|Question 1 | |A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room.
The most important reason for| |the nurse to elevate the casted leg is to | | | | | |A) | |Promote the client’s comfort | | | | | |B) | |Reduce the drying time | | | | | |C) | |Decrease irritation to the skin | | | | | |D) | |Improve venous return | | | | | | | |Review Information: The correct answer is D: Improve venous return. Elevating the leg both improves venous return and reduces swelling. | |Client comfort will be improved as well. | |Question 2 | |The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the | |client? | | | | |A) | |Clean the meatus, begin voiding, then catch urine stream | | | | | |B) | |Void a little, clean the meatus, then collect specimen | | | | | |C) | |Clean the meatus, then urinate into container | | | | | |D) | |Void continuously and catch some of the urine | | | | | | | |Review Information: The correct answer is A: Clean the meatus, begin voiding, then catch urine stream.
A clean catch urine is | |difficult to obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally with| |a steady stream prevents surface bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, | |once the client begins voiding it”s best to just slip the container into the stream. Other responses do not reflect correct | |technique. | |Question 3 | |Following change-of-shift report on an orthopedic unit, which client should the nurse see first? | | | | |A) | |16 year-old who had an open reduction of a fractured wrist 10 hours ago | | | | | |B) | |20 year-old in skeletal traction for 2 weeks since a motor cycle accident | | | | | |C) | |72 year-old recovering from surgery after a hip replacement 2 hours ago | | | | | |D) | |75 year-old who is in skin traction prior to planned hip pinning surgery. | | | | | | | |Review Information: The correct answer is C: 72 year-old recovering from surgery after a hip replacement 2 hours ago.
Look for | |the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk | |for life threatening hemorrhage and should be seen first. The 16 year-old should be seen next because it is still the first | |post-op day. The 75 year-old is potentially vulnerable to age-related physical and cognitive consequences in skin traction should| |be seen next. The client who can safely be seen last is the 20 year-old who is 2 weeks post-injury. | |Question 4 | |A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should | |the nurse document to most accurately describe the client’s condition? | | | | |A) | |Comatose, breathing unlabored | | | | | |B) | |Glascow Coma Scale 8, respirations regular | | | | | |C) | |Appears to be sleeping, vital signs stable | | | | | |D) | |Glascow Coma Scale 13, no ventilator required | | | | | | | |Review Information: The correct answer is B: Glascow Coma Scale 8, respirations regular. The Glascow Coma Scale provides a | |standard reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a neurological | |impairment. Using the term comatose provides too much room for interpretation and is not very precise. | |Question 5 | |When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic | |response to the drug? | | | | |A) | |Bleeding time | | | | | |B) | |Coagulation time | | | | | |C) | |Prothrombin time | | | | | |D) | |Partial thromboplastin time | | | | | | | |Review Information: The correct answer is C: Prothrombin time.
Coumadin is ordered daily, based on the client”s prothrombin time| |(PT). This test evaluates the adequacy of the extrinsic system and common pathway in the clotting cascade; Coumadin affects the | |Vitamin K dependent clotting factors. | |Question 6 | |A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is | |measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 | |liters/minute. What should the nurse do first? | | | | |A) | |Notify both the surgeon and provider | | | | | |B) | |Administer the prn dose of albuterol | | | | | |C) | |Apply oxygen at 2 liters per nasal cannula | | | | | |D) | |Repeat the peak flow reading in 30 minutes | | | | | | | |Review Information: The correct answer is B: Administer the prn dose of albuterol. | |Peak flow monitoring during exacerbations of asthma is recommended for clients with | |moderate-to-severe persistent asthma to determine the severity of the exacerbation | |and to guide the treatment. A peak flow reading of less than 50% of the client”s | |baseline reading is a medical alert condition and a short-acting beta-agonist must | |be taken immediately. | |Question 7 | |A client had 20 mg of Lasix (furosemide) PO at 10 AM.
