NCLEX-RN & NCLEX-PN Examination 2020 Question Bank, 1000 Plus Q & A with Rationale | 100 % Verified and Correct Answers, Already Graded A|
TEST BANK for NCLEX-RN & NCLEX-PN Examination
A c. What document should be in guiding the care of this client?
A) Client Self Determination Act
B) Physician's treatment orders
C) Advance Directives.
D) Clinical Pathway protocols
Review Information: The correct answer is: C) Advance Directives. This document specifies the client's wishes
You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant , a nursing student and yourself. To whom is it appropriate to assign complete care for
B) The nursing student
C) The licensed vocational nurse
D) The nursing assistant
Review Information: The correct answer is:A) Yourself.
While the nurse may delegate a bed bath for a stable client, this care should be performed by an RN for a new admission. Only tasks that do not require independent judgment should be delegated.
A mother brings her the clinic, complaining that the child seems to be The nurse expects to find which of the following on the initial history and physical assessment?
A) Increased temperature and lethargy
B) Rash and restlessness
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
Review Information: The correct answer is:B) Rash and restlessness.
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) "Her urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen."
D ) "We notice muscle weakness and some unsteadiness."
Review Information: The correct answer is:C) "Clothes are becoming tighter across her abdomen.".
One of the most common signs of neuroblastoma is increasing abdominal girth. The parents'' report that clothing is tight is significant, and should be followed by additional assessments.
A 16 year-old presents to the emergency department. The triage nurse finds that this teenager is legally married and signed the consent form for treatment. What would be the appropriate INITIAL action by the nurse?
A) Refuse to see the client until a parent or legal guardian can be contacted
B) Withhold treatment until telephone consent can be obtained from the spouse
C) Refer the client to a community pediatric hospital emergency room
D) Assess and treat in the same manner as any adult client
Review Information: The correct answer is:D) Assess and treat in the same manner as any adult client.
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this client, who is married, has the legal capacity of an adult.
A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the following is an appropriate task for an Unlicensed Assistive Personnel (UAP)?
A) Obtain a history of fluid loss
B) Report output of less than 30 ml/hr
C) Monitor response to IV fluids
D) Check skin turgor every four hours
Review Information: The correct answer is:B) Report output of less than 30 ml/hr.
When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is responsible for all care-related decisions,only implementation tasks should be assigned because they do not require independent judgment.
The nurse is assessing a 4 year-old for possible rheumatic fever. Which of the following would the nurse suspect is related to this diagnosis?
A) Diagnosis of chickenpox six months ago
B) Exposure to strep throat in daycare last month
C) Treatment for ear infection two months ago
D) Episode of fungal skin infection last week
Review Information: The correct answer is:B) Exposure to strep throat in daycare last month.
Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2-6 weeks). Therefore, the history of playmates recovering from strep throat would indicate that the child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an infection has no clinical symptoms.
When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the BEST action by the nurse is to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcing the manipulative behavior
C) Confront the client regarding the negative effects of his/her behavior on others
D) Develop a behavior modification plan that will promote more functional behavior
Review Information: The correct answer is:A) Discuss the feeling of reluctance with an objective peer or supervisor.
The nurse who is experiencing stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship.
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 the client's history of violence
D) Was necessary to maintain the therapeutic milieu of the unit
Review Information: The correct answer is:A) May result in charges of unlawful seclusion and restraint.
Seclusion should only be used when there is an immediate threat of violence or threatening behavior.
A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing diagnosis should have PRIORITY?
A) Pain related to ischemia
B) Risk for altered elimination: constipation
C) Risk for complication: dysrhythmias
Review Information: The correct answer is:A) Pain related to ischemia.
Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands.
The nurse manager who is responsible for hiring professional nursing staff is required to comply with the Americans with Disabilities Act. The provisions of the law require the nurse manager to
A) Maintain an environment free from hazards
B) Provide reasonable accommodations for disabled individuals
C) Make all necessary accommodations for disabled individuals
D) Consider only physical disabilities in making employment decisions
Review Information: The correct answer is:B) Provide reasonable accommodations for disabled individuals.
The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers also must make "reasonable accommodations.
The mother of a school-aged child in a long leg cast asks the nurse how to relieve itching inside the cast. Which of the following is appropriate for the nurse to suggest as a remedy?
A) Scratching the outside of the cast vigorously, applying pressure over the area
B) Blowing a hair dryer or heat lamp on the cast over the area that is itching
C) Using a long, smooth piece of wood to gently scratch the affected area
D) Applying an ice pack over the area of the cast that is affected
Review Information: The correct answer is:D) Applying an ice pack over the area of the cast that is affected.
Applying ice is a safe method of relieving the itching.
