The primary teaching for a client following an extracorporeal shock-wave lithotripsy
(ESWL) procedure is
A) Drink 3000 to 4000 cc of fluid each day for o
... [Show More] ne month
B) Limit fluid intake to 1000 cc each day for one month
C) Increase intake of citrus fruits to three servings per day
D) Restrict milk and dairy products for one month
The correct answer is A: Drink 3000 to 4000 cc of fluid each day for 1 month
16. A client on warfarin therapy following coronary artery stent placement calls the clinic
to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the
nurse?
A) Avoid Alka-Seltzer because it contains aspirin
B) Take Alka-Seltzer at a different time of day than the warfarin
C) Select another antacid that does not inactivate warfarin
D) Use on-half the recommended dose of Alka-Seltzer
The correct answer is A: Avoid Alka-Seltzer because it contains aspirin
17. The nurse is working with parents to plan home care for a 2 year-old with a heart
problem. A priority nursing intervention would be to
A) Encourage the parents to enroll in cardiopulmonary resuscitation class
B) Assist the parents to plan quiet play activities at home
C) Stress to the parents that they will need relief care givers
D) Instruct the parents to avoid contact with persons with infection
The correct answer is A: Encourage the parents to enroll in cardiopulmonary
resuscitation class
18. The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis
should receive priority in the plan of care?
A) Risk for injury
B) Self care deficit
C) Alteration in comfort
D) Alteration in mobility
The correct answer is C: Alteration in comfort
19. An unlicensed assistive staff member asks the nurse manager to explain the beliefs of
a Christian Scientist who refuses admission to the hospital after a motor vehicle accident.
The best response of the nurse would be which of these statements?
A) "Spiritual healing is emphasized and the mind contributes to the cure."
B) "The primary belief is that dietary practices result in health or illness."
C) "Fasting and prayer are initial actions to take in physical injury."
D) "Meditation is intensive in the initial 48 hours and daily thereafter."
The correct answer is A: "Spiritual healing is emphasized and the mind contributes to the
cure."
20. In order to be effective in administering cardiopulmonary resuscitation to a 5 yearold, the nurse must
A) Assess the brachial pulses
B) Breathe once every 5 compressions
C) Use both hands to apply chest pressure
D) Compress 80-90 times per minute
The correct answer is B: Breathe once every 5 compressions
21. The nurse is providing home care for a client with heart failure and pulmonary edema.
Which nursing diagnosis should have priority in planning care?
A) Impaired skin integrity related to dependent edema
B) Activity intolerance related to oxygen supply and demand imbalance
C) Constipation related to immobility
D) Risk for infection related to ineffective mobilization of secretions
The correct answer is B: Activity Intolerance related to oxygen supply and demand
imbalance
.
22. For which of the following mother-baby pairs should the nurse review the Coomb's
test in preparation for administering RhO (D) immune globulin within 72 hours of birth?
A) Rh negative mother with Rh positive baby
B) Rh negative mother with Rh negative baby
C) Rh positive mother with Rh positive baby
D) Rh positive mother with Rh negative baby
The correct answer is A: Rh negative mother with Rh positive baby
23. An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit
rectally. This is a sudden change in an otherwise healthy client. Which should the nurse
assess first?
A) Lung sounds
B) Urine output
C) Level of alertness
D) Appetite
The correct answer is C: Level of alertness
?
25. What is the major purpose of community health research?
A) Describe the health conditions of populations
B) Evaluate illness in the community
C) Explain the health conditions of families
D) Identify the health conditions of the environment
The correct answer is A: Describe the health conditions of populations
26. The recent increase in the reported cases of active tuberculosis (TB) in the United
States is attributed to which factor?
A) The increased homeless population in major cities
B) The rise in reported cases of positive HIV infections
C) The migration patterns of people from foreign countries
D) The aging of the population located in group homes
The correct answer is B: The rise in reported cases of positive HIV infections
27. A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for
treatment of Kawasaki Disease. The nurse recognizes that which of the following
scheduled immunizations will be
delayed?
