Practice Bank 1

1. The nurse manager identifies that time spent by staff in charting is excessive, with the requirement of overtime for completion of tasks. The nurse manager states that staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting. The nurse manager's leadership style is best described as a. b. c. d. Participative Laissez-faire Autocratic Group

2. The nurse is planning care for a 6 month-old infant. What must the nurse provide to assist in the development of trust? a. b. c. d. Security Comfort Food Warmth

3. Which of these actions is the most effective nursing intervention to prevent atelectasis from developing in a postoperative client who had a laparotomy? a. b. c. d. Ambulate client within 12 hours postop Assist the client slowly deep breathe and cough Splint the incision maintain adequate hydration

4. After treating a 4 month-old infant in the Emergency department for dehydration, the nurse finds the mother and
infant were driven to the hospital by an\ neighbor. Upon discharge, the emergency nurse supplies the infant with a properly positioned car seat. Indicate where the car seat should be positioned in a car

5. The nurse is caring for the following clients. Which client is at the highest risk for falling? a. b. c. d. The 59 year-old who had hip replacement surgery 4 days ago and is going to physical therapy The 67 year-old who is diabetic and has a draining ulcer on the right leg The 79 year-old who has arthritis and walks with the aid of a walker The 81 year-old who fell at home last week and is confused

6. During a teaching session by a nurse to a client about the patient controlled analgesia (PCA) planned for postoperative care, which statement by the client is incorrect and indicates that further teaching is needed? a. b. c. d. I will receive continuous dose of medication I should call the nurse before I take additional doses The machine will prevent an overdose of medication I will call assistance if my pain is not relieved

7. A nurse provides instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother is incorrect and indicates a need for additional instruction? a. I can switch to a bottle if I need to take a break form breastfeeding b. The baby should latch onto the nipple and areola areas c. I should position my baby completely facing me with my baby's mouth in front of my nipple

d. There may be times that I will need to manually express my milk 8. A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be appropriate to assign the UAP? a. b. c. d. A middle-aged client diagnosed with an obsessive compulsive disorder A 76 year-old client diagnosed with severe depression A young adult who reports to be a heoin addict and states I am in withdrawal and seeing spider An adolescent diagnosed with dehydration and anorexia

9. A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nause, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being too sick to return to work. The client is diagnosed with somatoform disorder. In formulating a plan of care, the nurse must consider that the client's behavior a. b. c. d. would respond to psychoeducational strategies could be modified through reality therapy is manipulative to avoid work responsibilities is controlled by the subconscious mind

10. The nurse receives a telephone order from the health care provider for acetaminophen (Tylenol) 1000 mg by mouth for a client's headache. What should the nurse add to the following order when documenting it in the chart? (Write the answer) Acetaminophen (Tylenol) 1000 mg by mouth for headache, one time dose. _____________ Dr. Smith 10/1/2012 at 2:30 pm (1430) by N. Nurse, RN 11. A client has just returned to the medical-surgical unit postop for a segmental lung resection. After assessing the client, which is the first action a nurse should take? a. b. c. d. Suction excessive tracheobronchial secrretions Monitor the oxygen saturation with the application of an oximeter Assist the client to turn, deep breathe and cough Administer the prn pain medication

12. the nurse is caring for an 87 year-old client who complains of urinary retention. Which finding should be reported immediately to the health care provider? a. b. c. d. Burning with urination Infrequent voiding Fecal impaction Stress incontinence

13. Prior to a plaster cast application a nurse should include what point in the discussion with the client of what should happen? a. b. c. d. The casted extremity will be placed on a cloth-covered surface The cast material will be dipped several times into the tepid water The cast should be covered with cotton material until it fully dries The wet cast should be handled with the palms of hands until fully dry

14. A client reports taking lithium (Eskalith, Lithobid) as prescribed. Which of these findings indicate early signs of lithium toxicity? a. b. c. d. Ataxia, agnosia, and course hand tremors Vomiting, diarrhea, and lethargy Pruritus, rash, and photosensitivity Electrolyte imbalance, tinnitus, and cardiac arrhythmias

15. A nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action? a. b. c. d. Lethargy Dizzy spells Periorbital edema Shortness of breath

16. A nurse is caring for clients over the age of 70. the nurse is aware that when giving medications to older clients, it is best to use what approach?

a. b. c. d.

Avoid drugs with side effects that impact cognition Do not stop a medication entirely Review the drug regimen yearly Start low and go slow

17. While caring for a client, a nurse notes a pulsating mass in the client's periumbilical area. Which of these assessments is appropriate for the nurse to perform on the mass? a. b. c. d. Measure the length Auscutate Palpate Percuss

18. A nurse admits a client transferred from the emergency room (ER). The client, diagnosed with myocardial infarction, is complaining of substernal chest pain, diaphoresis and nausea. What should be the first action taken by the nurse? a. b. c. d. Get the PRN 12 lead EKG taken Administer morphine sulfate as ordered Obtain vital signs Give a PRN sublingual nitroglycerine

19. To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, a nurse should take which action? a. b. c. d. Administer antidysrhythmics prn as ordered Assist the client to use bedside commode Maintain the client o strict bed rest Administer stool softeners every day as ordered

20. Which statement by the client during the initial assessment in the emergency department most strongly suggests suspected domestic violence? a. b. c. d. I have tried leaving home, but have always gone back No one else in the family is as accident prone as I am I have only been married for two months I am determined to leave my house in a week

ANSWER KEY: 1. CORRECT: A. Participative Rationale: Learning Objective: Lesson 1 Management of Care A participative style of management involves staff in decision-making processes. Staff/manager intercations are open and trusting. Most work efforts are joint endeavors. 2. CORRECT: A. Security Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance While the infant has many physical needs, it must be touched, loved, and stimulated to develop security and trust. 3. CORRECT: B. Assist the client to slowly deep breathe and cough Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential Deep air excursion by slow deep breathing, and coughing will expand the lungs and stimulate surfactant production. This is the priority to prevent pulmonary complications after surgery. The nurse should instruct the client on how to splint the abdomen when coughing. Humidification, hydration and nutrition all play a part in the prevention of atelectasis 4. CORRECT: Rationale: Learning Objective: Lesson 2 Safety and Infection Nurses are responsible for promoting the continued safety of infants and children outside of the hospital. Emergency Department and Women's Services staff are trained in child seat placement. All infants should be safely restrained in car seats in a rear-facing car seat until they reach 12 months and 20 pounds. Once the child is at least a year old and has outgrown a rear-facing car seat, the child can ride facing forward; the middle of the back seat is still the safest place to position the car seat. 5. CORRECT: D. The 81 year-old who fell at home last week and is confused Rationale: Learning Objective: Lesson 2 Safety and Infection Control Although all of the individuals might be at risk for falling, evidence shows that the greatest risk of falling is a person who is older than age 80, is confused, and has a history of falling 6. CORRECT: B. I should call the nurse before I take additional doses. Rationale: Learning Objective: Lesson 5 Basic Care and Comfort Patient controlled analgesia offers the client more control in the prevention and relief of sever pain. The client should be

