Toughest Exam On Nursing Licensure: Quiz!

1. A male client tells the nurse that there is a big bug in his bed. The most therapeutic nursing response would be:

Silence

“Where’s the bug? I’ll kill it for you.”

“I don’t see a bug in your bed, but you seem afraid.”

“You must be seeing things.”

This response does not contradict the client’s perception, is honest, and shows empathy.

Explanation

This response does not contradict the client’s perception, is honest, and shows empathy.

2. The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother in the hospital room is wrong. The nurse determines that two babies were placed in the wrong cribs. The most appropriate nursing action would be to:

Determine who is responsible for the mistake and terminate his or her employment.

Record the event in an incident/variance report and notify the nursing supervisor.

Reassure both mothers, report to the charge nurse, and do not record.

Record detailed notes of the event on the mother’s medical record.

Every event that exposes a client to harm should be recorded in an incident report, as well as reported to the appropriate supervisors in order to resolve the current problems and permit the institution to prevent the problem from happening again.

Explanation

Every event that exposes a client to harm should be recorded in an incident report, as well as reported to the appropriate supervisors in order to resolve the current problems and permit the institution to prevent the problem from happening again.

3. In the admission care unit, which of the following client would the nurse give immediate attention?

A client who is 3 days postoperative with left calf pain.

A client who is postoperative hip pinning who is complaining of pain.

New admitted client with chest pain

A client with diabetes who has a glucoscan reading of 180.

The client with chest pain may be having a myocardial infarction, and immediate assessment and intervention is a priority.

Explanation

The client with chest pain may be having a myocardial infarction, and immediate assessment and intervention is a priority.

4. The nurse observes the female client in the psychiatric ward that she is having a hard time sleeping at night. The nurse asks the client about it and the client says, "I can't sleep at night because of fear of dying." What is the best initial nursing response?

“It must be frightening for you to feel that way. Tell me more about it.”

“Don’t worry, you won’t die. You are just here for some test.”

“Why are you afraid of dying?”

“Try to sleep. You need the rest before tomorrow’s test.”

Acknowledging a feeling tone is the most therapeutic response and provides a broad opening for the client to elaborate feelings.

Explanation

Acknowledging a feeling tone is the most therapeutic response and provides a broad opening for the client to elaborate feelings.

5. Which of the following will best describe a management function?

Writing a letter to the editor of a nursing journal.

Negotiating labor contracts.

Directing and evaluating nursing staff members.

Explaining medication side effects to a client.

Directing and evaluation of staff is a major responsibility of a nursing manager.

Explanation

Directing and evaluation of staff is a major responsibility of a nursing manager.

6. An infant is brought to the health care clinic for three immunizations at the same time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations should:

Be drawn in the same syringe and given in one injection.

Be mixed and inject in the same sites.

Not be mixed and the nurse must give three injections in three sites.

Be mixed and the nurse must give the injection in three sites.

Immunization should never be mixed together in a syringe, thus necessitating three separate injections in three sites. Note: some manufacturers make a premixed combination of immunization that is safe and effective.

Explanation

Immunization should never be mixed together in a syringe, thus necessitating three separate injections in three sites. Note: some manufacturers make a premixed combination of immunization that is safe and effective.

7. In the hospital lobby, the registered nurse overhears a two staff members discussing about the health condition of her client. What would be the appropriate action for the registered nurse to take?

Join in the conversation, giving her input about the case.

Ignore them, because they have the right to discuss anything they want to.

Tell them it is not appropriate to discuss such things.

Report this incident to the nursing supervisor.

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

Explanation

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

8. A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse taking care of the client knows that the primary treatment goal is to:

Provide distraction.

Support but limit the behavior.

Prohibit the behavior.

Point out the behavior.

Support and limit setting decrease anxiety and provide external control.

Explanation

Support and limit setting decrease anxiety and provide external control.

9. The nurse assesses the health condition of the female client. The client tells the nurse that she discovered a lump in the breast last year and hesitated to seek medical advice. The nurse understands that, women who tend to delay seeking medical advice after discovering the disease are displaying what common defense mechanism?

Intellectualization.

Suppression.

Repression.

Denial.

Denial is a very strong defense mechanism used to allay the emotional effects of discovering a potential threat. Although denial has been found to be an effective mechanism for survival in some instances, such as during natural disasters, it may in greater pathology in a woman with potential breast carcinoma.

Explanation

Denial is a very strong defense mechanism used to allay the emotional effects of discovering a potential threat. Although denial has been found to be an effective mechanism for survival in some instances, such as during natural disasters, it may in greater pathology in a woman with potential breast carcinoma.

10. The client is brought to the emergency department because of serious vehicle accident. After an hour, the client has been declared brain dead. The nurse who has been with the client must now talk to the family about organ donation. Which of the following consideration is necessary?

Include as many family members as possible.

Take the family to the chapel.

Discuss life support systems.

Clarify the family’s understanding of brain death.

The family needs to understand what brain death is before talking about organ donation. They need time to accept the death of their family member. An environment conducive to discussing an emotional issue is needed.

Explanation

The family needs to understand what brain death is before talking about organ donation. They need time to accept the death of their family member. An environment conducive to discussing an emotional issue is needed.

11. A community health nurse is providing a health teaching to a woman infected with herpes simplex 2. Which of the following health teaching must the nurse include to reduce the chances of transmission of herpes simplex 2?

“Abstain from intercourse until lesions heal.”

“Therapy is curative.”

“Penicillin is the drug of choice for treatment.”

“The organism is associated with later development of hydatidiform mole.

Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting infection to one’s sexual partner.

Explanation

Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting infection to one’s sexual partner.

12. The ambulance team calls the emergency department that they are going to bring a client who sustained burns in a house fire. While waiting for the ambulance, the nurse will anticipate emergency care to include assessment for:

Gas exchange impairment

Hypoglycemia.

Hyperthermia.

Fluid volume excess.

Smoke inhalation affects gas exchange.

Explanation

Smoke inhalation affects gas exchange.

13. The community nurse is teaching the group of mothers about the cervical mucus method of natural family planning. Which characteristics are typical of the cervical mucus during the "fertile" period of the menstrual cycle?

Absence of ferning.

Thin, clear, good spinnbarkeit.

Thick, cloudy.

