practice exam

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention?

Burp the infant frequently. These infants usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger. Burping frequently will reduce gastric distention, and increase the likelihood that the infant will retain the feeding. Feedings should be given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged to the extent possible, but this will not increase the likelihood that the feeding will be retained. Record the type, amount, and character of the vomit, as well as its relation to the feeding. The amount of feeding volume lost is usually refed to the infant.

The nurse is planning interventions for a school-aged child hospitalized with acute poststreptococcal glomerulonephritis in need of diversional activity. Which activity should the nurse expect to include?

playing a card game with someone the same age. Generally, school-age children enjoy activities with their peers first, then family members, and lastly younger children. School-age children like to be busy but also to accomplish something. This helps to meet their task of industry versus inferiority, feeling good about what they are able to accomplish.

The nurse is administering 5,000 units heparin subcutaneously to a client (see the accompanying image). The nurse should:

use a shorter needle. Heparin should be administered into subcutaneous tissue at a 90-degree angle using a 27-gauge 5/8-inch (1.6-cm) needle. The medication should not be administered into the muscle. In order to prevent hematoma formation, the nurse should not rotate the tip of the needle or aspirate before injecting the heparin.

The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?

"Assume a reclining or flat position." The client needs to assume a safe and comfortable position during an attack, which may last several hours. The client's location when the attack occurs may dictate the most reasonable position. Ideally, the client should lie down immediately in a reclining or flat position to control the vertigo. The danger of a serious fall is real. Placing the head between the knees will not help prevent a fall and is not practical because the attack may last several hours. Concentrating on breathing may be a useful distraction, but it will not help prevent a fall. Closing the eyes does not help prevent a fall.

A client with acute mania is to receive lithium carbonate 600 mg PO three times daily and 2 mg of haloperidol PO at bedtime. Which action should the nurse take?

Give the medications as prescribed. Lithium commonly is combined with an antipsychotic agent, such as haloperidol, or a benzodiazepine such as lorazepam. Antipsychotic agents, such as haloperidol, are prescribed to produce a neuroleptic effect until the lithium, produces a clinical response. After a clinical response is achieved, the antipsychotic agent usually is discontinued. Additionally, the dosages of each drug listed are appropriate. Therefore, the nurse would administer the drugs as prescribed.

The nurse is reviewing this worksheet with the unlicensed assistive personnel (UAP) when prioritizing afternoon nursing care. What is the priority order for the nurse's administration of client care at 1300 hours?

It is important for the nurse to prioritize care in an efficient manner. The highest priority for the afternoon is administering requested pain medication for a postoperative client. Next, the intravenous piggyback would be initiated; the wound dressing could be changed while the IV is infusing. A client on a toileting schedule would be taken to the restroom as the last priority; this task that could also be delegated.

Which client has the highest risk of ovarian cancer?

45-year-old woman who has never been pregnant The incidence of ovarian cancer increases in women who have never been pregnant, are older than age 40, are infertile, or have menstrual irregularities. Other risk factors include a family history of breast, bowel, or endometrial cancer. The risk of ovarian cancer is reduced in women who have taken hormonal contraceptives, have had multiple births, or have had a first child at a young age.

While making a home visit to a multigravid client 2 weeks after the birth of term twins, the nurse observes that the client looks pale, has dark circles around her eyes, and is breastfeeding one of the twins. The client's apartment is clean, and nothing appears out of place. The client tells the nurse that she completed three loads of laundry this morning. What is the priority need to address for this client?

Fatigue related to home maintenance and caring for twins. Most postpartum clients have excessive fatigue after childbirth. This multigravida has dark circles around her eyes and is pale, which can indicate anemia or excessive sleep deprivation. The client maintains a spotless environment, has completed three loads of laundry, and is trying to breastfeed twins.There is no evidence of anxiety.There is no evidence of imbalanced nutrition.Anemia is not a nursing diagnosis.

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation?

Measle Measles warrants airborne isolation, which aims to prevent transmission of disease by airborne nuclei droplets. Other infections necessitating respiratory isolation include varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact isolation; and cholera, enteric isolation.

A nurse is teaching a client about withdrawal from the excessive use of caffeine. What will the nurse include in the teaching? Select all that apply.

One of the first symptoms of withdrawal will be a headache. Drink fluids to help with the withdrawal. Nausea and muscle pain may occur with withdrawal. The symptoms of caffeine withdrawal are headache, fatigue, drowsiness, irritability, and depression. Nausea and muscle pain can also occur. Drinking fluids during the withdrawal can prevent dehydration. Stopping the caffeine abruptly will not lessen symptoms.

A nurse is teaching a parent of a toddler diagnosed with conjunctivitis to administer the ophthalmic ointment. Which action by the mother indicates that further instruction is necessary?

The mother holds the eyelids open with her fingers. Washing hands before and after administration to an infected eye is very important to prevent the spread of conjunctivitis. Applying the ointment to the lower conjunctival sac ensures the medication will adequately cover the eye. Cleaning the eye prior to administration helps the medication be absorbed and decreases the bacteria in the eye. Holding the eyelids open will not allow application of the medication to the lower conjunctival sac.

Which is the most effective way for a nurse to assess for posterior nasal bleeding in a client who has had nasal surgery?

Use a penlight to inspect the back of the pharynx for bleeding. The best way for the nurse to detect posterior nasal bleeding is to use a penlight to observe the back of the pharynx.The nasal drip pad will remain dry with posterior nasal bleeding.Checking the client's hemoglobin and hematocrit every 8 hours will not help detect bleeding in its earliest stages.Nausea can occur postoperatively for several reasons; bleeding is just one reason.

