NACE PN TO RN
The nurse is performing a psychosocial assessment on an adolescent age 14. Which emotional response is typical during early adolescence?
Correct answer: Moodiness. During early adolescence, a child may become moody. Frequent anger &combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence.
Which is the most numerous type of white blood cell (WBC)?
Correct answer: Neutrophil. Neutrophil are the most numerous of the WBCs, comprising about 65%. Lymphocytes are the second most abundant. Eosinophils account for about 2%, while basophils are the least abundant.
Which clinical indicator is the nurse most likely to identify when exploring the history of a client with insomnia?
Correct answer: Irritability. Insomnia is the inability to fall asleep or stay sleep. Individuals who experience insomnia complain of unrefreshed sleep, daytime sleepiness, trouble concentrating, irritability, and waking up several times at night.
Which of the following is the sixth provision of the Code of Ethics for Nurses?
Correct Answer: "The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action."
Of the following, which is the normal blood pressure range for an adolescent?
Correct Answer: 110-120/60-80
Which is a FALSE statement regarding factors contributing to the development of schizophrenia?
Correct Answer: In order for someone to be diagnosed with schizophrenia, they must show brain damage on a brain scan. Experts now agree that schizophrenia develops as a result of interplay between biological disposition and the kind of environment a person is exposed to. However there are no medical tests that will diagnose schizophrenia.
The nurse at the family planning clinic has performed teaching on oral contraceptives. The nurse knows that the teaching has been effective when one of the clients responds:
Correct Answer: "I can't take 'the pill' if I have gallbladder disease." Oral contraceptive is contraindicated in women with gallbladder disease and those who are heavy smokers. There is not an age specification. Menstrual flow is decreased with the use of oral contraceptives.
The day after delivery, a new mother asks why her milk is so creamy and yellow. What is the best response for the nurse to make?
Correct Answer: "This is normal. It will soon turn to real milk. "The client is describing colostrum. Milk comes in about 72 hours after delivery. "I would not worry about it" and "you are coming along fine" do not address the question asked by the mother.
A healthy first time pregnant client asks the nurse, "How long will I stay in the hospital after my baby is born." The client is scheduled for a Caesarean section. The nurse understands the average timeframe for the hospital stay for a Caesarean section is what?
Correct Answer: 72 hours. The hospital stay for a healthy mother who has delivered an infant varies depending on the type of delivery. The length of stay in the hospital for a vaginal birth is typically 24 to 48 hours. The length of stay in the hospital for a Caesarean section that does not have any complications is 72 hours.
Which of the following patients would a nurse not administer Erythromycin to?
Correct Answer: A person with multiple sclerosis. An antibiotic is indicated if there is a possible infection. Multiple sclerosis is not characterized by infections.
Which of the following types of wounds is characterized by black, dry tissue?
Correct Answer: Black wounds. Wounds are divided into the following types: black wounds, yellow wounds and red wounds. Black wounds are necrotic, dry tissue that are prone to infection. In order to remove the dead tissue, surgical debridement is used.
The community nurse is planning a smoking cessation program. What would be the first step in developing a health promotion program?
Correct Answer: Conducting health risk surveys First conduct initial assessments to determine if there is a health risk. Then follow the course of action in place in this event.
When testing a client's pupils for accommodation, the nurse should interpret which findings as normal?
Correct Answer: Constriction and convergence. During accommodation, the pupils should constrict and converge equally on an object. Pupils normally dilate in darkness and when a person stares at an object across a room. Divergence is never a normal response.
When providing instructions to the adolescent regarding physical development of her body, the RN should do all of the following EXCEPT
Correct Answer: Discuss the importance of avoiding social events in order to stay out of trouble. Socialization is very important to teenagers and is a normal part of their development. The other answers (b, c, and d) are all accurate instructions and discussions for the adolescent regarding development.
The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of what?
Correct Answer: Fat. A diet containing excessive fat seems to contribute to autoimmunity - overreaction of the body against constituents of its own tissues. Immune dysfunction has been linked to deficient - not excessive - intake of protein, vitamin A and zinc.
