PNC 520 Exam
A 9-month-old is seen in the well child clinic. During the nursing assessment, the mother asks, "Shouldn't he be making baby sounds by now? My friend's little boy is the same age and he is already saying 'dada'." The nurse reports the mother's concerns to the doctor for follow-up based on the knowledge that infants should be making rudimentary sounds by age: A) 2 months B) 1 month C) 4 months D) 8 months
A) 2 months
A client is receiving closed catheter irrigation. During the shift, 950 mL of normal saline irrigant is instilled, and a total of 1725 mL is found in the drainage bag. The nurse calculates the client's urinary output to be which of the following amounts? A) 775 mL B) 950 mL C) 1725 mL D) 2675 mL
A) 775 mL
A client is admitted to the hospital with acute renal failure. Which assessment finding should be reported immediately? A) Irregular heart rate B) Pedal edema C) Complaint of headache D) Urine output of 30ml per hour
A) Irregular heart rate
A 32-year-old patient is being admitted to the medical floor with a diagnosis of bronchiectasis. She has a chronic cough with expectoration of copious amounts of purulent sputum and hemoptysis. An appropriate outcome criterion is that the: A) Patient demonstrates improved ventilation and adequate oxygenation. B) Patient may have activity intolerance related to fatigue. C) Nurse encourages alternating rest and activity. D) Patient uses incentive spirometer 10x each hour while awake.
A) Patient demonstrates improved ventilation and adequate oxygenation
A client pulls out his right-side chest tube. What is the immediate action by the practical nurse? A) Place an occlusive dressing over the puncture site B) Position the client on his right side C) Call for the on-site physician D) Place a saline dressing over the exit site
A) Place an occlusive dressing over the puncture site
A client asks the nurse why her newborn baby needs an injection of vitamin K. The nurse should make which statement to the client? A) "Newborns have sterile bowels. The vitamin K will colonize the bowel with necessary bacteria." B) "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." C) "Your newborn needs vitamin K to develop immunity." D) "The vitamin K will protect your newborn from becoming jaundiced."
B) "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."
A CBC, urinalysis, and x-ray examination of the chest are ordered for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse? A) "Don't worry; these tests are routine." B) "They are done to identify other health risks." C) "They determine whether surgery will be safe." D) "I don't know; your health care provider ordered them."
B) "They are done to identify other health risks."
A client with newly diagnosed COPD is admitted to the unit. Which nursing diagnosis should receive the highest priority? A) Alteration in skin integrity B) Alteration in oxygenation C) Alteration in nutrition D) Alteration in mobility
B) Alteration in oxygenation
A nurse from another department arrives on the unit and begins talking about the recent admission of a particular client. This nurse sits down at the nursing station and logs on to the computer. The nurse notes that she is looking over the various clients' records on the unit. What would be the appropriate reaction for the nurse to take? A) Approach the nurse immediately and inform her that she is violating patient confidentiality. B) Approach the nurse and ask her why she is looking at client records on the unit. C) Immediately notify the charge nurse of the situation. D) Look over the records with her and answer any questions she may have.
B) Approach the nurse and ask her why she is looking at client records on the unit.
A nurse is caring for a patient with a hearing impairment. Which measure should the nurse do first? A) Call the hospital's American Sign Language practitioner. B) Ask significant others how the patient communicates at home. C) Arrange for a social worker to visit with the patient and family members. D) Arrange for a family member to stay with the patient continually.
B) Ask significant others how the patient communicates at home
A 50-year-old female has been admitted to the cardiac unit for a cardiac catheterization. While preparing the patient for the test she states she has an allergy to shrimp. What is the next action the nurse should take? A) Place an allergy band around the patient's wrist B) Ask what symptoms she experiences when she eats shrimp C) Inform the physician of the allergy D) Prepare the patient for the catheterization
B) Ask what symptoms she experiences when she eats shrimp
A client taking spironolactone (Aldactone) complains of irregular heart rate, diarrhea, and stomach cramping. Which of the following would be a priority assessment for this client? A) Assess sodium level for hypernatremia B) Assess potassium level for hyperkalemia C) Assess white blood cell count for neutropenia D) Assess hemoglobin levels for anemia
B) Assess potassium level for hyperkalemia
The nurse enters a room and finds the client sitting on the floor next to the bed. The client tells the nurse, "I was trying to reach the TV button and slipped. I'm fine. Nothing to worry about." The nurse will: A) Apply a waist restraint to remind the client not to get up without assistance. B) Assess the client for injuries and notify the physician of the incident. C) Ask the nursing assistant why the client was allowed to fall. D) Help the client back to bed and make sure the TV button is in reach.
