Russell Practice Test: 1

Correct response: Dorsal surface Explanation: To feel for warmth, the nurse should use the dorsal surface, or back, of the hand. The fingertips are best for distinguishing texture and shape; the finger pads, for assessing hair texture, grasping tissues, and feeling lymph node enlargement; and the ulnar surface, for feeling thrills and fremitus. You Selected: Ulnar surface

A nurse is performing a head-to-toe assessment. Which part of the hand should the nurse use to evaluate this client's body for warmth?

Correct response: "I remove white patches on my tongue and cheeks with my toothbrush." Explanation: White patches on the tongue and oral mucosa indicate infection; the client should report, not remove, them. The child should use a soft toothbrush to prevent injury to the fragile oral mucosa. To prevent stomatitis, the child should rinse the mouth every 2 to 4 hours with a nonirritating solution, such as baking soda and water or normal saline solution, and should avoid commercial mouthwashes containing alcohol, which may dry the oral mucosa. You Selected: "I don't use bottled mouthwashes."

During chemotherapy for lymphoma, a child, age 15, is at risk for stomatitis. Which statement by the child supports a nursing diagnosis of Deficient knowledge related to mouth care?

Correct response: "It's difficult to be a working parent, but having a nanny will provide your baby with a consistent caregiver while you're gone." Explanation: According to Erickson, consistent, predictable, reliable care helps the infant develop trust and enables achievement of subsequent developmental stages. Giving advice and using inappropriate self-disclosure blocks communication. There's no evidence that a nanny is better than day care as long as the infant receives safe, consistent, loving care. You Selected: "You should really think about taking a minimum of 6 weeks off to rest and recover."

The night before discharge, a client expresses guilt that she'll have to return to work in 3 weeks and leave her infant with a nanny. The client asks the nurse for an opinion about using a nanny. What should the nurse say first?

Correct response: notify the nursing supervisor to see if a staff member can sit with the client. Explanation: The nurse should notify the nursing supervisor to see if an available staff member can sit with the client. If staffing doesn't allow, the nurse should see if a family member is available to sit with the client. A client should never be left alone while the nurse summons assistance. The nurse should contact the physician to obtain a restraint order when all other measures fail, and the client should be restrained in the least restrictive manner possible. You Selected: order soft restraints from the storeroom.

The nurse is caring for a client with a fractured hip. The client becomes combative, confused, and tries to get out of bed. His vital signs and pulse oximetry results are unchanged. The nurse should:

rash on skin of face, chest, and arms reports severe itching all over inspiratory wheezes Explanation: Rash, inspiratory wheezes, and reports of severe itching indicate that the client is having an allergic reaction to the antibiotic. A heart rate of 86 is within normal limits and reports of mouth being dry is not indicative of an allergic reaction.

The nurse is obtaining vital signs from a client who is receiving an intravenous antibiotic for the first time. Which observation made by the nurse requires immediate intervention? Select all that apply.

Correct response: "What's the infant's usual daily diet?" Explanation: Iron deficiency anemia is the most common nutritional deficiency in infants between ages 9 months and 15 months. Anemia in a 1-year-old is mostly nutritional in origin, and its cause will be suggested by a detailed nutritional history. The other questions would not be helpful in diagnosing anemia. You Selected: "What's the pattern and appearance of bowel movements?"

A 1-year-old infant is pale, but the physical examination is normal. Blood studies reveal a hematocrit of 24% (0.24). Which question by the nurse to the parents would be most useful in helping to establish a diagnosis of anemia?

Correct response: Inform the nurse director that she's violating the client's right to privacy and ask her to return the chart. Explanation: Under the Health Insurance Portability and Accountability Act (HIPAA)(Health Canada), personal health information may not be used for purposes not related to health care. The nurse director isn't providing health care to the client and shouldn't have access to the chart, regardless of the client's condition. The nurse director should be confronted and asked to return the client's chart. If she doesn't comply, the nurse should report the incident to her nurse-manager, who will report the infraction to the proper authorities. The staff nurse shouldn't report the incident to the medical director. You Selected: Report the incident to the medical director.

A 33-year-old client who tested positive for the human immunodeficiency virus (HIV) is admitted to the medical unit with pancreatitis. A nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director, who says that the client is her neighbor's son. What should the nurse do to protect the client's right to privacy?

Correct response: Elevate the foot of the bed. Explanation: To relieve edema of the toes, the nurse should raise the affected extremity above the heart level such as by elevating the foot of the bed. Contacting the orthopedic surgeon is not necessary at this time. Applying ice may be effective but raising the extremity will be more effective. Using traction is not indicated. You Selected: Contact the orthopedic surgeon.

A child with a fractured left femur receives a cast. A short time later, the nurse notices that the toes on the child's left foot are edematous. Which nursing action would be most appropriate?

