printing 2

Question: The nurse is caring for an 18-month-old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time?

Answer: A side-lying position

Question: The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would be the nurse obtain?

Answer: A triple-lumen catheter

Question: A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which would the nurse determine is a harmful measure in preventing constipation?

Answer: Adding 1 tablespoon of mineral oil to a bowl of cereal daily

Question: The parents of a neonate who is not circumcised asks the nurse why the foreskin should not be retracted. The nurse explains that retracting the foreskin would be avoided because which complication may occur?

Answer: Adhesions

Question: During a fire drill, the nurse enters a laundry room and a waste basket is marked as on "fire." The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher and returns to the laundry room. Which action by the nurse shows that additional training is needed?

Answer: Aiming at the top flames of the fire

Question: The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?

Answer: Alternating air pad

Question: A client in her 24th week of pregnancy is admitted to the hospital in preterm labor. She asks the nurse if her baby will live if the labor cannot be stopped. Which diagnostic test would the nurse expect the primary health care provider to prescribe?

Answer: Amniocentesis for fetal surfactant level

Question: The nurse is caring for a client receiving digoxin. The nurse monitors the client for which early manifestation of digoxin toxicity?

Answer: Anorexia

Question: The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse would question which prescription?

Answer: Apply cold compresses to the affected area.

Question: A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse would avoid which measure at this time to assist in relieving the back discomfort?

Answer: Assist the client to ambulate in the room.

Question: The nurse is planning a dietary menu for a client with heart failure who is being treated with digoxin and furosemide. Which would be the best dinner choice from the daily menu?

Answer: Baked fish, mashed potatoes, and carrot-raisin salad

Question: A client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage. Which type of drainage is expected?

Answer: Bloody

Question: The nurse is collecting data from a client with hypertension being treated with diuretic therapy. The nurse would monitor the client for hypokalemia if the client is receiving which diuretic?

Answer: Bumetanide

Question: The nurse reinforces teaching a client on how to administer enoxaparin subcutaneously. The nurse determines that the client understands the correct procedure if the client does which on a return demonstration?

Answer: Bunches the skin before injection

Question: The nurse is caring for a client with liver disease. Laboratory studies are performed, and the client's serum calcium level is 13 mg/dL. The nurse checks to see that which medication is available in the stock medication supply area on the clinical nursing unit that may be needed to treat this calcium imbalance?

Answer: Calcitonin

Question: The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse would tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet?

Answer: Calcium and vitamin D

Question: The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning, and all connections are snug. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. The nurse would conclude which is the problem, and what action would be taken?

Answer: Channels of gastric secretions may be bypassing the holes in the tube; turning the client will promote stomach emptying.

Question: A child is brought to the emergency room, and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse would perform which action first?

Answer: Check the circulation, airway, and breathing status of the child.

Question: A client with a fractured femur is placed in skeletal traction. The nurse would do which to monitor for nerve injury?

Answer: Check the neurovascular status of the affected extremity.

Question: A client has experienced pulmonary embolism. The nurse would assess for which symptom that is most commonly reported?

Answer: Chest pain that occurs suddenly

Question: The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely manifestation of this condition in the medical record?

Answer: Choking with feedings

Question: The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse would perform which action?

Answer: Clap the hand or slap on the mattress.

Question: A client who was struck by a car while jogging is brought to the emergency department by emergency medical services. The client is unconscious, and a ruptured spleen is suspected. Emergency measures are instituted but are unsuccessful. The client's fiancé is with the client and tells the nurse that the client is an organ donor. In anticipation that the client's eyes will be donated, which would the nurse implement?

Answer: Close the deceased client's eyes and place gauze and a small ice pack on the eyes.

Question: A client's preoperative vital signs are temperature 98.6°F (37°C) orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action would the nurse take first?

Answer: Compare these values to those recorded previously.

Question: The nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse would do which at this time?

Answer: Continue monitoring the client because the data reflect acceptable progress.

Question: The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made?

Answer: Coughing occurs with suctioning.

Question: Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication would the nurse assess based on the previously known data?

Answer: Crackles in the lungs

Question: A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder?

