NCSBSN Study Question PART 3
A 12 year-old child is admitted with a broken arm and is told surgery is required. The nurse finds him crying and unwilling to talk. What is the most appropriate response by the nurse? A) Give him privacy B) Tell him he will get through the surgery with no problem C) Try to distract him D) Make arrangements for his friends to visit
A
A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client's medication administration record. The nurse should notify the health care provider if the client received which medication during the preceding 24 hours? A) Digoxin (Lanoxin) B) Diltiazem (Cardizem) C) Nitroglycerine ointment D) Metoprolol (Toprol XL)
A
A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the registered nurse implement first? A) Gastric lavage PRN B) Antidote N-acetylcysteine (NAC) (Mucomyst) for age per pharmacy C) Start a Dextrose 5% with 0.33% normal saline IV to keep vein open D) Activated charcoal per pharmacy
A
A client diagnosed with chronic depression is maintained on tranylcypromine (Parnate). An important nursing intervention is to teach the client to avoid which of the following foods? A) Wine, beer, cheese, liver and chocolate B) Wine, citrus fruits, yogurt and broccoli C) Beer, cheese, beef and carrots D) Wine, apples, sour cream and beef steak
A
A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A) Should be taken in the morning B) May decrease the client's energy level C) Must be stored in a dark container D) Will decrease the client's heart rate
A
A client has just been diagnosed with breast cancer. The nurse enters the room and the client tells the nurse that she is stupid. What is the most therapeutic response by the nurse? A) Explore what is going on with the client B) Accept the client's statement without comment C) Tell the client that the comment is inappropriate D) Leave the client's room
A
A client is admitted to the hospital with findings of liver failure with ascites. The health care provider orders spironolactone (Aldactone). What is the pharmacological effect of this medication? A) Promotes sodium and chloride excretion B) Increases aldosterone levels C) Depletes potassium reserves D) Combines safely with antihypertensives
A
A client is discharged on warfarin sulfate (Coumadin). Which statement by the client indicated a need for further teaching? A) "I know I must avoid crowds." B) "I will keep all laboratory appointments." C) "I plan to use an electric razor for shaving." D) "I will report any bruises for bleeding."
A
A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? A) Blood pressure 94/60 B) Heart rate 76 BPM C) Urine output 50 ml/hour D) Respiratory rate 16
A
A client is to begin taking Fosamax. The nurse must emphasize which of these instructions to the client when taking this medication? "Take Fosamax... A) on an empty stomach." B) after meals." C) with calcium." D) with milk 2 hours after meals."
A
A client tells the RN she has decided to stop taking sertraline (Zoloft) because she doesn't like the nightmares, sex dreams, and obsessions she's experiencing since starting on the medication. What is an appropriate response by the nurse? A) "It is unsafe to abruptly stop taking any prescribed medication." B) "Side effects and benefits should be discussed with your health care provider." C) "This medication should be continued despite unpleasant symptoms." D) "Many medications have potential side effects."
A
A client with a panic disorder has a new prescription for Xanax (alprazolam). In teaching the client about the drug's actions and side effects, which of the following should the nurse emphasize? A) Short-term relief can be expected B) The medication acts as a stimulant C) Dosage will be increased as tolerated D) Initial side effects often continue
A
A client with tuberculosis is started on Rifampin. Which one of the following statements by the nurse would be appropriate to include in teaching? "You may notice: A) an orange-red color to your urine." B) your appetite may increase for the first week." C) it is common to experience occasional sleep disturbances." D) if you take the medication with food, you may have nausea."
A
A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process? A) Disruption of fetal glucose supply B) Pancreatic insufficiency C) Maternal insulin dependency D) Reduced glycogen reserves
A
A nurse has administered several blood transfusions over 3 days to a 12 year-old client with Thalassemia. What lab value should the nurse monitor closely during this therapy? A) Hemoglobin B) Red Blood Cell Indices C) Platelet count D) Neutrophil percent
A
A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? A) the muscles B) the cerebellum C) the kidneys D) the leg bones
A
After assessing a 70 year-old male client's laboratory results during a routine clinic visit, which one of the following findings would indicate an area in which teaching is needed: A) Serum albumin 2.5 g/dl B) LDL Cholesterol 140 mg/dl C) Serum glucose 90 mg/dl D) RBC 5.0 million/mm3
A
At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states "My blood pressure is usually much lower." The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours B) check blood pressure again in 2 months C) see the health care provider immediately D) visit the health care provider within 1 week for a BP check
A
Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that it: A) considers client and staff needs B) conserves time spent on planning C) frees the nurse manager to handle other priorities D) allows requests for special privileges
A
During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse? A) The client's self-report is the most important consideration B) Cultural sensitivity is fundamental to pain management C) Clients have the right to have their pain relieved D) Nurses should not prejudge a client's pain using their own values
A
In addition to standard precautions, a nurse should implement contact precautions for which client? A) 60 year-old with herpes simplex B) 6 year-old with mononucleosis C) 45 year-old with pneumonia D) 3 year-old with scarlet fever
A
Included in teaching the client with tuberculosis taking isoniazid (INH) about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical? A) Liver function B) Kidney function C) Blood sugar D) Cardiac enzymes
A
The client asks the nurse how the health care provider could tell she was pregnant "just by looking inside." What is the best explanation by the nurse? A) Bluish coloration of the cervix and vaginal walls B) Pronounced softening of the cervix C) Clot of very thick mucous that obstructs the cervical canal D) Slight rotation of the uterus to the right
A
