PREDICTOR TEST 1
Prioritization/Triage: 10 items
Fundamentals: 15 items
Room Assignment: 2 items
Delegation: 4 items
Geriatrics: 5 items
Pedia: 10 items
GUT: 5 items
Endo: 6 items
Gastro: 15 items
Musculo: 10 items
Neuro: 6 items
F&E: 5 items
Infectious: 10 items
Cardio: 5 items
Diet: 5 items
MCN/OB: 7 items
Pharma: 19 items
Psych: 10 items
Respi: 10 items
TOTAL: 159 items
1. A nurse attending a summer camp for children with medical conditions and disabilities would prioritize which of the following child?
a. A child with sickle cell anemia who has left upper quadrant pain
b. A child with spina bifida who has musty urine
c. A child with spina bifida who is complaining of headache
d. A child with spina bifida who has a runny nose and cough
RATIONALE: C. A headache in a child with spina bifida would suggest the onset of increased intracranial pressure, probably due to infection or shunt malfunction. A neurological problem would merit the nurse’s immediate attention because it could prove to be life-threatening.
2. A charge nurse in the station receives the following telephone call, which telephone call should the charge nurse respond to first?
a. A pediatrician stating that a child will be admitted for an infected circumcision
b. The pharmacy requesting clarification of an IV order
c. The laboratory reporting that a child scheduled for a tonsillectomy has an abnormal bleeding time
d. A staff nurse reporting that a child is in respiratory difficulty and the pediatrician cannot be located
RATIONALE: D. A child in respiratory difficulty would have the greatest priority, because the child may be in a life-threatening condition. A quick decision must be made by the charge nurse as to what to do about the child’s respiratory condition.
3. Which telephone call from the students’ mothers should the school nurse return to first?
a. A telephone call notifying the school nurse that the child has a temperature of 1020 F and a rash covering the trunk and upper extremities of the body
b. A telephone call notifying the school nurse that a child underwent an emergency appendectomy during the previous night
c. A telephone call notifying the school nurse that the child’s pediatrician has informed the mother that the child will need cardiac repair surgery within the next few days
d. A telephone call notifying the school nurse that the child’s pediatrician has informed the mother that the child has head lice
RATIONALE: A. A high fever accompanied by a body rash could indicate that the child has a communicable disease and could expose other students to infection. The school nurse would want to investigate this telephone call immediately, so that plans could be instituted to control the spread of such infection.
4. A triage nurse must decide which of the following children should be examined first by the pediatrician. Which child would the triage nurse prioritize?
a. A 5-year-old child with laryngotracheobronchitis who has wheezing on auscultation and a respiratory rate of 30 breaths per minute
b. A 7-month-old infant who fell from the sofa into the carpeted floor, hitting the head
c. A 4-year-old who fell off a bicycle and has several bleeding lacerations requiring sutures
d. A 6-year-old child experiencing asthma that has diminished wheezing and is very irritable
RATIONALE: D. Diminished wheezing in a child with asthma indicates possible worsening of respiratory obstruction, especially when coupled with irritability which is a sign of air hunger.
5. A nurse is planning to conduct a newborn assessment. Upon entering the room, which of the following infants will the nurse need to attend first?
a. An infant drooling with quiet respirations of 30 breaths per minute
b. An infant jittering with respirations of 55 breaths per minute
c. An infant showing yellowish discoloration of the skin
d. An infant with apnea of 10 seconds
RATIONALE: B. Jitteriness and increased respirations are characteristics of hypoglycemia in a newborn and requires an immediate intervention before neurologic damage can occur. An apnea of 10 seconds is considered normal in newly born infants. An infant who is drooling with RR of 30 is considered within the normal parameters. A yellowish discoloration of the skin may be an indication of hyperbilirubinemia and requires blood exchange transfusion but hypoglycemia is more immediate than this infant. (Saunders Comprehensive, p.347)
6. Shortly after arriving for the evening shift, the triage nurse evaluates several clients who came in the emergency department. Which client should receive highest priority?
a. A middle-aged man, diaphoretic and complaining of severe chest pain radiating to the jaw
b. An elderly woman complaining of loss of appetite and fatigue for the past week
c. A basketball player limping and complaining of pain and swelling in the right ankle
d. A housewife with 225 mg/dL glucose complaining of thirst
RATIONALE: A. These are likely signs of an acute myocardial infarction (MI), which is a cardiovascular emergency requiring immediate attention. Acute MI is potentially fatal if not treated immediately.
7. Which client would be the RN’s priority in an acute care situation?
a. A client with diabetes who has a glucose reading of 180
b. A client 3 days postoperative with left calf pain
c. A newly admitted client with chest pain
d. A client who is complaining of pain following surgery from hip pinning
RATIONALE: C. The client with chest pain may be having myocardial infarction, and immediate assessment and intervention are priorities.
8. The nurse manager has requested a social worker to see the following clients. Which one requires assistance first?
a. A 79-year-old woman, with newly diagnosed stroke, homeless and without any insurance coverage
b. A 55-year-old man, with a history of recent myocardial infarction (MI) who is in the midst of divorce
c. An 89-year-old man with TYPE 2 diabetes and with heart failure and no insurance coverage
d. A 30-year-old woman who is newly diagnosed with HIV and without insurance coverage
RATIONALE: A. Although all of the clients need social service and discharge assistance, the client who is newly diagnosed with diabetes is at greatest risk for complications from the condition and is potential for poor management. Proper diet and safe medication administration would be difficult for a person who is homeless.
9. What are the first nursing actions for a client admitted to the emergency department following an accident?
a. Align the spine, check pupils, and check for hemorrhage
b. Check respirations, circulation, and neurological response
c. Check respirations, stabilize spine, check circulation
d. Assess level of consciousness, circulation
RATIONALE: C. Checking the airway would be a priority, and a neck injury should be suspected.
10. What level of prevention is the nurse’s goal in the community following an earthquake?
a. Primary level of prevention
b. Secondary level of prevention
c. Tertiary level of prevention
d. Quaternary level of prevention
RATIONALE: C. The nurse’s goal is to reduce the extent of injury, death, and damage after this crisis (e.g., by providing housing for survivors, obtaining physical care, providing counseling and support for families).
1. Upon entering a child’s room, the nurse notes that the child’s chest tube becomes disconnected from the Pleurevac. What should the nurse do first?
a. Clamp the chest tube closer to the drainage system
b. Apply pressure directly over the incision site
c. Clamp the chest tube near the incision site
d. Reconnect the chest tube to the Pleurevac
RATIONALE: C. This action stops the sucking of air through the tube and prevents entry of concomitants. In addition, clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube.
2. A client should be able to describe the signs of pacemaker malfunction. Which behavior by the client indicates that this goal has been met?
a. State the estimated life of the battery, and understands the need for prophylactic replacement
b. Identifies the need to monitor the rate daily
c. Identifies the significance of drainage or discoloration around the battery insertion site
d. Identifies the need to report rate changes and symptoms such as dizziness and hiccoughs
RATIONALE: D. Periodic checks on pacemaker function are essential and may be accompanied by pulse taking, frequent EKGs, telephone transmission of EKG. Generally, rate changes greater than 15 beats should be reported to the physician, as other symptoms such as syncope, dizziness, hiccoughs (diaphragmatic stimulation), dyspnea, chest pain, and fluid retention.
3. What is the most appropriate action for the nurse to take when the high pressure alarm repeatedly sounded on a client’s ventilator?
a. Check all connection sites on the ventilator
b. Administer cough suppressants as ordered PRN
c. Assess the need to suction excess sputum
d. Administer morphine ordered for “fighting” the ventilator
RATIONALE: C. Always assess the client first
4. What nursing intervention should be implemented before the deflation of tracheostomy cuff?
a. Take the pulse oximetry reading
b. Have the obturator available
c. Encourage deep breathing and coughing
d. Suction the trachea and mouth
RATIONALE: D. Secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated.
5. A patient with Chronic Renal Failure is being maintained on Peritoneal Dialysis. Which of the following is NOT an indication that the patient is developing possible Peritonitis?
a. Blood-tinged drainage after two exchanges
b. Rigid abdomen with abdominal pain
c. Decreased rate of fluid return
d. Nausea and vomiting
RATIONALE: A. One of the possible complications of peritoneal dialysis is peritonitis. The signs and symptoms may include: nausea, vomiting, abdominal pain or tenderness or rigidity, and cloudy dialysate. Blood-tinged or slightly bloody drainage may be observed during the first one to two exchanges, and is not considered to be abnormal.
6. You are caring for a patient with Colostomy. In preparing a teaching plan for this patient which of the following would be an incorrect statement?
a. Irrigation is necessary since the fecal contents are liquid
b. That the stoma should be dark pink to red in appearance
c. That the bag should be checked when starting new medication to be sure that it is completely dissolved
d. That the bag/appliance should be changed q 2-3 days
RATIONALE: A. A colostomy is one form of bowel diversion created through surgical intervention. Choices B, C and D are all proper statements concerning colostomy care, and should be included by the nurse in the teaching plan. However, Choice A refers to an Ileostomy; the contents of such are liquid unlike the colostomy, and therefore irrigation is not required.
7. You are caring for a patient receiving hyperalimentation (Total Parenteral Nutrition). The flow rate ordered is 60cc/hr. After two hours the patient complains of feeling extremely nauseous, and of having a bad headache. Which of the following would be the most appropriate intervention by the nurse?
a. Stop the infusion immediately
b. Increase the flow rate as the patient is likely hypoglycemic
c. Decrease the flow rate and observe the patient
d. Check the patient's glucose level and urinary output
RATIONALE: D. Patients on TPN must be monitored closely, and the rate of the infusion maintained as ordered. If the rate is too fast, hyperosmolar diuresis occurs, and the patient may complain of headache, nausea, chills and may have an elevated temperature. The rate of the infusion must NEVER be increased or decreased abruptly, nor should it be changed. In this situation, the nurse should suspect hyperglycemia, and should immediately check the patient's glucose level through (Finger Stick), as well as urinary output, as diuresis is likely. Notifications of the M.D. of the patient’s symptoms, as well as your assessment findings are also part of the nursing interventions.
