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1.

The nursing care plan for a toddler diagnosed with Kawasaki Disease
(mucocutaneous lymph node syndrome) should be based on the high risk for
development of which problem?
) !hronic vessel pla"ue formation
#) $ulmonary embolism
!) %cclusions at the vessel bifurcations
D) Coronary artery aneurysms
&. nurse has 'ust received a medication order which is not legible. (hich
statement best re)ects assertive communication?
) *+ cannot give this medication as it is written. + have no idea of what you
mean.*
B) "Would you please clarify what you have written so I am sure I am
reading it correctly?"
!) *+ am having di,culty reading your handwriting. +t would save me time if
you would be more careful.*
D) *$lease print in the future so + do not have to spend e-tra time attempting
to read your writing.*
.. The nurse is discussing negativism with the parents of a ./ month0old
child. 1ow should the nurse tell the parents to best respond to this behavior?
) 2eprimand the child and give a 13 minute *time out*
#) 4aintain a permissive attitude for this behavior
C) Use patience and a sense of humor to deal with this behavior
D) ssert authority over the child through limit setting
5. n ambulatory client reports edema during the day in his feet and an ankle
that disappears while sleeping at night. (hat is the most appropriate follow0
up "uestion for the nurse to ask?
) *1ave you had a recent heart attack?*
#) *Do you become short of breath during your normal daily activities?*
!) *1ow many pillows do you use at night to sleep comfortably?*
D) "Do you smoe?"
3. The nurse is planning care for a client during the acute phase of a sickle
cell vaso0occlusive crisis. (hich of the following actions would be most
appropriate?
) 6luid restriction 1///cc per day
#) mbulate in hallway 5 times a day
C) !dminister analgesic therapy as ordered
D) 7ncourage increased caloric intake
8. (hile working with an obese adolescent9 it is important for the nurse to
recogni:e that obesity in adolescents is most often associated with what
other behavior?
) ;e-ual promiscuity
B) "oor body image
!) Dropping out of school
D) Drug e-perimentation
<. nurse and client are talking about the client=s progress toward
understanding his behavior under stress. This is typical of which phase in the
therapeutic relationship?
) $re0interaction
#) %rientation
C) Woring
D) Termination
>. nurse is eating in the hospital cafeteria when a toddler at a nearby table
chokes on a piece of food and appears slightly blue. The appropriate initial
action should be to
) #egin mouth to mouth resuscitation
#) ?ive the child water to help in swallowing
C) "erform # abdominal thrusts
D) !all for the emergency response team
@. The emergency room nurse admits a child who e-perienced a sei:ure at
school. The father comments that this is the Arst occurrence9 and denies any
family history of epilepsy. (hat is the best response by the nurse?
) *Do not worry. 7pilepsy can be treated with medications.*
B) "$he sei%ure may or may not mean your child has epilepsy&"
!) *;ince this was the Arst convulsion9 it may not happen again.*
D) *Bong term treatment will prevent future sei:ures.*
1/. nurse admits a . week0old infant to the special care nursery with a
diagnosis of bronchopulmonary dysplasia. s the nurse reviews the birth
history9 which data would be most consistent with this diagnosis?
!) 'estational age assessment suggested growth retardation
#) 4econium was cleared from the airway at delivery
!) $hototherapy was used to treat 2h incompatibility
D) The infant received mechanical ventilation for & weeks
11. $arents of a 8 month0old breast fed baby ask the nurse about increasing
the babyCs diet. (hich of the following should be added Arst?
!) Cereal
#) 7ggs
!) 4eat
D) Duice
1&. victim of domestic violence states9 *+f + were better9 + would not have
been beat.* (hich feeling best describes what the victim may be
e-periencing?
) 6ear
#) 1elplessness
C) (elf)blame
D) 2e'ection
1.. The nurse is assessing the mental status of a client admitted with
possible organic brain disorder. (hich of these "uestions will best assess the
function of the clientCs recent memory?
) *Eame the year.* *(hat season is this?* (pause for answer after each
"uestion)
#) *;ubtract < from 1// and then subtract < from that.* (pause for answer)
*Eow continue to subtract < from the new number.*
C) "I am going to say the names of three things and I want you to
repeat them after me* blue+ ball+ pen&"
D) *(hat is this on my wrist?* (point to your watch) Then ask9 *(hat is the
purpose of it?*
15. (hich o-ygen delivery system would the nurse apply that would provide
the highest concentrations of o-ygen to the client?
