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PNLE I Nursing Practice (PM)
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Question 1
During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements?
A
remove the inner cannula
B
limit suction pressure to 150-180 mmHg
C
suction for 15-20 seconds
D
wear eye goggles
Question 1 Explanation:
It is important to protect the RN’s eyes from the possible contamination of coughed-up secretions
Question 2
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
Primary nursing method
B
Functional method
C
Team method
D
Case management method
Question 2 Explanation:
It describes functional nursing. Staff is assigned to specific task rather than specific clients.
Question 3
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
tender, movable lump
B
dimpling of the breast tissue
C
round, well-defined lump
D
pain on breast self-examination
Question 3 Explanation:
The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a dimpling appearance.
Question 4
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 4 Explanation:
It best explains what informed consent is and provides for legal rights of the patient
Question 5
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
avoid contact with the client’s roommate
D
keep the client’s room door open
Question 5 Explanation:
Handwashing is the best method for reducing cross-contamination. Gowns and gloves are not always required when entering a client’s room.
Question 6
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
Facial edema with ecchymosis that looks like a handprint
D
Red bruise mark and ecchymosis on face
Question 6 Explanation:
This is an example of objective data of both pulmonary status and direct observation on the skin by the nurse.
Question 7
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
chart that the client was found on the floor next to the bed
C
call the physician
D
fill out an incident report
Question 7 Explanation:
This is closest to suggesting action-assessment, rather than paperwork- and is therefore the best of the four.
Question 8
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
Ignore them, because it is their right to discuss anything they want to
C
Report this incident to the nursing supervisor
D
Tell them it is not appropriate to discuss the condition of the client
Question 8 Explanation:
The behavior should be stopped. The first step is to remind the staff that confidentiality may be violated
Question 9
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
Picture windows
B
Clear and shiny floors
C
Brightly lit rooms
D
Unwashed dishes in the sink
Question 9 Explanation:
It is a safety hazard to have shiny floors because they can cause falls.
Question 10
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
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
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
Get a court order making the baby a ward of the court
D
Do nothing except record the mother’s statement in the medical record
Question 10 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 11
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 feels raised
C
both the areas that look red and feel raised
D
Only the area that looks reddened
Question 11 Explanation:
Parents should be taught to feel the area that is raised and measure only that.
Question 12
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
check the laboratory data for serum albumin, hematocrit, and hemoglobin
D
complete a police report on elder abuse
Question 12 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 13
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 Physician
C
The Registered Nurse caring for the client
D
The mother of the girl
Question 13 Explanation:
Even though the mother is a minor, she is legally able to sign consent for her own child.
Question 14
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 4-year-old with VSD following cardiac catheterization
B
A 9-year-old child diagnosed with rheumatic fever
C
A 5-month-old with Kawasaki disease
D
A young infant after pyloromyotomy
Question 14 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 15
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
reactivation of an old tuberculosis infection
B
increased incidence of new cases of tuberculosis in persons over 65 years old
C
greater exposure to diverse health care workers
D
respiratory problems are characteristic in this population
Question 15 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 16
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
instill prophylactic medication in the infant’s eyes
C
confirm identification of the infant and apply bracelet to mother and infant
D
wrap the infant in a prewarmed blanket and cover the head
Question 16 Explanation:
The first priority, beside maintaining a newborn’s patent airway, is body temperature.
Question 17
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 17 Explanation:
This describes a mentor
Question 18
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
“You are needlessly placing other people at risk for communicable diseases”
C
“You and I need to review your rationale for this decision”
D
“Your decision can be viewed as a form of child abuse and neglect”
Question 18 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 19
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
an elderly woman complaining of a loss of appetite and fatigue for the past week
B
A football player limping and complaining of pain and swelling in the right ankle
C
A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon
D
A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw
Question 19 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 20
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 frequent hand washing and maintain good hygiene”
C
“Get a weekly WBC count”
D
“Do not share a bathroom with children or pregnant woman”
Question 20 Explanation:
Frequent hand washing and good hygiene are the best means of preventing infection.
Question 21
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 am afraid I will get the most serious clients in the unit”
C
“I do not feel competent to go and work on that area”
D
“I have a vacation day coming and would like to take that now”
Question 21 Explanation:
This action demonstrates a lack of responsibility and the nurse should attempt negotiation with the nurse manager.
Question 22
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
team method
D
case method
Question 22 Explanation:
Case management. The nurse assumes total responsibility for meeting the needs of the client during her entire duty.
