FLORIDA UNIVERSITY PEDIATRICS NUR 416 CAT 3 KAPLAN 2 LATEST 2021/2022
1. The nurse auscultates crackles throughout all lung fields and measures a heart
... [Show More] rate of 132 bpm, a respiratory rate of 30, and blood pressure of 102/54 mm Hg in a client recovering from an esophagectomy. Which action will the nurse take first?
1. Place the client on continuous pulse oximetry.
2. Monitor the client for changes in blood pressure.
3. Notify the health care provider.
4. Assist the client to use the incentive spirometer.
Ans: 3
2. The nurse assigns a client diagnosed with cancer who is receiving chemotherapy to a nursing assistive personnel (NAP). Which instruction is most important for the nurse to include?
1. Perform hand hygiene frequently.
2. Wear a mask when entering the room.
3. Monitor the roommate for signs of infection.
4. Monitor the amount of protein the client eats.
Ans: 1
3. The nurse provides care for a client diagnosed with a bone infection. The client was given intravenous morphine 3 hours ago and cannot have another dose for an hour. The client reports pain that is rated as 6 out of 10. The nurse implements several nonpharmacological approaches. The client’s pain level is now a 3 out of
10. Which action should the nurse take next?
1. Notify the health care provider.
2. Administer the morphine early.
3. Instruct the client that the next dose cannot be given for an hour.
4. Ask the client what an acceptable pain level is.
Ans: 4
4. The nurse provides care for a client who was in a car accident as the result of falling asleep at the wheel. The client reports only being able to sleep 3 to 4 hours a night over the past month, due to stress. The client reports waking up frequently during the night. Which outcome is most appropriate for the nurse to include in the client’s plan of care?
1. Client will verbalize a plan to implement a sleep promoting program within the next week.
2. Client will fall asleep with less difficulty over the next 2 weeks.
3. Client will achieve a more normal sleep pattern within 2 to 4 weeks.
4. Client will achieve an improved sense of adequate sleep over the next 4 weeks.
Ans: 1
5. The nurse reviews medications prescribed for a client recovering from surgery. Which prescription causes the nurse the most concern?
1. Diphenhydramine 50 mg PO at bedtime, as needed.
2. Furosemide 40 mg IV q.d.
3. Morphine sulfate 2 mg IV every hour, as needed, for pain.
4. Oxygen at 2 L/min via nasal cannula.
Ans: 2
6. The nurse reads the result of a tuberculosis (TB) skin test on a client with no known risk factors for TB. Which finding will the nurse interpret as a positive result?
1. Erythema of 5 or more millimeters.
2. Induration of 5 or more millimeters.
3. Induration of 10 or more millimeters.
4. Induration of 15 or more millimeters.
Ans: 4
7. The nurse provides care to an older adult client suspected of being a victim of physical abuse. Which action is appropriate for the nurse to implement when providing care to the client? (Select all that apply.)
1. Place the client in a single room near the nurses’ station.
2. Assess the client for bilateral injuries in ankles or wrist.
3. Identify, collect, and preserve physical evidence of abuse.
4. Take photographs to document signs of physical abuse.
5. Use standardized tool to screen for elder mistreatment.
Ans: 2, 3, 5
8. A client receiving an enema reports cramping and discomfort when the nurse releases the clamp and places the container 12 inches above the client’s hip level. Which action will the nurse take next?
1. Instruct the client to take deep breaths.
2. Discontinue the enema.
3. Clamp the tubing.
4. Lower the enema bag below the level of the hips.
Ans: 3
9. The nurse assesses clients waiting to be seen by the health care provider. Which client does the nurse identify to be seen first?
1. Client with myasthenia gravis reporting double vision and drooping of the right eye lid.
2. Client with a flat 9 mm induration area at the site of a tuberculin skin test placed 48 hours ago.
3. Client with a mean arterial pressure of 80 mm Hg.
4. Client with lung disease reporting dyspnea after walking up stairs.
Ans: 2
10. A client experiences wide QRS complexes on telemetry, numbness of the feet, and tingling of both hands. Which medication will the nurse question before administering to this client?
