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PNLE I Nursing Practice (PM)
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Question 1
A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of the test. Which of the following would be the best rationale for this?
A
greater exposure to diverse health care workers
B
reactivation of an old tuberculosis infection
C
respiratory problems are characteristic in this population
D
increased incidence of new cases of tuberculosis in persons over 65 years old
Question 1 Explanation:
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.
Question 2
The mother of the client tells the nurse, “ I’m not going to have my baby get any immunization”. What would be the best nursing response to the mother?
A
“Your baby will not be able to attend day care without immunizations”
B
“Your decision can be viewed as a form of child abuse and neglect”
C
“You are needlessly placing other people at risk for communicable diseases”
D
“You and I need to review your rationale for this decision”
Question 2 Explanation:
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.
Question 3
A client visits the clinic for screening of scoliosis. The nurse should ask the client to:
A
stand up as straight and tall as possible
B
bend over at a 45-degree angle from the waist
C
bend all the way over and touch the toes
D
bend over at a 90-degree angle from the waist
Question 3 Explanation:
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.
Question 4
A staff nurse has had a serious issue with her colleague. In this situation, it is best to:
A
Discuss this with the supervisor
B
Not discuss the issue with anyone. It will probably resolve itself
C
Tell other members of the network what the team member did
D
Try to discuss with the colleague about the issue and resolve it when both are calmer
Question 4 Explanation:
Waiting for emotions to dissipate and sitting down with the colleague is the first rule of conflict resolution.
Question 5
Which of the following would be the most important goal in the nursing care of an infant client with eczema?
A
decreasing the itching
B
providing for adequate nutrition
C
preventing infection
D
maintaining the comfort level
Question 5 Explanation:
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.
Question 6
A community health nurse is schedule to do home visit. She visits to an elderly person living alone. Which of the following observation would be a concern?
A
Unwashed dishes in the sink
B
Brightly lit rooms
C
Clear and shiny floors
D
Picture windows
Question 6 Explanation:
It is a safety hazard to have shiny floors because they can cause falls.
Question 7
A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. The nurse prepared the consent form and it should be signed by:
A
The Registered Nurse caring for the client
B
The 15-year-old mother of the baby boy
C
The mother of the girl
D
The Physician
Question 7 Explanation:
Even though the mother is a minor, she is legally able to sign consent for her own child.
Question 8
The pediatrics unit is understaffed and the nurse manager informs the nurses in the obstetrics unit that she is going to assign one nurse to float in the pediatric units. Which statement by the designated float nurse may put her job at risk?
A
“I do not get along with one of the nurses on the pediatrics unit”
B
“I do not feel competent to go and work on that area”
C
“ I am afraid I will get the most serious clients in the unit”
D
“I have a vacation day coming and would like to take that now”
Question 8 Explanation:
This action demonstrates a lack of responsibility and the nurse should attempt negotiation with the nurse manager.
Question 9
The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose confidential information when:
A
The father of a woman who just delivered a baby is on the phone to find out the sex of the baby
B
A researcher from an institutionally approved research study reviews the medical record of a patient
C
The client asks the nurse to discuss the her condition with the family
D
The nurse discusses the condition of the client in a clinical conference with other nurses
Question 9 Explanation:
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
Question 10
The nurse is making a health teaching to the parents of the client. In teaching parents how to measure the area of induration in response to a PPD test, the nurse would be most accurate in advising the parents to measure:
A
The entire area that feels itchy to the child
B
both the areas that look red and feel raised
C
Only the area that feels raised
D
Only the area that looks reddened
Question 10 Explanation:
Parents should be taught to feel the area that is raised and measure only that.
Question 11
On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which in the following clients should receive highest priority?
A
A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw
B
A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon
C
an elderly woman complaining of a loss of appetite and fatigue for the past week
D
A football player limping and complaining of pain and swelling in the right ankle
Question 11 Explanation:
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.
Question 12
The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of hypoglycemia should be taught to a client?
A
warm, flushed skin
B
hunger and thirst
C
palpitation and weakness
D
increase urinary output
Question 12 Explanation:
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
Question 13
The nurse is teaching the client about breast self-examination. Which observation should the client be taught to recognize when doing the examination for detection of breast cancer?
A
pain on breast self-examination
B
dimpling of the breast tissue
C
round, well-defined lump
D
tender, movable lump
Question 13 Explanation:
The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a dimpling appearance.
Question 14
A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager safely assign to the float nurse?
A
A child diagnosed with Kawasaki disease and with cardiac complications
B
A child who has had a nephrectomy for Wilm’s tumor
C
A child receiving an IV chelating therapy for lead poisoning
D
A child who had multiple injuries from a serious vehicle accident
Question 14 Explanation:
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.
Question 15
An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following would be the best nursing response of the nurse?
A
“The vomiting is due to the nausea that accompanies pyloric stenosis”
B
“Your baby eats too rapidly and overfills the stomach, which causes vomiting
C
“Your baby needs to be burped more thoroughly after feeding”
D
“Your baby can’t empty the formula that is in the stomach into the bowel”
Question 15 Explanation:
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.
Question 16
The registered nurse is planning to delegate task to a certified nursing assistant. Which of the following clients should not be assigned to a CAN?
A
A client with chronic venous insufficiency
B
A client who had a CVA in the past two months
C
A client with Chronic renal failure
D
A client diagnosed with diabetes and who has an infected toe
Question 16 Explanation:
The patient is experiencing a potentially serious complication related to diabetes and needs ongoing assessment by an RN
Question 17
A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an amputation. The client tells the nurse that he will not sign the consent form and he does not want any surgery or treatment because of religious beliefs about reincarnation. What is the role of the RN?
A
call a family meeting
B
encourage the client to have the surgery
C
inform the client of other options
D
discuss the religious beliefs with the physician
Question 17 Explanation:
The physician may not be aware of the role that religious beliefs play in making a decision about surgery.
Question 18
A nurse is assigned to care to a client with Parkinson’s disease. What interventions are important if the nurse wants to improve nutrition and promote effective swallowing of the client?
A
Sit in an upright position to eat
B
Feed the client
C
Eat solid food
D
Give liquids with meals
Question 18 Explanation:
Client with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing.
Question 19
A registered nurse has been assigned to six clients on the 12-hour shift. The RN is responsible for every aspect of care such as formulating the care of plan, intervention and evaluating the care during her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. This nursing care illustrates of what kind of method?
A
team method
B
primary nursing method
C
case method
D
functional method
Question 19 Explanation:
Case management. The nurse assumes total responsibility for meeting the needs of the client during her entire duty.
Question 20
A male client comes to the clinic for check-up. In doing a physical assessment, the nurse should report to the physician the most common symptom of gonorrhea, which is:
A
pruritus
B
WBC in the urine
C
Dysuria
D
pus in the urine
Question 20 Explanation:
Pus is usually the first symptom, because the bacteria reproduce in the bladder.
