Anda di halaman 1dari 8

Parents are concerned that their 11 year-old child Tuberculosis (TB).

Which of the following


OB Q. is a very picky eater. The nurse suggests which of diagnostic tests is essential for determining the
Question 1 the following as the best initial approach? presence of active TB?
Which of these women in the labor and delivery Consider a liquid supplement to increase A) Tuberculin skin testing
A)
unit would the nurse check first when the water calories B) Sputum culture
breaks (ROM) for all of them within a 2 minute Discuss consequences of an unbalanced diet C) White blood cell count
period? B)
with the child D) Chest x-ray
A multigravida with station at +2, C) Provide fruit, vegetable and protein snacks
contractions at 15 minutes apart with Question 9
A) Encourage the child to keep a daily For which of the following mother-baby pairs
duration of 30 seconds, cervix dilated at 7 D)
cm, and 50% effacement log of foods eaten should the nurse review the Coombs' test in
A multigravida with station at -1, Question 5 preparation for administering Rho (D) immune
contractions at 15 minutes apart with The nurse is assessing a pregnant client in her third globulin within 72 hours of birth?
B)
duration of 30 seconds, cervix dilated at 3 trimester. The parents are informed that the A) Rh negative mother with Rh positive baby
cm, and 10% effacement ultrasound suggests that the baby is small for B) Rh negative mother with Rh negative baby
A primipara with station at 0, contractions at gestational age (SGA). An earlier ultrasound C) Rh positive mother with Rh positive baby
C) 20 minutes apart with duration of 20 seconds, indicated normal growth. The nurse understands
that this change is most likely due to what factor?
Rh positive mother with Rh negative
cervix dilated at 2 cm and 10% effacement D)
A) Sexually transmitted infection
baby
A primipara with station at 1,
B) Exposure to teratogens Question 10
contractions at 15 minutes apart with
D) C) Maternal hypertension An unlicensed assistive staff member asks the
duration of 35 seconds, cervix dilated nurse manager to explain the beliefs of a Christian
at 5 cm and 50% effacement D) Chromosomal abnormalities
Scientist who refuses admission to the hospital
Question 2 Question 6 after a motor vehicle accident. The best response
The nurse is caring for an 87 year-old client with An 80 year-old nursing home resident has a of the nurse would be which of these statements?
urinary retention. Which finding should be temperature of 101.6 degrees Fahrenheit rectally. "Spiritual healing is emphasized and the
This is a sudden change in an otherwise healthy A)
reported immediately? mind contributes to the cure."
client. Which should the nurse assess first? "The primary belief is that dietary practices
A) Fecal impaction B)
B) Infrequent voiding A) lung sounds result in health or illness."
C) Stress incontinence B) urine output "Fasting and prayer are initial actions to take
C)
C) level of alertness in physical injury."
D) Burning with urination
D) appetite "Meditation is intensive in the initial
Question 3 D)
Question 7 48 hours and daily thereafter."
A 36 year-old female client has a hemoglobin level
of 14 g/dl and a hematocrit of 42% following a While giving care to a 2 year-old client, the nurse
D&C. Which of the following would the nurse should remember that the toddler's tendency to say Question 11
expect to find when assessing this client? "no" to almost everything is an indication of what The nurse has been teaching an apprehensive
psychosocial skill? primipara who has had initial difficulty in nursing
A) Capillary refill less than 3 seconds
B) Pale mucous membranes A) Stubborn behavior the newborn. What observation at the time of
B) Rejection of parents discharge suggests that initial breast feeding is
C) Respirations 36 breaths per minute
C) Frustration with adults effective?