) Fenturi mask
#) $artial rebreather mask
C) ,on)rebreather mas
D) ;imple face mask
13. nurse is caring for a client who had a closed reduction of a fractured
right wrist followed by the application of a Aberglass cast 1& hours ago.
(hich Anding re"uires the nurse=s immediate attention?
) !apillary reAll of Angers on right hand is . seconds
#) ;kin warm to touch and normally colored
C) Client reports pricling sensation in the right hand
D) ;light swelling of Angers of right hand
18. +ncluded in teaching the client with tuberculosis taking +E1 about follow0
up home care9 the nurse should emphasi:e that a laboratory appointment for
which of the following lab tests is critical?
!) -iver function
#) Kidney function
!) #lood sugar
D) !ardiac en:ymes
1<. (hich client is at highest risk for developing a pressure ulcer?
) &. year0old in traction for fractured femur
#) <& year0old with peripheral vascular disease9 who is unable to walk without
assistance
C) .# year)old with left sided paresthesia and is incontinent of urine
and stool
D) ./ year0old who is comatose following a ruptured aneurysm
1>. (hich contraindication should the nurse assess for prior to giving a child
immuni:ation?
) 4ild cold symptoms
#) !hronic asthma
C) Depressed immune system
D) llergy to eggs
1@. The nurse is caring for a & year0old who is being treated with chelation
therapy9 calcium disodium edetate9 for lead poisoning. The nurse should be
alert for which of the following side eGects?
) Eeuroto-icity
#) 1epatomegaly
C) ,ephroto/icity
D) %toto-icity
&/. newborn is having di,culty maintaining a temperature above @>
degrees 6ahrenheit and has been placed in a warming isolette. (hich action
is a nursing priority?
) $rotect the eyes of the neonate from the heat lamp
B) 0onitor the neonate1s temperature
!) (arm all medications and li"uids before giving
D) void touching the neonate with cold hands
&1. t a senior citi:ens meeting a nurse talks with a client who has diabetes
mellitus Type 1. (hich statement by the client during the conversation is
most predictive of a potential for impaired skin integrity?
) *+ give my insulin to myself in my thighs.*
B) "(ometimes when I put my shoes on I don2t now where my toes
are&"
!) *1ere are my up and down glucose readings that + wrote on my calendar.*
D) *+f + bathe more than once a week my skin feels too dry.*
&&. 5 year0old hospitali:ed child begins to have a sei:ure while playing with
hard plastic toys in the hallway. %f the following nursing actions9 which one
should the nurse do Arst?
) $lace the child in the nearest bed
#) dminister +F medication to slow down the sei:ure
!) $lace a padded tongue blade in the childCs mouth
D) 3emove the child2s toys from the immediate area
&.. The nurse is at the community center speaking with retired people. To
which comment by one of the retirees during a discussion about glaucoma
would the nurse give a supportive comment to reinforce correct information?
) *+ usually avoid driving at night since lights sometimes seem to make
things blur.*
#) *+ take half of the usual dose for my sinuses to maintain my blood
pressure.*
!) *+ have to sit at the side of the pool with the grandchildren since + canCt
swim with this eye problem.*
D) "I tae e/tra 4ber and drin lots of water to avoid getting
constipated&5
&5. The nurse is teaching a parent about side eGects of routine
immuni:ations. (hich of the following must be reported immediately?
!) Irritability
#) ;light edema at site
!) Bocal tenderness
D) Temperature of 1/&.3 6
&3. client is admitted with the diagnosis of pulmonary embolism. (hile
taking a history9 the client tells the nurse he was admitted for the same thing
twice before9 the last time 'ust . months ago. The nurse would anticipate the
health care provider ordering
) $ulmonary embolectomy
#) Fena caval interruption
C) Increasing the coumadin therapy to an I,3 of 6)7
D) Thrombolytic therapy
&8. woman in her third trimester complains of severe heartburn. (hat is
appropriate teaching by the nurse to help the woman alleviate these
symptoms?
