Board Exam Nursing Test

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

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.

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

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

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”.

Informed consent means that the physician must provide the client or their surrogates with enough information about the procedure so that they can make healthcare judgments that align with their own values and goals. This ensures that the client is fully aware of the risks, benefits, and alternatives of the procedure and can make an informed decision about their healthcare. It also respects the client's autonomy and right to make decisions about their own body.

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

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

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

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

This describes a mentor

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

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

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

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

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.

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.

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

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

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

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

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

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.

It describes the mass in the greatest detail.

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.

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

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

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.

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.

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

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.

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.

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

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

The nurse may not disclose confidential information when the father of a woman who just delivered a baby is on the phone to find out the sex of the baby. This is because revealing the sex of the baby without the mother's consent would be a breach of confidentiality. The nurse must prioritize protecting the privacy and confidentiality of the client and her medical information.

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.

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

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

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.

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

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

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

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

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

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

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.

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

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