instructed to initiate additional doses as needed when the pain is increased. The client needs to know to call for assistance when insufficient control of the pain is present. The other statements illustrate correct knowledge. 7. CORRECT: A. I can switch to a bottle if I need to take a break form breast feeding. Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Babies adapt more quickly to the breast when they are not confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple weakens the baby's suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the learning stage of breast feeding. 8. CORRECT: A. A middle-aged client diagnosed with an obsessive-complusive disorder Rationale: Learning Objective: Lesson 1 Management of Care The UAP can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition and has more of a situation of expected outcomes. 9. CORRECT: D. is controlled by the subconscious mind Rationale: Learning Objective: Lesson 4 Psychosocial Integrity Persons with somatoform disorder do not intend to feign illness. Their complaints are not under their conscious control. Showing intention to use feigned physical complaints to accomplish some goal is call ed malingering or a factitious disorder. 10. CORRECT: Telephone order Rationale: The word telephone order must written out to differentiate it from a verbal order or one written by the health care provider directly in the chart. Abbreviations should not be used. To health care provider needs to countersign the order according to the facility policy. 11. CORRECT: A. Suction excessive tracheobronchial secretions Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential Suctioning the excessive tracheobronchial secretions that are present in post-thoracic surgery clients is the priority to maintain an open airway. The application of the pulse oximeter would be next with pain medication given and the mobility last. 12. CORRECT: C. Fecal impaction Rationale: Learning Objective: Lesson 5 Basic Care and Comfort The nurse should report fecal impaction or frequent constipation which result in obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in older adults in both males and females. In addition, in men it also may indicate an enlarged prostate. Infrequent voiding may be associated with the amount of fluid intake in this age group. Stress incontinence is an expected finding that may or may not be treated. Burning on urination in this age group may indicated bladder infections or perineal irritations. 13. CORRECT: D. The wet cast should be handled with the palms of hands until fully dry Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential The cast will be handled with the palms of the hands and need to be lifted at 2 points of the extremity while it is drying. This will prevent stress of the injury and pressure indentation areas on the cast. The cast should be uncovered and be placed on a firm surface. 14. CORRECT: B. Vomiting, diarrhea, and lethargy Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Serum lithium level should be between 0.8 1.2 mEq\/L (remember, the exact number may vary slightly depending on the lab). Diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination may be early signs of lithium toxicity. Toxicity increases with increasing serum lithium levels, but clients may exhibit toxic finding at lithium levels below 2.9 mEq/L. Dehydration, other medications and other conditions can interfere with lithium levels. 15. CORRECT: B. Dizzy spells Rationale: Learning Objective: Lesson 8 Physiological Adaptation Cardiac dysrhythmias may cause a transient drop in cardiac output and decreased blood flow to the brain. Near syncope refers to lightheadedness, dizziness, temporary confusion. Such spells may indicate runs of ventricular tachcardia or periods of asystole and should be reported immediately after a verification of the cardiac status. 16. CORRECT: D. Start low and go slow Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Due to physiological changes in the older adult, as well as conditions such as dehydration, hyperthermia,immobility and liver disease, the metabolism of drugs may be altered to be decreased. As a result, drugs can accumulate to toxic levels and cause serious adverse reactions. 17. CORRECT: B. Auscultate Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Auscultation of the abdomen and the finding of a bruit would confirm the presence of an abdominal aneurysm. This would form the basis of information to be given to the health care provider. The mass should not be palpated or percussed because of the risk of rupture. 18. CORRECT: B. Administer morphine sulfate as ordered Rationale: Learning Objective: Lesson 8 Physiological Adaptation To decrease the client's pain is the priority at this time. As long as pain is present a danger exists for the extension of the infarcted area. Morphine will decrease the oxygen demands of the heart, dilate the coronary arteries and act as a mild diuretic. Since the client is diagnosed with an MI the narcotic analgesic should be given instead of the NTG which is more for angina. 19. CORRECT: D. Administer stool softeners every day as ordered Rationale: Learning Objective: Lesson 8 Physiological Adaptation Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If

constip[ation occurs then laxatives would be necessary to prevent straining. If straining on defecation (Valsalva maneuver) produced rhythm disturbances, then antidysrhythmics would be appropriate. 20. CORRECT: A. I have tried leaving home, but have always gone back. Rationale: Learning Objective: Lesson 4 Psychosocial Integrity Persons being abused or neglected often develop a high tolerance for abuse. They commonly blame themselves for being abused or neglected. All members in the family are affected by the behavior of abuse, even if they are not the actual object of the abuse. For these reasons, persons who have been abused or neglected often have an extensive history of being abused. They struggle for along time before actions are taken to leave permanently.

Practice Bank 2
1. The health care provider has just finished writing the admission orders for a client diagnosed with pneumonia and sepsis, who has a history of type 1 diabetes. Prioritize how the nurse should complete the orders listed below (Rank from 1-5, with 1 being top priority). ___ ___ ___ ___ ___ IV normal saline at 100 mL/hr Blood and sputum cultures Oxygen 2 liters per nasal canula Ceftriaxone (Rocephin) 1 gram every 12 hours Finger stick before each meal and at bedtime 2. The nurse is caring fir a client diagnosed with a venous stasis ulcers on one leg. Which nursing intervention would be most effective to promote healing? a. b. c. d. Improve the client's nutritional status Begin the ordered proteolytic debridement of the wound Initiate whirlpool bath therapy Apply dressings using sterile technique

3. A newly promoted nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be best approach? a. b. c. d. Obtain an interview guide from human resources (HR) for consistency in interviewing each candidate Vary the interview style for each candidate to learn different techniques Use simple questions requiring yes and no answers to gain definitive information Ask personal information of each applicant to assure he/she can meet job demands

4. The nurse is reviewing client assignments at the beginning of the shift. Which task could be safely delegated to an unlicensed assistive personnel (UAP)? a. b. c. d. Monitor a client's response to passive range of motion exercises Stay with a client during the self-administration of insulin Cleanse and dress a small decubitus ulcer on the leg Empty a client's colostomy bag

5. A newly admitted adult client has a diagnosis of Hepatitis A. The charge nurse should reinforce to staff members that the priority routine infection control strategy, in addition to handwashing, is which of these approaches? a. b. c. d. Wear a gown to change soiled linens from incontinence Place appropriate precaution signs outside and inside the room Use a mask with a shield if there is a risk of fluid splash Have gloves on while handling bedpans with feces