8. Which of the following is an abnormal finding when observing water-sealed chest drainage for proper functioning?
a. Bubbling initially with coughing and deep inspiration
b. Continuous bubbling where the water seal is maintained
c. Water level fluctuations with breathing
d. A collection chamber that is less than 1/2 full
RATIONALE: B. Water sealed chest drainage is designed to remove air and/or fluid from the pleural cavity, and to restore negative pressure in the pleural cavity, which promotes the re-expansion of the lung. In observing the water-seal drainage system, the nurse can expect to see all of the above with the exception of Choice B as continuous bubbling can indicate a possible air leak in the system.
9. A patient is receiving Incentive Spirometry post-operatively. Which of the following would demonstrate misunderstanding on the part of the nurse regarding this treatment modality?
a. The patient should be medicated for pain, PRN prior to beginning the treatment
b. The head of the bed should be elevated to at least 45 degrees
c. The therapy should begin on the second or third post-op day
d. The patient should be taught to hold their breath following inspiration, and then to exhale slowly
RATIONALE: C. Incentive Spirometry is used post-operatively especially after thoracic and abdominal surgery to prevent collapse of the air passages or atelectasis. In assisting the patient, the nurse should employ choices A, B and D and although it is more effective with the head of the bed elevated, it can be performed from any position. It should be started immediately as atelectasis can start as soon as one hour post-operatively.
10. Which of the following statement is correct about the management of a Hemovac or Jackson-Pratt drainage device?
a. Keep the drainage device uncompressed
b. Assess amount, color, and characteristic of drainage
c. Empty the drainage device every 4 hours
d. Pin the drainage tubing to the sheet
RATIONALE: B. The characteristics of drainage must be monitored for changes.
11. The most important nursing concern for a client following an ileostomy is to:
a. Allow the client to observe irrigation
b. Assure that pouch opening exactly fits the stoma size
c. Change the stoma pouch daily when full
d. Maintain skin-protective barrier
RATIONALE: D. The first concern is the stoma and the condition of the skin around the stoma. The effluent (drainage) from the stoma is made up of digestive enzymes. The pouch opening should be more than 1/8 inch larger than the stoma.
12. Following a cystectomy and formation of an ileal conduit, the nurse should instruct the client to empty the urine pouch:
a. Twice a day
b. Every hour
c. Once before bedtime
d. Every 3 to 4 hours
RATIONALE: D. Urine flow is continuous. The bag has an outlet valve for easy drainage every 3 to 4 hours. The pouch should be changed every 3 to 5 days or sooner if the adhesive is loose.
13. In what position should the nurse place the child following the insertion of a chest tube?
a. Reverse trendelenburg
b. Supine or on the unaffected side
c. Lateral on the affected side
d. Semi-Fowler’s position
RATIONALE: D. This position allows for maximum lung expansion, as well as allowing for gravity to drain any fluids from the chest cavity via the tube.
14. Arrange the following according to order: NGT insertion procedure
- Measure to determine the length of insertion
- Insert tube by asking the patient to swallow
- Position the patient to High Fowler’s and wash hands
- Secure NGT by using tape
- Inspect the nostril patency
__, __, __, __, __
RATIONALE: 3,5,1,2,4. Intubation procedures: (1) Place the client in high Fowler’s, (2) measure from tip of nose to earlobe to xyphoid process to determine the length of insertion, (3) lubricate tube about 3 inches with a water soluble jelly, (4) instruct client to bend head forward, (5) insert into nostril and advanced backward, (6) have the client sip water, and advance the tube as client swallows, (7) advance until reaching the taped mark; tape tube in place when correct placement is confirmed.
(Saunder’s Comprehensive, p.234)
15. A client who underwent lumbar tap would be best placed in what position to prevent headache?
a. Lateral, right side
b. Supine with the foot part elevated at 30°
c. Prone with pillows supporting the head
d. Semi Fowler’s position
RATIONALE: B. To avoid the complication of a painful spinal headache that can last for several days, the client is kept flat in a supine position for approximately 4 to 12 hours postoperatively. Headaches are believed to be caused by seepage of cerebral spinal fluid from the puncture site. By keeping the client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons.
1. A client is admitted with hyperthyroidism. In what room would the RN place the client?
a. A room with a client with the same diagnosis
b. Across from the RN’s station
c. A room with a client who had cholecystectomy
d. A private room
RATIONALE: D. The client with hyperthyroidism is typically nervous and often has insomnia and emotional lability. A calm, subdued environment with reduced stimuli and sensory input would be beneficial. Having two clients with nervousness or insomnia would be too much stimuli for each other. Placing across the RN’s station provides a great deal of activity at the RN’s station.
2. During a mass disaster who among the patients who need to be discharged to accommodate the incoming pt?
a. A patient, who had undergone endarterectomy the previous day, with a GCS of 15
b. A patient with COPD with an O2 saturation of 93%
c. A patient with DM with glucose reading of 250 mg/dl
d. A child with maculopapular rashes on the trunks and upper extremities
RATIONALE: A. The patient with a GCS of 15 is the most stable among the presented patients. The remaining patients still require nursing intervention and frequent assessment.
1. Which client situation would be inappropriate for the RN to delegate care to the nursing assistant?
a. A client with soft restraints who is very agitated and crying
b. An elderly woman who is confused and needs assistance with eating
c. A client who is stable postoperative and needs to ambulate
d. A routine temperature check must be done for a client at the end of the shift
RATIONALE: A. The RN cannot delegate the responsibility for assessment and evaluation of clients. The status of the client in restraints requires further assessment to determine if there are additional causes for the behavior.
2. Which task is appropriate for an RN to give to a nursing assistant?
a. Irrigating a Foley catheter that is not draining well
b. Taking vital signs on a client who is postoperative with blood transfusion that is about to end
c. Assisting a client to eat who was recently admitted after stroke
d. Admitting the client to the unit who is being transferred from the ICU
RATIONALE: B. The function is routine; a dangerous transfusion reaction is not likely to occur at the conclusion of this treatment. Irrigating Foley catheter can be assigned to an LPN/LVN. Assisting a client to eat requires assessment of a licensed professional for potential for aspiration in a client who is newly admitted who had a stroke. Assessment status and admission is the role of the RN.
3. Which activity is appropriate to delegate to a nursing assistant?
a. Assist patient with rheumatoid arthritis in eating
b. Ambulate patient with Parkinson’s to the bathroom
c. Perform wound dressing to a client with third degree burn
d. Feeding a client with NGT
RATIONALE: A. Feeding the patient with rheumatoid arthritis is the safest patient that the nursing assistant can handle and the task is within the scope of the nursing assistant.
4. A charge nurse who plans to delegate patients in the ward would most likely delegate which patient and task to an RN? Select all.
a. Ambulation with patient who has chest tube 1 day
b. Application of pneumatic compression device with arterial occlusive disease 2 hours prior to angiography
c. Assisting a COPD patient performing purse lip breathing with complaints of dyspnea
d. Insulin administration in a DM patient with glucose reading of 325 mg/dL glucose and is restless
RATIONALE: CD. These patients require immediate attention and frequent assessment that can be performed by an RN. Ambulating can be assigned to a nursing assistant and applying a pneumatic compression device to an LPN/LVN.
1. What patterns reflect the age-related change in taste perception experienced by elderly clients?
a. Use of bland, easily digested food
b. Decreased intake of fluids
c. Increased consumption of salts and sweets
d. Ingestion of more bread, rice, and pasta
RATIONALE: C. With a change in taste sensations, client who are elderly increases the amount of food seasonings, especially sweets and salt, to compensate for this loss; these products are also readily accessible. The health implications must be closely monitored.
2. The best indication of dehydration in a client who is 85 years old would be changes in:
a. Skin turgor
b. Urine output
c. Blood pressure
d. Hemoglobin (Hgb) levels
RATIONALE: B. The normal frequency, quantity, and characteristics of urine (specific gravity) would be the best choice. (Daily weight would be a better choice, if included).
3. Which of the following symptoms of hyperthyroidism would the nurse expect to find in an elderly client?
a. Palpitations and shortness of breath
b. Nervousness and insomnia
c. Moist skin and fine tremors
d. Anorexia and constipation
RATIONALE: A. The cardiac effect of excessive T4 on the client who is elderly is frequent atrial fibrillation and shortness of breath. The manifestations of hyperthyroidism in a client who is elderly are different from the average adult client.
4. A nurse conducting a physiologic assessment in an elderly would expect to find the following considered as a normal observation, except:
a. Diminished gag reflex
b. Senile deafness
c. Increased residual urine and nocturia
d. Increased salivation and diminished sense of taste
RATIONALE: D. Elderly has a decreased salivary outflow causing dry mouth and diminished sense of taste, which may reduce the person’s appetite and increased his consumption of sweet, salty , and spicy foods. (Better Elderly Care, p. 6)
5. Which of the following are considered age-related changes in the laboratory findings of an elderly client, except:
a. Increased BUN and creatinine
b. A drop in hemoglobin
c. Increased protein
d. Decreased platelet-release factors
RATIONALE: D. An elderly may show a decrease granular constituents and increase platelet-release factors possibly due to diminished bone marrow and increased fibrinogen levels. (Better Elderly Care, p. 7)
1.Which diversionary activity would be most appropriate for the nurse to provide for a 16-month-old who is hospitalized?
a. Jumbo crayons and coloring book
b. Toy xylophone
c. Cardboard puzzles
d. A windup mobile
RATIONALE: B. The best diversion for a 16-month-old who is hospitalized would be anything that makes noise or makes a mess; a xylophone, which certainly makes noise (“music”), would be the best choice.
2. Which recreational activity for a hospitalized adolescent would be most appropriate?
a. School work that can be brought to the hospital
b. A television to watch in the two-bed hospital room
c. Various novels that an adolescent want to read
d. A board game, such as checkers or monopoly
RATIONALE: C. Novelty reading is an enjoyable activity for the adolescents.
