EXAM 1 PRACTICE QUESTIONS (Sets Combined)
The nurse is caring for a premature infant diagnosed with patent ductus arteriosus (PDA). Which medication should the nurse anticipate administering to this client? A) Indomethacin B) Propranolol C) Antibiotics D) Prostaglandin E1
A
The nurse is caring for an infant diagnosed with hypoplastic left heart syndrome. The client has recently been scheduled for surgery to repair the defect. Which procedure does the nurse anticipate needing to provide client teaching about to the client's family? A) Norwood procedure B) Jatene procedure C) Rastelli procedure D) Damus-Kaye-Stansel procedure
A
A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired Gas Exchange. Which action is appropriate when providing care based on this nursing diagnosis? A) Place the client in low-Fowler position to improve gas exchange B) Monitor the client's oxygen saturation intermittently C) Encourage frequent amulation D) Use continuous endotracheal suctioning instead of coughing and deep breathing
A
A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which intervention is appropriate to decrease an infant's risk for SIDS? A) Using firm bedding B) Ensuring the room temperature is at least 80°F at all times C) Recommending bed sharing D) Placing the infant in a prone position for sleeping
A
During a routine prenatal visit, a client who is 24 weeks pregnant has a blood pressure of 143/91. The client's blood pressure at her previous visit was 121/82. A urine dipstick test reveals a trace amount of protein. The nurse identifies which nursing diagnosis as appropriate for the client at this time? A) Risk for Imbalanced Fluid Volume B) Chronic Pain C) Risk for Delayed Development D) Constipation
A
During what period of gestation do congenital heart defects usually develop? A) First 8 weeks of gestation B) Second trimester C) Third trimester D) Last 4 weeks of gestation
A
How does a brainstem abnormality contribute to the risk of SIDS when an infant is placed on his stomach to sleep? A) It decreases the infant's arousal and head turning responses during times of asphyxia. B) It decreases the infant's respiratory drive during NREM sleep. C) It increases periods of apnea, resulting in hypoxia and unconsciousness. D) It increases the risk of aspiration and airway obstruction.
A
The clinic nurse is educating a group of new moms on the risk factors and prevention of respiratory syncytial virus (RSV). What should the nurse stress as the best way to prevent RSV? A) Hand washing B) Monitoring temperature C) Administering antibiotics D) Limiting fluid intake
A
The community nurse is caring for a client who is 32 weeks pregnant and diagnosed with preeclampsia. Which statement indicates that the client requires additional teaching? A) "It is normal for my urine may become darker and smaller in amount each day." B) "I should call the doctor if I develop a headache or blurred vision." C) "Pain in the top of my abdomen is a sign my condition is worsening." D) "Lying on my left side as much as possible is good for the baby."
A
The mother of a baby born with a congenital heart defect is upset, as no one else in the family has been born with this condition. To determine the cause of the defect, which question is appropriate for the nurse to ask the mother? A) "Did you consume any alcohol before you knew you were pregnant?" B) "Is there a history of diabetes in your family?" C) "Was the baby's father exposed to any toxins in the work environment?" D) "Do you have a history of hypertension?"
A
The nurse has identified Ineffective Peripheral Tissue Perfusion as a nursing diagnosis for a client with disseminated intravascular coagulation (DIC). What intervention would be appropriate for the client? A) Carefully repositioning the client every 2 hours B) Administering oxygen C) Monitoring oxygen saturation D) Encouraging deep breathing and coughing
A
The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse? A) Blood pressure of 142/92 mmHg B) Pulse of 92 beats per minute C) Respiratory rate of 24 per minute D) Weight gain of 16 oz per week
A
The nurse is placing a newborn baby in the nursery crib with the baby's back down. The mother tells the nurse that she doubts the baby will be able to sleep that way, as all the family members sleep on their stomachs. Which action by the nurse is appropriate? A) Instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome (SIDS) and it will not interfere with sleep. B) Place the baby on the stomach. C) Suggest the mother place the baby on the stomach when at home. D) Instruct the mother that babies do not really care in which position they are in but placing on the back is easier to provide care.
