NURCO
A female patient undergoes a total abdominal hysterectomy. When assessing the patient 10hrs later, the nurse identifies which finding as an early sign of shock. A. Restlessness B. Pale, warm, dry skin C. Heart rate of 110 bpm D. Urine output of 30mL/hr
A. Restlessness
Which of the following organisms is the most common cause of urinary tract infection (UTI) in children? A. Escherichia coli B. Staphylococcus C. Klebsiella D. Pseudomonas
A. Escherichia coli
Nurse Kim is teaching a group of parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature? A. Eustachian Tube B. Nasopharynx C. Tympanic Membrane D. External ear canal
A. Eustachian Tube
At what stage of labor and delivery does a primigravida differs mainly from a multigravida? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
A. Stage 1
The exchange of gases takes place in which of the following organs? A. Kidney B. Lungs C. Liver D. Heart
B. Lungs
The nurse at the high school works with the trainers to develop early identification of injuries. The nurse teaches the trainers that adolescent soccer players are at increased risk for which abnormality? A. Varus knee deformities B. Valgus kneed deformities C. Varus ankle deformities D. Valgus ankle deformities
A. Varus knee deformities
Which are the most important nursing actions when speaking with an older adult who is hearing impaired? Select all that apply. I. Limit background noise II. Raise the pitch of your voice III. Stand directly in front of the patient when speaking IV. Raise the volume of your voice while speaking directly toward the patient's good ear A. 1 and 2 B. 1, 4 and 5 C. 1 and 4 D. 4 and 5
C. 1 and 4
A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: A. 1 minute B. 5 seconds C. 10 seconds D. 30 seconds
C. 10 seconds
Which patient below is at MOST risk for developing ARDS and has the worst prognosis? A 52-year-old male patient with a pneumothorax B. A 48-year-old male being treated for diabetic ketoacidosis C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection D. A 30-year-old female with cystic fibrosis
C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection
When attempting to administer a 10:00 PM sleeping medication, the nurse assesses that the patient appears to be asleep. What should the nurse do? A. Withhold the drug B. Notify the physician C. Awaken the patient to administer the drug D. Administer it later if the patient awakens during the night
C. Awaken the patient to administer the drug
Baby blue eyes is a neonate who has a very-low-birthweight. Nurse Josie carefully monitors inspiratory pressure and oxygen (O2) concentration to prevent which of the following? A. Meconium aspiration syndrome B. Respiratory syncytial virus (RSV) C. Bronchopulmonary dysplasia (BPD) D. Respiratory distress syndrome (RDS)
C. Bronchopulmonary dysplasia (BPD)
The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient's first priority concerning self-injection in this situation is to: A. Assess the injection site B. Select the appropriate injection site C. Check the syringe to verify that the nurse has removed the prescribed insulin dose D. Clean the injection site in a circular manner with an alcohol sponge
C. Check the syringe to verify that the nurse has removed the prescribed insulin dose
At what stage of labor is the mother advised to bear down? A. Anytime the mother feels like bearing down B. In between uterine contractions to prevent uterine rupture C. During a uterine contraction D. When the mother feels pressure in the rectal area.