Which would be essential for the nurse to include at the change of shift | |report? | | | | | |A) | |The client lost 2 pounds in 24 hours | | | | | |B) | |The client’s potassium level is 4 mEq/liter. | | | | |C) | |The client’s urine output was 1500 cc in 5 hours | | | | | |D) | |The client is to receive another dose of Lasix at 10 PM | | | | | | | |Review Information: The correct answer is C: The client’s urine output was 1500 cc in 5 hours. Although all of these may be | |correct information to include in report, the essential piece would be the urine output. | |Question 8 | |A client has been tentatively diagnosed with Graves’ disease (hyperthyroidism). Which of these findings noted on the initial | |nursing assessment requires quick intervention by the nurse? | | | | |A) | |a report of 10 pounds weight loss in the last month | | | | | |B) | |a comment by the client “I just can’t sit still. | | | | | |C) | |the appearance of eyeballs that appear to “pop” out of the client’s eye sockets | | | | | |D) | |a report of the sudden onset of irritability in the past 2 weeks | | | | | | | |Review Information: The correct answer is C: the appearance of eyeballs that appear to “pop” out of the client”s eye sockets. | |Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves” Disease. It can result in corneal abrasions with | |severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be | |needed. | |Question 9 | |The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding | |would cause the nurse to call the provider immediately? | | | | |A) | |prolonged inspiration with each breath | | | | | |B) | |expiratory wheezes that are suddenly absent in 1 lobe | | | | | |C) | |expectoration of large amounts of purulent mucous | | | | | |D) | |appearance of the use of abdominal muscles for breathing | | | | | | | |Review Information: The correct answer is B: expiratory wheezes that are suddenly absent in 1 lobe. Acute asthma is characterized| |by expiratory wheezes caused by obstruction of the airways.
Wheezes are a high pitched musical sounds produced by air moving | |through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest. However, sudden cessation | |of wheezing is an ominous or bad sign that indicates an emergency — the small airways are now collapsed. | |Question 10 | |During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer’s disease with family | |members. Which of these interventions would be most helpful at this time? | | | | |A) | |leave a book about relaxation techniques | | | | | |B) | |write out a daily exercise routine for them to assist the client to do | | | | | |C) | |list actions to improve the client’s daily nutritional intake | | | | | |D) | |suggest communication strategies | | | | | | | |Review Information: The correct answer is D: suggest communication strategies. Alzheimer”s disease, a progressive chronic | |illness, greatly challenges caregivers.
The nurse can be of greatest assistance in helping the family to use communication | |strategies to enhance their ability to relate to the client. By use of select verbal and nonverbal communication strategies the | |family can best support the client’s strengths and cope with any aberrant behavior. | |Question 11 | |An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 160/100 to | |180/110 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report | |immediately to the provider? | | | | |A) | |Slurred speech | | | | | |B) | |Incontinence | | | | | |C) | |Muscle weakness | | | | | |D) | |Rapid pulse | | | | | | | |Review Information: The correct answer is A: Slurred speech.
Changes in speech patterns and level of conscious can be indicators | |of continued intracranial bleeding or extension of the stroke. Further diagnostic testing may be indicated. | |Question 12 | |A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the parent | |indicates that teaching has been inadequate? | | | | | |A) | |”I will keep the cast uncovered for the next day to prevent burning of the skin. | | | | | |B) | |”I can apply an ice pack over the area to relieve itching inside the cast. ” | | | | | |C) | |”The cast should be propped on at least 2 pillows when my child is lying down. | | | | | |D) | |”I think I remember that my child should not stand until after 72 hours. ” | | | | | | | |Review Information: The correct answer is D: “I think I remember that my child should not stand until after 72 hours. “. Synthetic| |casts will typically set up in 30 minutes and dry in a few hours. Thus, the client may stand within the initial 24 hours.
With | |plaster casts, the set up and drying time, especially in a long leg cast which is thicker than an arm cast, can take up to 72 | |hours. Both types of casts give off a lot of heat when drying and it is preferable to keep the cast uncovered for the first 24 | |hours. Clients may complain of a chill from the wet cast and therefore can simply be covered lightly with a sheet or blanket. | |Applying ice is a safe method of relieving the itching. | |Question 13 | |Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that mmediate action is required? | | | | | |A) | |pH below 7. 3 | | | | | |B) | |Potassium of 5. | | | | | |C) | |HCT of 60 | | | | | |D) | |Pa O2 of 79% | | | | | | | |Review Information: The correct answer is C: HCT of 60. This high hematocrit is indicative of severe dehydration which requires | |priority attention in diabetic ketoacidosis. Without sufficient hydration, all systems of the body are at risk for hypoxia from a| |lack of or sluggish circulation.