A
The nurse is planning care for a baby born to a mother who smoked during the pregnancy. The mother states that she believes in bed sharing. Which nursing diagnosis would be appropriate for this baby? A) Risk for Sudden Infant Death Syndrome (SIDS) B) Readiness for Enhanced Parenting C) Anxiety D) Deficient Knowledge
A
The nurse is planning care for a pediatric client recovering from surgery to repair a congenital heart defect. Which intervention should the nurse include to support the client's fluid status? A) Encourage oral intake of fluids when permitted. B) Limit oral and intravenous intake of fluids. C) Continue normal saline administration even after oral intake is normal. D) Convert the intravenous line to a saline lock immediately after surgery.
A
The student nurse attends a workshop on culture and diversity with regard to sudden infant death syndrome (SIDS) and is now aware that the rate of occurrence is highest among which group of infants? A) American Indians B) Caucasians C) Asians D) Hispanics
A
Which is believed to be the cause of preeclampsia? A) Placental dysfunction B) Liver disease C) Anxiety D) Low sodium intake
A
Which pathological change related to disseminated intravascular coagulation (DIC) occurs late in the course of the disease? A) Hemorrhage B) Formation of small clots C) Damage to the endothelium D) Brain ischemia
A
Which population should the nurse assigned to care for pediatric clients recognize as having the highest risk of hospitalization due to RSV? A) Alaskan Native infants B) African American infants C) Native American infants D) Asian American infants
A
A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which variables should the nurse highlight as contributing to increased risk of SIDS? Select all that apply. A) Prone sleeping B) Side sleeping C) Loose bedding D) Bed sharing E) Supine sleeping
A, B, C, D
The nurse is planning care for the parents of an infant who died as the result of sudden infant death syndrome. Which collaborative interventions does the nurse plan for when providing care to these parents? Select all that apply. A) A psychosocial assessment B) A grief counselor referral C) A psychotherapist referral D) A visit from the chaplain E) A respiratory therapist referral
A, B, C, D
The nurse working in the emergency department (ED) is assessing an infant client. Which findings does the nurse anticipate in a child diagnosed with respiratory syncytial virus (RSV)? Select all that apply. A) Rhinorrhea B) Irritability C) Grunting D) Bradypnea E) Tachypnea
A, B, C, E
Which action should the nurse carry out for the laboring client who has been diagnosed with preeclampsia? A) Place the client in the room closest to the nurse's station, even if it is a shared room. B) Place the client in left lateral position when the client feels the urge to push. C) Monitor client's fetus intermittently while client is in first stage of labor. D) Encourage the client to be alone in the room without family in order to maintain a quiet environment.
B
When assessing the risk of a newborn for sudden infant death syndrome (SIDS), which are risk factors that the nurse should consider? Select all that apply. A) Race B) Gender C) Father's age D) Age E) Eye color
A, B, D
Which prevention strategies would be the most beneficial for the nurse to discuss with the parents of a child who has had repeated admissions for respiratory syncytial virus (RSV) bronchiolitis? Select all that apply. A) Do not smoke, and avoid all secondhand smoke around the child. B) Practice frequent hand washing. C) Encourage physical activity and play. D) Consider alternatives to sending the child to daycare. E) Ensure an adequate nutritional intake.
A, B, D
The nurse is providing postpartum care for a client who gave birth by cesarean section several hours ago. The client had preeclampsia during the last 3 weeks of pregnancy. Which interventions are appropriate for this client within the first 48 hours after birth? Select all that apply. A) Assessment of deep tendon reflexes B) Assessment of intake and output C) Oxygen 2 liters nasal cannula as prescribed D) Seizure precautions E) Vital sign assessment
A, B, D, E
The nurse is assessing a toddler diagnosed with tetralogy of Fallot (TOF). Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply. A) Palpable thrill in the pulmonic area B) Nail clubbing C) Cough D) Apneic periods E) Knee-chest position
A, B, E
Which best describes how congenital defects are categorized? A) By the severity of defect B) By the pathophysiology and hemodynamics of defect C) By the location of defect D) By the infant's age when the defect was diagnosed
B
A client is admitted to the intensive care unit with disseminated intravascular coagulation (DIC). Which clinical manifestations does the nurse anticipate? Select all that apply. A) Tachycardia B) Increased blood glucose level C) Decreased breath sounds D) Confusion E) Thick, tenacious bronchial secretions
A, C, D
A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective Peripheral Tissue Perfusion. Which actions interventions are appropriate for this diagnosis? Select all that apply. A) Monitor the client's level of consciousness and mental status. B) Elevate the client's knees on the bed or with a pillow. C) Minimize the use of tape on the client's skin. D) Assess extremity pulses, warmth, and capillary refill. E) Carefully reposition the client at least every 2 hours.