C. During a uterine contraction
The nurse is assessing the effectiveness of the interventions they implemented on the patient. The patient is doing what part of the nursing process: A. Assessment B. Diagnosis C. Implementation D. Evaluation
D. Evaluation
Which of the following is the best method for performing a physical examination on a toddler? A. From head to toe B. Distally to proximally C. From abdomen to toes, then to head D. From least to most intrusive
D. From least to most intrusive
A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? A. Nausea or vomiting B. Abdominal pain or diarrhea C. Hallucinations or tinnitus D. Lightheadedness or paresthesia
D. Lightheadedness or paresthesia
Which of the following will probably result in a break in sterile technique for respiratory isolation? A. Opening the patient's window to the outside environment B. Turning on the patient's room ventilator C. Failing to wear gloves when administering a bed bath D. Opening the door of the patient's room leading into the hospital corridor
D. Opening the door of the patient's room leading into the hospital corridor
The nurse is assessing the respiratory status of a client who suffered a fractured rib. The nurse should expect to note which finding? A. Slow deep respirations B. Rapid deep respirations C. Paradoxical respirations D. Pain, especially with inspiration
D. Pain, especially with inspiration
When the shiny portion of the placenta comes out first is called which of the following mechanisms? A. Duncan B. Rigens C. Marmets D. Schultze
D. Schultze
The nurse is completing a thorough assessment of the spine. The nurse is concerned about the spinal curve in the young child and documents the exaggerated lumbar curve. Which condition was likely documented? A. Scoliosis B. Lordosis C. Kyphosis D. Kyphoscoliosis
B. Lordosis
In a female client with burns on the legs, which nursing intervention helps prevent contractures? A. Apply knee splints B. Elevating the foot of the bed C. Hyperextending the client's palms D. Performing shoulder range-of-motion exercises
A. Apply knee splints
.The HCP is adducting the newborn's hip while pushing the thigh forward to detect developmental dysplasia of the hip (DDH). The nurse should identify this screening test as which maneuver? A. Barlow maneuver B. Pavlik maneuver C. Gowers maneuver
A. Barlow maneuver
A 1-year-old and 2-months-old child weighing 26 Ib (11.8kg) is admitted for traction to treat congenital hip dislocation. When preparing the patient's room, the nurse anticipates using which traction system? A. Bryant's traction B. Buck's extension traction C. Overhead suspension traction D. 90-90 traction
A. Bryant's traction
Which pulse should the nurse palpate during rapid assessment of an unconscious adult? A. Carotid B. Brachial C. Femoral D. Radial
A. Carotid
Population-focused nursing practice requires which of the following processes? A. Community Diagnosis B. Nursing process C. Community organizing D. Epidemiologic process
A. Community Diagnosis
The nurse is to administer an eye irrigation to a patient's right eye. What should the user do? A. Direct the flow of solution from the inner to the cuter cantus B. Irrigate with an Asepto syringe two inches from the eye C. Don sterile gloves before beginning the procedure D. Position the patient in a right lateral position
A. Direct the flow of solution from the inner to thecuter cantus
The nurse is admitting a patient to the unit who was transferred from the Emergency Department. When facilitating communication, the nurse should: A. Ensure that the patient has an effective way to communicate with health team members B. Use interviewing techniques to control the direction of the patients communication C. Minimize energy spent by the patient on negative feelings and concerns D. Refocus on the positive
A. Ensure that the patient has an effective way to communicate with health team members
In evaluating a client's fluid intake and output record. Fluid intake and urine output should relate in which way? A. Fluid intake should be approximately equal to the urine output B. Fluid intake should be half the urine output C. Fluid intake should be inversely proportional to the urine output D. Fluid should double the urine output
A. Fluid intake should be approximately equal to the urine output
When planning care for a male client with burns on the upper torso, which nursing diagnosis should take the highest priority? A. Ineffective airway clearance related to edema of the respiratory passages B. Impaired physical mobility related to the disease process C. Disturbed sleep pattern related to facility environment D. Risk for infection related to breaks in the skin
A. Ineffective airway clearance related to edema of the respiratory passages
The home care nurse is helping a patient with short-term memory loss on how to remember to take multiple drugs throughout the day. The nurse should: A. Instruct the patient to put medications in a weekly organizational pill container B. Design a chart of the medications the patient takes each day during the week C. Ask a family member to call the patient when medications are to be taken D. Suggest that the patient wear a watch with an alarm
A. Instruct the patient to put medications in a weekly organizational pill container
During an assessment of a 45-year-old patient with asthma, the nurse noted wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change? A. Laryngospasm B. Pulmonary edema C. Narrowing of the airway D. Over distension of the alveoli
A. Laryngospasm
The chamber of the heart that receives oxygenated blood from the lungs is the A. Left atrium B. Right atrium C. Left ventricle D. Right ventricle
A. Left atrium
An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of: A. Metabolic acidosis B. Respiratory acidosis C. Overcompensated respiratory acidosis D. Combined respiratory and metabolic acidosis
A. Metabolic acidosis
While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should: A. Notify the doctor B. Look for other signs of abuse C. Recognize this as a normal finding D. Ask about a family history of Tay-Sachs disease
A. Notify the doctor
When delivering the baby's head, the nurse supports the mother's perineum to prevent a tear. What is this technique called? A. Ritgen's technique B. Smith's technique C. Duncan's technique D. Braxton-Hick's
A. Ritgen's technique
Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? A. "I need to drink ½ to 2 quarters of liquid each day" B. "I need to take a laxative such as milk of magnesia or if I don't have a BM every day." C. "If my bowel pattern changes on its own, I should call you." D. "Eating my meals at regular times is likely to result in regular BM."
