Practice Exam #13 - 40 questions

 

1. In addition to standard precautions, a nurse should implement contact precautions for which client?
A) 60 year-old with herpes simplex
B) 6 year-old with mononucleosis
C) 45 year-old with pneumonia
D) 3 year-old with scarlet fever

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2. A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client’s greatest risk factors for osteoporosis?
A) History of menopause at age 50
B) Taking high doses of steroids for arthritis for many years
C) Maintaining an inactive lifestyle for the past 10 years
D) Drinking 2 glasses of red wine each day for the past 30 years

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3. Which contraindication should the nurse assess for prior to giving a child immunizations?
A) Mild cold symptoms
B) Chronic asthma
C) Depressed immune system
D) Allergy to eggs

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4. The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child?
A) Using a moist soft brush or cloth to clean teeth and gums
B) Swabbing teeth and gums with flavored mouthwash
C) Offering a bottle of water for the child to drink
D) Brushing with toothpaste and flossing each tooth

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5. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?
A) "I'm going to try feeding my baby some rice cereal."
B) "When he wakes at night for a bottle, I feed him."
C) "I dip his pacifier in honey so he'll take it."
D) "I keep formula in the refrigerator for 24 hours."

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6. A client with a fractured femur has been in Russell’s traction for 24 hours. Which nursing action is associated with this therapy?
A) Check the skin on the sacrum for breakdown
B) Inspect the pin site for signs of infection
C) Auscultate the lungs for atelectasis
D) Perform a neurovascular check for circulation

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7. The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
A) Irritability
B) Slight edema at site
C) Local tenderness
D) Seizure activity

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8. Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that it:
A) considers client and staff needs
B) conserves time spent on planning
C) frees the nurse manager to handle other priorities
D) allows requests for special privileges

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9. A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct?
A) Days 7-10
B) Days 10-13
C) Days 14-16
D) Days 17-19

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10. The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action?
A) Periorbital edema
B) Dizzy spells
C) Lethargy
D) Shortness of breath

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11. At a senior citizens meeting a nurse talks with a client who has Type 1 diabetes mellitus. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?
A) "I give my insulin to myself in my thighs."
B) "Sometimes when I put my shoes on 1 don't know where my toes are."
C) "Here are my up and down glucose readings that I wrote on my calendar."
D) "If I bathe more than once a week my skin feels too dry."

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12. Which client is at highest risk for developing a pressure ulcer?
A) 23 year-old in traction for fractured femur
B) 72 year-old with peripheral vascular disease, who is unable to walk without assistance
C) 75 year-old with left sided paresthesia who is incontinent of urine and stool
D) 30 year-old who is comatose following a ruptured aneurysm

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13. A 16 year-old boy is admitted for Ewing's sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the initial treatment most often includes
A) amputation just above the tumor
B) surgical excision of the mass
C) bone marrow graft in the affected leg
D) radiation and chemotherapy

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14. The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. What is the nurse’s best response to the parents?
A) "Your child must use a care seat until he weighs at least 40 pounds."
B) "The child must be 5 years of age to use a regular seat belt."
C) "Your child must reach a height of 50 inches to sit in a seat belt."
D) "The child can use a regular seat belt when he can sit still."

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15. A woman in her third trimester complains of severe heartbum. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
A) Drink small amounts of liquids frequently
B) Eat the evening meal just before retiring
C) Take sodium bicarbonate after each meal
D) Sleep with head propped on several pillows

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16. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the provider ordering
A) pulmonary embolectomy
B) vena caval interruption
C) increasing the Coumadin therapy to an INR of 3-4
D) thrombolytic therapy

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17. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
A) Neurotoxicity
B) Hepatomegaly
C) Nephrotoxicity
D) Ototoxicity

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18. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in an incubator. Which action is a nursing priority?
A) Protect the eyes of the neonate from the heat lamp
B) Monitor the neonate’s temperature
C) Warm all medications and liquids before giving
D) Avoid touching the neonate with cold hands

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19. What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention?
A) Set good examples themselves
B) Protect their child from outside influences
C) Make sure their child understands all the safety rules
D) Discuss the consequences of not wearing protective devices

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20. A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially?
A) Conduct guided imagery or distraction
B) Ensure that the stump is elevated the first day post-op
C) Wrap the stump snugly in an elastic bandage
D) Administer opioid narcotics as ordered

