Final Practice Questions

A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? Select all that apply.

- Scaly lesions - Reddened papules

A nurse in the pediatric clinic is taking the health history of a toddler with an exacerbation of eczema. What are the nurse's priority assessments of the child? Select all that apply.

- Wearing cotton clothes - Tolerance of new foods

A child with a history of asthma is brought to the emergency department experiencing an acute exacerbation of asthma. Which nursing assessment findings support this conclusion? Select all that apply.

- Wheezing - Tachycardia

A nurse is caring for a client with acute kidney injury. Which findings should the nurse anticipate when reviewing the laboratory report of the client's blood level of calcium, potassium, and creatinine? Select all that apply.

- Calcium: 7.6 mg/dL (1.9 mmol/L) - Potassium 6.0 mEq/L (6.0 mmol/L) - Creatinine: 3.2 mg/dL (194 mcmol/L)

A healthcare provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply.

- Double vision - Difficulty swallowing saliva - Drooping of the upper eyelids

A nurse is caring for a school-aged child with type 1 diabetes and determines that the child is experiencing an episode of hyperglycemia. What assessments led the nurse to this conclusion? Select all that apply.

- Dry skin - Increased thirst - Deep, rapid breathing

A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? Select all that apply.

- Gown - Gloves - Goggles

An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? Select all that apply.

- Instilling saline nose drops - Maintaining contact precautions - Suctioning mucus with a bulb syringe

The nurse is planning care for a 2-month-old infant who is diagnosed with bronchopulmonary dysplasia (BPD). Which activities may inhibit the infant's ability to learn through sensorimotor experiences? Select all that apply.

- Oxygen therapy by tent - Frequent arterial blood gases (ABG) - Contact isolation due to respiratory syncytial virus (RSV)

A nurse is obtaining a health history from the newly-admitted client who has chronic pain in the right knee. What should the nurse include in the pain assessment? Select all that apply.

- Pain history, including location, intensity, and quality of pain - Pain pattern, including precipitating and alleviating factors

The laboratory reports of a client reveal that the serum creatinine value is 7 mg/dL (618.8 mmol/L) and the blood urea nitrogen (BUN) value is 240 mg/dL (85.68 mmol/L). Which integumentary manifestations can be noticed in this client? Select all that apply.

- Pruritus - Ecchymosis - Uremic frost

A nurse is caring for a group of children with the diagnosis of autism. Which signs and symptoms are associated with this disorder? Select all that apply.

- Repetitive activities - Self-injurious behaviors - Lack of communication with others

A 2-year-old child is brought to the emergency department after the sudden onset of high fever, drooling, and respiratory distress. What nursing actions should the nurse perform? Select all that apply.

- Start an intravenous line. - Draw a blood sample for a complete blood count and differential. - Assess oxygen saturation of the blood and administer oxygen by mask if it is below 94%. - Assess the child's temperature and administer an antipyretic if the rectal temperature is higher than 101° F (38.3° C).

While working in a neuromuscular clinic the nurse monitors infants for symptoms of cerebral palsy. Which statements by infants' mothers indicate the need for further evaluation for cerebral palsy? Select all that apply.

- "My baby was able to turn from front to back by 2 months of age." - "All of my other children were sitting alone by this age. This baby doesn't seem to be anywhere near sitting alone."

The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis? Select all that apply.

- Confusion - Excessive thirst - Fruity-scented breath

A woman fractured her left tibia and fibula one week ago and has a cast in place. She is taking acetaminophen (Tylenol) with codeine for pain and an oral contraceptive. She began experiencing left calf pain 3 days ago and began having shortness of breath and chest pain 15 minutes ago. When the shortness of breath and chest pain increase, she calls the emergency department and communicates this information to the triage nurse. What is the triage nurse's best response?

"Give me your name and address. I am sending an ambulance to your home. You need emergency care."

A nurse is teaching skin and basic care to the mother of a 6-month-old infant with eczema. Which statement indicates that the mother needs further teaching?

"I'll have to be careful not to cut my baby's nails short."

The nurse is teaching a client self-management care in preventing and spreading methicillin-resistant Staphylococcus aureus (MRSA). Which statements made by the client indicate the need for further learning? Select all that apply.

- "I can share athletic equipment." - "I can participate in contact sports." - "I should sit on upholstered furniture."

