Practice Exam #15 - 40 questions

 

1. Which of these women in the labor and delivery unit would the nurse check first when the water breaks (ROM) for all of them within a 2 minute period?
A) A multigravida with station at +2, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 7 cm, and 50% effacement
B) A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement
C) A primipara with station at 0, contractions at 20 minutes apart with duration of 20 seconds, cervix dilated at 2 cm and 10% effacement
D) A primipara with station at 1, contractions at 15 minutes apart with duration of 35 seconds, cervix dilated at 5 cm and 50% effacement

Answer: Only for registered users. Please login!

 

2. 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

Answer: Only for registered users. Please login!

 

3. A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?
A) Capillary refill less than 3 seconds
B) Pale mucous membranes
C) Respirations 36 breaths per minute
D) Complaints of fatigue when ambulating

Answer: Only for registered users. Please login!

 

4. Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach?
A) Consider a liquid supplement to increase calories
B) Discuss consequences of an unbalanced diet with the child
C) Provide fruit, vegetable and protein snacks
D) Encourage the child to keep a daily log of foods eaten

Answer: Only for registered users. Please login!

 

5. 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

Answer: Only for registered users. Please login!

 

6. 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

Answer: Only for registered users. Please login!

 

7. 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

Answer: Only for registered users. Please login!

 

8. The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB?
A) Tuberculin skin testing
B) Sputum culture
C) White blood cell count
D) Chest x-ray

Answer: Only for registered users. Please login!

 

9. For which of the following mother-baby pairs should the nurse review the Coombs’ test in preparation for administering Rh0 (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

Answer: Only for registered users. Please login!

 

10. 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."

Answer: Only for registered users. Please login!

 

11. The nurse has been teaching an apprehensive primipara who has had initial difficulty in nursing the newborn. What observation at the time of discharge suggests that initial breast feeding is effective?
A) The mother feels calmer and talks to the baby while nursing
B) The mother awakens the newborn to feed whenever it falls asleep
C) The newborn falls asleep after 3 minutes at the breast
D) The newborn refuses the supplemental bottle of glucose water

Answer: Only for registered users. Please login!

 

12. The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention?
A) pulse oximetry of 85%
B) nocturia
C) crackles in lungs
D) diaphoresis

Answer: Only for registered users. Please login!

 

13. 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

Answer: Only for registered users. Please login!

 

14. 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

Answer: Only for registered users. Please login!

 

15. 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

Answer: Only for registered users. Please login!

 

16. 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

Answer: Only for registered users. Please login!

 

17. 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

Answer: Only for registered users. Please login!

 

18. A client arrived in the USA from a developing country 1 week ago. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS. There is a history of these findings: unintended weight loss, drug abuse, night sweats, productive cough and a "feeling of being hot all the time." The nurse should assign the client to share a room with a client with the diagnosis of
A) Acute tuberculosis with a productive cough of discolored sputum for over three months
B) Lupus and vesicles on one side of the middle trunk from the back to the abdomen
C) Pseudomembranous colitis and C. difficile
D) Exacerbation of polyarthritis with severe pain

Answer: Only for registered users. Please login!

 

19. 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

Answer: Only for registered users. Please login!

 

20. 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

Answer: Only for registered users. Please login!

 

21 . The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered
A) Expected
B) Rude
C) Professional
D) Enjoyable

Answer: Only for registered users. Please login!

 

22. The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: “We are concerned about the possible occurrence of sudden infant death syndrome (SIDS).” In order to take appropriate action, the nurse must understand that
A) The child is within the age group most susceptible to SIDS
B) The peak age for occurrence of SIDS is 8 to 12 months of age
C) The apnea monitor is not effective on a child in this age group
D) 95% of SIDS cases occur before 6 months of age

Answer: Only for registered users. Please login!

 

23. 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."

Answer: Only for registered users. Please login!

 

24. When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by
A) Reduced oxygen capacity of cells due to lack of iron
B) An imbalance between red cell destruction and production
C) Depression of red and white cells and platelets
D) Inability of sickle shaped cells to regenerate

Answer: Only for registered users. Please login!

 

25. An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by
A) tachypnea
B) acidic byproducts
C) vomiting and dehydration
D) hyperpyrexia

Answer: Only for registered users. Please login!

 

26. A nurse is teaching a class for new parents at a local community center. The nurse would stress thatis most hazardous for an 8 month-old child.
A) riding in a car
B) falling off a bed
C) an electrical outlet
D) eating peanuts

Answer: Only for registered users. Please login!

 

27. The mother of a burned child asks the nurse to clarify what is meant by a third degree bum. The best response by the nurse is
A) "The top layer of the skin is destroyed."
B) "The skin layers are swollen and reddened."
C) "All layers of the skin were destroyed in the burn."
D) "Muscle, tissue and bone have been injured."

Answer: Only for registered users. Please login!

 

28. The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be high
A) calorie, low fat, low sodium
B) protein, low fat, low carbohydrate
C) protein, high calorie, unrestricted fat
D) carbohydrate, low protein, moderate fat

Answer: Only for registered users. Please login!

 

29. The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body?
A) the skin
B) the lungs
C) the muscles
D) bowel and bladder

Answer: Only for registered users. Please login!

 

30. A client’s admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client?
A) Moist mucous membranes
B) Urinary frequency
C) Poor skin turgor
D) Increased blood pressure

Answer: Only for registered users. Please login!

 

31. 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

Answer: Only for registered users. Please login!

 

32. 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 Type 1 diabetes mellitus 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 who is a grand multipara has cervical dilation of 4 cm and is 50% effaced
D) An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum

Answer: Only for registered users. Please login!

 

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

Answer: Only for registered users. Please login!

 

34. The nurse is attending a workshop about caring for persons infected with hepatitis. Which characteristic is most appropriate when defining the incidence rate of hepatitis?
A) The number of persons in a population who develop hepatitis B during a specific period of time
B) The total number of persons in a population who have hepatitis B at a particular time
C) The percentage of deaths resulting from hepatitis B during a specific time
D) The occurrence of hepatitis B in the population at a particular time

Answer: Only for registered users. Please login!

 

35. 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

Answer: Only for registered users. Please login!

 

36. The nurse is assessing a newborn delivered at home by a client addicted to heroin. Which of the following would the nurse expect to observe?
A) Hypertonic neuro reflex
B) Immediate CNS depression
C) Lethargy and sleepiness
D) Jitteriness at 24-48 hours

Answer: Only for registered users. Please login!

 

37. Which action is most likely to ensure the safety of the nurse while making a home visit?
A) Observe no evidence of weapons in the home during the visit
B) Prior to the visit, review the client's record for any previous entries about violence
C) Remain alert at all times and leave if cues suggest the home is not safe
D) Carry a cell phone, pager and/or hand held alarm for emergencies

Answer: Only for registered users. Please login!

 

38. Asa client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid
A) surfing
B) scuba diving
C) parasailing
D) swimming

Answer: Only for registered users. Please login!

 

39. In order to be effective in administering cardiopulmonary resuscitation to a 5 year-old, 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

Answer: Only for registered users. Please login!

 

40. A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn findings 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

Answer: Only for registered users. Please login!

 

Practice Exam #15 - 40 questions