Which of the following blood transfusion reactions is a rare, but severe reaction in which the donated blood type is not compatible with that of the patient?
Correct Answer: Hemolytic A hemolytic transfusion reaction is a serious complication that occurs when the red blood cells that were given during a transfusion are destroyed by the person's immune system. An allergic transfusion reaction is usually due to a patient's sensitivity to the plasma proteins of the donor's blood. A febrile transfusion reaction is caused by the incompatibility of leukocytes.
A woman is two months pregnant when her five-year-old child develops rubella. What is most likely to be given to the mother?
Correct Answer: Immune serum globulin Immune serum globulin gives her a passive immunity and helps keep her from developing rubella, which can have devastating effect on her unborn child. MMR is a live virus and is not given to pregnant women. RhoGam prevents anti Rh antibody development. There is no such thing as rubella antitoxin.
Nurses require leadership skills. Of the following leadership types, which relinquishes some control to the members of the group?
Correct Answer: Laissez-faire. The type of leader in Choice A actively seeks input from members of the group. Situational leaders are flexible and utilize a combination of the other leadership types depending on the most effective way of completing the task. An autocratic leader dominates the group rather than seeking suggestions from the group.
An infant is startled by a loud noise. The nurse understands this reaction to the loud noise is the result of:
Correct Answer: Moro reflex. The Moro reflex is used to determine an infant's nervous system maturity. This reflex goes away when a child reaches 4 to 6 months old. Typically, when a child hears a loud noise or reacts to a sudden change in position, this reflex occurs.
Which of the following is a high risk factor for diabetes mellitus?
Correct Answer: Native American The highest risk factors include: Native Americans, obesity (BMI of 30 or higher), and an immediate family history (sibling or parent). African American and Hispanic populations are also at high risk.
A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for stroke?
Correct Answer: Obesity. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, hormonal contraceptive use, emotional stress, family history of stroke, and advancing age. The clients' race, gender and bronchial asthma are not risk factors for stroke.
To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following?
Correct Answer: Organs The purpose of deep palpation, in which the nurse indents the client's skin approximately 1-1/2", is to assess underlying organs and structures such as the kidneys and spleen. Skin turgor, hydration, and temperature can be assessed using light touch or light palpation.
Which of the following phases of disaster management is primarily concerned with physical and mental health and safety of the disaster response team?
Correct Answer: Recovery. Preparedness looks for the most effective way of caring for a patient once a disaster occurs. Recovery takes into consideration the actions necessary for everyone to return to a state of normalcy after a disaster. Mitigation takes into consideration the actions that can help prevent the occurrence of a disaster.
The nurse knows that in the past, inadequate community and occupational skills often limited clients who had severe mental illness. Today, though, some teaching is best done in the client's own setting. What would be the priority of this community-based teaching?
Correct Answer: Social skills training. Individuals with severe mental illness often benefit from social skills training, focusing primarily on the teaching of basic coping skills necessary to live as autonomously as possible in the community. Job training will come after the client is able to interact well with others. ADL skills are beneficial, but clients will be taught these skills in their own setting. Conflict management skills will be taught after the social skills training.
A 20-year-old patient is admitted to the hospital with respiratory failure. He's intubated, given oxygen, and is coughing with copious secretions in his lungs. What should be done first?
Correct Answer: Suction the lungs The first priority is to make sure the client's airways are clear and that he can breathe. The other choices can be addressed after ensuring the client can breathe.
In a client with acute hepatitis, the nurse assesses the client's aspartate aminotransferase (AST) range on the laboratory test at 520 units. What should the nurse understand about this test value?
Correct Answer: The AST is elevated. In clients with acute hepatitis, liver disease and myocardial infarction, the aspartate aminotransferase (AST) is elevated. The normal range for this enzyme in the blood is 10 to 26 units per liter. In clients with acute hepatitis, the enzyme may be elevated four times above the normal range.
A client has had pain in the right leg for 3 weeks. The nurse understands that the MOST LIKELY effect of this pain is?
Correct Answer: The disruption of sleep. Pain can have many effects on the human body. Clients with acute pain may have a decrease in appetite, decrease in fluid intake, nausea, vomiting and disruption in sleep.
