Practice Exam 4

A day-shift nurse on the pediatric neurologic unit has just received a report from the previous shift. Which infant should the nurse assess first?

Answer: A restless infant with a high-pitched cry who was transferred from the ICU the previous evening An infant's restlessness and high-pitched cry can indicate increased cranial pressure. Because the infant was transferred from the ICU the previous night, assessing for ICP should be a nursing priority. The infant with a pulse of 140-160 bpm exhibits normal parameters. Although the nurse should assess a low-grade fever on the third post-op day, this stable infant is not the priority at this time. Decreased respirations are indicative of ICP, but this infant's resps of 38 breaths per minute would not be a priority concern.

A nurse is giving a shift report about a client in labor. Which of the following information is the least important to include to complete the report at the change of shift?

Answer: Bottle or breastfeeding preference Rationale: Feeding preference is the least important information to be reported to the oncoming shift. Feeding preference plans will be important after delivery as many mothers breastfeed within an hour of delivery. The client's obstetrical history is higher priority because it provides information about previous birthing experience. Information on cervical effacement, dilation, and station indicates the current state of labor and is essential for planning continuity of care for this client. Nurses on the oncoming shift should also know the extent of the support the client will need and who is currently providing that support.

A nurse is frustrated by the inability to make much progress establishing a therapeutic relationship with a client with bipolar disorder. The nurse's most professional response would be to:

Answer: Discuss the situation with a more experienced peer Rationale: A collaborative approach is always a better way to address challenging situations; additional input may provide insight to help the nurse provide more effective client care. Asking to be reassigned and suggesting that another nurse might provide more effective care are avoidant responses that do not address the underling issues. At this time, there is no indication that a medication reevaluation is necessary.

A couple in the antenatal unit is not satisfied with the care they are receiving. They have spent the past 15 minutes expressing dissatisfaction to the nurse about the care the client is receiving today. What is the most appropriate response by the nurse?

Answer: Encourage the family to identify their frustrations and fears Rationale: This response will assist the family in identifying their frustrations and fears so the nurse can work toward resolving their issues. It is inappropriate to tell the client about staffing-related issues or to give them a time limit for which they are able to express their concerns. The nurse manager may need to be brought into the situation but first the nurse should try to work toward resolving the issue with the clients.

A couple seeks emergency crisis intervention because one client slapped the other client repeatedly the night before. The first client who inflicted the violence reports a childhood marred by an abusive relationship with a parent. To assess for the likelihood of further violence and abuse, the nurse should determine that the first client:

Answer: Has learned violence as an acceptable behavior Rationale: Family violence is usually a learned behavior. This could is at risk for further violence. Poor, not moderate, impulse control indicates a risk for more violence. Violent people generally are jealous and possessive and feel insecure in their relationships.

A child with cystic fibrosis has been admitted to the pediatric unit. What type of diet should the nurse request for the client?

Answer: High-calorie, high-protein Rationale: A high-calorie, high-protein diet is necessary to ensure adequate growth. Some children require up to two times the recommended daily allowance of calories. Pancreatic enzyme activity is lost and malabsorption of fats, proteins, and carbs occurs.

One hour after receiving nalbuphine for pain during labor, a primigravida gives birth to a full-term neonate with symptoms of respiratory depression. The nurse anticipates that the neonate will require the administration of which drug?

Answer: Naloxone Rationale: The drug of choice to reverse opioid-induced respiratory depression in a neonate is naloxone, which reverses the effect of opioids

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant?

Answer: Serum potassium level of 3 mEq/L Rationale: A serum potassium level of 3mEq/L is below the normal, indicating hypokalemia. Because hypokalemia may cause cardiac arrhythmias and asystole, it's the most significant finding

A nurse-manager on an oncology unit has been informed that she must determine which nursing care delivery system (NCDS)/nursing care delivery model (NCDM) is best for efficient client care, client satisfaction, and cost reduction. Knowing that two or three registered nurses, four licensed practical nurses, and five nursing assistants are generally on duty on each shift and that the clients can easily be grouped by geographic location and client care needs, the nurse-manager and her staff appropriately decide to implement which NCDS/NCDM?

Answer: Team nursing Rationale: Team nursing is efficient and less costly to implement than primary or case management systems. Because staff members know each other well, they can function effectively as a team. Although functional nursing is the most cost-effective, care is commonly fragmented and clients are less satisfied. Case management and primary nursing require more registered nurses than are available.

A client with a clamped chest tube in place has become increasingly short of breath throughout the shift and reports pain to the right chest wall. The nurse understands that the most likely cause is:

Answer: Tension pneumothorax Rationale: Atmospheric pressure is greater than the pressure inside the pleural space. If a chest tube were clamped for a period of time, the intrathoracic pressure would increase, and subsequently so would the tension. The other choices are not reflective of a clamped chest tube.

The nurse is planning care for an older adult with an indwelling catheter who is at risk for septic shock. Which nursing action will be most important for this client?

Answer: Using aseptic technique when caring for the catheter Rationale: Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because of the mortality rate of septic shock is as high as 90%, particularly in clients younger than age 2 and older than age 65. Administering IV fluid replacement, obtaining vital signs every 4 hours, and monitoring red blood cell counts for an increase are not measures to prevent septic shock.

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks gestation?

Thin, wasted appearance Rationale: The premature neonate characteristically exhibits a thin, wasted appearance