B) Assess the client for injuries and notify the physician of the incident
A 77-year-old female is admitted with a 2-week history of polyuria, fatigue and ketotic breath. What assessment would be a priority for the nurse to obtain first? A) Weight and height B) Blood sugar level C) Temperature D) Potassium level
B) Blood sugar level
A client in the hospital has an indwelling urinary catheter, and the nurse is instructing the nursing student in the appropriate care to provide. Which one of the following does the practical nurse teach the student to do? A) Use clean technique to obtain a specimen for culture and sensitivity. B) Cleanse down the length of the catheter C) Empty the drainage bag every 12 hours D) Place the drainage bag on the client's lap when transporting the client.
B) Cleanse down the length of the catheter
A 67 year old who is receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia and leukopenia. The client has been losing weight due to anorexia and has limited mobility. The practical nurse is planning care. What is the most important priority when planning care for this client? A) Assessing vital signs every 4 hours B) Collaboration with the intraprofessional team (dietician and physical therapy) to plan interventions. C) Focusing care on nursing care interventions only D) Providing meticulous mouth care
B) Collaboration with the intraprofessional team (dietician and physical therapy) to plan interventions.
A 52-year-old male was hospitalized for knee surgery. He was discharged on day 3 with a home visiting nurse to perform daily wound care. The nurse gathers the following data: Temperature 37.7 (oral), pulse 74, resp rate 32. Client complains of dyspnea and cough. What should the nurse do first? A) Arrange for daily home care visits B) Complete a physical assessment C) Notify the Health care provider D) Document the findings in the medical record
B) Complete a physical assessment
A child with a newly applied left leg cast initially feels fine, then starts to cry and tells his mother his leg hurts. What should the nurse do first? A) Assess temperature and pulse B) Complete a neurovascular assessment of the left leg. C) Provide prn pain medication D) Provide passive range of motion to the left leg.
B) Complete. a neurovascular assessment of the left leg
A client has a peripheral IV infusing in the left hand. The patient states that her hand hurts. The nurse notes the IV site is erythematous, edematous and warm to touch. What should the nurse do? A) Reduce the intravenous flow and reassess in 1 hour. B) Discontinue the infusion and remove the IV catheter. C) Inform the patient that the redness and soreness is normal with IV therapy and will resolve soon. D) Assess the intravenous site and raise the IV bag higher.
B) Discontinue the infusion and remove the IV catheter
A client has just been diagnosed with right leg deep vein thrombosis (DVT). Which intervention should the nurse implement? A) Vigorous range of motion to the right leg B) Elevation of the right leg C) Hourly calf measurements D) Ice packs to the right leg
B) Elevation of the right leg
A father expresses concerns about his son's upcoming surgery. The nurse listens to the father's concerns and validates his feelings. What component of the nurse-client relationship is the nurse demonstrating? A) Respect B) Empathy C) Trust D) Intimacy
B) Empathy
A 50-year-old woman is admitted post-operatively for repair of hip fracture and splenectomy after a motor vehicle accident. Three hours post-op her level of consciousness (LOC) is decreased. Vital signs are BP 82/56; HR 120; RR 28; skin cool and clammy; no complaints of SOB; lung sounds clear; u/o 20ml/hr; T 36.5 C; WBC 9000. Based on this information, what condition apprears to be developing? A) Neurogenic shock B) Hypovolemic shock C) Cardiogenic shock D) Septic shoc
B) Hypovolemic Shock
A 74-year-old patient is admitted to a nursing home with a diagnosis of Alzheimer's dementia. The nurse observes the resident having difficulty swallowing during breakfast. The nurse should: A) Provide a straw for liquids B) Notify the health care provider C) Instruct the PSW to feed the client D) Position the client reclined at 45 degrees
B) Notify the health care provider
A 9 month old is admitted with a gastrointestinal infection. Which assessment finding requires further follow up and intervention? A) Heart rate of 130 /min B) Sunken anterior fontanel C) Moist mucous membranes D) 6 wet diapers in the last 24 hours.