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21. The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?
A) bounding pulse
B) rapid respirations
C) oliguria
D) neck veins are distended

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22. The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When coming to a conclusion using the Ballard scale, which of these factors may affect the score?
A) Birth weight
B) Racial differences
C) Fetal distress in labor
D) Birth trauma

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23. Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
A) Venturi mask
B) Partial rebreather mask
C) Non-rebreather mask
D) Simple face mask

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24. Which of the following situations is most likely to produce sepsis in the neonate?
A) Maternal diabetes
B) Prolonged rupture of membranes
C) Cesarean delivery
D) Precipitous vaginal birth

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25. A4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
A) Place the child in the nearest bed
B) Administer IV medication to slow down the seizure
C) Place a padded tongue blade in the child’s mouth
D) Remove the child's toys from the immediate area

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26. A 78 year-old client with pneumonia has a productive cough, but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration?
A) Suction the client frequently while restrained
B) Secure all 4 restraints to 1 side of bed
C) Obtain a sitter for the client while restrained
D) Request an order for a cough suppressant

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27. A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that such remedies
A) destroy organisms causing disease
B) maintain fluid balance
C) boost the immune system
D) increase bodily energy

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28. A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?
A) Regulate the neonate’s temperature using a radiant heater
B) Withhold feedings while under the phototherapy
C) Provide water feedings at least every 2 hours
D) Protect the eyes of neonate from the phototherapy lights

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29. The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to
A) restrict visitors to immediate family
B) avoid arousal of the client except for family visits
C) keep client's hips flexed at no less than 90 degrees
D) apply a warming blanket for temperatures of 98 degrees Fahrenheit or less

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30. A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach?
A) Vary the interview style for each candidate to learn different techniques
B) Use simple questions requiring ”yes" and ”no" answers to gain definitive information
C) Obtain an interview guide from human resources for consistency in interviewing each candidate
D) Ask personal information of each applicant to assure he/she can meet job demands

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31. When suctioning a client's tracheostomy, the nurse should instill saline in order to
A) decrease the client's discomfort
B) reduce viscosity of secretions
C) prevent client aspiration
D) remove a mucus plug

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32. A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?
A) Call the health care provider
B) Access the site by cutting a window in the cast
C) Simply record the findings in the nurse's notes only
D) Outline the spot with a pencil and note the time and date on the cast

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33. Included in teaching the client with tuberculosis taking isoniazid (INH) about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
A) Liver function
B) Kidney function
C) Blood sugar
D) Cardiac enzymes
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34. The nurse is at the community center speaking with retired people about glaucoma. Which comment by one of the retirees would the nurse support to reinforce correct information?
A) "I usually avoid driving at night since lights sometimes seem to make things blur."
B) "I take half of the usual dose for my sinuses to maintain my blood pressure."
C) "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem."
D) "I take extra fiber and drink lots of water to avoid getting constipated."

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35. The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspects of this care is/are
A) sedation as needed to prevent exhaustion
B) antibiotic therapy for 10 to 14 days
C) humidified air and increased oral fluids
D) antihistamines to decrease allergic response

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36. A nurse is performing the routine daily cleaning of a tracheostomy. During the procedure, the client coughs and displaces the tracheostomy tube. This negative outcome could have avoided by
A) placing an obturator at the client’s bedside
B) having another nurse assist with the procedure
C) fastening clean tracheostomy ties before removing old ties
D) placing the client in a flat, supine position

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37. A client who is 12 hour post-op becomes confused and says: “Giant sharks are swimming across the ceiling.” Which assessment is necessary to adequately identify the source of this client's behavior?
A) Cardiac rhythm strip
B) Pupillary response
C) Pulse oximetry
D) Peripheral glucose stick

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38. A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process?
A) Disruption of fetal glucose supply
B) Pancreatic insufficiency
C) Maternal insulin dependency
D) Reduced glycogen reserves

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39. A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial temperature is 95 degrees Fahrenheit (35 degrees Celsius) axillary. The nurse recognizes that cold stress may lead to what complication?
A) Lowered BMR
B) Reduced PaO2
C) Lethargy
D) Metabolic alkalosis

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40. A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention?
A) Capillary refill of fingers on right hand is 3 seconds
B) Skin warm to touch and normally colored
C) Client reports prickling sensation in the right hand
D) Slight swelling of fingers of right hand

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Practice Exam #13 - 40 questions