1. Diltiazem.
2. Furosemide.
3. Spironolactone.
4. Metoprolol tartrate.
Ans: 3
11. The nurse provides care for a client diagnosed with leukemia. The nurse notes the client has vomited a large amount of bloody emesis. Which action should the nurse take first?
1. Measure the vomitus before dumping it.
2. Assess the client’s last platelet count.
3. Notify the health care provider.
4. Complete a head to toe assessment.
Ans: 3
12. The nurse is teaching a client who has undergone a cataract extraction with intraocular implant. Which instruction does the nurse include in the discharge teaching? (Select all that apply.)
1. Avoid activities that require bending over.
2. Place an eye shield on the surgical eye at bedtime.
3. Avoid lifting anything over 5 pounds.
4. Contact the surgeon if eye scratchiness occurs.
5. Take acetaminophen for minor eye discomfort.
Ans: 1, 2, 3, 5
13. An infant diagnosed with pertussis is being discharged home with the parents. Which information will the nurse include in the parents’ teaching plan? (Select all that apply.)
1. Hand hygiene using an alcohol-based hand rub is effective against pertussis.
2. Family members and others in close contact with the infant should be vaccinated.
3. Airborne isolation precautions are required for 5 days after the start of antibiotic therapy.
4. Pertussis is most severe for the elderly.
5. Even if a person’s immunization status for pertussis is unknown, it is safe to immunize again.
Ans: 1, 3, 5
14. The nurse reviews the care needs for assigned clients. Which client will the nurse assess first?
1. Client with ulcerative colitis who reports rectal bleeding.
2. Client with an acute kidney injury with a urine output of 100 mL over the past 6 hours.
3. Client with angina pectoris who reports a headache after receiving a dose of prescribed nitroglycerin.
4. Client with a radioactive implant for cervical cancer who is in the bathroom.
Ans: 4
15. The nurse teaches a client how to self-administer nasal drops. Which statement is part of these instructions?
1. “Occlude one nostril prior to instilling the drops.”
2. “Store the medication vial in the refrigerator between doses.”
3. “Shake the medication vial for several minutes before opening.”
4. “Sit with the neck flexed backward for 5 minutes after instilling the drops.”
Ans: 4
16. The nurse assists the code team treating a client with asystole. Cardiopulmonary resuscitation (CPR) is in process. Which direction by the code team leader requires the nurse to intervene?
1. “Push hard and push fast during compressions.”
2. “Give atropine 1 mg followed by an NS flush.”
3. “Give epinephrine 1 mg every 3 to 5 minutes.”
4. “Continue CPR for 2 minutes and then check rhythm.”
Ans: 2
17. The nurse provides care to a 10-month-old infant. For which statement made by the parent will the nurse intervene? (Select all that apply.)
1. “My child has a two-word vocabulary.”
2. “My child gained 1 ounce this week.”
3. “My child cannot walk unless I hold under the arms.”
4. “My child cries and spreads the arms in and out when I bump the crib.”
5. “My child’s soft spot on top of the head is still open.”
Ans: 2, 4
18. The charge nurse assigns several clients to a novice nurse who is fresh off unit orientation. Which client will the charge nurse assign the novice nurse to provide care during this shift? (Select all that apply.)
1. A client on airborne precautions for newly diagnosed tuberculosis (TB).
2. A client diagnosed with chronic obstructive pulmonary disease (COPD) discharging tomorrow.
3. A client diagnosed with acute pneumonia on a bilevel positive airway pressure (BiPAP) machine.
4. A client status postoperative for a vaginal hysterectomy done earlier in the
day.
5. A toddler diagnosed with respiratory syncytial virus (RSV) admitted an
hour ago. Ans: 2, 4
19. The nurse teaches a group of nursing students about cultural competency. Which strategy will the nurse include to improve the students' cultural competency? (Select all that apply.)
1. Participate in continuing education classes about culturally congruent
care.