Question 21
The newly hired staff nurse has been working on a medical unit for 3 weeks. The nurse manager has posted the team leader assignments for the following week. The new staff knows that a major responsibility of the team leader is to:
A
Provide care to the most acutely ill client on the team
B
Document the assessments completed by the team members
C
Know the condition and needs of all the patients on the team
D
Supervise direct care by nursing assistants
Question 21 Explanation:
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
Question 22
The nurse is making a discharge instruction to a client receiving chemotherapy. The client is at risk for bone marrow depression. The nurse gives instructions to the client about how to prevent infection at home. Which of the following health teaching would be included?
A
“Avoid contact with others while receiving chemotherapy”
B
“Do not share a bathroom with children or pregnant woman”
C
“Get a weekly WBC count”
D
“Do frequent hand washing and maintain good hygiene”
Question 22 Explanation:
Frequent hand washing and good hygiene are the best means of preventing infection.
Question 23
While in the hospital lobby, the RN overhears the three staff discussing the health condition of her client. What would be the appropriate nursing action for the RN to take?
A
Tell them it is not appropriate to discuss the condition of the client
B
Join in the conversation, giving them supportive input about the case of the client
C
Report this incident to the nursing supervisor
D
Ignore them, because it is their right to discuss anything they want to
Question 23 Explanation:
The behavior should be stopped. The first step is to remind the staff that confidentiality may be violated
Question 24
A mother in labor told the nurse that she was expecting that her baby has no chance to survive and expects that the baby will be born dead. The mother accepts the fate of the baby and informs the nurse that when the baby is born and requires resuscitation, the mother refuses any treatment to her baby and expresses hostility toward the nurse while the pediatric team is taking care of the baby. The nurse is legally obligated to:
A
Do nothing except record the mother’s statement in the medical record
B
Notify the pediatric team that the mother has refused resuscitation and any treatment for the baby and take the baby to the mother
C
Record the statement of the mother, notify the pediatric team, and observe carefully for signs of impaired bonding and neglect as a reasonable suspicion of child abuse
D
Get a court order making the baby a ward of the court
Question 24 Explanation:
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
Question 25
A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s family members come to visit, they would be adhering to respiratory isolation precautions when they:
A
put on gowns, gloves and masks
B
wash their hands when leaving
C
keep the client’s room door open
D
avoid contact with the client’s roommate
Question 25 Explanation:
Handwashing is the best method for reducing cross-contamination. Gowns and gloves are not always required when entering a client’s room.
Question 26
A 80-year-old female client is brought to the emergency department by her caregiver, on the nurse’s assessment; the following are the manifestations of the client: anorexia, cachexia and multiple bruises. What would be the best nursing intervention?
A
talk to the client about the caregiver and support system
B
complete a gastrointestinal and neurological assessment
C
complete a police report on elder abuse
D
check the laboratory data for serum albumin, hematocrit, and hemoglobin
Question 26 Explanation:
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.
Question 27
A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck and arms. The client is scratching the affected areas. What would be the best nursing intervention to prevent the client from scratching the affected areas?
A
A posey jacket to the torso
B
Clove-hitch restraints to the hands
C
Mittens to the hands
D
elbow restraints to the arms
Question 27 Explanation:
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.
Question 28
The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is essential to prevent hypoxemia?
A
administering 100% oxygen to reduce the effects of airway obstruction during suctioning.
B
encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions
C
removing oral and nasal secretions
D
aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning
Question 28 Explanation:
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.
Question 29
The nurse caring to a client has completed the assessment. Which of the following will be considered to be the most accurate charting of a lump felt in the right breast?
A
“mass in the right breast 4cmx1cm
B
“hard nodular mass in right breast nipple”
C
“firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’
D
“abnormally felt area in the right breast, drainage noted”
Question 29 Explanation:
It describes the mass in the greatest detail.
Question 30
The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric stenosis. The appropriate nursing response would be:
A
Their baby acquired it due to a formula allergy
B
There is no way to determine this preoperatively
C
Their baby developed this condition during the first few weeks of life
D
Their baby was born with this condition
Question 30 Explanation:
Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown. It develops during the first few weeks of life.
Question 31
The client is brought to the emergency department after a serious accident. What would be the initial nursing action of the nurse to the client?
A
check respiration, stabilize spine, check circulation
B
align the spine, check pupils, check for hemorrhage
Checking the airway would be a priority, and a neck injury should be suspected
Question 32
The nurse is assigned to care the client with infectious disease. The best antimicrobial agent for the nurse to use in handwashing is:
A
Soap and water
B
Hexachlorophene (Phisohex)
C
Isopropyl alcohol
D
Chlorhexidine gluconate (CHG) (Hibiclens)
Question 32 Explanation:
CHG is a highly effective antimicrobial ingredient, especially when it is used consistently over time.
Question 33
The nurse in the medication unit passes the medications for all the clients on the nursing unit. The head nurse is making rounds with the physician and coordinates clients’ activities with other departments. The nurse assistant changes the bed lines and answers call lights. A second nurse is assigned for changing wound dressings; a licensed practitioner nurse takes vital signs and bathes the clients. This illustrates of what method of nursing care?
A
Case management method
B
Functional method
C
Team method
D
Primary nursing method
Question 33 Explanation:
It describes functional nursing. Staff is assigned to specific task rather than specific clients.
Question 34
The night shift nurse is making rounds. When the nurse enters a client’s room, the client is on the floor next to the bed. What would be the initial action of the nurse?
A
call the physician
B
fill out an incident report
C
chart that the client was found on the floor next to the bed
D
chart that the patient fell
Question 34 Explanation:
This is closest to suggesting action-assessment, rather than paperwork- and is therefore the best of the four.
Question 35
The hospitalized client with a chronic cough is scheduled for bronchoscopy. The nurse is tasks to bring the informed consent document into the client’s room for a signature. The client asks the nurse for details of the procedure and demands an explanation why the process of informed consent is necessary. The nurse responds that informed consent means:
A
The patient releases the physician from all responsibility for the procedure.
B
The physician must give the client or surrogates enough information to make health care judgments consistent with their values and goals.
C
The immediate family may make decision against the patient’s will.
D
The patient agrees to a procedure ordered by the physician even if the client does not understand what the outcome will be.
Question 35 Explanation:
It best explains what informed consent is and provides for legal rights of the patient
Question 36
A nurse manager assigned a registered nurse from telemetry unit to the pediatrics unit. There were three patients assigned to the RN. Which of the following patients should not be assigned to the floated nurse?
A
A 5-month-old with Kawasaki disease
B
A young infant after pyloromyotomy
C
A 9-year-old child diagnosed with rheumatic fever
D
A 4-year-old with VSD following cardiac catheterization
Question 36 Explanation:
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.
