Nursing Board Exam Quiz: Test Your Clinical Knowledge

The 50-year-old man with severe chest pain radiating to his jaw and diaphoresis (sweating) should receive the highest priority. This presentation strongly suggests a potential cardiac event, such as a heart attack, which requires immediate medical attention. The other cases, while needing assessment, are less likely to be immediately life-threatening.

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

This response is the most direct and immediate. It addresses the inappropriate behavior directly with the family member, which is a case of potential need for advocacy and patient’s rights. It also provides an opportunity to educate the family member on appropriate ways to communicate with the client.

The nurse who witnesses 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”.

The behavior should be stopped immediately to prevent any breach of confidentiality. The first step is to remind the staff that discussing a client's health condition in public places is inappropriate and violates privacy regulations.

Waiting for emotions to dissipate and sitting down with the colleague to discuss the issue calmly is the first rule of conflict resolution. Direct communication can help resolve misunderstandings and promote a healthy working relationship.

In the nursing profession, a mentor is an experienced and knowledgeable nurse who voluntarily guides, supports, and trains a less experienced nurse, often referred to as a mentee or protégé. Mentorship is a key component in fostering professional growth and development within the nursing field. It helps bridge the gap between theoretical knowledge and practical application, ensuring that new nurses are well-prepared to deliver high-quality patient care. Additionally, mentorship contributes to the retention of nursing staff by creating a supportive and nurturing work environment.

This response best explains what informed consent is and provides for the legal rights of the patient. Informed consent involves ensuring that the patient or their surrogate has enough information to make an informed decision about their healthcare, in alignment with their values and goals.

Frequent hand washing and maintaining good hygiene are the best means of preventing infection, especially for clients who are immunocompromised due to bone marrow suppression from chemotherapy. It helps reduce the risk of infection by minimizing exposure to harmful pathogens.

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

Phenytoin (Dilantin) can cause venous irritation due to its alkalinity and should be mixed with normal saline. Mixing it with other solutions like dextrose or Lactated Ringer’s can cause precipitation of the drug.

Delegating tasks involves considering the complexity of the task, the stability of the patient, and the competency of the person to whom the task is delegated. Giving an oatmeal bath to an infant with eczema is a routine and non-complex task that can be safely performed by a UAP. However, tasks such as monitoring the intake and output of a comatose toddler with salicylate poisoning, performing a complete bed bath on a 2-year-old with multiple injuries, and checking the IV of a preschooler with Kawasaki disease are more complex and require nursing judgment, making them less suitable for delegation to a UAP.

In the functional method, nursing tasks are divided among the team members based on their skills and scope of practice. Each member is assigned specific duties rather than being responsible for all the care needs of a particular group of patients. For example, the medication nurse handles medications, the head nurse coordinates care, the nurse assistant changes bed linens and answers call lights, another nurse changes wound dressings, and the licensed practical nurse takes vital signs and bathes the clients. This approach emphasizes task efficiency and specialization.

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

The physician may not be aware of the role that religious beliefs play in the client's decision about surgery. It is important for the RN to communicate this to the physician so that the healthcare team can address the client's concerns appropriately and consider alternative treatments or approaches.

Clients with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing and helps prevent choking.

The team leader is responsible for the overall management of all clients and staff on the team. Knowing the condition and needs of all the patients is essential for coordinating care and ensuring that all team members are providing appropriate and effective care.

Dysuria (painful urination) is usually the first and most common symptom of gonorrhea. While pus or discharge can occur, dysuria is often the initial symptom reported by patients.

The correct assignment for a float nurse from the obstetrics unit in the pediatric unit would be a child who has had a nephrectomy for Wilms tumor. This postoperative care involves routine tasks such as pain management and wound care, aligning with the float nurse's experience. However, patients with complex needs like multiple injuries from a vehicle accident, Kawasaki disease with cardiac complications, or IV chelating therapy for lead poisoning should not be assigned, as these demand specialized pediatric care beyond the float nurse's expertise. Consultation with the nursing supervisor ensures appropriate patient assignments.

Hypoglycemia can cause symptoms such as palpitations and weakness due to low blood sugar levels. Recognizing these signs early is crucial for a client with diabetes to take corrective actions promptly.

Pre-Suctioning and post-suctioning ventilation with 100% oxygen is important in reducing hypoxemia, which occurs when the flow of gasses in the airway is obstructed by the suctioning catheter.

Even though the mother is a minor, she is legally able to sign consent for her own child. The law generally recognizes the rights of minor parents to make medical decisions for their children

Shiny floors can be a safety hazard because they can cause falls, especially for elderly individuals. It is important to ensure that the living environment is safe and reduces the risk of accidents.

