Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category?
A) An infant with
... [Show More] intermittent bulging anterior fontanel between crying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
D) A school-age child with singed eyebrows and hair on the arms - ANSWER-is B: A toddler with severe deep abrasions over 98% of the body .
When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to
A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is supplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client - ANSWER-is C: notify the admissions office and wait to apply the bracelet
The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken?
A) Leave the order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification - ANSWER-is D: Call the provider for clarification
An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway - ANSWER-is D: open the client''s airway
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs - ANSWER-is D: Auscultate the lungs
Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery. - ANSWER-is C: 72 year-old recovering from surgery after a hip replacement 2
hours ago 1
A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the
suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
A) Why don't we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the insertion?
C) Let's check to see if the suppository is in far enough.
D) Did you feel any stool in the intestinal tract? - ANSWER-is B: That was done correctly. Did you have any problems with the
insertion? 1
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care?
A) airborne precautions
B) droplet precautions
C) contact precautions
D) compromised host precautions - ANSWER-is C: contact precautions 1
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching?
A) Void a little, clean the meatus, then collect specimen
B) clean the meatus, begin voiding, then catch urine stream
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine - ANSWER-is B: clean the meatus, begin voiding, then catch urine stream
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The provider orders Lanoxin (digoxin) 125 mg PO and furosomide 40 mg every
day. Which of these foods would the nurse reinforce for the client to eat at least daily?
A) spaghetti
B) watermelon
C) chicken
D) tomatoes - ANSWER-is B: watermelon
1
A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take?
A) Look up the policy on needle sticks
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management - ANSWER-is C: Immediately wash the hands with vigor 1
As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do?
A) Ask the student: "What did you forget to do?"
B) Stop. Tell me why aspiration is needed.
C) Loudly state: "You forgot to aspirate."
D) Walk up and whisper in the student's ear "Stop. Aspirate. Then inject." - ANSWER-is D: Walk up and whisper in the student's ear "Stop. Aspirate. Then
inject." 1
A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
A) Comatose, breathing unlabored
B) Glascow Coma Scale 8, respirations regular
C) Appears to be sleeping, vital signs stable
D) Glascow Coma Scale 13, no ventilator required - ANSWER-is B: Glascow Coma Scale 8, respirations regular
1
A client enters the emergency department unconscious via ambulance from the
client's work place. What document should be given priority to guide the direction of care for this client?
A) The statement of client rights and the client self determination act
B) Orders written by the health care provider
C) A notarized original of advance directives brought in by the partner
D) The clinical pathway protocol of the agency and the emergency department - ANSWER-is C: A notarized original of advance directives brought in by the
partner 1
The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager?
A) An admission at the change of shifts with atrial fibrillation and heart failure - PN
B) Client who had a major stroke 6 days ago - PN nursing student
C) A child with burns who has packed cells and albumin IV running - charge nurse
D) An elderly client who had a myocardial infarction a week ago - UAP - ANSWER-is A: An admission at the change of shifts with atrial fibrillation and
heart failure - PN 1
A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment?
A) Increased temperature and lethargy
B) Restlessness and increased mucus production
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor - ANSWER-is B: Restlessness and increased mucus production 2
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "The urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen."
D) "We notice muscle weakness and some unsteadiness." - ANSWER-is C: "Clothes are becoming tighter across her abdomen."
2
A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?
A) Ask the teenager to wait until a parent or legal guardian can be contacted
B) Withhold treatment until telephone consent can be obtained from the partner
C) Refer the teenager to a community pediatric hospital emergency department
D) Proceed with the triage process in the same manner as any adult client - ANSWER-is D: Proceed with the triage process in the same manner as any adult
client 2
A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
A) Converse with the client to determine if the mucous membranes are impaired
B) Report hourly outputs of less than 30 ml/hr
C) Monitor client's ability for movement in the bed
D) Check skin turgor every 4 hours - ANSWER-is B: Report output of less than 30 ml/hr 2
The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?
A) Our child had chickenpox 6 months ago.
B) Strep throat went through all the children at the day care last month.
C) Both ears were infected over 3 months age.
D) Last week both feet had a fungal skin infection. - ANSWER-is B: Strep throat went through all the children at the day care last
month.
2
A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcement of the manipulative behavior
C) Confront the client about the negative effects of behaviors on other clients and staff
D) Develop a behavior modification plan that will promote more functional behavior - ANSWER-is A:
Discuss the feeling of reluctance with an objective peer or supervisor
2
A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action
A) May result in charges of unlawful seclusion and restraint
B) Leaves the nurse vulnerable for charges of assault and battery
C) Was appropriate in view of the client's history of violence
D) Was necessary to maintain the therapeutic milieu of the unit - ANSWER-is A: May result in charges of unlawful seclusion and restraint
2
A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?
A) Pain related to ischemia
B) Risk for altered elimination: constipation
C) Risk for complication: dysrhythmias
D) Anxiety related to pain - ANSWER-is A: Pain related to ischemia 2
The provisions of the law for the Americans with Disabilities Act require nurse managers to
A) Maintain an environment free from associated hazards
B) Provide reasonable accommodations for disabled individuals
C) Make all necessary accommodations for disabled individuals
D) Consider both mental and physical disabilities - ANSWER-is B: Provide reasonable accommodations for disabled individuals
2
A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance?
A) "I have problems with diarrhea."
B) "I have difficulty falling asleep."
C) "I have diminished sexual function."
D) "I often feel jittery." - ANSWER-is C: "I have diminished sexual function."
2
A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate?
A) "I will keep the cast for the next day uncovered to prevent burning of the skin."
