1. The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is
A) Advising client to restrict sodium intake
B) Taking the blood pressure in the left arm
C) Elevating her left arm above heart level
D) Compressing the drainage device
The correct answer is B: Taking the blood pressure in the left arm
For those clients who have had a unilateral mastectomy, blood pressure should not be measured on the affected side to avoid the possibility of lymphedema.
2. A 70 year-old post-operative client has elevated serum BUN, Hct, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is:
A) Impaired gas exchange
B) Metabolic acidosis
C) Renal insufficiency
D) Fluid volume deficit
The correct answer is D: Fluid volume deficit In fluid volume deficit, serum BUN, Na+ and hematocrit may be elevated secondary to hemoconcentration.
3. The nurse is caring for an acutely ill 10 year-old client. Which of the following assessments would require the nurses immediate attention?
A) Rapid bounding pulse
B) Temperature of 38.5 degrees Celsius
C) Profuse Diaphoresis
D) Slow, irregular respirations
The correct answer is D: Slow, irregular respirations A slow and irregular respiratory rate is a sign of fatigue in an acutely ill child. Fatigue can rapidly lead to respiratory arrest.
4. A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age?
A) Death is personified as the bogeyman or devil
B) Death is perceived as being irreversible
C) The child feels guilty for the grandmother's death
D) The child is worried that he, too, might die
The correct answer is A: Death is personified as the bogeyman or devil
Personification of death is typical of this developmental level.
5. The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?
A) Expiratory wheezes
B) Blurred vision
D) Dilated pupils
The correct answer is C: Acites
Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to acites due to the increased protal pressure as well as a lowered osmotic pressure
6. A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present
A) Temperature of 37.5 degrees Celsius with painful urination
B) An open wound on their heel
C) Insomnia and daytime fatigue
D) Nausea with 2 episodes of vomiting
The correct answer is B: An open wound on their heel
When signs of infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the infection is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.
7. A client who is terminally ill has been receiving high doses of an opiod analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli,what orders would the nurse expect from the health care provider?
A) Decrease the analgesic dosage by half
B) Discontinue the analgesic
C) Continue the same analgesic dosage
D) Prescribe a less potent drug
The correct answer is C: Continue the same analgesic dosage
Dying patients who have been in chronic pain will probably continue to experience pain even though unresponsive. Pain medication should be continued at the same dose, if effective
8. A newborn presents with a pronounced cephalhematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?
A) Pain related to periosteal injury
B) Impaired mobility related to bleeding
C) Parental anxiety related to knowledge deficit
D) Injury related to intercranial hemorrhage
The correct answer is C: Parental anxiety related to knowledge deficit
This hematoma is related to pressure at the time of labor and birth. The condition resolves over a period of weeks to months. Parental anxiety must be addressed by listening to their fears and explaining the nature of this alteration. Caput Succinidanium which is edema typically will go away within a few days. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri
9. While caring for a child with Reye's Syndrome, the nurse should give which action the highest priority?
A) Monitor intake and output
B) Provid good skin care
C) Assess level of consciousness
D) Assis with range of motion
The correct answer is C: Assess level of consciousness
Altered level of consciousness suggests increasing intercranial pressure related to cerebral edema.
10. A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse’s contribution and begins to find objections to the suggestion. The nurse manager's best response is to
A) Let’s move on to a new action that deals with the problem.
B) I think you need to reserve judgment until after all suggestions are offered.
C) Very well thought out. Your analytic skills and interest are incredible.
D) Let’s move to the ‘what if…’ as related to these objections for an exploration of spin off ideas.
The correct answer is D: Let’s move to the ‘what if…’ as related to these objections for an exploration of spin off ideas.
The goal of brainstorming is to gather as many ideas as possible without judgment that slows the creative process and may discourage innovative ideas. Exploration of the nurses objections would encourage the generation of new ideas.
11. A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include
A) The escalation of fees with a decreased reimbursement percentage
B) High costs of diagnostic and end-of-life treatment procedures
C) Increased numbers of elderly and of the chronically ill of all ages
D) A steep rise in health care provider fees and in insurance premiums
The correct answer is A: The escalation of fees with a decreased reimbursement percentage
The percentage of the gross national product representing health care costs rose dramatically with reimbursement based on fee for service. Reimbursement for Medicare and Medicaid recipients based on fee for service also escalates health care costs.