B) Sunken anterior fontanel
A 75-year-old male with stable COPD is admitted to the medical unit for weight loss. He has had a 20% weight loss over the last 2 months. The client tells the practical nurse that they have been using edible marijuana to try and increase their appetite. He asks the nurse not to tell anyone. What is the best response by the practical nurse? A) Tell the client that this is illegal activity B) Tell the client that you have to share this information with the health care team as it may affect their care C) Tell the client you will keep this information private and not tell anyone D) Ask the client where they obtained this product
B) Tell the client that you have to share this information with the health care team as it may affect their care
Morphine sulfate, 2.5 mg IV, is prescribed for a child. The safe paediatric dose is 0.05 to 0.1 mg/kg/dose. The child weighs 50 kg. Which statement most accurately describes the prescribed dosage for this child? A) The dose is too low B) The dose is within the safe dosage range C) The dose is too high D) There is not enough information to determine the safe dosage range
B) The dose is within the safe dosage range
The nurse is told than an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client? A) Wear a mask and gloves B) Wear a gown and gloves C) Wear gloves only D) Avoid touching the client's clothes
B) Wear a gown and gloves
A 20-year-old college student comes to the college health clinic reporting increasing anxiety, loss of appetite, and an inability to concentrate. What is the most appropriate response by the nurse? A) "With whom have you shared your feelings of anxiety?" B) "How are your grades?" C) "It seems that this has been a difficult time for you. How long have you been feeling this way?" D) "Let's talk about all of your problems. Are you having difficulty adjusting?"
C) "It seems that this has been a difficult time for you. How long have you been feeling this way?"
A lobectomy is scheduled for a patient with squamous cell carcinoma of the lung. The patient tells the nurse, "I would rather have radiation than surgery." What is the most appropriate therapeutic response? A) "Surgery is the treatment of choice for stage I lung cancer." B) "Are you afraid that the surgery will be very painful?" C) "Tell me what you know about the various treatments available." D) "Did you have bad experiences with previous surgeries?"
C) "Tell me what you know about the various treatments available."
A 73-year-old female is diagnosed with right breast cancer and is admitted to the medical unit. She has had several radiation treatments on her right breast. Which of the following assessment findings requires immediate follow up? A) Skin to right breast is dry and scaly B) Right breast is slightly larger in size than left breast C) 3cm x 2cm open area on right breast that is red and draining yellow exudate D) Skin to right breast is pink, warm and dry
C) 3cm x 2cm open area on right breast that is red and draining yellow exudate
Which client is at greatest risk for the development of obstructive sleep apnea? A) 58-year-old man with diabetes mellitus and a history of sinus infections B) 38-year-old man with gastroesophageal reflux disease C) 48-year-old woman who is approximately 50 pounds overweight D) 28-year-old woman who is 8 months pregnant
C) 48 year old woman who is approximately 50 pounds overweight
A client is taking lansoprazole (Prevacid) for the chronic management of stomach ulcers. If prescribed, which medication would be appropriate for the client if needed for a headache? A) Naprosyn (Aleve) B) Ibuprofen (Advil) C) Acetaminophen (Tylenol) D) Acetylsalicylic acid (aspirin)
C) Acetaminophen (Tylenol)
A 72-year-old client is receiving digoxin (Lanoxin) daily. The nurse suspects digoxin toxicity after noting which signs and symptoms? A) Serum potassium level of 3.9 mEq/L B) Apical pulse rate of 63 beats per minute C) Anorexia, nausea and vomiting D) Digoxin level of 0.8 ng/ml
C) Anorexia, nausea and vomiting
A client has limited visitors because of active Tuberculosis. The client states "I am better off dead." Which response by the nurse is most therapeutic? A) Tell the client a social work referral has been made to discuss their feelings B) Tell the client that they have so much to live for C) Ask the client what makes them feel that way D) Explaining to the client that the details of their illness so that they won't feel that way
C) Ask the client what makes them feel that way
A 42-year-old female was hospitalized for abdominal surgery to remove ovarian cysts. The nurse gathers the following data: Abdomen soft with hypoactive bowel sounds, abdominal dressing dry and intact, bladder palpated above level of symphis pubis What should the nurse do first? A) Ambulate the client to the washroom to void B) Notify the Health care provider C) Ask the client when they last emptied their bladder D) Assess badder fullness with a bladder scanner
C) Ask the client when they last emptied their bladder
The nurse is caring for a postrenal transplant client taking cyclosporin (Sanimmune). The nurse notes an increase in one of the client's vital signs, and the client is complaining of a headache. Which is the vital sign that is most likely increased? A) Respirations B) Pulse C) Blood pressure D) Temperature
C) Blood pressure
The client with acquired immunodeficiency syndrome has begun therapy with zidovudine (Retrovir). The nurse should carefully monitor which laboratory result during treatment with this medication? A) Blood glucose level B) Blood culture C) Complete Blood Count D) Blood Urea Nitrogen
