Practice Tests: Practice Exam #2 - 60 questions

All 60 questions are randomized each time you take the test, and do not appear in the same order here.

 

Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment?

A) An increase in appetite
B) A decrease in fluid retention
C) A decrease in lethargy
D) A reduction in jaundice

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The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk?

A) Donating blood
B) Using public bathrooms
C) Unprotected sex
D) Touching a person with AIDS

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While interviewing a new admission, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to

A) ask the client what she is feeling
B) assess the client for auditory hallucination
C) recognize the behavior as a side effect of medication
D) re-focus the discussion on a less anxiety provoking topic

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A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse?

A) Listen quietly without comment
B) Ask for further information on the spies
C) Confront the client’s delusion
D) Contact the government agency

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The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate?

A) Increased serum glucose
B) Decreased albumin
C) Decreased potassium
D) Increased sodium retention

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A client, recovering from alcoholism, asks the nurse, "What can I do when I start recognizing relapse triggers within myself?" How might the nurse best respond?

A) "When you have the impulse to stop in a bar, contact a sober friend and talk with him."
B) "Go to an AA meeting when you feel the urge to drink."
C) "It is important to exercise daily and get involved in activities that will cause you not to think about drug use."
D) "Let’s talk about possible options you have when you recognize relapse triggers in yourself."

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Therapeutic nurse-client interaction occurs when the nurse

A) assists the client to clarify the meaning of what the client has said
B) interprets the client’s covert communication
C) praises the client for appropriate feelings and behavior
D) advises the client on ways to resolve problems

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Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills?

A) Offer the client frequent opportunities to interact with 1 person
B) Provide the client with frequent opportunities to interact with other clients
C) Assist the client to analyze the meaning of the withdrawn behavior
D) Discuss with the client the focus that other clients have similar problems

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An important goal in the development of a therapeutic inpatient milieu is to

A) provide a businesslike atmosphere where clients can work on individual goals
B) provide a group forum in which clients decide on unit rules, regulations, and policies
C) provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions
D) discourage expressions of anger because they can be disruptive to other clients

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A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts ’’You think you’re so perfect and pure and good." An appropriate response for the nurse is

A) "Is that why you’ve been staring at me?"
B) "You seem to be in a really bad mood."
C) "Perfect? I don’t quite understand."
D) "You seem angry right now."

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A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which nursing action is the best in response to the client’s attire?

A) Gently remind her that she is no longer on stage
B) Directly assist client to her room for appropriate apparel
C) Quietly point out to her the dress of other clients on the unit
D) Tactfully explain appropriate clothing for the hospital

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When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue as indicating a need for intervention.

A) Angry outbursts at significant others
B) Fear of being left alone
C) Giving away valued personal items
D) Experiencing the loss of a boyfriend

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Which statement made by a client indicates to the nurse that the client may have a thought disorder?

A) "I’m so angry about this. Wait until my partner hears about this."
B) "I’m a little confused. What time is it?"
C) "I can't find my 'mesmer' shoes. Have you seen them?"
D) "I’m fine. It's my daughter who has the problem."

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In a psychiatric setting, the nurse limits touch or contact used with clients to handshaking because

A) some clients misconstrue hugs as an invitation to sexual advances
B) handshaking keeps the gesture on a professional level
C) refusal to touch a client denotes lack of concern
D) inappropriate touch often results in charges of assault and battery

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A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are

A) brittle hair, lanugo, amenorrhea
B) diarrhea, nausea, vomiting, dental erosion
C) hyperthermia, tachycardia, increased metabolic rate
D) excessive anxiety about symptoms

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Which intervention best demonstrates the nurse's sensitivity to a 16 year-old’s appropriate need for autonomy?

A) Alertness for feelings regarding body image
B) Allows young siblings to visit
C) Provides opportunity to discuss concerns without presence of parents
D) Explores his feelings of resentment to identify causes

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The nurse's primary intervention for a client who is experiencing a panic attack is to

A) develop a trusting relationship
B) assist the client to describe his experience in detail
C) maintain safety for the client
D) teach the client to control his or her own behavior

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A client was admitted to the eating disorder unit with bulimia nervosa. The nurse assessing for a history of complications of this disorder expects

A) Respiratory distress, dyspnea
B) Bacterial gastrointestinal infections, overhydration
C) Metabolic acidosis, constricted colon
D) Dental erosion, parotid gland enlargement

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Which of the following times is a depressed client at highest risk for attempting suicide?

A) Immediately after admission, during one-to-one observation
B) 7 to 14 days after initiation of antidepressant medication and psychotherapy
C) Following an angry outburst with family
D) When the client is removed from the security room

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A client is admitted to a psychiatric unit with delusions. What findings could the nurse observe that would be consistent with delusional thought patterns?

A) Flight of ideas and hyperactivity
B) Suspiciousness and resistance to therapy
C) Anorexia and hopelessness
D) Panic and multiple physical complaints

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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."

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Parents call the emergency room to report that a toddler has swallowed drain cleaner. The triage nurse instructs them to call for emergency transport to the hospital. The nurse would also suggest that the parents give the toddler sips of while waiting for an ambulance.

A) Tea
B) Water
C) Milk
D) Soda

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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

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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

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The nurse is preparing the teaching plan for a group of parents about risks to toddlers and is including the proper communication in the event of accidental poisoning. The nurse should tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate?

A) The parents’ name and telephone number
B) The currency of the immunization and allergy history of the child
C) The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the ingested substance
D) The affected child's age and weight

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The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would the nurse suspect is relevant to 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 at 3 months of age.
D) Last week both feet had a fungal skin infection.