Question 23
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
restricting fluids to 1500 ml/day
C
reducing physical and emotional stress
D
administering insulin-replacement therapy
Question 23 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 24
The nurse is assigned to care the client with infectious disease. The best antimicrobial agent for the nurse to use in handwashing is:
A
Hexachlorophene (Phisohex)
B
Isopropyl alcohol
C
Chlorhexidine gluconate (CHG) (Hibiclens)
D
Soap and water
Question 24 Explanation:
CHG is a highly effective antimicrobial ingredient, especially when it is used consistently over time.
Question 25
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
Check the IV of a preschooler with Kawasaki disease
C
Monitor the I&O of a comatose toddler client with salicylate poisoning
D
Give an outmeal bath to an infant with eczema
Question 25 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 26
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
palpitation and weakness
C
increase urinary output
D
hunger and thirst
Question 26 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 27
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
Ask the spouse to sign the consent
B
Call the surgeon
C
Get a verbal consent from the parents of the client
D
Obtain a consent from the client as soon as possible
Question 27 Explanation:
The priority is to let the surgeon know, who in turn may ask the husband to sign the consent.
Question 28
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
stand up as straight and tall as possible
C
bend all the way over and touch the toes
D
bend over at a 45-degree angle from the waist
Question 28 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 29
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
Give the family member the number for an Elder Abuse Hot line
D
Document what the family member has said
Question 29 Explanation:
This response is the most direct and immediate. This is a case of potential need for advocacy and patient’s rights.
Question 30
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
“hard nodular mass in right breast nipple”
C
“firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’
D
“mass in the right breast 4cmx1cm
Question 30 Explanation:
It describes the mass in the greatest detail.
Question 31
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 diagnosed with diabetes and who has an infected toe
B
A client with Chronic renal failure
C
A client with chronic venous insufficiency
D
A client who had a CVA in the past two months
Question 31 Explanation:
The patient is experiencing a potentially serious complication related to diabetes and needs ongoing assessment by an RN
Question 32
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
discuss the religious beliefs with the physician
B
call a family meeting
C
encourage the client to have the surgery
D
inform the client of other options
Question 32 Explanation:
The physician may not be aware of the role that religious beliefs play in making a decision about surgery.
Question 33
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 had multiple injuries from a serious vehicle accident
C
A child receiving an IV chelating therapy for lead poisoning
D
A child who has had a nephrectomy for Wilm’s tumor
Question 33 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 34
A staff nurse has had a serious issue with her colleague. In this situation, it is best to:
A
Tell other members of the network what the team member did
B
Try to discuss with the colleague about the issue and resolve it when both are calmer
C
Not discuss the issue with anyone. It will probably resolve itself
D
Discuss this with the supervisor
Question 34 Explanation:
Waiting for emotions to dissipate and sitting down with the colleague is the first rule of conflict resolution.
Question 35
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
Supine with the head turned to the left
C
Bed sloped at a 45 degree angle with the head lowest and the legs highest
D
Low Fowler’s with knees gatched at 30 degrees
Question 35 Explanation:
This position increases venous return, improves cardiac volume, and promotes adequate ventilation and cerebral perfusion
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
Ask several other nurses how they feel about pediatrics and find someone else who is willing to accept the assignment
B
resign on the spot from the nursing position and apply for a position that does not require floating
C
Refuse the assignment and leave the unit requesting a vacation a day
D
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
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
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 needs to be burped more thoroughly after feeding”
B
“The vomiting is due to the nausea that accompanies pyloric stenosis”
C
“Your baby can’t empty the formula that is in the stomach into the bowel”
D
“Your baby eats too rapidly and overfills the stomach, which causes vomiting
Question 37 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 38
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
encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions
D
administering 100% oxygen to reduce the effects of airway obstruction during suctioning.
Question 38 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 39
Which of the following would be the most important goal in the nursing care of an infant client with eczema?
A
maintaining the comfort level
B
decreasing the itching
C
preventing infection
D
providing for adequate nutrition
Question 39 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 40
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
pus in the urine
B
Dysuria
C
pruritus
D
WBC in the urine
Question 40 Explanation:
Pus is usually the first symptom, because the bacteria reproduce in the bladder.