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the discharge list in order to make room for a new admission? A) A middle aged client with a 7 year history of being ventilator dependent and who was admitted with bacterial pneumonia five days ago B) A young adult with Type 2 diabetes mellitus for over 10 years and who was admitted with antibiotic-induced diarrhea 24 hours ago C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and who was admitted with Stevens-Johnson syndrome that morning D) An adolescent with a positive HIV test and who was admitted for acute cellulitis of the lower leg 48 hours ago
A
The nurse is assessing a client with chronic obstructive pulmonary disease receiving oxygen for low PaO2 levels. Which assessment is a nursing priority? A) Evaluating SaO2 levels frequently B) Observing skin color changes C) Assessing for clubbing fingers D) Identifying tactile fremitus
A
The nurse is assessing a client's home in preparation for discharge. Which of the following should be given priority consideration? A) Family understanding of client needs B) Financial status C) Location of bathrooms D) Proximity to emergency services
A
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse? A) Decreased breath sounds in right lower lobe B) Aspiration of a residual of 100cc of formula C) Decrease in bowel sounds D) Urine output of 250 cc in past 8 hours
A
The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to A) restrict visitors to immediate family B) avoid arousal of the client except for family visits C) keep client's hips flexed at no less than 90 degrees D) apply a warming blanket for temperatures of 98 degrees Fahrenheit or less
A
The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child? A) Using a moist soft brush or cloth to clean teeth and gums B) Swabbing teeth and gums with flavored mouthwash C) Offering a bottle of water for the child to drink D) Brushing with toothpaste and flossing each tooth
A
The nurse is caring for a 10 year-old child who has just been diagnosed with diabetes insipidus. The parents ask about the treatment prescribed, vasopressin. A What is priority in teaching the child and family about this drug? A) The child should carry a nasal spray for emergency use B) The family must observe the child for dehydration C) Parents should administer the daily intramuscular injections D) The client needs to take daily injections in the short-term
A
The nurse is caring for a 2 month-old infant with a congenital heart defect. Which of the following is a priority nursing action? A) Provide small feedings every 3 hours B) Maintain intravenous fluids C) Add strained cereal to the diet D) Change to reduced calorie formula
A
The nurse is caring for a client with asthma who has developed gastroesophageal reflux disease (GERD). Which of the following medications prescribed for the client may aggravate GERD? A) Anticholinergics B) Corticosteroids C) Histamine blocker D) Antibiotics
A
The nurse is explaining the effects of cocaine abuse to a pregnant client. Which of the following must the nurse understand as a basis for teaching? A) Cocaine use can cause fetal growth retardation B) The drug has been linked to neural tube defects C) Newborn withdrawal generally occurs immediately after birth D) Breast feeding promotes positive parenting behaviors
A
The nurse is performing a neurological assessment on a client post right cerebral vascular accident (CVA). Which finding, if observed by the nurse, would warrant immediate attention? A) Decrease in level of consciousness B) Loss of bladder control C) Altered sensation of stimuli D) Emotional lability
A
The nurse is planning care for an 8 year-old child. Which of the following should be included in the plan of care? A) Encourage child to engage in activities in the playroom B) Promote independence in activities of daily living C) Talk with the child and allow him to express his opinions D) Provide frequent reassurance and cuddling
A
The nurse is preparing to administer a tube feeding to a postoperative client. To accurately assess for a gastrostomy tube placement, the PRIORITY is to A) auscultate the abdomen while instilling 10 cc of air into the tube B) place the end of the tube in water to check for air bubbles C) retract the tube several inches to check for resistance D) measure the length of tubing from nose to epigastrium
A
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is to A) verify correct placement of the tube B) check that the feeding solution matches the dietary order C) aspirate abdominal contents to determine the amount of last feeding remaining in stomach D) ensure that feeding solution is at room temperature
A
The nurse is talking with the family of an 18 months-old newly diagnosed with retinoblastoma. A priority in communicating with the parents is A) Discuss the need for genetic counseling B) Inform them that combined therapy is seldom effective C) Prepare for the child's permanent disfigurement D) Suggest that total blindness may follow surgery
A
The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. What is the nurse's best response to the parents? A) "Your child must use a care seat until he weighs at least 40 pounds." B) "The child must be 5 years of age to use a regular seat belt." C) "Your child must reach a height of 50 inches to sit in a seat belt." D) "The child can use a regular seat belt when he can sit still."
A
The spouse of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which of the following actions by the nurse should be a PRIORITY? A) Link the caregiver with a support group B) Ask friends to visit regularly C) Schedule a home visit each week D) Request anti-anxiety prescriptions
A
What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention? A) Set good examples themselves B) Protect their child from outside influences C) Make sure their child understands all the safety rules D) Discuss the consequences of not wearing protective devices
A
Which individual is at greatest risk for developing hypertension? A) 45 year-old African American attorney B) 60 year-old Asian American shop owner C) 40 year-old Caucasian nurse D) 55 year-old Hispanic teacher
A
Which of these clients, all of whom have the findings of a board-like abdomen, would the nurse suggest that the provider examine first? A) An elderly client who stated, "My awful pain in my right side suddenly stopped about 3 hours ago." B) A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy C) A middle-aged client admitted with diverticulitis who has taken only clear liquids for the past week D) A teenager with a history of falling off a bicycle without hitting the handle bars
A
Which of these questions is priority when assessing a client with hypertension? A) "What over-the-counter medications do you take?" B) "Describe your usual exercise and activity patterns." C) "Tell me about your usual diet." D) "Describe your family's cardiovascular history."
