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Nursing Test I • D) A 5-month-old with Kawasaki

disease
Scope of this Nursing Test I is parallel to
the NP1 NLE Coverage: The RN floated from the telemetry unit
would be least prepared to care for a young
• Foundation of Nursing infant who has just had GI surgery and
• Nursing Research requires a specific feeding regimen.
• Professional Adjustment
• Leadership and Management 3. A nurse in charge in the pediatric unit is
absent. The nurse manager decided to
assign the nurse in the obstetrics unit to the
pediatrics unit. Which of the following
patients could the nurse manager safely
All the questions in the quiz along with their assign to the float nurse?
answers are shown below. Your answers
are bolded. The correct answers have a
green background while the incorrect ones • A) A child who had multiple injuries
have a red background. from a serious vehicle accident
• B) A child diagnosed with Kawasaki
1. The registered nurse is planning to disease and with cardiac
delegate tasks to unlicensed assistive complications
personnel (UAP). Which of the following • C) A child who has had a
task could the registered nurse safely nephrectomy for Wilm’s tumor
assigned to a UAP? • D) A child receiving an IV chelating
therapy for lead poisoning
• A) Monitor the I&O of a comatose
toddler client with salicylate RN floated from the obstetrics unit should be
poisoning able to care for a client with major
• B) Perform a complete bed bath on abdominal surgery, because this nurse has
a 2-year-old with multiple injuries experienced caring for clients with cesarean
from a serious fall births.
• C) Check the IV of a preschooler
with Kawasaki disease 4. The registered nurse is planning to
• D) Give an outmeal bath to an infant delegate task to a certified nursing
with eczema assistant. Which of the following clients
should not be assigned to a CAN?
Bathing an infant with eczema can be safely
delegated to an aide; this task is basic and • A) A client diagnosed with diabetes
can competently performed by an aid. and who has an infected toe
• B) A client who had a CVA in the
2. A nurse manager assigned a registered past two months
nurse from telemetry unit to the pediatrics • C) A client with Chronic renal failure
unit. There were three patients assigned to • D) A client with chronic venous
the RN. Which of the following patients insufficiency
should not be assigned to the floated
nurse? The patient is experiencing a potentially
serious complication related to diabetes and
• A) A 9-year-old child diagnosed with needs ongoing assessment by an RN
rheumatic fever
• B) A young infant after 5. The nurse in the medication unit passes
pyloromyotomy the medications for all the clients on the
• C) A 4-year-old with VSD following nursing unit. The head nurse is making
cardiac catheterization rounds with the physician and coordinates
clients’ activities with other departments.
The nurse assistant changes the bed lines someone else who is willing to
and answers call lights. A second nurse is accept the assignment
assigned for changing wound dressings; a • D) Refuse the assignment and leave
licensed practitioner nurse takes vital signs the unit requesting a vacation a day
and bathes the clients. This illustrates of
what method of nursing care? The nurse is ethically obligated to inform the
person responsible for the assignment and
• A) Case management method the person responsible for the unit about the
• B) Primary nursing method nurse’s skill level. The nurse therefore
• C) Team method avoids a situation of abandoning clients and
• D) Functional method exposing them to greater risks

It describes functional nursing. Staff is 8. An experienced nurse who voluntarily


assigned to specific task rather than specific trained a less experienced nurse with the
clients. intention of enhancing the skills and
knowledge and promoting professional
advancement to the nurse is called a:
6. A registered nurse has been assigned
to six clients on the 12-hour shift. The RN is
responsible for every aspect of care such as • A) mentor
formulating the care of plan, intervention and • B) team leader
evaluating the care during her shift. At the • C) case manager
end of her shift, the RN will pass this same • D) change agent
task to the next RN in charge. This nursing
care illustrates of what kind of method? This describes a mentor