Question 37
The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP). Which of the following task could the registered nurse safely assigned to a UAP?
A
Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall
B
Give an outmeal bath to an infant with eczema
C
Monitor the I&O of a comatose toddler client with salicylate poisoning
D
Check the IV of a preschooler with Kawasaki disease
Question 37 Explanation:
Bathing an infant with eczema can be safely delegated to an aide; this task is basic and can competently performed by an aid.
Question 38
A newly hired nurse on an adult medicine unit with 3 months experience was asked to float to pediatrics. The nurse hesitates to perform pediatric skills and receive an interesting assignment that feels overwhelming. The nurse should:
A
Inform the nursing supervisor and the charge nurse on the pediatric floor about the nurse’s lack of skill and feelings of hesitations and request assistance
B
resign on the spot from the nursing position and apply for a position that does not require floating
C
Ask several other nurses how they feel about pediatrics and find someone else who is willing to accept the assignment
D
Refuse the assignment and leave the unit requesting a vacation a day
Question 38 Explanation:
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 abandoning clients and exposing them to greater risks
Question 39
Which is true about informed consent?
A
A nurse may accept responsibility signing a consent form if the client is unable
B
A physician will not subject himself to liability if he withholds any facts that are necessary to form the basis of an intelligent consent
C
Obtaining consent is not the responsibility of the physician
D
If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the signature is that of the purported person and that the person’s condition is as indicated at the time of signing
Question 39 Explanation:
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”.
Question 40
During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements?
A
limit suction pressure to 150-180 mmHg
B
suction for 15-20 seconds
C
remove the inner cannula
D
wear eye goggles
Question 40 Explanation:
It is important to protect the RN’s eyes from the possible contamination of coughed-up secretions
Question 41
A client admitted to the hospital and diagnosed with Addison’s disease. What would be the appropriate nursing action to the client?
A
providing a low-sodium diet
B
reducing physical and emotional stress
C
restricting fluids to 1500 ml/day
D
administering insulin-replacement therapy
Question 41 Explanation:
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.
Question 42
The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should the nurse position the client?
A
Bed sloped at a 45 degree angle with the head lowest and the legs highest
B
Supine with the head turned to the left
C
Low Fowler’s with knees gatched at 30 degrees
D
Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow
Question 42 Explanation:
This position increases venous return, improves cardiac volume, and promotes adequate ventilation and cerebral perfusion
Question 43
A nurse caring to a client with Alzheimer’s disease overheard a family member say to the client, “if you pee one more time, I won’t give you any more food and drinks”. What initial action is best for the nurse to take?
A
Talk to the family member and explain that what she/he has said is not appropriate for the client
B
Take no action because it is the family member saying that to the client
C
Document what the family member has said
D
Give the family member the number for an Elder Abuse Hot line
Question 43 Explanation:
This response is the most direct and immediate. This is a case of potential need for advocacy and patient’s rights.
Question 44
The nurse on the night shift is about to administer medication to a preschooler client and notes that the child has no ID bracelet. The best way for the nurse to identify the client is to ask:
A
Another staff nurse to identify this child
B
The other children in the room what the child’s name is
C
The child, “Is your name____________?”
D
The adult visiting, “The child’s name is ____________________?”
Question 44 Explanation:
The only acceptable way to identify a preschooler client is to have a parent or another staff member identify the client.
Question 45
An experienced nurse who voluntarily trained a less experienced nurse with the intention of enhancing the skills and knowledge and promoting professional advancement to the nurse is called a:
A
mentor
B
case manager
C
team leader
D
change agent
Question 45 Explanation:
This describes a mentor
Question 46
A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes that consent has not been signed after preoperative medications were given. What should the nurse do?
A
Get a verbal consent from the parents of the client
B
Call the surgeon
C
Obtain a consent from the client as soon as possible
D
Ask the spouse to sign the consent
Question 46 Explanation:
The priority is to let the surgeon know, who in turn may ask the husband to sign the consent.
Question 47
A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be most correct in mixing it with:
A
5% dextrose in water
B
Normal Saline
C
Heparinized normal saline
D
Lactated Ringer’s solution
Question 47 Explanation:
Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it should be mixed with normal saline.
Question 48
The physician instructed the nurse that intravenous pyelogram will be done to the client. The client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to:
A
test renal tubular function and the patency of the urinary tract
B
outline the kidney vasculature
C
determine the size, shape, and placement of the kidneys
D
measure renal blood flow
Question 48 Explanation:
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.
Question 49
An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the swollen face resembling a handprint. The nurse does further assessment to the client. How would the nurse document the finding?
A
Facial edema with ecchymosis that looks like a handprint
B
Red bruise mark and ecchymosis on face
C
Facial edema, with red marks; crackles in the lung
D
Facial edema with ecchymosis and handprint mark: crackles and wheezes
Question 49 Explanation:
This is an example of objective data of both pulmonary status and direct observation on the skin by the nurse.
Question 50
After a birth, the physician cut the cord of the baby, and before the baby is given to the mother, what would be the initial nursing action of the nurse?
A
instill prophylactic medication in the infant’s eyes
B
confirm identification of the infant and apply bracelet to mother and infant
C
wrap the infant in a prewarmed blanket and cover the head
D
examine the infant for any observable abnormalities
Question 50 Explanation:
The first priority, beside maintaining a newborn’s patent airway, is body temperature.
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PNLE I Nursing Practice (EM)
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Question 1
A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of the test. Which of the following would be the best rationale for this?
A
respiratory problems are characteristic in this population
B
increased incidence of new cases of tuberculosis in persons over 65 years old
C
reactivation of an old tuberculosis infection
D
greater exposure to diverse health care workers
Question 1 Explanation:
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.
Question 2
The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose confidential information when:
A
The nurse discusses the condition of the client in a clinical conference with other nurses
B
A researcher from an institutionally approved research study reviews the medical record of a patient
C
The father of a woman who just delivered a baby is on the phone to find out the sex of the baby
D
The client asks the nurse to discuss the her condition with the family
Question 2 Explanation:
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
Question 3
A staff nurse has had a serious issue with her colleague. In this situation, it is best to:
A
Discuss this with the supervisor
B
Tell other members of the network what the team member did
C
Try to discuss with the colleague about the issue and resolve it when both are calmer
D
Not discuss the issue with anyone. It will probably resolve itself
Question 3 Explanation:
Waiting for emotions to dissipate and sitting down with the colleague is the first rule of conflict resolution.
Question 4
A 80-year-old female client is brought to the emergency department by her caregiver, on the nurse’s assessment; the following are the manifestations of the client: anorexia, cachexia and multiple bruises. What would be the best nursing intervention?
A
complete a gastrointestinal and neurological assessment
B
talk to the client about the caregiver and support system
C
complete a police report on elder abuse
D
check the laboratory data for serum albumin, hematocrit, and hemoglobin
Question 4 Explanation:
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.