Yellow and sticky.

Under high estrogen levels, during the period surrounding ovulation, the cervical mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.

Explanation

Under high estrogen levels, during the period surrounding ovulation, the cervical mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.

14. The physician calls the nursing unit to leave an order. The senior nurse had conversation with the other staff. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not know the physician or the client to whom the order pertains. The nurse should:

Ask the physician to call back after the nurse has read the hospital policy manual.

Take the telephone order.

Refuse to take the telephone order.

Ask the charge nurse or one of the other senior staff nurses to take the telephone order.

Get a senior nurse who know s the policies, the client, and the doctor. Generally speaking, a nurse should not accept telephone orders. However, if it is necessary to take one, follow the hospital’s policy regarding telephone orders. Failure to follow hospital policy could be considered negligence. In this case, the nurse was new and did not know the hospital’s policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the nurse should not take the order unless a) no one else is available and b) it is an emergency situation.

Explanation

Get a senior nurse who know s the policies, the client, and the doctor. Generally speaking, a nurse should not accept telephone orders. However, if it is necessary to take one, follow the hospital’s policy regarding telephone orders. Failure to follow hospital policy could be considered negligence. In this case, the nurse was new and did not know the hospital’s policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the nurse should not take the order unless a) no one else is available and b) it is an emergency situation.

15. Which of the following complications during a breech birth the nurse needs to be alarmed?

Abruption placenta.

Caput succedaneum.

Pathological hyperbilirubinemia.

Umbilical cord prolapse

Because umbilical cord’s insertion site is born before the fetal head, the cord may be compressed by the after-coming head in a breech birth.

Explanation

Because umbilical cord’s insertion site is born before the fetal head, the cord may be compressed by the after-coming head in a breech birth.

16. A hospitalized client cannot find his handkerchief and accuses other cient in the room and the nurse of stealing them. Which is the most therapeutic approach to this client?

Divert the client’s attention.

Listen without reinforcing the client’s belief.

Inject humor to defuse the intensity.

Logically point out that the client is jumping to conclusions.

Listening is probably the most effective response of the four choices.

Explanation

Listening is probably the most effective response of the four choices.

17. Which telephone call from a student's mother should the school nurse take care of at once?

A telephone call notifying the school nurse that a child underwent an emergency appendectomy during the previous night.

A high fever accompanied by a body rash could indicate that the child has a communicable disease and would have exposed other students to the infection. The school nurse would want to investigate this telephone call immediately so that plans could be instituted to control the spread of such infection.

Explanation

A high fever accompanied by a body rash could indicate that the child has a communicable disease and would have exposed other students to the infection. The school nurse would want to investigate this telephone call immediately so that plans could be instituted to control the spread of such infection.

18. The nurse is assigned to care to a 17-year-old male client with a history of substance abuse. The client asks the nurse, "Have you ever tried or used drugs?" The most correct response of the nurse would be:

“Yes, once I tried grass.”

“No, I don’t think so.”

“Why do you want to know that?”

“How will my answer help you?”

The client may perceive this as avoidance, but it is more important to redirect back to the client, especially in light of the manipulative behavior of drug abusers and adolescents.

Explanation

The client may perceive this as avoidance, but it is more important to redirect back to the client, especially in light of the manipulative behavior of drug abusers and adolescents.

19. A female client who has a 28-day menstrual cycle asks the community health nurse when she get pregnant during her cycle. What will be the best nursing response?

It is the most accurate statement of physiological facts for a 28-day menstrual cycle: ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization could occur from sperm deposited before ovulation.

Explanation

It is the most accurate statement of physiological facts for a 28-day menstrual cycle: ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization could occur from sperm deposited before ovulation.

20. The nursing applicant has given the chance to ask questions during a job interview at a local hospital. What should be the most important question to ask that can increase chances of securing a job offer?

Begin with questions about client care assignments, advancement opportunities, and continuing education.

Decline to ask questions, because that is the responsibility of the interviewer.

Ask as many questions about the facility as possible.

This choice implies concern for client care and self-improvement.

Explanation

This choice implies concern for client care and self-improvement.

21. A newborn infant with Down syndrome is to be discharged today. The nurse is preparing to give the discharge teaching regarding the proper care at home. The nurse would anticipate that the mother is probably at the:

40 years of age

20 years of age.

35 years of age.

20 years of age.

Perinatal risk factors for the development of Down syndrome include advanced maternal age, especially with the first pregnancy.

Explanation

Perinatal risk factors for the development of Down syndrome include advanced maternal age, especially with the first pregnancy.

22. Which of the following action is an accurate tracheal suctioning technique?

25 seconds of continuous suction during catheter insertion.

20 seconds of continuous suction during catheter insertion.

10 seconds of intermittent suction during catheter withdrawal.

15 seconds of intermittent suction during catheter withdrawal.

Suctioning is only done for 10 seconds, intermittently, as the catheter is being withdrawn.

Explanation

Suctioning is only done for 10 seconds, intermittently, as the catheter is being withdrawn.

23. The nurse is teaching a group of women about fertility awareness, the nurse should emphasize that basal body temperature:

Can be done with a mercury thermometer but no a digital one.

The average temperature taken each morning.

Should be recorded each morning before any activity.

Has a lower degree of accuracy in predicting ovulation than the cervical mucus test.

The basal body temperature is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 ºC to 36.3ºC during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop in temperature may be seen, after ovulation in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 ºC. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.

Explanation

The basal body temperature is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 ºC to 36.3ºC during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop in temperature may be seen, after ovulation in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 ºC. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.

24. The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a closed chest drainage system. The fluctuation has stopped, the nurse would:

Vigorously strip the tube to dislodge a clot.

Raise the apparatus above the chest to move fluid.

Increase wall suction above 20 cm H2O pressure.

Ask the client to cough and take a deep breath.

Asking the client to cough and take a deep breath will help determine if the chest tube is kinked or if the lungs has reexpanded.

Explanation

Asking the client to cough and take a deep breath will help determine if the chest tube is kinked or if the lungs has reexpanded.

25. The client with rheumatoid arthritis is for discharge. In preparing the client for discharge on prednisone therapy, the nurse should advise the client to:

Wear sunglasses if exposed to bright light for an extended period of time.

Take oral preparations of prednisone before meals.

Have periodic complete blood counts while on the medication.

Never stop or change the amount of the medication without medical advice.

In preparing the client for discharge that is receiving prednisone, the nurse should caution the client to (a) take oral preparations after meals; (b) remember that routine checks of vital signs, weight, and lab studies are critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication in a light-resistant container.

Explanation

In preparing the client for discharge that is receiving prednisone, the nurse should caution the client to (a) take oral preparations after meals; (b) remember that routine checks of vital signs, weight, and lab studies are critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication in a light-resistant container.

26. After a cystectomy and formation of an ileal conduit, the nurse provides instruction regarding prevention of leakage of the pouch and backflow of the urine. The nurse is correct to include in the instruction to empty the urine pouch:

Every 3-4 hours.

Every hour.

Twice a day.

Once before bedtime.

Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-4 hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is loose).

Explanation

Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-4 hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is loose).

27. A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when:

Client is oriented when aroused from sleep, and goes back to sleep immediately.

Blood pressure is decreased from 160/90 to 110/70.

Client refuses dinner because of anorexia.

Pulse is increased from 88-96 with occasional skipped beat.

This suggests that the level of consciousness is decreasing.

Explanation

This suggests that the level of consciousness is decreasing.

28. A pregnant client tells the nurse that she is worried about having urinary frequency. What will be the most appropriate nursing response?

“Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes.”

“Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily.”

Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding.

Explanation

Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding.

29. Which of the following describes a health care team with the principles of participative leadership?

Each member of the team can independently make decisions regarding the client’s care without necessarily consulting the other members.

The physician makes most of the decisions regarding the client’s care.

The team uses the expertise of its members to influence the decisions regarding the client’s care.

Nurses decide nursing care; physicians decide medical and other treatment for the client.

It describes a democratic process in which all members have input in the client’s care.

Explanation

It describes a democratic process in which all members have input in the client’s care.

30. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) must be given to a client after birth fo the fetus. The nurse is correct to explain that oxytocin:

Minimizes discomfort from “afterpains.”

Suppresses lactation.

Promotes lactation.

Maintains uterine tone.

Oxytocin (Pitocin) is used to maintain uterine tone.

Explanation

Oxytocin (Pitocin) is used to maintain uterine tone.

31. A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting that the baby may have hypothyroidism when mother states that her baby does not:

Sit up.

Pick up and hold a rattle.

Roll over.

Hold the head up.

Development normally proceeds cephalocaudally; so the first major developmental milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks of life. In hypothyroidism, the infant’s muscle tone would be poor and the infant would not be able to achieve this milestone.

Explanation

Development normally proceeds cephalocaudally; so the first major developmental milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks of life. In hypothyroidism, the infant’s muscle tone would be poor and the infant would not be able to achieve this milestone.

32. Which of the following nursing intervention is essential for the client who had pneumonectomy?

Medicate for pain only when needed.

Connect the chest tube to water-seal drainage.

Notify the physician if the chest drainage exceeds 100mL/hr.

Encourage deep breathing and coughing.

Surgery and anesthesia can increase mucus production. Deep breathing and coughing are essential to prevent atelectasis and pneumonia in the client’s only remaining lung.

Explanation

Surgery and anesthesia can increase mucus production. Deep breathing and coughing are essential to prevent atelectasis and pneumonia in the client’s only remaining lung.

33. A client who undergone appendectomy 3 days ago is scheduled for discharge today. The nurse notes that the client is restless, picking at bedclothes and saying, "I am late on my appointment," and calling the nurse by the wrong name. The nurse suspects:

Panic reaction.

Medication overdose.

Toxic reaction to an antibiotic.

Delirium tremens.

The behavior described is likely to be symptoms of delirium tremens, or alcohol withdrawal (often unsuspected on a surgical unit.)

Explanation

The behavior described is likely to be symptoms of delirium tremens, or alcohol withdrawal (often unsuspected on a surgical unit.)

34. Which of the following treatment modality is appropriate for a client with paranoid tendency?

Activity therapy.

Individual therapy.

Group therapy.

Family therapy.

This option is least threatening.

Explanation

This option is least threatening.

35. A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby. Which hormone, normally secreted during the postpartum period, influences both the milk ejection reflex and uterine involution?

Oxytocin.

Estrogen.

Progesterone.

Relaxin.

Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland.

Explanation

Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland.

36. A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside, saying, "I need to go to an appointment." What is the appropriate nursing intervention?

Tell the client that he cannot bang on the door.

Ignore this behavior.

Escort the client going back into the room.

Ask the client to move away from the door.

Gentle but firm guidance and nonverbal direction is needed to intervene when a client with schizophrenic symptoms is being disruptive.

Explanation

Gentle but firm guidance and nonverbal direction is needed to intervene when a client with schizophrenic symptoms is being disruptive.

37. The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. Which of the following would the nurse give to the child?

Cola with ice

Yellow noncitrus Jello

Cool cherry Kool-Aid

A glass of milk

After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding.

Explanation

After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding.

38. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should:

Place the client in a private room.

Wear an N 95 respirator when caring for the client.

Put on a gown every time when entering the room.

Don a surgical mask with a face shield when entering the room.

The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator.

Explanation

The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator.

39. The nurse advised the pregnant woman that smoking and alcohol should be avoided during pregnancy. The nurse takes into account that the developing fetus is most vulnerable to environment teratogens that cause malformation during:

The entire pregnancy.

The third trimester.

The first trimester.

The second trimester.

The first trimester is the period of organogenesis, that is, cell differentiation into the various organs, tissues, and structures.

Explanation

The first trimester is the period of organogenesis, that is, cell differentiation into the various organs, tissues, and structures.

40. After therapy with the thrombolytic alteplase (t-PA), what observation will the nurse report to the physician?

3+ peripheral pulses.

Change in level of consciousness and headache.

Occasional dysrhythmias.

Heart rate of 100/bpm.

This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any gastrointestinal or internal bleeding.

Explanation

This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any gastrointestinal or internal bleeding.

41. The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye drops. The nurse is correct in advising the parents to place the drops:

In the middle of the lower conjunctival sac of the infant’s eye.

Directly onto the infant’s sclera.

In the outer canthus of the infant’s eye.

