Practice Exam #21 - 40 questions

 

1. The nurse is caring for a post-op colostomy client. The client begins to cry, saying "I'll never be attractive again with this ugly red thing." What should be the first action taken by the nurse?
A) Arrange a consultation with a sex therapist experienced in working with colostomy clients
B) Suggest sexual positions that hide the colostomy
C) Invite the partner to participate in colostomy care after viewing an instructional video
D) Encourage the client to discuss her feelings about the colostomy

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2. A schizophrenic client talks animatedly but the staff are unable to understand what the client is communicating. The client is observed mumbling to herself and speaking to the radio. A desirable outcome for this client’s care will be
A) expresses feelings appropriately through verbal interactions
B) accurately interprets events and behaviors of others
C) demonstrates improved social relationships
D) engages in meaningful and understandable verbal communication

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3. The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents?
A) Report a persistent cough to the health care provider
B) The child can return to school in 4 days
C) Administer chewable aspirin for pain
D) The child may gargle with saline as necessary for discomfort

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4. An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question, "Where do babies come from?" What is the nurse's best response to the parent?
A) "When a child asks a question, give a simple answer."
B) "Children ask many questions, but are not looking for answers."
C) "This question indicates interest in sex beyond this age."
D) "Full and detailed answers should be given to all questions."

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5. The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which finding would the nurse expect?
A) Pelvic tip downward
B) Right leg lengthening
C) Ortolani sign
D) Characteristic limp

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6. At a routine clinic visit, parents express concern that their 4 year-old is wetting the bed several times a month. What is the nurse's best response?
A) "This is normal at this time of day.”
B) "How long has this been occurring?"
C) "Do you offer fluids at night?"
D) "Have you tried waking her to urinate?"

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7. The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital gown only. What is the rationale for this nursing intervention?
A) To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue
B) To cover the bony prominence and areas where there is skin breakdown
C) The client knows what type of clothing to wear when weighed
D) To reduce the tendency of the client to hide objects under his or her clothing

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8. The nurse is caring for a client with benign prostatic hypertrophy (BPH). Which of the following assessments would the nurse anticipate finding?
A) Large volume of urinary output with each voiding
B) Involuntary voiding with coughing and sneezing
C) Frequent urination
D) Urine is dark and concentrated

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9. A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
A) Call the health care provider
B) Check vital signs
C) Position in high Fowler's
D) Administer oxygen

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10. A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?
A) Maintain good nutrition
B) Stay in school
C) Keep in contact with the child's father
D) Get adequate sleep

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11. Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication?
A) Involuntary rhythmic stereotypic movements and tongue protrusion
B) Cheek puffing, involuntary movements of extremities and trunk
C) Agitation, constant state of motion
D) Hyperpyrexia, severe muscle rigidity, malignant hypertension

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12. A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is of most concern to the nurse?
A) 50% increase in birth weight
B) Head circumference greater than chest
C) Crying when the parents leave
D) Able to stand up briefly in play pen

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13. A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first?
A) Provide the ordered humidified oxygen via mask
B) Suction the mouth and the nose
C) Check the mouth and radial pulse
D) Start the ordered intravenous fluids

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14. A client continually repeats phrases that others have just said. The nurse recognizes this behavior as
A) autistic
B) echopraxis
C) echolalic
D) catatonic

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15. Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about readiness for toilet training?
A) The child learns voluntary sphincter control through repetition
B) Myelination of the spinal cord is completed by this age
C) Neuronal impulses are interrupted at the base of the ganglia
D) The toddler can understand cause and effect

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16. In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse should emphasize that a priority for their child is to
A) avoid overheating during physical activities
B) maintain normal activity with some restrictions
C) be cautious of others with viruses or temperatures
D) maintain routine immunizations

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17. The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the nurse anticipate?
A) bronchial breath sounds in outer lung fields
B) decreased tactile fremitus
C) hacking, nonproductive cough
D) hyper-resonance of areas of consolidation

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18. When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client’s family to
A) avoid smoking near the client
B) turn off oxygen during meals
C) adjust the liter flow to 10 as needed
D) remind the client to keep mouth closed

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19. The nurse is caring for a 14 month-old just diagnosed with cystic fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. What is the best response by the nurse?
A) 1 in 4 chance for each child to carry that trait
B) 1 in 4 risk for each child to have the disease
C) 1 in 2 chance of avoiding the trait and disease
D) 1 in 2 chance that each child will have the disease