C) Complete blood count
A client with chronic kidney disease is receiving ferrous sulfate (Feosol). The nurse should monitor the client for which common side effect associated with this medication? A) Headache B) Weakness C) Constipation D) Diarrhea
C) Constipation
A 66 year old patent with pain associated with angina pectoris is given sublingual nitroglycerin. The nurse knows this medication will: A) Dull nerve endings in the myocardium B) Inhibit pain sensors in the brain stem C) Dilate blood vessels and increase circulation D) Increase Respirations and cause drowsiness
C) Dilate blood vessels and increase circulation
A client and their family complain to the charge nurse that they did not receive any updates on the client's condition overnight and now the nurses have limited visitors because of a chest infection. After the charge nurse listens to their concerns, what action(s) would demonstrate the professional standard for 'Leadership'? A) Develop solutions to address infection prevention and control on the unit. B) Tell the family that all visitors need to be restricted to avoid the spreading of infection C) Discuss the issue with the health care team to gather more information to develop a possible resolution to the situation D) Take advantage of this learning opportunity to teach the staff about communication
C) Discuss the issue with the health care team to gather more information to develop a possible resolution to the situation
A 70-year-old female patient with heart failure has woke up during the night complaining of shortness of breath. Which of the following should the nurse do first? A) Medicate for anxiety B) Call the health care provider immediately C) Elevate the head of the bed to 45 degrees D) Suctioning the client's airway
C) Elevate the head of the bed to 45 degrees
A client has just returned to a nursing unit following bronchoscopy. Which of the following nursing interventions is a priority for this client? A) Administering atropine orally B) Administering a stool softener for constipation C) Ensuring the return of the gag/cough reflex before offering foods or fluids D) Encouraging additional fluids for the next 24 hours
C) Ensuring the return o the gag/cough reflex before offering foods or fluids
A 68-year-old male was hospitalized for exacerbation of COPD. The nurse gathers the following data: Client with abdominal breathing, clubbed nails and thick yellow sputum. Which of the following is a priority intervention? A) Document the findings in the medical record B) Teach the client how to plan a protein rich diet C) Explain to the client the need for increased fluid intake D) Complete an abdominal assessment
C) Explain to the client the need for increased fluid intake
A 20-year-old university student who has type 1 diabetes normally walks each evening as part of her exercise regimen. She now plans to enroll in a swimming class to meet her physical education requirement. What should the nurse teach the patient that adjustments to her treatment plan should include? A) Time her morning insulin injection so that the peak action will occur during her swimming class B) Delaying the normal meal before the swimming class until the session is over C) Monitoring her glucose level before, during, and after swimming to determine the need for alterations in food or insulin D) Adding 10 units of regular insulin to her usual morning dose on the days she plans to swim
C) Monitoring her glucose level before, during and after swimming to determine the need for alterations in food or insulin
A 74-year-old male is admitted to a nursing home with a diagnosis of Alzheimer's dementia. The nurse observes the resident having difficulty swallowing during breakfast.The nurse should: A) Provide a straw for liquids B) Position the client reclined at 45 degrees. C) Notify the health care provider D) Instruct the PSW to feed the client
C) Notify the health care provider
A client is receiving furosemide (lasix). Which of the following physician orders would the nurse question? A) Daily weights B) Potassium Chloride 20meq PO daily C) Potassium restricted diet D) Daily electrolyte levels
C) Potassium restricted diet
A client is taking Digoxin (Lanoxin)and Furosemide (Lasix) for heart failure. Which of the following lab value needs to be monitored closely and why? A) Calcium, because hypocalcemia can be a sign of worsening heart failure B) PH, because alkalosis can be a sign of respiratory depression C) Potassium, because hypokalemia can lead to digoxin toxicity D) Sodium, because hypernatremia can lead to digoxin toxicity
C) Potassium, because hypokalemia can lead to digoxin toxicity
A 3-month-old infant is receiving continuous intravenous (IV) therapy because of dehydration. In providing nursing care for her, the nurse's priority should be to: A) Promote fluid elimination B) Help the infant adjust to restricted activities C) Prevent interference with the IV therapy D) Relieve the infant's anxiety
C) Prevent interference with the IV therapy
A 3-month-old infant is admitted to the paediatric unit for treatment of bronchiolitis. Oxygen therapy is ordered for the infant primary to: A) Reduce fever B) Liquefy secretions C) Relieve dyspnea and hypoxia D) Reduce anxiety and restlessness
C) Relieve dyspnea and hypoxia
A care provider was seen taping a washcloth over the mouth of an 85-year-old client to keep her quiet. What should the nurse do? A) Dismiss the worker, report to the employer, and document. B) Concur with the behaviour of the care provider. C) Remove the washcloth, assess the client, and report. D) Check the client's care plan.
