1.
A young adult is involved in a motorcycle accident and is brought to the emergency room. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders?
Correct Answer
B. "MorpHine sulfate 10 mg IM q3 4h."
Explanation
Strategy: "Question which of the following orders" indicates an incorrect order.
(1) H1 receptor blocker, used as an antiemetic
(2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure
(3) stool softener, used for an immobilized patient
(4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers
2.
The nurse returns to the desk and finds four phone messages to return. Which of the following messages should the nurse return FIRST?
Correct Answer
B. A man complains of heartburn that radiates to the jaw.
Explanation
Strategy: Determine the least stable client.
(1) caused by reflux of gastric contents into esophagus, treatment is small, frequent meals, don't consume fluids with food, don't wear tight clothing
(2) correct—indicates chest pain, needs to seek medical attention immediately
(3) caused by menopause, treat with hormone replacement therapy (HRT)
(4) should treat with rest and ice
3.
A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions?
Correct Answer
B. Head of bed elevated 60–90°.
Explanation
Strategy: Remember the positioning strategy.
(1) head of bed not elevated enough
(2) correct—facilitates swallowing and movement of tube through gastrointestinal tract
(3) not the best position
(4) not the best position
4.
The nurse monitors the fluid status of an older patient receiving IV fluids following surgery. Which of the following symptoms suggests to the nurse that the patient has fluid volume overload?
Correct Answer
B. Cool skin, respiratory crackles, pulse 86 and bounding.
Explanation
Strategy:
(1) indicates dehydration
(2) correct—will see bounding pulse, elevated BP, distended neck veins, edema, headache, polyuria, diarrhea, liver enlargement
(3) symptoms could be from causes other than volume overload
(4) slightly reduced output, CVP would be elevated, normal CVP 3 to 12 mm/H2O, involuntary eye movements not seen
5.
A woman has been diagnosed with systemic lupus (SLE) and shares with the nurse, "I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy because I have lupus." Which of the following responses by the nurse is BEST?
Correct Answer
B. "How long have you been in remission?"
Explanation
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) maternal morbidity and mortality are increased with SLE (2) correct—should be in remission for at least 5 months prior to conceiving (3) gestation not affected by SLE (4) recommended that a woman wait 2 years following diagnosis before conceiving
6.
The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?
Correct Answer
A. Confirm that all staff members understand and comply with the treatment plan.
Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) correct—to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program
(2) not of primary importance in designing an effective behavior modification program
(3) not of primary importance in designing an effective behavior modification program
(4) not of primary importance in designing an effective behavior modification program
7.
A client received six units of regular insulin 3 hours ago. The nurse is MOST concerned if which of the following is observed?
Correct Answer
C. DiapHoresis and trembling.
Explanation
Strategy: "MOST concerned" indicates a complication.
(1) Kussmaul respirations are signs of hyperglycemia
(2) not indicative of hypoglycemia
(3) correct—regular insulin peaks in 2 to 4 hours; indicates hypoglycemia; give skim milk
(4) not indicative of hypoglycemia
8.
The nursing assistant reports to the nurse that a client who is 1 day postoperative after an angioplasty refuses to eat and states, "I just don't feel good." Which of the following actions by the nurse is BEST?
Correct Answer
A. Talk with the client about how the client is feeling.
Explanation
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is the assessment appropriate? Yes.
(1) correct—assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias
(2) assess cause of problem before implementing
(3) assess cause of problem before implementing
(4) more important to assess what is happening now
9.
The nurse prepares a patient for a cesarean section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section
Correct Answer
C. Contains lower amounts of narcotics than are given before general surgery.
Explanation
Strategy: Think about the action of the medications.
(1) decreased dosage of narcotics are used
(2) dosages of sedatives and hypnotics will be similar
(3) correct—decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant
(4) dosages of narcotics are reduced
10.
The nurse cares for patient placed in balanced suspension traction with a Thomas splint and Pearson attachment because of a fractured right femur. The nurse notes that the patient's left leg is externally rotated. The nurse should take which of the following actions?
Correct Answer
A. Place a trochanter roll on the outer aspect of the thigh.
Explanation
Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) correct—holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee
(2) exercise would not prevent future external rotation of the leg
(3) adduction (add to midline of body) does not change external rotation, internal rotation is not beneficial, normal alignment is required
(4) leg will externally rotate unless propped in proper alignment
11.
The nurse prepares a 5-year-old child for surgery. The nurse notes that the child's parents are divorced and have joint legal custody. The informed consent for surgery has been signed by the mother. Which of the following actions by the nurse is BEST?