• A) primary nursing method 9. The pediatrics unit is understaffed and


• B) case method the nurse manager informs the nurses in the
• C) team method obstetrics unit that she is going to assign
• D) functional method one nurse to float in the pediatric units.
Which statement by the designated float
Case management. The nurse assumes nurse may put her job at risk?
total responsibility for meeting the needs of
the client during her entire duty. • A) “I do not get along with one of the
nurses on the pediatrics unit”
7. A newly hired nurse on an adult • B) “I have a vacation day coming
medicine unit with 3 months experience was and would like to take that now”
asked to float to pediatrics. The nurse • C) “I do not feel competent to go
hesitates to perform pediatric skills and and work on that area”
receive an interesting assignment that feels • D) “ I am afraid I will get the most
overwhelming. The nurse should: serious clients in the unit”

• A) resign on the spot from the This action demonstrates a lack of


nursing position and apply for a responsibility and the nurse should attempt
position that does not require negotiation with the nurse manager.
floating
• B) Inform the nursing supervisor and 10. The newly hired staff nurse has been
the charge nurse on the pediatric working on a medical unit for 3 weeks. The
floor about the nurse’s lack of skill nurse manager has posted the team leader
and feelings of hesitations and assignments for the following week. The
request assistance new staff knows that a major responsibility
• C) Ask several other nurses how of the team leader is to:
they feel about pediatrics and find
• A) Provide care to the most acutely • A) A nurse may accept responsibility
ill client on the team signing a consent form if the client is
• B) Know the condition and needs of unable
all the patients on the team • B) Obtaining consent is not the
• C) Document the assessments responsibility of the physician
completed by the team members • C) A physician will not subject
• D) Supervise direct care by nursing himself to liability if he withholds any
assistants facts that are necessary to form the
basis of an intelligent consent
The team leader is responsible for the • D) If the nurse witnesses a consent
overall management of all clients and staff for surgery, the nurse is, in effect,
on the team, and this information is essential indicating that the signature is that
in order to accomplish this of the purported person and that the
person’s condition is as indicated at
the time of signing
11. A 15-year-old girl just gave birth to a
baby boy who needs emergency surgery.
The nurse prepared the consent form and it The nurse who witness a consent for
should be signed by: treatment or surgery is witnessing only that
the client signed the form and that the
client’s condition is as indicated at the time
• A) The Physician
of signing. The nurse is not witnessing that
• B) The Registered Nurse caring for the client is “informed”.
the client
• C) The 15-year-old mother of the
14. A mother in labor told the nurse that
baby boy
she was expecting that her baby has no
• D) The mother of the girl chance to survive and expects that the baby
will be born dead. The mother accepts the
Even though the mother is a minor, she is fate of the baby and informs the nurse that
legally able to sign consent for her own when the baby is born and requires
child. resuscitation, the mother refuses any
treatment to her baby and expresses
12. A nurse caring to a client with hostility toward the nurse while the pediatric
Alzheimer’s disease overheard a family team is taking care of the baby. The nurse
member say to the client, “if you pee one is legally obligated to:
more time, I won’t give you any more food
and drinks”. What initial action is best for • A) Notify the pediatric team that the
the nurse to take? mother has refused resuscitation
and any treatment for the baby and
• A) Take no action because it is the take the baby to the mother
family member saying that to the • B) Get a court order making the
client baby a ward of the court
• B) Talk to the family member and • C) Record the statement of the
explain that what she/he has said is mother, notify the pediatric team,
not appropriate for the client and observe carefully for signs of
• C) Give the family member the impaired bonding and neglect as a
number for an Elder Abuse Hot line reasonable suspicion of child abuse
• D) Document what the family • D) Do nothing except record the
member has said mother’s statement in the medical
record
This response is the most direct and
immediate. This is a case of potential need Although the statements by the mother may
for advocacy and patient’s rights. not create a suspicion of neglect, when they
are coupled with observations about
13. Which is true about informed consent? impaired bonding and maternal attachment,
they may impose the obligation to report 17. While in the hospital lobby, the RN
child neglect. The nurse is further obligated overhears the three staff discussing the
to notify caregivers of refusal to consent to health condition of her client. What would
treatment be the appropriate nursing action for the RN
to take?
15. The hospitalized client with a chronic
cough is scheduled for bronchoscopy. The • A) Tell them it is not appropriate to
nurse is tasks to bring the informed consent discuss the condition of the client
document into the client’s room for a • B) Ignore them, because it is their
signature. The client asks the nurse for right to discuss anything they want
details of the procedure and demands an to
explanation why the process of informed • C) Join in the conversation, giving
consent is necessary. The nurse responds them supportive input about the
that informed consent means: case of the client
• D) Report this incident to the
• A) The patient releases the nursing supervisor
physician from all responsibility for
the procedure. The behavior should be stopped. The first
• B) The immediate family may make step is to remind the staff that confidentiality
decision against the patient’s will. may be violated
• C) The physician must give the
client or surrogates enough 18. A staff nurse has had a serious issue
information to make health care with her colleague. In this situation, it is best
judgments consistent with their to:
values and goals.
• D) The patient agrees to a
procedure ordered by the physician • A) Discuss this with the supervisor
even if the client does not • B) Not discuss the issue with
understand what the outcome will anyone. It will probably resolve itself
be. • C) Try to discuss with the colleague
about the issue and resolve it when
both are calmer
It best explains what informed consent is
and provides for legal rights of the patient • D) Tell other members of the
network what the team member did
16. A hospitalized client with severe
necrotizing ulcer of the lower leg is schedule Waiting for emotions to dissipate and sitting
for an amputation. The client tells the nurse down with the colleague is the first rule of
that he will not sign the consent form and he conflict resolution.
does not want any surgery or treatment
because of religious beliefs about 19. The nurse is caring to a client who just
reincarnation. What is the role of the RN? gave birth to a healthy baby boy. The nurse
may not disclose confidential information
when:
• A) call a family meeting
• B) discuss the religious beliefs with
the physician • A) The nurse discusses the
• C) encourage the client to have the condition of the client in a clinical
surgery conference with other nurses
• D) inform the client of other options • B) The client asks the nurse to
discuss the her condition with the
family
The physician may not be aware of the role
• C) The father of a woman who just
that religious beliefs play in making a
delivered a baby is on the phone to
decision about surgery.
find out the sex of the baby
• D) A researcher from an • B) Low Fowler’s with knees gatched
institutionally approved research at 30 degrees
study reviews the medical record of • C) Supine with the head turned to
a patient the left
• D) Bed sloped at a 45 degree angle
The nurse has no idea who the person is on with the head lowest and the legs
the phone and therefore may not share the highest
information even if the patient gives
permission This position increases venous return,
improves cardiac volume, and promotes
20. A 17-year-old married client is adequate ventilation and cerebral perfusion
scheduled for surgery. The nurse taking
care of the client realizes that consent has 23. The client is brought to the emergency
not been signed after preoperative department after a serious accident. What
medications were given. What should the would be the initial nursing action of the
nurse do? nurse to the client?