) Drink small amounts of li"uids fre"uently
#) 7at the evening meal 'ust before retiring
!) Take sodium bicarbonate after each meal
D) (leep with head propped on several pillows
&<. The nurse is teaching the mother of a 3 month0old about nutrition for her
baby. (hich statement by the mother indicates the need for further teaching?
) *+Cm going to try feeding my baby some rice cereal.*
#) *(hen he wakes at night for a bottle9 + feed him.*
C) "I dip his paci4er in honey so he2ll tae it&"
D) *+ keep formula in the refrigerator for &5 hours.*
&>. 6or a 8 year0old child hospitali:ed with moderate edema and mild
hypertension associated with acute glomerulonephritis (?E)9 which one of
the following nursing interventions would be appropriate?
!) Institute sei%ure precautions
#) (eigh the child twice per shift
!) 7ncourage the child to eat protein0rich foods
D) 2elieve boredom through physical activity
&@. (hich statement by the client with chronic obstructive lung disease
indicates an understanding of the ma'or reason for the use of occasional
pursed0lip breathing?
) *This action of my lips helps to keep my airway open.*
B) "I can e/pel more when I pucer up my lips to breathe out&"
!) *4y mouth doesnCt get as dry when + breathe with pursed lips.*
D) *#y prolonging breathing out with pursed lips the little areas in my lungs
donCt collapse.*
./. 3< year0old male client has hemoglobin of 1/ mgHdl and a hematocrit of
.&I. (hat would be the most appropriate follow0up by the home care nurse?
!) !s the client if he has noticed any bleeding or dar stools
#) Tell the client to call @11 and go to the emergency department
immediately
!) ;chedule a repeat 1emoglobin and 1ematocrit in 1 month
D) Tell the client to schedule an appointment with a hematologist
.1. (hich response by the nurse would best assist the chemically impaired
client to deal with issues of guilt?
) *ddiction usually causes people to feel guilty. Don=t worry9 it is a typical
response due to your drinking behavior.*
B) "What have you done that you feel most guilty about and what
steps can you begin to tae to help you lessen this guilt?"
!) *Don=t focus on your guilty feelings. These feelings will only lead you to
drinking and taking drugs.*
D) *Jou=ve caused a great deal of pain to your family and close friends9 so it
will take time to undo all the things you=ve done.*
.&. n adolescent client comes to the clinic . weeks after the birth of her Arst
baby. ;he tells the nurse she is concerned because she has not returned to
her pre0pregnant weight. (hich action should the nurse perform Arst?
) 2eview the clientCs weight pattern over the year
#) sk the mother to record her diet for the last &5 hours
C) 8ncourage her to tal about her view of herself
D) ?ive her several pamphlets on postpartum nutrition
... (hich of the following measures would be appropriate for the nurse to
teach the parent of a nine month0old infant about diaper dermatitis?
) Kse only cloth diapers that are rinsed in bleach
B) Do not use occlusive ointments on the rash
!) Kse commercial baby wipes with each diaper change
D) Discontinue a new food that was added to the infantCs diet 'ust prior to the
rash
.5. 18 year0old client is admitted to a psychiatric unit with a diagnosis of
attempted suicide. The nurse is aware that the most fre"uent cause for
suicide in adolescents is
!) "rogressive failure to adapt
#) 6eelings of anger or hostility
!) 2eunion wish or fantasy
D) 6eelings of alienation or isolation
.3. mother brings her &8 month0old to the well0child clinic. ;he e-presses
frustration and anger due to her childCs constantly saying *no* and his refusal
to follow her directions. The nurse e-plains this is normal for his age9 as
negativism is attempting to meet which developmental need?
) Trust
#) +nitiative
C) Independence
D) ;elf0esteem
.8. 6ollowing mitral valve replacement surgery a client develops $F!=s. The
health care provider orders a bolus of Bidocaine followed by a continuous
Bidocaine infusion at a rate of & mgmHminute. The +F solution contains &
grams of Bidocaine in 3// cc=s of D3(. The infusion pump delivers 8/
microdropsHcc. (hat rate would deliver 5 mgm of BidocaineHminute?
!) 9: microdrops;minute
#) &/ microdropsHminute
!) ./ microdropsHminute
D) 5/ microdropsHminute
.<. couple asks the nurse about risks of several birth control methods.
(hat is the most appropriate response by the nurse?
