to an exercise group. 3. Administer the clozapine, and notify the physician. 4. Withhold the clozapine, and notify the primary care provider.
4. Withhold the clozapine, and notify the primary care provider.
According to Diane, her LMP is November 15, 2002, using the Naegle's rule what is her EDC? A. August 23, 2003 B. August 18, 2003 C. July 22, 2003 D. February 22, 2003
A
Which of the following would cause a false-positive result on a pregnancy test? A. The test was performed less than 10 days after an abortion B. The test was performed too early or too late in the pregnancy C. The urine sample was stored too long at room temperature D. A spontaneous abortion or a missed abortion is impending
A - Explanation A false-positive reaction can occur if the pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false- negative results.
A nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply. A. Allows for fetal movement B. Is a measure of kidney function C. Surrounds, cushions, and protects the fetus D. Maintains the body temperature of the fetus E. Prevents large particles such as bacteria from passing to the fetus F. Provides an exchange of nutrients and waste products between the mother and the fetus
A, B, C, D
The nurse knows that there are psychological maternal changes that occurs during pregnancy in a primigravida patient. Select all the normal psychological maternal changes that happens throughout pregnancy. A. Ambivalence B. Breast tenderness C. Emotional lability D. Body image changes E. Bonding or relationship with the fetus F. Nausea and vomiting G. Syncope H. Urinary frequency
A, C, D, E
A 36 weeks gestation pregnant woman is complaining of urinary urgency and frequency. The nurse explained that the enlarging fetus is pressing the bladder which causes frequent urination. This is normally occuring during the first and third trimesters of pregnancy. The nurse advices the patient to do the following measures to prevent urinary frequency. Select all the necessary measures that the nurse can provide to the patient. A. Drink 2 quarts of fluid during the day B. Engaging in a regular exercise C. Performing Kegel exercises D. Soaking in a warm sitz bath E. Limiting fluid intake during the evening
A, C, E
A primigravida patient who is 12 weeks pregnant visits a helath promotion program in the community pertaining to the pregnancy care. A group of nursing student is educating the public about measures to prevent discomfort of pregnancy. The primigravida patient asks one of the student about measures on how to prevent heartburn she is experiencing throughout the day. Select all the necessary measures to prevent the primigravia patient's complaint. A. Eating small, frequent meals and avoiding fatty and spicy food B. Eating high fiber foods and increase drinking fluids C. Drinking milk between milk D. Arranging frequent rest periods throughout the day E. Sitting upright for 30 minutes after a meal F. Engaging in regular exercise
A, C, E
The practical nurse (PN) is monitoring a child who is manifesting signs of shock after a motor vehicle collision. Which finding is most important for the PN to report to the charge nurse? a) narrowing pulse pressure b) apprehension c) irritability d) thirst
Answer: A Rationale: As shock progresses, perfusion in the microcirculation becomes marginal despite compensatory adjustments, and the signs of decompensated shock become pronounced, such as tachycardia and narrowing pulse pressure (A). (The difference between systolic and diastolic blood pressure), which should be reported immediately. (B,C, and D) are not as significant as (A).
The mother of a male newborn calls the clinic to inquire about the formation of a yellow crust over her son's circumcision area. What information should the practical nurse (PN) provide? a) do not remove the yellow crust from the site b) stop using petroleum around the head of the penis c) bring him into the clinic d) tightly fasten the diaper
Answer: A Rationale: Crust formation is part of the healing process and should be removed (A). (C) is not indicated at this time. The diaper should be fastened loosely, not tightly (D) which can place pressure on the incision site. (B) assists in the healing process and should not be discontinued.
The practical nurse (PN) identifies an increased frequency of otitis media (OM) is children who are coming to the clinic. Based on this finding, which age group should the PN monitor a child for signs and symptoms of OM? a) toddler b) preschooler c) school ager d) adolescent
Answer: A Rationale: Infants and toddlers (A) are most prone to otitis media due to the anatomical structure of the eustachian tube that allows fluid and microbial entry into the middle ear. (B, C, and D) are most susceptible to acute infectious diseases acquired through environmental transmission from daycare or school settings.
Which nonfood item is the most common cause of respiratory arrest in young children? a) latex balloons b) broken rattles c) buttons d) pacifiers
Answer: A Rationale: Nonfood items cause the majority of choking deaths in young children. Latex balloons (A), whether partially inflated, uninflated, or popped, are the leading cause of pediatric choking that leads to aspiration of small objects (A,B, and D) because they experience the environment by placing objects in the mouth, but (A) is the leading cause of death causing respiratory obstruction and arrest.
