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Scope of this Nursing Test I is parallel to the NP1 NLE Coverage: Foundation of Nursing Nursing Research Professional Adjustment Leadership and Management
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
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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
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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
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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
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Case management method
Primary nursing method
Team method
Functional method
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Primary nursing method
Case method
team method
functional method
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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
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Mentor
Team leader
Case manager
Change agent
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“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”
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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
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The Physician
The Registered Nurse caring for the client
The 15-year-old mother of the baby boy
The mother of the girl
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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
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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
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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
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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.
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Call a family meeting
Discuss the religious beliefs with the physician
Encourage the client to have the surgery
Inform the client of other options
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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
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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
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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
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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
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Normal Saline
Heparinized normal saline
5% dextrose in water
Lactated Ringer’s solution
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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
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Assess the level of consciousness and circulation
Check respirations, circulation, neurological response
Align the spine, check pupils, check for hemorrhage
Check respiration, stabilize spine, check circulation
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Eat solid food
Give liquids with meals
Feed the client
Sit in an upright position to eat
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Limit suction pressure to 150-180 mmHg
suction for 15-20 seconds
Wear eye goggles
Remove the inner cannula
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Warm, flushed skin
Hunger and thirst
Increase urinary output
Palpitation and weakness
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Administering insulin-replacement therapy
Providing a low-sodium diet
Restricting fluids to 1500 ml/day
reducing physical and emotional stress
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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.
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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
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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
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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
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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
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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
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“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
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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
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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
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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
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“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”
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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
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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
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Picture windows
Unwashed dishes in the sink
Clear and shiny floors
Brightly lit rooms
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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
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Elbow restraints to the arms
Mittens to the hands
Clove-hitch restraints to the hands
A posey jacket to the torso
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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
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Pruritus
Pus in the urine
WBC in the urine
Dysuria
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preventing infection
Maintaining the comfort level
providing for adequate nutrition
Decreasing the itching
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“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”
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Isopropyl alcohol
Hexachlorophene (Phisohex)
Soap and water
Chlorhexidine gluconate (CHG) (Hibiclens)
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“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”
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Tender, movable lump
Pain on breast self-examination
round, well-defined lump
Dimpling of the breast tissue
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