In the absence of insulin, which facilitates the transport of glucose into the cell, the body | |breaks down fats and proteins to supply energy ketones, a by-product of fat metabolism. These accumulate causing metabolic | |acidosis (pH < 7. 3), which would be the second concern for this client. The potassium and PaO2 levels are near normal. | |Question 14 | |The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would | |be necessary for preparing the client for this test? | | | | |A) | |Client should be NPO after midnight | | | | | |B) | |Client should receive a sedative medication prior to the test | | | | | |C) | |Discontinue anti-coagulant therapy prior to the test | | | | | |D) | |No special preparation is necessary | | | | | | | |Review Information: The correct answer is D: No special preparation is necessary. This is a non-invasive procedure and does not | |require preparation other than client education. | |Question 15 | |A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition? | | | | | |A) | |dyspnea | | | | |B) | |heart murmur | | | | | |C) | |macular rash | | | | | |D) | |hemorrhage | | | | | | | |Review Information: The correct answer is B: heart murmur.
Large, soft, rapidly developing vegetations attach to the heart | |valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce | |findings of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore, the vegetations may travel | |to various organs such as spleen, kidney, coronary artery, brain and lungs, and obstruct blood flow. | |Question 16 | |The nurse explains an autograft to a client scheduled for excision of a skin tumor.
The nurse knows the client understands the | |procedure when the client says, “I will receive tissue from | | | | | |A) | |a tissue bank. ” | | | | | |B) | |a pig. | | | | | |C) | |my thigh. ” | | | | | |D) | |synthetic skin. | | | | | | | |Review Information: The correct answer is C: my thigh. “. Autografts are done with tissue transplanted from the client”s own | |skin. | |Question 17 | |A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be | |expected by the nurse? | | | | |A) | |Diffuse expiratory wheezing | | | | | |B) | |Loose, productive cough | | | | |C) | |No relief from inhalant | | | | | |D) | |Fever and chills | | | | | | | |Review Information: The correct answer is A: Diffuse expiratory wheezing. In asthma, the airways are narrowed, creating | |difficulty getting air in. A wheezing sound results. | |Question 18 | |A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing | |interventions should receive priority? | | | | |A) | |Maintaining proper body alignment | | | | | |B) | |Frequent neurovascular assessments of the affected leg | | | | | |C) | |Inspection of pin sites for evidence of drainage or inflammation | | | | |D) | |Applying an over-bed trapeze to assist the client with movement in bed | | | | | | | |Review Information: The correct answer is B: Frequent neurovascular assessments of the affected leg. The most important activity | |for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition | |of this neurovascular problem and early intervention may prevent permanent limb damage. | |Question 19 | |The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about | |this condition. What area is a priority for the nurse to discuss at this time? | | | | |A) | |Daily needs and concerns | | | | | |B) | |The overview cardiac rehabilitation | | | | | |C) | |Medication and diet guideline | | | | | |D) | |Activity and est guidelines | | | | | | | |Review Information: The correct answer is A: Daily needs and concerns. At 2 days post-MI, the client’s education should be | |focused on the immediate needs and concerns for the day. | |Question 20 | |A 3 year-old child is brought to the clinic by his grandmother to be seen for “scratching his bottom and wetting the bed at | |night. ” Based on these complaints, the nurse would initially assess for which problem? | | | | |A) | |allergies | | | | | |B) | |scabies | | | | | |C) | |regression | | | | | |D) | |pinworms | | | | | | |Review Information: The correct answer is D: pinworms. Signs of pinworm infection include intense perianal itching, poor sleep | |patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span. Scabies is an itchy skin | |condition caused by a tiny, eight-legged burrowing mite called Sarcoptes scabiei . The presence of the mite leads to intense | |itching in the area of its burrows. | |Question 21 | |The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? | | | | |A) | |Risk for dehydration | | | | | |B) | |Ineffective airway clearance | | | | | |C) | |Altered nutrition | | | | | |D) | |Risk for injury | | | | | | | |Review Information: The correct answer is B: Ineffective airway clearance. The most common form of TEF is one in which the | |proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by| |a short fistula at or near the bifurcation. Thus, a priority is maintaining an open airway, preventing aspiration. Other nursing | |diagnoses are then addressed. | |Question 22 | |The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner| |menu would be best? | | | | |A) | |Fish sticks, french fries, banana, cookies, milk | | | | | |B) | |Ground beef patty, lima beans, wheat roll, raisins, milk | | | | | |C) | |Chicken nuggets, macaroni, peas, cantaloupe, milk | | | | | |D) | |Peanut butter and jelly sandwich, apple slices, milk | | | | | | | |Review Information: The correct answer is B: Ground beef patty, lima beans, wheat roll, raisins, milk. Iron rich foods include | |red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the | |best choice: It is high in iron and is appropriate for a toddler. | |Question 23 | |The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance? | | | | |A) | |Metabolic acidosis | | | | | |B) | |Metabolic alkalosis | | | | | |C) | |Some increase in the serum hemoglobin | | | | | |D) | |A little decrease in the serum potassium | | | | | | | |Review Information: The correct answer is B: Metabolic alkalosis.