A, C, D
The mother of an 8-month-old baby who has developed respiratory syncytial virus (RSV)/bronchiolitis wants to know which factors contribute to the risk of contracting RSV. Which response by the nurse is appropriate? A) "There is a higher risk in children who are being breastfed." B) "There is no way to avoid the illness." C) "There is a higher risk in children who are exposed to secondary cigarette smoke." D) "It is seen more frequently in children who do not attend daycare."
C
A baby will be having surgery to correct a congenital heart defect. On which topic should the parents be instructed regarding the care of the child before surgery? A) Restricting immunizations until after the surgery B) Preventing exposure to infection C) Implementing no particular precautions D) Restricting fluids for a week before the surgery
B
A client with disseminated intravascular coagulation (DIC) is anxious and has decreased oxygen saturation. Which is the priority nursing diagnosis for this client? A) Acute Pain B) Impaired Gas Exchange C) Ineffective Peripheral Tissue Perfusion D) Anxiety
B
A client with disseminated intravascular coagulation (DIC) is experiencing joint pain. Which nursing intervention is appropriate for this client? A) Splints B) Cool compresses C) Heat D) Ice
B
A client with preeclampsia begins to demonstrate manifestations of seizure activity. Which intervention by the nurse is most likely to protect the client and fetus from injury? A) Elevate the client's legs B) Place the client on the left side and protect the airway C) Place the client in the supine position D) Elevate the head of the bed
B
A nurse is caring for a pregnant client who is hypertensive. Which additional clinical manifestations leads the nurse to believe that the client is experiencing early preeclampsia? A) Persistent headache B) Excessive protein in the urine C) Right-sided abdominal pain D) Severe epigastric pain
B
A pregnant client is diagnosed with HELLP syndrome. Based on this diagnosis, which laboratory findings are consistent with diagnosis of HELLP? A) Decreased liver enzymes B) Hemolysis C) Elevated lipid panel D) Increased platelet count
B
The mother of a 5-month-old baby, who attends daycare, is concerned because the child has developed a runny nose, cough, and low-grade fever over the last few days. These symptoms are consistent with which condition? A) Meningitis B) Respiratory syncytial virus (RSV) bronchiolitis C) Bronchitis D) The common cold
B
The nurse is caring for a client with disseminated intravascular coagulation (DIC). Which should the nurse identify as a priority intervention for this client? A) Frequent ambulation B) Maintenance of skin integrity C) Preparation for radiograph procedures D) Restricting fluids
B
The nurse is caring for an adult client who was diagnosed with a congenital heart defect as a child, which was later repaired with surgery. Which common complication of a heart defect should the nurse monitor that the client may still be at risk for? A) Deep vein thrombosis B) Endocarditis C) Atherosclerosis D) Shock
B
The nurse is developing a plan of care for a toddler diagnosed with respiratory syncytial virus (RSV). Which intervention is inappropriate for this client? A) Offer small, frequent meals. B) Encourage to ambulate frequently. C) Encourage oral intake. D) Monitor intake and output.
B
The nurse is evaluating care provided to a new mother whose infant is at risk for sudden infant death syndrome (SIDS). Which statement by the mother indicates teaching has been effective? A) "I need to purchase loose-fitting sheets and blankets for the bed." B) "I plan to quit smoking." C) "I will place my baby in a side-lying position for sleep." D) "I will bottle-feed my baby since breastfeeding is a risk factor for SIDS."
B
The nurse is providing parenting teaching regarding reducing the risk of sudden infant death syndrome (SIDS). Which teaching point is a priority for the nurse to include? A) Instruct on side-lying and face-down positions when in the crib. B) Instruct on face-up position when in the crib. C) Ensure adequate nutritional intake for the mother and newborn. D) Encourage good hand washing.
B
The nurse provides discharge instructions to the parents of a child recovering from surgery to repair a congenital heart defect. What statement indicates that teaching has been effective? A) "Our child should be restricted in play and activity for at least 6 months." B) "Our child will need to take antibiotics prior to having dental surgery." C) "Fluids should be restricted to maximize lung function." D) "Our child should not return to normal activities for at least 2 years."