B. "I need to take a laxative such as milk of magnesia or if I don't have a BM every day."
The nurse is teaching the adolescent who requires surgical treatment for scoliosis. Which is the nurse's best explanation regarding the goal of the surgery? A. "The surgery will allow you to grow to be taller" B. "The surgery will decrease the recurrence of pain" C. "The surgery will prevent problems with breathing D. "The surgery will allow your clothes to fit you better."
B. "The surgery will decrease the recurrence of pain"
A male client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction would best prevent skin damage? A. "Minimize sun exposure from 1 to 4 pm when the sun is strongest" B. "Use sunscreen with a sun protection factor of 6 or higher" C. "Apply sunscreen even on overcast days" D. "When at the beach, sit in the shade to prevent sunburn"
C. "Apply sunscreen even on overcast days"
The parents of the child with Duchenne muscular dystrophy just learned that children with the disease have limited life expectancy. Which explanation by the nurse is best when the parents ask how their child will be treated knowing that the life expectancy is limited? A. "Due to your child's cognitive impairment, your child will be unaware of a shortened life" B. "We will focus on maximizing your child's abilities and promoting your child's comfort" C. "There is not enough known about this disease to know what will happen in the future" D. "Nothing is likely to happen for a long time ago; we'll deal with it when the time comes."
B. "We will focus on maximizing your child's abilities and promoting your child's comfort"
The unit secretary tells the nurse that the physician has just ordered a low-calorie diet for a patient who is overweight. Place these nursing interventions in the order in which they should be implemented. I. Verify the dietary order II. Determine food preferences III. Teach specifics about a low calorie diet IV. Review a meal plan designed by the patient V. Assess the patient's motivation to follow the diet A. 1, 5, 3, 2, 4 B. 1, 5, 2, 3, 4 C. 5, 1, 2, 4, 3 D. 5, 1, 2, 3, 4
B. 1, 5, 2, 3, 4
A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: A. 1 L/min B. 2 L/min C. 6 L/min D. 10 L/min
B. 2 L/min
Vaccines are what kind of immunity? A. Passive immunity B. Active immunity C. Compromised immunity D. Intact immunity
B. Active immunity
During the exudate phase of acute respiratory distress syndrome (ARDS), the patient's lung cells that produce surfactant have become damaged. As the nurse you know this will lead to? A. Bronchoconstriction B. Atelectasis C. Upper airway blockage D. Pulmonary edema
B. Atelectasis
Which of the priorities would be the priority nursing diagnosis for a client with an ectopic pregnancy? A. Risk for infection B. Pain C. Knowledge deficit D. Anticipatory grieving
B. Pain
The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: A. Call the physician B. Place the tube in a bottle of sterile water C. Immediately replace the chest tube system D. Place the sterile dressing over the disconnection site.