Which finding should the practical nurse confirm with the parents of an infant who is admitted with possible intussusception? a) red currant jelly stools b) clay colored stools c) constant abdominal pain d) projectile vomiting after meals
Answer: A Rationale: Red currant jelly stools (A) is a sign of intussusception, which causes a mixture of stool, mucous, and blood as the intestines telescopes inside itself. (D) is associated with pyloric stenosis. (B) is consistent with biliary obstruction. Infants with intussusception usually have periods of severe pain followed by intervals in which they appear comfortable, not (C).
A 6 year old who had a tonsillectomy 12 hours ago is complaining of thirst. What should the practical nurse (PN) offer? a) popsicle b) lemonade c) orange juice d) chocolate milk
Answer: A Rationale: Small amounts of clear liquids without red dyes should be offered to the child. Popsicles (A) are cold and help soothe a dry throat. Citrus drinks (B and C) are acidic and irritate the operative site in the posterior oropharynx. Milk (D) thickens oral mucus which makes swallowing more difficult and causes coughing.
The practical nurse is caring for a 6 year old girl who had surgery 12 hours ago. The child tells the PN that she does not have pain but a few minutes later, tells her parents that she does. What child development concept is relevant to this situation? a) inconsistency in pain reporting suggests that pain not present b) a child may have pain yet deny its presence to the nurse c) truthful reporting of pain should occur by this age d) children use pain experiences to manipulate their parents
Answer: B Rationale: A child may fear receiving an injection for pain or may believe that pain is a deserved punishment for some misdeed, so the pain is denied (D) when the nurse asks the child, who then readily admits having pain to a parent. This behavior should not be interpreted as (C) but as a valid indication of pain. (A and C) are incorrect interpretations of this behavior.
The practical nurse (PN) is observing a group of children at a day care center to determine whether children are achieving developmental milestones. Which activity should the PN identify as typical for a 2 year old child's cognitive development? a) has a vocabulary of about 1000 words b) uses short sentences to express self c) initiates play with other children d) recognizes right and wrong
Answer: B Rationale: Although children develop at different rates, a 2 year old typically uses short sentences to express independence and control (B) and has a vocabulary of up to 300 words, not (A). At the age of 2 years, a toddler is developing negativism without understanding the concepts of right and wrong (D). A 2 year old engages in solitary play and parallel play but does not initiate or cooperative with other children (C) in play, which begins with socialization of the preschool child.
The practical nurse (PN) is talking with a group of elementary students about bicycle safety. Which information should the PN provide? a) wearing protective gear on a bicycle is a voluntary measure b) children should wear a bicycle helmet when riding a bicycle c) bicycle injuries involve a collision with an automobile d) riding double is allowed if the bicycle has an extra large seat
Answer: B Rationale: Bicycle accidents that result in head injuries are a common, accidental cause of morbidity and mortality, so bicycle safety and some state laws mandate that children should wear a protective helmet (B). (A, C, and D) do not provide accurate information.
The mother of a 9 month old male infant is concerned because he cries whenever she leaves him with a sitter. What is the best response for the practical nurse (PN) to provide? a) "Have you noticed whether your baby is teething?" b) "Crying when you leave him in a healthy sign of attachment." c) "Consider taking the baby to the doctor because he may be ill." d) "You could consider leaving the infant more often so he can adjust."
Answer: B Rationale: Healthy attachment is manifested by stranger anxiety in late infancy (B). Pain from teething expressed by the infant's cries does not occur only when the mother leaves the infant with another person (A). The PN should evaluate the infant's developmental needs (C) before suggesting the infant may be ill. An infant who manifests stranger anxiety is best supported by the mother if the infant is left for shorter periods of time, not (D).
Which preoperative action is most important for the practical nurse (PN) to implement for a newborn with meningomyelocele? a) document vital signs b) prevent skin breakdown c) minimize the risk for infection d) monitor neurologic functioning
Answer: C Rationale: A meningomyelocele provides a direct entry for bacteria into the central nervous system, leading to meningitis. Measures that protect the integrity of the meningomyelocele sac and infection control measures should be implemented to minimize the risk of infection (C). (A,B, and D) should be implemented but do not have the priority of (C).