A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and intervention, what would be the MOST desirable outcome?
Correct Answer: The student accepts a referral to a substance abuse counselor. All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.
The nurse is teaching a client who drinks alcohol heavily about maintaining a healthy heart. The nurse should include which point in her teaching?
Correct Answer: Use alcohol in moderation. Alcohol may be used in moderation as long as there are no other contraindications for its use. Having a diet high in cholesterol and saturated fat, and a sedentary lifestyle are all known risk factors for cardiac disease. The client should be encouraged to quit smoking, exercise three to four times per week, and consume a diet low in cholesterol and saturated fat.
A patient with Addison's disease has been given an inadequate steroid dosage. Which of the following are NOT symptoms the patient could experience?
Correct Answer: Weight gain. Weight loss is more likely. Fatigue, weakness, and dizziness are often indicated.
A menopausal woman tells her nurse that she experiences discomfort from vaginal dryness during sexual intercourse, and asks, "What should I use as a lubricant?" The nurse should recommend:
Correct Answer: a water-soluble lubricant. A water-soluble jelly should be used. Petroleum jelly, body creams, and body lotions are not water soluble. Less-frequent intercourse is an inappropriate response.
The nurse observes a child's nasal discharge. The discharge is clear in both nasal cavities. The discharge most likely indicates what type of condition?
Correct Answer: allergy. A child who has clear, watery discharge is associated with allergies. The remaining answer choices are not the best options as bloody discharge is indicative of a nosebleed or a trauma. Itchy mucus containing discharge indicates an upper respiratory infection. If there is mucoid or purulent nasal discharge in one side of the nostrils, the child may have a foreign body lodged in the nostril.
The nurse understands a child with HIV who is classified as Category C can have all except which of the following manifestations?
Correct Answer: anemia. The clinical manifestations that are seen with the category C classification of HIV include recurrent and multiple infections, encephalopathy, kaposi's sarcoma, lymphoma, cytomegalovirus, toxoplasmosis, and wasting syndrome. Anemia is a clinical manifestation of the Category B HIV classification.
A client is discharged from a hospital's psychiatric unit. The physician writes an order for Zyprexa. As the nurse prepares the teaching plan for the Zyprexa medication, the nurse should teach the client to do what?
Correct Answer: avoid smoking The serum levels of antipsychotic medications, such as Zyprexa, can be decreased when an individual smokes tobacco products. When taking Zyprexa, the client should avoid exposure to direct sunlight. Avoiding foods containing tyramine would be dangerous if the client was prescribed a monoamine oxidase inhibitor (MAOI). Further, instructing the client to eat a high protein, high carbohydrate diet is not a requirement for a client who is prescribed Zyprexa. This dietary instruction is recommended for clients with bipolar disorder.
The nurse documents scalp edema that crosses the lines of the skull in the newborn as what?
Correct Answer: caput succedaneum. Since a caput succedaneum is just superficial and beneath the scalp, the swelling can cross the suture lines. Molding is overriding of the cranial plates, and cephalohematoma does not cross the suture lines, since it results when blood is trapped beneath the periosteum. Cranial distention is not a term used in newborn assessment.
According to studies done on gay and lesbian families, what significant differences might be expected in parent/child and peer relationships of children raised in a gay/ lesbian household as compared with traditional heterosexual parenting?
Correct Answer: children seem to experience no differences. It has not been found that children in gay and lesbian families are more inclined to use drugs
The nurse is talking with a woman who has been told she will never be able to bear children. The woman states, "I have decided to adopt a baby, because there are so many children in the world who need the kind of home I could provide a child." The nurse recognizes this woman is using what defense mechanism?
Correct Answer: compensation. Compensation is covering a weakness with a more desirable trait or behavior, such as replacing the desire to have children with adopting a child. Denial is avoiding unwanted realities by refusing to acknowledge they exist, such as the woman who refuses to accept that she is unable to bear children. Rationalization is justifying behavior with faulty logic, such as the woman who uses drugs or alcohol and says that it is due to being unable to have children. Displacement is discharging emotion from one person or object to another person or object, such as the woman who learns she cannot have children and goes home and argues with her husband.
A female client who complains of chest pain is admitted. The nurse can expect which of the following laboratory tests ordered by the physician to confirm a myocardial infarction diagnosis?
Correct Answer: creatine kinase The physician orders laboratory tests and diagnostic tests to confirm a diagnosis of myocardial infarction. Creatine kinase is an enzyme located in the cardiac muscle, brain and skeletal muscle. As this enzyme rises, there is injury to the muscle cells. Further, the higher the serum CK, the more the muscle tissue that is damaged. Electrocardiogram, radionuclide imaging and hemodynamic monitoring are used to diagnosis a myocardial infarction. However, these are diagnostic tests and not laboratory tests.
Which leadership style is based on the belief that every member of the group should have input into the development of goals and problem solving?
Correct Answer: democratic leadership. Autocratic leadership is focused and maintains strong control, makes decisions, and addresses all problems. The autocratic leader dominates and commands rather than seek suggestions or input. The laissez-faire leader assumes a passive, nondirective, and inactive approach and relinquishes part or all of the leadership responsibilities to group members. The situational leader uses a combination approach based on the circumstances.
The physician prescribes home oxygen therapy for a client with pulmonary fibrosis. The nurse collaborates with the social worker assigned to the client about arranging the home oxygen therapy. Which health team member will be responsible for evaluating the client's knowledge of home oxygen use?
Correct Answer: home health nurse. The home health nurse is responsible for evaluating the client's knowledge of home oxygen use. The social worker is only responsible for coordinating the services. The hospital staff nurse and physician do not observe the client in the home, so they cannot adequately evaluate the client's knowledge of home oxygen use.
Before applying a cord clamp, the nurse assesses the umbilical cord for the presence of vessels. The findings that are often associated with genitourinary abnormalities are what?
Correct Answer: one artery, one vein. Two arteries and one vein are present in a normal umbilical cord. The presence of one artery in the umbilical cord is associated with genitourinary abnormalities.
Which of the following is the normal serum electrolyte level for magnesium?
Correct answer: 1.6 to 2.4 mEq/L
The nurse is developing discharge plans for a 65-year-old client. The discharge plans indicate the client will be discharged home with home health nursing care. The nurse provides the home health agency with details regarding the needs of the patient. The nurse made which of the following to the home health agency?
Correct answer: A referral. A referral is recommending home care services or giving information to an home care service regarding the client and the client's needs. Typically the sources of referral to a home care agency are family members, nurses, physicians, social workers, discharge planners or therapists.
A nurse who violates the civil rights of an individual may be committing what?
Correct answer: A tort. A tort is the process of violating civil law when dealing with an individual or an individual's property. The types of torts are commission and omission. Further, negligence and malpractice are not the best choices as these deal with unintentional torts.
A client is admitted with tuberculosis. The client should be placed in which type of precaution based isolation?
Correct answer: Airborne. The nurse should use airborne precautions when caring for a client with known or suspected tuberculosis to reduce the spread of the tuberculosis. Precautions that are employed are private room that has its own hand washing station and bathroom, special ventilation system that is separate from the hospital wide ventilation system and providing masks for anyone entering the room to see the client.
In which of the following stages of reaction toward stress does a body increase in hormone levels in order to mobilize for a fight?
Correct answer: Alarm. During the exhaustion stage, the body becomes "exhausted" because it did not positively respond to the stress. The body undergoes many physiological changes such as taking more air into the lungs in order to prepare for fight or flight during the resistance stage.
A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stool to look like which of the following?
Correct answer: Black and tarry. Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes in the blood. Vomitus associated with upper GI tract bleeding is commonly described as coffee ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding.
Which of the following tasks can a registered nurse delegate to a nursing assistant in an acute mental health setting?
Correct answer: Checking for sharp objects. A nursing assistant may be assigned to search a client's luggage or room for potentially harmful objects, such as glass or sharp metal. A mental status assessment should be conducted by the nurse on admission. Administering medication cannot be delegated to an unlicensed person. A nurse or physician must discuss the treatment plan with the client
Which of the following behaviors does NOT show improvement in a client with Obsessive Compulsive Disorder?