A
Which of these statements best describes the characteristic of an effective reward-feedback system? A) Specific feedback is given as close to the event as possible B) Staff are given feedback in equal amounts over time C) Positive statements precede a negative statement D) Performance goals should be higher than what is attainable
A
A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client's greatest risk factors for osteoporosis? A) History of menopause at age 50 B) Taking high doses of steroids for arthritis for many years C) Maintaining an inactive lifestyle for the past 10 years D) Drinking 2 glasses of red wine each day for the past 30 years
B
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease (PID). The nurse recognizes that this condition most frequently follows which type of infection? A) Trichomoniasis B) Chlamydia C) Staphylococcus D) Streptococcus
B
A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially? A) Conduct guided imagery or distraction B) Ensure that the stump is elevated the first day post-op C) Wrap the stump snugly in an elastic bandage D) Administer opioid narcotics as ordered
B
A client diagnosed with cirrhosis is started on lactulose (Cephulac). The main purpose of the drug for this client is to A) add dietary fiber B) reduce ammonia levels C) stimulate peristalsis D) control portal hypertension
B
A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure A) right heart function B) left heart function C) renal tubule function D) carotid artery function
B
A client has had a positive reaction to purified protein derivative (PPD). The client asks the nurse what this means. The nurse should indicate that the client has A) active tuberculosis B) been exposed to mycobacterium tuberculosis C) never had tuberculosis D) never been infected with mycobacterium tuberculosis
B
A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the provider ordering A) pulmonary embolectomy B) vena caval interruption C) increasing the Coumadin therapy to an INR of 3-4 D) thrombolytic therapy
B
A client is prescribed warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in the nurse's discharge instruction? A) Maintain a consistent intake of green leafy foods B) Report any nose or gum bleeds C) Take Tylenol for minor pains D) Use a soft toothbrush
B
A client is receiving Total Parenteral Nutrition (TPN) via a Hickman catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? A) Check that the catheter tip is intact B) Apply a pressure dressing to the site C) Monitor respiratory status D) Assess for mental status changes
B
A client is receiving lithium carbonate 600 mg T.I.D. to treat bipolar disorder. Which of these indicate early signs of toxicity? A) Ataxia and course hand tremors B) Vomiting, diarrhea and lethargy C) Pruritus, rash and photosensitivity D) Electrolyte imbalance and cardiac arrhythmias
B
A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these? A) Double vision and visual halos B) Extremity tingling and numbness C) Confusion and lightheadedness D) Sensitivity of sunlight
B
A client telephones the clinic to ask about a home pregnancy test she used this morning. The nurse understands that the presence of which hormone strongly suggests a woman is pregnant? A) Estrogen B) HCG C) Alpha-fetoprotein D) Progesterone
B
A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which A) increase the heart rate B) lead to dehydration C) are considered aerobic D) may be competitive
B
A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is GREATEST A) during the night shift when staffing is limited B) when the client's mood improves with an increase in energy level C) at the time of the client's greatest despair D) after a visit from the client's estranged partner
B
A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial temperature is 95 degrees Fahrenheit (35 degrees Celsius) axillary. The nurse recognizes that cold stress may lead to what complication? A) Lowered BMR B) Reduced PaO2 C) Lethargy D) Metabolic alkalosis
B
A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in an incubator. Which action is a nursing priority? A) Protect the eyes of the neonate from the heat lamp B) Monitor the neonate's temperature C) Warm all medications and liquids before giving D) Avoid touching the neonate with cold hands
B
A nurse admits a client transferred from the emergency room (ER). The client, diagnosed with a myocardial infarction, is complaining of substernal chest pain, diaphoresis and nausea. The first action by the nurse should be to A) order an EKG B) administer morphine sulfate C) start an IV D) measure vital signs
B
A nurse is assigned to care for a comatose diabetic on IV insulin therapy. Which task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)? A) Check the client's level of consciousness B) Obtain the regular blood glucose readings C) Determine if special skin care is needed D) Answer questions from the client's spouse about the plan of care
B
A triage nurse has these 4 clients arrive in the emergency department within a 15 minute period. Which client should the triage nurse send back to be seen first? A) A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying B) A teenager who got a singed beard while camping C) An elderly client with complaints of frequent liquid brown colored stools D) A middle aged client with intermittent pain behind the right scapula
B
An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The nurse understands that which of the following is true in regards to giving immunizations to this child? A) Live vaccines are withheld in children with renal chronic illness B) The MMR vaccine should be given now, prior to the transplant C) An inactivated form of the vaccine can be given at any time D) The risk of vaccine side effects precludes giving the vaccine
B
An older adult client is to receive and antibiotic, gentamicin. What diagnostic finding indicates the client may have difficult excreting the medication? A) High gastric pH B) High serum creatinine C) Low serum albumin D) Low serum blood urea nitrogen
B
As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following? A) What and how much the client drinks, according to family and friends B) The blood alcohol level of the client C) The blood pressure level of the client D) The blood glucose level of the client
B
At a senior citizens meeting a nurse talks with a client who has Type 1 diabetes mellitus. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity? A) "I give my insulin to myself in my thighs." B) "Sometimes when I put my shoes on I don't know where my toes are." C) "Here are my up and down glucose readings that I wrote on my calendar." D) "If I bathe more than once a week my skin feels too dry."
B
Clients taking lithium must be particularly sure to maintain adequate intake of which of these elements? A) Potassium B) Sodium C) Chloride D) Calcium
B
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His partner states he fell down the stairs 2 hours ago. The nurse should A) place a call to the client's provider for instructions B) send him to the emergency room for evaluation C) reassure the client's partner that the symptoms are transient D) instruct the client's partner to call the provider if his symptoms become worse
B
The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure? A) "He has been taking long naps for a week." B) "He has had an ear infection for the past 2 days." C) "He has been eating more red meat lately." D) "He seems to be going to the bathroom more frequently."