6. A client with chronic heart failure should be instructed to contact a home health nurse if which finding occurs? a. b. c. d. Weight gain of two pounds or more in a 48 hour period Appearance of non-pitting ankle edema Urinating four to five times each day A significant decrease in appetite

7. A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus further assessment by use of which approach? a. Administer a standardized tool that measures depression b. Inquire about use of alcohol or other nonprescribed substances

c. Observe the client's affect and behavior during the visit d. Obtain a family health history, including emotional problems or mental illness 8. A 10 year-old child is recovering from a splenectomy after a traumatic injury. The child's laboratory results show a hemoglobin of 8.8 g/dL and a hematocrit of 26 percent. What is a priority approach that the nurse should include in the plan of care for the child? a. b. c. d. Restrict the consumption of carbonated beverages Plan for regularly scheduled rest periods Promote a diet rich in iron and lean red meats Encourage bed activities and games for the next five days

9. While explaining an illness to a 10 year-old, what should a nurse keep in mind about the cognitive development at this age? a. b. c. d. Children of this age are able to make simple association of ideas Conclusions are based on previous experiences Interpretation of events originate from their own perspective They are able to think logically in the organization of facts

10. Which of these approaches would be the best strategy for a nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes mellitus? a. b. c. d. Ask questions during practice Allow another diabetic to assist Observe a return demonstration Give written pre and post tests

11. Which statement by a client who will undergo a myelogram indicates a contraindication for this test? a. b. c. d. I suffer from claustrophobia I had severe headache after a prior spinal tap I am allergic to shrimp I can lie still for thirty minutes

12. A nurse is planning care for a client with increased intracranial pressure. What is the best position for this client? a. b. c. d. Side-lying with head flat Semi-Fowler's Low Fowler's Trendelenburg

13. During a 12-hour shift, a client underwent a transurethral resection of the prostate (TURP), had an IV intake of 1200 mL, oral intake of 400 mL, continuous bladder irrigation of 2400 mL, 2 syringe flushes of 50 mL each, and Foley catheter output of 3000 mL. What is the end of shift fluid intake? (Write the answer using a whole number) ________ mL. 14. A staff nurse complaints to a nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The initial response by the nurse manager should be which of these statements? a. b. c. d. I can assure that I will look into the matter in due time I would like for you to approach the UAP about the problem the next time it occurs I will arrange for a conference with you and the UAP within the next week I will add this concern to the agenda for the next unit meeting so we can discuss it

15. How should a nurse instruct the client who is prescribed an inhaler, to breathe in the medication? a. b. c. d. As quickly as possible Deeply for three to four seconds Until hearing whistling by the spacer As slowly as possible

16. A client who lives an assisted living facility tells a nurse I am so depressed. Life isn't worth living anymore. What is the best response by the nurse to this statement?

a. b. c. d.

Think of the many positive things in life today. Have you thought about hurting yourself? Did you tell any of this to your family? Come on, it's not that bad.

17. A nurse is talking by telephone with a parent of a four year-old child who has chickenpox. Which approach demonstrates appropriate teaching by the nurse? a. b. c. d. Chewable aspirin is the preferred analgesic Topical cortisone ointment relieves itching The illness is only contagious prior to lesion eruption Papules, vesicles, and crusts will be present at one time

18. During the care of a client with Legionnaire's disease, which finding would require a nurse's immediate attention? a. b. c. d. Dry mucus membranes in the mouth A decrease in respiratory rate from 34 to 24 Decrease in chest wall expansion Pleuritic pain on inspiration

19. A nurse is caring for a client who is receiving procainamide (Pronestyl) intravenously. It is important for the nurse to monitor which of these parameters? a. b. c. d. Neurological signs Serum potassium levels Hourly urinary output Continuous EKG readings

20. To prevent drug resistance from developing, a nurse should be aware that which of these items is a characteristic of the typical treatment plan to eliminate the tuberculosis bacilli? a. b. c. d. High doses of B complex vitamins Administering two anti-tuberculosis drugs Aminoglycosides antibiotics An anti-inflammatory agent

ANSWER KEY: 1. CORRECT: Rationale: For establishing priorities, first look at the ABC's. Oxygen administration is the first priority (and the client's oxygen saturation is probably low given the patient has pneumonia). The next priority would be to have the lab come and draw blood for the cultures;this must be done prior to starting the antibiotics. Then an IV must be started (since the antibiotic is ordered IV). Even though the patient is diabetic and it is dinner time, a finger stick is the last thing on the list to complete. 2. CORRECT: A. Improve the client's nutritional status Rationale: Learning Objective: Lesson 5 Basic Care and Comfort The goal of clinical management in a client diagnosed with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help. Venous ulcers take a long time to heal so proper nutritional therapy is the most important intervention. 3. CORRECT: A. Obtain an interview guide from human resources (HR) for the consistency in interviewing each candidate Rationale: Learning Objective: Lesson 1 Management of Care An interview guide used for each candidate enables the nurse manager to be more objective in the decision making. The nurse manager should use resources available in the agency before the manager attempts to develop one from scratch. Certain personal questions are prohibited, an HR can identify these for novice managers. 4. CORRECT: D. Empty a client's colostomy bag Rationale: Learning Objective: Lesson 1 Management of Care The UAP may empty a client's colostomy bag. This is an uncomplicated, routine task with an expected outcome. The other tasks involve one or more parts of the nursing process and cannot be delegated to the UAP. 5. CORRECT: D. Have gloves on while handling bedpans with feces Rationale: Learning Objective: Lesson 2 Safety and Infection Control The specific measure to prevent the spread of hepatitis A is careful handling and protection while working with fecal material. All of the other actions are correct but not the priority routine in infection control strategy that is used with hepatitis A. 6. CORRECT: A. Weight gain of two pounds or more in a 48 hour period Rationale: Learning Objective: Lesson 8 Physiological Adaptation It is critical for clients to report and be treated for rapid weight gain, decreased urinary output, worsening nocturnal orthopnea, pitting ankle edema, and other findings of chronic heart failure. Hospitalization may be avoided with early intervention.