A registered nurse teaches a client regarding the therapeutic management of herpes simplex virus. Which statements made by the client indicates the need for further teaching? Select all that apply.

- "I should use a sitz bath only with warm water." - "I should clean the lesion once a day with saline."

A 12-year-old child with type 2 diabetes is scheduled for abdominal surgery. Which factors are most important for the nurse to consider during the postoperative period? Select all that apply.

- The blood glucose level will increase because of the stress of surgery. - Diabetic control is usually maintained with insulin after surgery.

Several hours after administering insulin, the nurse is assessing a client for an adverse response to the insulin. Which client responses are indicative of a hypoglycemic reaction? Select all that apply.

- Tremors - Confusion - Diaphoresis

A woman who is 34 weeks pregnant is hospitalized for pyelonephritis. Which assessments should the nurse include in the plan of care? Select all that apply.

- Urine output - Temperature - Blood pressure - Uterine contractions

A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism?

A 59-year-old who had a knee replacement

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism?

An obese client with leg trauma

What is the priority nursing intervention for a client with stroke who is transitioned from ED to other settings?

Assessing the level of consciousness

A nurse is caring for a client with scoliosis of the thoracic spine and lumbar spine. Which risk does the nurse suspect in the client?

Cardiac function impairment

A client reports fever, redness, skin breakdown, and inflammation on the leg. Upon assessment, the nurse finds the area to be tender and edematous with diffused borders. What could be the possible condition?

Cellulitis

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client?

Contact precautions

What is the priority goal for a client with asthma who is being discharged from the hospital with prescriptions for inhaled bronchodilators?

Demonstrates use of a metered-dose inhaler

A client has a diagnosis of multiple sclerosis and is currently in remission. The client is a parent of two active preschoolers. What should the nurse encourage the client to do?

Develop a flexible schedule for completion of routine daily activities.

A client is undergoing diagnostic testing to determine if the client has myasthenia gravis. The nurse understands that the test that is most specific for determining the presence of this disease is what?

Edrophonium chloride test

The nurse is caring for a client who has sustained blunt trauma to the forearm. The nurse assesses the client for which early sign of compartment syndrome?

Escalating pain in the fingers

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

Inactivity

A client reports redness, itching, burning, and pain in the palms and elbows. On assessing, the nurse finds demarcated, silvery, scaling plaques in the area. Which drug does the nurse expect in the client's prescription?

Intralesional injection of corticosteroids

A client is admitted to the hospital in the oliguric phase of acute kidney injury. The nurse estimates that the urine output for the last 12 hours is about 200 mL. The nurse reviews the plan of care and notes a prescription for 900 mL of water to be given orally over the next 24 hours. What does the nurse conclude about the amount of fluid prescribed?

It will compensate for both insensible and expected output over the next 24 hours.

The nurse anticipates that the family of a child with cerebral palsy is at risk for difficult parenting issues. What does the nurse conclude is the probable basis for this difficulty?

Loss of the expected healthy child

A client is admitted to the hospital with a diagnosis of Crohn disease. What is most important for the nurse to include in the teaching plan for this client?

Meeting nutritional needs

A nurse manager is providing a class on cystic fibrosis for the pediatric staff nurses. Physiologic adaptations to cystic fibrosis are a result of which problem?

Pathology of mucus-secreting glands

A client sustains a complex comminuted fracture of the tibia with soft tissue injuries after being hit by a car while riding a bicycle. Surgical placement of an external fixator is performed to maintain the bone in alignment. Postoperatively it is most essential for the nurse to do what?

Perform a neurovascular assessment of both lower extremities.

A 3-year-old boy in respiratory distress is treated in the emergency department. A diagnosis of acute spasmodic laryngitis (spasmodic croup) is made. At the time of discharge, the mother asks how to handle another attack at home. What should the nurse recommend?

Placing him near a cool-mist humidifier

A 7-year-old child with juvenile idiopathic arthritis has difficulty getting ready for school in the morning because of joint pain and stiffness. Which recommendation should the nurse make to the family?

Provide warm, moist heat to the affected joints before arising.

A client was diagnosed with ulcerative colitis. Two months after the diagnosis, the client is readmitted for an exacerbation of the illness. The client is weak, thin, and irritable. The client states, "I am now ready for surgery to create an ileostomy." Which nursing intervention will best meet the client's priority need?

