Answer and Rationale: Board Exam Nursing Test I NLE

1.  D. Bathing an infant with eczema can be safely delegated to an aide; this task is basic and can competently performed by an aid.

2. B. The RN floated from the telemetry unit would be least prepared to care for a young infant who has just had GI surgery and requires a specific feeding regimen.

3. C. RN floated from the obstetrics unit should be able to care for a client with major abdominal surgery, because this nurse has experienced caring for clients with cesarean births.

4. A. The patient is experiencing a potentially serious complication related to diabetes and needs ongoing assessment by an RN

5. D. It describes functional nursing. Staff is assigned to specific task rather than specific clients.

6. B. Case management. The nurse assumes total responsibility for meeting the needs of the client during her entire duty.

7. B. The nurse is ethically obligated to inform the person responsible for the assignment and the person responsible for the unit about the nurse’s skill level. The nurse therefore avoids a situation of abandoningclients and exposing them to greater risks

8. A. This describes a mentor

9. B. This action demonstrates a lack of responsibility and the nurse should attempt negotiation with the nurse manager.

10. B. The team leader is responsible for the overall management of all clients and staff on the team, and this information is essential in order to accomplish this

11. C. Even though the mother is a minor, she is legally able to sign consent for her own child.

12. B.  This response is the most direct and immediate. This is a case of potential need for advocacy and patient’s rights.

13. D.  The nurse who witness a consent for treatment or surgery is witnessing only that the client signed the form and that the client’s condition is as indicated at the time of signing. The nurse is not witnessing that the client is “informed”.

14. C. Although the statements by the mother may not create a suspicion of neglect, when they are coupled with observations about impaired bonding and maternal attachment, they may impose the obligation to report child neglect. The nurse is further obligated to notify caregivers of refusal to consent to treatment

15. C. It best explains what informed consent is and provides for legal rights of the patient

16. B. The physician may not be aware of the role that religious beliefs play in making a decision about surgery.

17. A. The behavior should be stopped. The first step is to remind the staff that confidentiality may be violated

18. C. Waiting for emotions to dissipate and sitting down with the colleague is the first rule of conflict resolution.

19. C. The nurse has no idea who the person is on the phone and therefore may not share the information even if the patient gives permission

20. A. The priority is to let the surgeon know, who in turn may ask the husband to sign the consent.

21. A. Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it should be mixed with normal saline.

22. A. This position increases venous return, improves cardiac volume, and promotes adequate ventilation and cerebral perfusion

23. D. Checking the airway would be a priority, and a neck injury should be suspected

24. D. Client with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing.

25. C.  It is important to protect the RN’s eyes from the possible contamination of coughed-up secretions

26. D. There has been too little food or too much insulin. Glucose levels can be markedly decreased (less than 50 mg/dl). Severe hypoglycemia may be fatal if not detected

27. D. Because the client’s ability to react to stress is decreased, maintaining a quiet environment becomes a nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial.

28. D.  Presuctioning and postsuctioning ventilation with 100% oxygen is important in reducing hypoxemia which occurs when the flow of gases in the airway is obstructed by the suctioning catheter.

29. B. This is an example of objective data of both pulmonary status and direct observation on the skin by the nurse.

30. C.  These are likely signs of an acute myocardial infarction (MI). An acute MI is a cardiovascular emergency requiring immediate attention. Acute MI is potentially fatal if not treated immediately.

31. D. Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, and the bruises may be attributed to ataxia, frequent falls, vertigo or medication.

32. B. This is closest to suggesting action-assessment, rather than paperwork- and is therefore the best of the four.

33. C. The only acceptable way to identify a preschooler client is to have a parent or another staff member identify the client.

34. C. It describes the mass in the greatest detail.

35. C. Intravenous pyelogram tests both the function and patency of the kidneys. After the intravenous injection of a radiopaque contrast medium, the size, location, and patency of the kidneys can be observed by roentgenogram, as well as the patency of the urethra and bladder as the kidneys function to excrete the contrast medium.

36. C. This is the recommended position for screening for scoliosis. It allows the nurse to inspect the alignment of the spine, as well as to compare both shoulders and both hips.

37. A.  Handwashing is the best method for reducing cross-contamination. Gowns and gloves are not always required when entering a client’s room.

38. B. Pyloric stenosis is an anomaly of the upper gastrointestinal tract. The condition involves a thickening, or hypertrophy, of the pyloric sphincter located at the distal end of the stomach. This causes a mechanical intestinal obstruction, which leads to vomiting after feeding the infant. The vomiting associated with pyloric stenosis is described as being projectile in nature. This is due to the increasing amounts of formula the infant begins to consume coupled with the increasing thickening of the pyloric sphincter.

39. B. Increased incidence of TB has been seen in the general population with a high incidence reported in hospitalized elderly clients. Immunosuppression and lack of classic manifestations because of the aging process are just two of the contributing factors of tuberculosis in the elderly.

40. D. Parents should be taught to feel the area that is raised and measure only that.

41. C. It is a safety hazard to have shiny floors because they can cause falls.

42. D. The first priority, beside maintaining a newborn’s patent airway, is body temperature.

43. B.  The purpose of restraints for this child is to keep the child from scratching the affected areas. Mittens restraint would prevent scratching, while allowing the most movement permissible.

44. C. Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown. It develops during the first few weeks of life.

45. B. Pus is usually the first symptom, because the bacteria reproduce in the bladder.

46. A. Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection.

47. D. Frequent hand washing and good hygiene are the best means of preventing infection.

48. D. CHG is a highly effective antimicrobial ingredient, especially when it is used consistently over time.

49. A.  The mother may have many reasons for such a decision. It is the nurse’s responsibility to review this decision with the mother and clarify any misconceptions regarding immunizations that may exist.

50. D. The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a dimpling appearance.