7. CORRECT: C. Observe the client's affect and behavior during the visit Rationale: Learning Objective: Lesson 4 Psychosocial Integrity Although it is important to begin an assessment for depression immediately, the assessment should not be aggressively intrusive. A direct assessment should be conducted to confirm the observations and concerns of the family member. 8. CORRECT: B. Plan for regularly scheduled rest periods Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential The initial priority for this client is rest due to the lack of sufficient red blood cells to carry oxygen. The normal hemoglobin is between 10.0 and 15.0 g/dL for this age of child. Note that all of the options are correct actions that may be used for various reasons. 9. CORRECT: D. They are able to think logically in the organization of facts Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Children in the concrete operations stage, according to Piaget, are capable of mature though when they are allowed to mentally or physically manipulate and organize objects. 10. CORRECT: C. Observe a return demonstration Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Since this is a psychomotor skill, observation of the client doing the task is the best way to know if the client has learned the proper technique. 11. CORRECT: C. I am allergic to shrimp Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. A headache after a spinal tap is often from a lack forcing fluids after the procedure. 12. CORRECT: C. Low Fowler's Rationale: Learning Objective: Lesson 8 Physiological Adaptation Maintaining the head of the bed at 15-20 degrees reduces cerebral venous congestion. Low Fowler's is the degree of elevation and Semi-Fowler's is 35 to 45 degree head of bed elevation. 13. CORRECT: 4100 Rationale: (1200 mL + 400 mL + 2400 mL + 100 mL) = 4100 mL. The amount of irrigation fluid must be included in intake; only the urine collected from the Foley catheter is considered output (subtract the amount of irrigation fluid from the amount in the Foley) 14. CORRECT: B. I would like for you to approach the UAP about the problem the next time it occurs Rationale: Learning Objective: Lesson 1 Management of Care Part of the manager's role is to help the staff manage conflict among themselvees. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager's intervention when possible. This is an approach at the first level of management. If the two staff members cannot resolve the issue then the manager would have a conference with the two staff to facilitate a negotiation for a win-win result. 15. CORRECT: B. Deeply for three to four seconds Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies The client should be instructed to breathe in the medication for three to four seconds in order to receive the correct dosage of medication. The other approaches are incorrect actions. 16. CORRECT: B. Have you thought about hurting yourself? Rationale: Learning Objective: Lesson 4 Psychosocial Integrity It is appropriate and necessary to determine if someone who has voiced thoughts about death is considering a suicidal act. This response is most therapeutic under the circumstances. To say comment with the intent that all is well denies the validity of the client's statement. To ask if the family knows of these feelings lacks focus on the client and thus, is not a correct answer. Remember that often the options that focus on the client are the better options. 17. CORRECT: D. Papules, vesicles, and crusts will be present at one time Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance All three stages of the chicken pox lesions will be present on the child's body at the same time. 18. CORRECT: C. Decrease in chest wall expansion Rationale: Learning Objective: Lesson 8 Physiological Adaptation The respiratory status of a client with this acute bacterial pneumonia known as Legionnaire's disease is critical. Note that all of these findings would be of concern the task is to select the priority. Chest wall expansion reflects a possible decrease in the depth and effort of respirations. Further findings of restlessness may indicate hypoxemia. If these occurred the client may then need mechanical ventilation. 19. CORRECT: D. Continuous EKG readings Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Procainamide (Pronestyl) is used to suppress cardiac arrhythmias. When administered intravenously, it must be accompanied by continuous cardiac monitoring. 20. CORRECT: B. Administering two anti-tuberculosis drugs Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Resistance of the tubercle bacilli often occurs to a single antimicrobial agent. Therefore, therapy with multiple drugs over a long period of time helps to ensure eradication of the organism.

Practice Bank 3

1. Several client are admitted to an adult medical unit. For which client condition(s) would the nurse institute airborne precautions? a. b. c. d. A tentative diagnosis of viral pneumonia with productive brown sputum A positive purified protein derivative (PPD) test with an abnormal chest x-ray Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) Advanced carcinoma of the lung with hemoptysis mixed with a yellow tinge

2. Which task for a client diagnosed with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)? a. b. c. d. Assess with documentation of skin turgor and skin color changes Suggest foods that are high in iron and those easily consumed Report mental status changes and the degree of mental clarity Test stool for occult blood and urine for glucose with a report of the results

3. The nurse is performing pulmonary assessment on a client. Indicate the correct sequence of pulmonary assessment by numbering the steps below from 1 to 5. ___ ___ ___ ___ Percussion Auscultation Palpation Inspection 4. A nurse notes an abrupt onset of confusion in an older adult client. Which recently ordered medication would have most likely contributed to this change? a. b. c. d. Cardiac glycoside Antihistamine Liquid antacid Anticoagulant

5. A client treated for depression tells a nurse at the mental health clinic I recently purchased a handgun because I am thinking about suicide. The first action by the nurse should be which of these? a. b. c. d. Phone the family to warn them of the risk Notify the primary care provider immediately Respect the client's confidential disclosure Suggest inpatient psychiatric care

6. A client receiving chemotherapy has developed sores in the mouth. The client asks a nurse why this has happened. How should the nurse respond? a. b. c. d. This always happens with chemotherapy. It is a sign that the medication is working. You need to have better oral hygiene. The cells in the mouth are sensitive to the chemotherapy.

7. A nurse is assigned to a newly hospitalized adolescent. What should be the major threat experienced by this hospitalized adolescent? a. b. c. d. Pain management Altered body image Separation form family Restricted physical activity

8. A nurse is teaching a school-aged child and family about the use of inhalers prescribed for asthma. What is the best way to evaluate effectiveness of the treatments? a. b. c. d. Observe use of peak-flow meter Rely on child's self-report Monitor pulse rate Note skin color changes

9. The mother of a two month-old baby calls a pediatrician's nurse two days after the first DTaP, inactivated polio vaccine (IPV), Hepatitis B and Haemophilus influenzae type B (HIB) immunizations. She reports that the baby feels very warm, cries inconsolably for as long as three hours, and has had several shaking spells. In addition to referring the mother to the emergency room, the nurse should document the reaction on the baby's record and

expect which immunization to be most associated with the findings that were reported to be displayed by the infant? a. b. c. d. Hepatitis B HIB DTaP IPV

10. A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What actions should the nurse take first? a. b. c. d. Gain client's trust by not being hurried during the intake process Ask client if there are any old injuries also present Interview the client privately without the persons who came with the client Photograph the specific injuries in question for documentation on the chart

11. The nurse is caring for two children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance? a. b. c. d. Aortic stenosis Ventricular septal defect Patent ductus arteriosus Atrial septal defect

12. The mother of a three month-old infant tells the nurse that I want to change from formula to whole milk and add cereal and meats to my infant's diet. What should be emphasized as the nurse teaches about infant nutrition? a. b. c. d. Fluoridated tap water should be used to dilute milk Whole milk is difficult for an infant to digest Solid foods should be introduced at three to four months Supplemental apple juice can be used between feedings

13. During the discharge teaching about exercises for an affected extremity of a client with a long leg cast, the nurse should recommend which of these exercises? a. b. c. d. Isotonic Isometric Aerobic Range of motion

14. A nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by which action? a. b. c. d. Hyperoxygenation with 100% O2 for one or two minutes before and after each suction pass Minimize a suction pass to 60 seconds while slowly rotating the lubricated catheter insertion of a fenestrated catheter with a whistle tip without suction Complete a suction pass in 30 seconds with a pressure of 150 mm Hg

15. The nurse is caring for a client who had a laparoscopy with excision of endometriosis. Where would the nurse
expect to find the incision?