Complaints of fatigue when The mother feels calmer and talks to the baby
D) D) Assertion of control A)
ambulating while nursing
Question 8
Question 4 B) The mother awakens the newborn to feed
The nurse is caring for a client suspected to have
1
whenever it falls asleep The nurse is teaching a mother who will breast AIDS. There is a history of these findings:
The newborn falls asleep after 3 minutes at feed for the first time. Which of the following is a unintended weight loss, drug abuse, night sweats,
C) priority? productive cough and a "feeling of being hot all
the breast
Show her films on the physiology of the time." The nurse should assign the client to
The newborn refuses the A)
D) lactation share a room with a client with the diagnosis of
supplemental bottle of glucose water
B) Give the client several illustrated pamphlets Acute tuberculosis with a productive cough
Question 12 A)
Assist her to position the newborn at the of discolored sputum for over three months
The nurse is caring for a client with congestive C) Lupus and vesicles on one side of the middle
breast B)
heart failure. Which finding requires the nurse's trunk from the back to the abdomen
immediate attention? Give her privacy for the initial
D) C) Pseudomembranous colitis and C. difficile
A) pulse oximetry of 85% feeding
Question 16
Exacerbation of polyarthritis with
B) nocturia D)
The recent increase in the reported cases of active
severe pain
C) crackles in lungs
tuberculosis (TB) in the United States is attributed Question 19
D) diaphoresis
to which factor? A 15 month-old child comes to the clinic for a
Question 13 The increased homeless population in major follow-up visit after hospitalization for treatment
The nurse is taking a health history from parents of A) of Kawasaki Disease. The nurse recognizes that
cities
a child admitted with possible Reye's syndrome. The rise in reported cases of positive HIV which of the following scheduled immunizations
Which recent illness would the nurse recognize as B) will be delayed?
infections
increasing the risk to develop Reye's syndrome? A) MMR
The migration patterns of people from
A) rubeola C) B) Hib
foreign countries
B) meningitis C) IPV
The aging of the population located
C) varicella D) D) DTaP
in group homes
D) hepatitis

Question 20
What is the major purpose of community health
research?
Question 17
A) Describe the health conditions of populations
The nasogastric tube of a post-op gastrectomy B) Evaluate illness in the community
Question 14 client has stopped draining greenish liquid. The
C) Explain the health conditions of families
The nurse is caring for a client with end-stage nurse should
heart failure. The family members are distressed A) irrigate it as ordered with distilled water Identify the health conditions of the
D)
about the client's impending death. What action B) irrigate it as ordered with normal saline environment
should the nurse do first? place the end of the tube in water to see if the Question 21
Explain the stages of death and dying to the C)
A) water bubbles The nurse is taking a health history from a Native
family American client. It is critical that the nurse must
withdraw the tube several inches and
B) Recommend an easy-to-read book on grief D) remember that eye contact with such clients is
reposition it
Assess the family's patterns for dealing with considered
C) Question 18
death A) Expected
D) Ask about their religious affiliations A client arrived in the USA from a developing B) Rude
country 1 week ago. The client is to be admitted to
Question 15 C) Professional
the medical surgical unit with a diagnosis of

2
D) Enjoyable regenerate visit for a mild respiratory infection. Koplik spots
are noted on the oral mucous membranes. The
Question 22 Question 25
nurse should then assess which area of the body?
The nurse discovers that the parents of a 2 year-old An adolescent client is admitted in respiratory
A) the skin
child continue to use an apnea monitor each night. alkalosis following aspirin overdose. The nurse
The parents state: “We are concerned about the recognizes that this imbalance was caused by B) the lungs
possible occurrence of sudden infant death C) the muscles
A) tachypnea
syndrome (SIDS).” In order to take appropriate B) acidic byproducts D) bowel and bladder
action, the nurse must understand that Question 30
C) vomiting and dehydration
The child is within the age group most A client's admission urinalysis shows the specific
A) D) hyperpyrexia
susceptible to SIDS gravity value of 1.039. Which of the following
The peak age for occurrence of SIDS is 8 to Question 26
B) assessment data would the nurse expect to find
12 months of age A nurse is teaching a class for new parents at a when assessing this client?
The apnea monitor is not effective on a child local community center. The nurse would stress
C) A) Moist mucous membranes
in this age group that _______ is most hazardous for an 8 month-
old child. B) Urinary frequency
95% of SIDS cases occur before 6 C) Poor skin turgor
D) A) riding in a car
months of age D) Increased blood pressure
B) falling off a bed
Question 23
C) an electrical outlet
The parents of a child who has recently been
D) eating peanuts
diagnosed with asthma ask the nurse to explain the Question 31
condition to them. The best response is "Asthma The nurse is caring for a client with Meniere's
causes Question 27 disease. When teaching the client about the
the airway to become narrow and obstructs The mother of a burned child asks the nurse to disease, the nurse should explain that the client
A)
airflow." clarify what is meant by a third degree burn. The should avoid foods high in
air to be trapped in the lungs because the best response by the nurse is A) calcium
B)
airways are dilated." A) "The top layer of the skin is destroyed." B) fiber
the nerves that control respiration to become B) "The skin layers are swollen and reddened." C) sodium
C)
hyperactive." "All layers of the skin were destroyed in the
C) D) carbohydrate
a decrease in the stress hormones burn."
