Practice Tests: Practice Exam #5 - 45 questions

All 45 questions are randomized each time you take the test, and do not appear in the same order here.

 

Priority

1. The nurse must know that the most accurate oxygen delivery system available is
A) the Venturi mask
B) nasal cannula
C) partial non-rebreather mask
D) simple face mask

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2. A client arrives in the emergency department after a radiologic accident at a local factory. The first action of the nurse would be to
A) begin decontamination procedures for the client
B) ensure physiologic stability of the client
C) wrap the client in blankets to minimize staff contamination
D) double bag the client’s contaminated clothing

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3. The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the formation of deep vein thrombosis?
A) Elevate the foot of the bed
B) Apply knee high support stockings
C) Encourage passive exercises
D) Prevent pressure at back of knees

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4. If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?
A) Obtain emergency equipment
B) Assess heart rate, rhythm and all pulses
C) Apply pressure to the vessel insertion site
D) Use cold packs at the exit incision site

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5. The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for puerperal infection?
A) 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery
B) 2 days post partum, temperature of 101.2 degrees Fahrenheit this morning
C) 3 days post partum, temperature of 100.8 degrees Fahrenheit the past 2 days
D) 4 days post partum, temperature of 100 degrees Fahrenheit since delivery

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6. The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally disconnects from the drainage tube. The first action the nurse should take is
A) reconnect the tube
B) raise the collection chamber above the client's chest
C) call the health care provider
D) clamp the chest tube

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7. A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which of the following is appropriate reinforcement of information by the nurse?
A) "Drink at least 8 glasses of water a day."
B) "Be sure to take the medication with food."
C) "It is safe to take with oral contraceptives."
D) "Stop the medication after 5 days."

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8. A client calls the evening health clinic to state “I know I have a severely low sugar since the Lantus insulin was given 3 hours ago and it peaks in 2 hours.” What should be the nurse’s initial response to the client?
A) What else do you know about this type of insulin?
B) What are you feeling at this moment?
C) Have you eaten anything today?
D) Are you taking any other insulin or medication?

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9. The nurse is caring for a client who is receiving total parenteral nutrition (TPN) (hyperalimentation and lipids). What is the priority nursing action on every 8 hour shift?
A) Monitor blood pressure, temperature and weight
B) Change the tubing under sterile conditions
C) Check urine glucose, acetone and specific gravity
D) Adjust the infusion rate to provide for total volume

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10. The nurse reviews an order to administer Rh (D) immune globulin to an Rh negative woman following the birth of an Rh positive baby. Which assessment is a priority before the nurse gives the injection?
A) Newborn's blood type
B) Coombs' test results
C) Previous RhoGAM history
D) Gravida and parity

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11. A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the nurse?
A) foul smelling urine
B) burning on urination
C) elevated temperature
D) nausea and anorexia

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12. The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism following treatment for chronic renal disease. Which of the following lab data should receive priority attention?
A) Calcium and phosphorus levels
B) Blood sugar
C) Urine specific gravity
D) Blood urea nitrogen

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13. When caring for a client with urinary incontinence, which content should be reinforced by the nurse?
A) hold the urine to increase bladder capacity
B) avoid eating foods high in sodium
C) restrict fluid to prevent elimination accidents
D) avoid taking antihistamines

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14. A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to
A) maintain fluid and electrolyte balance
B) manage post-operative pain
C) ambulate the client within 1 hour of surgery
D) control bladder spasms

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15. A client with a fracture of the radius had a plaster cast applied 2 days ago. The client complains of constant pain and swelling of the fingers. The first action of the nurse should be
A) elevate the arm no higher than heart level
B) remove the cast
C) assess capillary refill of the exposed hand and fingers
D) apply a warm soak to the hand

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16. A client is 2 days post operative. The vital signs are: BP - 120/70, HR -- 110 BPM, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?
A) Heart rate
B) Respiratory rate
C) Blood pressure
D) Temperature

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17. A client is waiting to have an intravenous pyelogram (IVP). The most important information to be obtained by the nurse prior to the procedure is
A) time of the client's last meal
B) client's allergy history
C) assessment of the peripheral pulses
D) results of the blood coagulation studies