Answer: Decreased respiratory depth and rate and dysrhythmias

Question: A pediatric nurse arrives at work and is told to report (float) to the emergency department (ED) for the day because the ED is expecting numerous victims to arrive following a train crash. The nurse has never worked in the ED and is anxious about floating to this area. Which is the appropriate nursing action?

Answer: Discuss her anxieties and concerns with the nursing supervisor about floating.

Question: The nurse is collecting data on a pregnant client in her 22nd week. The nurse prepares to use a fetoscope to auscultate the fetal heart rate. The nurse hears a fetal heart rate of 115 beats per minute. Which action would the nurse take?

Answer: Document the assessment.

Question: The nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick, white mucoid vaginal discharge is present. Based on these findings, the nurse determines that which action is the best?

Answer: Document the findings.

Question: The nurse is reinforcing instructions to the assistive personnel (AP) who will be caring for a client with security devices (hand restraints). How often would the nurse instruct the AP to check the client's skin and circulation under the security devices?

Answer: Every 30 minutes

Question: A client scheduled for a thyroidectomy says to the nurse, "I am so scared to get cut in my neck." Based on the client's statement, the nurse determines that the client is experiencing which problem?

Answer: Fear about impending surgery

Question: The nurse is assessing a client who is at 32 weeks of gestation. It has been 4 weeks since her last visit. Which assessment needs to be reported to the primary health care provider?

Answer: Fundal height, 38 cm

Question: The nurse is assigned to care for a client on contact precautions. On review of the client's record, the nurse notes that the client has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client's room and obtains which necessary protective items?

Answer: Gloves, mask, gown, and goggles

Question: The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids?

Answer: Hypertension

Question: The nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse would then examine the results of serum electrolytes to see whether which electrolyte imbalance is present?

Answer: Hypokalemia

Question: A client wishes to donate blood for a family member and asks the nurse about the procedure for identifying compatibility. The nurse tells the client that which test will be done to test compatibility?

Answer: Indirect Coombs

Question: A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?

Answer: Informing the surgeon of the situation

Question: A pregnant woman reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following an assessment, tuberculosis is suspected. A sputum culture is obtained and identifies the Mycobacterium tuberculosis in the sputum. The nurse reinforces instructions to the client regarding therapeutic management of tuberculosis. Which statement is included in therapeutic management?

Answer: Isoniazid plus rifampin will be required for a total of 9 months.

Question: The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that there is a need for further teaching if the client verbalized which statement?

Answer: Keep the oxygen concentrator as close to the room wall as possible.

Question: The nurse is caring for a client who had a small bowel resection the previous day and has continuous gastric suction attached to the nasogastric tube. Which intravenous solution would the nurse anticipate to be prescribed for the client?

Answer: Lactated Ringer's solution

Question: A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure?

Answer: Left lateral Sims' position

Question: A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Answer: Metabolic acidosis

Question: A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that a client with an ileostomy is at risk for developing?

Answer: Metabolic acidosis

Question: The nurse is reviewing the record of a client in the labor room. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?

Answer: Minus (-) 1 station

Question: The nurse is assisting in preparing a plan of care for a client who will be receiving a calcium antagonist to prevent preterm delivery. Which action does the nurse include in the plan of care for the client to detect a side effect of the medication?

Answer: Monitor for increases in maternal and fetal heart rates.

Question: The nurse administers medications to the wrong client. During the investigation of the incident, it was determined that the nurse failed to check the client's identification bracelet before administering the medications. The nursing supervisor evaluates the situation and determines that the nurse can be guilty of negligence because negligence is correctly characterized by which statement?

Answer: Negligence is defined as the failure to meet established standards of care.

Question: The nurse is monitoring a client for Biot's respirations. Which condition causes Biot's respirations?

Answer: Neurological disorders

Question: A primary health care provider (PHCP) has written a prescription for a preoperative client to have "enemas until clear." The nurse has administered three enemas, and the client is still passing brown liquid stool. Which action would the nurse take next?

Answer: Notify the primary health care provider.

Question: The nurse notes that a client in labor has foul-smelling amniotic fluid, a maternal temperature of 101°F, and a urine output of 150 mL during the past 2 hours. The nurse would do which action at this time?

Answer: Notify the registered nurse of a possible maternal infection.

Question: The nurse has assisted with obtaining a blood specimen for arterial blood gas (ABG) analysis. The nurse avoids doing which to properly obtain and send the specimen?

Answer: Obtain a 3-mL syringe that is used for parenteral medication.

Question: An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. Which is the best position to place this infant at this time?

Answer: On his or her left side

Question: The nurse is preparing a plan of care for a client who will be returning from surgery following a right lung wedge resection. Included in the plan of care is that in the postoperative period, the nurse would avoid which positioning?

Answer: On the right side

Question: A child is admitted to the hospital with sickle cell crisis. The nurse checks this child for which frequent symptom of the disorder?

Answer: Pain

Question: The nurse is urging a client to cough and deep breathe after a nephrectomy. The client tells the nurse, "That's easy for you to say! You don't have to do this." The nurse interprets that the client's statement is likely a result of which contributing factor?

Answer: Pain that is intensified because the location of the incision is near the diaphragm

Question: The nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse would check which first?

Answer: Peripheral pulses

Question: A client newly admitted to the labor unit reports to the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse checks the client and notes that the umbilical cord is protruding from the vagina. Which action would the nurse take first?

Answer: Place the client in the Trendelenburg position.

Question: A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD) and has an arterial blood gas test done. Which results would the nurse expect to note?

Answer: Po2 of 60 mm Hg and Pco2 of 50 mm Hg

Question: One unit of packed red blood cells has been prescribed for a client postoperatively because the client's hemoglobin level is low. The primary health care provider prescribes diphenhydramine to be administered before the administration of the transfusion. Why is this medication being given?

Answer: Prevent a rash and pruritus

Question: The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data would the nurse expect to note as having been documented in the child's record?

Answer: Projectile vomiting

Question: A client has a prescription to have radial arterial blood gases (ABGs) drawn. Before drawing the sample, an Allen's test will be performed. In performing the Allen's test, which blood vessel(s) would the nurse occlude?

Answer: Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery

Question: The nurse suspects that a coworker is substance impaired and is self-administering opioid medications rather than administering them to clients as prescribed. Which action would the nurse take?

Answer: Report the information to a supervisor.

Question: The nurse is assisting in caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. When collecting data on the client, the nurse checks which first?

Answer: Respiratory status

Question: The nurse is caring for a woman in the labor room. The primary health care provider prescribes an oxytocic medication for the woman to augment her labor. Which finding indicates a need to discontinue the oxytocic medication?

Answer: Resting interval of 50 seconds

Question: The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item would the nurse advise the parents to include in the child's diet?

Answer: Rice

Question: The nurse is assisting in monitoring a client who may be started on parenteral nutrition (PN). The nurse reviews the client's laboratory results and determines that the client is at risk of severe malnutrition if the report indicates which critical level?

Answer: Serum albumin 2.8 g/dL

Question: The client calls the health care clinic and tells the nurse that he was bitten by a tick. The client asks the nurse about the first signs of Lyme disease. The nurse would respond with which characteristic of stage 1 of Lyme disease?

Answer: Skin rash

Question: A client has just been treated with cardioversion. The nurse should check which measure first?

Answer: Status of airway

Question: The nurse is inserting an indwelling urinary catheter in a client and begins to inflate the balloon when the client starts complaining of pain. Which action would the nurse take?

Answer: Stop inflating the balloon, allow the saline solution to drain into the syringe and advance the catheter further before reinflating the balloon

Question: The nurse is caring for a new postoperative client and is monitoring the client for signs of shock. The nurse monitors for which signs of this postoperative complication?

Answer: Tachycardia, cold skin, and hypotension

Question: The nurse having strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this fellow employee by which action?

Answer: Telling a friend that this employee hates her

Question: The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse would include which piece of information in discussions with the client?

Answer: The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

Question: The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder?

Answer: The client complains of leg edema, and skin breakdown has started.

Question: The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for a potassium deficit?

Answer: The client receiving nasogastric suction

Question: A postoperative client is using an incentive spirometer. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds, then exhales slowly. The client takes one breath and returns the incentive spirometer to the bedside. Based on this observation, which interpretation would the nurse make?

Answer: The client should be repeating the sequence 10 to 20 times in each session.

Question: A client who is 36 hours post-myocardial infarction has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation is made?

Answer: The preactivity pulse rate is 86 beats per minute; the postactivity pulse rate is 94 beats per minute.