A) MMR
B) Hib
C) IPV
D) DtaP
The correct answer is A: MMR
28. The nurse is assessing a pregnant client in her third trimester. The parents are
informed that the ultrasound suggests that the baby is small for gestational age (SGA). An
earlier ultrasound indicated normal growth. The nurse understands that this change is
most likely due to what factor?
A) Sexually transmitted infection
B) Exposure to teratogens
C) Maternal hypertension
D) Chromosomal abnormalities
The correct answer is C: Maternal hypertension
29. After the shift report in a labor and delivery unit which of these clients would the
nurse check first?
A) A middle aged woman with asthma and diabetes mellitus Type 1 has a BP of 150/94
B) A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
C) A young woman is a grand multipara has cervical dilation of 4 cm and 50% effaced
D) An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and
coughing up frothy sputum
The correct answer is D: An adolescent who is 18 weeks pregnant has a report of no fetal
heart tones and coughing up frothy sputum
30. The nurse is caring for an 87 year-old client with urinary retention. Which finding
should be reported immediately?
A) Fecal impaction
B) Infrequent voiding
C) Stress incontinence
D) Burning with urination
The correct answer is A: Fecal impaction
31. The nasogastric tube of a post-op gastrectomy client has stopped draining greenish
liquid. The nurse should
A) Irrigate it as ordered with distilled water
B) Irrigate it as ordered with normal saline
C) Place the end of the tube in water to see if the water bubbles
D) Withdraw the tube several inches and reposition it
The correct answer is B: Irrigate it as ordered with normal saline
32. The parents of a child who has recently been diagnosed with asthma ask the nurse to
explain the condition to them. The best response is "Asthma causes…
A) the airway to become narrow and obstructs airflow."
B) air to be trapped in the lungs because the airways are dilated."
C) the nerves that control respiration to become hyperactive."
D) a decrease in the stress hormones which prevents the airways from opening."
The correct answer is A: the airway to become narrow and obstructs airflow."
33. The nurse is assessing a child with suspected lead poisoning. Which of the following
assessments is the nurse most likely to find?
A) Complaints of numbness and tingling in feet
B) Wheezing noted when lung sound auscultated
C) Excessive perspiration
D) Difficulty sleeping
The correct answer is A: Complaints of numbness and tingling in feet
34. The nurse is caring for a client with end-stage heart failure. The family members are
distressed about the client's impending death. What action should the nurse do first?
A) Explain the stages of death and dying to the family
B) Recommend an easy-to-read book on grief
C) Assess the family's patterns for dealing with death
D) Ask about their religious affiliations
The correct answer is C: Assess the family''s patterns for dealing with death
35. The nurse is caring for a client with Meniere's disease. When teaching the client about
the disease, the nurse should explain that the client should avoid foods high in
A) Calcium
B) Fiber
C) Sodium
D) Carbohydrate
The correct answer is C: Sodium
36. The nurse is teaching a mother who will breast feed for the first time. Which of the
following is a priority?
A) Show her films on the physiology of lactation
B) Give the client several illustrated pamphlets
C) Assist her to position the newborn at the breast
D) Give her privacy for the initial feeding
The correct answer is C: Assist her to position the newborn at the breast
37. The nurse is taking a health history from parents of a child admitted with possible
Reye's Syndrome. Which recent illness would the nurse recognize as increasing the risk
to develop Reye's
Syndrome?
A) Rubeola
B) Meningitis
C) Varicella
D) Hepatitis
The correct answer is C: Varicella
38. While giving care to a 2 year-old client, the nurse should remember that the toddler's
tendency to say "no" to almost everything is an indication of what psychosocial skill?
A) Stubborn behavior
B) Rejection of parents
C) Frustration with adults
D) Assertion of control
The correct answer is D: Assertion of control
39. A postpartum client admits to alcohol use throughout the pregnancy. Which of the
following newborn assessments suggests to the nurse that the infant has fetal alcohol
syndrome?
A) Growth retardation is evident
B) Multiple anomalies are identified
C) Cranial facial abnormalities are noted
D) Prune belly syndrome is suspected
The correct answer is C: Cranial facial abnormalities are noted [Show Less]