3. Which milestone should the nurse expect an 8-month-old infant to have reached?
a. Rolls over and sits with support
b. Has a three-word vocabulary
c. Transfers objects to another hand
d. Recognizes, but is fearful of strangers
RATIONALE: D. An 8-month-old infant both recognizes and is fearful of strangers. This developmental milestone is known as “Stranger anxiety”. Rolling over and sitting with support is a characteristic of 5-6 months while transferring objects from one hand to another is seen in a 7-month-old infant.
43. When assessing a newborn for congestive heart failure, the nurse should observe for the most common sign of:
a. Peripheral edema
b. Distended neck veins
d. Pulmonary edema
RATIONALE: C. The most common sign of cardiac problems (including congestive heart failure) in the newborn is tachycardia, or a heart rate consistently over 160 beats/min.
5. A 4-year-old boy appears very anxious and frightened before receiving a rectal suppository as a preoperative medication. Which statement by the nurse would be most appropriate in helping the child take this medication?
a. “Take a nice, big, deep breath and then let me hear you count to five.”
b. “Be a big kid, everyone’s waiting for you.”
c. “Lie still now and I’ll let you have one present before you even have your operation.”
d. “You look so scared. Want to know a secret? This wont hurt a bit!”
RATIONALE: A. Preschool children commonly experience fears and fantasies regarding invasive procedures. The nurse should attempt to momentarily distract the child with a simple task that can be easily accomplished while the child remains in the side-lying position. The suppository can be slipped while the child is counting, and then the nurse can praise the child for cooperating, while holding the buttocks together to prevent expulsion of the suppository.
6. Which of the following is appropriate for a 5 year-old child whose mother just recently died?
a. The child thinks it is a punishment for his behavior
b. The child frequently asks why his mother died
c. The child thinks that his mother is only sleeping
d. The child experiences depression and isolation
RATIONALE: A. When a parent dies, the preschooler can be overwhelmed with feelings of guilt for having wished and therefore caused the death. Clarifying the children that wishes cannot and do not make events occur is essential in helping them overcome their guilt and anxiety.
7. The nurse seeks to provide appropriate diversional activities for a school-age child with chorea associated with rheumatic fever. The best activity for the nurse to select would be:
a. Cutting out paper dolls
b. Watching educational television
c. String beads to make necklace
d. Assembling a puzzle
RATIONALE: B. Chorea includes sudden, aimless, irregular movement of the extremities. Fine motor movements become a source of difficulty and frustration for a child with chorea associated with rheumatic fever. Watching television would not involve any active fine motor activity on the child’s part.
8. The grandparents of a 6-month-old infant diagnosed with cerebral palsy asked the nurse to recommend something that they could purchase for their grandchild to assist with the required care. The best item for the nurse to suggest would be:
a. Feeding utensils that promote independence
b. An infant feeding seat
c. A mobile to hang over the infant’s crib
d. A potty chair
RATIONALE: B. The infant with cerebral palsy is at high risk for ineffective airway clearance because of a difficulty in sucking and swallowing. Aspiration can occur. Therefore, feeding the infant in an upright position is essential, and an infant feeding chair would assist in accomplishing this task. In addition to being fed in an upright position, the infant with cerebral palsy should also be fed slowly and in a relaxed manner. As an infant grows older, mealtimes should emphasize obtaining adequate nutrition rather than manners and cleanliness.
9. Treatment was delayed for a 4-year-old child with congenital hip dysplasia. The child has now undergone surgery and is on a spica cast. Which object should the nurse immediately remove from the child’s bed because of its potential safety hazards?
b. A sponge ball
c. A stuffed animal
d. A toy gun
RATIONALE: A. Legos are small, plastic building blocks that could easily slip under the child’s cast and lead to a break in the skin integrity and even infection.
10. The nurse should know that the client who is at risk for a developmental problem is:
a. A 5-year-old with asthma on cromolyn sodium
b. A 4-year-old who frequently suffers tonsillitis
c. A 3-year-old with acute glomerulonephritis on antihypertensives and antibiotics
d. An 18-month-old with cystic fibrosis
RATIONALE: D. A developmental task of an 18-month-old toddler is to explore and learn about the environment. The respiratory complications associated with cystic fibrosis could prevent these developmental tasks from occurring.
1. A child on his fifth day admission with acute glomerulonephritis shows the presence of blood and protein in the urinalysis. The most appropriate action for the nurse is to?
a. Request the laboratory to reanalyze the urine specimen
b. Notify the pediatrician
c. Collect another urine specimen from the child and submit it to the laboratory
d. Note the finding in the chart and file the report in the child’s chart
RATIONALE: D. During the acute phase of acute glomeulonephritis, it is expected that the urine will show evidence of hematuria and mild proteinuria.
2. A nurse assigned to a child with Acute Glomerulonephritis is picking up the doctor's orders to be placed in the Kardex. Which of the orders should the nurse question?
a. Daily blood pressure
b. Daily weights
c. Bed rest
d. Strict I & O
RATIONALE: A. Blood pressure elevation is a serious and frequent complication associated with Acute Glomerulonephritis. The nurse should expect to assess blood pressure every 4 to 6 hours with vital signs.
3. A client with a history of Polycystic Kidney Disease is admitted to the Renal Unit for evaluation for dialysis. Which of the following lab values would be MOST significant in determining renal function?
a. Creatinine 8.7 mg/dl
b. BUN 90 mg/dl
c. Serum K+ 7.0 mEq/l
d. Uric Acid 7.5
RATIONALE: A. Although BUN is a measure of kidney function, patients who are dehydrated (without kidney disease) can show an elevation in blood urea nitrogen (BUN). Creatinine is a specific indicator of renal function and/or failure.
4. An 8 year old girl is admitted with R/O Acute Glomerulonephritis. Considering the usual prescribed treatment for this diagnosis, which would be the earliest clinical manifestation of a response to treatment?
a. Decreased blood pressure
b. Increased urine output
c. Decreased edema
d. Increased serum protein
RATIONALE: B. When the inflammatory process begins to resolve renal function improves. Urinary output must increase before the blood pressure or edema decreases. Serum protein loss is not the problem in acute glomerulonephritis.
5. The nurse notices that the weight of a young school-age child hospitalized with acute glomerulonephritis has increased by 1 kg in the past 3 days. The child’s mother has been bringing in meals from home to encourage the child to eat. The nurse should suspect that which homemade food most likely has contributed to his weight gain?
a. Hard boiled egg and skimmed milk
c. Chicken soup
d. Pasta and cookies
d. Grilled cheese sandwiches
RATIONALE: D. All cheeses are high in sodium and must be avoided during the acute phase of acute glomerulonephritis because they may contribute to fluid retention and edema.
1. A client was recently diagnosed with hypothyroidism. Nursing assessment would reveal the most common clinical manifestations of hypothyroidism, which are:
a. Decreased facial expression, diarrhea, and weight gain
b. Increased body temperature, tachycardia, and fatigue
c. Decreased exercise tolerance and facial and pitting edema
d. Increased sluggishness, increased cold intolerance, and puffy eyelids
RATIONALE: D. A deficiency of thyroid hormone causes widespread metabolic changes. Alterations in fluid and electrolyte balance due to increased capillary permeability leads to fluid retention that result in edema, particularly in the eyelids, hands, and feet.
2. On her first post-partum day, a woman who is diabetic has been eating a full diet, and her insulin was reduced to one-third of the dosage received during pregnancy. Which sign(s) and/or symptom(s) would indicate that the client is experiencing hyperglycemia?
a. Profuse perspiration
c. Flushed face
e. rapid pulse
f. Deep, rapid perspirations
RATIONALE: BCDEF. Confusion, irritability, and lethargy are associated with high blood sugar levels. Flushed face is associated with dehydration which results from high blood sugar. Headache can either result from high or low blood sugar. Hyperglycemia can lead to hypovolemic shock, with a rapid, thready pulse from severe dehydration. Deep, rapid breathing (Kussmaul breathing) is an attempt to compensate for the increased carbon dioxide level resulting from ketoacidosis. Profuse diaphoresis or perspiration is incorrect because it is associated with an insulin reaction or a low blood sugar.
3. Which of the following will the nurse caring for a client with Cushing’s syndrome should expect?
a. Skeletal-muscle wasting, because glucocorticoids promote protein and fat mobilization
b. Hypoglycemia due to increased insulin production
c. Discoloration and hyperpigmentation of the skin due to increased pituitary secretion of ACTH
d. Dependent edema and severe hypokalemia due to abnormal aldosterone secretion
RATIONALE: A. Lassitude and muscle weakness are clearly signs of Cushing’s syndrome. Catabolism from gluconeogenesis occasionally results in a marked decreased in skeletal mass, and the client’s extremities may appear wasted. Choice D is partially correct, hypersecretion of aldosterone in Cushing’s syndrome is rare; however, large quantities of cortisol tend to increase sodium and water retention and potassium excretion. Edema and hypokalemia occur only in severe cases. Hypoglycemia is incorrect because gluconeogenesis from excess cortisol secretion results in hyperglycemia. Discoloration and hyperpigmentation occur with adrenal insufficiency.
4. Appropriate nursing actions for a client with Addison’s disease would include:
a. Administering insulin replacement therapy
b. Reducing physical and emotional stress
c. Providing a low-sodium diet
d. Restricting fluids to 1500 ml/day
RATIONALE: B. Because the clients ability to react to stress is decreased, maintaining a quiet environment is a nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial. To promote optimal hydration and sodium intake, fluid intake is increased, particularly fluids containing electrolytes, such as broths, carbonated beverages, and juices.
5. A newly admitted patient is manifesting irritability, tremors, and weight loss. What laboratory test would the nurse expect?
RATIONALE: C. The patient exhibits signs and symptoms of possible hyperthyroidism that can be confirmed by assessing the thyroxine level of the patient.
6. You are assigned to care for a patient with SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone). In developing a nursing care plan, which of the following needs would have the highest priority?
c. Activity Intolerance
RATIONALE: D. Although a patient with SIADH has many needs, the one with the highest priority is that of safety. The patient with SIADH is at risk for dilutional hyponatremia which may result in seizures. Therefore, of the diagnoses given; safety would have the highest priority. Oxygenation - is not a problem in these patients, and Nutrition, although dietary changes may be needed to manage fluid and electrolyte disturbances associated with this syndrome, it does not take priority over safety.