In the inner canthus of the infant’s eye.

The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conjunctival sac.

Explanation

The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conjunctival sac.

42. A female client with cancer has radium implants. The nurse wants to maintain the implants in the correct position. The nurse should position the client:

Flat in bed.

On the side only.

With the foot of the bed elevated.

With the head elevated 45-degrees (semi-Fowler’s).

Clients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal packing. The client may roll to the side for meals but the upper body should not be raised more than 20 degrees.

Explanation

Clients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal packing. The client may roll to the side for meals but the upper body should not be raised more than 20 degrees.

43. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time?

Timing and recording length of contractions.

Monitoring.

Preparing for an emergency cesarean birth.

Checking the perineum for bulging.

The oxytocic effect of Pitocin increases the intensity and durations of contractions; prolonged contractions will jeopardize the safety of the fetus and necessitate discontinuing the drug.

Explanation

The oxytocic effect of Pitocin increases the intensity and durations of contractions; prolonged contractions will jeopardize the safety of the fetus and necessitate discontinuing the drug.

44. A mother is in the third stage of labor. Which of the following signs will help the nurse determine the signs of placental separation?

The uterus becomes globular.

The umbilical cord is shortened.

The fundus appears at the introitus.

Mucoid discharge is increased.

Signs of placental separation include a change in the shape of the uterus from ovoid to globular.

Explanation

Signs of placental separation include a change in the shape of the uterus from ovoid to globular.

45. The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse needs to have knowledge of which psychodynamic principle?

The major fundamental mechanism is regression.

The client’s symptoms are imaginary and the suffering is faked.

An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks sympathy, attention and love.

Somatoform disorders provide a way of coping with conflicts.

Explanation

Somatoform disorders provide a way of coping with conflicts.

46. The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is receiving digoxin. Which of the following questions will be asked by the nurse to the parents of the child in order to assess the client's risk for digoxin toxicity?

“Has he been exposed to any childhood communicable diseases in the past 2-3 weeks?”

“Has he been taking diuretics at home?”

“Do any of his brothers and sisters have history of cardiac problems?”

“Has he been going to school regularly?”

The child who is concurrently taking digoxin and diuretics is at increased risk for digoxin toxicity due to the loss of potassium. The child and parents should be taught what foods are high in potassium, and the child should be encouraged to eat a high-potassium diet. In addition, the child’s serum potassium level should be carefully monitored.

Explanation

The child who is concurrently taking digoxin and diuretics is at increased risk for digoxin toxicity due to the loss of potassium. The child and parents should be taught what foods are high in potassium, and the child should be encouraged to eat a high-potassium diet. In addition, the child’s serum potassium level should be carefully monitored.

47. The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection for Creatinine clearance is to be done. The client tells the nurse, "I can't remember what this test is for." The best response by the nurse is:

“It provides a way to see if you are passing any protein in your urine.”

“It tells how well the kidneys filter wastes from the blood.”

“It tells if your renal insufficiency has affected your heart.”

“The test measures the number of particles the kidney filters.”

Determining how well the kidneys filter wastes states the purpose of a Creatinine clearance test.

Explanation

Determining how well the kidneys filter wastes states the purpose of a Creatinine clearance test.

48. While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on assessing the condition of the client. The nurse notes that the newborn's respiration is 72 breaths per minute. What would be the initial nursing action?

Burp the newborn.

Stop the feeding.

Continue the feeding.

Notify the physician.

A normal respiratory rate for a newborn is 30-40 breaths per minute.

Explanation

A normal respiratory rate for a newborn is 30-40 breaths per minute.

49. The nurse is counseling a couple in their mid 30's who have been unable to conceive for about 6 months. They are concerned that one or both of them may be infertile. What is the best advice the nurse could give to the couple?

“Start planning adoption. Many couples get pregnant when they are trying to adopt.”

“Consult a fertility specialist and start testing before you get any older.”

“Have sex as often as you can, especially around the time of ovulation, to increase your chances of pregnancy.”

Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed to produce a pregnancy. Older couples will experience a longer time to get pregnant.

Explanation

Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed to produce a pregnancy. Older couples will experience a longer time to get pregnant.

50. The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with sign of preterm labor. The nurse expects that the drug will:

Treat infection.

Suppress labor contraction.

Stimulate the production of surfactant.

Reduce the risk of hypertension.

Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant.

Explanation

Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant.

51. A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care unit. The nurse placed the client in a semi-Fowler's position primarily to:

Facilitate movement and reduce complications from immobility.

Fully aerate the lungs.

Splint the wound.

Promote drainage and prevent subdiaphragmatic abscesses.

After surgery for a ruptured appendix, the client should be placed in a semi-Fowler’s position to promote drainage and to prevent possible complications.

Explanation

After surgery for a ruptured appendix, the client should be placed in a semi-Fowler’s position to promote drainage and to prevent possible complications.

52. Which of the following will help the nurse determine that the expression of hostility is useful?

Expression of anger dissipates the energy.

Energy from anger is used to accomplish what needs to be done.

Expression intimidates others.

Degree of hostility is less than the provocation.

This is the proper use of anger.

Explanation

This is the proper use of anger.

53. The physician orders a dose of IV phenytoin to a child client. In preparing in the administration of the drug, which nursing action is not correct?

Infuse the phenytoin into a smaller vein to prevent purple glove syndrome.

Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy.

Plan to give phenytoin over 30-60 minutes, using an in-line filter.

Flush the IV tubing with normal saline before starting phenytoin.

Phenytoin should be infused or injected into larger veins to avoid the discoloration know as purple glove syndrome; infusing into a smaller vein is not appropriate.

Explanation

Phenytoin should be infused or injected into larger veins to avoid the discoloration know as purple glove syndrome; infusing into a smaller vein is not appropriate.

54. A pregnant client in late pregnancy is complaining of groin pain that seems worse on the right side. Which of the following is the most likely cause of it?

Beginning of labor.

Bladder infection.

Constipation.

Tension on the round ligament.

Tension on round ligament occurs because of the erect human posture and pressure exerted by the growing fetus.

Explanation

Tension on round ligament occurs because of the erect human posture and pressure exerted by the growing fetus.