2. Develop culturally competent approaches to care.
3. Talk with clients about their cultural views of health.
4. Assess own skill level and seek improvement.
5. Realize that personal preferences can influence the client’s preferences.
Ans: 1, 2, 3, 4
20. The nurse manager is concerned about increased instances of client confusion and disorientation in the intensive care unit (ICU). Which nursing intervention is most effective in resolving this issue?
1. Promote daytime periods of sleep.
2. Monitor noise levels during the night.
3. Prioritize and cluster care activities.
4. Turn off TVs and unnecessary lights.
Ans: 2
21. The nurse provides care to a client with asthma. Which co-morbid condition does the nurse identify as a trigger for an acute asthma episode?
1. Psoriasis.
2. Cellulitis.
3. Rheumatoid arthritis.
4. Hiatal hernia.
Ans: 4
22. The nurse manager creates a discharge teaching form for clients with acquired immunodeficiency syndrome (AIDS). Which statement will the manager include on this form? (Select all that apply.)
1. Avoid children who have just gotten a live vaccine.
2. A condom is necessary during sexual activity.
3. Contact sports, such as football, must be avoided.
4. Drug paraphernalia must not be shared with others.
5. Sexual activity must be restricted to a single partner.
Ans: 1, 2, 4
23. The nurse provides pain management teaching to an older adult client diagnosed with osteoarthritis (OA). Which medication does the nurse discuss as the initial treatment of choice for OA pain?
1. Morphine.
2. Acetaminophen.
3. Ibuprofen.
4. Cyclobenzaprine.
Ans: 2
24. The nurse prepares teaching materials to review chest physiotherapy with the parents of a pediatric client diagnosed with cystic fibrosis (CF). Which observation indicates to the nurse that additional teaching is needed? (Select all that apply.)
1. Blood pressure 110/68 mm Hg.
2. Pulse oximetry 88% on room air.
3. Respiratory rate 24 breaths/min.
4. Ecchymosis over the back and lateral chest.
5. Complaint of pain with deep inspiration.
Ans: 2, 4, 5
25. The nurse receives a verbal prescription from a health care provider (HCP) during a client emergency. Which action does the nurse take to ensure client safety? (Select all that apply.)
1. Record the prescription in the client’s medical record.
2. Read back the prescription to verify the accuracy of the prescription.
3. Date and time the prescription that was issued during the emergency.
4. Record the HCPs prescriber number.
5. Document the nurse’s own name and title.
Ans: 1, 2, 3
26. A client in the postanesthesia care unit (PACU) reports nausea to the nurse. Which medication will the nurse given intravenously for this client's problem? (Select all that apply.)
1. Hydroxyzine.
2. Promethazine.
3. Ondansetron.
4. Aluminum hydroxide.
5. Sucralfate.
Ans: 1, 2, 3
27. After being notified that a client is seeking legal counsel about care received while hospitalized, the nurse manager investigates a staff nurse’s performance regarding the client’s care. Which nursing action will concern the nurse manager? (Select all that apply.)
1. The nurse mailed prescriptions to the client after discharge.
2. The nurse consulted the wound care nurse for the client’s area of skin breakdown.
3. The nurse found a referral for home care with laboratory results faxed after the client was discharge.
4. The nurse delegated sterile wound care to nursing assistive personnel
(NAP).
5. The nurse administered an oral pain medication when an intramuscular
dose was prescribed. Ans: 1, 3, 4, 5
28. The nurse provides care for an infant who has a fractured femur. Which statement regarding pain in an infant is accurate? (Select all that apply.)
1. Infants cannot feel pain.
2. Infants cannot express pain.
3. Infants have the same sensitivity to pain as older children.
4. Pain scales do not work well with infants.
5. Absorption of pain medication is faster in an infant than an adult.
Ans: 3, 5
29. The nurse provides care for a client diagnosed with new onset atrial fibrillation. The client’s health care provider prescribes a transesophageal echocardiogram (TEE). What reason will the nurse give to the client as the primary reason for performing a TEE?