B
The nurse assesses the use of coping mechanisms by an adolescent 1 week after the client had a motor vehicle accident resulting in multiple serious injuries. Which of these characteristics are most likely to be displayed? A) Ambivalence, dependence, demanding B) Denial, projection, regression C) Intellectualization, rationalization, repression D) Identification, assimilation, withdrawal
B
The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after hearing the report? A) The client with asthma who is now ready for discharge B) The client with a peptic ulcer who has been vomiting all night C) The client with chronic renal failure returning from dialysis D) The client with pancreatitis who was admitted yesterday
B
The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75 year-old client's A) poor nutritional status B) decreased gastrointestinal motility C) increased splanchnic blood flow D) altered peripheral resistance
B
The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse's immediate attention? A) "I have bad muscle spasms in my lower leg of the affected extremity." B) "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger." C) "I have to use the bedpan to pass my water at least every 1 to 2 hours." D) "It seems that the pain medication is not working as well today."
B
The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience A) high fever B) nausea C) face and neck edema D) night sweats
B
The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's IMMEDIATE action? A) Periorbital edema B) Dizzy spells C) Lethargy D) Shortness of breath
B
The nurse is caring for a client with a new order for bupropion (Wellbutrin) for treatment of depression. The order reads "Wellbutrin 175 mg. BID x 4 days." What is the appropriate action? A) Give the medication as ordered B) Question this medication dose C) Observe the client for mood swings D) Monitor neuro signs frequently
B
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? A) Apply dressing using sterile technique B) Improve the client's nutrition status C) Initiate limb compression therapy D) Begin proteolytic debridement
B
The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? A) "You need to regain your strength before attempting such exertion. B) "When you can climb 2 flights of stairs without problems, it is generally safe." C) "Have a glass of wine to relax you, then you can try to have sex." D) "If you can maintain an active walking program, you will have less risk."
B
The nurse is planning care for a client who is taking cyclosporin (Neoral). What would be an appropriate nursing diagnosis for this client? A) Alteration in body image B) High risk for infection C) Altered growth and development D) Impaired physical mobility
B
The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response? A) Electrical energy fields B) Spinal column manipulation C) Mind-body balance D) Exercise of joints
B
The nurse is teaching a client about the difference between tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). Which statement is true with regards to tardive dyskinesia? A) TD develops within hours or years of continued antipsychotic drug use in people under 20 and over 30 B) It can occur in clients taking antipsychotic drugs longer than 2 years C) Tardive dyskinesia occurs within minutes of the first dose of antipsychotic drugs and is reversible D) TD can easily be treated with anticholinergic drugs
B
The nurse is teaching a group of college students about breast self-examination. A woman asks for the best time to perform the monthly exam. What is the best reply by the nurse? A) "The first of every month, because it is easiest to remember" B) "Right after the period, when your breasts are less tender" C) "Do the exam at the same time every month" D) "Ovulation, or mid-cycle is the best time to detect changes"
B
The nurse is teaching a school-aged child and family about the use of inhalers prescribed for asthma. What is the best way to evaluate effectiveness of the treatments? A) Rely on child's self-report B) Use a peak-flow meter C) Note skin color changes D) Monitor pulse rate
B
The nurse is teaching about nonsteroidal anti-inflammatory drugs (NSAIDs) to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions? A) Reporting joint stiffness in the morning B) Taking the medication 1 hour before or 2 hours after meals C) Using alcohol in moderation unless driving D) Continuing to take aspirin for short term relief
B
The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an appropriate finger food? A) Hot dog pieces B) Sliced bananas C) Whole grapes D) Popcorn
B
When teaching a client about an oral hypoglycemic medication, the nurse should place primary emphasis on A) recognizing findings of toxicity B) taking the medication at specified times C) increasing the dosage based on blood glucose D) distinguishing hypoglycemia from hyperglycemia
B
When teaching a client with a new prescription for lithium (Lithane) for treatment of a bi-polar disorder which of these should the nurse emphasize? A) Maintaining a salt restricted diet B) Reporting vomiting or diarrhea C) Taking other medication as usual D) Substituting generic form if desired
B
Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A) Angina at rest B) Thrombus formation C) Dizziness D) Falling blood pressure
B
Which of the following assessments by the nurse would indicate that the client is having a possible adverse response to the isoniazid (INH)? A) Severe headache B) Appearance of jaundice C) Tachycardia D) Decreased hearing
B
Which of the following situations is most likely to produce sepsis in the neonate? A) Maternal diabetes B) Prolonged rupture of membranes C) Cesarean delivery D) Precipitous vaginal birth
B
Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct? A) It is to observe reactive service and product problem solving B) Improvement of the processes in a proactive, preventive mode is paramount C) A chart audits to finds common errors in practice and outcomes associated with goals D) A flow chart to organize daily tasks is critical to the initial stages
B
While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age? A) 1 year of age B) 2 years of age C) 3 years of age D) 4 years of age
B
A 3 year-old child has tympanostomy tubes in place. The child's parent asks the nurse if he can swim in the family pool. The BEST response from the nurse is A) "Your child should not swim at all while the tubes are in place." B) "Your child may swim in your own pool but not in a lake or ocean." C) "Your child may swim if he wears ear plugs." D) "Your child may swim anywhere."
C
A 52 year-old post menopausal woman asks the nurse how frequently she should have a mammogram. What is the nurse's best response? A) "Your doctor will advise you about your risks." B) "Unless you had previous problems, every 2 years is best." C) "Once a woman reaches 50, she should have a mammogram yearly." D) "Yearly mammograms are advised for all women over 35."
C
A 78 year-old client with pneumonia has a productive cough, but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration? A) Suction the client frequently while restrained B) Secure all 4 restraints to 1 side of bed C) Obtain a sitter for the client while restrained D) Request an order for a cough suppressant
C
A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear? A) Change in body image B) An unfamiliar environment C) Perceived loss of control D) Guilt over being hospitalized
C
A child who has recently been diagnosed with cystic fibrosis (CF) is being assessed by a pediatric clinic nurse. Which finding of this disease would the nurse not expect to see at this time? A) Positive sweat test B) Bulky greasy stools C) Moist, productive cough D) Meconium ileus
C
A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that such remedies A) destroy organisms causing disease B) maintain fluid balance C) boost the immune system D) increase bodily energy
C
A client being discharged from the cardiac step-down unit following a myocardial infarction (MI), is given a prescription for a beta-blocking drug. A nursing student asks the charge nurse why this drug would be used by a client who is not hypertensive. What is an appropriate response by the charge nurse? A) "Most people develop hypertension following an MI." B) "A beta-Blocker will prevent orthostatic hypotension." C) "This drug will decrease the workload on his heart." D) "Beta-blockers increase the strength of heart contractions."