• A) Call the surgeon • A) assess the level of


• B) Ask the spouse to sign the consciousness and circulation
consent • B) check respirations, circulation,
• C) Obtain a consent from the client neurological response
as soon as possible • C) align the spine, check pupils,
• D) Get a verbal consent from the check for hemorrhage
parents of the client • D) check respiration, stabilize spine,
check circulation
The priority is to let the surgeon know, who
in turn may ask the husband to sign the Checking the airway would be a priority, and
consent. a neck injury should be suspected

21. A 12-year-old client is admitted to the 24. A nurse is assigned to care to a client
hospital. The physician ordered Dilantin to with Parkinson’s disease. What
the client. In administering IV phenytoin interventions are important if the nurse
(Dilantin) to a child, the nurse would be wants to improve nutrition and promote
most correct in mixing it with: effective swallowing of the client?

• A) Normal Saline • A) Eat solid food


• B) Heparinized normal saline • B) Give liquids with meals
• C) 5% dextrose in water • C) Feed the client
• D) Lactated Ringer’s solution • D) Sit in an upright position to eat

Phenytoin (Dilantin) can cause venous Client with Parkinson’s disease are at a high
irritation due to its alkalinity, therefore it risk for aspiration and undernutrition. Sitting
should be mixed with normal saline. upright promotes more effective swallowing.

22. The nurse is caring to a client who is 25. During tracheal suctioning, the nurse
hypotensive. Following a large should implement safety measures. Which
hematemesis, how should the nurse position of the following should the nurse
the client? implements?