B. Place the tube in a bottle of sterile water
To ensure homogenization when diluting powdered medication in a vial, the nurse should: A. Shake the vial vigorously B. Role the vial gently between the palms C. Invert the vial and let it stand for 1min D. Do nothing after adding the solution to the vial
B. Role the vial gently between the palms
The nurse is assessing a burn patient and is trying to determine the size of the patient's burns. The nurse is correct when they use the following tool: A. Glasgow Coma Scale B. Rule of Nines C. Body Mass Index D. Numerical Rating Scale
B. Rule of Nines
When teaching a group of adolescents about male hormone production, which of the following would the nurse include as being produced by the Leydig cells? A. Follicle-stimulating hormone B. Testosterone C. Luteinizing hormone D. Gonadotropin-releasing hormone
B. Testosterone
The child with hip pain for several months was diagnosed with Legg-Calve-Perthes disease. What should the nurse emphasize when preparing to teach the child and family about the treatment? A. Once treatment starts, it will likely continue for about 5mos B. The treatment goal is a pain-free joint with full ROM C. Activities requiring hip adduction are not encouraged for joint placement D. Most of the treatments will be completed while the child is hospitalized
B. The treatment goal is a pain-free joint with full ROM
The nurse is teaching a patient recently diagnosed with diabetes mellitus the step-by-step procedure of administering an insulin injection. However, after two sessions, the patient is still reluctant to self-administer the insulin. The nurse should: A. Have the patient administer the injection to an orange B. Keep reinforcing the principles that have been presented C. Give the patient an opportunity to explore concerns about the injection D. Determine if a member of the family is willing to administer the insulin
C. Give the patient an opportunity to explore concerns about the injection
The nurse is preparing to care for the hospitalized child with autism. Which intervention should the nurse implement? A. Hold and stroke the child while doing the assessment B. Play the radio or turn in the tv for distraction C. Have the parents bring the child's favorite toy from home D. Provide plenty of age appropriate foods on the meal tray
C. Have the parents bring the child's favorite toy from home
The nurse is planning teaching about bacterial meningitis for a group of parents. Which statement should the nurse include when teaching the parents? A. Symptoms of meningitis often develop over time, making it easier to diagnose than other infections B. Having a seizure associated with a high temperature usually indicates a problem other than meningitis C. High risk children 2-10 years and other children 11years and older should receive the meningococcal conjugate vaccine (MCV4) D. IV antibiotics are administered to family members who may have been in close contact with the child
C. High risk children 2-10 years and other children 11years and older should receive the meningococcal conjugate vaccine (MCV4)
What hormones are being secreted by islets of Langerhans? A. Progesterone B. Testosterone C. Insulin D. Hemoglobin
C. Insulin
The teen is brought to an ED with a possible SCI. To minimize the extent of the damage to the spinal cord, which classification of medication should the nurse expect to administer? A. Antibiotic B. Analgesic C. Steroid medication D. Antihypertensive medication
C. Steroid medication
To ensure that the baby will breathe as soon as the head is delivered, the nurse's priority action is to? A. Slap the baby's buttocks to make the baby cry B. Clamp the cord about 6 inches from the base .C. Suctions the nose and mouth to remove mucous secretion. D. Check the APGAR score of the baby
C. Suctions the nose and mouth to remove mucous secretion.
The nurse is planning to develop teaching material for new mothers. The nurse should plan to include information about which common practice can increase the risk of developmental dysplasia of the hip (DDH)? A. Carrying a child in a backpack B. Carrying a child in a front-pack C. Swaddling of a child D. Extended time in a car seat
C. Swaddling of a child
When removing a contaminated gown, the nurse should be careful that the first thing she touches is the: A. Inside of the gown B. Cuffs of the gown C. Waist tie and neck tie at the back of the gown D. Waist tie in front of the gown
C. Waist tie and neck tie at the back of the gown
A patient has been hospitalized in the ICU for a near drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS? A. Infiltrates only on the upper lobes B. Enlargement of the heart with bilateral lower lobe infiltrates C. White-out infiltrates bilaterally D. Normal chest x-ray
C. White-out infiltrates bilaterally