) Eorplant is safe and may be removed easily
B) <ral contraceptives should not be used by smoers
!) Depo0$rovera is convenient with few side eGects
D) The +KD gives protection from pregnancy and infection
.>. The nurse is caring for a client in the late stages of myotrophic Bateral
;clerosis (.B.;.). (hich Anding would the nurse e-pect?
) !onfusion
#) Boss of half of visual Aeld
!) ;hallow respirations
D) $onic)clonic sei%ures
.@. client e-periences post partum hemorrhage eight hours after the birth
of twins. 6ollowing administration of +F )uids and 3// ml of whole blood9 her
hemoglobin and hematocrit are within normal limits. ;he asks the nurse
whether she should continue to breast feed the infants. (hich of the
following is based on sound rationale?
!) ",ursing will help contract the uterus and reduce your ris of
bleeding&"
#) *#reastfeeding twins will take too much energy after the hemorrhage.*
!) *The blood transfusion may increase the risks to you and the babies.*
D) *Bactation should be delayed until the *real milk* is secreted.*
5/. client complained of nausea9 a metallic taste in her mouth9 and Ane
hand tremors & hours after her Arst dose of lithium carbonate (Bithane). (hat
is the nurse=s best e-planation of these Andings?
) These side eGects are common and should subside in a few days
B) $he client is probably having an allergic reaction and should
discontinue the drug
!) Taking the lithium on an empty stomach should decrease these symptoms
D) Decreasing dietary intake of sodium and )uids should minimi:e the side
eGects
51. The nurse is caring for a post0surgical client at risk for developing deep
vein thrombosis. (hich intervention is an eGective preventive measure?
) $lace pillows under the knees
#) Kse elastic stockings continuously
C) 8ncourage range of motion and ambulation
D) 4assage the legs twice daily
5&. The parents of a newborn male with hypospadias want their child
circumcised. The best response by the nurse is to inform them that
) !ircumcision is delayed so the foreskin can be used for the surgical repair
B) $his procedure is contraindicated because of the permanent
defect
!) There is no medical indication for performing a circumcision on any child
D) The procedure should be performed as soon as the infant is stable
5.. The nurse is teaching parents about the treatment plan for a & weeks0old
infant with Tetralogy of 6allot. (hile awaiting future surgery9 the nurse
instructs the parents to immediately report
!) -oss of consciousness
#) 6eeding problems
!) $oor weight gain
D) 6atigue with crying
55. n infant weighed < pounds > ounces at birth. +f growth occurs at a
normal rate9 what would be the e-pected weight at 8 months of age?
!) Double the birth weight
#) Triple the birth weight
!) ?ain 8 ounces each week
D) dd & pounds each month
53. The nurse is caring for a 1. year0old following spinal fusion for scoliosis.
(hich of the following interventions is appropriate in the immediate post0
operative period?
) 2aise the head of the bed at least ./ degrees
#) 7ncourage ambulation within &5 hours
C) 0aintain in a =at position+ logrolling as needed
D) 7ncourage leg contraction and rela-ation after 5> hours
58. client asks the nurse about including her & and 1& year0old sons in the
care of their newborn sister. (hich of the following is an appropriate initial
statement by the nurse?
) *6ocus on your sonsC needs during the Arst days at home.*
#) *Tell each child what he can do to help with the baby.*
!) *;uggest that your husband spend more time with the boys.*
D) "!s the children what they would lie to do for the newborn&"
5<. nurse is caring for a & year0old child after corrective surgery for
Tetralogy of 6allot. The mother reports that the child has suddenly begun
sei:ing. The nurse recogni:es this problem is probably due to
!) ! cerebral vascular accident
#) $ostoperative meningitis
!) 4edication reaction
D) 4etabolic alkalosis
5>. client with schi:ophrenia is receiving 1aloperidol (1aldol) 3 mg t.i.d..
The client=s family is alarmed and calls the clinic when *his eyes rolled
upward.* The nurse recogni:es this as what type of side eGect?
) %culogyric crisis
#) Tardive dyskinesia
C) ,ystagmus
D) Dysphagia
5@. home health nurse is at the home of a client with diabetes and arthritis.