55. Most couples are using "natural" family planning methods. Most accidental pregnancies in couples preferred to use this method have been related to unprotected intercourse before ovulation. Which of the following factor explains why pregnancy may be achieved by unprotected intercourse during the preovulatory period?

Ovum viability.

Tubal motility.

Spermatozoal viability.

Secretory endometrium.

Sperm deposited during intercourse may remain viable for about 3 days. If ovulation occurs during this period, conception may result.

Explanation

Sperm deposited during intercourse may remain viable for about 3 days. If ovulation occurs during this period, conception may result.

56. The nurse in the psychiatric ward informed the male client that he will be attending the 9:00 AM group therapy sessions. The client tells the nurse that he must wash his hands from 9:00 to 9:30 AM each day and therefore he cannot attend. Which concept does the nursing staff need to keep in mind in planning nursing intervention for this client?

Depression underlines ritualistic behavior.

Fear and tensions are often expressed in disguised form through symbolic processes.

Ritualistic behavior makes others uncomfortable.

Unmet needs are discharged through ritualistic behavior.

Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral defense of hand washing decreases anxiety by avoiding group therapy.

Explanation

Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral defense of hand washing decreases anxiety by avoiding group therapy.

57. Which of the following situations cannot be delegated by the registered nurse to the nursing assistant?

A postoperative client who is stable needs to ambulate.

Client in soft restraint who is very agitated and crying.

A confused elderly woman who needs assistance with eating.

Routine temperature check that must be done for a client at end of shift.

The registered nurse cannot delegate the responsibility for assessment and evaluation of clients. The status of the client in restraint requires further assessment to determine if there are additional causes for the behavior.

Explanation

The registered nurse cannot delegate the responsibility for assessment and evaluation of clients. The status of the client in restraint requires further assessment to determine if there are additional causes for the behavior.

58. The nurse noticed that the signed consent form has an error. The form states, "Amputation of the right leg" instead of the left leg that is to be amputated. The nurse has administered already the preoperative medications. What should the nurse do?

Call the physician to reschedule the surgery.

Call the nearest relative to come in to sign a new form.

Cross out the error and initial the form.

Have the client sign another form.

The responsible for an accurate informed consent is the physician. An exception to this answer would be a life-threatening emergency, but there are no data to support another response.

Explanation

The responsible for an accurate informed consent is the physician. An exception to this answer would be a life-threatening emergency, but there are no data to support another response.

59. Which of the following signs and symptoms that require immediate attention and may indicate most serious complications during pregnancy?

Severe abdominal pain or fluid discharge from the vagina.

Excessive saliva, “bumps around the areolae, and increased vaginal mucus.

Fatigue, nausea, and urinary frequency at any time during pregnancy.

Ankle edema, enlarging varicosities, and heartburn.

Severe abdominal pain may indicate complications of pregnancy such as abortion, ectopic pregnancy, or abruption placenta; fluid discharge from the vagina may indicate premature rupture of the membrane.

Explanation

Severe abdominal pain may indicate complications of pregnancy such as abortion, ectopic pregnancy, or abruption placenta; fluid discharge from the vagina may indicate premature rupture of the membrane.

60. A client who hallucinates is not in touch with reality. It is important for the nurse to:

Isolate the client from other patients.

Maintain a safe environment.

Orient the client to time, place, and person

Establish a trusting relationship.

It is of paramount importance to prevent the client from hurting himself or herself or others.

Explanation

It is of paramount importance to prevent the client from hurting himself or herself or others.

61. The nurse is providing an orientation regarding case management to the nursing students. Which characteristics should the nurse include in the discussion in understanding case management?

Main objective is a written plan that combines discipline-specific processes used to measure outcomes of care.

Main purpose is to identify expected client, family and staff performance against the timeline for clients with the same diagnosis.

Main focus is comprehensive coordination of client care, avoid unnecessary duplication of services, improve resource utilization and decrease cost.

Primary goal is to understand why predicted outcomes have not been met and the correction of identified problems.

There are several models of case management, but the commonality is comprehensive coordination of care to better predict needs of high-risk clients, decrease exacerbations and continually monitor progress overtime.

Explanation

There are several models of case management, but the commonality is comprehensive coordination of care to better predict needs of high-risk clients, decrease exacerbations and continually monitor progress overtime.

62. The nurse wants to know if the mother of a toddler understands the instructions regarding the administration of syrup of ipecac. Which of the following statement will help the nurse to know that the mother needs additional teaching?

“I’ll give the medicine if my child gets into some toilet bowl cleaner.”

“I’ll give the medicine if my child gets into some aspirin.”

“I’ll give the medicine if my child gets into some plant bulbs.”

“I’ll give the medicine if my child gets into some vitamin pills.

Syrup of ipecac is not administered when the ingested substances is corrosive in nature. Toilet bowl cleaners, as a collective whole, are highly corrosive substances. If the ingested substance “burned” the esophagus going down, it will “burn” the esophagus coming back up when the child begins to vomit after administration of syrup of ipecac.

Explanation

Syrup of ipecac is not administered when the ingested substances is corrosive in nature. Toilet bowl cleaners, as a collective whole, are highly corrosive substances. If the ingested substance “burned” the esophagus going down, it will “burn” the esophagus coming back up when the child begins to vomit after administration of syrup of ipecac.

63. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition complicated by hypertension. A new pregnant woman in active labor is admitted in the same unit. The nurse manager assigned the same nurse to the second client. The nurse feels that the client with hypertension requires one-to-one care. What would be the initial action of the nurse?

Accept the new assignment and complete an incident report describing a shortage of nursing staff.

Report the incident to the nursing supervisor and request to be floated.

Accept the new assignment and provide the best care.

The nurse is obligated to inform the nurse manager about changes in the condition of the client, which may change the decision made by the nurse manager.

Explanation

The nurse is obligated to inform the nurse manager about changes in the condition of the client, which may change the decision made by the nurse manager.

64. The nurse is completing an assessment to a newborn baby boy. The nurse observes that the skin of the newborn is dry and flaking and there are several areas of an apparent macular rash. The nurse charts this as:

Icterus neonatorum

Multiple hemangiomas

Erythema toxicum

Milia

Erythema toxicum is the normal, nonpathological macular newborn rash.

Explanation

Erythema toxicum is the normal, nonpathological macular newborn rash.