Correct answer: Client uses "will power" to stop rituals. The client can employ appropriate intervention techniques and more about the disease process such as B, C and D. "Will power" alone will not be effective in dealing with Obsessive Compulsive Disorder. The client can employ appropriate intervention techniques by refraining from rituals during times of stress, using the "thought-stopping" strategy when experiencing obsessive thoughts, and verbalizing rituals and stress relationships.
After running several tests, Dr. Smith realizes that the microorganisms in his patient, Tom are rapidly multiplying. However, the microorganisms are not causing any damage. This multiplication of microorganisms is known as which of the following?
Correct answer: Colonization. An infectious agent is an organism that can cause disease. A particulate respirator is a mask worn on the faces of medical personnel. They block organisms from entering the body. A reservoir is a place where the conditions are conducive for the growth and development of microorganisms.
A client is scheduled to have a blood transfusion. The client asks the nurse, "What types of diseases are transmitted through blood transfusions?" The nurse should respond that there is a low risk of contracting diseases through blood transfusions. However, a possible illness is which of the following?
Correct answer: CytomegalovirusBlood borne diseases and diseases that are transmitted through a transfusion are Hepatitis B, Hepatitis C, HIV, Cytomegalovirus and Malaria, to name a few. Also, the nurse should assure the client that the transmission of these diseases is low since blood banks have rigorous screening procedures to test blood.
What is the best way for a client with reoccurring kidney stones to prevent further kidney stones?
Correct answer: Drink plenty of fluids Drinking enough fluid is the most important thing a person can do to prevent kidney stones. While the other foods will add nutrients to the diet, they do not address the development of further kidney stones.
A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for which of the following?
Correct answer: Fatigue and weakness. RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Nausea and vomiting may occur in CRF, but do not result from faulty RBC production. Dyspnea and cyanosis are associated with fluid excess, not CRF. Thrush, which signals fungal infection, and circumoral pallor which reflects decreased oxygenation, are not signs of CRF.
A client with major depression frequently is irritable, abrasive, and uncooperative and refuses to participate in group activities. When working with this client, the nurse should use which approach?
Correct answer: Firmness. By taking a firm approach, the nurse sets limits and establishes boundaries for the client's behavior, which helps ensure safety and gives the client a sense of control. A joyful or humorous approach may make the client feel guilty about being depressed. An aloof approach does not enable the client to initiate interpersonal contact or encourage communication.
A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called what?
Correct answer: Flight of ideas. Flight of ideas describes a thought pattern in which a client moves rapidly from one topic to the next with some connection. Looseness of association describes a pattern in which ideas lack an apparent logical connection to one another. Tangential thoughts seem to be related but miss the point. A client who talks around the subject and includes a lot of unnecessary information is exhibiting circumstantial thinking.
What hormone does the anterior pituitary produce?
Correct answer: Follicle-stimulating hormone. The anterior pituitary regulates several physiological processes including stress, growth, and reproduction. Its regulatory functions are achieved through the secretion of various peptide hormones that act on target organs including the adrenal gland, liver, bone, thyroid gland, and gonads.
The nurse is caring for a client with chest trauma. Which nursing diagnosis takes highest priority?
Correct answer: Impaired gas exchange. For a client with chest trauma, a diagnosis of impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other options are possible nursing diagnoses for this client, they take lower priority.
When obtaining a health history, the nurse expects a client with a diagnosis of Myasthenia Gravis to report which of the following signs or symptoms?
Correct answer: Low lying eyelids. A client with Myasthenia Gravis may report that his or her eyelids feel low or drooping, which is known as ptosis. Additional signs and symptoms of Myasthenia Gravis is dysphonia, enlarged thymus gland, strabismus, muscle weakness and diplopia.
The client had a nephrectomy for the removal of kidney due to major lacerations two hours ago. What is a nursing priority?
Correct answer: Maintain the drainage tube patency The nurse should monitor the drainage tube patency every 4 hours for 24 to 48 hours after the client's nephrectomy procedure. By doing so, the nurse can ensure the client's tubes drain freely and help prevent hydronephrosis, which is urine collected in the renal pelvis because of obstruction with the outflow of the urine.