B) "I can apply an ice pack over the area to relieve itching inside the cast."
C) "The cast should be propped on at least 2 pillows when my child is lying down."
D) "I think I remember that standing cannot be done until after 72 hours." - ANSWER-is D: "I think I remember that standing cannot be done until after 72
hours." 3
Which statement best describes time management strategies applied to the role of a nurse manager?
A) Schedule staff efficiently to cover the needs on the managed unit
B) Assume a fair share of direct client care as a role model
C) Set daily goals with a prioritization of the work
D) Delegate tasks to reduce work load associated with direct care and meetings - ANSWER-is C: Set daily goals with a prioritization of the work
3
The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these?
A) Lymphedema and nerve palsy
B) Hearing loss and ataxia
C) Headaches and vomiting
D) Abdominal mass and weakness - ANSWER-is D: Abdominal mass and weakness 3
A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?
A) "I will only have to wear this for 6 months."
B) "I should inspect my skin daily."
C) "The brace will be worn day and night."
D) "I can take it off when I shower." - ANSWER-is A: "I will only have to wear this for 6 months." 3
The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self scheduling knowing that this method will
A) Improve the quality of care
B) Decrease staff turnover
C) Minimize the amount of overtime payouts
D) Improve team morale - ANSWER-is D: Improve team morale 3
A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?
A) Diffuse expiratory wheezing
B) Loose, productive cough
C) No relief from inhalant
D) Fever and chills - ANSWER-is A: Diffuse expiratory wheezing 3
The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's
complaints. The nurse manager's next action should be to
A) Walk up to the health care provider and quietly state: "Stop this unacceptable behavior."
B) Allow the staff nurse to handle this situation without interference
C) Notify the of the other administrative persons of a breech of professional conduct
D) Request an immediate private meeting with the health care provider and staff nurse - ANSWER-is D:
Request an immediate private meeting with the health care provider and staff nurse
3
A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states "I demand to be released now " The appropriate action is for the nurse to
A) You cannot be released because you are still suicidal.
B) You can be released only if you sign a no suicide contract.
C) Let's discuss your decision to leave and then we can prepare you for discharge.
D) You have a right to sign out as soon as we get an order from the health care provider's discharge order. - ANSWER-! is C: Let's discuss your decision to leave and then we can prepare you for discharge.
3
A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?
A) Dyspnea
B) Heart murmur
C) Macular rash
D) Hemorrhage - ANSWER-is B: Heart murmur Large, soft, rapidly developing vegetations attach to the heart valves.
3
A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability
to
A) Stabilize thermoregulation
B) Maintain alveolar surface tension
C) Begin normal pulmonary blood flow
D) Regulate intra cardiac pressure - ANSWER-is B: Maintain alveolar surface tension 3
An 18 year-old client is admitted to intensive care from the emergency room
following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority
assessment should be
A) Response to stimuli
B) Bladder control
C) Respiratory function
D) Muscle weakness - ANSWER-is C: Respiratory function 4
The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care?
A) Hourly urine output
B) White blood count
C) Blood glucose every 4 hours
D) Temperature every 2 hours - ANSWER-is A: Hourly urine output 4
The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance?
A) Assume a decision-making role
B) Seek input from staff
C) Use a non-directive approach
D) Shared decision-making with others - ANSWER-is A: Assume a decision making role 4
The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Some increase in the serum hemoglobin
D) A little decrease in the serum potassium - ANSWER-is B: Metabolic alkalosis 4
Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform?
A) Take a history on a newly admitted client
B) Adjust the rate of a gastric tube feeding
C) Check the blood pressure of a 2 hours post operative client
D) Check on a client receiving chemotherapy - ANSWER-is C: Check the blood pressure of a 2 hours post operative client
4
A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is
A) Call for emergency transport to the hospital
B) Immobilize the limb and joints above and below the injury
C) Assess the child and the extent of the injury
D) Apply cold compresses to the injured area - ANSWER-is C: Assess the child and the extent of the injury 4
When interviewing the parents of a child with asthma, it is most important to gather what information about the child's environment?
A) Household pets
B) New furniture
C) Lead based paint
D) Plants such as cactus - ANSWER-is A: Household pets 4
An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider?
A) Slurred speech
B) Incontinence
C) Muscle weakness
D) Rapid pulse - ANSWER-is A: Slurred speech 4
A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem?
A) Allergies
B) Scabies
C) Regression
D) Pinworms - ANSWER-is D: Pinworms 4
A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse?
A) Investigating the client's insurance coverage for home IV antibiotic therapy
B) Determining if there are adequate hand washing facilities in the home
C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver
D) Selecting the appropriate venous access device - ANSWER-is C: Assessing the client''s ability to participate in self care and/or the
reliability of a caregiver 4
The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse?
A) "Folic acid should be taken before and after conception."
B) "Multivitamin supplements are recommended during pregnancy."
C) "A well balanced diet promotes normal fetal development."
D) "Increased dietary iron improves the health of mother and fetus." - ANSWER-is A: "Folic acid should be taken before and after conception."
5
A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse?
A) Telfa dressing with antibiotic ointment
B) Moist sterile non adherent dressing
C) Dry sterile dressing that is occlusive
D) Sterile occlusive pressure dressing - ANSWER-is B: Moist sterile non adherent dressing 5
A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning?
A) Use ready-to-feed commercial infant formula
B) Boil the tap water for 10 minutes prior to preparing the formula
C) Let tap water run for 2 minutes before adding to concentrate
D) Buy bottled water labeled "lead free" to mix the formula - ANSWER-is C: Let tap water run for 2 minutes before adding to concentrate
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