65. The nurse is teaching exercises that are good for pregnant women increasing tone and fitness and decreasing lower backache. Which of the following should the nurse exclude in the exercise program?

Stand with legs apart and touch hands to floor three times per day.

Ten minutes of walking per day with an emphasis on good posture.

Ten minutes of swimming or leg kicking in pool per day.

Pelvic rock exercise and squats three times a day.

Bending from the waist in pregnancy tends to make backache worse.

Explanation

Bending from the waist in pregnancy tends to make backache worse.

66. The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn becomes slightly cyanotic. What is the initial nursing action?

Elevate his head to promote gravity drainage of secretions.

Wrap him in another blanket, to reduce heat loss.

Stimulate him to cry,, to increase oxygenation.

Aspirate his mouth and nose with bulb syringe.

Gentle aspiration of mucus helps maintain a patent airway, required for effective gas exchange.

Explanation

Gentle aspiration of mucus helps maintain a patent airway, required for effective gas exchange.

67. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a client's room and notes that the client's tube has become disconnected from the Pleurovac. What would be the initial nursing action?

Apply pressure directly over the incision site.

Clamp the chest tube near the incision site.

Clamp the chest tube closer to the drainage system.

Reconnect the chest tube to the Pleurovac.

This stops the sucking of air through the tube and prevents the entry of contaminants. In addition, clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube.

Explanation

This stops the sucking of air through the tube and prevents the entry of contaminants. In addition, clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube.

68. The community health nurse makes a home visit to a family. During the visit, the nurse observes that the mother is beating her child. What is the priority nursing intervention in this situation?

Assess the child’s injuries.

Report the incident to protective agencies.

Refer the family to appropriate support group.

Assist the family to identify stressors and use of other coping mechanisms to prevent further incidents.

Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is the first priority.

Explanation

Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is the first priority.

69. Which of the following is the most frequent cause of noncompliance to the medical treatment of open-angle glaucoma?

The frequent nausea and vomiting accompanying use of miotic drug.

Loss of mobility due to severe driving restrictions.

Decreased light and near-vision accommodation due to miotic effects of pilocarpine.

The painful and insidious progression of this type of glaucoma.

The most frequent cause of noncompliance to the treatment of chronic, or open-angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal accommodation, making night driving difficult and hazardous, reducing the client’s ability to read for extended periods and making participation in games with fast-moving objects impossible.

Explanation

The most frequent cause of noncompliance to the treatment of chronic, or open-angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal accommodation, making night driving difficult and hazardous, reducing the client’s ability to read for extended periods and making participation in games with fast-moving objects impossible.

70. A client who undergone left nephrectomy has a large flank incision. Which of the following nursing action will facilitate deep breathing and coughing?

Push fluid administration to loosen respiratory secretions.

Have the client lie on the unaffected side.

Maintain the client in high Fowler’s position.

Coordinate breathing and coughing exercise with administration of analgesics.

Because flank incision in nephrectomy is directly below the diaphragm, deep breathing is painful. Additionally, there is a greater incisional pull each time the person moves than there is with abdominal surgery. Incisional pain following nephrectomy generally requires analgesics administration every 3-4 hours for 24-48 hours after surgery. Therefore, turning, coughing and deep-breathing exercises should be planned to maximize the analgesic effects.

Explanation

Because flank incision in nephrectomy is directly below the diaphragm, deep breathing is painful. Additionally, there is a greater incisional pull each time the person moves than there is with abdominal surgery. Incisional pain following nephrectomy generally requires analgesics administration every 3-4 hours for 24-48 hours after surgery. Therefore, turning, coughing and deep-breathing exercises should be planned to maximize the analgesic effects.

71. A couple seeks medical advice in the community health care unit. A couple has been unable to conceive; the man is being evaluated for possible problems. The physician ordered semen analysis. Which of the following instructions is correct regarding collection of a sperm specimen?

Collect a specimen at the clinic, place in iced container, and give to laboratory personnel immediately.

Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours.

Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately.

Collect specimen at night, refrigerate, and bring to clinic the next morning.

Is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48-72 hours.

Explanation

Is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48-72 hours.

72. The child client has undergone hip surgery and is in a spica cast. Which of the following toy should be avoided to be in the child's bed?

A toy gun.

A stuffed animal.

A ball.

Legos.

Legos are small plastic building blocks that could easily slip under the child’s cast and lead to a break in skin integrity and even infection. Pencils, backscratchers, and marbles are some other narrow or small items that could easily slip under the child’s cast and lead to a break in skin integrity and infection.

Explanation

Legos are small plastic building blocks that could easily slip under the child’s cast and lead to a break in skin integrity and even infection. Pencils, backscratchers, and marbles are some other narrow or small items that could easily slip under the child’s cast and lead to a break in skin integrity and infection.

73. The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day is encouraged to the client. the primary reason for this is to:

Reduce the size of existing stones.

Prevent crystalline irritation to the ureter.

Reduce the size of existing stones

Increase the hydrostatic pressure in the urinary tract.

Increasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi.

Explanation

Increasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi.

74. Which of the following statement describes the role of a nurse as a client advocate?

A nurse may override clients’ wishes for their own good.

A nurse has the moral obligation to prevent harm and do well for clients.

A nurse helps clients gain greater independence and self-determination.

A nurse measures the risk and benefits of various health situations while factoring in cost.

An advocate role encourage freedom of choice, includes speaking out for the client, and supports the client’s best interests.

Explanation

An advocate role encourage freedom of choice, includes speaking out for the client, and supports the client’s best interests.

75. A client with lung cancer is admitted in the nursing care unit. The husband wants to know the condition of his wife. How should the nurse respond to the husband?

Find out what information he already has.

Suggest that he discuss it with his wife.

Refer him to the doctor.

Refer him to the nurse in charge.

It is best to establish baseline information first.

Explanation

It is best to establish baseline information first.

76. The nurse is planning to talk to the client with an antisocial personality disorder. What would be the most therapeutic approach?

Provide external controls.

Reinforce the client’s self-concept.

Give the client opportunities to test reality.

Gratify the client’s inner needs.

Personality disorders stem from a weak superego, implying a lack of adequate controls.

Explanation

Personality disorders stem from a weak superego, implying a lack of adequate controls.