Question 32
D) which prevents the airways from "Muscle, tissue and bone have been
D) After the shift report in a labor and delivery unit
opening." injured." which of these clients would the nurse check first?
Question 24 Question 28 A middle aged woman with asthma and Type
When teaching parents about sickle cell disease, The nurse is providing diet instruction to the A)
1 diabetes mellitus has a BP of 150/94
the nurse should tell them that their child's anemia parents of a child with cystic fibrosis. The nurse A middle aged woman with a history of two
is caused by would emphasize that the diet should be high B)
prior vaginal term births is 2 cm dilated
Reduced oxygen capacity of cells due to lack A) calorie, low fat, low sodium A young woman who is a grand multipara
A)
of iron B) protein, low fat, low carbohydrate C) has cervical dilation of 4 cm and is 50%
An imbalance between red cell destruction C) protein, high calorie, unrestricted fat effaced
B)
and production carbohydrate, low protein, moderate An adolescent who is 18 weeks
Depression of red and white cells and D)
C) fat D) pregnant has a report of no fetal heart
platelets
D) Inability of sickle shaped cells to Question 29 tones and coughing up frothy sputum
The nurse is assessing a young child at a clinic Question 33
3
The nurse is assessing a child with suspected lead home by a client addicted to heroin. Which of the throughout the pregnancy. Which of the following
poisoning. Which of the following assessments is following would the nurse expect to observe? newborn findings suggests to the nurse that the
the nurse most likely to find? A) Hypertonic neuro reflex infant has fetal alcohol syndrome?
A) Complaints of numbness and tingling in feet B) Immediate CNS depression A) Growth retardation is evident
Wheezing noted when lung sound C) Lethargy and sleepiness B) Multiple anomalies are identified
B)
auscultated D) Jitteriness at 24-48 hours C) Cranial facial abnormalities are noted
C) Excessive perspiration D) Prune belly syndrome is suspected
D) Difficulty sleeping PALMER
Question 1
A nursing student asks the nurse manager to
explain the forces that drive health care reform.
Question 37
The appropriate response by the nurse manager
Which action is most likely to ensure the safety of should include
the nurse while making a home visit?
The escalation of fees with a decreased
Observe no evidence of weapons in the home A)
A) reimbursement percentage
Question 34 during the visit High costs of diagnostic and end-of-life
Prior to the visit, review the client's record B)
The nurse is attending a workshop about caring for B) treatment procedures
persons infected with hepatitis. Which for any previous entries about violence Increased numbers of elderly and of the
Remain alert at all times and leave if cues C)
characteristic is most appropriate when defining C) chronically ill of all ages
the incidence rate of hepatitis? suggest the home is not safe
A steep rise in provider fees and in
The number of persons in a population who Carry a cell phone, pager and/or hand D)
D) insurance premiums
A) develop hepatitis B during a specific period held alarm for emergencies
of time Question 2
Question 38
The total number of persons in a population The nurse manager identifies that time spent by
B) As a client is being discharged following staff in charting is excessive, requiring overtime
who have hepatitis B at a particular time
resolution of a spontaneous pneumothorax, he tells for completion. The nurse manager states that
The percentage of deaths resulting from the nurse that he is now going to Hawaii for a
C) "staff will form a task force to investigate and
hepatitis B during a specific time vacation. The nurse would warn him to avoid develop potential solutions to the problem, and
The occurrence of hepatitis B in the A) surfing report on this at the next staff meeting." The nurse
D)
population at a particular time B) scuba diving manager's leadership style is best described as
Question 35 C) parasailing A) Laissez-faire
The nurse is providing home care for a client with D) swimming B) Autocratic
heart failure and pulmonary edema. Which nursing Question 39 C) Participative
diagnosis should have priority in planning care? D) Group
In order to be effective in administering
Impaired skin integrity related to dependent cardiopulmonary resuscitation to a 5 year-old, the
A) Question 3