Question 41
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
elbow restraints to the arms
B
Mittens to the hands
C
Clove-hitch restraints to the hands
D
A posey jacket to the torso
Question 41 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 42
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?
check respiration, stabilize spine, check circulation
D
align the spine, check pupils, check for hemorrhage
Question 42 Explanation:
Checking the airway would be a priority, and a neck injury should be suspected
Question 43
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
Lactated Ringer’s solution
C
Normal Saline
D
Heparinized normal saline
Question 43 Explanation:
Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it should be mixed with normal saline.
Question 44
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
determine the size, shape, and placement of the kidneys
B
measure renal blood flow
C
outline the kidney vasculature
D
test renal tubular function and the patency of the urinary tract
Question 44 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 45
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
Know the condition and needs of all the patients on the team
B
Provide care to the most acutely ill client on the team
C
Supervise direct care by nursing assistants
D
Document the assessments completed by the team members
Question 45 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 46
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
Give liquids with meals
B
Feed the client
C
Eat solid food
D
Sit in an upright position to eat
Question 46 Explanation:
Client with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing.
Question 47
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
A researcher from an institutionally approved research study reviews the medical record of a patient
B
The father of a woman who just delivered a baby is on the phone to find out the sex of the baby
C
The nurse discusses the condition of the client in a clinical conference with other nurses
D
The client asks the nurse to discuss the her condition with the family
Question 47 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 48
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
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
A nurse may accept responsibility signing a consent form if the client is unable
Question 48 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 49
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 adult visiting, “The child’s name is ____________________?”
C
The child, “Is your name____________?”
D
The other children in the room what the child’s name is
Question 49 Explanation:
The only acceptable way to identify a preschooler client is to have a parent or another staff member identify the client.
Question 50
The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric stenosis. The appropriate nursing response would be:
A
There is no way to determine this preoperatively
B
Their baby was born with this condition
C
Their baby acquired it due to a formula allergy
D
Their baby developed this condition during the first few weeks of life
Question 50 Explanation:
Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown. It develops during the first few weeks of life.
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PNLE I Nursing Practice (EM)
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Question 1
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 needs to be burped more thoroughly after feeding”
B
“Your baby can’t empty the formula that is in the stomach into the bowel”
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 1 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 2
A client admitted to the hospital and diagnosed with Addison’s disease. What would be the appropriate nursing action to the client?
A
reducing physical and emotional stress
B
providing a low-sodium diet
C
restricting fluids to 1500 ml/day
D
administering insulin-replacement therapy
Question 2 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 3
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
resign on the spot from the nursing position and apply for a position that does not require floating
B
Ask several other nurses how they feel about pediatrics and find someone else who is willing to accept the assignment
C
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
D
Refuse the assignment and leave the unit requesting a vacation a day
Question 3 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 4
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 immediate family may make decision against the patient’s will.
C
The patient agrees to a procedure ordered by the physician even if the client does not understand what the outcome will be.
D
The physician must give the client or surrogates enough information to make health care judgments consistent with their values and goals.
Question 4 Explanation:
It best explains what informed consent is and provides for legal rights of the patient
Question 5
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
chart that the patient fell
C
fill out an incident report
D
chart that the client was found on the floor next to the bed
Question 5 Explanation:
This is closest to suggesting action-assessment, rather than paperwork- and is therefore the best of the four.
Question 6
The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of hypoglycemia should be taught to a client?
A
hunger and thirst
B
palpitation and weakness
C
warm, flushed skin
D
increase urinary output
Question 6 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 7
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 7 Explanation:
It is a safety hazard to have shiny floors because they can cause falls.
Question 8
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
Monitor the I&O of a comatose toddler client with salicylate poisoning
B
Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall
C
Give an outmeal bath to an infant with eczema
D
Check the IV of a preschooler with Kawasaki disease
Question 8 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 9
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 Physician
C
The mother of the girl
D
The Registered Nurse caring for the client
Question 9 Explanation:
Even though the mother is a minor, she is legally able to sign consent for her own child.
Question 10
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
Obtain a consent from the client as soon as possible
B
Ask the spouse to sign the consent
C
Get a verbal consent from the parents of the client
D
Call the surgeon
Question 10 Explanation:
The priority is to let the surgeon know, who in turn may ask the husband to sign the consent.
Question 11
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 11 Explanation:
The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a dimpling appearance.
Question 12
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
Red bruise mark and ecchymosis on face
B
Facial edema, with red marks; crackles in the lung
C
Facial edema with ecchymosis that looks like a handprint
D
Facial edema with ecchymosis and handprint mark: crackles and wheezes
Question 12 Explanation:
This is an example of objective data of both pulmonary status and direct observation on the skin by the nurse.