77. Before the administration of digoxin, the nurse completes an assessment to a toddler client for signs and symptoms of digoxin toxicity. Which of the following is the earliest and most significant sign of digoxin toxicity?

Tinnitus

Nausea and vomiting

Vision problem

Slowing in the heart rate

One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart rate that falls below the norm of about 100-120 bpm would indicate Bradycardia and would necessitate holding the medication and notifying the physician.

Explanation

One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart rate that falls below the norm of about 100-120 bpm would indicate Bradycardia and would necessitate holding the medication and notifying the physician.

78. The nurse is caring to a client diagnosed with severe depression. Which of the following nursing approach is important in depression?

Protect the client against harm to others.

Provide the client with motor outlets for aggressive, hostile feelings.

Reduce interpersonal contacts.

Deemphasizing preoccupation with elimination, nourishment, and sleep.

It is important to externalize the anger away from self.

Explanation

It is important to externalize the anger away from self.

79. The client's jaw and cheekbone is sutured and wired. The nurse anticipates that the most important thing that must be ready at the bedside is:

Suture set.

Tracheostomy set.

Suction equipment.

Wire cutters.

The priority for this client is being able to establish an airway.

Explanation

The priority for this client is being able to establish an airway.

80. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means that:

Gloves are worn when handling the client’s tissue, excretions, and linen.

Both client and attending nurse must wear masks at all times.

Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed in cough and tissue techniques.

Full isolation; that is, caps and gowns are required during the period of contagion.

Proper handling of sputum is essential to allay droplet transference of bacilli in the air. Clients need to be taught to cover their nose and mouth with tissues when sneezing or coughing. Chemotherapy generally renders the client noninfectious within days to a few weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is established, many institutions require the client to wear a mask when visitors are in the room or when the nurse is in attendance. Client should be in a well-ventilated room, without air recirculation, to prevent air contamination.

Explanation

Proper handling of sputum is essential to allay droplet transference of bacilli in the air. Clients need to be taught to cover their nose and mouth with tissues when sneezing or coughing. Chemotherapy generally renders the client noninfectious within days to a few weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is established, many institutions require the client to wear a mask when visitors are in the room or when the nurse is in attendance. Client should be in a well-ventilated room, without air recirculation, to prevent air contamination.

81. The nurse in the neonatal care unit is supervising the actions of a certified nursing assistant in giving care to the newborns. The nursing assistant mistakenly gives a formula feeding to a newborn that is on water feeding only. The nurse is responsible for the mistake of the nursing assistant:

Always, as a representative of the institution.

Always, because nurses who supervise less-trained individuals are responsible for their mistakes.

If the nurse failed to determine whether the nursing assistant was competent to take care of the client.

Only if the nurse agreed that the newborn could be fed formula.

The nurse who is supervising others has a legal obligation to determine that they are competent to perform the assignment, as well as legal obligation to provide adequate supervision.

Explanation

The nurse who is supervising others has a legal obligation to determine that they are competent to perform the assignment, as well as legal obligation to provide adequate supervision.

82. The physician ordered tetracycline PO qid to a child client who weights 20kg. The recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single dose that can be safely administered to this child?

1 g

500 mg

250 mg

125 mg

The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs 20kg and the maximum dose is 50mg/kg, this would indicate a total daily dose of 1000mg of tetracycline. In this case, the child is being given this medication four times a day. Therefore the maximum single dose that can be given is 250mg (1000 mg of tetracycline divided by four doses.)

Explanation

The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs 20kg and the maximum dose is 50mg/kg, this would indicate a total daily dose of 1000mg of tetracycline. In this case, the child is being given this medication four times a day. Therefore the maximum single dose that can be given is 250mg (1000 mg of tetracycline divided by four doses.)

83. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client. The nurse caring to the client provides instructions that the nasal spray must be used exactly as directed to prevent the development of:

Increased nasal congestion.

Nasal polyps

Bleeding tendencies.

Tinnitus and diplopia.

Phenylephrine, with frequent and continued use, can cause rebound congestion of mucous membranes.

Explanation

Phenylephrine, with frequent and continued use, can cause rebound congestion of mucous membranes.

84. An older adult client wakes up at 2 o'clock in the morning and comes to the nurse's station saying, "I am having difficulty in sleeping." What is the best nursing response to the client?

“I’ll give you a sleeping pill to help you get more sleep now.”

“Perhaps you’d like to sit here at the nurse’s station for a while.”

“Would you like me to show you where the bathroom is?”

“What woke you up?”

This option shows acceptance (key concept) of this age-typical sleep pattern (that of waking in the early morning).

Explanation

This option shows acceptance (key concept) of this age-typical sleep pattern (that of waking in the early morning).

85. The nurse is conducting a lecture to a class of nursing students about advance directives to preoperative clients. Which of the following statement by the nurse js correct?

“The spouse, but not the rest of the family, may override the advance directive.”

“An advance directive is required for a “do not resuscitate” order.”

“A durable power of attorney, a form of advance directive, may only be held by a blood relative.”

“The advance directive may be enforced even in the face of opposition by the spouse.”

An advance directive is a form of informed consent, and only a competent adult or the holder of a durable power of attorney has the right to consent or refuse treatment. If the spouse does not hold the power of attorney, the decisions of the holder, even if opposed by the spouse, are enforced.

Explanation

An advance directive is a form of informed consent, and only a competent adult or the holder of a durable power of attorney has the right to consent or refuse treatment. If the spouse does not hold the power of attorney, the decisions of the holder, even if opposed by the spouse, are enforced.

86. A tracheostomy cuff is to be deflated, which of the following nursing intervention should be implemented before starting the procedures?

Suction the trachea and mouth.

Have the obdurator available.

Encourage deep breathing and coughing.

Do a pulse oximetry reading.

Secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated.

Explanation

Secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated.

87. The client has had a right-sided cerebrovascular accident. In transferring the client from the wheelchair to bed, in what position should a client be placed to facilitate safe transfer?

Weakened (L) side of the cient next to bed.

Weakened (R) side of the client next to bed.

Weakened (L) side of the client away from bed.

Weakened (R) side of the cient away from bed.

With a right-sided cerebrovascular accident the client would have left-sided hemiplegia or weakness. The client’s good side should be closest to the bed to facilitate the transfer.