Correct Answer
D. Continue the child's preoperative preparation.
Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) no reason to notify the physician
(2) no reason to call the OR
(3) consent from either divorced parent is sufficient
(4) correct—parent or legal guardian required to give informed consent prior to surgical procedure
12.
The nurse cares for clients on the neurology unit. What is the MOST appropriate action for the nurse to take after noting that a client suddenly develops a fixed and dilated pupil?
Correct Answer
D. Contact the pHysician.
Explanation
Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment or validation? No. Determine the outcome of the implementations.
(1) assessment; situation does not require validation
(2) assessment; has symptoms of increased intracranial pressure (ICP)
(3) implementation; would increase the ICP
(4) correct—implementation; fixed and dilated pupil represents a neurological emergency
13.
A mother brings her 2-year-old to the pediatrician's office. Which of the following symptoms suggests to the nurse that the child has strabismus?
Correct Answer
C. The child closes one eye to see a poster on the wall.
Explanation
Strategy: Think about each answer choice.
(1) suggestive of refractive error, myopia (nearsightedness), able to see objects at close range
(2) suggestive of refractive error
(3) correct—visual axes are not parallel, so the brain receives two images
(4) suggestive of cataracts or problem with peripheral vision
14.
The nurse administers morphine 6 mg IV push to a patient for postoperative pain. Following administration of the drug, the nurse observes the following: BP 100/68, pulse 68, respirations 8, client sleeping quietly. Which of the following nursing actions is MOST appropriate?
Correct Answer
C. Administer naloxone (Narcan).
Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) should be given Narcan for low respiratory rate
(2) problem is low respirations; this may be administered after medication
(3) correct—IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action
(4) unnecessary
15.
The school nurse instructs a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates further teaching is necessary?
Correct Answer
B. "I should induce vomiting if my child swallows lighter fluid."
Explanation
Strategy: "Further teaching is necessary" indicates an incorrect statement.
(1) Appropriate action; terminate exposure to the poison and then contact poison control for further instructions
(2) correct—vomiting contraindicated when child ingests hydrocarbons because of danger of aspiration
(3) 'poison-proofs' the medication
(4) store in locked cabinets
16.
The nurse cares for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?
Correct Answer
D. Serve the meal to the client in the seclusion room.
Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) should remain in the seclusion room
(2) should have meal at regular time
(3) should have meal at regular time
(4) correct—should eat at regular time; remain in the seclusion room for client's safety
17.
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of the body?
Correct Answer
C. Maintain aseptic technique during procedures.
Explanation
Strategy: Think "Maslow."
(1) psychosocial, not highest priority
(2) physical, use standard precautions
(3) correct—safety is a priority for the client who is at high risk for infection
(4) psychosocial, important for an adolescent but is not highest priority
18.
The home health care nurse cares for a client diagnosed with type 1 diabetes. The client is maintained on a regimen of NpH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past 2 days were 205 and 233 mg/dL. The nurse expects the physician to take which of the following actions?
Correct Answer
B. Order three additional units of NpH insulin at 10 P.M.
Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) diet should not be reduced
(2) correct—dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia
(3) peaks in 4 to 6 hours, would not prevent dawn phenomena
(4) would adjust snack, not eliminate it
19.
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a 5-year-old is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse 3 hours after admission, should be reported to the physician?
Correct Answer
B. There is clear fluid draining from the client's right ear.
Explanation
Strategy: Think about how each answer choice relates to a head injury.
(1) not priority
(2) correct—indicates a rupture of meninges and presents a potential complication of meningitis
(3) not priority
(4) is not a change in assessment
20.
A psychiatric nurse is assigned to conduct an admission nursing history on a new client. The admission should include which of the following?
Correct Answer
C. Data addressing a biopsychosocial approach, including a family system assessment.
Explanation
Strategy: Think about each answer choice.
(1) depends on opinions that are not based on a complete assessment
(2) limits the degree of information that is obtained from the client
(3) correct—complete nursing history includes biopsychosocial data; client's psychosocial and physical status are evaluated along with an assessment of the client's family system and social support network; evaluation of the client's cognitive ability is important during the physiological status assessment
(4) is necessary information about mental status but is also an incomplete assessment
21.
Prochlorperazine maleate (Compazine) 10 mg IM is ordered for a client. The client is also to receive butorphanol (Stadol) 2 mg IM. Before administering these medications, the nurse should take which of the following actions?
Correct Answer
C. Draw the medications in separate syringes.
Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) should monitor blood pressure and heart rate for orthostatic hypotension; respiration and temperature are not as high a priority
(2) inappropriate
(3) correct—Compazine should be considered incompatible in a syringe with all other medications
(4) unnecessary
22.