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18. What must the nurse emphasize when teaching a client with depression about a new prescription for nortriptyline (Pamelor)?
A) Symptom relief occurs in a few days
B) Alcohol use is to be avoided
C) Medication must be stored in the refrigerator
D) Episodes of diarrhea can be expected

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19. Before administering a feeding through a gastrostomy tube, what is the priority nursing assessment?
A) Measure the vital signs
B) Palpate the abdomen
C) Assess for breath sounds
D) Verify tube patency

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20. The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by the nurse?
A) pruritic rash
B) dry, hacking cough
C) chronic fatigue
D) elevated temperature

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21. The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been prescribed. Today's prothrombin level is 40 seconds (normal range 10-14 seconds). Which of the following findings requires priority follow-up?
A) Gum bleeding
B) Lung sounds
C) Homan's sign
D) Generalized weakness

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22. The registered nurse (RN) is making decisions regarding client room assignments on a pediatric unit. Which possible roommate would be most appropriate for a 3 year-old child with minimal change nephrotic syndrome?
A) 2 year-old with respiratory infection
B) 3 year-old fracture whose sibling has chickenpox
C) 4 year-old with bilateral inguinal hernia repair
D) 6 year-old with a sickle cell anemia crisis

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23. The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first?
A) Administer calcium gluconate
B) Call the provider immediately
C) Discontinue the magnesium sulfate
D) Perform additional assessments

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24. A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?
A) Repeat glycohemoglobin in 24 hours
B) Document Accu-checks, intake and output every 4 hours
C) Humulin N 20 units IV push
D) IV fluids of 0.9% normal saline at 125 ml per hour

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25. The nurse performs an assessment during a fluid exchange for the client who is 48 hours post-insertion of an abdominal Tenckhoff catheter for peritoneal dialysis. The nurse knows that the appearance of which of the following needs to be reported to the provider immediately?
A) slight pink-tinged drainage
B) abdominal discomfort
C) muscle weakness
D) cloudy drainage

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Safety and Infection Control


1. After an explosion at a factory one of the employees approaches the nurse and says “I am an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks should the nurse assign first to this worker who wants to help care for the wounded workers?
A) Get temperatures
B) Take blood pressure
C) Palpate pulses
D) Check alertness

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2. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client?
A) Reverse
B) Airborne
C) Standard precautions
D) Contact

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3. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to handwashing, is which of these?
A) Place appropriate signs outside and inside the room
B) Use a mask with a shield if there is a risk of fluid splash
C) Wear a gown to change soiled linens from incontinence
D) Have gloves on while handling bedpans with feces

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4. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these interventions would be a priority for the nurse to implement?
A) Have the client cough into a tissue and dispose in a separate bag
B) Instruct the client to cover the mouth with a tissue when coughing
C) Reinforce that everyone should wash their hands before and after entering the room
D) Place client in a negative pressure private room and have all who enter the room use masks with shields

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5. A nurse who is assigned to the emergency department needs to understand that gastric lavage is a priority in which situation?
A) An infant who has been identified as suffering from botulism
B) A toddler who has eaten a number of ibuprofen tablets
C) A preschooler who has swallowed powdered plant food
D) A school aged child who has taken a handful of vitamins

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6. The parents of a toddler who is being treated for pesticide poisoning ask: “Why is activated charcoal used? What does it do?” What is the nurse's best response?
A) "Activated charcoal decreases the body’s absorption of the poison from the stomach."
B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child."
C) "This substance helps to get the poison out of the body through the gastrointestinal system."
D) "The action may bind or inactivate the toxins or irritants that are ingested by children and adults."