Correct response: Cholinergic blocker Explanation: Atropine sulfate is a cholinergic blocker. It isn't a parasympathomimetic agent, a sympatholytic agent, or an adrenergic blocker. You Selected: Parasympathomimetic agent

A client complains of periorbital aching, tearing, blurred vision, and photophobia in the right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client's therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. The nurse knows atropine sulfate belongs to which drug classification?

Correct answers: shift work sleep apnea caffeine intake in the evening Excessive worry or anxiety Explanation: Shift work can disrupt the circadian rhythm. Sleep apnea can cause a reduction in oxygen to the brain, which can reduce the quality of rest. Caffeine is a stimulant and, if taken too close to bedtime, it can interfere with falling asleep. Excessive worry or anxiety causes an increase in adrenaline, which enhances alertness and reduces sleepiness. A consistent bedtime routine and reduction of external stimuli promote good sleep.

A client informs the nurse that the client has difficulty sleeping. About which conditions does the nurse question the client to determine factors that inhibit adequate sleep patterns? Select all that apply.

Correct response: Standard precautions Explanation: Standard precautions are all that are required in caring for a client with a botulism infection. Botulism isn't transmitted by air, contact, or droplets. You Selected: Contact precautions

A client is admitted to the emergency department with complaints of double vision, difficulty swallowing, dry mouth, and muscle weakness. A nurse also observes that the client has drooping eyelids and slurred speech. He states that he recently ate home-canned green beans. The nurse suspects exposure to botulism. What type of infection control precaution is necessary?

Correct response: bananas and oranges. Explanation: Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the client to increase intake of potassium-rich foods, such as bananas and oranges. Fresh green vegetables, milk, and creamed corn aren't good sources of potassium. You Selected: fresh green vegetables.

A client is receiving furosemide, 40 mg by mouth twice per day. In the plan of care, the nurse should emphasize teaching the client about the importance of consuming:

Correct response: Notify the physician of the client's lack of progress and request a diabetes education department consult. Explanation: The nurse should notify the physician of the client's lack of progress and request a consult with the diabetes education department. The nurse can't consult the diabetes department without a physician's order. There's no need to delay the client's discharge if his condition is stable and he's physically ready for discharge. The client should be encouraged to be as independent as possible, and it isn't appropriate to consult with the family without the client's permission. You Selected: Consult with family members and begin family insulin administration education.

A client newly diagnosed with diabetes mellitus is experiencing difficulty with self-administration of insulin. Despite further teaching, the client shows little improvement. What action by the nurse is most appropriate?

Correct response: Check all allergies of the client. Explanation: The priority action for the nurse is checking to see if the client has any allergies, as lung scans are contraindicated in clients that have a hypersensitivity to the radiopharmaceutical dye. After that it is important to also explain the procedure, obtain the vital signs, and during the procedure watch for any gas leaks. You Selected: Obtain the client's vital signs.

A client suspected of having a pulmonary embolus is scheduled for a lung scan. What is the most important action for the nurse prior to the procedure?

Correct response: autonomy Explanation: Autonomy ascribes the right of the individual to make his or her own decisions. In this case, the client is capable of making decisions, and the nurse should support the client's autonomy. Beneficence and justice are not the principles that directly relate to the situation. Advocacy is the nurse's role in supporting the principle of autonomy. You Selected: beneficence

A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the health care provider recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." When considering a response to the client, which ethical principle should the nurse consider?

Correct response: Arrange to have staff check on the client every 15 to 30 minutes. Explanation: A common reason for hospitalization in clients with DID is suicidal ideations or gestures. For the client's safety, frequent checks should be done. Family interactions might be therapeutic for the client, and the family may be able to provide a more thorough history because of the client's dissociation from traumatic events. Seizure activity is not an expected symptom of DID. Because of the possibility of suicide, the client's room should be close to the nurses' station. You Selected: Place the client in a quiet room away from the noise of the nurses' station.

A client with dissociative identity disorder (DID) requires hospitalization. Which intervention would most likely appear in the client's plan of care plan?

Correct response: uterine atony Explanation: Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is at higher risk for hemorrhage. Thrombophlebitis doesn't increase the risk of hemorrhage during the postpartum period. The client's hemoglobin level and lochia flow are within acceptable limits. You Selected: thrombophlebitis

A multiparous client has given birth vaginally to a healthy neonate. It is now her first postpartum day. Which factor would the nurse identify as putting this client at risk for developing hemorrhage?

Correct response: "Breast milk is ideal for your baby, so his stomach will digest it quickly, which requires more feedings." Explanation: Breast milk is the ideal food for a neonate. As a result, the neonate will digest and use all of the nutrients in each feeding quickly. Coaching the mother must include relaying this information to allay maternal concerns about producing an adequate supply of milk. Although a lactation consultant may be helpful, the nurse should be able to provide the mother with adequate information. Telling the client not to worry ignores her concern. Suggesting supplementation with formula indicates that the mother's breast-feeding attempts are unsatisfactory. Nurses shouldn't suggest giving formula to a breast-feeding neonate. You Selected: "Let me call the lactation consultant to make sure that your baby is feeding properly."