Question 13
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
Normal Saline
B
Heparinized normal saline
C
5% dextrose in water
D
Lactated Ringer’s solution
Question 13 Explanation:
Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it should be mixed with normal saline.
Question 14
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
Dysuria
B
WBC in the urine
C
pruritus
D
pus in the urine
Question 14 Explanation:
Pus is usually the first symptom, because the bacteria reproduce in the bladder.
Question 15
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
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
Do nothing except record the mother’s statement in the medical record
Question 15 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 16
A client visits the clinic for screening of scoliosis. The nurse should ask the client to:
A
bend over at a 45-degree angle from the waist
B
stand up as straight and tall as possible
C
bend all the way over and touch the toes
D
bend over at a 90-degree angle from the waist
Question 16 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 17
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
Document what the family member has said
B
Talk to the family member and explain that what she/he has said is not appropriate for the client
C
Take no action because it is the family member saying that to the client
D
Give the family member the number for an Elder Abuse Hot line
Question 17 Explanation:
This response is the most direct and immediate. This is a case of potential need for advocacy and patient’s rights.
Question 18
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 young infant after pyloromyotomy
B
A 9-year-old child diagnosed with rheumatic fever
C
A 5-month-old with Kawasaki disease
D
A 4-year-old with VSD following cardiac catheterization
Question 18 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 19
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
Only the area that feels raised
B
Only the area that looks reddened
C
both the areas that look red and feel raised
D
The entire area that feels itchy to the child
Question 19 Explanation:
Parents should be taught to feel the area that is raised and measure only that.
Question 20
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
wrap the infant in a prewarmed blanket and cover the head
B
confirm identification of the infant and apply bracelet to mother and infant
C
examine the infant for any observable abnormalities
D
instill prophylactic medication in the infant’s eyes
Question 20 Explanation:
The first priority, beside maintaining a newborn’s patent airway, is body temperature.
Question 21
Which is true about informed consent?
A
A physician will not subject himself to liability if he withholds any facts that are necessary to form the basis of an intelligent consent
B
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
C
A nurse may accept responsibility signing a consent form if the client is unable
D
Obtaining consent is not the responsibility of the physician
Question 21 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 22
Which of the following would be the most important goal in the nursing care of an infant client with eczema?
A
preventing infection
B
decreasing the itching
C
maintaining the comfort level
D
providing for adequate nutrition
Question 22 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 23
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
Give liquids with meals
C
Feed the client
D
Eat solid food
Question 23 Explanation:
Client with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing.
Question 24
During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements?
A
suction for 15-20 seconds
B
remove the inner cannula
C
limit suction pressure to 150-180 mmHg
D
wear eye goggles
Question 24 Explanation:
It is important to protect the RN’s eyes from the possible contamination of coughed-up secretions
Question 25
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
case manager
C
change agent
D
mentor
Question 25 Explanation:
This describes a mentor
Question 26
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
team method
D
case method
Question 26 Explanation:
Case management. The nurse assumes total responsibility for meeting the needs of the client during her entire duty.
Question 27
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
“firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’
C
“hard nodular mass in right breast nipple”
D
“abnormally felt area in the right breast, drainage noted”
Question 27 Explanation:
It describes the mass in the greatest detail.
Question 28
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 who has had a nephrectomy for Wilm’s tumor
C
A child diagnosed with Kawasaki disease and with cardiac complications
D
A child receiving an IV chelating therapy for lead poisoning
Question 28 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 29
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
inform the client of other options
B
discuss the religious beliefs with the physician
C
call a family meeting
D
encourage the client to have the surgery
Question 29 Explanation:
The physician may not be aware of the role that religious beliefs play in making a decision about surgery.
Question 30
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
determine the size, shape, and placement of the kidneys
B
measure renal blood flow
C
test renal tubular function and the patency of the urinary tract
D
outline the kidney vasculature
Question 30 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 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?