12. The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to
A) Begin cardiopulmonary resuscitation
B) Prepare for immediate defibrillation
C) Notify the "Code" team and health care provider
D) Assess airway breathing and circulation
The correct answer is D: Assess airway breathing and circulation
The nurse must first assess the client to determine the appropriate next step. In this case the first step the nurse must take is to evaluate the A, B, C''s.
13. The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client?
A) Instruct the client to wear a high efficiency particulate air mask in public places.
B) Ask a family member to supervise daily compliance
C) Schedule weekly clinic visits for the client
D) Ask the health care provider to change the regimen to fewer medications
The correct answer is B: Ask a family member to supervise daily compliance
Direct-observed therapy (DOT) is a recognized method for ensuring client compliance to the drug regimen. The program can be set up to directly observe the client taking the medication in the clinic, home, workplace or other convenient location.
14. A woman who delivered 5 days ago and had been diagnosed with preeclampsia calls the hospital triage nurse hotline to ask for advice. She states “ I have had the worst headache for the past 2 days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps.” What should the nurse do next?
A) Advise the client that the swings in her hormones may have that effect. However, suggest for her to call her health care provider within the next day.
B) Advise the client to have someone bring her to the emergency room as soon as possible
C) Ask the client to stay on the line, get the address and send an ambulance to the home
D) Ask what the client has taken? How often? Ask about other specific complaints.
The correct answer is C: Ask the client to stay on the line, get the address and send an ambulance to the home
The correct response is C. The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital. For at risk clients, preeclampsia and eclampsia may occur prior to, during or after delivery. After delivery the window of time can be up to ten days.
15. A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?
A) Playing with toys in a back yard flower garden
B) Eating small amounts of grass while playing "farm"
C) Playing with cars on the pavement near burning leaves
D) Throwing a ball to a neighborhood child who has poison ivy
The correct answer is C: Playing with cars on the pavement near burning leaves
Smoke from burning leaves or stems of the poison ivy plant can produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis.
16. The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting." The nurse manager's leadership style is best described as
The correct answer is C: Participative
Participative style of management involves staff in decision-making processes. Staff/manager interactions are open and trusting. Most work efforts are joint.
17. A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best reponse by the nurse?
A) Avoid Alka-Seltzer because it contains aspirin
B) Take Alka-Seltzer at a different time of day than the warfarin
C) Select another antacid that does not inactivate warfarin
D) Use on-half the recommended dose of Alka-Seltzer
The correct answer is A: Avoid Alka-Seltzer because it contains aspirin
Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin, an antiplatelet drug, will potentiate the anticoagulant effect of warfarin and may result in excess bleeding
18. A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in the plan of care within the initial 24 hours for this client?
A) Wear masks with shields if potential splash
B) Use disposable utensils and plates for meals
C) Wear gown and gloves during client contact
D) Provide soft easily digested food with frequent snacks
The correct answer is C: Wear gown and gloves during client contact
HAV is usually transmitted via the fecal-oral route. That means that someone with the virus handles food without washing his or her hands after using the bathroom. The virus can also be contracted by drinking contaminated water, eating raw shellfish from water polluted with sewage or being in close contact with a person who''s infected — even if that person has no signs and symptoms. In fact, the disease is most contagious before signs and symptoms ever appear. The nurse should recognize the importance of isolation precautions from the initial contact with the client on admission until the noncontagious convalescence period.
19. A confused client has been placed in physical restraints by order of the health care provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?
A) Assist the client with activities of daily living
B) Monitor the clients physical safety
C) Evaluate for basic comfort needs
D) Document mental status and muscle strength
The correct answer is A: Assist with activities of daily living
The person to whom the activity is delegated must be capable of performing it . The UAP is capable of assisting clients with basic needs
20. The nurse admits an elderly Mexican-American migrant worker after an accident that occurred during work. To facilitate communication the nurse should initially ?
A) Request a Spanish interpreter
B) Speak through the family or co-workers
C) Use pictures, letter boards, or monitoring
D) Assess the client's ability to speak English
The correct answer is D: Assess the client''s ability to speak English
Despite the cultural heritage, the nurse cannot make assumptions. Stereotyping is to be avoided. The nurse should assess the client''s comfort and ability in speaking English