C
A client has been started on a long term corticosteroid therapy. Which of the following comments by the client indicate the need for further teaching? A) "I will keep a weekly weight record." B) "I will take medication with food." C) "I will stop taking the medication for 1 week every month." D) "I will eat foods high in potassium."
C
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is A) Maintain fluid and electrolyte balance B) Control nausea C) Manage pain D) Prevent urinary tract infection
C
A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to A) begin intravenous therapy B) initiate continuous blood pressure monitoring C) administer oxygen therapy D) institute cardiac monitoring
C
A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which finding would require the nurse's IMMEDIATE attention? A) increased restlessness B) tachycardia C) tracheal deviation D) tachypnea
C
A client is receiving and IV antibiotic infusion and is scheduled to have blood drawn at 1:00 pm for a "peak" antibiotic level measurement. The nurse notes that the IV infusion is running behind schedule and will not be competed by 1:00. The nurse should: A) Notify the client's health care provider B) Stop the infusion at 1:00 pm C) Reschedule the laboratory test D) Increase the infusion rate
C
A client on telemetry begins having premature ventricular beats (PVBs) at 12 per minute. In reviewing the most recent laboratory results, which would require immediate action by the nurse? A) Calcium 9 mg/dl B) Magnesium 2.5 mg/dl C) Potassium 2.5 mEq/L D) PTT 70 seconds
C
A client who is 12 hour post-op becomes confused and says: "Giant sharks are swimming across the ceiling." Which assessment is necessary to adequately identify the source of this client's behavior? A) Cardiac rhythm strip B) Pupillary response C) Pulse oximetry D) Peripheral glucose stick
C
A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? A) Gravida 4 para 2 B) Gravida 2 para 1 C) Gravida 3 para 1 D) Gravida 3 para 2
C
A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving aminophylline, 25mg/hour. Which one of the following findings by the nurse would require immediate intervention? A) Decreased blood pressure and respirations B) Flushing and headache C) Restlessness and palpitations D) Increased heart rate and blood pressure
C
A client with paranoid thoughts refuses to eat because of the belief that the food is poisoned. The appropriate statement at this time for the nurse to say is A) "Here, I will pour a little of the juice in a medicine cup to drink it to show you that it is OK." B) "The food has been prepared in our kitchen and is not poisoned." C) "Let's see if your partner could bring food from home." D) "If you don't eat, I will have to suggest for you to be tube fed."
C
A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach? A) Vary the interview style for each candidate to learn different techniques B) Use simple questions requiring "yes" and "no" answers to gain definitive information C) Obtain an interview guide from human resources for consistency in interviewing each candidate D) Ask personal information of each applicant to assure he/she can meet job demands
C
A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process? A) Regulate the neonate's temperature using a radiant heater B) Withhold feedings while under the phototherapy C) Provide water feedings at least every 2 hours D) Protect the eyes of neonate from the phototherapy lights
C
A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is A) start a peripheral IV B) initiate closed-chest massage C) establish an airway D) obtain the crash cart
C
A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention? A) Capillary refill of fingers on right hand is 3 seconds B) Skin warm to touch and normally colored C) Client reports prickling sensation in the right hand D) Slight swelling of fingers of right hand
C
A nurse is caring for a client who has just been admitted with an overdose of aspirin. The following lab data is available: PaO2 95, PaCO2 30, pH 7.5, K 3.2 mEq/l. Which should be the nurse's first action? A) Monitor respiratory rate B) Monitor intake and output every hour C) Assist the client to breathe into a paper bag D) Prepare to administer oxygen by mask
C
A nurse is evaluating the quality of home care for a client with Alzheimer's disease. It would be a priority to reinforce which statement by a family member? A) "At least 2 full meals a day should be eaten." B) "We go to a group discussion every week at our community center." C) "We have safety bars installed in the bathroom and have 24 hour alarms on the doors." D) "Taking the medication 3 times a day is not a problem."