1. A patient about to undergo sigmoidoscopy would be appropriately placed in what position?
a. Right side lying with knees flexed
b. Left Lateral with knees flexed
c. Recumbent Position
d. Prone with foot part elevated by pillow
RATIONALE: B. During sigmoidoscopy the client is placed in the left lateral position to facilitate insertion of the flexible scope into the sigmoid colon. Flexing the knees allows exposure of the anal area for easy insertion.
2. Following Total Gastrectomy patients will require vitamin replacement. Of the following, which vitamin is ESSENTIAL and MUST be given throughout life:
a. Vitamin C
b. Vitamin B6
c. Vitamin D
d. Vitamin B12
RATIONALE: D. Following Total Gastrectomy the production of Intrinsic Factor is permanently destroyed. This is necessary (Intrinsic Factor) for the absorption of Vitamin B12 from the GI tract. As a result patients must receive Vitamin B12 by parenteral route throughout life, or a condition known as Pernicious Anemia will develop, and can prove to be fatal. Regular IM injections on a monthly basis of 100-200ug is the usual therapeutic dose.
3. The nurse knows that the drainage is normal 4 days after sigmoid colostomy when the material is:
a. Solid formed
b. Green liquid
d. Loose feces
RATIONALE: D. Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed. Page 839 of Joyce Black
4. The nurse’s preparation of the client undergoing IV cholangiogram includes:
a. Forcing fluids for 6 to 8 hours before the examination
b. Administering radiopaque tablets the evening before the examination
c. Informing the client about possible reactions when the contrast medium is injected
d. A fatty meal the evening before the examination
RATIONALE: C. The client should be informed of possible sensations such as warmth, flushing of face and a salty taste from the IV contrast medium.
5. A client with acute pancreatitis is complaining of numbness with circumoral tingling and muscle cramps. What interventions are appropriate for these manifestations?
a. Request an order for serum sodium test
b. Assess for hypocalcemia
c. Assess for hypoglycemia
d. Administer potassium IV
RATIONALE: B. Calcium is lost in the fat necrosis, and saponification (formation of calcium soap) may occur. Circumoral tingling and muscle cramps are early signs of hypocalcemia. Assess for signs of tetany by checking Chvostek’s and Trousseau’s signs.
6. A client has frequent stools, with poor oral intake of both fluids and solids. While administering the ordered parenteral hyperalimentation, it is important to remember that hyperalimentation solutions are:
a. Hypertonic solutions used primarily to increase osmotic pressure of blood plasma
b. Hypotonic solutions used primarily for hydration when hemoconcentration is present
c. Hyperosmolar solutions used primarily to reverse negative nitrogen balance
d. Alkalyzing solutions used to treat metabolic acidosis, thus reducing cellular swelling
RATIONALE: C. Parenteral hyperalimentation solutions are hyperosmolar solutions containing amino acids, 10 to 25 % glucose, multivitamins, and electrolytes. These solutions are administered through large veins such as subclavian vein to avoid the inflammation or thrombosis they tend to cause in peripheral veins. These solutions are given to clients with disturbance of ingestion, digestion, or absorption that are combined with excessive catabolism.
7. Following Gastric Resection, patients are prone to developing Dumping Syndrome. Which of the following types of dietary intake by the patient would be MOST helpful to either reduce or prevent this syndrome from developing?
a. Moderate fat, low carbohydrate
b. High fat, high carbohydrate
c. Low fat, low carbohydrate
d. Moderate fat, high carbohydrate
RTIONALE: A. One of the more common problems following Gastric surgery is Dumping Syndrome. Dietary management is the key to reduce or prevent this potential problem from developing. The diet should contain moderate amounts of fat, as well as be low in carbohydrates, especially small molecular carbohydrates such as sucrose and glucose. These dietary modifications will result in decreased hypertonicity of the intestinal contents, and prevent osmotic pull of extracellular fluid into the intestinal area, lessening the possibility for Dumping Syndrome to develop.
8. A client, admitted 3 days ago fro GI bleeding from a duodenal ulcer, has had a stable vital signs, an Hgb of 13.0, and an Hct of 40. The intervention most likely to help this client at this point is to:
a. Infuse 2 units of packed RBCs over 5 hours
b. Maintain strict bed rest and a calm environment
c. Teach the client about preoperative and postoperative GI surgical care
d. Administer an antibiotic and proton pump inhibitor (Prilosec), if ordered
RATIONALE: D. The client is stable, and conservative therapy is preferred for as long as possible.
9. The night RN reports that a client, admitted with a diagnosis of gastric ulcer, is complaining of syncope and vertigo. What is the initial nursing intervention by the RN?
a. Check the client’s vital signs
b. Keep the client on bed rest
c. Give a stat dose of sucralfate (Carafate)
d. Call for stat Hgb and Hct
RATIONALE: B. The priority is to maintain client safety. With syncope and vertigo, the client is at risk for falling. After the patient is safe, vital signs and laboratory Hgb and Hct can be done.
10. What is the appropriate nursing action following a liver biopsy?
a. Place the client is supine, in a semi-Fowler’s position
b. Draw blood for a CBC
c. Check vital signs every 15 minutes for 1 hour
d. Place the client on his left side
RATIONALE: C. The client must be observed for signs of hemorrhage.
11. The physician suspects that a client has a peptic ulcer. After the first 48 to 72 hours, which diet would the nurse expect the physician to order?
a. Frequent feedings of clear liquids
b. Small feedings of bland food
d. A regular diet given frequently in small amounts
RATIONALE: B. Bland feedings should be given in small amounts on a frequent basis to neutralize the hydrochloric acid and prevent overload.
12. While a T-tube is clamped, the nurse should observe a client after a cholecystectomy for signs of:
b. Abdominal discomfort
c. Increased respiratory rate
RATIONALE: B. Following clamping of the T-tube, the client should be observed for signs of abdominal distress, pain, nausea, chills, fever. These symptoms may be caused by a localized reaction to bile, edema, or obstructed flow. Severe abdominal pain may indicate leakage of bile into the peritoneal cavity. Eructation or burping may occur after eating if bile flow was insufficient. Jaundice is a late symptom of biliary obstruction.
13. Which of the following choices best describes the pain associated with duodenal ulcer?
a. Continuous, dull pain in the right lower quadrant
b. Gnawing, epigastric pain 1 to 3 hours after eating
c. Dull epigastric pain that occurs one half hour after eating
d. Sharp, intermittent pain the left upper quadrant
RATIONALE: B. The pain is described as aching, burning, cramp-like, and gnawing, occurring at some time after eating, depending on where the ulcer is.
14. Dietary instructions for a client with peptic ulcer disease (PUD) should include:
a. Eating mainly bland foods and milk or dairy products
b. Eliminating intake of alcohol and coffee
c. Reducing intake of high-fiber foods (e.g. whole grains)
d. Eating small, frequent meals and a bedtime snack
RATIONALE: B. These substances stimulate the production of hydrochloric acid, which is detrimental in PUD. Eating bland foods and dairy products is no longer believed to be necessary for a client with peptic ulcer disease.
15. A 52-year-old client who is admitted to rule out peptic ulcer disease (PUD) suddenly complains of severe abdominal pain. On palpation, the abdomen is rigid with rebound tenderness. These findings indicate
a. Pyloric stenosis
b. GI hemorrhage
d. Paralytic ileus
RATIONALE: C. The presented signs and symptoms are classic signs of perforation.
1. The doctor has ordered ambulation on crutches, with no weight bearing on the affected limb. An appropriate crutch gait for the nurse to teach the client would be:
a. Two-point gait
b. Three-point gait
c. Four-point gait
d. Tripod gait
RATIONALE: B. The three-point gait is appropriate when weight bearing is not allowed on the affected limb. The swing-to and swing-through crutch gaits may also be used when only leg can be used for weight bearing.
2. Following a client’s total hip replacement, what nursing intervention is priority?
a. Initiate passive exercise as soon as possible
b. Turning client to unaffected side with abduction pillow between legs
c. Prevent hip dislocation by maintaining leg adduction using a trocanter roll
d. Provide an overhead trapeze
RATIONALE: B. If a client’s leg is adducted after replacement, dislocation may occur. The client should be turned to the unaffected side with an abduction pillow between legs.
3. Assessment of a client following a recent fracture of the humerus revealed increasing pain with extension of the fingers of the left hand. Distal pulse is strong in the limb. Capillary refill is brisk, and there does not appear to be any restriction of the fingers from the cast. The most likely explanation of the pain is:
a. Disuse syndrome from immobility
b. Possible development of compartment syndrome
c. Compression of nerve at the fracture site
d. Normal response to sudden movement of fingers
RATIONALE: B. Pain from passive movement or stretching of fingers is characteristic of the development of compartment syndrome. The cast is acting as a “space-limiting” sleeve around the muscle, nerves, and blood vessels, resulting in increased tissue pressure. Skin color, temperature, capillary refill, and quality of peripheral pulses are not reliable clinical indicators of compartment syndrome.
4. Immediately on returning to the recovery room, a client’s above-the-knee (AK) amputation stump should initially be:
a. Wrapped in elastic bandage to reduce edema formation
b. Elevate on a the foot of the bed to reduce recurrence of edema and hemorrhage
c. Placed on Buck’s traction to prevent skin and muscle retraction
d. Firmly bandaged to a padded board to prevent contractures
RATIONALE: B. to reduce bleeding and edema, the stump is elevated for the first 24 hours; after 24 hours, however, hip flexion contracture may occur with prolonged elevation.
5. To facilitate proper drying of a long leg cast, which measure should the nurse include in the plan of care?
a. Place the client on a bed board.
b. Use only the tips of the fingers to handle the cast.
c. Leave the cast exposed to the air.
d. Encourage the client to remain in one position.
RATIONALE: C. The cast should be fully exposed to the air to help it dry properly.