edema nurse must The nurse is working with parents to plan home
Activity intolerance related to oxygen supply
B) A) assess the brachial pulses care for a 2 year-old with a heart problem. A
and demand imbalance
B) breathe once every 5 compressions priority nursing intervention would be to
C) Constipation related to immobility
C) use both hands to apply chest pressure encourage the parents to enroll in
Risk for infection related to A)
D) D) compress 80-90 times per minute cardiopulmonary resuscitation (CPR) class
ineffective mobilization of secretions assist the parents to plan quiet play activities
Question 40 B)
Question 36 at home
A postpartum client admits to alcohol use
The nurse is assessing a newborn delivered at C) stress to the parents that they will need relief
4
care givers than the warfarin
instruct the parents to avoid contact Select another antacid that does not
D) C)
with persons with infection inactivate warfarin
Use on-half the recommended dose
Question 7 D)
of Alka-Seltzer
A client has been taking alprazolam (Xanax) for 3
days. Nursing assessment should reveal which Question 10
Question 4 expected effect of the drug? The nurse notes an abrupt onset of confusion in an
A) Tranquilization, numbing of emotions elderly patient. Which of the following recently-
Which of these clients would the triage nurse ordered medications would most likely contribute
request the provider examine immediately? B) Sedation, analgesia
to this change?
A 5 month-old infant who has audible C) Relief of insomnia and phobias
A) A) Anticoagulant
wheezing and grunting Diminished tachycardia and tremors B) Liquid antacid
D)
An adolescent who has soot over the face and associated with anxiety
B) C) Antihistamine
shirt
Question 8 D) Cardiac glycoside
A middle-aged man with second degree
C) A woman who delivered 5 days ago and had
burns over the right hand Question 11
been diagnosed with pregnancy induced
A toddler with singed ends of long hypertension (PIH) calls the hospital triage nurse The nurse is teaching a 27 year-old client with
D) asthma about their therapeutic regime. Which
hair that extends to the waist hotline to ask for advice. She states, “I have had
the worst headache for the past 2 days. It pounds statement would indicate the need for additional
Question 5 instruction?
and by the middle of the afternoon everything I
The nurse is caring for a client with Rheumatoid A) "I should monitor my peak flow every day."
Arthritis. Which nursing diagnosis should receive look at looks wavy. Nothing I have taken helps.”
What should the nurse do next? "I should contact the clinic if I am using my
priority in the plan of care? B)
Advise the client that the swings in her medication more often."
A) Risk for injury
hormones may have that effect. However, "I need to limit my exercise, especially
B) Self care deficit A) C)
suggest for her to call her provider within activities such as walking and running."
C) Alteration in comfort the next day. "I should learn stress reduction and
D) Alteration in mobility D)
Advise the client to have someone bring her relaxation techniques."
B)
Question 6 to the emergency room as soon as possible.
Question 12
The nurse is caring for a client with active Ask the client to stay on the line, get the
C) address and send an ambulance to the In assessing a post partum client, the nurse
tuberculosis who has a history of noncompliance. palpates a firm fundus and observes a constant
Which of the following actions by the nurse would home.
trickle of bright red blood from the vagina. What is
represent appropriate care for this client? Ask what the client has taken? How the most likely cause of these findings?
A)
Instruct the client to wear a high efficiency D) often? Ask about other specific A) Uterine atony
particulate air mask in public places. complaints. B) Genital lacerations
Ask a family member to supervise daily
B) Question 9 C) Retained placenta
compliance
A client on warfarin therapy following coronary D) Clotting disorder
C) Schedule weekly clinic visits for the client
artery stent placement calls the clinic to ask if he
Ask the health care provider to Question 13
can take Alka-Seltzer for an upset stomach. What
D) change the regimen to fewer is the best response by the nurse? The nurse is caring for a 75 year old client in
congestive heart failure. Which finding suggests
medications Avoid Alka-Seltzer because it contains
that digitalis levels should be reviewed?