Question 5
A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes that consent has not been signed after preoperative medications were given. What should the nurse do?
A
Get a verbal consent from the parents of the client
B
Ask the spouse to sign the consent
C
Call the surgeon
D
Obtain a consent from the client as soon as possible
Question 5 Explanation:
The priority is to let the surgeon know, who in turn may ask the husband to sign the consent.
Question 6
After a birth, the physician cut the cord of the baby, and before the baby is given to the mother, what would be the initial nursing action of the nurse?
A
examine the infant for any observable abnormalities
B
confirm identification of the infant and apply bracelet to mother and infant
C
wrap the infant in a prewarmed blanket and cover the head
D
instill prophylactic medication in the infant’s eyes
Question 6 Explanation:
The first priority, beside maintaining a newborn’s patent airway, is body temperature.
Question 7
The client is brought to the emergency department after a serious accident. What would be the initial nursing action of the nurse to the client?
A
check respiration, stabilize spine, check circulation
align the spine, check pupils, check for hemorrhage
Question 7 Explanation:
Checking the airway would be a priority, and a neck injury should be suspected
Question 8
The mother of the client tells the nurse, “ I’m not going to have my baby get any immunization”. What would be the best nursing response to the mother?
A
“Your decision can be viewed as a form of child abuse and neglect”
B
“You are needlessly placing other people at risk for communicable diseases”
C
“Your baby will not be able to attend day care without immunizations”
D
“You and I need to review your rationale for this decision”
Question 8 Explanation:
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.
Question 9
A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be most correct in mixing it with:
A
Lactated Ringer’s solution
B
Heparinized normal saline
C
Normal Saline
D
5% dextrose in water
Question 9 Explanation:
Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it should be mixed with normal saline.
Question 10
The nurse is assigned to care the client with infectious disease. The best antimicrobial agent for the nurse to use in handwashing is:
A
Isopropyl alcohol
B
Soap and water
C
Chlorhexidine gluconate (CHG) (Hibiclens)
D
Hexachlorophene (Phisohex)
Question 10 Explanation:
CHG is a highly effective antimicrobial ingredient, especially when it is used consistently over time.
Question 11
A client admitted to the hospital and diagnosed with Addison’s disease. What would be the appropriate nursing action to the client?
A
administering insulin-replacement therapy
B
providing a low-sodium diet
C
reducing physical and emotional stress
D
restricting fluids to 1500 ml/day
Question 11 Explanation:
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.
Question 12
A mother in labor told the nurse that she was expecting that her baby has no chance to survive and expects that the baby will be born dead. The mother accepts the fate of the baby and informs the nurse that when the baby is born and requires resuscitation, the mother refuses any treatment to her baby and expresses hostility toward the nurse while the pediatric team is taking care of the baby. The nurse is legally obligated to:
A
Get a court order making the baby a ward of the court
B
Record the statement of the mother, notify the pediatric team, and observe carefully for signs of impaired bonding and neglect as a reasonable suspicion of child abuse
C
Do nothing except record the mother’s statement in the medical record
D
Notify the pediatric team that the mother has refused resuscitation and any treatment for the baby and take the baby to the mother
Question 12 Explanation:
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
Question 13
An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following would be the best nursing response of the nurse?
A
“Your baby can’t empty the formula that is in the stomach into the bowel”
B
“Your baby needs to be burped more thoroughly after feeding”
C
“The vomiting is due to the nausea that accompanies pyloric stenosis”
D
“Your baby eats too rapidly and overfills the stomach, which causes vomiting
Question 13 Explanation:
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.
Question 14
The nurse is teaching the client about breast self-examination. Which observation should the client be taught to recognize when doing the examination for detection of breast cancer?
A
dimpling of the breast tissue
B
round, well-defined lump
C
pain on breast self-examination
D
tender, movable lump
Question 14 Explanation:
The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a dimpling appearance.
Question 15
A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. The nurse prepared the consent form and it should be signed by:
A
The 15-year-old mother of the baby boy
B
The mother of the girl
C
The Physician
D
The Registered Nurse caring for the client
Question 15 Explanation:
Even though the mother is a minor, she is legally able to sign consent for her own child.
Question 16
An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the swollen face resembling a handprint. The nurse does further assessment to the client. How would the nurse document the finding?
A
Facial edema, with red marks; crackles in the lung
B
Facial edema with ecchymosis and handprint mark: crackles and wheezes
C
Red bruise mark and ecchymosis on face
D
Facial edema with ecchymosis that looks like a handprint
Question 16 Explanation:
This is an example of objective data of both pulmonary status and direct observation on the skin by the nurse.
Question 17
The hospitalized client with a chronic cough is scheduled for bronchoscopy. The nurse is tasks to bring the informed consent document into the client’s room for a signature. The client asks the nurse for details of the procedure and demands an explanation why the process of informed consent is necessary. The nurse responds that informed consent means:
A
The patient releases the physician from all responsibility for the procedure.
B
The physician must give the client or surrogates enough information to make health care judgments consistent with their values and goals.
C
The immediate family may make decision against the patient’s will.
D
The patient agrees to a procedure ordered by the physician even if the client does not understand what the outcome will be.
Question 17 Explanation:
It best explains what informed consent is and provides for legal rights of the patient
Question 18
The night shift nurse is making rounds. When the nurse enters a client’s room, the client is on the floor next to the bed. What would be the initial action of the nurse?
A
chart that the patient fell
B
fill out an incident report
C
call the physician
D
chart that the client was found on the floor next to the bed
Question 18 Explanation:
This is closest to suggesting action-assessment, rather than paperwork- and is therefore the best of the four.
Question 19
A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager safely assign to the float nurse?
A
A child who had multiple injuries from a serious vehicle accident
B
A child diagnosed with Kawasaki disease and with cardiac complications
C
A child who has had a nephrectomy for Wilm’s tumor
D
A child receiving an IV chelating therapy for lead poisoning
Question 19 Explanation:
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.
Question 20
While in the hospital lobby, the RN overhears the three staff discussing the health condition of her client. What would be the appropriate nursing action for the RN to take?
A
Join in the conversation, giving them supportive input about the case of the client
B
Tell them it is not appropriate to discuss the condition of the client
C
Ignore them, because it is their right to discuss anything they want to
D
Report this incident to the nursing supervisor
Question 20 Explanation:
The behavior should be stopped. The first step is to remind the staff that confidentiality may be violated
Question 21
The physician instructed the nurse that intravenous pyelogram will be done to the client. The client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to:
A
measure renal blood flow
B
determine the size, shape, and placement of the kidneys
C
outline the kidney vasculature
D
test renal tubular function and the patency of the urinary tract
Question 21 Explanation:
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.