6. Upon a client’s admission for extracapsular fracture of the left femur, the nurse notes that the affected extremity appears:
a. Internally rotated.
b. To have foot-drop.
c. Blanched over the fracture site.
d. Shorter than the other leg.
RATIONALE: D. The affected leg will be shorter and externally rotated. “Extracapsular” means “outside the capsule.”
7. The nurse observes a client in the orthopedic clinic using a long pencil to scratch the skin under the cast. The nurse should:
a. Ask the physician for an oral medication order to relieve itching.
b. Take the Pencil away from the client.
c. Assist the client by gently rolling the casted leg in the palmar surfaces of the nurse’s hands while the client scratches.
d. Explain to the client that scratching under the cast should be avoided, because it may break the skin and cause an infection.
RATIONALE: D. It is not safe to insert any foreign object under a cast, because the skin may break and become infected. Scratching also disturbs the padded surface under the cast, causing it to become wrinkled, which may lead to skin irritation and breakdown. Itching under the cast can be relieved by directing air (from a blower) under the cast.
8. A client is admitted to the orthopedic unit with a long leg cast, which is used to immobilize a transverse fracture of the right tibia fibula. The plaster of paris cast is damp, and the client is complaining that it feels very hot. The nurse should:
a. Tell the client not to worry; this is a common complaint.
b. Explain to the client that the cast will feel hot for several hours as the moisture evaporates and the cast hardens.
c. Recognize that this is a sign of excessive pressure on the soft tissues and notify the physician.
d. Administer Meperidine (Demerol), 50 mg IM, to relieve discomfort.
RATIONALE: B. A freshly applied cast generates heat as moisture evaporates and the cast hardens. To facilitate drying, it should be exposed to the air. Do not use plastic covers or Chux on pillows to elevate the limb, because they tend to slow drying.
9. Following an amputation, a nursing measure to help reduce the size of the stump once the surgical wound is healed is:
a. Wrapping moist, warm soaks on the thigh.
b. Elevation of the stump on a pillow when reclining.
c. Applying an elastic bandage.
d. Pushing the stump against a hard surface.
RATIONALE: C. After the stump has healed; an elastic bandage is applied to it to produce shrinkage and a conical shape. It is a compression dressing, with maximal compression at the distal end of the stump and minimal compression at the proximal end. The stump is wrapped with a clean bandage each day and rewrapped four times each day to maintain compression.
10. Which statement correctly describes the four-point gait used when partial weight bearing is permitted?
a. Move both crutches forward together, then swing legs through.
b. Move the right crutch ahead, and then follow with the left foot.
c. Move the left crutch and the right foot forward together.
d. Move both crutches and the weaker leg forward at the same time.
RATIONALE: B. The idea of four points means a crutch, the opposite foot, the other crutch, then the opposite foot. Each moves separately.
1. Where would the nurse place the call light for a client with a right- sided brain attack and left homonymous hemianopsia?
a. Where the client prefers
b. Directly in front of the client
c. On the client’s left side
d. On the client’s right side
RATIONALE: D. The client has left visual field blindness. The client will see only from the right side.
2. A client with seizure disorder is admitted for pneumonia. If the client has a generalized tonic-clonic seizure, what is appropriate action for the nurse to perform during the seizure episode?
a. Ventilate the client with an “ambu bag” if apneic
b. Move hard objects away from the client’s head
c. Suction secretions
d. Open the mouth to insert oral airway
RATIONALE: B. With a tonic-clonic seizure, there is muscle rigidity, then muscle jerking. The nurse must provide for the safety of the client by clearing the environment. During seizure there should be nothing in the client’s mouth; doing so could cause injury to the client or nurse. Restraints can further cause injury.
3. As a result of Guillane-Barre syndrome, a client has a nursing diagnosis of “high risk for disuse.” What intervention would be a priority to be included in the nursing care plan?
a. Use an air mattress
b. Perform active and passive range-of-motion exercise every 2 hours
c. Turn and reposition client every 2 hours
d. Apply continuous splints to extremities to prevent contractures
RATIONALE: B. Active and passive range-of-motion exercises not only preserve muscle function, but also prevent contractures. In addition, skin integrity and circulation are maintained.
4. For a client with multiple sclerosis, what teaching is necessary to prevent fatigue?
a. Avoid extremes of temperature
b. Avoid physical exercise
c. Install safety devices in the home
d. Attend support group meetings
RATIONALE: A. Extremes of heat and cold will exacerbate symptoms. Heat delays transmission of impulses and increases fatigue.
5. Diagnosis of myasthenia gravis is frequently based on the client’s response to an intravenous injection of endrophonium (Tensilon). If the client responds positively to this drug, the nurse should expect:
a. Relief of ptosis, but not of weakness, in other facial muscles
b. A prompt and dramatic increase in muscle strength
c. Exacerbation of symptomatology
d. A slight increase in muscle strength that is countered by an increase in muscle fatigability
RATIONALE: B. Endrophonium (Tensilon) is a short acting anticholinesterase compound. A positive Tensilon test result (a prompt and dramatic increase in muscle strength) is consistent with the diagnosis of myasthenia gravis.
6. In caring for a client with ALS (Amyotrophic Lateral Sclerosis), the nursing diagnosis with the highest priority would be:
a. Impaired Physical Mobility
b. Altered Role Performance
c. Potential for Ineffective Airway Clearance
d. Potential for Impaired Verbal Communication
RATIONALE: C. ALS is a progressive and usually fatal disease which affects the motor neurons; as they die; muscular function is affected resulting in progressive weakness, atrophy, spasticity of the muscles including the muscles of respiration. While other Choices are all potential diagnoses, choice C would be the diagnosis with the highest priority. Remember a patent airway is essential to life, and must be maintained.
F & E:
1. Which change in fluid or electrolyte status would the nurse find is consistent with syndrome of inappropriate antidiuretic hormone (SIADH)?
a. Urine output of 2500 mL/24 hr
b. Serum sodium of 150 mEq
c. Presence of edema
d. Urine specific gravity of 1.036
RATIONALE: D. SIADH is an increase in the antidiuretic hormone, which results in increased total body water and hyponatremia. Urine is concentrated and volume is decreased. Because of increase in intravascular volume hemodilution of the serum sodium occurs. Intravascular volume and weight increases, but there is no interstitial edema.
2. A 76-year-old man has become overly concerned regarding constipation. The client has abused the use of laxatives and developed chronic diarrhea. The nurse knows that the client is at risk for which of the following electrolyte imbalance?
a. Azotemia, hyperkalemia, and hyponatremia
b. Bicarbonate excess, hypokalemia, and hypomagnesia
c. Hyperkalemia, hypocalcemia, and hyponatremia
d. Hypomagnesia, hypocalcemia, and hypokalemia
RATIONALE: D. Magnesium, calcium, and potassium are lost through the GI tract.
3. A client is admitted with a 72-hour history of nausea and vomiting as a result of severe gastritis. What is the RN’s priority intervention?
a. Obtain a stool for occult blood
b. Obtain history of diet and medications
c. Start an IV and prepare to give ringer’s lactate
d. Assess for hypokalemia and hypovolemia
RATIONALE: D. Potassium depletion is common in gastrointestinal losses. After 72 hours, the danger of hypokalemia is an important assessment, with prompt IV replacement a priority. Although IV fluids are needed, Ringer’s lactate would intensify an already present metabolic alkalosis from the loss of gastrointestinal acids.
4. What assessment finding(s) will the RN expect to see in a client with prerenal kidney failure?
a. Elevated Hct
b. Oliguria with elevated specific gravity
c. Increased BP and pulse
d. Tachypnea and orthopnea
RATIONALE: B. Prerenal failure is frequently the result of renal ischemia due to decreased volume to the kidneys, as in third spacing and shock. Prerenal failure usually results from intravascular fluid volume deficit. Urine output is decreased, and the urine is more concentrated.
5. The client is started on a regular diet following gastric surgery. The client receives the following for lunch:
8 oz apple juice
½ cup of herb tea
½ turkey sandwich on white bread
½ cup of orange Jello with mandarin oranges
½ cup of cottage cheese
How many milliliters of fluid would be recorded in the intake and output?
RATIONALE: 650 ml. There are 30 mL in 1 ounce; 8 ounces in a cup; 4 ounces in ½ cup, 8 ounces of apple juice is 240 ml; 1 cup of tea is 240 ml; and ½ cup of Jello is 120 ml.
1. A client’s skin test, sputum smear, culture, and chest x-ray are conclusive for tuberculosis. The nurse tells the client that respiratory isolation will require:
a. Caps and gowns during the period of contagion
b. Both client and attending nurse wearing masks at all times
c. Gloves when handling the client’s tissue, excretions, and linen
d. Nurse and visitors wearing masks, and proper handling of sputum
RATIONALE: D. Proper handling of sputum is essential to allay droplet transference of bacilli in the air. Clients need to be taught to cover the nose and mouth with tissue when sneezing or coughing. Chemotherapy generally renders the client noninfectious within days to a few weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is established, many institutions require client to wear mask, as well as the visitors and the nurse. Clients should be in a well-ventilated room, without air recirculation, to prevent air contamination.
2. How can RN’s most effectively control transmission of methicillin- resistant Staphylococcus aureus (MRSA)?
a. Place client in total isolation
b. Use gloves and wash hands before and after client contact
c. Use masks and gowns during care of the client with MRSA
d. Do nasal culture on health care workers
RATIONALE: B. Contact isolation, which includes gloves and hand washing, has been advised by the Centers for Disease Control and Prevention (CDC) to control transmission of MRSA.
3. A client receiving chemotherapy is at risk for bone marrow depression. The nurse instructs the client about how to prevent infection at home. Client teaching includes which of the following statements?
a. “Get a weekly white blood cell count.”
b. “Wash hands frequently and maintain good hygiene.”
c. “Do not share bathroom with children or pregnant women.”
d. “Avoid contact with others while receiving chemotherapy.”
RATIONALE: B. Frequent hand washing and good hygiene are the best means of preventing infection.