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7. Which of these nursing diagnoses, appropriate for elderly clients, would indicate the client is at greatest risk for falls?
A) Sensory perceptual alterations related to decreased vision
B) Alteration in mobility related to fatigue
C) Impaired gas exchange related to retained secretions
D) Altered patterns of urinary elimination related to nocturia

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8. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first?
A) Institute seizure precautions
B) Monitor neurologic status every hour
C) Place in respiratory/secretion precautions
D) Cefotaxime IV 50 mg/kg/day divided q6h

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9. Several clients are admitted to an adult medical unit. For which client condition(s) would the nurse institute airborne precautions?
A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV)
B) A positive purified protein derivative (PPD) test with an abnormal chest x-ray
C) A tentative diagnosis of viral pneumonia with productive brown sputum
D) Advanced carcinoma of the lung with hemoptysis

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10. A client is scheduled to receive an oral solution of radioactive iodine. In order to reduce hazards, the priority information for the nurse to include in client teaching is which of these statements?
A) "In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation."
B) "Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice."
C) "Your family can use the same bathroom that you use without any special precautions."
D) "Drink plenty of water and empty your bladder often during the initial 3 days of therapy."

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11. The nurse is to administer a new medication to a client. Which of these actions best demonstrate awareness of safe, proficient nursing practice?
A) Verify the order for the medication. Prior to giving the medication the nurse should say, "Please state your name."
B) Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band.
C) As the room is entered say "What is your name?" then check the client's name band.
D) Verify the client's allergies on the admission sheet and order. Verify the client's name on the nameplate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?"

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12. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice (Pediculus Humanus Capitis) in the school. The information that would be most important to include is reflected in which of these statements?
A) "The treatment medication requires reapplication in 8 to 10 days."
B) "Bedding and clothing can be boiled or steamed to kill lice."
C) "Children should not share hats, scarves and combs."
D) "Nit combs are necessary to comb lice eggs (nits) out of children's hair."

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13. Which approach is the best way to prevent infections when providing care to clients in the home setting?
A) Handwashing before and after examination of clients
B) Wearing nonpowdered latex-free gloves to examine the client
C) Using a barrier between the client's furniture and the nurse's bag
D) Wearing a mask with a shield during any eye/mouth/nose examination

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14. A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. Which lunch selection suggests the client has learned about necessary dietary changes?
A) grilled chicken sandwich and skim milk
B) roast beef, mashed potatoes, and green beans
C) peanut butter sandwich, banana, and iced tea
D) barbeque beef, baked beans, and cole slaw

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15. A school nurse has a 10 year-old child with a history of epilepsy with tonic-clonic seizures attending classes regularly. The school nurse should inform the teacher that if the child experiences a seizure in the classroom, the most important action to take during the seizure would be to
A) move any chairs or desks at least 3 feet away from the child
B) note the sequence of movements with the time lapse of the event
C) provide privacy as much as possible to minimize frightening the other children
D) place the hands or a folded blanket under the head of the child

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16. A parent calls the hospital hot line and is connected to the triage nurse. The caller proclaims: “I found my child with odd stuff coming from the mouth and an unmarked bottle nearby.” Which of these comments would be the best tool for the nurse to determine if the child has swallowed a corrosive substance?
A) "Ask the child if the mouth is burning or throat pain is present."
B) "Take the child’s pulse at the wrist and see if the child is has trouble breathing lying flat."
C) "What color is the child’s lips and nails and has the child voided today?"
D) "Has the child had vomiting, diarrhea or stomach cramps?"

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17. Which of these clients would the nurse recommend keeping in the hospital during an internal disaster at that facility?
A) An adolescent diagnosed with sepsis 7 days ago and whose vital signs are maintained within low normal limits.
B) A middle-aged woman known to have had an uncomplicated myocardial infarction 4 days ago
C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis
D) A young adult in the second day of treatment for an overdose of acetometaphen

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18. When an infant car seat is properly installed, the infant should face
A) forward, so child may look out window
B) backward, so child faces the seat
C) the side window, to increase sensory stimulation
D) upward, as child lies on back with seat installed sideways

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19. Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours?
A) An infant with a positive culture of stool for Shigella
B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
D) A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin

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20. Which of these actions is the primary nursing intervention designed to limit transmission of a client’s Salmonella infection?
A) Wash hands thoroughly before and after client contact
B) Wear gloves when in contact with body secretions
C) Double glove when in contact with feces or vomitus
D) Wear gloves when disposing of contaminated linens

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Practice Tests: Practice Exam #5 - 45 questions