Which of the following BEST describes the application of time management strategies in the role of the nurse manager?
A) Scheduling staff efficiently to cover client needs
B) Assuming a fair share of the client care as a role model
C) Setting daily goals to prioritize work
D) Delegating tasks to reduce work load
Review Information: The correct answer is:C) Setting daily goals to prioritize work.
Time management strategies must include setting priorities and meeting goals.
The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse observes that suggest this problem include
A) Lymphedema and nerve palsy
B) Hearing loss and ataxia
C) Headaches and vomiting
D) Abdominal mass and weakness
Review Information: The correct answer is:D) Abdominal mass and weakness.
Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability.
A fifteen year-old client has been placed in a Milwaukee Brace. Which one of the following statements from the client indicates the need for additional teaching?
A) "I will only have to wear this for six 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."
Review Information: The correct answer is:A) "I will only have to wear this for six months.".
The brace must be worn long-term, usually for 1-2 years.
The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that
A) Quality of care will improve
B) Staff turnover should decrease
C) Flexible scheduling will occur
D) Team morale will improve
Review Information: The correct answer is:D) Team morale will improve.
Nurses are more satisfied with autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision-maker of the schedule.
A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?
A) Diffuse expiratory wheezing
B) Loose, productive cough
C) No relief from inhalant
D) Fever and chills
Review Information: The correct answer is:A) Diffuse expiratory wheezing.
In asthma, the airways are narrowed - creating difficulty getting air in and a wheezing sound.
The nurse manager hears a physician loudly criticizing one of the staff nurses in the hearing of others. The employee does not respond to the physician's complaints. The nurse manager's FIRST action should be
A) Walk up to the physician and quietly ask that this unacceptable behavior stop
B) Allow the staff nurse to handle this situation without interference
C) Notify the Nursing Director and Medical Staff Chief of a breech of professional conduct
D) Request an immediate private meeting with the physician and staff nurse
Review Information: The correct answer is:D) Request an immediate private meeting with the physician and staff nurse.
Assertive communication respects the needs of all parties to express themselves, but not at the expense of others. The nurse manager needs first to protect clients and other staff from this display and come to the assistance of the nurse employee.
A client voluntarily admits herself to the hospital due to suicidal ideation. The client has been on the unit for two days and is now demanding to be released. The MOST appropriate action is for the nurse to
A) Tell the client that she cannot be released because she is still suicidal
B) Inform the client that she can be released only if she signs a no suicide contract
C) Discuss with the client the decision to leave and prepare for her discharge
D) Instruct her regarding her right to sign out upon receipt of the physician's discharge order
Review Information: The correct answer is:C) Discuss with the client the decision to leave and prepare for her discharge.
Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision allows opportunity for other interventions.
A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?
B) Heart murmur
C) Macular rash
Review Information: The correct answer is:B) Heart murmur.
Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce symptoms of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore, the vegetations may travel to various organs such as spleen, kidney, coronary artery, brain and lungs and obstruct blood flow.
A nurseadmits a premature infant who has respiratory distress syndrome. 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
Review Information: The correct answer is:B) Maintain alveolar surface tension.
Respiratory distress syndrome is primarily a disease related to developmental delay in lung maturation. Although many factors lead to the development of the problem, the central factor relates to the lack of a normally functioning surfactant system due to immaturity in lung development.
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
A) Response to stimuli
B) Bladder control
C) Respiratory function
D) Muscle weakness
Review Information: The correct answer is:
C) Respiratory function.
Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problems identified, respiratory assessment is a priority.
The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care?
A) Hourly urine output
B) White blood count
C) Blood glucose every four hours
D) Temperature every two hours
Review Information: The correct answer is:A) Hourly urine output.
Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition.
The nurse admitting a 5 month-old who vomited nine times in the past six hours should observe for signs of
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
Review Information: The correct answer is:B) Metabolic alkalosis.
Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss and lead to metabolic alkalosis.
A child is injured on the school playground and appears to have a fractured leg. The FIRST action the school nurse should take is
A) Call for emergency transport to the hospital
B) Immobilize the limb and joints above and below the injury
C) Assess the child and the extent of the injury
D) Apply cold compresses to the injured area
Review Information: The correct answer is:C) Assess the child and the extent of the injury.
When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).
As the nurse interviews the parents of a child with asthma, it is a PRIORITY to ask about
A) Household pets
B) New furniture
C) Lead based paint
D) Plants such as cactus
Review Information: The correct answer is:A) Household pets.
Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust.
An 80 year-old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressure has ranged from 180/110 to 160/100. Over the past several hours, the nurse noted increasing lethargy. Which of the following assessments should the nurse report IMMEDIATELY to the physician?
A) Slurred speech
C) Muscle weakness
D) Rapid pulse
Review Information: The correct answer is:A) Slurred speech.