B
The nurse assesses fatigue in an infant with acute bronchiolitis due to respiratory syncytial virus (RSV). Which nursing diagnosis would be most appropriate for the infant? A) Acute Pain B) Ineffective Tissue Perfusion C) Activity Intolerance D) Decreased Cardiac Output
C
The nurse is planning care for a child with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should the nurse include in the child's plan of care to address the nursing diagnosis Impaired Gas Exchange? Select all that apply. A) Weigh daily. B) Monitor vital signs and pulse oximetry. C) Administer oxygen as prescribed. D) Weigh diapers. E) Provide frequent rest periods.
B, C
The nurse is caring for a client who has been admitted to labor and delivery. What should the nurse recognize as risk factors for disseminating intravascular coagulation (DIC)? Select all that apply. A) Multiparity B) Placental abruption C) Preterm labor D) Fetal death E) Gestational diabetes
B, D
A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding through the gastrointestinal tract. Which does the nurse anticipate administering to this client as a first line treatment? A) Aspirin B) Warfarin (Coumadin) C) Fresh frozen plasma and platelets D) Heparin
C
A nurse caring for a client with suspected disseminated intravascular coagulation (DIC). Which test result is common in DIC? A) Decreased prothrombin time B) Increased platelet count C) Decreased fibrinogen level D) Decreased partial thromboplastin time
C
A nurse is assessing a client during labor and delivery. Which condition should the nurse recognize as a risk factor for disseminated intravascular coagulation (DIC)? A) Gestational diabetes B) Polyhydramnios C) Placental abruption D) Placenta previa
C
An infant with respiratory syncytial virus (RSV) bronchiolitis is prescribed intubation to maintain an adequate airway. Who will the nurse collaborate with to maintain the endotracheal tube and ventilation? A) An advanced practice nurse B) The primary healthcare provider C) A respiratory therapist D) A play therapist
C
Sudden infant death syndrome is diagnosed A) when an autopsy reveals a brainstem defect. B) when an infant dies after being shaken violently. C) when an autopsy fails to find a cause of death. D) when an infant is found dead in their crib.
C
The nurse identifies assessment findings for a client with preeclampsia. Blood pressure is 158/100 mmHg; urinary output 50 mL/hour; crackles in the lungs on auscultation; urine protein 1+; 1+ edema hands, feet, ankles. On the next hourly assessment, which new assessment finding would indicate worsening of the condition? A) Blood pressure 159/100 mmHg B) Urinary output 40 mL/hour C) Urine protein 2+ D) Lungs clear to auscultation
C
The nurse is analyzing data collected after assessing a child with a congenital heart defect that decreases pulmonary blood flow. Which nursing diagnosis would be applicable for this client? A) Acute Pain B) Ineffective Breathing Pattern C) Decreased Cardiac Output D) Excess Fluid Volume
C
The nurse is providing care to a client diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which assessment finding indicates that treatment has been effective? A) Client ingesting small amounts of clear fluids when encouraged B) Client resting in bed with limited interest in play or activities C) Client respiratory rate within normal limits for age D) Client coughing copious amounts of green sputum and requires occasional suctioning
C
The nurse observes a toddler, admitted with possible respiratory syncytial virus (RSV) bronchiolitis, grunting with expiration. Which action by the nurse is appropriate? A) Assist the child to clear the nasal passages. B) Limit fluids. C) Suction the airway to relieve the obstruction. D) Lay the child on his back.
C
The pediatric nurse is providing education to a new mother regarding ways to decrease the risk of sudden infant death syndrome (SIDS). Which statement by the nurse is appropriate? A) "You should keep the baby with you at all times to assess for apnea." B) "Make sure the baby has a soft blanket and pillow when sleeping." C) "It is recommended that you place your baby on his back for sleep." D) "SIDS has been linked to immunizations. I recommend that you avoid immunizing your baby."
C
The primary cells involved in infection by respiratory syncytial virus (RSV) are the A) smooth muscle cells in the bronchi and bronchioles. B) granular pneumonocytes in the alveoli. C) squamous epithelial cells of the bronchioles and alveoli. D) macrophages and monocytes of the bronchioles and alveoli.
C
Which is the most appropriate outcome for the nurse to select for a 78-year-old resident of a long-term care facility with regard to preventing RSV? A) The client's airways will remain clear of secretions. B) The client's fluid intake will meet daily requirements of 2000 mL per day. C) The client will demonstrate knowledge of proper hand washing techniques. D) The client will meet daily nutritional needs as provided by a nutritionist.