16. What is the priority information a nurse should teach a client after an extracorporeal shock-wave lithotripsy (ESWL) procedure? a. b. c. d. Increase intake of citrus fruits to three servings per day for two months. Limit fluid intake to 1,000 mL each day for two months. Drink 3,000 to 4,000 mL of fluid each day for one month. Restrict milk and dairy products for one to two months.

17. The parents of a 15 month-old child ask a nurse to explain their child's lab results and how the results show the child has iron deficiency anemia. The nurse's response should include which statement? a. b. c. d. The blood cells that carry nutrients to the cells are too large and indicate a lack of iron rich food. There are not enough total blood cells in your child's circulation from a not eating enough foods with iron. Although the results are here, your health care provider needs to talk with you about the details. Your child has fewer red blood cells that carry oxygen and this is called anemia.

18. A novice nurse on the unit notes that a nurse manager seems to be highly respected by the nursing staff. The novice nurse is surprised when one of the nurses states: The manager makes all decisions and rarely asks for our input. What is the best description of the nurse manager's management style? a. b. c. d. Laissez faire or permissive Autocratic or authoritarian Participative or democratic Ultraliberal or communicative

19. An ambulatory client reports edema during the day in the feet and ankles that disappears while the client sleeps during the night. What is the most appropriate follow-up question for a nurse to ask? a. b. c. d. Have you had a recent heart attack? Do you become short of breath during your normal daily activities? Do you smoke daily or every other day? How many pillows do you use at night to sleep comfortably?

20. A client exhibiting confusion has been placed in physical restraints by an order of the health care provider. Which task could be assigned to an unlicensed assistive personnel (UAP)? a. b. c. d. Assist the client with activities of daily living Document mental status and muscle strength Evaluate for basic comfort needs Monitor the client's physical safety

ANSWER KEY: 1. CORRECT: B. A positive purified protein derivative (PPD) test with an abnormal chest x-ray Rationale: Learning Objective: Lesson 2 Safety and Infection Control The client who must be placed in airborne precautions is the client with these findings that suggest a suspicious tuberculin lesion. A sputum spear for acid fast bacillus would be done next. CMV usually causes no signs or symptoms in children and adults with healthy immune systems. Good handwashing is recommended for CMV. When findings do occur, they are often similar to those of mononucleosis, including sore throat, fever, muscle aches and fatigue. 2. CORRECT: D. Test stool for occult blood and urine for glucose with a report of the results Rationale: Learning Objective: Lesson 1 Management of Care The UAP can do routine, and unchanging procedures which have known expected outcomes. These tasks do not require judgments or decision making. 3. CORRECT: Inspection, Palpation, Percussion, Auscultation Rationale: Inspection is first, observing of pattern of breathing, symmetry, anteroposterior and transverse chest diameters, as well as skin color, sounds and odors. The nurse will then palpate the posterior and anterior chest, noting any tenderness, crepitus, or tactile fremitus. The next step is percusision, which is performed in a systematic manner, usually from side to side from apex (top) of lungs to base (bottom), listening to changes in tone from one area to another. Lastly, the lungs are auscultated, listening over the anterior, posterior and lateral chest for expected or adventitious sounds. 4. CORRECT: B. Antihistamine Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Older adults are more susceptible to the side effect of anticholinergic drugs, such as antihistamines. Antihistamines often cause confusion in the older adult, especially at higher doses. 5. CORRECT: B. Notify the primary care provider immediately Rationale: Learning Objective: Lesson 4 Psychosocial Integrity This client has two critical points in suicide guidelines: a report of suicidal intent and a formulated plan with steps to implement it. The primary care provider with other members of the health care team will arrange for treatment given the client's serious risk for self-destructive behavior. Hospitalization with family therapy is indicated. The nurse should never agree to help a client keep secrets from the health c are team. 6. CORRECT: D. The cells in the mouth are sensitive to the chemotherapy. Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral therapies The epithelial cells in the mouth are very sensitive to chemotherapy due to their high rate of cell turnover. 7. CORRECT: B. Altered body image Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance The hospitalized adolescent may see each of these as a threat. However, the major threat felt when hospitalized for this

age group is the fear of an altered body image. There is great emphasis on physical appearance during this developmental stage. 8. CORRECT: A. Observe use of peak-flow meter Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies The peak flow meter, if used correctly, shows effectiveness of inhalants. 9. CORRECT: C. DtaP Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance DTaP immunization is a vaccine that protects against diptheria, tetanus, and pertussis (whooping cough). The majority of reactions occur with the administration of the DTaP vaccination. Contradictions to giving repeat DtaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within several days of the immunization. 10. CORRECT: C. Interview the client privately without the persons who came with the client Rationale: Learning Objective: Lesson 4 Psychosocial Integrity It is critical to separate the client from anyone who came in with the client whether it be a partner or friend. With the use of the nursing process the nurse's first action when a client is unstable or has potential problems is further assessment of the situation. The correct answer is the one most focused on gathering more information. During the private intake assessment the nurse would possibly institute the other actions in the remaining options. 11. CORRECT: B. Ventricular septal defect Rationale: Learning Objective: Lesson 8 Physiological Adaptation While assessments for conduction disturbance should be included following the repair of any defect, it is a priority for this condition. A ventricular septal defect is an abnormal opening between the right and left ventricles. The atrioventricular bundle (bundle of His), is a part of the electrical conduction system of the heart. It extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. Either method involves manipulation of the ventricular septum, thereby increasing risk of interrupting the conduction pathway. Consequently, postoperative complications include conduction disturbances. 12. CORRECT: B. Whole milk is difficult for an infant to digest Rationale: Learning Objective: Lesson 5 basic care and Comfort Cow's milk is not given to infants younger than 1 year because the tough, hard curd that develops in the digestive tract is difficult to digest. In addition, it contains little iron and creates a high renalsolute load. If infants drink milk with a minimal introduction to solid food they will have a tendency to develop anemia. 13. CORRECT: B. Isometric Rationale: Learning Objective: Lesson 5 Basic Care and Comfort A nurse should instruct the client on isometric exercises for the muscles of the casted extremity. This means the client should be instructed to alternately contract and relax muscles without moving the affected part. The client should also be instructed to do active range of motion exercises for every joint that is not immobilized at regular and frequent intervals of at least every four hours. 14. CORRECT: A. Hyperoxygenation with 100% O2 for one to two minutes before and after each suction pass Rationale: Learning Objective: Lesson 8 Physiological Adaptation Administer supplemental 100% oxygen through the mechanical ventilator or manual resuscitation bag for one to two minutes before, after and between suctioning passes to prevent hypoxemia. 15. CORRECT: Rationale: Learning Objective: Lesson 8 Physiological Adaptation Laparoscopy is the most common procedure used to diagnose and treat endometriosis. A small incision is made near the belly button and the abdomen is filled with CO2 gas; the lighted laparoscope is then inserted into the abdomen. (Two other small incisions are also typically made in the abdomen.) 16. CORRECT: C. Drink 3,000 to 4,000 mL of fluid each day for one month. Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential Drinking three to four quarts (3,000 to 4,000 mL) of fluid each day will aid passage of fragments of the broken up renal calculi and help prevent formation of new calculi. 17. CORRECT: D. Your child has fewer red blood cells that carry oxygen and this is called anemia. Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential The results of a complete red blood cell count in clients with iron deficiency anemia will show decreased red blood cell numbers, a low hemoglobin and microcytic, hypochromic red blood cells. This is a simple and clear explanation. There is no reason to defer answering the question to the health care provider. 18. CORRECT: B. Autocratic or authoritarian Rationale: Learning Objective: Lesson 1 Management of Care Autocratic leadership style is suggested in this situation. It is appropriate for groups with little education and experience who need strong direction. A participative or democratic style is usually more successful on nursing units with a mix of staff experience. 19. CORRECT: B. Do you become short of breath during your normal daily activities? Rationale: Learning Objective: Lesson 8 Physiological Adaptation Edema and shortness of breath with exertion are the findings of right-sided heart failure, which causes increased pressure in the systemic venous system due to poor right hear cardiac output. To equalize this pressure, fluid backing up from the right heart shifts into the interstitial spaces causing peripheral edema. The lower extremities are first affected by edema in the ambulatory client due to gravity, with a pattern of worsening edema during that day that improves when the client is supine while sleeping. The supine posture causes redistribution of the fluid, as well as facilitating renal perfusion and increased diuresis, which often causes nocturia.

This question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid volume excess, both associated with right-sided heart failure. Assessment for orthopnea, which is associated with left-heart failure, would be an appropriate follow-up question. Recent myocardial infarction and smoking history will not provide as much relevant information in this situation. A broader question about a history of heart problems would also be appropriate in determining whether this client is at risk of developing heart failure. 20. CORRECT: A. Assist the client with activities of daily living Rationale: Learning Objective: Lesson 1 Management of Care The person to whom the activity is delegated must be capable of performing it. The UAP is capable of assisting clients with basic needs and routine tasks.

Practice Bank 4
1. The father of an eight month-old infant asks a nurse if the child's vocalizations are normal for age. Which sound should the nurse expect at this age? a. b. c. d. Cooing Throaty sounds Imitation of sounds Laughter

2. As a client is being discharged following a resolution of a spontaneous pneumothorax, the client tells a nurse: I am now going to Hawaii for a vacation. The nurse should warn the client to avoid which activity? a. b. c. d. Parasailing Swimming Surfing Scuba diving

3. The visiting nurse makes a postpartum visit to a married female client and her husband. Upon arrival, the nurse observes that the client has a black eye and numerous bruises on her arms and legs. The initial nursing intervention should be what approach? a. b. c. d. Interview the client in a private place in the home to determine the injuries origin Call the police to report indications of domestic violence Leave the home because of the unsafe environment Confront the husband about the condition of his wife

4. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? a. b. c. d. Side-lying on the right with the head elevated 10 degrees Side-lying on the left with the head elevated 10 degrees Side-lying on the right with the head elevated 35 degrees Side-lying on the left with the head elevated 35 degrees

5. A 30 year-old primigravida arrives at the labor and delivery unit to be admitted for severe preeclampsia. She states she has a headache. Lab results indicate elevated liver enzymes. Indicate the area of the client's body that would provide you with more information about her laboratory results

6. A client had a left upper-lobectomy. Which site should the nurse listen to in order to assess the client is meeting this goal, Lung sounds clear following chest physiotherapy. Indicate the area on the image below

7. A nurse is assessing a 17 year-old female client with bulimia. Which of these laboratory reports would the nurse anticipate? a. b. c. d. Increased sodium retention Increased serum glucose Decreased albumin Decreased potassium

8. The nurse is caring for a client with a colostomy pouch. During a teaching session, when should the nurse teach that the pouch should be emptied? a. b. c. d. After each fecal elimination prior to meals when it is 1/3 to full at the same time each day

9. The nurse observes a client with a diagnosis of obsessive-compulsive disorder on an inpatient psychiatric unit. Which behavior is consistent with this medical diagnosis? a. b. c. d. Verbalized suspicions about thefts on the unit Preference for consistent caregivers Repetitive, involuntary movements Repeatedly checking that a door is locked

10. A couple experienced the loss of a seven month-old fetus. In planning for discharge, what should a nurse emphasize? a. b. c. d. To focus on the other healthy children and move through the loss To seek causes for the fetal death and come to some safe conclusion To plan for another pregnancy within two years and maintain physical health To discuss feelings with each other and use support persons

11. Ac client returned from surgery for a repair of the intestine after being diagnosed with a perforated appendix and localized peritonitis. In view of this diagnosis, how should a nurse position the client in a bed? a. b. c. d. Semi-Fowler Prone Dorsal recumbent Supine

12. A client is prescribed warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in a nurse's discharge instruction? a. b. c. d. Maintain a consistent intake of green leafy foods Report any bleeding from the nose or gums Use a soft toothbrush Take Tylenol for minor pains

13. When providing nursing interventions to reduce a 102-degree Fahrenheit fever in a toddler who has been diagnosed with an infection, what is the most effective intervention? a. Give a tepid sponge bath prior to giving an antipyretic b. Apply extra layers of clothing to prevent shivering

c. Immerse the child in a tub containing cool water d. Use medications to lower the temperature set point 14. When teaching adolescents about sexually transmitted diseases, what should a nurse emphasize that is the most common infection? a. b. c. d. Human Immunodeficiency virus (HIV) Herpes Chlamydia Gonorrhea

15. A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include which approach? a. b. c. d. Increased numbers of older adults and of the chronically ill of all ages High costs of diagnostic and end-of-life treatment procedures The escalation of fees with a decreased reimbursement percentage A steep rise in provider fees and in insurance premiums

16. The school nurse is providing information for teachers at a school where a 10 year-old child with epilepsy attends. What is the most important action a teacher can take when the child experiences a tonic-clonic seizure in the classroom? a. b. c. d. Place the hands or a folded blanket under the head of the child Provide privacy as much as possible to minimize frightening the other children Note the sequence of movement with the time lapse of the event Move any chairs or desks at least three feet away from the child