Changes in speech patterns and level of conscious can be indicators of continued intercranial bleeding. Treatment options may change based on further diagnostic tests.
A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would INITIALLY assess for
Review Information: The correct answer is:D) Pinworms.
Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span.
A 72 year-old client with osteomyelitis requires a six week course of intravenous antibiotics. In planning for home care, the MOST important action by the nurse is
A) Investigating the client's insurance coverage for home IV antibiotic therapy
B) Determining if there are adequate hand washing facilities in the home
C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver
D) Selecting the appropriate venous access device
Review Information: The correct answer is:C) Assessing the client''s ability to participate in self care and/or the reliability of a caregiver.
The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option.
The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. The BEST response by the nurse is
A) "Folic acid should be taken before and after conception."
B) "Multivitamin supplements are recommended during pregnancy."
C) "A well balanced diet promotes normal fetal development."
D) "Increased dietary iron improves the health of mother and fetus."
Review Information: The correct answer is:A) "Folic acid should be taken before and after conception.".
The American Academy of Pediatrics recommends that all childbearing women increase folic acid from dietary sources and/or supplements. There is evidence that increased amounts of folic acid prevents neural tube defects.
The nurse is caring for a newborn with a neural tube defect. The BEST covering for the lesion is
A) Telfa dressing with antibiotic ointment
B) Moist sterile nonadherent dressing
C) Dry sterile dressing
D) Sterile occlusive pressure dressing
Review Information: The correct answer is:B) Moist sterile nonadherent dressing.
Before surgical closure the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.
A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning?
A) Use ready-to-feed commercial infant formula
B) Boil the tap water for 10 minutes prior to preparing the formula
C) Let tap water run for 2 minutes before adding to concentrate
D) Buy bottled water labeled "lead free" to mix the formula
Review Information: The correct answer is:C) Let tap water run for 2 minutes before adding to concentrate.
Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or lead solder used insealing water pipes. Letting tap water run for several minutes will diminish the lead contamination.
A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The MOST appropriate intervention for this client is
A) Position client in upright position while eating
B) Place client on a clear liquid diet
C) Tilt head back to facilitate swallowing reflex
D) Offer finger foods such as crackers or pretzels
Review Information: The correct answer is:A) Position client in upright position while eating.
An upright position facilitates proper chewing and swallowing.
The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from
A) a tissue bank."
B) a pig."
C) my thigh."
D) synthetic skin."
Review Information: The correct answer is:C) my thigh.".
Autografts are done with tissue transplanted from the client''s own skin.
The nurse is caring for a newborn with tracheoesophageal fistula. Which of the following nursing diagnoses is a PRIORITY?
A) Risk for dehydration
B) Ineffective airway clearance
C) Altered nutrition
D) Risk for injury
Review Information: The correct answer is:B) Ineffective airway clearance.
The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula at or near the bifurcation. Thus, a priority is maintaining an open airway, preventing aspiration. Other nursing diagnoses are then addressed.
A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The MOST important reason for the nurse to elevate the casted leg is to
A) Promote the client's comfort
B) Reduce the drying time
C) Decrease irritation to the skin
D) Improve venous return
Review Information: The correct answer is:D) Improve venous return.
Elevating the leg both improves venous return and reduces swelling.
A nurse is working with family members of a newly diagnosed client with Alzheimer's disease. Which of the following interventions is MOST helpful?
A) Teaching relaxation techniques
B) Implementing a daily exercise routine
C) Improving daily nutritional intake
D) Suggesting communication strategies
Review Information: The correct answer is:D) Suggesting communication strategies.
Since Alzheimer''s disease is a progressive chronic illness that greatly challenges caregivers, the nurse can be of greatest assistance in helping family to identify language changes, and select verbal and nonverbal communication strategies to minimize aberrant behavior.
The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to
A) Maintain previous calorie intake
B) Keep a candy bar available at all times
C) Reduce carbohydrates intake to 25% of total calories
D) Keep a regular schedule of meals and snacks
Review Information: The correct answer is:D) Keep a regular schedule of meals and snacks.
Currently, calorie-controlled diets with strict mealplans are rarely suggested for clients who have diabetes. Try to incorporate schedule or food changes into clients'' existing dietary patterns. Help clients learn to read labels and identify specific canned foods, frozen entrees, or other foods which are acceptable and those which should be avoided.