1. To measure the cardiac index.
2. To rule out thrombus in the heart.
3. To estimate the ejection fraction.
4. To observe ventricular wall motion.
Ans: 2
30. The nurse provides care for a pediatric client suspected of having the respiratory syncytial virus (RSV). Which transmission-based precaution does the nurse initiate once influenza and adenovirus are ruled out for this client?
1. Airborne precautions.
2. Droplet precautions.
3. Reverse precautions.
4. Contact precautions.
Ans: 4
31. The nurse develops a teaching plan for a client with hyperlipidemia. Which lifestyle change will the nurse include in the plan? (Select all that apply.)
1. Consume a diet low in saturated fat.
2. Engage in regular, high-intensity aerobic activity.
3. Stop tobacco use by any possible means.
4. Avoid exposure to second-hand smoke.
5. Consume a diet low in soluble fiber.
Ans: 1, 3, 4
32. The nurse who is a practicing Muslim requests to wear a hijab while working. Which action will the nurse manager take next?
1. Decline the request.
2. Make the accommodation.
3. Advocate for modification of the organization’s dress code.
4. Review the organization’s dress code policy.
Ans: 4
33. The nurse provides care for a client diagnosed with insomnia. Which intervention does the nurse include in the nursing care plan?
1. Encourage afternoon naps.
2. Provide dairy products 30 minutes before bedtime.
3. Advise the client to vary retire and awake times.
4. Limit naps to less than 60 minutes.
Ans: 2
34. The nurse is proving care for several clients. Which client need will the nurse address first?
1. Client with a stroke needing a hand splint reapplied.
snack.
2. Client with diabetes and a fasting blood glucose of 78 mg/dL requesting a
3. Client with diarrhea needing the bedside commode emptied.
4. Client with emphysema requesting assistance with ambulation.
Ans: 4
35. The nurse provides care to a newly admitted client. At which time will the nurse conduct a medication reconciliation? (Select all that apply.)
1. At every clinic appointment.
2. At the pharmacy.
3. Upon discharge to home.
4. Upon entry into the unit.
5. Upon transfer to a skilled unit.
Ans: 1, 3, 4, 5
36. The nurse provides care for a client experiencing a fever who also reports bone pain, redness, and swelling. The client asks the nurse which treatment will likely be prescribed by the health care provider (HCP). Which response from the nurse is the most accurate?
1. “Usually a few days of bed rest and antibiotics are needed.”
2. “You will need surgery and then antibiotics for a few weeks.”
3. “Antibiotics will be prescribed for several weeks, which you can take at home.”
4. “If the area improves with rest and warm compresses, you might just need pain medication.”
Ans: 3
37. The nurse assesses a newborn. Which finding alerts the nurse that the newborn is at risk for hyperbilirubinemia?
1. Caput succedaneum.
2. Hyperglycemia.
3. Petechiae.
4. Cephalhematoma.
Ans: 4
38. Which safety measure is appropriate for the nurse to use to prevent the development of a pressure injury when providing care to clients? (Select all that apply.)
1. Encourage dorsiflexion exercises of the foot.
2. Limit the client’s intake of caffeinated fluids.
3. Encourage the client to hold the breath and try to exhale when moving up
in bed.
4. Use a turning or lift sheets or devices to turn or transfer clients.
5. Avoid a strong massage over bony prominences.
Ans: 4, 5
39. A client sues the nurse and the hospital for malpractice. Which resource will the nurse refer to determine if the client’s suit is legitimate?
1. Medical record.
2. Standards of care.
3. American Nurses Association Code of Ethics.
4. The Joint Commission standards.
Ans: 2
40. A client who takes alendronate asks the nurse when the medication can be stopped. Which response by the nurse is best?
1. “People usually have to take this medication for a few months.”
2. “Unfortunately, you will need to take this medication for the rest of your
life.”
3. “After a few doses, the frequency and need to take this medication will be
reevaluate”
4. “A scan will be repeated in 3 years, and if your bone mass stabilizes, it can be discontinued.”
Ans: 4
41. The nurse provides care for a client admitted to the hospital for an ischemic cerebrovascular event. The nurse is scheduled to administer clopidogrel, aspirin, and dexamethasone to the client. Which action should the nurse take? (Select all that apply.)