The client has di,culty drawing up insulin. +t would be most appropriate for
the nurse to refer the client to
!) ! social worer from the local hospital
#) n occupational therapist from the community center
!) physical therapist from the rehabilitation agency
D) nother client with diabetes mellitus and takes insulin
3/. client was admitted to the psychiatric unit after complaining to her
friends and family that neighbors have bugged her home in order to hear all
of her business. ;he remains aloof from other clients9 paces the )oor and
believes that the hospital is a house of torture. Eursing interventions for the
client should appropriately focus on eGorts to
) !onvince the client that the hospital staG is trying to help
#) 1elp the client to enter into group recreational activities
C) "rovide interactions to help the client learn to trust sta>
D) rrange the environment to limit the client=s contact with other clients
31. client is scheduled for a percutaneous transluminal coronary
angioplasty ($T!). The nurse knows that a $T! is the
) ;urgical repair of a diseased coronary artery
#) $lacement of an automatic internal cardiac deAbrillator
C) "rocedure that compresses pla?ue against the wall of the
diseased coronary artery to improve blood =ow
D) Eon0invasive radiographic e-amination of the heart
3&. newborn has been diagnosed with hypothyroidism. +n discussing the
condition and treatment with the family9 the nurse should emphasi:e
) They can e-pect the child will be mentally retarded
B) !dministration of thyroid hormone will prevent problems
!) This rare problem is always hereditary
D) $hysical growthHdevelopment will be delayed
3.. priority goal of involuntary hospitali:ation of the severely mentally ill
client is
) 2e0orientation to reality
#) 7limination of symptoms
C) "rotection from harm to self or others
D) 2eturn to independent functioning
35. 1@ year0old client is paraly:ed in a car accident. (hich statement used
by the client would indicate to the nurse that the client was using the
mechanism of *suppression*?
) *+ donCt remember anything about what happened to me.*
B) "I2d rather not tal about it right now&"
!) *+tCs the other entire guyCs faultL 1e was going too fast.*
D) *4y mother is heartbroken about this.*
33. The nurse is caring for a woman & hours after a vaginal delivery.
Documentation indicates that the membranes were ruptured for .8 hours
prior to delivery. (hat are the priority nursing diagnoses at this time?
) ltered tissue perfusion
#) 2isk for )uid volume deAcit
!) 1igh risk for hemorrhage
D) 3is for infection
38. . year0old had a hip spica cast applied & hours ago. +n order to facilitate
drying9 the nurse should
!) 8/pose the cast to air and turn the child fre?uently
#) Kse a heat lamp to reduce the drying time
!) 1andle the cast with the abductor bar
D) Turn the child as little as possible
3<. client is scheduled for an +ntravenous $yelogram (+F$). +n order to
prepare the client for this test9 the nurse wouldM
) +nstruct the client to maintain a regular diet the day prior to the
e-amination
#) 2estrict the clientCs )uid intake 5 hours prior to the e-amination
C) !dminister a la/ative to the client the evening before the
e/amination
D) +nform the client that only 1 -0ray of his abdomen is necessary
3>. 6ollowing a diagnosis of acute glomerulonephritis (?E) in their 8 year0old
child9 the parent=s remarkM N(e 'ust don=t know how he caught the diseaseLO
The nurseCs response is based on an understanding that
) ?E is a streptococcal infection that involves the kidney tubules
#) The disease is easily transmissible in schools and camps
!) The illness is usually associated with chronic respiratory infections
D) It is not "caught" but is a response to a previous B)hemolytic
strep infection
3@. The nurse is caring for a &/ lbs (@ kg) 8 month0old with a . day history of
diarrhea9 occasional vomiting and fever. $eripheral intravenous therapy has
been initiated9 with 3I de-trose in /...I normal saline with &/ m7" of
potassium per liter infusing at .3 mlHhr. (hich Anding should be reported to
the health care provider immediately?
) . episodes of vomiting in 1 hour
#) $eriodic crying and irritability
!) Figorous sucking on a paciAer
D) ,o measurable voiding in 7 hours
8/. (hile caring for the client during the Arst hour after delivery9 the nurse
determines that the uterus is boggy and there is vaginal bleeding. (hat
should be the nurseCs Arst action?
!) Chec vital signs
#) 4assage the fundus
!) %Ger a bedpan
D) !heck for perineal lacerations
81. The nurse is assessing an infant with developmental dysplasia of the hip.
(hich Anding would the nurse anticipate?