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20. In providing care to a 14 year-old adolescent with scoliosis, which of the following will be most difficult for this client?
A) Compliance with treatment regimens
B) Looking different from their peers
C) Lacking independence in activities
D) Reliance on family for their social support

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21 . The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet?
A) Vegetables
B) Cereal
C) Fruit
D) Meats

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22. During seizure activity which observation is the priority to enhance further direction of treatment?
A) Observe the sequence or types of movement
B) Note the time from beginning to end
C) Identify the pattern of breathing
D) Determine if loss of bowel or bladder control occurs

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23. The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus
B) Opening the bottom of the pouch, allowing the flatus to be expelled
C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
D) Assisting the client to ambulate to reduce the flatus in the pouch

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24. A nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource?
A) The state nurse practice act in which the assignment is made
B) With a nurse colleague who has worked in that state 2 years ago
C) The policies and procedures of the assigned agency in that state
D) The Nursing Social Policy Statement within the United States

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25. The parents of a 7 year-old tell the nurse their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents?
A) The ethical sense and feelings of justice are developing
B) Attempts to control the family use new coping styles
C) Insecurity and attention getting are common motives
D) Complex thought processes help to resolve conflicts

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26. Which of these principles should the nurse apply when performing a nutritional assessment on a 2 year-old client?
A) An accurate measurement of intake is not reliable
B) The food pyramid is not used in this age group
C) A serving size at this age is about 2 tablespoons
D) Total intake varies greatly each day

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27. A client with HIV infection has a secondary herpes simplex type 1 (HSV-1) infection. The nurse knows that the most likely reason for the HSV-1 infection in this client is
A) immunosuppression
B) emotional stress
C) unprotected sexual activities
D) contact with saliva

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28. The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mother's lap. Which of the following should the nurse do first?
A) Elicit reflexes
B) Measure height and weight
C) Auscultate heart and lungs
D) Examine the ears

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29. A client is unconscious following a tonic-clonic seizure. What should the nurse do first?
A) check the pulse
B) administer Valium
C) place the client in a side-lying position
D) place a tongue blade in the mouth

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30. The nurse has been assigned to four clients in the emergency room, each experiencing one of these conditions. Which client condition would the nurse check first?
A) Viral pneumonia with atelectasis
B) Spontaneous pneumothorax with a respiratory rate of 38
C) Tension pneumothorax with slight tracheal deviation to the right
D) Acute asthma with episodes of bronchospasm

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31. The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. What action should the nurse take?
A) Notify the provider
B) Palpate the anterior fontanel
C) Feel the posterior fontanel
D) Record these normal findings

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32. A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include?
A) Allow the child to continue normal activities
B) Schedule frequent rest periods
C) Limit exposure to other children
D) Restrict activities to inside the house

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33. The nurse understands that during the "tension building" phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of
A) anger
B) helplessness
C) calm
D) explosiveness

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34. When counseling parents of a child who has recently been diagnosed with hemophilia, what must the nurse know about the offspring of a normal father and a carrier mother?
A) It is likely that all sons are affected
B) There is a 50% probability that sons will have the disease
C) Every daughter is likely to be a carrier
D) There is a 25% chance a daughter will be a carrier

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35. The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown
A) Ileostomy
B) Transverse colostomy
C) Ileal conduit
D) Sigmoid colostomy

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36. A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis?
A) Low hemoglobin
B) Hypernatremia
C) High serum creatinine
D) Hyperkalemia

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37. The nurse is teaching a client who has a hip prosthesis following total hip replacement. Which of the following should be included in the instructions for home care?
A) Avoid climbing stairs for 3 months
B) Ambulate using crutches only
C) Sleep only on your back
D) Do not cross your legs

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38. The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation?
A) Glucose level of 120
B) History of myocardial infarction
C) Long term steroid usage
D) Diet high in carbohydrates

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39. A 7 year-old child is hospitalized following a major bum to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to
A) Promote healing and strengthen the immune system
B) Provide a well balanced nutritional intake
C) Stimulate increased peristalsis absorption
D) Spare protein catabolism to meet metabolic needs

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40. A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by
A) requiring the client to mop the floor
B) restricting the client’s fluids throughout the day
C) withholding privileges each time the voiding occurs
D) toileting the client more frequently with supervision

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Practice Exam #21 - 40 questions