Question: A primary health care provider prescribes an intravenous fat emulsion solution for a client who will be receiving parenteral nutrition (PN). The nurse would explain to the client the administration of the fat emulsion solution is for which reason?

Answer: To provide essential fatty acids and additional calories

Question: A hospitalized client is dyspneic and has been diagnosed with left pneumothorax by chest x-ray. Which sign or symptom observed by the nurse clearly indicates that the pneumothorax is rapidly worsening?

Answer: Tracheal deviation to the right

Question: The nurse is working in the emergency department and is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction?

Answer: Tripod positioning and dyspnea

Question: After a tonsillectomy, the child begins to vomit bright red blood. Which is the initial nursing action?

Answer: Turn the child to the side.

Question: A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects the cardiologist to write a prescription for the client to remain on bed rest. In which position would the bed be positioned?

Answer: With the head of bed elevated no more than 30 degrees

Question: The nurse is preparing a client scheduled for a bone marrow aspiration, and the client asks the nurse whether the procedure will be painful. The nurse would make which response to the client?

Answer: "A local anesthetic will be given and will decrease the discomfort."

Question: The nurse is reinforcing diet teaching for a client on a low-sodium diet for hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?

Answer: "Canned foods are inexpensive and are good to use on a low-sodium diet."

Question: The nurse is reinforcing instructions to a female client regarding the procedure for collecting a midstream urine sample. Which statement by the client indicates an understanding of the procedure?

Answer: "I need to collect the urine in the cup after I start to urinate."

Question: A clinic nurse is reinforcing home care instructions to a client with a diagnosis of glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma?

Answer: "I need to take my eye drops for the rest of my life."

Question: A client has been diagnosed with a hearing loss caused by age-related changes in the ear. The nurse reinforces information about obtaining and learning to use a hearing aid. Which statement by the client indicates understating of the information?

Answer: "I should obtain a hearing aid as soon as possible."

Question: The nurse has provided instructions to the mother of an infant with viral pneumonia. Which statement by the mother would indicate the need for further teaching?

Answer: "I understand I will need to have my baby on antibiotics for this pneumonia."

Question: The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching?

Answer: "I will give my child cough syrup if a cough develops."

Question: The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching?

Answer: "I will place a steam vaporizer in my child's bedroom."

Question: The nurse is assisting in conducting a prenatal session with a group of expectant parents. Which comment related to female hormones made by a parent indicates the need for further teaching?

Answer: "Prolactin is the hormone responsible for the initiation of labor."

Question: A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates understanding of this stress reduction measure?

Answer: "The best thing about this is that I can use it anywhere, anytime."

Question: The nursing student is asked to describe the size of the uterus in a pregnant client at the end of pregnancy. Which response by the student indicates an understanding of the anatomy of this structure?

Answer: "The uterus is round and weighs approximately 1000 grams."

Question: A client arrives at the ambulatory care center complaining of flulike symptoms. On data collection, the client tells the nurse that he was bitten by a tick and is concerned that the bite is causing the sick feelings. The client requests a blood test to determine the presence of Lyme disease. Which question would the nurse ask next?

Answer: "When were you bitten by the tick?"

Question: A registered nurse has just hung a 250-mL bag of packed red blood cells (PRBCs) on a client. The licensed practical nurse assisting in caring for the client plans to remain with the client for at least how many minutes following the start of the infusion?

Answer: 15 minutes

Question: The nurse is collecting physical assessment data for a patient with possible splenomegaly. The nurse should palpate which abdominal quadrant? Refer to figure.View Figure

Answer: 2

Question: The nurse is checking the apical heart rate of a client with a complaint of angina. The nurse places the stethoscope in which anatomical area? Refer to figure.View Figure

Answer: 4

Question: A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed for this client?

Answer: 5% dextrose in lactated Ringer's solution

Question: A blood glucose screening measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which prescription would the nurse anticipate for the client?

Answer: A 3-hour glucose tolerance test

Question: A client is being evaluated as a potential kidney donor for a family member. The donor asks the nurse why a different team of people other than the team working with the potential recipient is doing the evaluation. Which response would the nurse give to the client?

Answer: A conflict of interest by the team evaluating the recipient and the team evaluating the donor is avoided.