A new mother is concerned because her breast-feeding neonate wants to "nurse all the time." Which of the following responses is most appropriate to address the mother's concerns regarding her neonate's breast-feeding behavior?

Correct response: lung sounds equal bilaterally Explanation: Chest auscultation of equal bilateral breath sounds indicates that the chest tube is functioning properly (expansion of the involved lung). Arterial blood gas values may initially decrease with pneumothorax but typically return to normal within 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to pneumothorax, but they do not clearly determine if the chest is sufficiently re-expanded. The respiratory rate should return to near normal levels 12 to 20, usually no higher than 22. You Selected: normal arterial blood gas (ABG) studies

A nurse is caring for a client who required chest tube insertion for pneumothorax. Which finding indicates to the nurse that the chest tube is having the desired effect?

Correct response: preventing infection Explanation: The nurse needs to provide special care to the neural tube sac of a neonate born with a myelomeningocele to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture, creating a portal of entry for microorganisms. Promoting neural tube sac drainage may also place the neonate at risk for infection. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Adequate nutrition is a concern for all neonates, including those with a myelomeningocele. Like all neonates, a neonate with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure on the sac by using a sheet or blanket. You Selected: promoting neural tube sac drainage

A nurse is part of a team providing care to a neonate with a myelomeningocele. When implementing the neonate's plan of care, what is the priority action by the nurse?

Correct response: 75 Explanation: First, convert the client's weight to kilograms: 1 kg = 2.2 lb 99 lb divided by 2.2 lb/kg = 44 kg Then calculate the total daily dosage: 44 kg X 5 mg/kg = 220 mg/day Finally, divide the total daily dosage into three parts: 220 mg divided into 3 doses = 75 mg/dose Your response: 9

A nurse is preparing to administer phenytoin to a 99-lb client with a seizure disorder. The medication administration record documents phenytoin 5 mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin should be administered in the first dose? Record your answer as a whole number.

Correct response: "I'll tell you what the monitors show." Explanation: The client deserves a truthful answer, and the nurse should be objective without giving opinions. Relating what the monitors show is objective and truthful. Vague answers may be misleading and aren't therapeutic. You Selected: "I don't know for sure."

A pregnant client with vaginal bleeding asks a nurse how the fetus is doing. Which response is best?

Correct response: WBCs: 20 per high-power field Explanation: Urinary tract infections are more common in school-aged girls than in school-aged boys. A normal urinalysis would show less than 5 WBCs per high-power field. An elevated WBC count of 20 is an indication of bacteria and urinary tract infection. The normal range of urinary pH is 4.6 to 8.0. The presence of glucose or ketones in the urine does not indicate a urinary tract infection, but may indicate diabetes mellitus. You Selected: pH 7.8

An 11-year-old girl comes into the health care provider's office reporting dysuria. Which findings on the laboratory report are consistent with a urinary tract infection?

Correct response: 7 days after fertilization Explanation: Implantation occurs at the end of the first week after fertilization, when the blastocyst attaches to the endometrium. During the second week (14 days after implantation), implantation progresses and two germ layers, cavities, and cell layers develop. During the third week of development (21 days after implantation), the embryonic disk evolves into three layers, and three new structures — the primitive streak, notochord, and allantois — form. Early during the fourth week (28 days after implantation), cellular differentiation and organization occur. You Selected: 14 days after fertilization

During a health-teaching session, a pregnant client asks the nurse how soon the fertilized ovum becomes implanted in the endometrium. Which timeframe should the nurse appropriately supply?

Correct response: 8 to 10 Explanation: The client should perform at least 8 to 10 sustained, voluntary maximal inflation maneuvers with the incentive spirometer during each waking hour. Performing fewer than 8 maneuvers would reduce the respiratory benefits of this therapy. You Selected: 5 to 7

The nurse is caring for a client with pneumonia. As part of prescribed therapy, the client must use a bedside incentive spirometer to promote maximal deep breathing. The nurse checks to make sure the client is using the spirometer properly. During each waking hour, the client should perform a minimum of how many sustained, voluntary inflation maneuvers?

Correct response: "Keep a food diary and eat small, frequent meals." Explanation: Keeping a food diary to determine foods that produce or aggravate symptoms and eating small, frequent meals will help to manage symptom flare-ups long term. Managing stress with exercise can increase the time between flare-ups; however, joining a support group may not help to manage symptoms. Increased fiber, fatty foods, dairy products, alcohol, smoking, and caffeine can aggravate symptoms. Probiotics have not shown any benefit with the management of Crohn's disease symptoms. Steroids are not for long-term use. Short-term (3 to 4 months) steroid therapy is used with immune suppressants to induce disease remission until immune suppressant therapy can maintain the disease in remission. A multivitamin does not help to manage symptoms. You Selected: "Increase your intake of fiber and take a probiotic daily."

The nurse reinforces discharge education for a client with Crohn's disease. Which long-term symptom management instruction should the nurse reinforce to this client?