• A) Feet and legs elevated 20 • A) limit suction pressure to 150-180


degrees, trunk horizontal, head on mmHg
small pillow • B) suction for 15-20 seconds
• C) wear eye goggles • C) encouraging the patient to deep
• D) remove the inner cannula breathe and cough to facilitate
removal of upper-airway secretions
It is important to protect the RN’s eyes from • D) administering 100% oxygen to
the possible contamination of coughed-up reduce the effects of airway
secretions obstruction during suctioning.

26. The nurse is conducting a discharge Presuctioning and postsuctioning ventilation


instructions to a client diagnosed with with 100% oxygen is important in reducing
diabetes. What sign of hypoglycemia should hypoxemia which occurs when the flow of
be taught to a client? gases in the airway is obstructed by the
suctioning catheter.
• A) warm, flushed skin
• B) hunger and thirst 29. An infant is admitted and diagnosed
with pneumonia and suspicious-looking red
• C) increase urinary output
marks on the swollen face resembling a
• D) palpitation and weakness handprint. The nurse does further
assessment to the client. How would the
There has been too little food or too much nurse document the finding?
insulin. Glucose levels can be markedly
decreased (less than 50 mg/dl). Severe
• A) Facial edema with ecchymosis
hypoglycemia may be fatal if not detected
and handprint mark: crackles and
wheezes
27. A client admitted to the hospital and • B) Facial edema, with red marks;
diagnosed with Addison’s disease. What crackles in the lung
would be the appropriate nursing action to
• C) Facial edema with ecchymosis
the client?
that looks like a handprint
• D) Red bruise mark and ecchymosis
• A) administering insulin-replacement on face
therapy
• B) providing a low-sodium diet This is an example of objective data of both
• C) restricting fluids to 1500 ml/day pulmonary status and direct observation on
• D) reducing physical and emotional the skin by the nurse.
stress
30. On the evening shift, the triage nurse
Because the client’s ability to react to stress evaluates several clients who were brought
is decreased, maintaining a quiet to the emergency department. Which in the
environment becomes a nursing priority. following clients should receive highest
Dehydration is a common problem in priority?
Addison’s disease, so close observation of
the client’s hydration level is crucial.
• A) an elderly woman complaining of
a loss of appetite and fatigue for the
28. The nurse is to perform tracheal past week
suctioning. During tracheal suctioning, • B) A football player limping and
which nursing action is essential to prevent complaining of pain and swelling in
hypoxemia? the right ankle
• C) A 50-year-old man, diaphoretic
• A) aucultating the lungs to and complaining of severe chest
determine the baseline data to pain radiating to his jaw
assess the effectiveness of • D) A mother with a 5-year-old boy
suctioning who says her son has been
• B) removing oral and nasal complaining of nausea and vomited
secretions once since noon
These are likely signs of an acute • A) The adult visiting, “The child’s
myocardial infarction (MI). An acute MI is a name is ____________________?”
cardiovascular emergency requiring • B) The child, “Is your
immediate attention. Acute MI is potentially name____________?”
fatal if not treated immediately. • C) Another staff nurse to identify this
child
31. A 80-year-old female client is brought to • D) The other children in the room
the emergency department by her caregiver, what the child’s name is
on the nurse’s assessment; the following are
the manifestations of the client: anorexia, The only acceptable way to identify a
cachexia and multiple bruises. What would preschooler client is to have a parent or
be the best nursing intervention? another staff member identify the client.

• A) check the laboratory data for 34. The nurse caring to a client has
serum albumin, hematocrit, and completed the assessment. Which of the
hemoglobin following will be considered to be the most
• B) talk to the client about the accurate charting of a lump felt in the right
caregiver and support system breast?
• C) complete a police report on elder
abuse • A) “abnormally felt area in the right
• D) complete a gastrointestinal and breast, drainage noted”
neurological assessment • B) “hard nodular mass in right
breast nipple”
Assessment and more data collection are • C) “firm mass at five ‘ clock, outer
needed. The client may have quadrant, 1cm from right nipple’
gastrointestinal or neurological problems • D) “mass in the right breast
that account for the symptoms. The anorexia 4cmx1cm
could result from medications, poor
dentition, or indigestion, and the bruises
may be attributed to ataxia, frequent falls, It describes the mass in the greatest detail.
vertigo or medication.
35. The physician instructed the nurse that
32. The night shift nurse is making rounds. intravenous pyelogram will be done to the
When the nurse enters a client’s room, the client. The client asks the nurse what is the
client is on the floor next to the bed. What purpose of the procedure. The appropriate
would be the initial action of the nurse? nursing response is to:

