1. In planning care for a 6 month-old infant, what must the nurse provide to assist in the
development of trust?
A) Food
B) Warmth
C) Security
D)
... [Show More] Comfort
2. A nurse has just received a medication order which is not legible. Which statement best
reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean."
B) "Would you please clarify what you have written so I am sure I am reading it
correctly?"
C) "I am having difficulty reading your handwriting. It would save me time if you would be
more careful."
D) "Please print in the future so I do not have to spend extra time attempting to read your
writing."
3. What is the most important consideration when teaching parents how to reduce risks in the
home?
A) Age and knowledge level of the parents
B) Proximity to emergency services
C) Number of children in the home
D) Age of children in the home
4. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the
nurse enters the room to request something for pain. The nurse should
A) Administer a placebo
B) Encourage increased fluid intake
C) Administer the prescribed analgesia
D) Recommend relaxation exercises for pain control
5. While caring for a toddler with croup, which initial sign of croup requires the nurse's
immediate attention?
A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions
6. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial
assessment, the nurse would anticipate which of the following assessment findings?
A) Lethargy
B) Heat intolerance
C) Diarrhea
D) Skin eruptions
7. The emergency room nurse admits a child who experienced a seizure at school. The
father comments that this is the first occurrence, and denies any family history of epilepsy.
What is the best response by the nurse?
A) "Do not worry. Epilepsy can be treated with medications."
B) "The seizure may or may not mean your child has epilepsy."
C) "Since this was the first convulsion, it may not happen again."
D) "Long term treatment will prevent future seizures."
8. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What
nursing diagnosis best applies?
A) Risk for injury
B) Risk for knowledge deficit
C) Altered thought process
D) Disturbance in self-esteem
9. Which these findings would the nurse more closely associate with anemia in a 10 month-old
infant?
A) Hemoglobin level of 12 g/dI
B) Pale mucosa of the eyelids and lips
C) Hypoactivity
D) A heart rate between 140 to 160
10. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority
assessment in the first hour of care is
A) Heart rate
B) Pedal pulses
C) Lung sounds
D) Pupil responses
11. Which of these clients who are all in the terminal stage of cancer is least appropriate to
suggest the use of patient controlled analgesia (PCA) with a pump?
A) A young adult with a history of Down's syndrome
B) A teenager who reads at a 4th grade level
C) An elderly client with numerous arthritic nodules on the hands
D) A preschooler with intermittent episodes of alertness
12. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive
(NOFTT). Upon entering the room, the nurse would expect the baby to be
A) Irritable and "colicky" with no attempts to pull to standing
B) Alert, laughing and playing with a rattle, sitting with support
C) Skin color dusky with poor skin turgor over abdomen
D) Pale, thin arms and legs, uninterested in surroundings
13. As the nurse is speaking with a group of teens which of these side effects of chemotherapy
for cancer would the nurse expect this group to be more interested in during the discussion?
A) Mouth sores
B) Fatigue
C) Diarrhea
D) Hair loss
14. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the
nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees
Celsius). The appropriate nursing intervention is to
A) Call the health care provider immediately
B) Administer acetaminophen as ordered as this is normal at this time
C) Send blood, urine and sputum for culture
D) Increase the client's fluid intake
15. A client is admitted for first and second degree burns on the face, neck, anterior chest and
hands. The nurse's priority should be
A) Cover the areas with dry sterile dressings
B) Assess for dyspnea or stridor
C) Initiate intravenous therapy
D) Administer pain medication
16. Which of these clients who call the community health clinic would the nurse ask to come in
that day to be seen by the health care provider?
A) I started my period and now my urine has turned bright red.
B) I am an diabetic and today I have been going to the bathroom every hour.
C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go
to the bathroom.
D) I went to the bathroom and my urine looked very red and it didn’t hurt when I went.
17. Which of these parents’ comment for a newborn would most likely reveal an initial
finding of a suspected pyloric stenosis?
A) I noticed a little lump a little above the belly button.
B) The baby seems hungry all the time.
C) Mild vomiting that progressed to vomiting shooting across the room.
D) Irritation and spitting up immediately after feedings.
18. The nurse is assessing a child for clinical manifestations of iron deficiency anemia.
Which factor would the nurse recognize as cause for the findings?
A) Decreased cardiac output
B) Tissue hypoxia
C) Cerebral edema
D) Reduced oxygen saturation
19. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic
enzymes along with a diet
A) High in carbohydrates and proteins
B) Low in carbohydrates and proteins
C) High in carbohydrates, low in proteins
D) Low in carbohydrates, high in proteins
20. In evaluating the growth of a 12 month-old child, which of these findings would the
nurse expect to be present in the infant?
A) Increased 10% in height
B) 2 deciduous teeth
C) Tripled the birth weight
D) Head > chest circumference
21. A Hispanic client in the postpartum period refuses the hospital food because it is
"cold." The best initial action by the nurse is to
A) 1Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes
B) Ask the client what foods are acceptable or bad
C) Encourage her to eat for healing and strength
D) Schedule the dietitian to meet with the client as soon as possible
22. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are
normal for his age. Which of the following would the nurse expect at this age?
A) Cooing
B) Imitation of sounds
C) Throaty sounds
D) Laughter
23. The nurse should recognize that physical dependence is accompanied by what
findings when alcohol consumption is first reduced or ended?
A) Seizures
B) Withdrawal
C) Craving
D) Marked tolerance
24. Immediately following an acute battering incident in a violent relationship, the
batterer may respond to the partner’s injuries by
A) Seeking medical help for the victim's injuries
B) Minimizing the episode and underestimating the victim’s injuries
C) Contacting a close friend and asking for help
D) Being very remorseful and assisting the victim with medical care
25. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago.
During the nurse’s initial evening rounds the nurse notices a foul smell in the room. The client
makes all of these statements during their conversation. Which statement would alert the nurse to
a complication?
A) "I have a sharp pain in my chest when I take a breath."
B) "I have been coughing up foul-tasting, brown, thick sputum."
C) "I have been sweating all day."
D) "I feel hot off and on."
26. The nurse is performing an assessment on a client in congestive heart failure.
Auscultation of the heart is most likely to reveal
A) S3 ventricular gallop
B) Apical click
C) Systolic murmur
D) Split S2
27. Which of these observations made by the nurse during an excretory urogram indicate a
complicaton?
A) The client complains of a salty taste in the mouth when the dye is injected
B) The client’s entire body turns a bright red color
C) The client states “I have a feeling of getting warm.”
D) The client gags and complains “ I am getting sick.”
28. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest
tube. What is the best explanation for the nurse to provide this client?
A) "The tube will drain fluid from your chest."
B) "The tube will remove excess air from your chest."
C) "The tube controls the amount of air that enters your chest."
D) "The tube will seal the hole in your lung."
29. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of
the following should be reported immediately?
A) Blood urea nitrogen 50 mg/dl
B) Hemoglobin of 10.3 mg/dl
C) Venous blood pH 7.30
D) Serum potassium 6 mEq/L
30. The nurse is caring for a client undergoing the placement of a central venous catheter line.
Which of the following would require the nurse’s immediate attention?
A) Pallor
B) Increased temperature
C) Dyspnea
D) Involuntary muscle spasms
31. The nurse is performing a physical assessment on a client who just had an endotracheal tube
inserted. Which finding would call for immediate action by the nurse?
A) Breath sounds can be heard bilaterally
B) Mist is visible in the T-Piece
C) Pulse oximetry of 88
D) Client is unable to speak
32. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that
the client may need suctioning?
A) Drowsiness [Show Less]