C
The nurse is caring for a child who has just been diagnosed with an atrial septal defect (ASD). Which manifestations would the nurse expect upon assessment? Select all that apply. A) Pulmonary artery hypotension B) Midsystolic murmur at lower right sternal border C) Mitral valve regurgitation with cleft on mitral valve D) S1 heart tone may be split due to forceful left ventricular contraction E) Congestive heart failure
C, E
The nurse is instructing new parents on ways to decrease the risk of sudden infant death syndrome (SIDS) with their newborn son. What should be included in these instructions? Select all that apply. A) There is nothing that can be done, so requirements for toys and bedding are of no consequence. B) Instruct that it is more common in babies from ages 6 months to 18 months. C) Avoid placing the baby in the prone or side-lying position for sleep. D) Remind the parents that the syndrome is more common in females than males, and that they have a male child. E) Do not smoke near the child and reduce all exposure to secondhand smoke.
C, E
The nurse is assessing an adult client with respiratory syncytial virus (RSV). Which symptom will the nurse expect to assess that is not seen in infants with RSV? A) Rhinorrhea B) Cough C) Apnea D) Headache
D
A nurse is teaching a group of pregnant clients regarding seizures associated with eclampsia. Which statement associated with eclampsia are accurate? A) "The tonic phase of a grand mal seizure is evidenced by alternate contraction and relaxation of the muscles." B) "The clonic phase of a grand mal seizure is evidenced by muscular contraction and rigidity." C) "Seizures are rare in eclampsia, but they occur sometimes." D) "Seizures do not occur in preeclampsia."
D
A nurse working on an antepartum unit is providing care for a client with preeclampsia. Which laboratory value does the nurse anticipate for this client? A) Increased platelet count B) Decreased liver enzymes C) Decreased blood urea nitrogen (BUN) D) Increased serum creatinine
D
The nurse is assessing a client who is 20 weeks pregnant. Which health issue should the nurse recognize as increasing this client's risk for the development of preeclampsia? A) Treatment for vitamin D deficiency B) Surgery for ruptured appendix 1-year prior C) Fibrocystic breast disease D) Obesity
D
The nurse is caring for a pregnant woman with congenital heart disease. The woman asks if she will be able to have a vaginal delivery. Which answer by the nurse is correct? A) A Cesarean section is preferred because you will lose less blood than with a vaginal birth. B) A Cesarean section is preferred because there is a lower risk of infection than with a vaginal birth. C) A vaginal birth is preferred over a Cesarean section for women who have aortic stenosis. D) A vaginal birth is preferred because there is a lower risk of thrombophlebitis than with a Cesarean section.
D
The nurse is evaluating care provided to a client with disseminated intravascular coagulation (DIC). Which finding indicates care has been successful for this client? A) Heart rate 110 beats per minute B) Oxygen saturation level 86% C) Urine output 20 mL per hour D) No evidence of bleeding
D
The nurse is providing care to a 7-month-old child hospitalized with RSV/bronchiolitis. The nurse can expect to provide client teaching to the parents about which medication? A) Corticosteroids B) Nebulized epinephrine C) Antibiotics D) Nebulized hypertonic saline
D
The nurse is providing supportive care for the parents of an infant who died from sudden infant death syndrome (SIDS). Which action by the nurse is appropriate? A) Advising the parents that an autopsy is not necessary B) Refraining from recommending support groups until after the investigation C) Interviewing the parents to determine the cause of the SIDS incident D) Contacting the family's spiritual leader for support
D
The nurse is providing teaching to the parents of a child born with tetralogy of Fallot (TOF). Which statement should the nurse include in her teaching regarding this defect? A) "Increased pulmonary blood flow causes symptoms with this disease." B) "This disease consists of pulmonic stenosis, left ventricular hypertrophy, ventricular septal defect, and an overriding aorta." C) "Your child has a decreased amount of red blood cells because of this disease." D) "This disease consists of pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta."
D
The nurse is planning care for a new mother who smoked during the pregnancy and whose sister lost a child to sudden infant death syndrome (SIDS). Which interventions are appropriate for the nurse to include in the plan of care for the new mother and baby? Select all that apply. A) Information on bottle-feeding the infant B) Reasons why the child should sleep with others C) Ages at which the child should receive immunizations D) Using bedding that is firm E) Smoking cessation information
D, E