4. The staff nurse reports that one of the roommates has just been diagnosed with hepatitis A. Which action should be taken?
a. Ask the physician for immune globulin injection
b. Send a stool culture to the lab
c. Decrease protein and carbohydrate intake
d. Assess for jaundice and clay colored urine
RATIONALE: A. Immune globulin will give a high degree of immunity from Hepatitis A if given within 2 weeks of exposure. Hepatitis A has a 4-week incubation period during which time the immune globulin should be given to those exposed. Immunoglobulin is good for 3 months. This globulin is used as a prophylaxis before and after exposure. Page 1325 of J. Black Medical Surgical Nursing 2005 edition
5. The infection-control RN visits the staff after a client has been diagnosed with bacterial (meningococcal) meningitis. What statement by the RN reflects an understanding of the management of this client?
a. A skin culture on macular papular rash should be performed
b. Respiratory isolation is necessary for 24 hours after antibiotics are started
c. Abnormal general muscle contractions are expected
d. Instituting immediate reverse isolation
RATIONALE: B. After minimum of 24 hours of IV antibotics, the client is no longer considered communicable. Evaluation of the RNs knowledge is needed for safe and continuity of care.
6. Which of the following is true about caring a patient with Scabies? Select all that apply
- Mode of transmission: By close personal contact with the infected person or contaminated object
- Household members and contacts of the infected child needs to be treated at the same time
- Instruct parents that all clothing, bedding, and pillowcases used by the child need to be changed daily, washed in hot water with detergent, dried in a hot dryer, and iron before use.
- Non-washable toys and other items should be sealed in plastic bags for 4 days.
RATIONALE: ABCD. All of the following are appropriate nursing intervention for the patient.
7. When is a contact precaution necessary?
a. Patient came back from SE Asia with yellowish sclerae and pruritus
b. AIDS patient with reddish-brown lesions
c. Patient admitted with suspected meningococcal infection
d. Burn patient about to receive wet to dry dressing
RATIONALE: B. Skin lesion that occurs in an immunocompromised patient such as with AIDS is called Kaposis sarcoma. Interventions include instituting a contact precaution when giving care to the client and providing a protective isolation to the client.
8. A patient is complaining of night sweats and a cough more than two weeks. What other symptoms will the nurse needs to assess to support the diagnosis of tuberculosis?
a. Weight loss
b. Elevated fever
c. Rhonchi on auscultation
RATIONALE: A. A patient with suspected tuberculosis would occasionally report symptoms of fatigue, lethargy, anorexia, weight loss, low-grade fever, chills, night sweats, persistent cough and production of mucoid and mucopurulent sputum, which is occasionally streaked with blood, chest tightness and dull, aching chest pain that may accompany when the patient cough.
9. A client who is immunocompromised complains of “painful, itchy blisters” on the chest. What should the RN do?
a. Call the physician
b. Use gloves and gowns while assessing the lesions
c. Clarify if the client is on new medication
d. Isolate the client immediately
RATIONALE: B. the client may have herpes zoster (“shingles”). A viral infection. The RN should use standard precautions in assessing the lesion. Clients who are immunocompromised are at risk for infection.
10. A client with AIDS is afraid of getting toxoplasmosis. The most important precaution to take would be to:
a. Avoid contact with cats and birds
b. Wear a mask when traveling to foreign countries
c. Wear gloves when gardening
d. Wash all vegetables before cooking
RATIONALE: C. Toxoplasmosis is an opportunistic infection and a parasite of birds and mammal. The oocysts remain infectious in moist soil for about 1 year. Cats should not be avoided, but handling of litter should be avoided. Eating raw or uncooked meat, not vegetables is a mode of transmission.
1. In caring for a patient with DVT (Deep Vein Thrombosis), which of the following nursing interventions would be inappropriate?
a. Elevate the foot of the bed
b. Apply elastic stockings to both lower extremities
c. Apply warm, moist heat to the affected extremity
d. Teach patient to use a heel-toe gait when ambulating
RATIONALE: B. Nursing care for patients with DVT include bed rest, elevation of the extremity, application of warm, moist heat, anticoagulation therapy, and elastic stockings only if edema is present once the patient resumes ambulation. For the patient on bed rest, elastic stockings (TEDS), are applied to the unaffected extremity only. Note in elevating the legs NEVER use pillows under the knees and/or knee gatch the bed. Teaching the patient how to ambulate should also be included in your patient care.
2. An 18 month old with Tetralogy of Fallot has a "tet" spell after having an invasive procedure. To improve the child's cardiac status which of the following interventions should the nurse do initially?
a. Place the child in a knee chest position
b. Begin chest compressions
c. Administer oxygen
d. Position with HOB elevated
RATIONALE: A. A "tet" spell is when the child is having difficulty meeting oxygen demands. The knee chest position reduces venous blood return from the lower extremities and increases vascular resistance to divert blood flow to the pulmonary artery. Chest compression is to be initiated for cardiac arrest. Options C and D would not help to oxygenate a child with TOF.
3. The nurse is caring for a client who is 3 days post-myocardial infarction (MI). A desired outcome that demonstrates improvement would be:
a. Adequate vital signs and urinary output
b. Absence of ventricular tachycardia
c. Ability to take brisk walks in hospital corridor
d. Urine output less than 30 cc/hr
RATIONALE: A. Adequate vital signs and urinary output are parameters of adequate cardiac output and tissue perfusion. When cardiac output is sufficient, there is enough circulating blood volume to perfuse vital organs, including the renal system. A major determinant of BP and pulse is blood volume.
4. A client is in the coronary care unit recovery from an acute MI. the nurse should know that 90 percent of all clients with acute MI develop cardiac dysrhythmias. For which life-threatening dysrhythmias should the nurse be monitoring the client?
a. Ventricular tachycardia
b. Atrial flutter
c. Atrial tachycardia
d. Sinus bradycardia
RATIONALE: A. Ventricular tachycardia is a life-threatening dysrhythmia that requires immediate treatment.
5. Three hours after admission to the CCU for anterior myocardial infarction (MI), a client develops increasing ventricular ectopy, followed by a short burst of ventricular tachycardia. The first nursing action is to?
a. Repeat the morphine sulfate, per order
b. Notify the attending physician
c. Increase the flow of oxygen from 4 to 8 liters
d. Administer bolus lidocaine, per order
RATIONALE: D. Lidocaine is the treatment of choice in this situation. Ventricular tachycardia is a serious arrhythmia. It must be treated at once because it may compromise cardiac output and is considered a precursor to ventricular fibrillation.
1. The nurse suggests which of the following foods to minimize the risk of digitalis toxicity to a client who is on digoxin?
a. Fish, green beans, and cherry pie
b. Cottage cheese, cooked broccoli, and roast beef
c. Whole grain cereal, orange juice, and apricots
d. Turkey, green beans, and Italian bread
RATIONALE: C. These foods are high in potassium.
2. Which food should the nurse advise a client with a colostomy to avoid?
a. Cooked cereals
b. Carbonated drinks
c. Liver and bacon
d. Fresh cooked green beans
RATIONALE: B. Carbonated drinks, cabbage, sauerkraut, and nuts tend to increase flatulence, and most clients feel uncomfortable passing flatus into the colostomy bag, because it causes the bag to inflate. Onions, cheese, and fish may cause odorous drainage. Generally, the initial diet following a colostomy is a low-fiber for several weeks. As the diet is increased, the individual client can determine more accurately which food causes constipation, diarrhea, flatus, or dyspepsia.
3. Restricting dietary protein in chronic renal failure prevents accumulation of nitrogenous wastes and resulting azotemia. Which foods containing amino acids should be allowed with chronic renal failure?
b. Chicken and turkey
c. Milk and eggs
d. Roast beef
RATIONAL: C. The diet for clients with chronic renal failure is restricted in total amount of protein and amino acid content. Eggs and milk are generally included in the diet because they contain all the essential amino acids.
4. Dietary instructions for a client on long-term corticosteroid therapy include:
a. Increase calcium and vitamin D supplements to reduce osteoporosis
b. Reduce potassium to avoid cardiac complications
c. Increase carbohydrate intake to maintain ideal weight
d. Increase sodium intake to prevent dehydration
RATIONALE: A. Long-term corticosteroid therapy can result in osteoporosis and pathological fractures. Potassium loss occurs in this client so a need to increase potassium intake is necessary. The client needs a high protein, not high-carbohydrate diet to counteract muscle wasting caused by steroid therapy. The therapy causes sodium retention, not dehydration. Clients would need to restrict sodium intake.
5. While giving diet instructions after a cholecystectomy, the nurse would inform the client that:
a. After approximately 3 months, polyunsaturated fats can be added to the diet
b. The diet will not include fatty food for at least 1 year
c. The diet will be limited to 20g fat per day
d. There are no special dietary restrictions in the postoperative period, but the client will be more comfortable if large, fatty meals are avoided
RATIONALE: D. There is no specific dietary restriction following cholecystectomy. Clients are advised, however, to avoid foods high in fats. Most clients tend to avoid these foods anyway because they are more comfortable if they do so. Generally, after about 3 months, client may begin to experiment with certain foods to ascertain their tolerance to them.
MCN / OB:
1. What is the main reason for cautioning in using analgesia during delivery?
a. Hypoxia in newborn
b. Ability of mother to engage in delivery process
c. Decrease strength of uterine contractions
d. Diminished ability of mother to bear down
RATIONALE: A. Analgesia during delivery causes respiratory depression that compromises the newborns respirations leading to hypoxia.
2. A nurse admitting a client with PIH would prepare which of the following in the client’s bedside?
a. Suction equipment and oxygen
b. Fetal heart monitor
c. Blood pressure equipment
d. Padded side rails
RATIONALE: A. A client with PIH requires a patent airway and adequate oxygenation to deliver enough oxygen to the baby that might be decreased by the elevation of the mother’s blood pressure that can lead to abruption placenta. Fetal heart tone must be monitored also but adequate oxygenation must be ensured first.
3. A woman previously used a diaphragm for contraception before her pregnancy. Now at 6 weeks postpartum, she asks the nurse if she needs to have her diaphragm refitted. The best response is:
a. “No, it is not necessary. Once involution is completed, it should fit as it did before.”
b. “Yes, it should be refitted after pregnancy.”
c. “Yes, but you should wait until 3 months postpartum.”
d. “It isn’t advisable to use a diaphragm after giving birth to an infant.”