!) Une?ual leg length
#) Bimited adduction
!) Diminished femoral pulses
D) ;ymmetrical gluteal folds
8&. To prevent a valsalva maneuver in a client recovering from an acute
myocardial infarction9 the nurse would
) ssist the client to use the bedside commode
B) !dminister stool softeners every day as ordered
!) dminister antidysrhythmics prn as ordered
D) 4aintain the client on strict bed rest
8.. %n admission to the psychiatric unit9 the client is trembling and appears
fearful. The nurse=s initial response should be to
) ?ive the client orientation materials and review the unit rules and
regulations
B) Introduce him;her and accompany the client to the client1s room
!) Take the client to the day room and introduce her to the other clients
D) sk the nursing assistant to get the client=s vital signs and complete the
admission search
85. During the admission assessment on a client with chronic bilateral
glaucoma9 which statement by the client would the nurse anticipate since it is
associated with this problem?
) *+ have constant blurred vision.*
#) *+ canCt see on my left side.*
C) "I have to turn my head to see my room&"
D) *+ have specks )oating in my eyes.*
83. client with asthma has low pitched whee:es present on the Anal half of
e-halation. %ne hour later the client has high pitched whee:es e-tending
throughout e-halation. This change in assessment indicates to the nurse that
the client
!) @as increased airway obstruction
#) 1as improved airway obstruction
!) Eeeds to be suctioned
D) 7-hibits hyperventilation
88. (hich behavioral characteristic describes the domestic abuser?
) lcoholic
#) %ver conAdent
!) 1igh tolerance for frustrations
D) -ow self)esteem
8<. The nurse is caring for a client with a long leg cast. During discharge
teaching about appropriate e-ercises for the aGected e-tremity9 the nurse
should recommend
!) Isometric
#) 2ange of motion
!) erobic
D) +sotonic
8>. client is in her third month of her Arst pregnancy. During the interview9
she tells the nurse that she has several se- partners and is unsure of the
identity of the babyCs father. (hich of the following nursing interventions is a
priority?
) !ounsel the woman to consent to 1+F screening
B) "erform tests for se/ually transmitted diseases
!) Discuss her high risk for cervical cancer
D) 2efer the client to a family planning clinic
8@. 18 month0old child has 'ust been admitted to the hospital. s the nurse
assigned to this child enters the hospital room for the Arst time9 the toddler
runs to the mother9 clings to her and begins to cry. (hat would be the initial
action by the nurse?
) rrange to change client care assignments
B) 8/plain that this behavior is e/pected
!) Discuss the appropriate use of *time0out*
D) 7-plain that the child needs e-tra attention
</. (hile planning care for a & year0old hospitali:ed child9 which situation
would the nurse e-pect to most likely aGect the behavior?
) ;trange bed and surroundings
B) (eparation from parents
!) $resence of other toddlers
D) Knfamiliar toys and games
<1. (hile e-plaining an illness to a 1/ year0old9 what should the nurse keep in
mind about the cognitive development at this age?
) They are able to make simple association of ideas
#) They are able to think logically in organi:ing facts
C) Interpretation of events originate from their own perspective
D) !onclusions are based on previous e-periences
<&. The nurse is has 'ust admitted a client with severe depression. 6rom
which focus should the nurse identify a prioriy nursing diagnosis?
) Eutrition
#) 7limination
!) ctivity
D) (afety
<.. (hich playroom activities should the nurse organi:e for a small group of <
year0old hospitali:ed children?
) ;ports and games with rules
#) 6inger paints and water play
C) "Dress)up" clothes and props
D) !hess and television programs
<5. client is discharged following hospitali:ation for congestive heart failure.
The nurse teaching the family suggests they encourage the client to rest
fre"uently in which of the following positions?
!) @igh Aowler2s
#) ;upine
!) Beft lateral
D) Bow 6owlerCs
<3. The nurse is caring for a 1/ year0old on admission to the burn unit. %ne
assessment parameter that will indicate that the child has ade"uate )uid
replacement is
!) Urinary output of 6: ml per hour
#) Eo complaints of thirst
!) +ncreased hematocrit
D) ?ood skin turgor around burn
<8. (hich complication of cardiac catheteri:ation should the nurse monitor
for in the initial &5 hours after the procedure?