C) Remove the washcloth, assess the client, and report.
A nurse arrives at work and is told to float to the pediatric unit for the day because the unit is understaffed and needs additional nurses. The nurse has never worked in the pediatric unit. Which of the following is the appropriate nursing action? A) Report to the pediatric unit and accept any patient assignment B) Call the nursing supervisor. C) Report to the pediatric unit and discuss level of knowledge with the charge nurse and identify nursing care that can be performed safely. D) Refuse to work on the pediatric unit.
C) Report to the pediatric unit and discuss level of knowledge with the charge nurse and identify nursing care that can be performed safely.
A nurse is assigned to care for a group of clients. On review of the client's' medical records, the nurse determines that which client is at risk for fluid volume overload? A) The client who requires gastrointestinal feeding B) The client taking antihypertensives C) The client with renal failure D) The client with an ileostomy
C) The client with renal failure
A 75-year-old client, hospitalized with a stroke, becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate nursing measure? A) Restrain the client in bed B) Check the client every 15 minutes C) Use a bed exit safety monitoring device D) Ask a family member to stay with the client
C) Use a bed exit safety monitoring device
A 76-year-old client has a diagnosis of osteoporosis and arthritis of her knees and hips. The nurse should encourage which of the following exercise programs? A) Bicycling and bowling B) Weight training and square dancing C) Walking and water aerobics D) Aerobic dancing and swimming
C) Walking and water aerobics
A 6-month-old is brought to the emergency department by her mother. During the assessment, the nurse finds multiple bruises in different stages of healing and decreased range of motion of the right leg. X-ray confirms a fracture of the right femur. Which statement made by the mother would contribute to a diagnosis of child abuse? A) "She got her leg caught in the crib and twisted it." B) "I can't remember her falling or getting hurt." C) "She fell out of her car seat before I could get the belt fastened." D) "She hurt her leg while she was crawling."
D) "She hurt her leg while she was crawling."
A 77-year-old client has been in a long-term care facility for the past 6 months. He frequently uses his nurse call system to summon the nursing staff for minor tasks. Which one of the following actions by the nurse would be appropriate when he calls again? A) Have another staff member answer his call. B) Place the call system away from him so that some effort is required to reach it. C) Explain to him why the staff will not always respond to his call. D) Answer his call promptly.
D) Answer his call promptly
A corticosteroid cream is prescribed by a health care provider for a child with atomic dermatitis (eczema). The nurse reinforces instructions to the mother regarding how to apply the cream. Which instruction is appropriate? A) Avoid cleansing the area before applying the cream B) Apply the cream over the entire body C) Apply a thin layer of cream, and rub it into the area throughly D) Apply a thick layer of cream to affected areas only
D) Apply a THIN layer of cream, and rub it into the area throughly
A client arrives at the emergency room with a HR of 120, a RR of 48, and hemoptysis. The nurse should give priority to: A) Obtaining a history of the current illness B) Obtaining additional vital signs C) Checking arterial blood gases D) Applying oxygen via mask
D) Applying oxygen via mask
A 75 year-old patient is hospitalized with pneumonia. The nurse finds him on the floor with his oxygen mask off and his foley catheter pulled out. Which action should the nurse take initially? A) Place a pillow under his head. B) Examine the urinary meatus. C) Replace the oxygen mask immediately. D) Assess the client's current condition.
D) Assess the client's current condition.
A 70yr old female is on digoxin therapy. The nurse assesses the client is experiencing a toxic side effect. The symptom the nurse recognizes to be likely related to digoxin toxicity is: A) Tachycardia B) Muscle cramps C) Decreased BP D) Bradycardia
D) Bradycardia
The nurse is preparing to adminster medication through a nasogastric (NG) tube that is connected to suction. Which indicates the accurate procedure for medication administration? A) Change the suction setting to low intermittent suction for 30 minutes after medication administration. B) Aspirate the NG tube after medication administration to maintain patency. C) Position the client supine to assist with medication absorption. D) Clamp the NG tube for 30 minutes after medication administration.