RATIONALE: B. A Diaphragm should be refitted after each pregnancy for around 6 weeks postpartum. It should also be refitted if the woman loses or gains a significant amount of weight (15-20 lb), or has uterine or vaginal surgery.
4. To prevent displacement of radium implants in the cervix, the nurse should position the client:
a. On the side only
b. With the head elevated at 45 degrees (Semi Fowler’s position)
c. Flat in bed
d. With the foot of the bed elevated
RATIONALE: C. Clients with radioactive implants should be positioned flat in bed to prevent dislodgment of vaginal packing. The client may roll to the side for meals, but the upper body should not be raised more than 20 degrees.
5. Following a mastectomy, what follow-up care should the RN discuss with the client?
a. Change the dressing prn
b. Perform active ROM exercises with the affected arm
c. Resume normal activities as comfort allows
d. Wear rubber gloves when gardening
RATIONALE: D. Infections, cuts, and bruises on the affected side should be avoided by using gloves in doing household activities. Exercise should be initially passive. A specific, graduated exercise regimen should be outlined for the client at the discretion of the physician.
6. What information should the RN teach the woman with pelvic inflammatory disease (PID)?
a. Douche everyday
b. Refrain from sexual activity for 6 weeks
c. Change tampons at least every 4 hours when menstruating
d. Use an IUD for birth control
RATIONALE: C. Menstrual flow and wet tampon can be a culture medium for organism that can cause infections.
7. Health teaching for client with vaginal infection with Candida albicans should be planned and implemented to ensure her consistent and appropriate use of the prescribed medication. Which medication is effective in the treatment of monilial (yeast) vaginitis?
a. Metronidazole (Flagyl) oral tablets
b. Nystatin (Mycostatin) vaginal suppositories
c. Antibiotic (Bacitracin) ointment
d. Local applications of podophyllin
RATIONALE: B. Nystatin is the drug of choice for the treatment of vaginal infections caused by Candida albicans.
1. What time of day would the nurse expect to see signs of hypoglycemia in a client following NPH insulin given at 7:30 am?
a. 8:00 AM to 11:00 AM
b. 2: 00 PM to 5:00 PM
c. 8:00 PM to 11:00 PM
d. 2:00 AM to 5:00 AM
RATIONALE: B. NPH is an intermediate-acting insulin with peak effects between 6 to 12 hours after administration.
2. A client has been prescribed with tirofiban (Aggrastat) 50 ml to be mixed in a 250 ml bag of sterile normal saline. Which of the following adverse effect would the nurse needs to watch?
a. Weight gain
RATIONALE: C. Tirofiban (Aggrastat) is a blood thinner that is usually prescribed to patients with acute coronary syndrome and those undergoing percutaneous transluminal coronary angioplasty. Patients must be cautiously monitored for the risk of bleeding and thrombocytopenia.
3. A patient is on warfarin (Coumadin) therapy. What statement indicates ineffective teaching by the nurse?
a. I need to have my blood checked frequently
b. I can still continue drinking my green tea
c. I need to avoid all forms of NSAIDs
d. I will buy an electric razor for shaving
RATIONALE: B. Warfarin is an anticoagulant that increases the risk of bleeding. Foods that may alter the action of the drug includes those that contain Vit K found in green leafy vegetables.
4. A client with pellagra is prescribed with 500 mg of niacin PO daily. Which of the following observations requires to be reported to the MD?
a. Dark urine
d. Night sweats
RATIONALE: B. Niacin is a form of vitamins that stimulates lipid metabolism, tissue respiration, and glycogenolysis. It is usually prescribed to patient who has deficiency in niacin such as pellagra. Adverse effect of the drug includes excessive peripheral vasodilation, paresthesia, tingling, hepatic dysfunction, arrhythmias, and hyperpigmentation.
5. A nurse would question the MD about the administration of metoprolol (Lopressor) when the patient has?
a. Apical pulse 56 bpm
b. Weight gain of 1 kg for 2 days
c. Blood pressure of 140/100 mmHg
d. respirations of 12 breaths per minute
RATIONALE: A. When giving metoprolol to the patient always check patient’s apical rate before giving the drug. If it’s slower than 60 beats/minute, withhold drug and call the prescriber immediately.
6. A patient with bipolar disorder who is taking up lithium carbonate (Eskalith) is manifesting tremors. What would be the most appropriate action for the nurse to take?
a. Hold the next dose and check the lithium level
b. Note the observation in the patient’s chart as this is an expected side effect
c. Stop the drug immediately
d. Continue giving the next dose
RATIONALE: A. Tremors, diarrhea, vomiting, drowsiness, ataxia, and muscle weakness are signs of lithium toxicity. If these are observed instruct caregiver to withhold one dose and call the prescriber, but do not stop the drug abruptly. Lithium level should be checked because lithium has a narrow therapeutic margin.
7. A nurse understands that which of the following drug group would enhance that ASA side effects and therefore should not be used together?
d. Alkylating agents
RATIONALE: A. Anticoagulants inhibits platelet aggregation to prevent clot formation and potentiates the effect of ASA which also impedes clotting by blocking prostaglandin synthesis, which prevents formation of the platelet-aggregating substance.
8. Which of the following will the nurse identifies as side effects of using lidocaine?
a. Hyperesthesia, depression, palpitations, vomiting
b. Hallucinations, tremor, restlessness, blurring of vision
c. Tachypnea, double vision, diaphoresis, nervousness
d. Hypotension, urine retention, fatigue, dyspnea
RATIONALE: B. Side effects of lidocaine are confusion, tremor, lethargy, somnolence, stupor, restlessness, anxiety, hallucinations, nervousness, light-headedness, paresthesia, muscle twitching, seizures, hypotension, blurred vision, respiratory depression and arrest.
9. A client taking alendronate sodium (Fosamax) should be instructed to perform which of the following?
a. Never lie down after intake for atleast 30 minutes
b. Give with antacid
c. Take at bedtime for better absorption
d. Take together with vit C to facilitate absorption
RATIONALE: A. Patients taking Fosamax should never lie after drinking the medications for atleast 30 minutes to facilitate delivery to the stomach and prevent esophageal irritation. Patients are also advised to take supplemental calcium and vit D if intake is inadequate. Antacid must be taken at least 30 minutes interval.
10. The nurse caring the client taking fluphenazine decanoate (Prolixin) should watch the client for
a. Hypertensive crisis
b. Diet restrictions
c. I & O
d. Exposure to sunlight
RATIONALE: D. Fluphenazine decanoate (Prolixin) is an antipsychotic medication and the client should be caution for anticholinergic side effects such as constipation, dry mouth, side effects such as hypotension, urinary retention, blurring of vision, dry mouth, and photosensitivity. Extrapyramidal reactions, tardive dyskinesia, sedation, drowsiness, seizures, and neuroleptic malignant syndrome are also watched.
11. A client taking phenelzine sulfate (Nardil) develops symptoms of upper respiratory infection. The doctor orders pseudoephedrine HCL (Sudafed). What would be the most appropriate action for the nurse?
a. Withhold the pseudoephedrine HCL
b. Give pseudoephedrine HCL as ordered
c. Ask the doctor to consider other medication
d. Discuss the possible side effects with the client
RATIONALE: A. Phenelzine sulfate (Nardil) is a monoamine oxidase inhibitor and therefore should not be used with any hay fever or cold medications (which may potentiate its CNS stimulant properties, possibly leading to hypertensive crisis, stroke, or death.)
12. A client is started on haloperidol (Haldol). The nurse will observe for signs of:
a. Parkinsonian symptoms
b. Hypertensive crisis
c. Electrolyte imbalance
d. Liver toxicity
RATIONALE: A. Extrapyramidal (parkinsonian) symptoms can occur with large doses and long term therapy of haloperidol (Haldol).
13. Which of the following side effects of lithium carbonate should the nurse watch?
a. Fine tremors
b. Nausea and vomiting
c. Decreased level of consciousness
RATIONALE: C. Decrease level of consciousness is a sign of significant neurological side effects and is more serious.
14. A client admitted with a diagnosis of chronic atrial fibrillation is on a daily dose of warfarin (Coumadin) 2.5 mg. the serum international normalized ratio (INR) level is 4.7. What is the appropriate nursing intervention?
a. Monitor the client for signs of bleeding
b. Prepare to give the client protamine sulfate
c. Observe the client for the possibility of an embolic event
d. Have a PTT drawn to completely evaluate the level of anticoagulation
RATIONALE: A. The level of anticoagulation, as reflected by the INR, is too high and the client is at high risk for bleeding. The serum INR is done to evaluate the effectiveness of oral anticoagulants, especially warfarin (Coumadin). The normal value is 2.0 to 3.0 for clients on anticoagulant therapy.
15. Which outcome is the best indicator that digoxin has been effective?
a. Unlabored respirations and increased urinary output
b. Increased systolic and diastolic blood pressures
c. Increased BP and decreased pulse rate
d. Decreased pulse rate and increased urinary output
RATIONALE: D. The best indicator that digoxin has been effective in strengthening cardiac contraction and increasing glomerular filtration is a decrease in heart rate (Vagal effect) and increased urinary output. As a result of these drug effects, cardiac output is improved, raising BP and decreasing pulmonary congestion.
16. A client with severe, unstable angina pectoris is started on a nitroglycerin (Nitrostat) drip via IV pump. Which client outcome is expected from this intervention?
a. Client reports relief of chest pain
b. A decrease of BP to 110/60
c. No evidence of cardiac dysrhythmias
d. An increase of BP to 110/60
RATIONALE: A. Nitroglycerin dilates the coronary arteries and decreases the workload of the heart. It is specifically given for pain related to coronary artery disease (angina pectoris). In this case, a client with severe pain of unstable angina pectoris is treated with IV nitroglycerin.