1. Send a stool specimen to the hospital laboratory to test for occult blood.
2. Ask the client if there is any history of gastrointestinal bleeding or stomach
ulcers.
3. Administer the medications and write a note documenting the nurse’s
concern.
4. Hold the medications until the health care provider is expected to visit the
client.
5. Notify the health care provider that the client is at risk for a medication
interaction. Ans: 2, 5
42. While conducting an abdominal assessment the nurse palpates a small round mass above the client’s symphysis pubis. Which action will the nurse take first?
1. Auscultate the mass.
2. Ask the client to void.
3. Apply pressure to the mass.
4. Ask if the client is experiencing pain.
Ans: 2
43. The nurse receives report on assigned clients. Which client will the nurse assess first?
1. Client who had a myocardial infarction 3 hours ago and is experiencing two to three premature ventricular contractions per minute.
2. Client who had a lumbar puncture 2 hours ago and is reporting a headache rated as an 8 on a pain rating scale of 0 to 10.
3. Client who had a permanent pacemaker inserted 12 hours ago and is reporting dizziness.
4. Client who had a total hip replacement 8 hours ago and is in a semi- Fowler position.
Ans: 3
44. A nurse works to establish a nurse-client relationship with a client who is new to the mental health unit. Which task does the nurse perform during the introductory phase of the nurse-client relationship? (Select all that apply.)
1. Discuss confidentiality with the client.
2. Assist the client to explore feelings.
3. Clarify the client’s problem.
4. Summarize the client’s success.
5. Identify the tasks the client should accomplish.
Ans: 1, 3, 5
45. The nurse provides care for a client who reports a lack of appetite, nausea, and passing a small amount of liquid stool throughout the day for several days. Which action does the nurse do next?
1. Administer prescribed medication for constipation.
2. Consult with the dietitian regarding client’s diet.
3. Perform a digital rectal exam.
4. Obtain a stool sample from the client.
Ans: 3
46. While assessing an adolescent for a sore throat and fatigue, the nurse notes multiple wounds in different levels of healing on both of the client’s arms. Which action will the nurse take first?
1. Inquire as to how the wounds occurred.
2. Ask about a history of sexual abuse.
3. Assess the wounds for healing and signs of infection.
4. Report the findings to the nursing supervisor.
Ans: 3
47. The nurse performs triage at a mass casualty incident. Which client will the nurse recommend receive treatment first?
1. Adolescent client with abdominal bleeding and confusion.
2. School-aged child with lacerations on the face and scalp.
3. Older adult client with a chest wound who is apneic.
4. Adult client with an open fracture of the humerus with present radial pulses.
Ans: 1
48. A female client received 2 units of packed red blood cells (PRBCs) for gastrointestinal bleeding. Which finding indicates to the nurse that the client may need an additional transfusion? (Select all that apply.)
1. Pulse rate 115 beats/minute.
2. Blood pressure 82/40 mm Hg.
3. Hemoglobin 13 g/dL (130 g/dL).
4. Hematocrit 28%.
5. Red blood cell count 4 X 106 cells/µL (4.4 X 1012 cells/L).
Ans: 1, 2, 4
49. The nurse notes the client’s electrocardiogram (ECG) rhythm is torsades de pointes. Which assessment does the nurse complete after a normal sinus rhythm is restored?
1. Monitor for ST segment depression.
2. Monitor for QT interval prolongation.
3. Monitor for PR interval prolongation.
4. Monitor for narrow QRS complexes.
Ans: 2
50. The nurse manager reviews the importance of using best evidence when planning client care during a nursing staff meeting. Which nursing staff response indicates additional information is required regarding evidence-based practice? (Select all that apply.)
1. “I’m glad that standardized care plans are gone.”
2. “Care plans now will be customized and useful.”
3. “I always liked research and now we can do it with our clients.”
4. “A software program to help search for information will be helpful.”
5. “Now we know that interventions for care will work for our clients.” Ans: 1, 3
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