Question 22
A male client comes to the clinic for check-up. In doing a physical assessment, the nurse should report to the physician the most common symptom of gonorrhea, which is:
A
pruritus
B
WBC in the urine
C
Dysuria
D
pus in the urine
Question 22 Explanation:
Pus is usually the first symptom, because the bacteria reproduce in the bladder.
Question 23
The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should the nurse position the client?
A
Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow
B
Low Fowler’s with knees gatched at 30 degrees
C
Bed sloped at a 45 degree angle with the head lowest and the legs highest
D
Supine with the head turned to the left
Question 23 Explanation:
This position increases venous return, improves cardiac volume, and promotes adequate ventilation and cerebral perfusion
Question 24
The nurse is making a discharge instruction to a client receiving chemotherapy. The client is at risk for bone marrow depression. The nurse gives instructions to the client about how to prevent infection at home. Which of the following health teaching would be included?
A
“Avoid contact with others while receiving chemotherapy”
B
“Do not share a bathroom with children or pregnant woman”
C
“Do frequent hand washing and maintain good hygiene”
D
“Get a weekly WBC count”
Question 24 Explanation:
Frequent hand washing and good hygiene are the best means of preventing infection.
Question 25
The pediatrics unit is understaffed and the nurse manager informs the nurses in the obstetrics unit that she is going to assign one nurse to float in the pediatric units. Which statement by the designated float nurse may put her job at risk?
A
“ I am afraid I will get the most serious clients in the unit”
B
“I do not get along with one of the nurses on the pediatrics unit”
C
“I have a vacation day coming and would like to take that now”
D
“I do not feel competent to go and work on that area”
Question 25 Explanation:
This action demonstrates a lack of responsibility and the nurse should attempt negotiation with the nurse manager.
Question 26
The nurse is making a health teaching to the parents of the client. In teaching parents how to measure the area of induration in response to a PPD test, the nurse would be most accurate in advising the parents to measure:
A
The entire area that feels itchy to the child
B
Only the area that looks reddened
C
both the areas that look red and feel raised
D
Only the area that feels raised
Question 26 Explanation:
Parents should be taught to feel the area that is raised and measure only that.
Question 27
A community health nurse is schedule to do home visit. She visits to an elderly person living alone. Which of the following observation would be a concern?
A
Brightly lit rooms
B
Clear and shiny floors
C
Picture windows
D
Unwashed dishes in the sink
Question 27 Explanation:
It is a safety hazard to have shiny floors because they can cause falls.
Question 28
Which is true about informed consent?
A
If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the signature is that of the purported person and that the person’s condition is as indicated at the time of signing
B
Obtaining consent is not the responsibility of the physician
C
A nurse may accept responsibility signing a consent form if the client is unable
D
A physician will not subject himself to liability if he withholds any facts that are necessary to form the basis of an intelligent consent
Question 28 Explanation:
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”.
Question 29
The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric stenosis. The appropriate nursing response would be:
A
Their baby was born with this condition
B
Their baby developed this condition during the first few weeks of life
C
There is no way to determine this preoperatively
D
Their baby acquired it due to a formula allergy
Question 29 Explanation:
Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown. It develops during the first few weeks of life.
Question 30
A registered nurse has been assigned to six clients on the 12-hour shift. The RN is responsible for every aspect of care such as formulating the care of plan, intervention and evaluating the care during her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. This nursing care illustrates of what kind of method?
A
primary nursing method
B
functional method
C
case method
D
team method
Question 30 Explanation:
Case management. The nurse assumes total responsibility for meeting the needs of the client during her entire duty.
Question 31
The nurse on the night shift is about to administer medication to a preschooler client and notes that the child has no ID bracelet. The best way for the nurse to identify the client is to ask:
A
The other children in the room what the child’s name is
B
Another staff nurse to identify this child
C
The adult visiting, “The child’s name is ____________________?”
D
The child, “Is your name____________?”
Question 31 Explanation:
The only acceptable way to identify a preschooler client is to have a parent or another staff member identify the client.
Question 32
During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements?
A
limit suction pressure to 150-180 mmHg
B
remove the inner cannula
C
wear eye goggles
D
suction for 15-20 seconds
Question 32 Explanation:
It is important to protect the RN’s eyes from the possible contamination of coughed-up secretions
Question 33
A nurse manager assigned a registered nurse from telemetry unit to the pediatrics unit. There were three patients assigned to the RN. Which of the following patients should not be assigned to the floated nurse?
A
A 9-year-old child diagnosed with rheumatic fever
B
A 4-year-old with VSD following cardiac catheterization
C
A young infant after pyloromyotomy
D
A 5-month-old with Kawasaki disease
Question 33 Explanation:
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.
Question 34
A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an amputation. The client tells the nurse that he will not sign the consent form and he does not want any surgery or treatment because of religious beliefs about reincarnation. What is the role of the RN?
A
encourage the client to have the surgery
B
discuss the religious beliefs with the physician
C
call a family meeting
D
inform the client of other options
Question 34 Explanation:
The physician may not be aware of the role that religious beliefs play in making a decision about surgery.
Question 35
The nurse in the medication unit passes the medications for all the clients on the nursing unit. The head nurse is making rounds with the physician and coordinates clients’ activities with other departments. The nurse assistant changes the bed lines and answers call lights. A second nurse is assigned for changing wound dressings; a licensed practitioner nurse takes vital signs and bathes the clients. This illustrates of what method of nursing care?
A
Functional method
B
Case management method
C
Team method
D
Primary nursing method
Question 35 Explanation:
It describes functional nursing. Staff is assigned to specific task rather than specific clients.
Question 36
A newly hired nurse on an adult medicine unit with 3 months experience was asked to float to pediatrics. The nurse hesitates to perform pediatric skills and receive an interesting assignment that feels overwhelming. The nurse should:
A
Inform the nursing supervisor and the charge nurse on the pediatric floor about the nurse’s lack of skill and feelings of hesitations and request assistance
B
Ask several other nurses how they feel about pediatrics and find someone else who is willing to accept the assignment
C
Refuse the assignment and leave the unit requesting a vacation a day
D
resign on the spot from the nursing position and apply for a position that does not require floating
Question 36 Explanation:
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 abandoning clients and exposing them to greater risks
Question 37
The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is essential to prevent hypoxemia?
A
removing oral and nasal secretions
B
aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning
C
administering 100% oxygen to reduce the effects of airway obstruction during suctioning.
D
encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions
Question 37 Explanation:
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.
Question 38
A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck and arms. The client is scratching the affected areas. What would be the best nursing intervention to prevent the client from scratching the affected areas?
A
Clove-hitch restraints to the hands
B
A posey jacket to the torso
C
Mittens to the hands
D
elbow restraints to the arms
Question 38 Explanation:
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.