) angina at rest
B) thrombus formation
!) di::iness
D) falling blood pressure
<<. client is admitted to the emergency room with renal calculi and is
complaining of moderate to severe )ank pain and nausea. The client=s
temperature is 1//.> degrees 6ahrenheit. The priority nursing goal for this
client is
) 4aintain )uid and electrolyte balance
#) !ontrol nausea
C) 0anage pain
D) $revent urinary tract infection
<>. (hat would the nurse e-pect to see while assessing the growth of
children during their school age years?
) Decreasing amounts of body fat and muscle mass
B) -ittle change in body appearance from year to year
!) $rogressive height increase of 5 inches each year
D) Jearly weight gain of about 3.3 pounds per year
<@. The hospital has sounded the call for a disaster drill on the evening shift.
(hich of these clients would the nurse put Arst on the list to be discharged in
order to make a room available for a new admission?
!) ! middle aged client with a history of being ventilator dependent
for over . years and admitted with bacterial pneumonia 4ve days
ago
#) young adult with diabetes mellitus Type & for over 1/ years and admitted
with antibiotic induced diarrhea &5 hours ago
!) n elderly client with a history of hypertension9 hypercholesterolemia and
lupus9 and was admitted with ;tevens0Dohnson syndrome that morning
D) n adolescent with a positive 1+F test and admitted for acute cellulitus of
the lower leg 5> hours ago
>/. client has been newly diagnosed with hypothyroidism and will take
levothyro-ine (;ynthroid) 3/ mcgHday by mouth. s part of the teaching plan9
the nurse emphasi:es that this medicationM
!) (hould be taen in the morning
#) 4ay decrease the clientCs energy level
!) 4ust be stored in a dark container
D) (ill decrease the clientCs heart rate
>1. . year0old child comes to the pediatric clinic after the sudden onset of
Andings that include irritability9 thick muPed voice9 croaking on inspiration9
hot to touch9 sit leaning forward9 tongue protruding9 drooling and
suprasternal retractions. (hat should the nurse do Arst?
) $repare the child for -0ray of upper airways
#) 7-amine the childCs throat
!) !ollect a sputum specimen
D) ,otify the healthcare provider of the child2s status
>&. +n children suspected to have a diagnosis of diabetes9 which one of the
following complaints would be most likely to prompt parents to take their
school age child for evaluation?
!) "olyphagia
#) Dehydration
!) #ed wetting
D) (eight loss
>.. n 2E who usually works in a spinal rehabilitation unit is )oated to the
emergency department. (hich of these clients should the charge nurse
assign to this 2E?
) middle0aged client who says *+ took too many diet pills* and *my heart
feels like it is racing out of my chest.*
#) young adult who says *+ hear songs from heaven. + need money for beer.
+ "uit drinking & days ago for my family. (hy are my arms and legs 'erking?*
!) n adolescent who has been on pain medications for terminal cancer with
an initial assessment Anding of pinpoint pupils and a rela-ed respiratory rate
of 1/
D) !n elderly client who reports having taen a "large crac hit" B:
minutes prior to waling into the emergency room
>5. (hen teaching a client with coronary artery disease about nutrition9 the
nurse should emphasi:e
) 7ating . balanced meals a day
#) dding comple- carbohydrates
C) !voiding very heavy meals
D) Bimiting sodium to < gms per day
>3. The nurse is performing a neurological assessment on a client post right
!F. (hich Anding9 if observed by the nurse9 would warrant immediate
attention?
) Decrease in level of consciousness
#) Boss of bladder control
C) !ltered sensation to stimuli
D) 7motional lability
>8. child who has recently been diagnosed with cystic Abrosis is in a
pediatric clinic where a nurse is performing an assessment. (hich later
Anding of this disease would the nurse not e-pect to see at this time?
) $ositive sweat test
#) #ulky greasy stools
!) 4oist9 productive cough
D) 0econium ileus
><. The nurse is giving discharge teaching to a client < days post myocardial
infarction. 1e asks the nurse why he must wait 8 weeks before having se-ual
intercourse. (hat is the best response by the nurse to this "uestion?
!) "Cou need to regain your strength before attempting such
e/ertion&"
#) *(hen you can climb & )ights of stairs without problems9 it is generally
safe.*
!) *1ave a glass of wine to rela- you9 then you can try to have se-.*
D) *+f you can maintain an active walking program9 you will have less risk.*
>>. triage nurse has these 5 clients arrive in the emergency department
within 13 minutes. (hich client should the triage nurse send back to be seen
Arst?
