General Nursing Level 2

A nurse manager notices that a previously effective nurse appears to be distracted, at times forgets to document changes in clients' status, and rarely completes the required workload without help from another nurse. What should the nurse manager say to the nurse? 1 "You seem to be having difficulty completing your assignments. What can I do to help?" 2 "Why are you having trouble fulfilling your assignment? I need to know what's going on." 3 "Call me to help you organize your day—then you'll have time to complete your assignment." 4 "I've noticed that you always give part of your workload to another nurse. This is unacceptable."

1 "You seem to be having difficulty completing your assignments. What can I do to help?"

A 6-month-old infant weighing 15 lb is admitted with a diagnosis of dehydration. A prescription for oral rehydration therapy 4 mL/kg Pedialyte over 4 hours is made. What is the approximate amount of fluid that the infant should ingest during the 4 hours? 1 28 mL 2 32 mL 3 38 mL 4 42 mL

1 28 mL

A nurse reviews the preoperative instructions for a 3½-year-old child who is to undergo follow-up cleft palate surgery. Which instruction should the nurse question? 1 Tap water enema until clear this pm. 2 Start IV of D5% 0.45% NS at 6 am. 3 Nothing by mouth after 12 midnight. 4 Draw blood for HgB and Hct this pm.

1 Tap water enema until clear this pm.

A client has had a below-the-knee amputation of the leg. What is important for the nurse to consider when providing postoperative care for a client who had an amputation of a lower extremity? 1 The residual limb should be elevated for the first 24 hours. 2 Strict bed rest is maintained for at least several days. 3 Hemorrhage rarely occurs during the early postoperative period. 4 Health care providers usually change the dressing on the residual limb within 48 hours.

1 The residual limb should be elevated for the first 24 hours.

A client with a stage IV pressure ulcer is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number.

2

Acyclovir (Zovirax) 0.8 g by mouth is prescribed for a client with herpes zoster. The oral suspension contains 200 mg/5 mL. How much solution should the nurse administer? Record your answer using a whole number. ___mL

2

Within four to six hours after a client has a myocardial infarction, the nurse expects which blood level to increase? 1 Lactate dehydrogenase (LDH-1) 2 Creatine kinase-MB band (CK-MB) 3 Erythrocyte sedimentation rate (ESR) 4 Serum aspartate aminotransferase (AST)

2 Creatine kinase-MB band (CK-MB)

The neonate has a protruding tongue and a crease that transverses the entire width of each palm. The nurse recognizes that these findings are characteristic of what congenital condition? 1 Hypothyroidism 2 Down syndrome 3 Turner syndrome 4 Fetal alcohol syndrome

2 Down syndrome

A 10-year-old child is receiving oxygen 2 L/min by way of nasal cannula. The health care provider asks that pulse oximetry be started. What is the appropriate placement for the oximetry probe in a child of this age? 1 Great toe 2 Index finger 3 Radial pulse point 4 Popliteal pulse point

2 Index finger

A nurse is caring for a child with the diagnosis of lead poisoning. For which problem should the nurse assess the child initially? 1 Constipation resulting from the excretion of lead 2 Neurological injury caused by the ingestion of lead 3 Delayed development resulting from parental neglect 4 Inadequate nutrition resulting from decreased iron intake

2 Neurological injury caused by the ingestion of lead

A nurse is caring for an older bedridden male client who is incontinent of urine. What nursing intervention is the most satisfactory initial approach to managing urinary incontinence? 1 Restricting fluid intake 2 Offering the urinal regularly 3 Applying incontinence pants 4 Inserting an indwelling urinary catheter

2 Offering the urinal regularly

The nurse uses which principles of body mechanics when caring for immobilized clients? 1 Bending at the waist to provide the power for lifting 2 Placing the feet apart to increase the stability of the body 3 Keeping the body straight when lifting to reduce pressure on the abdomen 4 Relaxing the abdominal muscles while using the extremities to prevent strain

2 Placing the feet apart to increase the stability of the body

A nurse is caring for a client who just had surgery for a parotid tumor. Which nursing intervention is the priority in the immediate postoperative period? 1 Offering psychological support 2 Monitoring the client's fluid balance 3 Keeping the client's respiratory passages patent 4 Providing a pad and pencil for writing messages

3 Keeping the client's respiratory passages patent

A client is admitted to the mental health unit with the diagnosis of anorexia nervosa. What typical signs and symptoms of anorexia nervosa does the nurse expect the client to exhibit? 1 Slow pulse, mild weight loss, and alopecia 2 Compulsive behaviors, excessive fears, and nausea 3 Amenorrhea, excessive weight loss, and abdominal distention 4 Excessive activity, memory lapses, and an increase in the pulse rate

3 Amenorrhea, excessive weight loss, and abdominal distention

The nurse is assessing a newborn for developmental dysplasia of the hip (DDH). Where does the nurse look for extra skinfolds? 1 Calf muscles 2 Popliteal area 3 Back of the thigh 4 Lower portion of the abdomen

3 Back of the thigh

Two 20-year-old female clients on the psychiatric unit have become very much attached to each other and are found in bed together. They become angry and sarcastic when the nurse asks one of them to return to her own bed. How can the nurse best address this situation? 1 By asking the health care provider to transfer one of the clients to another unit 2 By limiting their privileges for several days because their behavior is undesirable 3 By adopting a matter-of-fact, nonjudgmental attitude and setting limits on the behavior 4 By supervising them carefully and separating them when possible throughout the day and always at night

3 By adopting a matter-of-fact, nonjudgmental attitude and setting limits on the behavior

A client in labor is admitted to the birthing unit. Assessment reveals that the fetus is in a footling breech presentation. What should the nurse consider about breech presentations when caring for this client? 1 Severe back discomfort will occur. 2 Length of labor usually is shortened. 3 Cesarean birth probably will be necessary. 4 Meconium in the amniotic fluid is a sign of fetal hypoxia.