Question 39
The newly hired staff nurse has been working on a medical unit for 3 weeks. The nurse manager has posted the team leader assignments for the following week. The new staff knows that a major responsibility of the team leader is to:
A
Provide care to the most acutely ill client on the team
B
Document the assessments completed by the team members
C
Know the condition and needs of all the patients on the team
D
Supervise direct care by nursing assistants
Question 39 Explanation:
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
Question 40
Which of the following would be the most important goal in the nursing care of an infant client with eczema?
A
providing for adequate nutrition
B
maintaining the comfort level
C
decreasing the itching
D
preventing infection
Question 40 Explanation:
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.
Question 41
The nurse caring to a client has completed the assessment. Which of the following will be considered to be the most accurate charting of a lump felt in the right breast?
A
“abnormally felt area in the right breast, drainage noted”
B
“firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’
C
“mass in the right breast 4cmx1cm
D
“hard nodular mass in right breast nipple”
Question 41 Explanation:
It describes the mass in the greatest detail.
Question 42
A nurse caring to a client with Alzheimer’s disease overheard a family member say to the client, “if you pee one more time, I won’t give you any more food and drinks”. What initial action is best for the nurse to take?
A
Take no action because it is the family member saying that to the client
B
Talk to the family member and explain that what she/he has said is not appropriate for the client
C
Give the family member the number for an Elder Abuse Hot line
D
Document what the family member has said
Question 42 Explanation:
This response is the most direct and immediate. This is a case of potential need for advocacy and patient’s rights.
Question 43
A client visits the clinic for screening of scoliosis. The nurse should ask the client to:
A
bend over at a 90-degree angle from the waist
B
bend over at a 45-degree angle from the waist
C
stand up as straight and tall as possible
D
bend all the way over and touch the toes
Question 43 Explanation:
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.
Question 44
The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP). Which of the following task could the registered nurse safely assigned to a UAP?
A
Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall
B
Give an outmeal bath to an infant with eczema
C
Check the IV of a preschooler with Kawasaki disease
D
Monitor the I&O of a comatose toddler client with salicylate poisoning
Question 44 Explanation:
Bathing an infant with eczema can be safely delegated to an aide; this task is basic and can competently performed by an aid.
Question 45
An experienced nurse who voluntarily trained a less experienced nurse with the intention of enhancing the skills and knowledge and promoting professional advancement to the nurse is called a:
A
team leader
B
change agent
C
case manager
D
mentor
Question 45 Explanation:
This describes a mentor
Question 46
On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which in the following clients should receive highest priority?
A
A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw
B
A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon
C
an elderly woman complaining of a loss of appetite and fatigue for the past week
D
A football player limping and complaining of pain and swelling in the right ankle
Question 46 Explanation:
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.
Question 47
The registered nurse is planning to delegate task to a certified nursing assistant. Which of the following clients should not be assigned to a CAN?
A
A client who had a CVA in the past two months
B
A client with chronic venous insufficiency
C
A client with Chronic renal failure
D
A client diagnosed with diabetes and who has an infected toe
Question 47 Explanation:
The patient is experiencing a potentially serious complication related to diabetes and needs ongoing assessment by an RN
Question 48
A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s family members come to visit, they would be adhering to respiratory isolation precautions when they:
A
put on gowns, gloves and masks
B
avoid contact with the client’s roommate
C
wash their hands when leaving
D
keep the client’s room door open
Question 48 Explanation:
Handwashing is the best method for reducing cross-contamination. Gowns and gloves are not always required when entering a client’s room.
Question 49
A nurse is assigned to care to a client with Parkinson’s disease. What interventions are important if the nurse wants to improve nutrition and promote effective swallowing of the client?
A
Feed the client
B
Give liquids with meals
C
Eat solid food
D
Sit in an upright position to eat
Question 49 Explanation:
Client with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing.
Question 50
The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of hypoglycemia should be taught to a client?
A
warm, flushed skin
B
hunger and thirst
C
palpitation and weakness
D
increase urinary output
Question 50 Explanation:
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
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Text Mode
Text Mode – Text version of the exam
Scope of this Nursing Test I is parallel to the NP1 NLE Coverage:
Foundation of Nursing
Nursing Research
Professional Adjustment
Leadership and Management
1. The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP). Which of the following task could the registered nurse safely assigned to a UAP?
Monitor the I&O of a comatose toddler client with salicylate poisoning
Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall
Check the IV of a preschooler with Kawasaki disease
Give an outmeal bath to an infant with eczema
2. A nurse manager assigned a registered nurse from telemetry unit to the pediatrics unit. There were three patients assigned to the RN. Which of the following patients should not be assigned to the floated nurse?
A 9-year-old child diagnosed with rheumatic fever
A young infant after pyloromyotomy
A 4-year-old with VSD following cardiac catheterization
A 5-month-old with Kawasaki disease
3. A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager safely assign to the float nurse?
A child who had multiple injuries from a serious vehicle accident
A child diagnosed with Kawasaki disease and with cardiac complications
A child who has had a nephrectomy for Wilm’s tumor
A child receiving an IV chelating therapy for lead poisoning
4. The registered nurse is planning to delegate task to a certified nursing assistant. Which of the following clients should not be assigned to a CAN?
A client diagnosed with diabetes and who has an infected toe
A client who had a CVA in the past two months
A client with Chronic renal failure
A client with chronic venous insufficiency
5. The nurse in the medication unit passes the medications for all the clients on the nursing unit. The head nurse is making rounds with the physician and coordinates clients’ activities with other departments. The nurse assistant changes the bed lines and answers call lights. A second nurse is assigned for changing wound dressings; a licensed practitioner nurse takes vital signs and bathes theclients. This illustrates of what method of nursing care?
Case management method
Primary nursing method
Team method
Functional method
6. A registered nurse has been assigned to six clients on the 12-hour shift. The RN is responsible for every aspect of care such as formulating the care of plan, intervention and evaluating the care during her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. This nursing care illustrates of what kind of method?
primary nursing method
case method
team method
functional method
7. A newly hired nurse on an adult medicine unit with 3 months experience was asked to float to pediatrics. The nurse hesitates to perform pediatric skills and receive an interesting assignment that feels overwhelming. The nurse should:
resign on the spot from the nursing position and apply for a position that does not require floating
Inform the nursing supervisor and the charge nurse on the pediatric floor about the nurse’s lack of skill and feelings of hesitations and request assistance
Ask several other nurses how they feel about pediatrics and find someone else who is willing to accept the assignment
Refuse the assignment and leave the unit requesting a vacation a day
8. An experienced nurse who voluntarily trained a less experienced nurse with the intention of enhancing the skills and knowledge and promoting professional advancement to the nurse is called a:
mentor
team leader
case manager
change agent
9. The pediatrics unit is understaffed and the nurse manager informs the nurses in the obstetrics unit that she is going to assign one nurse to float in the pediatric units. Which statement by the designated float nurse may put her job at risk?