D) Clamp the NG tube for 30 minutes after medication administration.
A dark-skinned patient has been admitted to the hospital in severe respiratory distress. What knowledge does the nurse use to assess for cyanosis in the patient? A) Cyanosis will blanch out with direct pressure to the soles of the feet in dark-skinned patients. B) Cyanosis in patients with dark skin can be seen only in the sclera. C) Cyanosis is not possible to assess in patients with dark skin. D) Cyanosis can be seen in the conjunctiva of the eye and mucous membranes of patients with dark skin.
D) Cyanosis can be seen in the conjunctiva of the eye and mucous membranes of patients with dark skin
A nurse is caring for a patient who has a diagnosis of dysphagia. What is the priority intervention to include in the plan of care for this patient? A) Facial exercises B) Allowing extra time for formation of words C) Referral to an occupational therapist for assessment D) Daily respiratory assessments
D) Daily respiratory assessments
A 67 year old who is receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia and leukopenia. The client has been losing weight due to anorexia and has limited mobility. The client received an infusion of platelets yesterday. The practical nurse assesses that the client has responded positively to the therapy based on which of the following assessments? A) Increase in WBC B) BP 120/66 C) Increased petechiae D) Decreased blood in urine
D) Decreased blood in urine
A 5-week-old infant is brought to the pediatrician's office with symptoms of irritability, weight loss, and projectile vomiting. Which assessment finding requires follow up? A) Green seedy stools B) Pale pink skin C) Heart rate of 136 D) Decreased skin turgor over chest wall
D) Decreased skin turgor over chest wall
A 21 year old college student must receive a 0.5ml IM injection. The nurse knows the most appropriate site would be: A) Ventrogluteal B) Vastus lateralis C) Dosogluteal D) Deltoid
D) Deltoid
A 24-year-old female is admitted to the unit at 0845 with a Glasgow Coma Scale (GCS) of 9,the nurse would: A) Prepare nursing history interview questions. B) Call the diet office and order her breakfast tray. C) Complete scheduled 0900 medication administration for other assigned patients before assessing this client. D) Ensure that oxygen and suction equipment are available at the bedside.
D) Ensure that oxygen and suction equipment are available at the bedside
A 23-year old comes to the family practice clinic stating she is 26 weeks pregnant. As part of her assessment, the nurse would anticipate that she describes: A) Dyspnea B) Difficulty urinating C) Mild vaginal bleeding D) Fetal movement
D) Fetal movement
Sulfonylureas have been prescribed for a client in the management of diabetes mellitustype 2. The nurse assesses for which of the following possible complications? A) Tinnitus B) Decreased insulin sensitivity C) Hyperglycaemia D) Hypoglycemia
D) Hypoglycemia
A 15-month-old continually turns his cup upside down and shakes milk from the spout. The mother is convinced that he does this on purpose and asks the nurse what she should do. The nurse's response should be guided by the knowledge that: A) Toddlers often misbehave to get the attention of adults B) Toddlers are able to use thought processes to experience events and reactions C) Negative actions that are not immediately punished will be repeated D) Manipulation of objects in their environment enables the toddler to learn about spatial relationships
D) Manipulation of objects in their environment enables the toddler to learn about spatial relationships
A client admitted with pneumonia and also with the diagnosis of major depression is tearful and refuses to eat dinner after a visit with a friend. What is the most therapeutic nursing action? A) Allow the client to skip the meal. B) Reinforce the importance of adequate nutrition. C) Provide the client with adequate quiet thinking time. D) Offer an opportunity to discuss the visit and why they are tearful.
D) Offer an opportunity to discuss the visit and why they are tearful
A mother is breastfeeding her newborn. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which suggestion to the client? A) Stop nursing during the period of nipple soreness to allow the nipples to heal. B) Nurse the newborn infant less frequently and substitute a bottle-feeding until the nipples become less sore. C) Avoid rotating breastfeeding positions so that the nipple will toughen. D) Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.
D) Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.