• A) chart that the patient fell • A) outline the kidney vasculature


• B) call the physician • B) determine the size, shape, and
placement of the kidneys
• C) chart that the client was found on
the floor next to the bed • C) test renal tubular function and the
patency of the urinary tract
• D) fill out an incident report
• D) measure renal blood flow
This is closest to suggesting action-
assessment, rather than paperwork- and is Intravenous pyelogram tests both the
therefore the best of the four. function and patency of the kidneys. After
the intravenous injection of a radiopaque
contrast medium, the size, location, and
33. The nurse on the night shift is about to patency of the kidneys can be observed by
administer medication to a preschooler client roentgenogram, as well as the patency of
and notes that the child has no ID bracelet. the urethra and bladder as the kidneys
The best way for the nurse to identify the function to excrete the contrast medium.
client is to ask:
36. A client visits the clinic for screening of Pyloric stenosis is an anomaly of the upper
scoliosis. The nurse should ask the client gastrointestinal tract. The condition involves
to: a thickening, or hypertrophy, of the pyloric
sphincter located at the distal end of the
• A) bend all the way over and touch stomach. This causes a mechanical
the toes intestinal obstruction, which leads to
• B) stand up as straight and tall as vomiting after feeding the infant. The
possible vomiting associated with pyloric stenosis is
described as being projectile in nature. This
• C) bend over at a 90-degree angle
is due to the increasing amounts of formula
from the waist
the infant begins to consume coupled with
• D) bend over at a 45-degree angle the increasing thickening of the pyloric
from the waist sphincter.

This is the recommended position for 39. A 70-year-old client with suspected
screening for scoliosis. It allows the nurse to tuberculosis is brought to the geriatric care
inspect the alignment of the spine, as well facilities. An intradermal tuberculosis test is
as to compare both shoulders and both hips. schedule to be done. The client asks the
nurse what is the purpose of the test. Which
37. A client with tuberculosis is admitted in of the following would be the best rationale
the hospital for 2 weeks. When a client’s for this?
family members come to visit, they would be
adhering to respiratory isolation precautions
• A) reactivation of an old tuberculosis
when they:
infection
• B) increased incidence of new
• A) wash their hands when leaving cases of tuberculosis in persons
• B) put on gowns, gloves and masks over 65 years old
• C) avoid contact with the client’s • C) greater exposure to diverse
roommate health care workers
• D) keep the client’s room door open • D) respiratory problems are
characteristic in this population
Handwashing is the best method for
reducing cross-contamination. Gowns and Increased incidence of TB has been seen in
gloves are not always required when the general population with a high incidence
entering a client’s room. reported in hospitalized elderly clients.
Immunosuppression and lack of classic
38. An infant is brought to the emergency manifestations because of the aging process
department and diagnosed with pyloric are just two of the contributing factors of
stenosis. The parents of the client ask the tuberculosis in the elderly.
nurse, “Why does my baby continue to
vomit?” Which of the following would be the 40. The nurse is making a health teaching
best nursing response of the nurse? to the parents of the client. In teaching
parents how to measure the area of
• A) “Your baby eats too rapidly and induration in response to a PPD test, the
overfills the stomach, which causes nurse would be most accurate in advising
vomiting the parents to measure:
• B) “Your baby can’t empty the
formula that is in the stomach into • A) both the areas that look red and
the bowel” feel raised
• C) “The vomiting is due to the • B) The entire area that feels itchy to
nausea that accompanies pyloric the child
stenosis” • C) Only the area that looks
• D) “Your baby needs to be burped reddened
more thoroughly after feeding” • D) Only the area that feels raised
Parents should be taught to feel the area scratching, while allowing the most
that is raised and measure only that. movement permissible.