A)
aspirin
A) Extreme fatigue
B) Take Alka-Seltzer at a different time of day
B) Increased appetite
5
C) Intense itching diversional activity? The child feels guilty for the grandmother's
C)
D) Constipation A) Kicking balloons with right leg death
Question 14 B) Playing "Simon Says" The child is worried that he, too,
D)
The nurse is teaching a client with atrial C) Playing hand held games might die
fibrillation about the use of Coumadin (warfarin) D) Throw bean bags Question 22
at home. The need to avoid which of these should Question 18 While caring for a child with Reye's syndrome, the
be emphasized to the client? The nurse is teaching a group of adults about nurse should give which action the highest
A) Large indoor gatherings modifiable cardiac risk factors. Which of the priority?
B) Exposure to sunlight following should the nurse focus on first? A) monitor intake and output
C) Active physical exercise A) Weight reduction B) provide good skin care
D) Foods rich in vitamin K B) Stress management C) assess level of consciousness
Question 15 C) Physical exercise D) assist with range of motion
A nurse who is a native English speaker admits an D) Smoking cessation Question 23
elderly Mexican-American migrant worker after Question 19 A 70 year-old post-operative client has elevated
an accident that occurred during work. To The nurse is assessing a client with portal serum BUN, HCT, Cl, and Na+. Creatinine and
facilitate communication the nurse should initially hypertension. Which of the following findings K+ are within normal limits. The nurse should
A) Request a Spanish interpreter would the nurse expect? perform additional assessments to confirm that an
B) Speak through the family or co-workers A) Expiratory wheezes actual problem is:
C) Use pictures, letter boards, or monitoring B) Blurred vision A) Impaired gas exchange
Assess the client's ability to speak C) Ascites B) Metabolic acidosis
D) C) Renal insufficiency
English D) Dilated pupils
Question 16 D) Fluid volume deficit
Question 20
To prevent keratitis in an unconscious client, the The nurse is caring for an acutely ill 10 year-old
nurse should apply moisturizing ointment to the client. Which of the following assessment findings
A) finger and toenail quicks would require the nurses immediate attention?
B) eyes A) Rapid bounding pulse
C) perianal area Temperature of 101.3 degrees Fahrenheit Question 24
B)
D) external ear canals (38.5 degrees Celsius) A 67 year-old client with non-insulin dependent
C) Profuse diaphoresis diabetes should be instructed to contact the out-
D) Slow, irregular respirations patient clinic immediately if the following
findings are present
Temperature of 99.5 degrees Fahrenheit with
A)
Question 21 painful urination
A parent tells the nurse that their 6 year-old child B) An open, reddened wound on the heel
who normally enjoys school, has not been doing C) Insomnia and daytime fatigue
well since the grandmother died 2 months ago. D) Nausea with 2 episodes of vomiting
Which statement most accurately describes Question 25
Question 17 thoughts on death and dying at this age?
The nurse is caring for a 5 year-old child whose A confused client has been placed in physical
Death is personified as the bogeyman or restraints by order of the provider. Which task
left leg is in skeletal traction. Which of the A)
devil could be assigned to an unlicensed assistive
following activities would be an appropriate
B) Death is perceived as being irreversible
6
personnel (UAP)? The nurse would anticipate that the child would be Question 33
A) Assist the client with activities of daily living deficient in which vitamins? The primary teaching for a client following an
B) Monitor the clients physical safety A) B, D, and K extracorporeal shock-wave lithotripsy (ESWL)
C) Evaluate for basic comfort needs B) A, D, and K procedure is
Document mental status and muscle C) A, C, and D "Drink 3000 to 4000 cc of fluid each day for
A)
D) D) A, B, and C one month."
strength "Limit fluid intake to 1000 cc each day for
Question 26 Question 30 B)
one month."
The nurse is providing foot care instructions to a A child is diagnosed with poison ivy. The mother "Increase intake of citrus fruits to three
client with arterial insufficiency. The nurse would tells the nurse that she does not know how her C)
servings per day."
identify the need for additional teaching if the child contracted the rash since he had not been
playing in wooded areas. As the nurse asks "Restrict milk and dairy products for
client stated D)
questions about possible contact, which of the one month."