“I do not get along with one of the nurses on the pediatrics unit”
“I have a vacation day coming and would like to take that now”
“I do not feel competent to go and work on that area”
“ I am afraid I will get the most serious clients in the unit”
10. The newly hired staff nurse has been working on a medical unit for 3 weeks. The nurse manager has posted the team leader assignments for the following week. The new staff knows that a major responsibility of the team leader is to:
Provide care to the most acutely ill client on the team
Know the condition and needs of all the patients on the team
Document the assessments completed by the team members
Supervise direct care by nursing assistants
11. A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. The nurse prepared the consent form and it should be signed by:
The Physician
The Registered Nurse caring for the client
The 15-year-old mother of the baby boy
The mother of the girl
12. A nurse caring to a client with Alzheimer’s disease overheard a family member say to the client, “if you pee one more time, I won’t give you any more food and drinks”. What initial action is best for the nurse to take?
Take no action because it is the family member saying that to the client
Talk to the family member and explain that what she/he has said is not appropriate for the client
Give the family member the number for an Elder Abuse Hot line
Document what the family member has said
13. Which is true about informed consent?
A nurse may accept responsibility signing a consent form if the client is unable
Obtaining consent is not the responsibility of the physician
A physician will not subject himself to liability if he withholds any facts that are necessary to form the basis of an intelligent consent
If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the signature is that of the purported person and that the person’s condition is as indicated at the time of signing
14. A mother in labor told the nurse that she was expecting that her baby has no chance to survive and expects that the baby will be born dead. The mother accepts the fate of the baby and informs the nurse that when the baby is born and requires resuscitation, the mother refuses any treatment to her baby and expresses hostility toward the nurse while the pediatric team is taking care of the baby. The nurse is legally obligated to:
Notify the pediatric team that the mother has refused resuscitation and any treatment for the baby and take the baby to the mother
Get a court order making the baby a ward of the court
Record the statement of the mother, notify the pediatric team, and observe carefully for signs of impaired bonding and neglect as a reasonable suspicion of child abuse
Do nothing except record the mother’s statement in the medical record
15. The hospitalized client with a chronic cough is scheduled for bronchoscopy. The nurse is tasks to bring the informed consent document into the client’s room for a signature. The client asks the nurse for details of the procedure and demands an explanation why the process of informed consent is necessary. The nurse responds that informed consent means:
The patient releases the physician from all responsibility for the procedure.
The immediate family may make decision against the patient’s will.
The physician must give the client or surrogates enough information to make health care judgments consistent with their values and goals.
The patient agrees to a procedure ordered by the physician even if the client does not understand what the outcome will be.
16. A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an amputation. The client tells the nurse that he will not sign the consent form and he does not want any surgery or treatment because of religious beliefs about reincarnation. What is the role of the RN?
call a family meeting
discuss the religious beliefs with the physician
encourage the client to have the surgery
inform the client of other options
17. While in the hospital lobby, the RN overhears the three staff discussing the health condition of her client. What would be the appropriate nursing action for the RN to take?
Tell them it is not appropriate to discuss the condition of the client
Ignore them, because it is their right to discuss anything they want to
Join in the conversation, giving them supportive input about the case of the client
Report this incident to the nursing supervisor
18. A staff nurse has had a serious issue with her colleague. In this situation, it is best to:
Discuss this with the supervisor
Not discuss the issue with anyone. It will probably resolve itself
Try to discuss with the colleague about the issue and resolve it when both are calmer
Tell other members of the network what the team member did
19. The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose confidential information when:
The nurse discusses the condition of the client in a clinical conference with other nurses
The client asks the nurse to discuss the her condition with the family
The father of a woman who just delivered a baby is on the phone to find out the sex of the baby
A researcher from an institutionally approved research study reviews the medical record of a patient
20. A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes that consent has not been signed after preoperative medications were given. What should the nurse do?
Call the surgeon
Ask the spouse to sign the consent
Obtain a consent from the client as soon as possible
Get a verbal consent from the parents of the client
21. A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be most correct in mixing it with:
Normal Saline
Heparinized normal saline
5% dextrose in water
Lactated Ringer’s solution
22. The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should the nurse position the client?
Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow
Low Fowler’s with knees gatched at 30 degrees
Supine with the head turned to the left
Bed sloped at a 45 degree angle with the head lowest and the legs highest
23. The client is brought to the emergency department after a serious accident. What would be the initial nursing action of the nurse to the client?
align the spine, check pupils, check for hemorrhage
check respiration, stabilize spine, check circulation
24. A nurse is assigned to care to a client with Parkinson’s disease. What interventions are important if the nurse wants to improve nutrition and promote effective swallowing of the client?
Eat solid food
Give liquids with meals
Feed the client
Sit in an upright position to eat
25. During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements?
limit suction pressure to 150-180 mmHg
suction for 15-20 seconds
wear eye goggles
remove the inner cannula
26. The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of hypoglycemia should be taught to a client?
warm, flushed skin
hunger and thirst
increase urinary output
palpitation and weakness
27. A client admitted to the hospital and diagnosed with Addison’s disease. What would be the appropriate nursing action to the client?
administering insulin-replacement therapy
providing a low-sodium diet
restricting fluids to 1500 ml/day
reducing physical and emotional stress
28. The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is essential to prevent hypoxemia?
aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning
removing oral and nasal secretions
encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions
administering 100% oxygen to reduce the effects of airway obstruction during suctioning.
29. An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the swollen face resembling a handprint. The nurse does further assessment to the client. How would the nurse document the finding?
Facial edema with ecchymosis and handprint mark: crackles and wheezes
Facial edema, with red marks; crackles in the lung
Facial edema with ecchymosis that looks like a handprint
Red bruise mark and ecchymosis on face
30. On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which in the following clients should receive highest priority?
an elderly woman complaining of a loss of appetite and fatigue for the past week
A football player limping and complaining of pain and swelling in the right ankle
A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw
A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon
31. A 80-year-old female client is brought to the emergency department by her caregiver, on the nurse’s assessment; the following are the manifestations of the client: anorexia, cachexia and multiple bruises. What would be the best nursing intervention?
check the laboratory data for serum albumin, hematocrit, and hemoglobin
talk to the client about the caregiver and support system
complete a police report on elder abuse
complete a gastrointestinal and neurological assessment
32. The night shift nurse is making rounds. When the nurse enters a client’s room, the client is on the floor next to the bed. What would be the initial action of the nurse?
chart that the patient fell
call the physician
chart that the client was found on the floor next to the bed
fill out an incident report
33. The nurse on the night shift is about to administer medication to a preschooler client and notes that the child has no ID bracelet. The best way for the nurse to identify the client is to ask:
The adult visiting, “The child’s name is ____________________?”
The child, “Is your name____________?”
Another staff nurse to identify this child
The other children in the room what the child’s name is
34. The nurse caring to a client has completed the assessment. Which of the following will be considered to be the most accurate charting of a lump felt in the right breast?
“abnormally felt area in the right breast, drainage noted”
“hard nodular mass in right breast nipple”
“firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’
“mass in the right breast 4cmx1cm
35. The physician instructed the nurse that intravenous pyelogram will be done to the client. The client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to:
outline the kidney vasculature
determine the size, shape, and placement of the kidneys
test renal tubular function and the patency of the urinary tract
measure renal blood flow
36. A client visits the clinic for screening of scoliosis. The nurse should ask the client to:
bend all the way over and touch the toes
stand up as straight and tall as possible
bend over at a 90-degree angle from the waist
bend over at a 45-degree angle from the waist
37. A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s family members come to visit, they would be adhering to respiratory isolation precautions when they:
wash their hands when leaving
put on gowns, gloves and masks
avoid contact with the client’s roommate
keep the client’s room door open
38. An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following would be the best nursing response of the nurse?
“Your baby eats too rapidly and overfills the stomach, which causes vomiting
“Your baby can’t empty the formula that is in the stomach into the bowel”
“The vomiting is due to the nausea that accompanies pyloric stenosis”
“Your baby needs to be burped more thoroughly after feeding”
39. A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of the test. Which of the following would be the best rationale for this?
reactivation of an old tuberculosis infection
increased incidence of new cases of tuberculosis in persons over 65 years old
greater exposure to diverse health care workers
respiratory problems are characteristic in this population
40. The nurse is making a health teaching to the parents of the client. In teaching parents how to measure the area of induration in response to a PPD test, the nurse would be most accurate in advising the parents to measure:
both the areas that look red and feel raised
The entire area that feels itchy to the child
Only the area that looks reddened
Only the area that feels raised
41. A community health nurse is schedule to do home visit. She visits to an elderly person living alone. Which of the following observation would be a concern?
Picture windows
Unwashed dishes in the sink
Clear and shiny floors
Brightly lit rooms
42. After a birth, the physician cut the cord of the baby, and before the baby is given to the mother, what would be the initial nursing action of the nurse?
examine the infant for any observable abnormalities
confirm identification of the infant and apply bracelet to mother and infant
instill prophylactic medication in the infant’s eyes
wrap the infant in a prewarmed blanket and cover the head
43. A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck and arms. The client is scratching the affected areas. What would be the best nursing intervention to prevent the client from scratching the affected areas?
elbow restraints to the arms
Mittens to the hands
Clove-hitch restraints to the hands
A posey jacket to the torso
44. The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric stenosis. The appropriate nursing response would be:
There is no way to determine this preoperatively
Their baby was born with this condition
Their baby developed this condition during the first few weeks of life
Their baby acquired it due to a formula allergy
45. A male client comes to the clinic for check-up. In doing a physical assessment, the nurse should report to the physician the most common symptom of gonorrhea, which is:
pruritus
pus in the urine
WBC in the urine
Dysuria
46. Which of the following would be the most important goal in the nursing care of an infant client with eczema?
preventing infection
maintaining the comfort level
providing for adequate nutrition
decreasing the itching
47. The nurse is making a discharge instruction to a client receiving chemotherapy. The client is at risk for bone marrow depression. The nurse gives instructions to the client about how to prevent infection at home. Which of the following health teaching would be included?
“Get a weekly WBC count”
“Do not share a bathroom with children or pregnant woman”
“Avoid contact with others while receiving chemotherapy”
“Do frequent hand washing and maintain good hygiene”
48. The nurse is assigned to care the client with infectious disease. The best antimicrobial agent for the nurse to use in handwashing is:
Isopropyl alcohol
Hexachlorophene (Phisohex)
Soap and water
Chlorhexidine gluconate (CHG) (Hibiclens)
49. The mother of the client tells the nurse, “ I’m not going to have my baby get any immunization”. What would be the best nursing response to the mother?
“You and I need to review your rationale for this decision”
“Your baby will not be able to attend day care without immunizations”
“Your decision can be viewed as a form of child abuse and neglect”
“You are needlessly placing other people at risk for communicable diseases”
50. The nurse is teaching the client about breast self-examination. Which observation should the client be taught to recognize when doing the examination for detection of breast cancer?
tender, movable lump
pain on breast self-examination
round, well-defined lump
dimpling of the breast tissue
Answers and Rationales
D. Bathing an infant with eczema can be safely delegated to an aide; this task is basic and can competently performed by an aid.
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.
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.
A. The patient is experiencing a potentially serious complication related to diabetes and needs ongoing assessment by an RN
D. It describes functional nursing. Staff is assigned to specific task rather than specific clients.
B. Case management. The nurse assumes total responsibility for meeting the needs of the client during her entire duty.
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
A. This describes a mentor
B. This action demonstrates a lack of responsibility and the nurse should attempt negotiation with the nurse manager.
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
C. Even though the mother is a minor, she is legally able to sign consent for her own child.
B. This response is the most direct and immediate. This is a case of potential need for advocacy and patient’s rights.
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”.
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
C. It best explains what informed consent is and provides for legal rights of the patient
B. The physician may not be aware of the role that religious beliefs play in making a decision about surgery.
A. The behavior should be stopped. The first step is to remind the staff that confidentiality may be violated
C. Waiting for emotions to dissipate and sitting down with the colleague is the first rule of conflict resolution.
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
A. The priority is to let the surgeon know, who in turn may ask the husband to sign the consent.
A. Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it should be mixed with normal saline.
A. This position increases venous return, improves cardiac volume, and promotes adequate ventilation and cerebral perfusion
D. Checking the airway would be a priority, and a neck injury should be suspected
D. Client with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing.
C. It is important to protect the RN’s eyes from the possible contamination of coughed-up secretions
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
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.
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.
B. This is an example of objective data of both pulmonary status and direct observation on the skin by the nurse.
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.
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.
B. This is closest to suggesting action-assessment, rather than paperwork- and is therefore the best of the four.
C. The only acceptable way to identify a preschooler client is to have a parent or another staff member identify the client.
C. It describes the mass in the greatest detail.
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.
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.
A. Handwashing is the best method for reducing cross-contamination. Gowns and gloves are not always required when entering a client’s room.
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.
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.
D. Parents should be taught to feel the area that is raised and measure only that.
C. It is a safety hazard to have shiny floors because they can cause falls.
D. The first priority, beside maintaining a newborn’s patent airway, is body temperature.
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.
C. Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown. It develops during the first few weeks of life.
B. Pus is usually the first symptom, because the bacteria reproduce in the bladder.
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.
D. Frequent hand washing and good hygiene are the best means of preventing infection.
D. CHG is a highly effective antimicrobial ingredient, especially when it is used consistently over time.
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.
D. The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a dimpling appearance.