The nurse is providing dietary teaching for the parents of a child with celiac disease. This child should avoid what?
Correct answer: Prepared puddings. A child with celiac disease must not consume food containing gluten and therefore should avoid prepared puddings, commercially prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley. The other choices do not contain gluten and are permitted when on a gluten free diet.
Which of the following has a a generic name of Albuterol Sulfate?
Correct answer: Proventil
Which of the following clinical signs would the nurse expect to see in a child with respiratory depression?
Correct answer: Shallow breathing. Respiratory depression is the breaths per minute that are less than 12 breaths per minute in a child who is two years of age and younger. Respiratory depression is one of the complications associated with opioids (for example morphine, codeine, Demerol, Oxycodone), which are a common analgesic given to client's after surgery or to treat a severe injury. Children who experience respiration depression exhibit clinical signs such as shallow breathing, sleepiness and small pupils.
All of the following are adverse reactions to phenelzine sulfate (Nardil) except which?
Correct answer: Tachypnea. Phenelzine sulfate (Nardil) is a antidepressant that belongs to the class of drugs called monoamine oxidase inhibitors (MAOI). Adverse reactions to Nardil include nausea, headaches (particularly in the back of the head), and anxiety.
The couple with the lowest risk of having a child with sickle cell disease is the one in which what is true?
Correct answer: The father is HbA and the mother is HbS. If the father has normal hemoglobin (HbA) and the mother has sickle cell disease (HbS), the couple has a 0% chance of having a child with sickle cell disease. If both parents have sickle disease, the couple has a 100% chance of having a child with sickle cell disease. If the father has sickle cell disease and the mother has sickle cell trait (HbAS), the couple has a 50% chance of having a child with sickle cell disease. lf both parents have sickle cell trait, the couple has a 25% chance of having a child with sickle cell disease.
Which of the following is the most common source of airway obstruction in an unconscious victim?
Correct answer: The tongue. The muscles in many cases that control the tongue relax, causing the tongue to obstruct the airway. When this occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back in place. If a neck injury is suspected, the jaw-thrust maneuver must be performed.
A client asks the nurse what treatments are used for xerosis. Which intervention should the nurse include in a teaching plan for the client?
Correct answer: Use a humidifier. Xerosis, which is dry skin, is caused by heat and low humidity. Therefore, it is important to use a humidifier to add moisture to the air in order to relieve dry, itchy skin.
The nurse is performing an assessment on a client who is complaining of pain in the abdomen. The nurse understands to do what?
Correct answer: Use palpation at the end of the assessment only. When performing an assessment on the abdomen, the palpation of the abdomen should be performed last. The reason is the pressure placed on the abdominal wall along with the contents will affect the bowel sounds that are heard through auscultation.
Which of the following is not a goal for a client with social phobia?
Correct answer: Use suppression. A client needs concrete goals to pursue. These goals might include managing fear in groups, verbalizing feelings in stressful situations, and developing a plan for stressful situations. Suppression, or avoidance of thoughts and feelings, would be very counterproductive to a person with social phobia.
You are caring for a client with a chest tube. You enter the room and find that the client has turned onto the side of the tube and disconnected the tube accidentally from the machine but is still connected to the patient. The appropriate initial action is to:
The Correct answer is: Place the tube in a bottle of sterile water. Once the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water and held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. The physician may be notified, but this is not the initial action necessary. Placing a dressing over the disconnection site will not prevent complications.
There are many rights the patient has when they are hospitalized. Which of the following is NOT a right to be considered with these patients?
The Correct answer is: The right to bring their own personal protection devices and medications into a health care facility. The client is not allowed to bring weapons or medications into a health care facility as delegated by hospital rules, policies, and procedures. The other answers are all rights of the client.
A client is brought to the emergency department and the physician determines he has gastrointestinal (GI) bleeding. In planning for his care, which of the following would be first priority?
The Correct answer is: assessment of vital signs Vital sign assessment would be the priority nursing intervention. This would provide an indication of the amount of blood loss that has occurred and also provide a baseline by which to monitor the progress of treatment. The other answers (b, c, and d) are important but not priority actions.