An injury that involves breakage of the skin. A. Bruise B. Petechiae C. Wound D. Inflammation
C. Wound
A nurse is providing instructions to a client who is receiving warfarin sodium (coumadin). Which statement made by the client indicates the need for further instructions? A. "I will use a hair-removing cream on my legs" B. "I will avoid drinking alcohol" C. "I will observe the color of my urine and stool" D. "I will take Ecotrin (enteric-coated aspirin) for my headaches"
D. "I will take Ecotrin (enteric-coated aspirin) for my headaches"
A female client is brought to the emergency department with second and third-degree burns on the left arm, left anterior leg, and anterior trunk. Using the rules of nines, what is the total body surface area that has been burned? A. 18% B. 27% C. 30% D. 36%
D. 36%
A patient is experiencing respiratory failure due to pulmonary edema. The physician suspects ARDS but wants to rule out a cardiac cause. A pulmonary artery wedge pressure is obtained. As the nurse you know that what measurement reading obtained indicates that this type of respiratory failure is NOT cardiac related? A. > 25 mmHg \B. < 10 mmHg C. > 50 mmHg D. < 18 mmHg
D. < 18 mmHg
The nurse is completing a health history and physical assessment for the 4y.o. who has a spastic-type CP. Which statements made by a parent indicate the appropriate care is being provided? Select all that apply: a. "I perform ROM exercises q4h to help prevent contractures" b. "I give my child a therapeutic massage after the stretching exercises to help manage pain." c. "I minimize the calories I provide with meals because my child is more prone to obesity." d. "I have my child wear a helmet during the day because of chronic tonic-clonic seizures" e. "Using utensils with large, padded handles makes it easier for my child to feed himself" A. a, e B. a, b, e C. c, d, e D. All except c
D. All except c
To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test? A. Red blood cell count B. Sputum culture C. Total hemoglobin D. Arterial blood gas (ABG) analysis
D. Arterial blood gas (ABG) analysis
The nurse is admitting a hospitalized child newly diagnosed with Reye's syndrome. Which action by the nurse would be most appropriate? A. Determining if the child had a bacterial infection recently B. Placing the child in a private room with droplet precautions C. Taking the child to the unit's play area to interact with others D. Assessing for signs of bleeding and for prolonged bleeding time
D. Assessing for signs of bleeding and for prolonged bleeding time
Which of the following would Nurse Brenda anticipate to evaluate if Bingo has been diagnosed with celiac disease and has an upper respiratory tract infection-related celiac crisis? A. Weight gain B. Respiratory distress C. Lethargy D. Watery diarrhea
D. Watery diarrhea
The physician orders a medicated powder to be applied to a patient's skin. When applying a medicated powder, it is essential that the nurse: A. Applies a thin layer in the direction of hair growth B. Protect the patient's face with a towel C. Dresses the area with dry sterile gauze D. Ensures that the skin surface is dry
D. Ensures that the skin surface is dry
During a physical exam on the 18-mos old, the nurse observed genu varum. What should the nurse do? A. Document the findings to the HCP B. Report this finding to the HCP C. Teach the parents about rickets D. Prepare the parent about using braces
A. Document the findings to the HCP
Which of the following is a function of epidemiology? A. Identifying the disease condition based on manifestations presented by a client B. Determining factors that contributed to the occurrence of pneumonia in a 3y.o. C. Determining the efficacy of the antibiotic used in the treatment of the 3y.o. client with pneumonia D. Evaluating the effectiveness of the implementation of the Integrated Management of Childhood Illness
D. Evaluating the effectiveness of the implementation of the Integrated Management of Childhood Illness
When teaching a female patient how take a sublingual tablet, the nurse should instruct the patient to place the table on the: A. Top of the tongue B . Roof of the mouth C. Floor of the mouth D. Inside of the cheek
D. Inside of the cheek
A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: A. Promote oxygen intake B. Strengthen the diaphragm C. Strengthen the intercostal muscles D. Promote carbon dioxide elimination
D. Promote carbon dioxide elimination
Nurse Lukring is caring for a patient with pneumonia. The patient is complaining of shortness of breath. The nurse knows that helping the patient to this position will help alleviate the patient's complaint: A. Sim's B. Lithotomy C. Prone D. Semi-fowler's
D. Semi-fowler's