41. A community health nurse is schedule 44. The parents of the hospitalized client
to do home visit. She visits to an elderly ask the nurse how their baby might have
person living alone. Which of the following gotten pyloric stenosis. The appropriate
observation would be a concern? nursing response would be:

• A) Picture windows • A) There is no way to determine this


• B) Unwashed dishes in the sink preoperatively
• C) Clear and shiny floors • B) Their baby was born with this
• D) Brightly lit rooms condition
• C) Their baby developed this
It is a safety hazard to have shiny floors condition during the first few weeks
because they can cause falls. of life
• D) Their baby acquired it due to a
formula allergy
42. After a birth, the physician cut the cord
of the baby, and before the baby is given to
the mother, what would be the initial nursing Pyloric stenosis is not a congenital
action of the nurse? anatomical defect, but the precise etiology is
unknown. It develops during the first few
weeks of life.
• A) examine the infant for any
observable abnormalities
• B) confirm identification of the infant 45. A male client comes to the clinic for
and apply bracelet to mother and check-up. In doing a physical assessment,
infant the nurse should report to the physician the
most common symptom of gonorrhea, which
• C) instill prophylactic medication in
is:
the infant’s eyes
• D) wrap the infant in a prewarmed
blanket and cover the head • A) pruritus
• B) pus in the urine
The first priority, beside maintaining a • C) WBC in the urine
newborn’s patent airway, is body • D) Dysuria
temperature.
Pus is usually the first symptom, because
43. A 2-year-old client is admitted to the the bacteria reproduce in the bladder.
hospital with severe eczema lesions on the
scalp, face, neck and arms. The client is 46. Which of the following would be the
scratching the affected areas. What would most important goal in the nursing care of an
be the best nursing intervention to prevent infant client with eczema?
the client from scratching the affected
areas? • A) preventing infection
• B) maintaining the comfort level
• A) elbow restraints to the arms • C) providing for adequate nutrition
• B) Mittens to the hands • D) decreasing the itching
• C) Clove-hitch restraints to the
hands Preventing infection in the infant with
• D) A posey jacket to the torso eczema is the nurse’s most important goal.
The infant with eczema is at high risk for
The purpose of restraints for this child is to infection due to numerous breaks in the
keep the child from scratching the affected skin’s integrity. Intact skin is always the
areas. Mittens restraint would prevent infant’s first line of defense against infection.
47. The nurse is making a discharge mother and clarify any misconceptions
instruction to a client receiving regarding immunizations that may exist.
chemotherapy. The client is at risk for bone
marrow depression. The nurse gives 50. The nurse is teaching the client about
instructions to the client about how to breast self-examination. Which observation
prevent infection at home. Which of the should the client be taught to recognize
following health teaching would be included? when doing the examination for detection of
breast cancer?
• A) “Get a weekly WBC count”
• B) “Do not share a bathroom with • A) tender, movable lump
children or pregnant woman” • B) pain on breast self-examination
• C) “Avoid contact with others while • C) round, well-defined lump
receiving chemotherapy” • D) dimpling of the breast tissue
• D) “Do frequent hand washing and
maintain good hygiene”
The tumor infiltrates nearby tissue, it can
cause retraction of the overlying skin and
Frequent hand washing and good hygiene create a dimpling appearance
are the best means of preventing infection.

48. The nurse is assigned to care the


client with infectious disease. The best
antimicrobial agent for the nurse to use in
handwashing is:

• A) Isopropyl alcohol
• B) Hexachlorophene (Phisohex)
• C) Soap and water
• D) Chlorhexidine gluconate (CHG)
(Hibiclens)

CHG is a highly effective antimicrobial


ingredient, especially when it is used
consistently over time.

49. The mother of the client tells the nurse,


“ I’m not going to have my baby get any
immunization”. What would be the best
nursing response to the mother?

• A) “You and I need to review your


rationale for this decision”
• B) “Your baby will not be able to
attend day care without
immunizations”
• C) “Your decision can be viewed as
a form of child abuse and neglect”
• D) “You are needlessly placing other
people at risk for communicable
diseases”

The mother may have many reasons for


such a decision. It is the nurse’s
responsibility to review this decision with the