17. A client with severe rheumatoid arthritis taking Indomethacin (Indocin) should be instructed to
a. Take the medication with food or antacids
b. Increase in oral fluid intake
c. Take together with NSAID for effective pain relief
d. Take antacid 30 minutes to 1 hour apart
RATIONALE: A. Indomethacin produces anti-inflammatory, analgesic, and antipyretic effects. It should be taken with food, milk, or antacid to prevent GI distress. The drug causes sodium retention so the patient should be watched for weight gain and increased in blood pressure. Using together with NSAID is not advisable because NSAID may mask signs and symptoms of infection.
18. Which of the following instructions is not appropriate to give to a patient taking triamcinolone (Kenalog)?
a. Instruct patient to avoid exposure to infections
b. Instruct to take drug with food or milk
c. Notify physician if sudden weight loss occur
d. Do not stop the drug abruptly or without prescriber’s consent
RATIONALE: C. One of the side effects of taking long term therapy of Kenalog is the presence of Cushingoid effects (moon face, buffalo hump) and the need to notify prescriber about sudden weight gain and swelling.
19. A client with influenza type A virus is admitted in the hospital and prescribed with amantadine HCL (Symmetrel) 200 mg PO daily in a single dose. Which of the following client’s response indicates a need for further teaching about the drug?
a. “I will to move slowly when changing positions or standing.”
b. “I will take the drug before sleep.”
c. “I will notify my doctor if I experience urine retention.”
d. “I will continue taking the drug for 7 days.”
RATIONALE: B. Symmetrel usually causes insomnia and the patient must be instructed to take a single dose preferably earlier before bedtime.
1. A client recently attempted suicide by slashing the wrists. The crisis intervention nurse and physician agree that hospitalization is not necessary for this client; therefore the nurse needs to:
a. Tell the client to make an appointment soon at the local mental health clinic
b. Wish the client luck and terminate the session
c. Make an appointment the next day and give client a telephone number where the nurse can be reached that night
d. Make an appointment for the client in 2 weeks, when the wrist might be healed
RATIONALE: C. On principle, crisis intervention needs to be immediately available to the client.
2. Which is the most appropriate response to a client who states emphatically, “I hate them”?
a. “I am here. Tell me more about your hate.”
b. “I will stay with you as long as you feel this way.”
c. “I understand how you can feel this way.”
d. “For whom do you have these feelings?”
RATIONALE: A. This statement seeks to clarify and further discuss the feelings. Offering of self is the best therapeutic communication in almost all psychiatric conditions. It involves safety and security for this patient.
3. A 19-year-old college student is admitted to the psychiatric hospital with a diagnosis of schizophrenic reaction. Seven weeks ago the client began to sleep and eat poorly, was mute for long periods of time, and stayed in the room, grinning and pointing at things. What should be the first nursing action on admitting the client to the unit?
a. Ask “Do you know where you are?”
b. Take the client to the assigned room
c. Assure the client that “You will be cared for.”
d. Introduce the client to some other clients
RATIONALE: B. This client needs basic, simple orientation that directly relates to here-and-now, and does not require verbal interaction. Introducing the client to other client is premature; the client needs one-to-one relationship first. Asking the client is incorrect because the client is mute, asking for response places a demand on the client at this time. Assuring the client that you will be cared for is a premature and a vague and meaningless communication.
4. A doctor asks the nurse to encourage activity by a client who hears voices and is withdrawn and negativistic. What would be the nurse best approach?
a. Demand that the client join group activity
b. Mention that the “voices” would want the client to participate
c. Tell the client that the nurse needs a partner for an activity
d. Give the client a long explanation of the benefits of the activity
RATIONALE: C. the nurse helps to promote activity by doing something for the client. Demanding will not work; the client cannot participate unless the nurse accompanies the client in the activity. Mentioning that the voices want the client to participate is wrong because psychosis should not be used to motivate a person.
5. A client is placed in isolation because of agitated behavior. The nurse knows it is essential that:
a. All the furniture be removed from the isolation room
b. Restraints be applied
c. The client is allowed to come out after 4 hours
d. A staff member must have a frequent contact with the client
RATIONALE: D. Frequent contact at times of stress is important, especially when client is isolated. Removing all furniture is incorrect because all furniture need not be removed, depending on the institution and the type of behavior exhibited by the client.
6. A newly admitted 45-year-old woman with obsessive-compulsive behavior frequently removes her shoes. The nurse understands that the client’s repetitive removing of shoes is probably an attempt to:
a. Control unacceptable impulses or feelings
b. Punish self for guilt feelings
c. Seek attention from the staff
d. Do what the voices the client hears
RATIONALE: A. A ritual such as what the client did is an attempt to allay anxiety cause by unconscious impulses that are frightening.
7. A teenage client has a history of car theft and traffic violations. The home environment has been permissive, and the teenager has been overly familiar and obsequious with the nurse. A new nurse, about to leave the locked unit, is holding the key as the client approaches and eagerly offers to unlock the door for the nurse saying, “The other nurses lets me.” Which first response by the nurse would be most appropriate?
a. Ask the client why he or she wants to unlock the door
b. Let the client turn the key in the lock, but stay close while the client does it
c. Go to the head nurse and ask if it’s all right for the client to unlock the door
d. Tell the client in a nice way that the behavior is not allowed
RATIONALE: C. Based on the client’s history of antisocial behavior, the client is probably attempting to use the nurse for his or her own purpose and is not truthful. Therefore, it is best that the new nurse on the unit go directly to the head nurse to check on what is permissible, and not to accept the client’s word. Telling the client in a nice way places the new nurse in an argumentative position with the client, who is likely to become defensive and say, “Oh, yes. I am allowed to open doors.” Asking why is not a therapeutic communication. Allowing the client to unlock the door may feed into the manipulative attempt by the client to get off the bed.
8. A nurse notices that a client with obsessive-compulsive is frequently washing her feet. The nurse understands that the primary treatment for a client with obsessive-compulsive behavior is to:
a. Point out the behavior
b. Support but limit the behavior
c. Prohibit the behavior
d. Provide distraction
RATIONALE: B. Support and limit-setting decrease anxiety and provide external control. Providing distraction is incorrect because it is not the primary goal; it is a method of limiting time for the obsessive-compulsive behavior.
9. What is the best goal the nurse can expect from a client with Alzheimer’s disease?
a. Hearing will be intact
b. The client is oriented in three spheres
c. The client will not wander off the unit
d. The client can dress himself
RATIONALE: D. Self-care is usually the basic, hoped-for goal—at whatever activity level. Expecting the client to be oriented in three spheres is not realistic to expect to a client who is disoriented. Expecting the client not to wander is incorrect because as a result of progressive confusion and memory loss, the client may continue to be “lost” and wander.
10. Which nursing approach would be best for a client with symptoms of severe depression?
a. Ask the client to join the nurse and other clients in the TV lounge
b. Allow the client for quiet thought, remain silent
c. Give the client a choice of recreational activity
d. State that the nurse would like to go with the client for a short walk
RATIONALE: D. This action will reduce isolation and withdrawal, while at the same time not putting the burden of decision making on the client. The client needs structured routine that is simple.
- A client abruptly sits up in bed, reports having difficulty breathing, and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?
- simple mask
- nonbreather mask
- face tent
- nasal cannula
- Which of the following would be most appropriate for a client with an Arterial Blood Gas (ABG) of pH = 7.5, PaCO2 = 26 mmHg, O2 saturation 96%, HCO3 = 24 mEq/L, and PaO2 = 94mmHg?
- Administer a prescribed decongestant.
- Instruct the client to breathe into a paper bag.
- Offer the client fluids frequently.
- Administer prescribed supplemental oxygen.
3. A client is brought to the emergency department in acute respiratory distress. After endotracheal intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the endotracheal tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?
- They help prevent subcutaneous emphysema.
- They help prevent pneumothorax.
- They help prevent cardiac arrhythmias.
- They help prevent pulmonary edema.
4. A client who weighs 175 lb (74.4 kg) is receiving aminophylline (aminophyllin) (400mg in 500ml) at 50ml/hour. The theophylline level is reported as 6mcg/ml. The nurse calls the physician who instructs the nurse to change the dosage to 0.45mg/kg/hour. The nurse should:
- Question the order because it’s too low.
- Question the order because it’s too high.
- Set the pimp at 45ml/hour.
- Stop the infusion and have the laboratory repeat the theophylline measurement.
5. The nurse orders supplemental oxygen for a client with a respiratory problem. To provide the highest possible oxygen concentration, the nurse expects to use which oxygen delivery device?
a. Nasal cannula
b. Venturi mask
c. Partial rebreathing mask
d. Nonrebreathing mask
6. The nurse is assisting with a subclavian vein central line insertion when the client’s oxygen saturation rapidly drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed further assessment findings supporting the presence of pneumothorax include:
a. Absent breath sounds on the affected side.
b. Paradoxical chest wall movement with respirations.
c. Tracheal deviation to the unaffected side.
d. Muffled or distant heart sounds.
7. While inspecting the client’s chest, the nurse notes that the chest wall contracts on inspiration and bulges on expiration. From this assessment, she suspects:
b. Flail chest
d. Tension pneumothorax
8. A client is admitted to the emergency department with a suspected overdose of an unknown drug. The client’s arterial blood gas values indicate respiratory acidosis. What should the nurse do first?
a. Prepare to assist with ventilation.
b. Monitor the client’s heart rhythm.
c. Prepare to begin gastric lavage.
d. Obtain urine for drug screening.
9. The client with acute bronchitis requires careful monitoring when receiving:
a. Oxygen therapy
b. Fluid resuscitation
c. Humidified air
d. Postural drainage
10. After insertion of a chest tube for pneumothorax, a client becomes hypotensive neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. The nurse suspects a tension pneumothorax has occurred. What cause of tension pheumothorax should the nurse check for?
a. Infection of the lung.
b. Kinked or obstructed chest tube.
c. Excessive water in the water-seal chamber.
d. Excessive chest tube drainage.
Davies’s NCLEX-RN 2nd Edition
Feur Nursing Review
Saunders Comprehensive Review© 2005
Wong’s Essentials of Pediatric Nursing © 2004
Nursing Drug Handbook © 2003 by Springhouse
Better Elderly Care © 2002 by Springhouse