The nurse cares for clients in the student health center. A client confides to the nurse that the client's boyfriend informed her that he tested positive for hepatitis B. Which of the following responses by the nurse is BEST?
Correct Answer
D. "Have you had unprotected sex with your boyfriend?"
Explanation
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes.
(1) nurse is interjecting own feelings
(2) will require testing; not best response initially
(3) implementation; receive HBIG for postexposure prophylaxis; may also receive HBV vaccine
(4) correct—assessment; transmitted through parenteral drug abuse and sexual contact; determine exposure before implementing
23.
A young adult patient constantly seeks attention from the nurses, stomping away from the nurses' station and pouting when requests are refused. Which of the following responses by the nurse is MOST appropriate?
Correct Answer
B. Give the patient unsolicited attention when the patient is exhibiting acceptable behaviors.
Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) staff should use a consistent undivided approach
(2) correct—reward non–attention-seeking behaviors by giving the patient unsolicited attention
(3) remain nonjudgmental, carry out limit-setting
(4) staff should use a consistent undivided approach
24.
After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions is MOST appropriate?
Correct Answer
B. Aspirate the gastric contents with a syringe.
Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) tube would be irrigated with normal saline after the position of the tube was evaluated
(2) correct—to confirm placement, nurse should aspirate and test the pH of the aspirate; results should be 0 to 4
(3) does not assess status of nasogastric tube
(4) does not assess status of nasogastric tube
25.
A middle-aged woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician's office a month later for a routine checkup, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery?
Correct Answer
B. "I have been having difficulty coping with the surgery and cry frequently."
Explanation
Strategy: Think about each answer choice. Does it describe an expected response to a crisis situation?
(1) will not be able to help others this soon after surgery
(2) correct—normal reaction 1 month later
(3) excessive, abnormal reaction
(4) indicates integration, too early for this stage
26.
The nurse cares for clients in outpatient surgery. The mother of a 4-year-old asks the nurse how to prepare her daughter for eye surgery. Which of the following statements by the nurse is BEST?
Correct Answer
C. "Use dolls or puppets to explain how to get ready for surgery."
Explanation
Strategy: Think about growth and development.
(1) appropriate for school-aged child
(2) preschooler can't relate to the concept of 1 hour
(3) correct—use puppet or doll to show where procedure is performed; explain procedure in simple terms and what the child will see, hear, taste, smell, and feel
(4) appropriate for school-aged child
27.
A client at 32 weeks’ gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, indicates a possible complication?
Correct Answer
A. The client's urine test is positive for glucose and acetone.
Explanation
Strategy: Determine how each answer choice relates to pregnancy.
(1) correct—abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency
(2) not unusual, caused by pressure of enlarging uterus on veins returning blood from lower extremities
(3) common near term with increased vascularity of vagina and perineum, only abnormal if bloody, foul-smelling, or abnormally colored
(4) not unusual, due to pressure of enlarging uterus
28.
A nurse cares for a client diagnosed with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days?
Correct Answer
C. The patient's albumin level is 4.0 g/dL.
Explanation
Strategy: Determine how each answer choice relates to nutritional status.
(1) appetite is not the best indicator
(2) weight gain may be fluid retention (ascites)
(3) correct—albumin levels are best indicators of long-term nutritional status
(4) low levels are caused by chemotherapy or cancer, not a good indicator because it takes long time to increase levels
29.
The nurse cares for clients on a medical/surgical unit and determines that several situations need to be addressed. Which of the following situations should the nurse attend to FIRST?
Correct Answer
D. The husband of a client reports to the nurse that his wife's nose began bleeding after she returned from radiation therapy.
Explanation
Strategy: Determine the least stable situation
(1) important issue that needs to be addressed after tending to the client who is bleeding
(2) patients take priority over personnel issues
(3) can be delegated to another staff member
(4) correct—should assess client to determine amount and cause of bleeding
30.
A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority?
Correct Answer
C. Provide adequate hydration.
Explanation
Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) not a priority
(2) not a priority
(3) correct—adequate hydration is a priority for any client with sickle cell crisis
(4) not a priority
31.
A client diagnosed with a peptic ulcer has a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the nurse should caution the client about which of the following?
Correct Answer
D. Avoid eating large meals that are high in simple sugars and liquids.
Explanation
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) client should recline for 30 minutes after eating
(2) fluids should be given between meals
(3) intake of carbohydrates should be reduced along with highly spiced foods
(4) correct—basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates