practice questions for test 2

the mother of a 6 year old child arrives at a clinic because the child has been experiencing scratchy red, and swollen eyes. the nurse notes a discharge from the eyes and sends a culture to the lab for analysis. chlamydial conjunctivitis is diagnosed. on the basis of this diagnosis the nurse determines that which requires further investigation A. possible trauma B. possible sexual abuse C. presence of an allergy D. presence of a respiratory infection

B. possible sexual abuse

the nurse is reviewing the laboratory results for a child scheduled for tonsillectomy. the nurse determines that which lab value is most significant to review? A. creatinine levels B. prothrombin time C. sedimentation rate D. blood urea nitrogen level

B. prothrombin time

the nurse preparing to care for a child after a tonsillectomy. the nurse documents on the plan of care to place the child in which position? A.supine B. side lying C. high followers D. trendelenburgs

B. side lying or prone o facilitate drainage

after a tonsillectomy the nurses reviews the health care provider postoperative prescriptions. which prescription should the nurse question? A. monitor for bleeding B. suction every 2 hours C. give no milk or milk products D. give clear, cool liquids when awake and alert

B. suction every 2 hours suctioning is not performed unless there is an airway obstruction because of the risk of trauma to the surgical site

the clinic nurse is assessing a child who is scheduled to receive a live virus vaccine. What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. A.the child has symptoms of a cold B.the child had a previous anaphylactic reaction to the vaccine C.mother reports that the child is having intermittent episodes of diarrhea D.mother reports that the child has not had an appetite and has been fussy E.the child has a disorder that caused a severely deficient immune system F.mother reports that the child has recently been exposed to an infectious disease

B. the child had a previous anaphylactic reaction the vaccine E. the child has a disorder that caused a severely deficient immune system

the nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. when analyzing the results of the urinalysis, which should the nurse most likely expect to note? A. hematuria B.proteinuria C.bacteriuria D.glucosuria

C. bacteriuria the urethral opening is located on the dorsum side of the penis. this anatomical characteristic facilitate entry of bacteria in the urine

the nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. which if stated by the mother indicates a need for further teaching? A. i need to wash my hands frequently B. i need to clean the eye as prescribed C. it is okay to share towels and washcloths D. i need to give the drops as prescribed

C. it is okay to share towels and washcloths

the clinic nurse prepares to administer a measles, mumps, rubella (MMR) vaccine to a 5 year old child. the nurse should administer the vaccine by which best route and in which best site? A.subcutaneously in the gluteal muscle B.intramuscularly in the deltoid muscle C.subcutaneously in the outer aspect of the upper arm D.intramuscularly in the anterolateral aspect of the thigh

C. subcutaneously in the outer aspect of the upper arm

the nurse performing an admission assessment on a 2 year old child has been diagnosed with nephrotic syndrome notes that which common characteristic is associated with this syndrome? A, hypertension B. generalized edema C.increased urinary output D.frank, bright red blood in the urine

B. generalized edema

a nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. the nurse should recognize which of the following data as risk factors for this condition (select all that apply) A. surgical repair of an atrial septal defect at age 2 B. measles infection during childhood C. hypertension for 5 years D. weight gain of 10 lb in past year E. diastolic murmur present

A, C, E

a nurse in a clinic is caring for a client who has been on long-term NSAID therapy to treat myocarditis. which of the following lab findings should the nurse report to the provider? A. platelets 100,000 B. serum glucose 110 mg/dL C. serum creatinine 0.7 mg/dL D. amino alanine transferase

A

a nurse is assessing a client who has splinter hemorrhages in her nail beds and reports a fever. the nurse should identify these findings as manifestation of which of the following disorder? A. infective endocarditis B. pericarditis C. myocarditis D. rheumatic endocarditis

A

a nurse educator is reviewing expected finding in a client who has right sided valvular heart disease with a group of nurses. which of the following findings should the nurse include in the discussion? (select all that apply) A. dyspnea B. client report of fatigue C. bradycardia D. pleural friction rub E. peripheral edema

A, B, E

a nurse is completed admission assessment of a client who has suspected pulmonary edema. which of the following manifestation are expected findings? (select all that apply) A. tachypnea B. persistent cough C. increased urinary output D. thick, yellow sputum E. orthopnea

A, B, E

A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. which of the following foods should the nurse recommend for the client? (select all that apply) A. 1 slice of cheddar cheese B. 1 medium beef hot dog C. 3 oz atlantic salmon D. 3 oz roasted chicken breast E. 2 oz lean baked ham

A, C, D

antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanovstomy tubes. the nurse provides discharge instructions to the parents regarding the administration of the antibiotic. which statement, if made by the parents, indicates understanding of the instruction providing? A. administer the antibiotics until they are gone B. administer the antibiotics if the child has a fever C.adminsiter the antibiotics until the child feels better D. begin to taper the antibiotics after 3 days of a fun course

A. administer the antibiotics until they are gone

the nurse is caring for child after tonsillectomy. the nurse monitors the child, knowing that which finding indicates the child is bleeding? A. frequent swallowing B. a decreased pulse rate C. complaints of discomfort D.an elevation in blood pressure

A. frequent swallowing

the nurse is performing an assessment on a child admitted to the hospital with probable diagnosis of nephrotic syndrome. which assessment findings should the nurse expect to observe? Select all that apply A.pallor B.edema C.anorexia D.proteinuria E.weight loss F.decreased serum lipids

A. pallor B.edema C.anorexia D.proteinuria

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). which intervention should the nurse include in the plan of care? Select all that apply A. place the infant in a private room B.ensure that the infants head is in a flexed position C.wear a mask at all times when in contact with the infant D.place the infant in a tent that delivered warm humidified air E.position the infant on the side with the head lower than the chest F. ensure that the nurses caring for the infant with RSV do not care for other high-risk children

A. plan etc infant in a private room F. ensure that the nurses caring for the infant with RSV do not care for other high-risk children RSV is a highly communicable disorder and is not transmitted via the airborne route wear gloves and a gown NO MASK an infant should be isolated in a private room or in a room with another infant with RSV infection The infant should be position with head and chest at a 30-40 degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. cool humidified oxygen is delivered to release hypoxemia, dyspnea, and insensible water loss from tachypnea

a child has been diagnosed with acute otitis media of the right ear. which interventions should the nurse include the plan of care? select all that apply A. provide soft diet B. position the child on the left side C. administer an antihistamine twice daily D. irrigate the right ear with normal saline every 8 hours E. administer ibuprofen for fever every 4 hours as prescribed and as needed F. instruct the parents about the need to administer the prescribed antibiotics of rate full course of therapy

A. provide support diet E. administer ibuprofen for fever every 4 hours as prescribed and as needed F. instruct the parents about the need to administer the prescribed antibiotics of rate full course of therapy

a nurse is teaching a client who has a new prescription of clopidogrel. which of the following instructions should the nurse include in the teaching (select all that apply) A. avoid the consuming grapefruit while taking this medication B. monitor for the presence of black, tarry stools C. use an electric razor when shaving D. schedule a weekly PT test E. limit food sources containing vitamin K while taking this medication

AB

a nurse is planning postoperative care for a client following a surgical placement of a synthetic graft to repair an aneurysm. which of the following interventions should the nurse include in the plan of care? (select all that apply) A. asses pedal pulses B. monitor for an increase in pain below the graft site C. maintain the client in high fowlers position D. administer prescribed anti platelet agents E. report hourly urine output of 60 mL

ABD

a nurse caring for a 72 year old client who is to undergo a percutaneous balloon valvuloplasty. the clients daughter asks the nurse to explain the expected outcome of this procedure. which of the following responses should the nurse give? A. this will improve blood flow in your mothers coronary arteries B. this will permit your mother to resume her activities of daily living C. this will prolong your mother life D. this will reverse the effects to the damaged area

B

a nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh-high compression stockings. which of the following actions should the nurse take? A. massage both legs firmly with lotion prior to applying the stockings B. apply the stockings in the morning upon awakening and before getting out of bed C. roll the stockings down to the knee to relieve discomfort on the legs D. remove the stockings while out of bed for 1 hours, four times a day to allow the legs rest

B

a nurse is caring for a client who has heart failure and reports increased SOB. The nurse increases the clients oxygen per protocol. Which of the following actions should the nurse take first? A. obtain the clients weight B. assist the client into a high fowlers position C. auscultate lung sounds D. check oxygen saturation

B

a nurse is caring for four clients. which of the following clients should the nurse identify as being at risk of acquiring rheumatic endocarditis A. older adult who has chronic obstructive pulmonary disease B. child who has streptococcal pharyngitis C. middle age adult who has lupus erythematous D. young adult who recently received a body tattoo

B

a nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. which of the following statements by the client indicates understanding of the teaching? A. i will be glad to get back to my exercise routine right away B. i will have my prothrombin time checked on a regular basis C. i will talk to my dentist about no longer needing antibiotics before dental exams D. i will continue to limit my intake of foods containing potassium

B

a nurse is completing discharge teaching with a client who has heart failure and is encouraged to increase potassium in his diet. which of the following food selections should the nurse include as having the highest source of potassium? A. 1 medium apple B. 1 medium baked potato C. 1 slice toast with 1 tbsp peanut butter D. 1 large scrambled egg

B

A child with rubeola(measles) is being admitted to the hospital in preparing for the admission of the child, the nurse should plan to place the child on which precautions? A.enteric B.airborne C.protective D.neutropenic

B. airborne

the nurse is caring for an infant with a diagnosis of bladder exstrophy. to protect the exposed bladder tissue, the nurse should plan which intervention? A. cover the bladder with petroleum jelly gauze B. cover the bladder with non-adherent plastic wrap C.apply a sterile distilled water dressing over the bladder mucosa D.keep the bladder tissue dry by covering it with dry sterile gauze

B. cover the bladder with non-adherent plastic wrap

a 10 year old child with asthma is treated for acute exacerbation in the emergency department. the nurse caring for the child should monitor for which sign knowing that it indicates a worsening of the condition? A. warm, dry skin B. decreased wheezing C. pulse rate of 90 beats/minute D. respiration of 18 breaths/minute

B. decreased wheezing

the emergency department nurse is caring for a child diagnosed with epiglottis. in assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction A.the child exhibits nasal flaring any bradycardia B. the child is leaning forward, with he chin thrust out C.the child has a low grade fever and complains of a sore throat D. the child is leaning backward, supporting himself or herself with the hands and arms

B. the child is leaning forward with the chin thrust out

After a tonsillectomy a child begins to vomit bright red blood. the nurse should take which initial action? A. maintain NPO status B. turn the child to the side C. administer the prescribed antiemetic D. notify the health care provider

B. turn the child to the side

the nurse is caring for an infant with bronchiolitis RSV . on the basis of this finding which is the most appropriate nursing action? A. initiate strict enteric precautions B.move the infant to a room with another child with RSV C.leave the infant in the present room because RSV is not contagious D.inform the staff that they must wear a mask, gloves, and gown when caring for the child.

B.move the infant to a room with another child with RSV

a nurse in the emergency department is admitting a client who has a possible dissecting abdominal aortic aneurysm. which of the following actions is the priority for the nurse to take? A. administer pain meds as prescribed B. provide a warm environment C. administer IV fluids as prescribed D. initiate a 12-lead ECG

C

a nurse is admitting a client who's suspected occlusion of a graft of the abdominal aorta. which of the following manifestations should the nurse expect? A. increase in urine output B. bounding pedal pulse C. increase in abdominal girth D> redness of the lower extremities

C

a nurse is caring for a client who has deep vein thrombosis and has been taking unfractionated heparin for 1 week. two days ago, the provider also prescribed warfarin. the client asks the nurse about receiving both heparin and warfarin a the same time. which of the following statements housed the nurse give? A. i will remind your provider that you are already receiving heparin B. your lab findings indicated that two anticoagulants were needed C. it takes 3 to 4 days before the therapeutic effects of warfarin are achieved and then the heparin can be discontinued D. only one of these meds is being given to treat your DVT

C

a nurse is completing the admission physical assessment of client who has a history of mitral valve insufficiency. which of the following findings should the nurse expect? A. S4 heart sound B. petechiae C.crackles in the lung bases D. splenomegaly

C

a child is scheduled to receive inactivated polio vaccine and the nurse preparing to administer the vaccine reviews the childs records. the nurse questions the administration of IPV if which is documented in the childs record? A.recent recovery from a cold B. a history of frequent respiratory infections C.a history of anaphylactic reaction to neomycin D. a local reaction at the site of injection of a previous IPV