The mother of a child with croup is having barking, coughing episodes calls the clinic for assistance. What action should the practical nurse (PN) recommend that the mother implement first? a) take the child outside in the cool air b) bring the child directly to the emergency room c) sit with the child in bathroom with a hot shower running d) have the child drink plenty of fluids
Answer: C Rationale: Croup (laryngotracheobronchitis) is a viral infection that causes a "barking" cough and varying degrees of inspiratory stridor, which often responds to a high humidity environment. Most children can be managed at home using the stream from a hot shower in a closed bathroom (C) which often stops laryngeal spasm. Increasing the child's fluid intake is important (D), but not a priority at this time.Although exposure to cold air (A) also relieves stridor, parents should be encouraged to use mist humidifier in the child's room. (B) is not necessary unless the child is having increasingly difficulty breathing that may lead to a compromised airway.
The practical nurse (PN) is interviewing a 10 year old girl about school and her extracurricular activities. She responds, "I like school. I play the flute in the school band, and I take tennis lessons." Based on Erikson's psychosocial theory, the PN identifies that this child is in what stage of development? a) identity b) intimacy c) industry d) initiative
Answer: C Rationale: Erikson's stage of industry (C) for a school aged child is demonstrated by successful participation in new skills and peer activities, such as sports and band. (A, B, and D) are achieved in other age groups.
The practical nurse (PN) collects information about infant growth and development milestones for infants who come to the clinic for a well child visit. Which findings should the PN document as normal infant growth and development? a) maternal iron stores persist during the first 12 months of life b) anterior fontanel closes by 6 to 10 months of age c) binocularity is well established by 8 months of age d) birth weight double by age 5 months and triples by 1 year
Answer: D Rationale: Infants gain approximately 1.5 pounds/month until age 5 to 6 months, when the birth weight doubles, and by 1 year of age, the birth weight usually triples (D). The anterior fontanel closes by 12 to 18 months of age, with the average being 14 months, not (B). Binocularity begins to develop by 6 weeks of age and should be well established by age 4 months, not (C). Maternally derived iron stores ares present for the first 5 to 6 months and gradually diminish, which results in an expected lowered hemoglobin levels toward the end of the first 6 months (A).
Q.12) A nurse is collecting data during the admission asessment of a client who is pregnant with twins. The client also has 5 year old child. The nurse would document which gravida and para status on this client? A. G1P1 B. G2P1 C. G2P2 D. G3P2
B
Which of the following prenatal laboratory test values would the nurse consider as significant? A. Hematocrit 33.5% B. Rubella titer less than 1:8 C. White blood cells 8,000/mm3 D. One hour glucose challenge test 110 g/dL
B Explanation A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters.
A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the nurse respond? A. "Yes, it produces no adverse effect." B. "No, it can initiate premature uterine contractions." C. "No, it can promote sodium retention." D. "No, it can lead to increased absorption of fat-soluble vitamins."
B Explanation Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oils is not known to increase absorption of fat-soluble vitamins, although laxatives in general may decrease absorption if intestinal motility is increased.
During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition? A. post partum phase B. first trimester C. second trimester D. third trimester
B Explanation First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.
The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The LPN should tell the patient that she can expect to feel the fetus move at which time? A. Between 10 and 12 weeks' gestation B. Between 16 and 20 weeks' gestation C. Between 21 and 23 weeks' gestation D. Between 24 and 26 weeks' gestation
B Explanation A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks' gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.
Which of the following would the nurse identify as a presumptive sign of pregnancy? A. Hegar sign B. Nausea and vomiting C. skin pigmentation changes D. positive serum pregnancy test
B Explanation resumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs. Hegar sign, skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.
A client at 36 weeks' gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? A. The ultrasound will help to locate the placenta B. The ultrasound identifies blood flow through the umbilical cord C. The test will determine where to insert the needle D. The ultrasound locates a pool of amniotic fluid
B. Explanation Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.
A 25-year-old client with diabetes type I visits the clinic to discuss her and her husband's desire to start a family. This diabetic client A. should be discouraged from becoming pregnant B. has a greater risk of complications during pregnancy C. should be informed about treatment for infertility D. will be able to carry out a completely normal pregnancy
B. Explanation Clients with DM are at greater risk for developing maternal and fetal complications during pregnancy.
During a lecture on reproduction, a student nurse asks the instructor what determines the sex of a fetus. Accurate information in response to this question would be: A. "The sex of the fetus is not determined until the eighth week of gestation." B. "The fertilization of the zygote is the point at which sex is determined." C. "Males have one less pair of chromosomes than females." D. "Sex is determined by the chromosomes contributed by the ovum."
B. Explanation The sex of the fetus is determined at the point that the sperm fertilizes the ovum to form the zygote. Sex is ultimately determined by the chromosome contributed by the sperm.
A client LMP began July 5. Her EDD should be which of the following? A. January 2 B. March 28 C. April 12 D. October 12
C Explanation To determine the EDD when the date of the client's LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client's EDD is April 12.
Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following? A. increased plasma HCG levels B. decreased intestinal motility C. decrease gastric acidity D. elevated estrogen levels
C Explanation During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester.
Which of the following represents the average amount of weight gained during pregnancy? A. 12 to 2 lbs B. 15 to 25 lbs C. 25 to 35 lbs D. 25 to 40 lbs
C Explanation The average amount of weight gained during pregnancy is 25 to 35 lb. This weight gain consists of the following: fetus - 7.5 lb; placenta and membrane - 1.5 lb; amniotic fluid - 2 lb; uterus - 2.5 lb; breasts - 3 lb; and increased blood volume - 2 to 4 lb; extravascular fluid and fat - 4 to 9 lb. A gain of 12 to 22 lb is insufficient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered excessive.
The nurse identifies substance abuse behaviors exhibited by a pregnant client during an initial prenatal screening. While promoting a therapeutic and accepting environment, the care managment by the nurse would be MOST appropriate if focused on which of the following? A. Discouraging substance use during pregnancy B. Termination of the pregnancy at an early stage C. Eliminating substance use during pregnancy D. Setting boundaries with the client in regards to substance use
C. Explanation Use of substances during pregnancy can lead to severe fetal or neonatal abnormalities, complications, and death. The primary goal of nursing care should be prevention or elimination of substance use during pregnancy.
Cervical softening and uterine souffle are classified as which of the following? A. diagnostic signs B. presumptive signs C. probable signs D. positive signs
C. Explanation Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy.Probable signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign, which is enlargement and softening of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.
During which of the following phase of the menstrual cycle is it ideal for implantation of a fertilized egg to occur? A. ischemic phase B. mentrual phase C. proliferative phase D. secretory phase
D
A client is pregnant with her third child. Medical history of the client indicates a previous precipitate labor and birth. Which of the following interventions would NOT be expected during labor of the present pregnancy? A. Use of magnesium sulfate B. Close monitoring of the fetus for hypoxia C. The nurse stays at the bedside constantly or as much as possible D. amnioinfusion will be performed
D Explanation Amnioinfusion is instillation of fluid into the amniotic sac within the uterus to treat oligohydraminios. This is not done to prevent precipitate labor and birth.
The LPN has initiated the administration of vancomycin via IV piggyback . In which of the following situations should the nurse recognize that the client may be experiencing a fatal reaction to this medication? A. The client start coughing B. The client complains of pain at the intravenous catheter insertion site C. The nurse hears the client snoring from the hall D. The nurse notices the client's neck and chest is bright red
D Explanation While administering vancomycin the LPN should know to monitor the client carefully for the development of Red Man Syndrome or anaphylactic shock. The common side effects of this medicine are pruritus, flushing and erythema to the head, neck, and upper body.
31) During the prenatal visit, the client states that she has been experiencing heartburn frequently. The LPN provides instruction on the cause and prevention of heartburn. When she ask to verbalize understanding of the information, which of the following statements by the client indicates further instruction may be necessary? A. "The sphincter that normally prevents stomach contents from going back up into the esophagus is relaxed." B. "I should try to avoid drinking fluids while I'm eating." C. "Eating six or seven small meals a day may help my symptoms." D. "I'll eat enough to ensure that I am full at every meal."
D Explanation It suggests that the instruction might need to be reinforced on preventing stomach distention.
When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following? A. thrombophlebitis B. pregnancy induced hypertension C. pressure on blood vessels from the enlarging uterus D. the force of gravity pulling down on the uterus
D - Explanation Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation. Pregnancy-induced hypertension is not associated with these symptoms. Gravity plays only a minor role with these symptoms.
Pediazole is a suspension medication that contains 200 mg erythromycin and 600 mg sulfisoxazole per 5 mL. The physician orders Pediazole 4 mL PO every 12 hours. How many mg of sulfisoxazole is this client receiving in a 24-hour period? A. 160 mg B. 320 mg C. 480 mg D. 960 mg
D. Explanation 600 mg/ 5 mL = x mg/ 4 mL 2400 = 5x x= 2400/5 x= 480 mg per dose x 2 = 960 mg in 24 hours.
Ativan 0.5 mg IM every 1 hour as needed is prescribed for a client experiencing delirium tremens. The medication vial reads 2mg/mL of solution. How many mL should the LPN draw into the syringe for single dose administration?
Possible correct answers: 0.25 mL0.25mL0.25ml0.25 ml Explanation 2mg/mL= 0.5mg/xmL 2x=0.5 x=0.5/2 x=0.25 mL