) & month old infant with a history of rolling oG the bed and has buldging
fontanels with crying
#) teenager who got a singed beard while camping
!) n elderly client with complaints of fre"uent li"uid brown colored stools
D) ! middle aged client with intermittent pain behind the right
scapula
>@. (hile planning care for a toddler9 the nurse teaches the parents about
the e-pected developmental changes for this age. (hich statement by the
mother shows that she understands the childCs developmental needs?
!) "I want to protect my child from any falls&"
#) *+ will set limits on e-ploring the house.*
!) *+ understand the need to use those new skills.*
D) *+ intend to keep control over our child.*
@/. The nurse is preparing to administer an enteral feeding to a client via a
nasogastric feeding tube. The most important action of the nurse is
!) Derify correct placement of the tube
#) !heck that the feeding solution matches the dietary order
!) spirate abdominal contents to determine the amount of last feeding
remaining in stomach
D) 7nsure that feeding solution is at room temperature
@1. nurse prepares to care for a 5 year0old newly admitted for
rhabdomyosarcoma. The nurse should alert the staG to pay more attention to
the function of which area of the body?
!) !ll striated muscles
#) The cerebellum
!) The kidneys
D) The leg bones
@&. The nurse anticipates that for a family who practices !hinese medicine
the priority goal would be to
) chieve harmony
#) 4aintain a balance of energy
!) 2espect life
D) 3estore yin and yang
@.. nurse enters a clientCs room to discover that the client has no pulse or
respirations. fter calling for help9 the Arst action the nurse should take is
) ;tart a peripheral +F
#) +nitiate closed0chest massage
C) 8stablish an airway
D) %btain the crash cart
@5. client is receiving digo-in (Bano-in) /.&3 mg. Daily. The health care
provider has written a new order to give metoprolol (Bopressor) &3 mg. #.+.D.
+n assessing the client prior to administering the medications9 which of the
following should the nurse report immediately to the health care provider?
!) Blood pressure E7;9:
#) 1eart rate <8
!) Krine output 3/ mlHhour
D) 2espiratory rate 18
@3. (hile assessing a 1 month0old infant9 which Anding should the nurse
report immediately?
) bdominal respirations
#) +rregular breathing rate
C) Inspiratory grunt
D) +ncreased heart rate with crying
@8. The nurse is caring for a client who had a total hip replacement 5 days
ago. (hich assessment re"uires the nurse=s immediate attention?
) + have bad muscle spasms in my lower leg of the aGected e-tremity.
B) "I Fust can2t 2catch my breath2 over the past few minutes and I
thin I am in grave danger&"
!) *+ have to use the bedpan to pass my water at least every 1 to & hours.*
D) *+t seems that the pain medication is not working as well today.*
@<. client has been taking furosemide (Basi-) for the past week. The nurse
recogni:es which Anding may indicate the client is e-periencing a negative
side eGect from the medication?
) (eight gain of 3 pounds
#) 7dema of the ankles
C) 'astric irritability
D) Decreased appetite
@>. The nurse is caring for a client with a venous stasis ulcer. (hich nursing
intervention would be most eGective in promoting healing?
) pply dressing using sterile techni"ue
B) Improve the client2s nutrition status
!) +nitiate limb compression therapy
D) #egin proteolytic debridement
@@. nurse is to administer meperidine hydrochloride (Demerol) 1// mg9
atropine sulfate (tropisol) /.5 mg9 and promethi:ine hydrochloride
($henergan) 3/ mg +4 to a pre0operative client. (hich action should the
nurse take Arst?
!) 3aise the side rails on the bed
#) $lace the call bell within reach
!) +nstruct the client to remain in bed
D) 1ave the client empty bladder
1//. During the evaluation of the "uality of home care for a client with
l:heimerCs disease9 the priority for the nurse is to reinforce which statement
by a family member?
) t least & full meals a day is eaten.
#) (e go to a group discussion every week at our community center.
C) We have safety bars installed in the bathroom and have G7 hour
alarms on the doors&
D) The medication is not a problem to have it taken . times a d1. The nursing
care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous
lymph node syndrome) should be based on the high risk for development of
which problem?