A) "I can only wear cotton socks."
following would the nurse recognize as highest Question 34
B) "I cannot go barefoot around my house."
risk for exposure? An infant has just returned from surgery for
C) "I will trim corns and calluses regularly."
Playing with toys in a back yard flower placement of a gastrostomy tube as an initial
"I should ask a family member to A)
D) garden treatment for tracheoesophageal fistula. The
inspect my feet daily." Eating small amounts of grass while playing mother asks: ”When can the tube can be used for
B)
Question 27 "farm" feeding?” The nurse's best response would be
A client is scheduled to have a blood test for Playing with cars on the pavement near which of these comments?
C)
cholesterol and triglycerides the next day. The burning leaves A) "Feedings can begin in 5 to 7 days."
nurse would tell the client Throwing a ball to a neighborhood B) "The feeding tube can be used immediately."
D)
A) "Be sure and eat a fat-free diet until the test." child who has poison ivy "The stomach contents and air must be
C)
"Do not eat or drink anything but water for drained first."
B) Question 31
12 hours before the blood test."
The nurse observes a staff member caring for a "Healing of the incision must be
D)
"Have the blood drawn within 2 hours of client with a left unilateral mastectomy. The nurse complete before feeding."
C)
eating breakfast." would intervene if she notices the staff member is Question 35
"Stay at the laboratory so 2 blood A) advising client to restrict sodium intake The community health nurse has been caring for
D)
samples can be drawn an hour apart." B) taking the blood pressure in the left arm an adolescent with a history of morbid obesity,
Question 28 C) elevating her left arm above heart level asthma, and hypertension, and is 22 weeks
A client who is terminally ill has been receiving D) compressing the drainage device pregnant. Which of these lab reports need to be
high doses of an opioid analgesic for the past called to the teen’s provider within the next hour?
Question 32
month. As death approaches and the client A) hemoglobin 11 g/L and calcium 6 mg/dl
becomes unresponsive to verbal stimuli, what The nurse has identified what appears to be magnesium 0.8 mEq/L and creatinine 3
ventricular tachycardia on the cardiac monitor of a B)
orders would the nurse expect from the health care mg/dl
provider? client being evaluated for possible myocardial
blood urea nitrogen 28 and glucose 225
infarction. The first action the nurse would C)
A) Decrease the analgesic dosage by half mg/dl
perform is to
B) Discontinue the analgesic
A) begin cardiopulmonary resuscitation D) hematocrit 33% and platelets 200,000
C) Continue the same analgesic dosage Question 36
B) prepare for immediate defibrillation
D) Prescribe a less potent drug C) notify the "Code" team and provider A client with hepatitis A (HAV) is newly admitted
Question 29 assess airway breathing and to the unit. Which action would be the priority to
The nurse is caring for a child with cystic fibrosis. D) include in this client’s plan of care within the
circulation initial 24 hours?
Wear masks with shields if there is potential 7
B) Use disposable utensils and plates for meals intensive care setting carefully monitors oxygen
C) Wear gown and gloves during client contact concentration. What is the most common
complication of this therapy?
Provide soft easily digested food with
D) A) Intraventricular hemorrhage
frequent snacks
B) Retinopathy of prematurity
Question 37
C) Bronchial pulmonary dysplasia
A nurse manager is using the technique of
D) Necrotizing enterocolitis
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:
"Let’s move on to a new action that deals
A)
with the problem."
"I think you need to reserve judgment until
B)
after all suggestions are offered."
"Very well thought out. Your analytic skills
C)
and interest are incredible."
"Let’s move to the ‘what if…’ as
D) related to these objections and
explore spin off ideas."
Question 38
A pre-term baby develops nasal flaring, cyanosis
and diminished breath sounds on one side. The
provider's diagnosis is spontaneous pneumothorax.
Which procedure should the nurse prepare for
first?
A) Cardiopulmonary resuscitation
B) Insertion of a chest tube
C) Oxygen therapy
D) Assisted ventilation
Question 39
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
Injury related to intracranial
D)
hemorrhage
Question 40
A nurse caring for premature newborns in an
8

Anda mungkin juga menyukai