A 36-year-old woman has undergone a total hip replacement. The postoperative orders include enoxaparin (Lovenox) daily. The nurse is aware that the rationale for this treatment is to: A) Prevent constipation B) Provide better pain control C) Maintain normal body temperature D) Produce an anticoagulant effect
D) Produce an anticoagulant effect
A client with Crohn's disease is malnourished and thin with dependent edema in the ankles. Based on this assessment, what nutritional element may they be deficient in? A) Carbohydrate B) Fats C) Iron D) Protein
D) Protein
A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function? A) Allows bony healing to begin before surgery. B) Provides rigid immobilization of the fracture site. C) Lengthens the fractured leg to prevent severing of blood vessels. D) Provides comfort by reducing muscle spasms and provides fracture immoblization
D) Provides comfort by reducing muscle spasms and provides fracture immoblization.
A nurse gives a double dose of acetaminophen (Tylenol) to a client who only requires a single dose. What, if anything, must the nurse do? A) Nothing, because this is an over-the-counter medication B) Instruct the PSW to assess the client C) Withhold the client's next dose of acetaminophen (Tylenol) D) Report the error as soon as possible
D) Report the error as soon as possible
A 6-month-old is seen for a well baby examination. On evaluation of the infant's development status, which of the following does the nurse expect that the child at this age will be able to do? A) Pull self to a standing position. B) Assume a sitting position independently. C) Creep on all four extremities. D) Roll completely over.
D) Roll completely over
A client is admitted to the hospital with acute renal failure. Which assessment finding should be reported immediately? A) Potassium level of 6.5meq/L B) Weight gain of 500 gm in the last week. C) Ph of 7.48 D) Blood pressure of 148/88
A) Potassium level of 6.5 meq/L
A client, is receiving a blood transfusion. Which observation requires immediate action by the nurse? A) Heart rate increase from 78 to 90 B) Cool and pale extremities C) Complaints of headache and fatigue D) Urticaria and wheezing
D) Urticaria and wheezing
The client with severe chronic bronchitis tells you that eating is difficult because he is very short of breath. What is your best response? A) "Avoid eating when you are short of breath so that you can use your energy for breathing." B) "Have your wife feed you solid foods, particularly avoiding those that cause you to have gas." C) "Try using your bronchodilator inhaler about 30 minutes before you plan to have a meal." D) "When you find eating solid food too difficult, just drink milk and milkshakes for the protein and calories."
"Try using your bronchodilator inhaler about 30 minutes before you plan to have a meal."
A 28-year-old female is 6 hours postpartum. During the assessment, the nurse palpates a fundus that is three fingers above the umbilicus and to the left of the midline. What should the nurse do first? A) Ask her when she last voided B) Assess her vital signs C) Provide her with adequate fluid intake D) Assist her to breastfeed her infant
A) Ask her when she last voided
A nurse is caring for a hospitalized 2 yr. old. Which of the following is the most appropriate play activity for the toddler? A) Playing with wooden building blocks B) Organized group games C) Board games D) Watching an age appropriate video
A) Playing with wooden building blocks
A 36-year-old patient is admitted to the neurology floor after being involved in a motor vehicle accident (MVA). His head hit the windshield, and he is being admitted for observation. During the afternoon he begins to complain of a headache, has two episodes of vomiting, and is more difficult to arouse. Which actions are a priority for the nurse to implement immediately A) Assess his neurological status and notify the physician immediately. B) Place him in a supine position and notify the physician immediately. C) Make the client NPO in preparation for possible surgery. D) Provide for a quiet environment to promote rest.
A) Assess his neurological status and notify the physician immediately
A client is ordered two units of red blood cells. What priority assessment is required to assess for fluid volume overload? A) Breath sounds B) Urine output C) Vital signs D) Peripheral pulses
A) Breath sounds
A family member of a client reports to the nurse that the client is difficult to wake up and is confused. What should the nurse do first? A) Complete a physical assessment B) Notify the physician C) Review the client's previous vital signs D) Notify the charge nurse
A) Complete a physical assessment
A 6-year-old is hospitalized for asthma. Which of the following activities would be appropriate to help this child resolve the crisis of hospitalization? A) Crayons and a colouring book B) A 1000-piece puzzle to complete C) A soft football to throw around the room D) A CD player and soothing music CDs
A) Crayons and a colouring book
A 5-week-old infant is brought to the paediatrician's office with symptoms of irritability, weight loss, and projectile vomiting. Which assessment finding requires follow up? A) Decreased skin turgor over chest wall B) Heart rate of 136 C) Pale pink skin D) Green seedy stools
A) Decreased skin turgor over chest wall
A nurse is performing a peripheral vascular assessment on an immobile client. Which of the following findings would the nurse be most concerned about? A) Edema and redness of left lower leg B) Thick and brittle toe nails C) Brown discoloration over anterior lower legs. D) Strong dorsalis pedis pulse
A) Edema and redness of left lower leg
The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate? A) Interrupt the client and offer to take her for a walk. B) Allow the client to complete her exercise program. C) Interrupt the client and weigh her immediately. D) Tell the client that she is not allowed to exercise vigorously.