In the integrated management of childhood illness, severe conditions generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital? A. Severe pneumonia B. Mastoiditis C. Severe febrile disease D. Severe dehydration
D. Severe dehydration
How does the nurse appropriately administer Mycostatin suspension in an infant? A. Have the infant drink water, and then administer Mycostatin in a syringe B. Place myostatin on the nipple of the feeding bottle and have the infant suck it C. Mix Mycostatin with the formula D. Swab Mycostatin on the affected areas
D. Swab Mycostatin on the affected areas
The nurse is educating the family whose child is newly diagnosed with scoliosis. What is the goal of therapy as explained by the nurse? A. Limit or stop the progression of the curvature of the spine B. Prepare the child for surgical correction at a later date C. Minimize the complication of prolonged immobilization D. Develop a pain management plan to minimize complications
A. Limit or stop the progression of the curvature of the spine
A mother has recently been informed that her child has Down's syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down's syndrome? A. Simian crease B. Brachycephaly C. Oily skin D. Hypotonicity
C. Oily skin
A client with a chest injury, has suffered a flail chest, the nurse assesses the client for which most distinctive signs of a flail chest. A. Cyanosis B. Hypotension C. Paradoxical chest movement D. Dyspnea, especially on exhalation
C. Paradoxical chest movement
After having an IV line in place for 72hours, a patient complains of tenderness, burning, and swelling. Assessment of the IV site reveals that it is warm and erythematous. This usually indicates: A. Infection B. Infiltration C. Phlebitis D. Bleeding
C. Phlebitis
You're providing care to a patient who was just transferred to your unit for the treatment of ARDS. The patient is in the exudate phase. The patient is ordered to have arterial blood gasses. Which results are expected during this early phase of acute respiratory distress syndrome that correlates with this diagnosis? A. PaO2 40, pH 7.59, HCO3 23 B. PaO2 85, pH 7.42, HCO3 26 C. PaO2 50, pH 7.20, HCO3 29 D. PaO2 55, pH 7.26, HCO3 19
A. PaO2 40, pH 7.59, HCO3 23
The child with autism has been admitted to a four-bed ward on a pediatric unit. What should the nurse admitting the child do about the room assignment? A. Request that the child be transferred to a private room B. Request that the child be transferred to a double room C. Admit the child to the room that has been preassigned D. Request that the child be assigned to an isolation room
A. Request that the child be transferred to a private room
A patient tells the nurse about experiencing problems with sleep and requests a sleeping medication. Which concept associated with drug therapy and quality of sleep is important for the nurse to understand when planning nursing care for this patient? A. Sedatives are not well tolerated by older adults B. Anti-anxiety drugs are the least helpful to support sleep C. Effectiveness of hypnotics increases with prolonged use D. Melatonin is the drug of choice for long term use in sleep disorders
A. Sedatives are not well tolerated by older adults
The nurse is assessing the vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment? A. Sitting upright B. Lying flat on the back with knees flexed C. Lying flat on the back with arms and legs fully extended D. Side-lying with the knees flexed
A. Sitting upright
During a pelvic exam, the nurse notes a purple-blue tinge of the cervix. The nurse documents this as which of the following? A. Braxton-Hicks sign B. Chadwick's sign C. Goodell's sign D. McDonald's sign
B. Chadwick's sign
The school-age child has an Ilizarov external fixator applied to a lower extremity for bone lengthening. Which intervention should the nurse implement when caring for the child? A. Loosening the bolts and lengthening the rods on the fixator every other day B. Cleaning the external fixator pin sites with sterile saline twice daily C. Discouraging the child from bearing any weight on the involved extremity D. Removing sections of the fixator apparatus when the child is positioned in bed
B. Cleaning the external fixator pin sites with sterile saline twice daily
A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the physician's office. The nurse would plan on having which of the following medications readily available for use? A. Diltiazem (Cardizem) B. Digoxin (Lanoxin) C. Propranolol (Inderal) D. Metoprolol (Lopressor)
B. Digoxin (Lanoxin)
An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of pneumothorax in this client? A. A low respiratory B. Diminished breathe sounds C. The presence of a barrel chest D. A sucking sound at the site of injury
B. Diminished breathe sounds