Vomiting causes loss of acid from the stomach. Prolonged | |vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, | |hyperactive reflexes, muscle twitching and elevated pulse. Options C and D are correct answers but not the best answers since | |they are too general. | |Question 24 | |A two year-old child is brought to the provider’s office with a chief complaint of mild diarrhea for two days. Nutritional | |counseling by the nurse should include which statement? | | | | |A) | |Place the child on clear liquids and gelatin for 24 hours | | | | | |B) | |Continue with the regular diet and include oral rehydration fluids | | | | | |C) | |Give bananas, apples, rice and toast as tolerated | | | | | |D) | |Place NPO for 24 hours, then rehydrate with milk and water | | | | | | | |Review Information: The correct answer is B: Continue with the regular diet and include oral rehydration fluids. Current | |recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate. | |Question 25 | |The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration.
In | |addition to oral rehydration fluids, the diet should include | | | | | |A) | |formula or breast milk | | | | | |B) | |broth and tea | | | | | |C) | |rice cereal and apple juice | | | | | |D) | |gelatin and ginger ale | | | | | | | |Review Information: The correct answer is A: formula or breast milk. The usual diet for a young infant should be followed. | |Question 26 | |A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take | |is | | | | | |A) |call for emergency transport to the hospital | | | | | |B) | |immobilize the limb and joints above and below the injury | | | | | |C) | |assess the child and the extent of the injury | | | | | |D) | |apply cold compresses to the injured area | | | | | | | |Review Information: The correct answer is C: assess the child and the extent of the injury. When applying the nursing process, | |assessment is the first step in providing care.
The “5 Ps” of vascular impairment can be used as a guide (pain, pulse, pallor, | |paresthesia, paralysis). | |Question 27 | |The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats | |to the diet. What should be emphasized as the nurse teaches about infant nutrition? | | | | | |A) | |Solid foods should be introduced at 3-4 months | | | | |B) | |Whole milk is difficult for a young infant to digest | | | | | |C) | |Fluoridated tap water should be used to dilute milk | | | | | |D) | |Supplemental apple juice can be used between feedings | | | | | | | |Review Information: The correct answer is B: Whole milk is difficult for a young infant to digest. Cow”s milk is not given to | |infants younger than 1 year because the tough, hard curd is difficult to digest. In addition, it contains little iron and creates| |a high renal solute load. | Question 28 | |The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in| |the teaching materials? | | | | | |A) | |Solid foods are introduced one at a time beginning with cereal | | | | | |B) |Finely ground meat should be started early to provide iron | | | | | |C) | |Egg white is added early to increase protein intake | | | | | |D) | |Solid foods should be mixed with formula in a bottle | | | | | | | |Review Information: The correct answer is A: Solid foods are introduced one at a time beginning with cereal. Solid foods should be added | |one at a time between 4-6 months. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the | |recommended first food. | Question 29 | |The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include | |which one of the following as a priority? | | | | | |A) | |Limit fluids | | | | | |B) | |Client controlled analgesia | | | | |C) | |Cold compresses to elbow | | | | | |D) | |Passive range of motion exercise | |