C
A nurse is performing the routine daily cleaning of a tracheostomy. During the procedure, the client coughs and displaces the tracheostomy tube. This negative outcome could have avoided by A) placing an obturator at the client's bedside B) having another nurse assist with the procedure C) fastening clean tracheostomy ties before removing old ties D) placing the client in a flat, supine position
C
A post-operative client is admitted to the post-anesthesia recovery room (PACU). The anesthetist reports that malignant hyperthermia occurred during surgery. The nurse recognizes that this complication is related to what factor? A) Allergy to general anesthesia B) Pre-existing bacterial infection C) A genetic predisposition D) Selected surgical procedures
C
A woman in labor calls the nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on the bed linens. The nurse knows that fetal monitoring must now assess for what complication? A) Early decelerations B) Late accelerations C) Variable decelerations D) Periodic accelerations
C
An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest." B) A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?" C) An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room
C
As a part of a 9 pound full-term newborn's assessment, the nurse performs a dextro-stick at 1 hour post birth. The serum glucose reading is 45 mg/dl. What action by the nurse is appropriate at this time? A) Give oral glucose water B) Notify the pediatrician C) Repeat the test in 2 hours D) Check the pulse oximetry reading
C
During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results indicate a level of 11%. Based on this result, what teaching should the nurse emphasize? A) Rotation of injection sties B) Insulin mixing and preparation C) Daily blood sugar monitoring D) Regular high protein diet
C
During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to A) increase fluids that are high in protein B) restrict fluids C) force fluids and reassess blood pressure D) limit fluids to non-caffeine beverages
C
In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? A) Polyphagia B) Dehydration C) Bed wetting D) Weight loss
C
In response to a call for assistance by a client in labor, the nurse notes that a loop on the umbilical cord protrudes from the vagina. What is the priority nursing action? A) call the health care provider B) check fetal heart beat C) put the client in knee-chest position D) turn the client to the side
C
Initial postoperative nursing care for an infant who has had a pyloromyotomy would INITIALLY include A) bland diet appropriate for age B) intravenous fluids for 3-4 days C) NPO then glucose and electrolyte solutions D) formula or breast milk as tolerated
C
The clinic nurse is counseling a substance-abusing post partum client on the risks of continued cocaine use. In order to provide continuity of care, which nursing diagnosis is a priority? A) Social isolation B) Ineffective coping C) Altered parenting D) Sexual dysfunction
C
The feeling of trust can BEST be established by the nurse during the process of the development of a nurse-client relationship by which of these characteristics? A) Reliability and kindness B) Demeanor and sincerity C) Honesty and consistency D) Sympathy and appreciativeness
C
The nurse administers cimetidine (Tagamet) to a 79 year-old male with a gastric ulcer. Which parameter may be affected by this drug, and should be closely monitored by the nurse? A) Blood pressure B) Liver function C) Mental status D) Hemoglobin
C
The nurse has just received report on a group of clients and plans to delegate care of several of the clients to a practical nurse (PN). The FIRST thing the RN should do before the delegation of care is A) Provide a time-frame for the completion of the client care B) Assure the PN that the RN will be available for assistance C) Ask about prior experience with similar clients D) Review the specific procedures unique to the assignment
C
The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action? A) Central venous pressure reading of 11 B) Respiratory rate of 22 C) Pulse rate of 48 BPM D) Blood pressure of 144/92
C
The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects? A) Neurotoxicity B) Hepatomegaly C) Nephrotoxicity D) Ototoxicity
C
The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? A) Narrowed QRS complex B) Shortened "PR" interval C) Tall peaked T waves D) Prominent "U" waves
C
The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding? A) bounding pulse B) rapid respirations C) oliguria D) neck veins are distended
C
The nurse is caring for a post-operative client who develops a wound evisceration. The first nursing intervention should be A) medicate the client for pain B) call the provider C) cover the wound with sterile saline dressing D) place the bed in a flat position
C
The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When coming to a conclusion using the Ballard scale, which of these factors may affect the score? A) Birth weight B) Racial differences C) Fetal distress in labor D) Birth trauma
C
The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dl. Which of the following would the nurse anticipate? A) Additional potassium will be given IV B) Blood for coagulation studies will be drawn C) Total parenteral nutrition (TPN) will be started D) Serum lipase levels will be evaluated
C
The nurse is providing care to a newly a hospitalized adolescent. What is the major threat experienced by the hospitalized adolescent? A) Pain management B) Restricted physical activity C) Altered body image D) Separation from family
C
The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspects of this care is/are A) sedation as needed to prevent exhaustion B) antibiotic therapy for 10 to 14 days C) humidified air and increased oral fluids D) antihistamines to decrease allergic response
C
The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching? A) "I'm going to try feeding my baby some rice cereal." B) "When he wakes at night for a bottle, I feed him." C) "I dip his pacifier in honey so he'll take it." D) "I keep formula in the refrigerator for 24 hours."
C
When teaching a client about the side effects of fluoxetine (Prozac), which of the following will the nurse include? A) Tachycardia blurred vision, hypotension, anorexia B) Orthostatic hypotension, vertigo, reactions to tyramine-rich foods C) Diarrhea, dry mouth, weight loss, reduced libido D) Photosensitivity, seizures, edema, hyperglycemia
C
When teaching a client with coronary artery disease about nutrition, the nurse should emphasize A) eating 3 balanced meals a day B) adding complex carbohydrates C) avoiding very heavy meals D) limiting sodium to 7 gms per day
C
Which client is at HIGHEST risk for developing a pressure ulcer? A) 23 year-old in traction for fractured femur B) 72 year-old with peripheral vascular disease, who is unable to walk without assistance C) 75 year-old with left sided paresthesia who is incontinent of urine and stool D) 30 year-old who is comatose following a ruptured aneurysm
C
Which medication is more helpful in treating bulimia than anorexia? A) Amphetamines B) Sedatives C) Anticholinergics D) Narcotics
C
Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy? A) Benzodiazepines B) Chlorpromazine (Thorazine) C) Succinylcholine (Anectine) D) Thiopental sodium (Pentothal Sodium)
C
Which of these findings indicate that a pump set to deliver a basal rate of 10 ml per hour plus PRN morphine drip for breakthrough pain is not working? A) The client complains of discomfort at the IV insertion site B) The client states "I just can't get relief from my pain" C) The level of the drug is 100 ml at 8 AM and is 80 ml at noon D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon
C
Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client? A) Venturi mask B) Partial rebreather mask C) Non-rebreather mask D) Simple face mask
C
While assessing a 1 month-old infant, which finding should the nurse report immediately? A) Abdominal respirations B) Irregular breathing rate C) Inspiratory grunt D) Increased heart rate with crying
C
While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? A) "I want to protect my child from any falls." B) "I will set limits on exploring the house." C) "I understand our child's need to use those new skills." D) "I intend to keep control over our child's behavior."
C
A 16 year-old boy is admitted for Ewing's sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the INITIAL treatment most often includes A) amputation just above the tumor B) surgical excision of the mass C) bone marrow graft in the affected leg D) radiation and chemotherapy
D
A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, skin hot to touch, sits leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A) Prepare the child for x-ray of upper airways B) Examine the child's throat C) Collect a sputum specimen D) Notify the healthcare provider of the child's status
D
A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states, "I refuse both radiation and chemotherapy because they are 'hot.'" The next action for the nurse to take is to A) document the situation in the notes B) report the situation to the health care provider C) talk with the client's family about the situation D) ask the client to talk about concerns regarding "hot" treatments
D
A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first? A) Place the child in the nearest bed B) Administer IV medication to slow down the seizure C) Place a padded tongue blade in the child's mouth D) Remove the child's toys from the immediate area
D
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication? A) Weight gain of 5 pounds B) Edema of the ankles C) Gastric irritability D) Decreased appetite
D
A client has gastroesophageal reflux. Which recommendation made by the nurse would be most helpful to the client? A) Avoid liquids unless a thickening agent is used B) Sit upright for at least 1 hour after eating C) Maintain a diet of soft foods and cooked vegetables D) Avoid eating 2 hours before going to sleep
D
A client has many delusions. As the nurse helps the client prepare for breakfast the client comments "Don't waste good food on me. I'm dying from this disease I have." The appropriate response would be A) "You need some nutritious food to help you regain your weight." B) "None of the laboratory reports show that you have any physical disease." C) "Try to eat a little bit, breakfast is the most important meal of the day." D) "I know you believe that you have an incurable disease."
D
A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The PRIORITY nursing assessment at this time is A) bowel sounds B) heart rate C) peripheral pulses D) lung sounds
D
A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client? A) Fresh juice, carrots, vanilla pudding B) Apple juice, ham salad, fresh pineapple C) Hamburger, fries, strawberry shake D) Red wine, fava beans, aged cheese
D
A client is treated in the emergency room for diabetic ketoacidosis and a glucose level of 650mg.D/L. In assessing the client, the nurse's review of which of the following tests suggests an understanding of this health problem? A) Serum calcium B) Serum magnesium C) Serum creatinine D) Serum potassium
D
A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take? A) Call the health care provider B) Access the site by cutting a window in the cast C) Simply record the findings in the nurse's notes only D) Outline the spot with a pencil and note the time and date on the cast
D
A client was admitted to the psychiatric unit for severe depression. After several days, the client continues to withdraw from the other clients. Which of these statements by the nurse would be the most appropriate to promote interaction with other clients? A) "Your team here thinks it's good for you to spend time with others. B) "It is important for you to participate in group activities." C) "Come with me so you can paint a picture to help you feel better." D) "Come play Chinese Checkers with Gloria and me."
D
A client with a fractured femur has been in Russell's traction for 24 hours. Which nursing action is associated with this therapy? A) Check the skin on the sacrum for breakdown B) Inspect the pin site for signs of infection C) Auscultate the lungs for atelectasis D) Perform a neurovascular check for circulation
D
A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct? A) Days 7-10 B) Days 10-13 C) Days 14-16 D) Days 17-19
D
A male client calls for a nurse because of chest pain. Which statement by the client would require the most immediate action by the nurse? A) "When I take in a deep breath, it stabs like a knife." B) "The pain came on after dinner. That soup seemed very spicy." C) "When I turn in bed to reach the remote for the TV, my chest hurts." D) "I feel pressure in the middle of my chest, like an elephant is sitting on my chest."
D
A male client is preparing for discharge following an acute myocardial infarction. He asks the nurse about his sexual activity once he is home. What would be the nurse's initial response? A) Give him written material from the American Heart Association about sexual activity with heart disease B) Answer his questions accurately in a private environment C) Schedule a private, uninterrupted teaching session with both the client and his wife D) Assess the client's knowledge about his health problems
D
A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss? A) The newborn needs additional assessments B) The mother should breast feed more often C) A change to formula is indicated D) The loss is within normal limits
D
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first? A) Raise the side rails on the bed B) Place the call bell within reach C) Instruct the client to remain in bed D) Have the client empty bladder
D
A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering? A) Oral Coumadin therapy B) Heparin 5000 units subcutaneously B.I.D. C) Heparin infusion to maintain the PTT at 1.5-2.5 times the control value D) Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value
D
A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms? A) Drink small amounts of liquids frequently B) Eat the evening meal just before retiring C) Take sodium bicarbonate after each meal D) Sleep with head propped on several pillows
D
After 4 electroconvulsive treatments over 2 weeks, a client is very upset and states "I am so confused. I lose my money. I just can't remember telephone numbers." The MOST therapeutic response for the nurse to make is A) "You were seriously ill and needed the treatments." B) "Don't get upset. The confusion will clear up in a day or two." C) "It is to be expected since most clients have the same results." D) "I can hear your concern and that your confusion is upsetting to you."
D
In discharge teaching, the nurse should emphasize that which of these is a common side effect of clozapine (Clozaril) therapy? A) Dry mouth B) Rhinitis C) Dry skin D) Extreme salivation
D
The clinic nurse is discussing health promotion with a group of parents. A mother is concerned about Reye's Syndrome, and asks about prevention. Which of these demonstrates appropriate teaching? A) "Immunize your child against this disease." B) "Seek medical attention for serious injuries." C) "Report exposure to this illness." D) "Avoid use of aspirin for viral infections."
D
The mother of a 4 month-old infant asks the nurse about the dangers of sunburn while they are on vacation at the beach. Which of the following is the best advice about sun protection for this child? A) "Use a sunscreen with a minimum sun protective factor of 15." B) "Applications of sunscreen should be repeated every few hours." C) "An infant should be protected by the maximum strength sunscreen." D) "Sunscreens are not recommended in children younger than 6 months."