The school nurse is approached by a mother who explains that her kindergarten child is constantly scratching the perianal area and that the area is irritated. The RN understands that she should instruct the mother to obtain a rectal specimen by a tape test and that the mother should obtain the specimen when?
The Correct answer is: in the morning, when the child awakens Visualization of pinworms by means of a tape test is necessary for the diagnosis. Transparent tape is lightly touched to the anus and then applied to a slide for microscopic examination. The best specimen is obtained as the child awakens, before toileting or bathing.
You are reading the result of a Mantoux test on a 2-year- old child. The results indicate an area of induration that measures 10 mm. What do you interpret these results as?
The Correct answer is: positive. Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age and in those with chronic illness or at high risk for environmental exposure to tuberculosis. For high risk groups, a reaction of 5mm or more is considered positive. A reaction of 15 mm or more is positive in children 4 years of age and older who have no risk factors.
Which must be included in a medication order?
The correct answer is physician's signature. The physician's signature must be included in a medication order. Other components of a medication order include the client's full name, drug name, dosage form, dose amount, administration route, time schedule, and the date and time of the order. The drug class and possible adverse reactions are not components of a medication order. Client allergies should be recorded in the client's chart, not on the medication order.
When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
The correct answer is strawberries. Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots and oranges rarely cause allergic reactions.
The nurse assesses a child who is dehydrated. The child has lost 15% of his body weight. The nurse suspects what of the child?
The correct answer is the child has severe dehydration. When a child has lost 10% of his or her body weight during dehydration, this indicates the child has severe dehydration. Mild dehydration is indicated when the child has lost up to 5% of his or her body weight. Moderate dehydration is represented when the child has lost 6-9% of his or her body weight.
The nurse who teaches nutrition at a community center is asked "how much water does a person need to drink daily". The nurse's best response would be:
The correct answer is two quarts. The average adult needs eight glasses, or two quarts, of water per day. The remaining answer choices are not correct.
The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammograms
The correct answer is yearly after age 40. The American Cancer Society recommends a mammogram yearly for women over age 40. The other statements are not correct. It is recommended that women between ages 20 and 40 have a professional breast examination (not a mammogram) every 3 years.
The client is prescribed morphine. The client is experiencing urinary retention. The nurse understands the physician may order which of the following?
The correct answer is: a lowered dose of morphine. If the client experiences the side effect of urinary retention due to the morphine, the physician may order a change in the dose or a lowered dosing of morphine. Also, the physician may instruct the nurse to catharize the client. The remaining answer choices are incorrect as they are orders the physician may give for other conditions such as constipation.
The nurse is assessing a client's pulse. Which pulse feature should the nurse document?
The correct answer is: amplitude. The nurse should document the rate, rhythm, and amplitude of a client's pulse. Pitch, timing, and intensity are not associated with pulse assessment.
Which of the following is MOST likely a characteristic found with individuals who are diagnosed with borderline personality disorder?
The correct answer is: identity disturbance. Individuals with borderline personality have an identity disturbance where the individual has difficulty keeping a stable mood and self image. Characteristics of personality disorders are unpredictable behavior, impulsiveness, and irritability. Timidness, social discomfort and fear of negative feedback are not typical with borderline personality but are found in individuals diagnosed with avoidant personality disorder.
A female client is discharged from the hospital post delivery. The nurse escorts a mother and her newborn to the car. Which of the following approaches should the nurse instruct the new mother to place the newborn?
The correct answer is: in the back seat of the car with the car seat facing backwards. While regulations may vary from state to state, it is recommended that an infant up to 1 year of age use a rear facing car seat or longer until they outgrow it.
Which of the following is a brand name for Rabeprazole?
Correct answer: Aciphex. Aciphex is a brand name for Rabeprazole. Carafate is a brand name for Sucralfate and azulfidine for Sulfasalazine. Zantac is Ranitidine.
Of the following, which is the normal range of respiration rate, in breaths per minute, for an adult?