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The nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate?

A) High doses of aspirin will be continued for some time
B) Complete recovery is expected within several days
C) Active range of motion exercises should be done frequently
D) The measles, mumps and rubella vaccine should be delayed

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A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to

A) limit milk and milk products
B) encourage bed activities and games
C) plan nursing care around lengthy rest periods
D) promote a diet rich in iron

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The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?

A) Antibiotic therapy for 10 days
B) Teach client isometric exercises for legs
C) Assess movement and sensation of extremities
D) Assist to stand up at bedside within the first 24 hours

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The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized?

A) Call the Poison Control Center once the situation is identified
B) Empty the child's mouth in any case of possible poisoning
C) Keep the child as quiet as possible if a toxic substance was inhaled
D) Do not induce vomiting if the poison is a hydrocarbon

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The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit?

A) Lethargy
B) Irritability
C) Negative Moro
D) Depressed fontanel

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The nurse is caring for a 4 year-old two hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately?

A) Vomiting of dark emesis
B) Complaints of throat pain
C) Apical heart rate of 110
D) Increased restlessness

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The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion?

A) Storing the packed red cells in the medicine refrigerator while starting IV
B) Slow the rate of infusion if the client develops fever or chills
C) Limit the infusion time of each of the unit to a maximum of 4 hours
D) Assess vital signs every 15 minutes throughout the entire infusion

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The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first?

A) Prothrombin Time (PT) and partial thromboplastin time (PTT)
B) Red blood cell and white blood cell counts
C) Blood urea nitrogen and creatinine clearance
D) Liver enzymes (AST and ALT)

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A nurse admits a premature infant who has respiratory distress syndrome (RDS). 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 intracardiac pressure

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The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to

A) assess for abdominal distention
B) maintain infant in an upright position
C) begin formula feedings when infant is alert
D) pump the shunt to assess for proper function

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A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: ”My child seems to have problems in learning to count and recognizing basic colors.” Based on this data, the nurse suspects that the child is most likely showing the effects of which problem?

A) congenital abnormalities
B) chronic toxoplasmosis
C) fetal alcohol syndrome (FAS)
D) lead poisoning

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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."

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The nurse is caring for a 4 year-old admitted after receiving bums to more than 50% of his body. Which laboratory data should be reviewed by the nurse as a priority in the first 24 hours?

A) Blood urea nitrogen
B) Hematocrit
C) Blood glucose
D) White blood count

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The nurse is caring for a client with a colostomy pouch. During a teaching session, the nurse appropriately recommends that the pouch be emptied

A) when it is 1/3 to 1/2 full
B) prior to meals
C) after each fecal elimination
D) at the same time each day

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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 the client’s

A) response to stimuli
B) bladder control
C) respiratory function
D) muscle weakness

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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

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The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The first assessment the nurse should perform is

A) orientation to time, place and person
B) pulse oximetry
C) circulation to casted extremity
D) blood pressure

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The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing?

A) Covering the wound with a dry dressing
B) Using hydrogen peroxide soak
C) Leaving the area open to dry
D) Applying a hydrocolloid or foam dressing

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A client is recovering from a thyroidectomy. While monitoring the client's initial post-operative condition, which of the following should the nurse report immediately?

A) Tetany and paresthesia
B) Mild stridor and hoarseness
C) Irritability and insomnia
D) Headache and nausea

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A client is scheduled for an intravenous pyelogram (IVP). Which of the following data from the client’s history indicate a potential hazard for this test?

A) Reflex incontinence
B) Allergy to shellfish
C) Claustrophobia
D) Hypertension

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A client enters the emergency department unconscious via ambulance. What document should be given priority to guide the rection of care for this client?

A) The statement of client rights and the client self determination act
B) Orders written by the 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

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A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important?

A) I got back from Central America a few weeks ago.
B) I had the best raw oysters last week.
C) I have many different sex partners.
D) I had a blood transfusion 15 years ago.

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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 intermittent bulging anterior fontanel between crying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with a lower leg fracture on one side and an upper leg fracture on the other
D) A school-age child with singed eyebrows and hair on the arms

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A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate?

A) Ambulate the client 4 hours after procedure
B) Maintain client on NPO status for 24 hours
C) Monitor vital signs
D) Change dressing every 8 hours

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The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis?

A) Respiratory rate
B) Peak air flow volumes
C) Pulse oximetry
D) Skin color

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A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on these data, what is the first nursing action?

A) Review other lab data
B) Notify the health care provider
C) Administer oxygen
D) Calm the client

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The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to

A) determine oxygen saturation
B) measure forced expiratory volume
C) monitor atmosphere for presence of allergens
D) provide metered doses for inhaled bronchodilator

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The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period?

A) Estrogen replacement therapy
B) 10% less than ideal body weight
C) Hypersensitivity to heparin
D) History of hepatitis

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During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?

A) "Mongolian spots are a normal finding in dark-skinned children."
B) "Port wine stains are often associated with other malformations."
C) "Telangiectatic nevi are normal and will disappear as the baby grows."
D) "The child is too young for consideration of surgical removal of these at this time."

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A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack?

A) Cheese crackers
B) Peanut butter sandwich
C) Potato chips
D) Vanilla cookies

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A nurse assigned to a manipulative client for 5 days becomes aware of feelings of 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

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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 a client history of violence
D) was necessary to maintain the therapeutic milieu of the unit

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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

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Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take?

A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary

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Practice Exam #2 - 60 questions