The correct method for determining the vastus lateralis site for IM injection is to: A. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm B. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh C. Palpate a 1st circular area anterior to the umbilicus D. Locate the upper aspect of the upper outer quadrant of the buttock about 5-8cm below the iliac crest
B. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh
Which instruction should Nurse Tom give to a male client who is having external radiation therapy? A. Protect the irritated skin from sunlight B. Eat 3-4hourse before treatment C. Wash the skin over regularly D. Apply lotion of oil to the radiated area when it is red or sore
B. Eat 3-4hourse before treatment
Effective skin disinfection before a surgical procedure includes which of the following methods? A. Having the patient take a tub bath on the morning of surgery B. Having the patient shower with an antiseptic soap on the evening before and after the morning of surgery C. Applying a topical antiseptic to the skin on the evening before surgery D. Shaving the site on the day before surgery
B. Having the patient shower with an antiseptic soap on the evening before and after the morning of surgery
Nurse Karen is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use? A. Prolonged half-life B. Poor absorption C. Potential for drug dependence D. Potential for hepatotoxicity
C. Potential for drug dependence
After teaching the parents of the preschooler who has undergone T and A (Tonsillectomy and adenoidectomy) about appropriate foods to give the child after discharge, which of the following, is stated by the parents as appropriate foods, indicates successful teaching? A. Meatloaf and uncooked carrots B. Pork and noodle casserole C. Cream of chicken soup and orange sherbet D. Hotdog and potato chips
C. Cream of chicken soup and orange sherbet
Nurse Sling is handling a 7-year-old child who has cystitis. Which of the following would Nurse Elena expect when assessing the child? A. Flank pain B. Costovertebral angle tenderness C. Dysuria D. High fever
C. Dysuria
The ability of the body to defend itself against the scientific invading agents such as bacteria, toxins, viruses, and foreign bodies: A. Hormones B. Secretion C. Immunity D. Glands
C. Immunity
A newborn's failure to pass meconium within the first 24 hours after birth may indicate which of the following? A. Hirschsprung disease B. Celiac disease C. Intussusception D. Abdominal wall defect
C. Intussusception
The nurse on night duty accidentally administered too much of a certain medication and has caused the patient to need immediate transfer to the ICU. Despite not being their intention, this mistake means that the nurse broke the principle of A. Autonomy B. Beneficence C. Non-maleficence D. Justice
C. Non-maleficence
Anna, a PHN at a far-flung province in Mindoro was invited to be the resource person in a training class for food handlers. Which of the following would she emphasize regarding the prevention of staphylococcal food poisoning? A. Food must be cooked properly to destroy staphylococcal microorganisms B. Food handlers and food servers must have a negative stool examination result C. Proper handwashing during food preparation is the best way of preventing the condition D. All cooking and eating utensils must be thoroughly washed.
C. Proper handwashing during food preparation is the best way of preventing the condition
A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do? A. Leave the medication at the patient's bedside B. Tell the patient to be sure to take the medication and then leave it at the bedside C. Return shortly to the patient's room and remain there until the patient takes the medication D. Wait for the patient to return to bed, and then leave the medication at the bedside
C. Return shortly to the patient's room and remain there until the patient takes the medication
A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription as soon after the date on which it was written. A. Within 1 month B. Within 3 months C. Within 6 months D. Within 12 months
C. Within 6 months
The nurse has been caring for a female patient for several days while diagnostic tests are being completed. The physician informs the patient that she has inoperable cancer and her prognosis is poor. After the physician leaves, the patient begins to cry. The nurse should: A. Touch the patient's hand to provide support B. Leave the room to give the patient privacy to cry C. Telephone the patient's family to inform them of the diagnosis D. Ask the patient how she feels to encourage ventilation of feelings
D. Ask the patient how she feels to encourage ventilation of feelings
The nurse is preparing to teach the child who has CP. What is the most important factor for the nurse to consider when teaching the child? A. Current age B. Type of cerebral palsy C. Prior illness experience D. Developmental level
D. Developmental level