The mother of a two month-old baby calls the nurse at a well-baby clinic two days after the first DTaP immunization. She reports that the baby feels very warm, has cried inconsolably for as long as three hours, and has had several shaking spells. The response of the nurse should be to
A) instruct the mother to call 911 for an ambulance to transport the infant
B) suggest that these are expected reactions and to begin every 4 hour antipyretics
C) tell the mother to take the infant immediately to the nearest emergency room
D) give instructions to bring the infant to the clinic now
Review Information: The correct answer is:A)instruct the mother to call 911 for an ambulance to transport the infant
The exhibited findings of the infant indicate a severe reaction to the immunizations. Immediate attention is needed & an ambulance with trained staff needs to transport because of the risk of grand mal seizures from potential encephalopathy which is a critical reaction. The mother would need to be instructed after this acute reaction to inform the provider of this reaction to the first dose of DTaP. Based on the need and risk involved to the infant, the health care provider may decide that further DTaP immunizations are contraindicated for life. The clinic nurse would need to document in the notes for this infant: the instructions given, findings reported by the mother and specific follow-up needs for the next clinic visit in relation to teaching and evaluation of the outcome of this event.
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
Review Information: The correct answer is:C) Unprotected sex.
Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risk for infection.
A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip, and hypoplastic philtrum of the upper lip. The mother states that the 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
A) Congenital abnormalities
B) Chronic toxoplasmosis
C) Fetal alcohol syndrome
D) Lead poisoning
Review Information: The correct answer is:C) Fetal alcohol syndrome.
Major features of fetal alcohol syndrome consist of facial and associated physical features, such as short palpebral fissure, hypoplastic philtrum, thinned upper lip, short, upturned nose. Behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome.
The nurse is performing the admission assessment of a client with an acute episode of asthma. Which of the following assessments would the nurse anticipate finding?
A) Prolonged inspiration
B) Expiratory wheezes
C) Expectorating large amounts of purulent mucous
Review Information: The correct answer is:B) Expiratory wheezes.
Asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest.
The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which of the following dinner menus would be BEST?
A) Fish sticks, french fries, banana, cookies, milk
B) Ground beef patty, lima beans, wheat roll, raisins, milk
C) Chicken nuggets, macaroni, peas, cantaloupe, milk
D) Peanut butter and jelly sandwich, apple slices, milk
Review Information: The correct answer is:B) Ground beef patty, lima beans, wheat roll, raisins, milk.
Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, dried fruits such as raisins. This dinner is the best choice, high in iron and is appropriate for a toddler.
A ten 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
Review Information: The correct answer is:C) Plan nursing care around lengthy rest periods.
The initial priority for this client is rest due to the inability of red blood cells to carry oxygen.
The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a PRIORITY?
A) Limit fluids
B) Client controlled analgesia
C) Cold compresses to elbow
D) Passive range of motion exercise
Review Information: The correct answer is:B) Client controlled analgesia.
Management of a crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum comfort.
As the nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki Disease who has received immunoglobulin therapy, which one of the following instructions would be MOST 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
Review Information: The correct answer is:D) The measles, mumps and rubella vaccine should be delayed.
Discharge instructions for a child with Kawasaki Disease should include immunoglobulin therapy may interfere with the body''s ability to form appropriate amounts of antibodies and live immunizations should be delayed.
The nurse is giving instructions to the parents of a child with Cystic Fibrosis. The nurse would emphasize that pancreatic enzymes should be taken
A) Once each day
B) Three times daily after meals
C) With each meal or snack
D) Each time carbohydrates are eaten
Review Information: The correct answer is:C) With each meal or snack.
Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of all foods that are eaten.
The nurse is assessing an eight month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be MOST likely to exhibit?
C) Negative Moro
D) Depressed fontanel
Review Information: The correct answer is:B) Irritability. Signs of IICP (increased intracranial pressure) in infants include bulging fontanel, instability, high-pitched cry, and cries when held. Vital sign changes include pulse that is variable, i.e., rapid, slow and bounding, or feeble. Respirations are more often slow, deep, and irregular.
The nurse is performing a physical assessment on a toddler. Which of the following should be the FIRST action?
A) Perform traumatic procedures
B) Use minimal physical contact
C) Proceed from head to toe
D) Explain the exam in detail
Review Information: The correct answer is:B) Use minimal physical contact.
The nurse should approach the toddler slowly and use minimal physical contact initially so as to gain the toddler''s cooperation. Be flexible in the sequence of the exam, and give only brief simple explanations just prior to the action.
A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of the following symptoms noted on the initial nursing assessment is expected?
A) Recent weight gain
B) Physical growth delay
C) Protruding eyeballs
D) Sudden onset of irritability
Review Information: The correct answer is:C) Protruding eyeballs.
Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves'' Disease.
When assessing a client admitted to the hospital for diabetic acidosis, which of the following clinical manifestations would the nurse expect?
A) A blood pH level above 7.5
B) Arterial blood PCO2 above 40
C) Blood pH level below 7.3
D) Arterial blood PCO2 below 10
Review Information: The correct answer is:C) Blood pH level below 7.3.
In the absence of insulin, which facilitates the transport of glucose into the cell, the body breaks down fats and proteins to supply energy ketones, a by-product of fat metabolism. These accumulate causing metabolic acidosis (pH < 7.3).
The nurse is explaining the proper use of syrup of ipecac to a group of parents. For which of the following accidental poisonings is the treatment appropriate?
A) Oven cleaner
B) Drain cleaner
D) Chewable vitamins
Review Information: The correct answer is:D) Chewable vitamins.
Of the above choices, poisoning with vitamins is the only case in which it is safe to induce vomiting with syrup of ipecac.
A two year-old child is brought to the pediatrician's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which one of the following statements?
A) Place the child on clear liquids and gelatin for 24 hours
B) Continue with the regular diet and include oral rehydration fluids
C) Give bananas, apples, rice and toast as tolerated
D) Place NPO for 24 hours, then rehydrate with milk and water
Review Information: The correct answer is:B) Continue with the regular diet and include oral rehydration fluids.
Current recommendations for mild to moderate diarrhea are to maintain a normal diet with rehydration fluids.
The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. The nurse's BEST recommendation for the client is
A) Nebulized treatments for home care
B) Adding a spacer device to the MDI canister
C) Asking a family member to assist the client with the MDI
D) Request a visiting nurse to follow the client at home
Review Information: The correct answer is:B) Adding a spacer device to the MDI canister.
The majority of pulmonary medications for COPD are delivered by inhalation.This is often preferred over oral administration because a lower drug dose is needed and systemic side effects are reduced. In addition, the onset of action of bronchodilator medication given via inhalation is faster.
Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?
A) Scratching the head more than usual
B) Flakes evident on a student's shoulders
C) Oval pattern occipital hair loss
D) Whitish oval specks sticking to the hair
Review Information: The correct answer is:D) Whitish oval specks sticking to the hair.
Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment includes shampoo application, such as lindane for children over 2 years of age, and meticulous combing and removal of all nits.
When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the BEST action the nurse would suggest to the parents is
A) Administer syrup of ipecac
B) Offer small amounts of water
C) Have the child drink milk
D) Give ginger ale or cola
Review Information: The correct answer is:B) Offer small amounts of water.
Small amounts of water will dilute the corrosive substance prior to gastric lavage.
A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicate a potential hazard for this test?
A) Reflex incontinence
B) Allergic to shellfish
Review Information: The correct answer is:B) Allergic to shellfish. It is important to know if the client has an allergy to iodine or shellfish. If the client does, they may have an allergic reaction to the IVP contrast dye injected during the procedure.
A high school nurse is advising a class of unwed pregnant students that the MOST important action they can perform to deliver a healthy child is
A) Maintaining good nutrition
B) Staying in school
C) Keeping in contact with the child's father
D) Getting adequate sleep
Review Information: The correct answer is:A) Maintaining good nutrition. Nurses can serve a pivotal role in providing nutritional education and case management interventions. Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Specifically, teens need to increase their intake of protein, vitamins, and minerals including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low-birth-weight babies.
The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which of the following should be included in the teaching materials?
A) Solid foods are introduced one at a time beginning with cereal
B) Finely ground meat should be started early to provide iron
C) Egg white is added early to increase protein intake
D) Solid foods should be mixed with formula in a bottle
Review Information: The correct answer is:A) Solid foods are introduced one at a time beginning with cereal.
Solid foods should be added one at a time between 4-6 months. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food.
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 four hours
D) Assess vital signs every 15 minutes throughout the entire infusion
Review Information: The correct answer is:C) Limit the infusion time of each of the unit to a maximum of four hours.
Infuse the specified amount of blood within 4 hours. If the infusion will exceed this time, the blood should be divided into appropriately sized quantities.
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 thisdata, what is the FIRST nursing action?
A) Review other lab data
B) Notify the physician
C) Administer oxygen
D) Calm the client
Review Information: The correct answer is:C) Administer oxygen.
The client has a low PCO2 due to increased respiratory rate from the hypoxemia and signs of respiratory alkalosis. Immediate intervention is indicated.
A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which of the following as the MOST important data?
A) Recent travel to Central America
B) Ingestion of raw shellfish last week
C) Multiple sex partners
D) Blood transfusion 15 years ago
Review Information: The correct answer is:D) Blood transfusion 15 years ago.
The client who was transfused prior to blood screening for hepatitis C may show symptoms many years later.
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
Review Information: The correct answer is:
A) Tetany and paresthesia.
Because the parathyroid gland may be damaged in this surgery, secondary hypocalcemia may occur. Symptoms of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures.
A client is admitted with a right upper lobe infiltrate, and also to rule out tuberculosis. The isolation precautions the nurse would institute include
A) Positive pressure ventilation
B) Gown and gloves
C) Particulate respirator mask
D) Barrier precautions
Review Information: The correct answer is:C) Particulate respirator mask.
Tight fitting, high-efficiency masks are required when caring for clients who have suspected communicable disease of the airborne variety.
A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report?
A) The client lost 2 pounds
B) The client's potassium level is 4 mEq/liter.
C) The client's urine output was 1500 cc in five hours
D) The client is to receive another dose of Lasix at 10 PM
Review Information: The correct answer is:C) The client's urine output was 1500 cc in five hours.
Although all of these may be correct information to include in report, the essential piece would be the urine output.
The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied
A) When it is one third to one half full
B) Prior to meals
C) After each fecal elimination
D) At the same time each day
Review Information: The correct answer is:A) When it is one third to one half full.
If the pouch becomes more than half full it may separate from the flange.
A couple asks the nurse about risks of several birth control methods. The MOST appropriate response by the nurse would be
A) Norplant is safe and may be removed easily
B) Oral contraceptives should not be used by smokers
C) Depo-Provera is convenient with few side effects
D) The IUD gives protection from pregnancy and infection
Review Information: The correct answer is:B) Oral contraceptives should not be used by smokers.
The use of oral contraceptives in a pregnant woman who smokes increases her risk of cardiovascular problems.
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
Review Information: The correct answer is:C) A decrease in lethargy. Lactulose produces and acid environment in the bowel and trapsammonia in the gut; the laxative effect then aids in removing the ammonia from the body. This decreases the effects of hepatic encephalopathy, including lethargy and confusion.
The mother of a 3 month-old infant tells the nurse that she wants to change from formula towhole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition?
A) Solid foods should be introduced at 3-4 months
B) Whole milk is difficult for a young infant to digest
C) Fluoridated tap water should be used to dilute milk
D) Supplemental apple juice can be used between feedings
Review Information: The correct answer is:B) Whole milk is difficult for a young infant to digest.
Cow''s milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. Also it contains little iron and creates a high renal solute load.
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 thrombusformation in the post-operative period?
A) Estrogen replacement therapy
B) 10% less than ideal body weight
C) Hypersensitivity to heparin
D) History of hepatitis
Review Information: The correct answer is:A) Estrogen replacement therapy.
Estrogen increases the hypercoagualability of the blood and increased the risk for development of thrombophlebitis.
The nurse is planning discharge for a 90 year-old client with musculo-skeletal weakness. Which of the following interventions would be MOST effective in preventing falls?
A) Place nightlights in bedroom
B) Wear eyeglasses at all times
C) Install grab bars in the bathroom
D) Teach muscle strengthening exercises
Review Information: The correct answer is:A) Place nightlights in bedroom.
Because more falls occur in the bedroom than any other location, begin there. However, work in partnership with the client and family so they are willing to move furniture, lamp cords, and storage areas; add lighting; remove throw rugs; and decrease other environmental hazards.
While obtaining the history of a two week-old infant during the well-baby exam, the nurse finds that the neonatal screening for phenylketonuria (PKU) was done when the infant was less than 24 hours-old. It is a PRIORITY for the nurse to
A) Schedule the infant for a repeat test in two weeks
B) Obtain a repeat blood test at this point
C) Contact the hospital of birth for the results
D) Document that the test results are pending
Review Information: The correct answer is:B) Obtain a repeat blood test at this point.
Testing for PKU is most reliable when protein has been ingested. A repeat blood specimen must be obtained by the third week of life if the initial specimen was taken from an infant less than 24 hours-old.
Two hours after the normal spontaneous vaginal delivery of a woman who is gravida 4 para 4, the nurse notes that the fundus is boggy and displaced slightly above and to the left of the umbilicus. The appropriate INITIAL nursing action is to
A) Assess lochia for color and amount
B) Monitor pulse and blood pressure
C) Call the physician immediately
D) Ask the woman to empty her bladder
Review Information: The correct answer is:D) Ask the woman to empty her bladder.
A full bladder can displace the uterus and prevent contraction. After the woman empties the bladder, the fundus should be assessed again.
An 8 year-old client is admitted to the hospital for surgery. The child's parent reports several allergies. Which of the following should all health care personnel be aware of?
D) Perfumed soap
Review Information: The correct answer is:C) Balloons.
Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non-latex gloves.
The nurse is caring for a client who is post-op following a thoracotomy. The client has two chest tubes in place,connected to one chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the MOST appropriate nursing action?
A) Clamp the chest tube
B) Call the surgeon immediately
C) Continue to monitor the client to see if the bubbling increases
D) Instruct the client to try to avoid coughing
Review Information: The correct answer is:C) Continue to monitor the client to see if the bubbling increases.
Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required.
The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. The nurse should instruct the client to
A) Complete the entire course of the medication for an effective cure
B) Begin treatment with acyclovir at the onset of symptoms of recurrence
C) Stop treatment if she thinks she may be pregnant to prevent birth defects
D) Continue to take prophylactic doses for at least five years after the diagnosis
Review Information: The correct answer is:B) Begin treatment with acyclovir at the onset of symptoms of recurrence.
When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective.
An eight year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which one of the following is the BEST choice?
A) Bologna sandwich, pudding, milk
B) Frankfurter, baked potato, milk
C) Chicken strips, corn on the cob, milk
D) Grilled cheese sandwich, apple, milk
Review Information: The correct answer is:C) Chicken strips, corn on the cob, milk.
This menu is lowest in sodium. Ideally, low fat milk would be available.
The nurse is teaching parents about accidental poisoning in children. Which of the following should be emphasized?
A) Start treatment before calling the Poison Control Center
B) Empty the child's mouth in any case of possible poisoning
C) Do not move the child if a toxic substance was inhaled
D) Induce vomiting if the poison is a hydrocarbon
Review Information: The correct answer is:B) Empty the child''s mouth in any case of possible poisoning.
Emptying the mouth of poison interferes with further ingestion and should be done first to limit contact with the substance.
Which of the following symptoms contraindicate the use of haloperidol (Haldol) and warrant withholding the dose?
A) Drowsiness, lethargy, and inactivity
B) Dry mouth, nasal congestion, and blurred vision
C) Rash, blood dyscrasias, severe depression
D) Hyperglycemia, weight gain, and edema
Review Information: The correct answer is:C) Rash, blood dyscrasias, severe depression. Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication to the use of neuroleptics.
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
Review Information: The correct answer is:C) Assess movement and sensation of extremities.
Following corrective surgery for scoliosis, neurological status requires special attention and assessment, especially that of the extremities.
A three 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
Review Information: The correct answer is:C) Potato chips.
Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible in persons with celiac disease.
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. The BEST response by the nurse is based on the knowledge that there is a
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
Review Information: The correct answer is:B) 1 in 4 risk for each child to have the disease.
Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease since neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having the disease, 50% chance of carrying the trait and a 25% chance of having neither the trait or the disease.
A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do FIRST?
A) Notify the physician
B) Administer the prn dose of Albuterol
C) Apply oxygen at 2 liters per nasal cannula
D) Repeat the peak flow reading in 30 minutes
Review Information: The correct answer is:
B) Administer the prn dose of Albuterol.
Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client''s baseline reading is a medical alert condition and a short-acting beta-agonist must be taken immediately.
What nursing observation signifies that a client has attained the stage of concrete operations (Piaget)?
A) Explores his environment using sight and movement
B) Can think in mental images or word pictures
C) Makes the moral judgment that "stealing is wrong"
D) Reasons that homework is time-consuming but necessary
Review Information: The correct answer is:C) Makes the moral judgment that "stealing is wrong".
The stage of concrete operations is depicted by logical thinking and moral judgments.
The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review FIRST?
A) Protime (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)
Review Information: The correct answer is:D) Liver enzymes (AST and ALT).
Because acetaminophen is toxic to the liver and causes hepatic cellular necrosis, liver enzymes are released into the blood stream and serum levels of those enzymes rise. Other lab values are reviewed as well.
The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include
A) Formula or breast milk
B) Broth and tea
C) Rice cereal and apple juice
D) Gelatin and ginger ale
Review Information: The correct answer is:A) Formula or breast milk.
The usual diet for a young infant should be followed.
The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk because this medication
A) Retards pepsin production
B) Stimulates hydrochloric acid production
C) Slows stomach emptying time
D） Decreases production of hydrochloric acid
Review Information: The correct answer is:B) Stimulates hydrochloric acid production.
Decadron increases the production of hydrochloric acid, which may cause gastrointestinal ulcers.
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
Review Information: The correct answer is:A) Assess for abdominal distention.
The child is observed for abdominal distention because cerebrospinal fluid may cause peritonitis or a postoperative ileus as a complication of distal catheter placement.
The mother of a two year-old hospitalized child asksthe nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The BEST response of the nurse would be to
A) Request the mother to remain with the child at all times
B) Explain that this behavior will stop with in a few days
C) Help the mother understand this is a normal response to hospitalization
D) Suggest that the mother "sneak out" of the child's room when he sleep
Review Information: The correct answer is:C) Help the mother understand this is a normal response to hospitalization.
The protest phase of separation anxiety is a normal response for a child this age.
When caring for a client receiving warfarin sodium (Coumadin), the nurse would monitor the results of the client's
A) Bleeding time
B) Coagulation time
C) Prothrombin time
D) Partial thromboplastin time
Review Information: The correct answer is:C) Prothrombin time.
Coumadin is ordered daily, based on the client''s prothrombin time (PT). This test evaluates the adequacy of the extrinsicsystem and common pathway in the clotting cascade; Coumadin affects the Vitamin K dependent clotting factors.
The nurse is caring for a four 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
Review Information: The correct answer is:D) Increased restlessness.
Restlessness and increased respiratory and heart rates are often early signs of hemorrhage.
care of infants and children.
The nurse admits a 7 year-old to the emergency room following a leg injury. X-rays show that there is a femur fracture near the epiphysis. The nurse should be aware that at this age, the injury MOST likely will
A) Heal quickly because of thin periosteum
B) Result in retarded bone growth
C) Stimulate bone growth in the affected leg
D) Show more rapid union than that of a younger child
Review Information: The correct answer is:
B) Result in retarded bone growth.
An epiphyseal (growth) plate fracture in a 7 year-old often results in retarded bone growth. Limbs will be different in length.
A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse assesses this as
C) Brady dysknesia
D) Tardive dyskinesia
Review Information: The correct answer is:D) Tardive dyskinesia.
Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue movements.
While the nurse assesses a 2 month-old infant, the mother expresses concern because a flat pink birthmark on the baby's forehead and eyelid has not gone away. The nurse should tell the parents that
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 surgical removal at this time
Review Information: The correct answer is:C) Telangiectatic nevi are normal and will disappear as the baby grows.
Telangiectatic nevi, salmon patch or stork bite birthmarks are a normal variation and the facial nevi will generally disappear by ages 1-2 years.
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 eight hours
Review Information: The correct answer is:C) Monitor vital signs.
The potential complication of this procedure is internal hemorrhage. Monitoring vital signs is critical to detect early indications of bleeding.
The nurse assessing a newborn notices that the breasts are enlarged bilaterally with a white, thin discharge. The INITIAL action of the nurse should be to
A) Notify the attending practitioner
B) Ask about medications taken in pregnancy
C) Record the findings as "normal"
D) Obtain fluid to send for culture
Review Information: The correct answer is:C) Record the findings as "normal".
Newborn infants of both sexes may have engorged breasts and may secrete milk during the first few days and weeks following birth.
A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive PRIORITY?
A) Maintaining proper body alignment
B) Frequent neurovascular assessments of the affected leg
C) Inspection of pin sites for evidence of drainage or inflammation
D) Applying an over-bed trapeze to assist the client with movement in bed
Review Information: The correct answer is:B) Frequent neurovascular assessments of the affected leg.
The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage.
The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The BEST response is
A) Drop the canister in water to observe floating
B) Estimate how many doses are usually in the canister
C) Count the number of doses as the inhaler is used
D) Shake the canister to detect any fluid movement
Review Information: The correct answer is:A) Drop the canister in water to observe floating.
Dropping the canister into a bowl of water assesses the amount of medications remaining in a metered-dose inhaler. The client should obtain a refill when the inhaler rises to the surface and begins to tip over.
While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is MOST important for the nurse to teach them to
A) Maintain good oral hygiene and dental care
B) Omit medication if the child is seizure free
C) Administer acetaminophen to promote sleep
D) Serve a diet that is high in iron
Review Information: The correct answer is:A) Maintain good oral hygiene and dental care.
Swollen and tender gums occur often with use of phenytoin. Oral hygiene and regular visits to the dentist should be emphasized.
A two year-old child has just been diagnosed with Cystic Fibrosis. The child's father asks the nurse "What are the chances that another child of ours will have Cystic Fibrosis?" Which of the following is the BEST response?
A) "The probability of recurrence is unknown."
B) "Cystic Fibrosis is more common in Asians."
C) "Each of your children have a 25% chance of having Cystic Fibrosis."
D) "The incidence of Cystic Fibrosis is approximately 1: 14,000 live births."
Review Information: The correct answer is:C) "Each of your children have a 25% chance of having Cystic Fibrosis.".
Cystic Fibrosis is an autosomal recessive disease. There is a 25% chance of each pregnancy of these parents resulting in a child with Cystic Fibrosis.
A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate
A) Non stress test
B) Abdominal ultrasound
C) Pelvic exam
D) X-ray of abdomen
Review Information: The correct answer is:B) Abdominal ultrasound.
The standard for diagnosis of placenta previa, which is suggested in the client''s history, is abdominal ultrasound.
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
Review Information: The correct answer is:C) Decreased potassium.
In bulimia, loss of electrolytes can occur in addition to signs and symptoms of starvation and dehydration.
An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze FIRST?
A) Potassium levels