3 Cesarean birth probably will be necessary.

A client with a suspected placenta previa is to have a repeat sonogram at 16 weeks' gestation. What nursing intervention is needed to prepare for this procedure? 1 Inserting an indwelling urinary catheter 2 Cleansing the abdomen with germicidal soap 3 Ensuring that the client drinks two 8-oz glasses of water 4 Administering a cleansing enema of 500 mL of normal saline

3 Ensuring that the client drinks two 8-oz glasses of water A full bladder helps stabilize the uterus during sonography, allowing better visualization of the fetus; two full glasses of water, ingested about 1 hour before the test, will fill the bladder. Emptying the bladder is inadvisable because a full bladder supports the uterus and improves visualization. Because the procedure is noninvasive, it is unnecessary to cleanse the skin. An enema is contraindicated when placenta previa is suspected and will not improve visualization of the uterus anyway.

A 13-month-old child is undergoing lumbar puncture for confirmation of a diagnosis of bacterial meningitis. During the procedure the nurse notes that the spinal fluid is cloudy. What does this finding indicate? 1Healthy spinal fluid 2Increased glucose level 3 Increased white blood cell (WBC) count 4 Rising number of red blood cells (RBCs)

3 Increased white blood cell (WBC) count

A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an α-fetoprotein test. She asks the nurse, "What does this test do?" The nurse bases the response on the knowledge that this test can reveal: 1 Kidney defects 2 Cardiac anomalies 3 Neural tube defects 4 Urinary tract anomalies

3 Neural tube defects

During the assessment of a client who was admitted to the hospital because of a productive cough, fever, and chills, the nurse percusses an area of dullness over the right posterior lower lobe of the lung. The nurse determines that the client's signs and symptoms may be indicative of: 1 Pleurisy. 2 Bronchitis. 3 Pneumonia. 4 Emphysema.

3 Pneumonia.

What should the nurse do to obtain an accurate urine output for a client with a continuous bladder irrigation (CBI)? 1 Measure the contents of the bedside drainage bag. 2 Stop the irrigation and determine the urine output. 3 Subtract the volume of irrigant from the total drainage. 4 Ensure the urine and irrigant drain into two separate bags.

3 Subtract the volume of irrigant from the total drainage.

When palpating a client's fundus on the second postpartum day, a nurse determines that it is above the umbilicus and displaced to the right. What does the nurse conclude? 1 There is a slow rate of involution. 2 There are retained placental fragments. 3 The bladder has become overdistended. 4 The uterine ligaments are overstretched.

3 The bladder has become overdistended.

When inserting a catheter to irrigate a client's colostomy, the nurse meets some resistance. What should the nurse do? 1 Probe with the irrigating catheter to determine the contour of the bowel 2 Obtain a more rigid tip for the irrigating catheter to insert into the stoma 3 Apply pressure to the irrigating catheter to overcome the spasm of the bowel 4 Instill a small amount of solution from the irrigating container into the stoma

4 Instill a small amount of solution from the irrigating container into the stoma

An infant with hydrocephalus has a ventriculoperitoneal shunt surgically inserted. What nursing care is essential during the first 24 hours after this procedure? 1 Medicating the infant for pain 2 Placing the infant in a high Fowler position 3 Positioning the infant on the side that has the shunt 4 Monitoring the infant for increasing intracranial pressure

4 Monitoring the infant for increasing intracranial pressure

The nurse observes that 12 hours after birth the neonate is hyperactive and jittery, sneezes frequently, has a high-pitched cry, and is having difficulty suckling. Further assessment reveals increased deep tendon reflexes and a diminished Moro reflex. What problem does the nurse suspect? 1 Cerebral palsy 2 Neonatal syphilis 3 Fetal alcohol syndrome 4 Opioid drug withdrawal

4 Opioid drug withdrawal

What is most important for a nurse to teach the parents of a child with Duchenne muscular dystrophy to do for their school-aged child? 1 Maintain a high-calorie diet. 2 Institute seizure precautions. 3 Restrict the use of larger muscles. 4 Perform range-of-motion exercises.

4 Perform range-of-motion exercises.

Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a cerebrovascular accident (CVA, also known as "brain attack")? 1 Glaucoma 2 Hypothyroidism 3 Continuous nervousness 4 Transient ischemic attacks (TIAs)

4 Transient ischemic attacks (TIAs)

A client's membranes rupture during labor, and the amniotic fluid is meconium stained. Which heart rate pattern indicates that the fetus's status is nonreassuring? 1 Early decelerations with average variability 2 Changes in baseline variability from 5 to 10 beats/min 3 Increases in fetal heart rate from 135 to 150 beats/min with fetal activity 4 Variable decelerations that last 60 seconds, then return to baseline tachycardia

4 Variable decelerations that last 60 seconds, then return to baseline tachycardia

In which muscle should a nurse administer an intramuscular injection to a 2-month-old infant? 1 Gluteal 2 Deltoid 3 Rectus femoris 4 Vastus lateralis

4 Vastus lateralis