12-20 30-45 breaths per minute is the normal range for an 3-6 month old babies. 24-32 is normal for a toddler, and 20-24 for a small child. The average breath rate drops with age and levels off during adolescence, to approximately 12-20 breaths per minute.
Pain has which of the following effects on respiratory rate?
Correct answer: Increases. Pain will increase respiratory and heart functions. This can be counteracted with morphine if indicated.
What is the normal value of urine potassium?
25-120 mEq/24 hr The normal value for urine potassium is 25-120 mEq/24 hr
The normal blood glucose range is which of the following?
Correct Answer:70-100 mg/dL
Which of the following is a brand name for Buspirone?
Correct answer: BuSpar
The nurse is teaching accident prevention to the parents of a toddler. Which instruction is MOST appropriate for the nurse to tell the parents?
Correct answer: Place locks on cabinets containing toxic substances. All household cleaners and poisons should be locked with childproof locks. The toddler's curiosity and the ability to climb and open doors and drawers makes poisoning a concern in this age group. Rollerblading is not an appropriate activity for toddlers. Toddlers lack the cognitive development to understand water safety. Pillows should not be placed in the crib of an infant to avoid suffocation; however, toddlers may use them.
The nurse is performing wound care. Which of the following practices violates surgical asepsis?
Correct answer: Pouring solution onto a sterile field cloth. Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other choices are practices that help ensure surgical asepsis.
Which of the following is a brand name for Metoclopramide HCL?
Correct answer: Reglan
Which of the following theorists was mentally disturbed?
Gordon Allport, Hans Eysenck, and Raymond Cattell. NONE OF THE ABOVE
Which of the following terms corresponds with the phrase: a woman that is pregnant?
Gravida Gravida is another word for pregnancy. Spermatogonia refers to male sperm cells. Placenta previa is when the placenta is too close to the cervix.
Which of the following is the generic name for Nizoral?
Ketoconazole. Isotretinoin is the generic name for Accutane. Nystatin is the generic name for Mycostatin and Flucinonide, a generic name for Lidex.
Which of the following will MOST help an elderly, hearing impaired client admitted to the hospital?
Limit bedside conversation to that which directly pertains to the patient. This creates the least amount of auditory disturbance for the patient. Lots of noise can be upsetting to those with hearing impairments.
The RN is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse use to dilute this medication?
Normal saline (0.9%) solution. Phenytoin (Dilantin) should be administered by injection into a large vein by intermittent intravenous infusion. Normal saline (0.9%) solution is the preferred solution. Dextrose should be avoided because of medication precipitation.
The nurse is developing a plan of care for the client in a crisis state. When developing the plan, the nurse considers which of the following?
The Correct answer is: A client's response to a crisis situation is individualized and what constitutes a crisis for one person may not constitute a crisis for another person. A crisis response can be described in similar terms, what constitute a crisis for one person may not constitute a crisis for another person because each person is unique. A crisis state does not mean that the person has an emotional or mental illness.
You are assigned to educate the nursing assistants regarding caring for the older adult. It is important that the assistants understand that which of the following situations portrays ageism?
The Correct answer is: Advising older adults to forgo aggressive treatment. Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older persons are different from "me" and will remain different from "me." Advising older adults to forgo (go without) aggressive treatment, when such a treatment would be offered as a possibility to the general population, displays ageism by treating the older adults as fundamentally different from the general population. The other answers identify supporting roles of the nurse for the older person.
The nurse has been ordered to collect a sputum specimen from a client. The professional nurse knows which of the following will facilitate obtaining the specimen?
The Correct answer is: Having the client take three deep breaths. The proper procedure to collect a specimen includes rinsing the mouth out to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or inhalation respiratory treatments so the best time to collect the specimen is early a.m. upon arising.
A 21-year-old female is diagnosed with dysthymic disorder. When obtaining a history from the female, what information should the nurse expect?
The correct answer is: irritability. In young adults and children, the symptoms noted with dysthymic disorder include irritability, depression, low self esteem, pessimism, and impaired social skills and social interactions. Talking excessively is more evident with children who have attention deficit hyperactivity disorder. Intense fear is associated with anxiety disorders. Further, compulsive behavior is not associated with individuals diagnosed with dysthymic disorder.
