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Exam Mode – Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam.
Text Mode – Text version of the exam 1. The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem? 2. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? 3. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior? 4. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask? 5. The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most 6. While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what 7. A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the 8. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial 9. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? 10. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth 11. Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby’s diet. Which of the following should be added first? 12. A victim of domestic violence states, “If I were better, I would not have been beat.” Which feeling best describes what the victim may be experiencing? 13. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the 14. Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client? 15. A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention? 16. Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for 17. Which client is at highest risk for developing a pressure ulcer? 18. Which contraindication should the nurse assess for prior to giving a child immunization? 19. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be 20. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action 21. At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is 22. A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first? 23. The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information? 24. The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately? 25. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering 26. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms? 27. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further 28. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate? 29. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing? 30. A 57 year-old male client has hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse? 31. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt? 32. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned 33. Which of the following measures would be appropriate for the nurse to teach the parent of a nine month-old infant about diaper dermatitis? 34. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is 35. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child’s constantly saying “no” and his refusal 36. Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 microdrops/cc. What rate would deliver 4 mgm of Lidocaine/minute? 37. A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse? 38. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? 39. A client experiences post partum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the 40. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). 41. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure? 42. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that 43. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report 44. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age? 45. The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period? 46. A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial 47. A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to 48. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls the clinic when “his eyes rolled upward.” The nurse recognizes this as what type of side effect? 49. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to 50. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all 51. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the 52. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize 53. A priority goal of involuntary hospitalization of the severely mentally ill client is 54. A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the 55. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time? 56. A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should 57. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would: 58. Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parent’s remark: “We just don’t know how he caught the disease!” The nurse’s response is based on an understanding that 59. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy 60. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action? 61. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate? 62. To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would 63. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to 64. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is 65. A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client 66. Which behavioral characteristic describes the domestic abuser? 67. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse 68. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the 69. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler 70. While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior? 71. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? 72. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a prioriy nursing diagnosis? 73. Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children? 74. A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions? 75. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluidPractice Mode
Exam Mode
Text Mode
appropriate?
other behavior?
therapeutic relationship?
action should be to
history, which data would be most consistent with this diagnosis?
function of the client’s recent memory?
which of the following lab tests is critical?
alert for which of the following side effects?
is a nursing priority?
most predictive of a potential for impaired skin integrity?
teaching?
to her pre-pregnant weight. Which action should the nurse perform first?
to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
following is based on sound rationale?
What is the nurse’s best explanation of these findings?
statement by the nurse?
of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
mechanism of “suppression”?
has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?
associated with this problem?
should recommend
identity of the baby’s father. Which of the following nursing interventions is a priority?
runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?
replacement is
Answers and Rationales
2000 mgm/500 cc = 4 mgm/x cc
2000x = 2000
x= 2000/2000 = 1 cc of IV solution/minute
CC x 60 microdrops = 60 microdrops/minute
Medical-Surgical Nursing Exam 9
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2 gm=2000 mgm
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, such as thromboembolic disorders.
The correct answer is C: Shallow respirations. A.L.S. is a chronic progressive disease that involves degeneration of the anterior horn of the spinal cord as well as the corticospinal tracts. When the intercostal muscles and diaphragm become involved, the respirations become shallow and coughing is ineffective.
The correct answer is A: “Nursing will help contract the uterus and reduce your risk of bleeding.” Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage.
The correct answer is A: These side effects are common and should subside in a few days. Nausea, metallic taste and fine hand tremors are common side effects that usually subside within days.
The correct answer is C: Encourage range of motion and ambulation. Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk.
The correct answer is A: Circumcision is delayed so the foreskin can be used for the surgical repair. Even if mild hypospadias is suspected, circumcision is not done in order to save the foreskin for surgical repair, if needed.
The correct answer is A: Loss of consciousness. While parents should report any of the observations, they need to call the health care provider immediately if the level of alertness changes. This indicates anoxia, which may lead to death. The structural defects associated with Tetralogy of Fallot include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy and overriding of the aorta. Surgery is often delayed, or may be performed in stages.
The correct answer is A: Double the birth weight. Although growth rates vary, infants normally double their birth weight by 6 months.