Pyloromyotomy is a surgical procedure involving the pylorus, and caring for an infant post-operatively may require specialized knowledge in pediatric surgical nursing. The floated nurse from the telemetry unit may not have the specific expertise in caring for an infant after pyloromyotomy. The other patients might be more within the floated nurse's general pediatric nursing knowledge. Patient assignments are complex decisions that take into consideration various factors, including the nurse's competencies, patient needs, and available resources. Always consult with the nursing supervisor or manager when making patient assignments in a healthcare setting.

This charting describes the mass in the greatest detail, including the location, size, and quadrant. This level of detail is crucial for accurate medical records and for guiding further assessments or interventions.

Pyloric stenosis is not a congenital anatomical defect, but it develops during the first few weeks of life. The precise etiology is unknown, but it is not acquired due to a formula allergy or present at birth.

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.

This statement may put the nurse's job at risk because it demonstrates a lack of responsibility and willingness to adapt to different assignments, which is an important aspect of nursing practice. Instead, the nurse should attempt to negotiate with the nurse manager to express concerns and seek appropriate support or training if needed.

This client may have complex care needs due to potential complications and recovery requirements following a recent stroke, including the need for frequent assessments, monitoring for changes in neurological status, and potential complications that may require skilled nursing judgment. Such tasks are beyond the typical scope of practice for a CNA and require the skills and assessment capabilities of a registered nurse.

In the primary nursing method, a registered nurse (RN) is responsible for the comprehensive care of a specific group of patients during their shift. The RN plans, implements, and evaluates all aspects of the patients' care and maintains continuity of care by handing over to the next RN at the end of the shift. This approach ensures that one nurse oversees all care activities and provides a high level of accountability and personalized care for the patients.

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.

The first priority, besides maintaining a newborn’s patent airway, is body temperature. Wrapping the infant in a prewarmed blanket and covering the head helps prevent hypothermia.

The priority is to let the surgeon know, who in turn may ask the husband to sign the consent. It is important to address the lack of consent immediately to ensure that the surgery proceeds with proper authorization.

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.

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. This is to protect the confidentiality and privacy of the client.

The initial action should be to assess the client and ensure their safety. After assessing the client and providing any necessary immediate care, the nurse should inform the physician about the incident. This prioritizes the client’s immediate health needs before documentation and paperwork.

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.

To maximize blood flow to the brain and vital organs in a hypotensive patient who has experienced significant blood loss, the modified Trendelenburg position (feet and legs elevated 20 degrees, trunk horizontal, head on a small pillow) is optimal as it promotes venous return while maintaining an open airway.

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.

To prevent the spread of infection during tracheal suctioning, the nurse must wear eye goggles to protect their eyes from potential contact with bodily fluids. Other measures, like appropriate suction pressure and duration, are also crucial for patient safety.

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.

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.

Dimpling of the breast tissue can be a sign of breast cancer. It indicates that something beneath the skin is pulling the skin inward, which can occur with tumors. Other signs to be aware of include lumps that are hard, immovable, and not well-defined, changes in skin texture, and nipple discharge, but dimpling is particularly important to recognize during a self-examination.

The only acceptable way to identify a preschooler client is to have a parent or another staff member who is familiar with the child verify their identity. This ensures accuracy and safety when administering medications.

This documentation provides a clear, objective description of the findings. It notes the presence of facial swelling (edema) and bruising (ecchymosis) in a pattern resembling a handprint, which is essential for accurate medical records and potential follow-up on the cause of the injury.

To screen for scoliosis, the nurse should ask the client to bend over at a 90-degree angle from the waist. This is the standard position for the Adam's Forward Bend Test, which is used to check for spinal curvature and asymmetry. It allows the nurse to observe the spine's alignment and identify any potential signs of scoliosis, such as uneven shoulder blades or a prominent rib hump.

Family members visiting a client with tuberculosis should adhere to respiratory isolation precautions by washing their hands when leaving and avoiding contact with the client's roommate. These actions help prevent the spread of tuberculosis bacteria, which can be transmitted through the air.

In an emergency situation, the nurse's initial action is to check respiration, circulation, and neurological response. This rapid assessment, often remembered by the acronym ABC (Airway, Breathing, Circulation), helps identify and prioritize life-threatening conditions. Ensuring the patient has a patent airway, is breathing adequately, and has sufficient blood circulation is crucial for immediate survival. While spinal stabilization and pupil checks are important, they are secondary to ensuring basic life functions.

Chlorhexidine gluconate (CHG) is a highly effective antimicrobial ingredient, especially when it is used consistently over time. It provides a broad spectrum of antimicrobial activity and is effective against a wide range of pathogens.

Parents should be taught to feel the area that is raised and measure only that. The induration is the palpable, raised, hardened area or swelling, and this is what is measured, not the redness or itchy areas.