During morning assessment, a nurse assesses four clients. Which client is the priority for follow up?

a 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line. The 73-year-old client with pneumonia should be the nurse's priority because of the oxygenation complications and the audible crackles that may result from fluid overload from the I.V. line. The 42-year-old client is younger and more mobile than the others. The 84-year-old client doesn't have pressing needs at this time. The nurse should evaluate the 48-year-old client if the client goes into atrial fibrillation, but this client isn't a priority at this time.

A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, and a temperature of 100°F (37.8°C). The nurse questions the client about a past diagnosis of what condition?

inflammatory bowel disease (IBD) IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. Colorectal cancer is usually diagnosed after the client complains of bloody stools; the client will rarely have abdominal discomfort with colorectal cancer. A client with diverticulitis commonly reports chronic constipation with occasional diarrhea, nausea, vomiting, and abdominal distention. Jaundice, coagulopathies, edema, and hepatomegaly are common signs of liver failure.

A client is receiving intravenous mannitol for treatment of a brain tumor. The client's intracranial pressure before administration of the mannitol was 14 mm Hg. Which assessment finding indicates that the medication is attaining a therapeutic effect?

intracranial pressure of 10 mm Hg. An expected finding with this osmotic diuretic is an intracranial pressure of 5-15 mm Hg. The medication is not administered to decrease agitation, lower systolic blood pressure, or decrease peripheral edema. The main therapeutic effect in brain tumor management is to decrease intracranial pressure.

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

mafenide. The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns. Gamma benzene hexachloride is a pediculicide used to treat lice infestation. Diazepam is an antianxiety agent that may be administered to clients with burns, but not to prevent infection. The opioid analgesic meperidine is used to help control pain in clients with burns.

The parent of a client who is disabled due to a traumatic amputation states to the nurse, "I am concerned that situations will occur and that I may not know what to do to help my child when we are at home." Which response by the nurse is the most appropriate to address the parent's concern?

"Talk to your child about needs and ask how you can be of assistance." There will be times where the best strategy for the parent to use is to ask what the client needs, and request that the client identify how the parent can best facilitate assistance and support in that specific situation. Although written information and the creation of a plan of care can be helpful, it is best to provide the parent with a general guideline to use since not all situations will be addressed in these materials. Focusing on the parent's limitations may limit communication and make the client hesitant to ask for assistance.

The client becomes upset when the nurse asks if the client has an advance directive and states, "Why do I need an advance directive?" What is the most appropriate explanation for the nurse to give this client about an advance directive?

"Let's talk about how an advance directive enables you to have your health care preferences known to your health care providers." The client's statement indicates a need to learn the purpose of an advance directive (which is to have the client's health care preferences made known to the health care providers). Inviting clients to talk about making decisions and stating their wishes about end-of-life care and health care treatment enables the clients to discuss what is important and culturally appropriate to them. An advance directive does not ensure the arrangement of ideal or optimal care in all medical circumstances, but assists the client to select desired care and a health care proxy. It gives the clients a voice in decision making and establishes that their wishes will be followed.

A client being treated for complications of chronic obstructive pulmonary disease needs to be intubated. The client has previously discussed their wish to not be intubated with the client's partner of 5 years, whom the client has designated as healthcare power of attorney. The client's children want their parent to be intubated. A nurse caring for this client knows that

clients commonly confer healthcare power of attorney on someone who shares their personal values and beliefs. The healthcare power of attorney is someone who can make decisions when the client can't. Clients tend to select individuals who share their personal values and beliefs as their healthcare power of attorney. Family members and designated surrogates don't always agree; state laws regarding surrogate decision makers may differ. The legal rights of a healthcare power of attorney in regards to healthcare decisions supersede those of family members. The law designates the healthcare power of attorney as the person to make decision; violating this designation could result in a lawsuit.

A client with type 2 diabetes has just started to take dulaglutide. The client reports having severe nausea. What should the nurse instruct the client to do to manage the nausea? Select all that apply.

Nausea is a common side effect when clients first start taking dulaglutide. To manage the nausea the nurse can suggest that the client eat smaller meals more frequently, drink beverages with ginger in them, and avoid fried foods. The client should decrease the fat content in the diet. The client should not stop using the drug unless prescribed by the health care provider.

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

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

A client is recovering from an acute myocardial infarction (MI). During the first week of the client's recovery, the nurse should stay alert for which abnormal heart sound?

pericardial friction rub A pericardial friction rub, which sounds like squeaky leather, may occur during the first week following an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other. Certain stenosed valves may cause a brief, high-pitched opening snap heard early in diastole. Graham Steele murmur is a high-pitched, blowing murmur with a decrescendo pattern; heard during diastole, it indicates pulmonary insufficiency, such as from pulmonary hypertension or a congenital pulmonary valve defect. An ejection click, associated with mitral valve prolapse or a rigid, calcified aortic valve, causes a high-pitched sound during systole.

A client's wife states, "I don't think lithium is helping my husband. He's been taking it for 2 days now, and he's still so hyper and thinks we're rich." Which response by the nurse would be most accurate?

"It takes 1 to 2 weeks for the drug to build up in the blood to be effective." To be effective, lithium must gradually increase in the client's bloodstream to a therapeutic level. This process takes approximately 1 to 2 weeks. Once a therapeutic level is achieved, the symptoms of mania will abate. Telling the wife that the client's symptoms are very acute and more time is needed gives the wife the impression that her husband is more seriously ill than would be expected, possibly causing the wife increased anxiety. Telling the wife that her concerns will be passed on to the health care provider does not provide the wife with the necessary information about the drug and its action. Telling the wife that an increased dosage may be necessary is inappropriate because the client has been receiving the drug for only 2 days.