C. a history of an anaphylactic reaction to neomycin

the mother of a hospitalized 2 year old child with viral larngotracheobronchitis asks the nurse why the health care provider did not prescribe antibiotics. which response should the nurse make? A. the child mat be allergic to antibiotics B. the child is to young to receive antibiotics C. antibiotics are not indicated unless a bacterial infection is present D. the child still has the maternal antibodies from birth and does not need anitbiotics

C. antibiotics are not indicated unless a bacterial infection is present

a nurse is admitting a client who has suspected rheumatic endocarditis. the nurse should anticipate a prescription from the provider for which of the following lab tests to assist in confirmation of this diagnosis? A. arterial blood gases B. serum albumin C. liver enzymes D. throat culture

D

a nurse is assessing a client who has chronic peripheral arterial disease (PAD). which of the following findings should the nurse expect? A. edema around the ankles and feet B. ulceration around the medial malleoli C. scaling eczema of the lower legs with stasis dermatitis D. pallor on elevation of the limbs, and rumor when the limbs are dependent

D

a nurse is caring for a client who has pericarditis. which of the following findings should the nurse expect? A. petechiae B. murmur C. rash D. friction rub

D

a nurse is teaching a client who has a new diagnosis of an aneurysm. the client asks the nurse to explain what causes an aneurysm to rupture. which of the following statement should the nurse give? A. this happens when the wall of an artery becomes thin and flexible B. this happens when there is turbulence in blood flow in the artery C. it is due to abdominal enlargement D. it is due to hypertension

D

a nurse is teaching a client who has been a new diagnosis of severe peripheral arterial disease. which of the following instructions should the nurse include? A. wear tightly fitted insulated socks with shoes when going outside B. elevate both legs above the heart when resting C. apply a heating pad to both legs for comfort D. place both legs in dependent position while sleeping

D

a child us receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of severe allergy to which substance? A. eggs B. penicillin C.sulfonamides D.a previous dose of hepatitis B vaccine or component

D. a previous dose of hepatitis B vaccine or component

an infant receives a diphtheria, tetanus and DTaP immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. which intervention should the nurse suggest to the parent? A.monitor the infant for a fever B.bring the infant back to the clinic C.apply a hot pack to the injection site D.apply a cold pack to the injection site

D. apply a cold pack to the injection site

the nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? A. caution should be used when straddling the infant on the hip B. vital signs should be take daily to check for bladder infection C.catheterization will be necessary when the infant does not void D. circumcision has been delayed to save tissue for surgical repair

D. circumcision has been delayed to save tissue for surgical repair........the straddling of the hip would be post surgery advice

the mother of an 8 year old child being treated for right lower lobe pneumonia at home calls the clinic nurse. the mother tells the nurse that the child complains of discomfort on the right side and the ibuprofen is not effective. Which instruction should the nurse provide for the mother? A. increase the dose of ibuprofen B. increase the frequency of ibuprofen C. encourage the child to lie on the left side D. encourage the child to lie on the right side

D. encourage the child to lie on the right side

a child with laryngotracheobronchitis is placed in a cool mist tent. the mother becomes concerned because the child is frightened, consistently crying, and trying to climb out of the tent. what is the most appropriate nursing action? A.tell the mother that the child must stay in the tent B.place a toy in the tent to make the child feel more comfortable C. call the health care provider and obtain a prescription for a mild sedative D.let the mother hold the child and direct the cool mist over the childs face

D. let the mother hold the child and direct the cool mist over the child face

the clinic nurse s providing instructions to a print of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent? A. the immunization schedule will need to be altered B. the child should not receive any hepatitis vaccines C. the child will receive all the immunizations except for the polio series D. the child will receive the recommended basic series of immunization along with a yearly influenza vaccination

D. the child will receive the recommended basic series of immunizations along with a yearly influenza vaccine

the nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. which statement by a parent indicates a need or further instruction? A. we need to encourage out child to drink fluids B. coughing spells amy be triggered by dust or smoke C.vomiting may occur when our child has coughing episodes D.we need to maintain droplet precautions and a quiet environment for at least 2 weeks

D. we need to maintain droplet precautions and a quiet environment for at least 2 weeks this is because the convalescent stage is the last stage of the whooping cough and the communicable period occurs primarily during the catarrhal stage which is the first stage when respiratory precautions should be taken