Replace the client's fluids and electrolytes

A mother arrives in the emergency department with her severely dehydrated infant. After being treated aggressively, the infant is rehydrated and ready to be discharged. What is the priority concern that the nurse should include in the discharge teaching plan for the mother?

Signs of dehydration in infants

The nurse considers that a 70-year-old female client can best limit further progression of osteoporosis by doing what?

Taking supplemental calcium and vitamin D

A school-aged child with cystic fibrosis has recurrent episodes of bronchitis, and the parents ask the nurse why this happens. What reason should the nurse include in the reply?

Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria.

The parents of a 4-year-old child call the health center and report that their child has a fever of 102.6° F (39.2° C), is complaining of a sore throat, and will not lie down, preferring to sit up and lean forward. The child is drooling and looks ill and agitated. In light of this information, what guidance should the nurse provide the family?

The child needs to be seen immediately by a healthcare provider.

A nurse is caring for several school-aged children with cystic fibrosis. Why does the nurse anticipate that these children will probably be small and underdeveloped for their age?

These children digest little food because pancreatic enzymes are blocked.

The parents of a 3-year-old child who has recurrent attacks of acute spasmodic laryngitis (spasmodic croup) ask the nurse why this happens to their child. What is the best rationale for the nurse to convey why this is a disorder of young children?

They have small airways.

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices?

They help the venous blood return to the heart.

The nurse provides discharge instructions to a male client who had an ureterolithotomy. The client has a history of recurrent urinary tract infections (UTIs). For which indicators of a UTI should the nurse instruct the client to be on the alert?

Urgency or frequency of urination

What strategy should the nurse employ to be effective when using play therapy with a 6-year-old child with autism?

Use mechanical and inanimate objects for play.

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching?

Wash hands with soap and water.

A woman who is admitted to the labor suite has herpes simplex virus type 2 (HSV-2) with active lesions in the perineal area. What should the nurse's plan of care include?

Withholding oral fluid intake

Which throat manifestations are the key features for a client with acute viral pharyngitis? Select all that apply.

- Scant or no tonsillar exudate - Slight erythema of the pharynx and tonsils

The nurse in a campus health clinic is assessing female students for risk factors associated with the future development of osteoporosis. What factors are included in this assessment? Select all that apply.

- Cigarette smoking - Familial predisposition - Inadequate intake of dietary calcium

An adolescent is found to have type 1 diabetes. The nurse plans to teach the adolescent that dietary control and exercise can help regulate the disorder. What additional information should the nurse include in the teaching plan? Select all that apply.

- Insulin therapy - Blood glucose monitoring - Adherence to the treatment regimen

Which responses should a nurse expect a client experiencing hypoglycemia to exhibit? Select all that apply.

- Palpitations - Tachycardia - Nervousness

A client with type 1 diabetes receives Humulin R insulin in the morning. Shortly before lunch the nurse identifies that the client is diaphoretic and trembling. What is the nurse's most appropriate action?

Assess the client's blood glucose level

A client is admitted to the emergency department with joint pain and swelling. Upon assessment the nurse suspects rheumatoid arthritis. Which findings support the nurse's conclusion? Select all that apply.

- Antinuclear antibodies - Inflammatory disease pattern - Disease in the bilateral symmetric joints

A client with a fracture is found to have compartment syndrome. Which interventions will be contraindicated? Select all that apply.

- Applying cold compresses - Elevating the extremity above heart level

A nurse is taking care of a client who has chronic back pain. What nursing considerations should be made when determining the client's plan of care? Select all that apply.

- Ask the client about the acceptable level of pain. - Administer the pain medications regularly around the clock.

A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client?

Maintain an open airway.

A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made, and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care?

Maintain standard and contact precautions.

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant enterococcus (VRE). After notifying the primary healthcare provider, which action should the nurse take to decrease the risk of transmission to others?

Move the client to a private room.

A client goes to the primary healthcare provider because of fatigue, double vision, and muscle weakness. A diagnosis of myasthenia gravis is suspected. When collecting a health history, the nurse expects the client to report which information?

Muscle weakness improving after a period of rest

Which findings in the older client are associated with a urinary tract infection (UTI)? Select all that apply.

- Confusion - Incontinence - Slight rise in temperature