A) Interrupt the client and offer to take her for a walk.
A client has a surgical creation of a colostomy. What is the most effective nursing intervention to initially help the client accept the colostomy? A) Introduce equipment needed to care for the colostomy. B) Provide literature containing factual data about colostomies. C) Ask a member of a support group to come to speak with the client. D) Point out the number of important people who have had colostomies.
A) Introduce equipment needed to care for the colostomy
90yr male patient has a stage 2 decubitus ulcer on the coccyx. Which nursing measure is best to prevent further progression of the ulcer A) Repositioning the client every two hours B) Place vitamin A and D ointment to the ulcer site C) Administer antiinflamatory drugs as ordered by the physician D) Bathing daily with lanolin application to skin
A) Repositioning the client every two hours
A client has been given morphine every 2 hours overnight. The nurse assess the client at 0800 and finds a respiratory rate of 6. The nurse would anticipate a blood gas result of: A) Respiratory Acidosis B) Respiratory Alkalosis C) Metabolic acidosis D) Metabolic alkalosis
A) Respiratory Acidosis
A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child? A) Tachycardia B) Dyspnea C) Hypotension D) Flushing
A) Tachycardia
A 36-year-old woman has been admitted to the hospital for knee surgery. Which of the following information that was obtained by the nurse during the preoperative assessment should be reported to the surgeon before surgery is performed? A) Knowledge of the possibility of an early, unplanned pregnancy B) Lack of knowledge about postoperative pain control C) Concern that she will be physically limited in caring for her children for a period postoperatively D) History of a postoperative infection following a prior cholecystectomy
B) Knowledge of the possibility of an early, unplanned pregnancy
A 75-year-old male with stable COPD is admitted to the medical unit for weight loss. He has had a 20% weight loss over the last 2 months. Which of the following is the priority nursing diagnosis? A) Anxiety related to dyspnea B) Nutrition less than body requirements related to increased energy expenditure C) Ineffective airway clearance related to thick secretions D) Risk for dehydration related to increased work of breathing
B) Nutrition less than body requirements related to increased energy expenditure
A 1-year-old boy is hospitalized for a fractured femur. There is a PRN order for pain medication. What is the best way to assess the child for pain? A) Ask the child to point to where it hurts B) Observe the child's behaviour and non verbal signs C) Ask the parent who is present if the child appears to be in pain D) Have the child look at pictures of faces and select the one that best describes how he feels right now
B) Observe the child's behaviour and non verbal signs
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and client is visibly anxious. The nurse anticipates the client is experiencing which of the following conditions? A) Pulmonary edema B) Pulmonary embolism C) Myocardial infarction D) Pneumonia
B) Pulmonary embolism
A 67 year old who is receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia and leukopenia. Which statement made by the patient during the admission history is of most concern to the practical nurse? A) "My appetite has decreased since starting the chemotherapy". B) "I've noticed that I bruise more easily since the chemotherapy started". C) "I take two aspirin every morning because of my joint pain". D) "My bowel movements are soft and brown".
C) "I take two aspirin every morning because of my joint pain".
A client is ordered to have blood and urine cultures and then is started on intravenous antibiotics. What action should the nurse take with regard to the specimen collection and antibiotic administration? A) Commence the antibiotics as soon as the medication is received from the pharmacy department B) Ask the physician for the correct order for specimen collection and medication administration C) Withdraw blood for the culture, take the urine sample from the in-dwelling catheter, and then commence the medication D) Perform the blood culture, administer the antibiotics, and then collect the urine sample from the urinary collection bag
C) Withdraw blood for the culture, take the urine sample from the in-dwelling catheter, and then commence the medication
A client received 20 units of NPH-Insulin subcutaneously at 8:00am. The nurse should check the client for a potential hypoglycaemic reaction at what time? A) 10:00am B) 11:00am C) 11:00pm D) 5:00pm
D) 5:00pm