D
The nurse anticipates that for a family who practices Chinese medicine the priority therapeutic goal would be to A) achieve harmony B) maintain a balance of energy C) respect life D) restore yin and yang
D
The nurse can BEST ensure the safety of a client suffering from dementia who wanders from the room by which action? A) Repeatedly remind the client of the time and location B) Explain the risks of walking with no purpose C) Use protective devices to keep the client in the bed or chair in the room D) Attach a wander-guard sensor band to the client's wrist
D
The nurse is assessing a woman in early labor. While positioning for a vaginal exam, she complains of dizziness and nausea and appears pale. Her blood pressure has dropped slightly. What should be the initial nursing action? A) Call the health care provider B) Encourage deep breathing C) Elevate the foot of the bed D) Turn her to her left side
D
The nurse is at the community center speaking with retired people about glaucoma. Which comment by one of the retirees would the nurse support to reinforce correct information? A) "I usually avoid driving at night since lights sometimes seem to make things blur." B) "I take half of the usual dose for my sinuses to maintain my blood pressure." C) "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem." D) "I take extra fiber and drink lots of water to avoid getting constipated."
D
The nurse is beginning nutritional counseling/teaching with a pregnant woman. What is the initial step in this interaction? A) Teach her how to meet the needs of self and her family B) Explain the changes in diet necessary for pregnant women C) Question her understanding and use of the food pyramid D) Conduct a diet history to determine her normal eating routines
D
The nurse is caring for a client receiving intravenous nitroglycerin for acute angina. What is the most important assessment during treatment? A) Heart rate B) Neurologic status C) Urine output D) Blood pressure
D
The nurse is caring for a client who is 4 days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty his colostomy pouch. What is the best response by the nurse? A) "You should be emptying the pouch yourself." B) "Let me demonstrate to you how to empty the pouch." C) "What have you learned about emptying your pouch?" D) "Show me what you have learned about emptying your pouch."
D
The nurse is performing an assessment of the motor function in a client with a head injury. The BEST technique is A) touching the trapezius muscle or arm firmly B) pinching any body part C) shaking a limb vigorously D) rubbing the sternum
D
The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse perform first? A) Explain that the procedure will help him to get well B) Show a cartoon character with a blood pressure cuff C) Explain that the blood pressure checks the heart pump D) Permit handling the equipment before putting the cuff in place
D
The nurse is teaching a client about the toxicity of digoxin. Which one of the following statements made by the client to the nurse indicates more teaching is needed? A) "I may experience a loss of appetite." B) "I can expect occasional double vision." C) "Nausea and vomiting may last a few days." D) "I must report a bounding pulse of 62 immediately."
D
The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately? A) Irritability B) Slight edema at site C) Local tenderness D) Seizure activity
D
The nurse is working in a high risk antepartum clinic. A 40 year-old woman in the first trimester gives a thorough health history. Which information should receive PRIORITY attention by the nurse? A) Her father and brother are insulin dependent diabetics B) She has taken 800 mcg of folic acid daily for the past year C) Her husband was treated for tuberculosis as a child D) She reports recent use of over-the counter sinus remedies
D
The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of A) Anonymity B) Beneficence C) Justice D) Autonomy
D
The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to A) Excessive fetal weight B) Low blood sugar levels C) Depletion of subcutaneous fat D) Progressive placental insufficiency
D
The visiting nurse makes a postpartum visit to a married female client. Upon arrival, the nurse observes that the client has a black eye and numerous bruises on her arms and legs. The initial nursing intervention would be to A) call the police to report indications of domestic violence B) confront the husband about abusing his wife C) leave the home because of the unsafe environment D) interview the client alone to determine the origin of the injuries
D
To prevent drug resistance from developing, the nurse is aware that which of the following is a characteristic of the typical treatment plan to eliminate the tuberculosis bacilli? A) An anti-inflammatory agent B) High doses of B complex vitamins C) Aminoglycoside antibiotics D) Administering two anti-tuberculosis drugs
D
What must be the priority consideration for nurses when communicating with children? A) Present environment B) Physical condition C) Nonverbal cues D) Developmental level
D
What would the nurse expect to see while assessing the growth of children during their school age years? A) Decreasing amounts of body fat and muscle mass B) Little change in body appearance from year to year C) Progressive height increase of 4 inches each year D) Yearly weight gain of about 5.5 pounds per year
D
When suctioning a client's tracheostomy, the nurse should instill saline in order to A) decrease the client's discomfort B) reduce viscosity of secretions C) prevent client aspiration D) remove a mucus plug
D
Which approach is a priority for the nurse who works with clients from many different cultures? A) Speak at least 2 other languages of clients in the neighborhood B) Learn about the cultures of clients who are most often encountered C) Have a list of persons for referral when interaction with these clients occur D) Recognize personal attitudes about cultural differences and real or expected biases
D
Which clinical finding would the nurse expect to assess first in a newborn with spastic cerebral palsy? A) cognitive impairment B) hypotonic muscular activity C) seizures D) criss-crossing leg movement
D
Which contraindication should the nurse assess for prior to giving a child immunizations? A) Mild cold symptoms B) Chronic asthma C) Depressed immune system D) Allergy to eggs
D
Which of the following laboratory results would suggest to the emergency room nurse that a client admitted after a severe motor vehicle crash is in acidosis? A) Hemoglobin 15 gm/dl B) Chloride 100 mEq/L C) Sodium 130 mEq/L D) Carbon dioxide 20 mEq/L
D
Which of the following should the nurse implement to prepare a client for a kidney, ureter, bladder (KUB) radiograph test? A) Client must be NPO before the examination B) Enema to be administered prior to the examination C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination D) No special orders are necessary for this examination
D
Which of these clients would the nurse monitor for the complication of C. difficile diarrhea? A) An adolescent taking medications for acne B) An elderly client living in a retirement center taking prednisone C) A young adult at home taking a prescribed aminoglycoside D) A hospitalized middle aged client receiving clindamycin
D