A
complete a police report on elder abuse
B
talk to the client about the caregiver and support system
C
check the laboratory data for serum albumin, hematocrit, and hemoglobin
D
complete a gastrointestinal and neurological assessment
Question 31 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 32
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 nurse discusses the condition of the client in a clinical conference with other nurses
D
The client asks the nurse to discuss the her condition with the family
Question 32 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 33
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 mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon
B
A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw
C
A football player limping and complaining of pain and swelling in the right ankle
D
an elderly woman complaining of a loss of appetite and fatigue for the past week
Question 33 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 34
The nurse is assigned to care the client with infectious disease. The best antimicrobial agent for the nurse to use in handwashing is:
A
Chlorhexidine gluconate (CHG) (Hibiclens)
B
Soap and water
C
Isopropyl alcohol
D
Hexachlorophene (Phisohex)
Question 34 Explanation:
CHG is a highly effective antimicrobial ingredient, especially when it is used consistently over time.
Question 35
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
greater exposure to diverse health care workers
C
reactivation of an old tuberculosis infection
D
increased incidence of new cases of tuberculosis in persons over 65 years old
Question 35 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 36
The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should the nurse position the client?
A
Low Fowler’s with knees gatched at 30 degrees
B
Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow
C
Supine with the head turned to the left
D
Bed sloped at a 45 degree angle with the head lowest and the legs highest
Question 36 Explanation:
This position increases venous return, improves cardiac volume, and promotes adequate ventilation and cerebral perfusion
Question 37
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 have a vacation day coming and would like to take that now”
C
“I do not get along with one of the nurses on the pediatrics unit”
D
“I do not feel competent to go and work on that area”
Question 37 Explanation:
This action demonstrates a lack of responsibility and the nurse should attempt negotiation with the nurse manager.
Question 38
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?
check respiration, stabilize spine, check circulation
D
align the spine, check pupils, check for hemorrhage
Question 38 Explanation:
Checking the airway would be a priority, and a neck injury should be suspected
Question 39
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 diagnosed with diabetes and who has an infected toe
B
A client with chronic venous insufficiency
C
A client with Chronic renal failure
D
A client who had a CVA in the past two months
Question 39 Explanation:
The patient is experiencing a potentially serious complication related to diabetes and needs ongoing assessment by an RN
Question 40
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
Ignore them, because it is their right to discuss anything they want to
B
Report this incident to the nursing supervisor
C
Tell them it is not appropriate to discuss the condition of the client
D
Join in the conversation, giving them supportive input about the case of the client
Question 40 Explanation:
The behavior should be stopped. The first step is to remind the staff that confidentiality may be violated
Question 41
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
keep the client’s room door open
B
avoid contact with the client’s roommate
C
put on gowns, gloves and masks
D
wash their hands when leaving
Question 41 Explanation:
Handwashing is the best method for reducing cross-contamination. Gowns and gloves are not always required when entering a client’s room.
Question 42
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 child, “Is your name____________?”
B
The adult visiting, “The child’s name is ____________________?”
C
Another staff nurse to identify this child
D
The other children in the room what the child’s name is
Question 42 Explanation:
The only acceptable way to identify a preschooler client is to have a parent or another staff member identify the client.
Question 43
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
“You and I need to review your rationale for this decision”
B
“Your baby will not be able to attend day care without immunizations”
C
“You are needlessly placing other people at risk for communicable diseases”
D
“Your decision can be viewed as a form of child abuse and neglect”
Question 43 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 44
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
“Do frequent hand washing and maintain good hygiene”
B
“Do not share a bathroom with children or pregnant woman”
C
“Avoid contact with others while receiving chemotherapy”
D
“Get a weekly WBC count”
Question 44 Explanation:
Frequent hand washing and good hygiene are the best means of preventing infection.
Question 45
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
Know the condition and needs of all the patients on the team
C
Supervise direct care by nursing assistants
D
Document the assessments completed by the team members
Question 45 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 46
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
elbow restraints to the arms
C
Mittens to the hands
D
Clove-hitch restraints to the hands
Question 46 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 47
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
removing oral and nasal secretions
C
encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions
D
aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning
Question 47 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 48
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
Team method
B
Case management method
C
Primary nursing method
D
Functional method
Question 48 Explanation:
It describes functional nursing. Staff is assigned to specific task rather than specific clients.
Question 49
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 was born with this condition
D
Their baby developed this condition during the first few weeks of life
Question 49 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 50
A staff nurse has had a serious issue with her colleague. In this situation, it is best to:
A
Not discuss the issue with anyone. It will probably resolve itself
B
Discuss this with the supervisor
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 50 Explanation:
Waiting for emotions to dissipate and sitting down with the colleague is the first rule of conflict resolution.
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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.