Explanation

With a right-sided cerebrovascular accident the client would have left-sided hemiplegia or weakness. The client’s good side should be closest to the bed to facilitate the transfer.

88. The emergency department has shortage of staff. The nurse manager informs the staff nurse in the critical care unit that she has to float to the emergency department. What should the staff nurse expect under these conditions?

The float staff nurse will be informed of the situation before the shift begins.

The staff nurse will be able to negotiate the assignments in the emergency department.

Cross training will be available for the staff nurse.

Client assignments will be equally divided among the nurses.

Assignments should be based on scope of practice and expertise.

Explanation

Assignments should be based on scope of practice and expertise.

89. A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan of care for this client, which nursing care is least likely to be done?

Deep-tendon reflexes once per shift.

Vital signs and FHR and rhythm q4h while awake.

Absolute bed rest.

Daily weight.

Although reducing environment stimuli and activity is necessary for a woman with mild preeclampsia, she will most probably have bathroom privileges.

Explanation

Although reducing environment stimuli and activity is necessary for a woman with mild preeclampsia, she will most probably have bathroom privileges.

90. The pregnant woman visits the clinic for check –up. Which assessment findings will help the nurse determine that the client is in 8-week gestation?

Leopold maneuvers.

Fundal height.

Positive radioimmunoassay test (RIA test).

Auscultation of fetal heart tones.

Serum radioimmunoassay (RIA) is accurate within 7days of conception. This test is specific for HCG, and accuracy is not compromised by confusion with LH.

Explanation

Serum radioimmunoassay (RIA) is accurate within 7days of conception. This test is specific for HCG, and accuracy is not compromised by confusion with LH.

91. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse is responsible for the overall planning, giving and evaluating care during the entire shift. After the shift, same responsibility will be endorsed to the next nurse in charge. This describes nursing care delivered via the:

Primary nursing method.

Case method.

Functional method.

Team method.

In case management, the nurse assumes total responsibility for meeting the needs of the client during the entire time on duty.

Explanation

In case management, the nurse assumes total responsibility for meeting the needs of the client during the entire time on duty.

92. The nurse is conducting a lecture to a group of volunteer nurses. The nurse is correct in imparting the idea that the Good Samaritan law protects the nurse from a suit for malpractice when:

The nurse stops to render emergency aid and leaves before the ambulance arrives.

The nurse acts in an emergency at his or her place of employment.

The nurse refuses to stop for an emergency outside of the scope of employment.

The nurse is grossly negligent at the scene of an emergency.

The Good Samaritan Law does not impose a duty to stop at the scene of an emergency outside of the scope of employment, therefore nurses who do not stop are not liable for suit.

Explanation

The Good Samaritan Law does not impose a duty to stop at the scene of an emergency outside of the scope of employment, therefore nurses who do not stop are not liable for suit.

93. The nurse is completing an obstetric history of a woman in labor. Which event in the obstetric history will help the nurse suspects dysfunctional labor in the current pregnancy?

Total time of ruptured membranes was 24 hours with the second birth.

First labor lasting 24 hours.

Uterine fibroid noted at time of cesarean delivery.

Second birth by cesarean for face presentation.

An abnormality in the uterine muscle could reduce the effectiveness of uterine contractions and lengthen the duration of subsequent labors.

Explanation

An abnormality in the uterine muscle could reduce the effectiveness of uterine contractions and lengthen the duration of subsequent labors.

94. The nurse is providing a health teaching to a group of parents regarding Chlamydia trachomatis. The nurse is correct in the statement, "Chlamydia trachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause:

Discoloration of baby and adult teeth.

Pneumonia in the newborn.

Snuffles and rhagades in the newborn.

Central hearing defects in infancy.

Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and conjunctivitis from Chlamydia.

Explanation

Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and conjunctivitis from Chlamydia.

95. The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications like:

Antihistamines.

NSAIDs.

Antacids.

Salicylates.

Antihistamines cause pupil dilation and should be avoided with glaucoma.

Explanation

Antihistamines cause pupil dilation and should be avoided with glaucoma.

96. The nurse in the nursing care unit is aware that one of the medical staff displays unlikely behaviors like confusion, agitation, lethargy and unkempt appearance. This behavior has been reported to the nurse manager several times, but no changes observed. The nurse should:

Continue to report observations of unusual behavior until the problem is resolved.

Discuss the situation with friends who are also nurses to get ideas .

Approach the partner of this medical staff member with these concerns.

The submission of reports about incidents that expose clients to harm does not remove the obligation to report ongoing behavior as long as the risk to the client continues.

Explanation

The submission of reports about incidents that expose clients to harm does not remove the obligation to report ongoing behavior as long as the risk to the client continues.

97. To assess if the cranial nerve VII of the client was damaged, which changes would not be expected?

Drooling and drooping of the mouth.

Inability to open eyelids on operative side.

Sagging of the face on the operative side.

Inability to close eyelid on operative side.

Inability to open eyelids on operative side is seen with cranial nerve III damage.

Explanation

Inability to open eyelids on operative side is seen with cranial nerve III damage.

98. The nurse is assessing on the client who is admitted due to vehicle accident. Which of the following findings will help the nurse that there is internal bleeding?

Frank blood on the clothing.

Thirst and restlessness.

Abdominal pain.

Confusion and altered of consciousness.

Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is difficult to recognized and evaluate because it is not apparent.

Explanation

Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is difficult to recognized and evaluate because it is not apparent.

99. The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, her membranes ruptured spontaneously 2 hours ago. While auscultating for the point of maximum intensity of fetal heart tones before applying an external fetal monitor, the nurse counts 100 beats per minute. The immediate nursing action is to:

Start oxygen by mask to reduce fetal distress.

Examine the woman for signs of a prolapsed cord.

Turn the woman on her left side to increase placental perfusion.

Take the woman’s radial pulse while still auscultating the FHR.

Taking the mother’s pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal Bradycardia.

Explanation

Taking the mother’s pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal Bradycardia.

100. After ileostomy, the nurse expects that the drainage appliance will be applied to the stoma:

When the client is able to begin self-care procedures.

24 hours later, when the swelling subsided.

In the operating room after the ileostomy procedure.

After the ileostomy begins to function.

The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful and excoriated.

Explanation

The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful and excoriated.