The correct answer is C: Maintain in a flat position, logrolling as needed. The bed should remain flat for at least the first 24 hours to prevent injury. Logrolling is the best way to turn for the client while on bed rest.
The correct answer is A: “Focus on your sons” needs during the first days at home.” In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.
The correct answer is A: A cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events. Cerebrovascular accidents may occur. Signs and symptoms include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures.
The correct answer is A: Oculogyric crisis. This refers to involuntary muscles spasm of the eye.
The correct answer is B: An occupational therapist from the community center. An occupational therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.
The correct answer is C: Provide interactions to help the client learn to trust staff. This establishes trust, facilitates a therapeutic alliance between staff and client.
The correct answer is C: Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow. PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization. Aorta coronary bypass Graft is the surgical procedure to repair a diseased coronary artery.
The correct answer is B: Administration of thyroid hormone will prevent problems. Early identification and continued treatment with hormone replacement corrects this condition.
The correct answer is C: Protection from self-harm and harm to others. Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled.
The correct answer is A: “I don”t remember anything about what happened to me.” Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A deliberate exclusion “voluntary forgetting” is generally used to protect one’s own self esteem.
The correct answer is D: Risk for infection. Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to both mother and the newborn.
The correct answer is A: Expose the cast to air and turn the child frequently. The child should be turned every 2 hours, with surface exposed to the air.
The correct answer is C: Administer a laxative to the client the evening before the examination. Bowel prep is important because it will allow greater visualization of the bladder and ureters.
The correct answer is D: It is not “caught” but is a response to a previous B-hemolytic strep infection. AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior, and is considered as a noninfectious renal disease.
The correct answer is D: No measurable voiding in 4 hours. The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys.
The correct answer is B: Massage the fundus. The nurse’s first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery.
The correct answer is A: Unequal leg length. Shortening of a leg is a sign of developmental dysplasia of the hip.
The correct answer is B: Administer stool softeners every day as ordered. Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent straining. If straining on defecation produced the valsalva maneuver and rhythm disturbances resulted then antidysrhythmics would be appropriate.
The correct answer is B: Introduce him/herself and accompany the client to the client’s room. Anxiety is triggered by change that threatens the individual’s sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting.
The correct answer is C: “I have to turn my head to see my room.”. Intraocular pressure becomes elevated which slowly produces a progressive loss of the peripheral visual field in the affected eye along with rainbow halos around lights. Intraocular pressure becomes elevated from the microscopic obstruction of the trabeculae meshwork. If left untreated or undetected blindness results in the affected eye.
The correct answer is A: Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions no support exists to indicate the need for suctioning.
The correct answer is D: Low self-esteem. Batterers are usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, have a low self-esteem, and have a great need to exercise control or power-over partner.
The correct answer is A: Isometric. The nurse should instruct the client on isometric exercises for the muscles of the casted extremity, i.e., instruct the client to alternately contract and relax muscles without moving the affected part. The client should also be instructed to do active range of motion exercises for every joint that is not immobilized at regular and frequent intervals.
The correct answer is A: Counsel the woman to consent to HIV screening. The client”s behavior places her at high risk for HIV. Testing is the first step. If the woman is HIV positive, the earlier treatment begins, the better the outcome.
The correct answer is B: Explain that this behavior is expected. During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parent, crying, and turning away from the stranger. These fears/behaviors extend into the toddler period and may persist into preschool.
The correct answer is B: Separation from parents. Separation anxiety if most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress.
The correct answer is B: Think logically in organizing facts. The child in the concrete operations stage, according to Piaget, is capable of mature thought when allowed to manipulate and organize objects.
The correct answer is D: Safety. Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan.
The correct answer is A: Sports and games with rules. The purpose of play for the 7 year-old is cooperation. Rules are very important. Logical reasoning and social skills are developed through play.
The correct answer is A: High Fowler”s. Sitting in a chair or resting in a bed in high Fowler”s position decreases the cardiac workload and facilitates breathing.
The correct answer is A: Urinary output of 30 ml per hour. For a child of this age, this is adequate output, yet does not suggest overload.