17. During an assessment of a client with cardiomyopathy, a nurse finds that the systolic blood pressure (BP) has decreased from 145 to 110 mm Hg and the heart rate (HR) has risen from 72 to 96 beats per minute and the client complains of episode dizzy spells. The nurse should implement which action? a. b. c. d. Restrict fluids for the next few hours Increase fluids that are high in protein Force fluids to the client with non-caffeine beverages Instruct client to force fluids for four hours

18. A nurse is teaching a group of women in a community clinic about prevention of osteoporosis. Which over-thecounter medication should the nurse recognize as having the most elemental calcium per tablet? a. b. c. d. Calcium gluconate Calcium citrate Calcium carbonate Calcium chloride

19. A client has a history of chronic obstructive pulmonary disease (COPD). A nurse enters the client's room to find that the nasal cannula is in proper position with the oxygen set at 6 liters per minute, the client's color is flushed and the respirations are 8 per minute. What should the nurse do first? a. b. c. d. Check the client's pulse for strength and rate Remove the nasal cannula for at least five minutes Lower the oxygen's flow rate Place client in a higher sitting position

20. A nurse is responsible for several older adult clients, including a client on bed rest with a skin tear and hematoma from a fall two days earlier. Which approach should the nurse take for the care of this client on bed rest? a. Retain the client to supervise the overall care with a detailed focus on the skin care of the client with delegation to a UAP to assist the client with self-care activities, elimination or mobility needs b. Assign a PN for medication administration and an unlicensed assistive personnel (UAP) to help the client with self-care activities, elimination, mobility and skin care needs c. Delegate to another RN to provide total care which should include medications, skin care and self care needs of this client d. Give a PN responsibility for the complete care of the client ton include everything except medication administration ANSWER KEY: 1. CORRECT: C. Imitation of sounds

Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Imitation of sounds such as da-da is expected at this time. Laughter occurs after the initial cooing. 2. CORRECT: D. Scuba diving Rationale: Learning Objective: Lesson 8 Physiological Adaptation The nurse would strongly emphasize the need for clients with history of spontaneous pneumothorax problems to avoid high altitude, flying in unpressurized aircraft and scuba diving. The negative pressure could cause the lung to collapse again. 3. CORRECT: A. Interview the client in a private place in the home to determine the injuries origin Rationale: Learning Objective: Lesson 4 Psychosocial Integrity It is a correct approach to assume domestic violence with further assessment. Separate suspected abused person from the partner until any battering has been ruled out by conversation in a private location in the home. No information is given of the situation that would warrant to leave or to call the police. To confront the partner is never a correct approach. This should be left to the authorities. 4. CORRECT: B. Side-lying on the left with the head elevated 10 degrees Rationale: Learning Objective: Lesson 8 Physiological Adaptation Gravity will draw the most blood flow to the dependent portion of the lung. For unilateral chest disease, it is best to place the healthiest part of the lung in the dependent position to enhance blood flow to the area where gas exchange will be best. Ventilation would be minimally affected in the right dependent lung. This position also enhances the drainage of the infected part of the lung. A head elevation of 35 degrees is counterproductive to therapeutic blood flow and the drainage of secretions. At this elevation stasis of secretions is enhanced at the lung bases. 5. CORRECT: Rationale: Learning Objective: Lesson 8 Physiological Adaptation Elevated liver enzymes occur from blood flow obstructed by fibrin deposits found when hemolysis occurs in severe preeclampsia. Subsequent liver distention follows and results in epigastric pain. The liver is located in the right upper quadrant of the abdomen. 6. CORRECT: Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Always auscultate breath sounds after chest physiotherapy for changes. These changes should be found in the base of the left lung if the goal is to clear consolidation, as in pneumonia. 7. CORRECT: D. Decreased potassium Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential In bulimia, loss of electrolytes such as potassium can occur in addition to other findings of starvation and dehydration. These clients are usually in a metabolic alkalosis state since they have a loss of acid form the stomach. In contrast, a person who has dilemma has a loss of bicarbonate to have an outcome of metabolic acidosis. However, the loss of potassium occurs in both situations of emesis and diarrhea. 8. CORRECT: C. when it is 1/3 to full Rationale: Learning Objective: Lesson 5 Basic Care and Comfort If the pouch becomes more than half full it may separate from the flange. Emptying before meals would possibly decrease the appetite. After each fecal elimination is unrealistic to fit into activities of life. At the same time each day does not account for the pouch being empty at that time. 9. CORRECT: D. Repeatedly checking that a door is locked Rationale: Learning Objective: Lesson 4 Psychosocial Integrity Behaviors that are repeated are consistent with the diagnosis of obsessive-compulsive disorders. These behaviors which are performed to reduce feelings of anxiety, often interfere with normal function and attendance at the place of employment. Verbalized suspicions reflect a paranoid thought process. Repetitive, involuntary movements are characteristic of some antipsychotic medication side effects. They are termed extrapyramidal effects such as tardive dyskinesia. 10. CORRECT: D. To discuss feelings with each other and use support persons Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance To communicate in a therapeutic manner, the nurse's goal is to help the couple begin the grief process by suggesting they talk to each other, seek family, friends and support groups to listen to their feelings. To look for causes or set a time to plan another pregnancy is inappropriate. 11. CORRECT: A. Semi-Fowler Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential The semi-Fowler position assists to have a download drainage flow of any fluid and prevents spread of infection throughout the abdominal cavity. 12. CORRECT: B. Report any bleeding from the nose or gums Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies The client should notify the health care provider if blood is noted in stools or urine, or any other signs of bleeding occur. Although all the other instructions are correct, it is most critical for the client to report any frank bleeding. 13. CORRECT: D. Use medications to lower the temperature set point Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Conditions such as infection, malignancy, allergy, central nervous system lesion and radiation cause the temperature setpoint to be raised. Because the temperature set point is normal in hyperthermia and elevated in fever, different measures must be taken in order to be effective. The most effective intervention in the management of fever is the administration of antipyretics which lower the set point. Too rapid cooling of a febrile child can lead to seizure activity. 14. CORRECT: C. Chlamydia Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance

Chlamydia has the highest incidence of any sexually transmitted disease in the USA. Prevention is similar to safe sex practices taught to prevent any sexually transmitted disease such as the use of a condom and spermicide for protection during intercourse. This infection has subtle findings so the infected persons are less likely to pursue medical attention. 15. CORRECT: C. The escalation of fees with a deceased reimbursement percentage Rationale: Learning Objective: Lesson 1 Management of Care The percentage of the gross national product representing health care costs rose dramatically with reimbursement based on fee for service. Reimbursement for Medicare and Medicaid recipients based on fee for service also escalates health care costs. 16. CORRECT: A. Place the hands or a folded blanket under the head of the child Rationale: Learning Objective: Lesson 2 Safety and Infection Control During seizure activity, the priority would be to protect the child from physical injury. The teacher could place a pillow, folded blanket or hands under the child's head to prevent head trauma. After protecting the head, the prioritized sequence of the actions would be to move furniture away from the child, note movements and time, and then provide privacy if possible. 17. CORRECT: D. Instruct client to force fluids for four hours Rationale: Learning Objective: Lesson 8 Physiological Adaptation Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent or more than 20 beats above the baseline usually accompanied by clinical findings such as dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. After having the client force fluids for one to two hours, the BP and HR need to be rechecked for changes. 18. CORRECT: C. Calcium carbonate Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Calcium carbonate contains 400 mg of elemental calcium in 1 gram of calcium carbonate. 19. CORRECT: B. Remove the nasal cannula for at least five minutes Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential The client has findings of oxygen toxicity so the removal of the cannula should be done first for at least five minutes. Then the nurse should have this sequence of actions; pulse assessment, change of position and then lower the oxygen flow rate and reapply if respirations are within normal parameters. A higher concentration of supplemental oxygen removes the hypoxic drive to breathe, leads to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. 20. CORRECT: A. Retain the client to supervise the overall care with a detailed focus on the skin care of the client with delegation to a UAP to assist the client with self-care activities, elimination or mobility needs Rationale: Learning Objective: Lesson 1 Management of Care The UAP can inspect and care for the skin while giving hygiene care. The nurse should supervise the UAP during this skin care since assessment and analysis are needed for the determination of the healing process progress.

Practice Bank 5
1. A client is admitted to the emergency room during an acute asthma attack. Which assessment should a nurse expect? a. b. c. d. Loose, productive cough Diffuse auditory expiratory wheezing Fever and chills A 60% forced expiratory volume

2. Which of these clients should a charge nurse assign to a practical nurse (PN)? a. A young adult client with a diagnostic history of schizophrenia with current alcohol withdrawal syndrome and a client diagnosed with chronic renal failure and anemia b. A middle-aged client diagnosed with hemiplegia is fed by a nasogastric tube and a client with a left leg below the knee amputation (BKA) in rehabilitation c. An older client with newly diagnosed type 2 diabetes mellitus and a client with history of AIDS admitted with a diagnosis of pneumonia d. An adolescent trauma victim newly admitted with a diagnosis of quadriplegia and a client one day post-op radial neck dissection 3. A 5 month-old os hospitalized with a diagnosis of bronchiolitis related to respiratory syncytial virus (RSV). The oarentstates thebaby has been sneezing and wheezing, has had a runny nose for 2 ays and has not eaten for over 9 hours. Vital signs are: temperature 100.2 degrees Fahrenheit (38 degrees Celsius), pulse 102, respiratory rate 32. Place the nurse's actions in order of priority (Rank from 1-6, with 1 being top priority). ___ ___ ___ ___ Assess for respiratory distress Promote adequate tissue oxygenation Provide family teaching Institute droplet isolation precautions

___ ___

Administer prescribed medications Promote desired fluid intake 4. A client experiences post partum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 mL of whjole blood, the hemoglobin and hematocrit are within normal limits. The client asks a nurse whether she should continue to breast feed the infants. Which statement by the nurse is based on sound rationale? a. b. c. d. The blood transfusion may increase the risks to you and the babies. Lactation should be delayed until the real milk is secreted. Breastfeeding twins will take too much energy after the hemorrhage. Nursing the twins will help contract the uterus and reduce the risk of bleeding.

5. A nurse is caring for a client diagnosed with an exacerbation of rheumatoid arthritis. Which nursing diagnosis should the nurse give as a priority in the plan of care? a. b. c. d. Risk for an alteration in mobility Risk for injury Self care deficit Alteration in comfort

6. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the discharge list in order to make room for a new admission? a. A young adult with type 2 diabetes mellitus for over 10 years and who was admitted with antibiotic-induced diarrhea 24hours ago b. An adolescent with a positive HIV test and who was admitted for acute cellulitis of the lower leg 48 hours ago c. An older adult client with a history of hypotension, hypercholesterolemia and lupus, and who was admitted with Stevens-Johnson syndrome that morning d. A middle aged client with a seven year history of being ventilator dependent and who was admitted with bacterial pneumonia five days ago 7. Following a diagnosis of acute glomerulonephritis (AGN) in their six year-old child, the parents remark: We just don't know how he caught the disease! A nurse's response should be based on an understanding of which of these points? a. b. c. d. The illness is usually associated with chronic respiratory infections AGN is a streptococcal infection that involves the kidney tubules The disease is easily transmissible in schools and camps It is not caught but is a response to a previous B-hemolytic strep infection

8. The nurse is caring for a client following a thyroidectomy. The laboratory results indicate hypocalcemia, probably related to parathyroid gland damage when the thyroid gland was removed. Identify the part of the body the nurse should check to assess Chvostek's sign.

9. What is the most important aspect for a nurse to include during the development of a home care plan for a client with severe arthritis? a. b. c. d. Maintain and preserve function Anticipate side effects of therapy Support coping with limitations Ensure compliance with medications

10. In preparing medications for a client with a gastrostomy tube, a nurse should contact the health care provider before administration of which drug through the tube? a. b. c. d. Lanoxin liquid Tylenol liquid (acetaminophen) Os-cal tablet (calcium carbonate) Cardizem SR tablet (diltiazem)

11. A nurse observes a staff member caring for a client who is postop for a left unilateral mastectomy. The nurse should intervene if the staff member is observed doing which action? a. b. c. d. Taking the blood pressure in the left arm Elevating the client's left arm above heart level Reinforcing the client to restrict sodium intake Compressing the drainage device

12. A client is admitted to the telemetry unit with diagnosis of mitral stenosis. The nurses is assessing the client's heart sounds. Indicate on the diagram where the nurse should place the stethoscope to best assess the mitral valve.

13. A client is scheduled to have a blood test for cholesterol and triglycerides the next day. What statement should a nurse include in the directions for the client? a. b. c. d. Have the blood drawn within two hours of eating breakfast. Do not eat or drink anything but water for 12 hours before the test. Stay at the laboratory so two blood samples can be drawn an hour apart. Be sure and eat a fat-free diet until the test.

14. A nurse is teaching parents of a seven month-old about adding table foods. Which substance is an appropriate finger food? a. b. c. d. Hot dog pieces cut in short pieces Whole purple and white grapes Sliced bananas cute vertically Popcorn with minimal kernels

15. A nurse is teaching a client with chronic renal failure (CRF) about medications. The client questions the purpose of aluminum hydroxide (Amphojel) in the medication regimen. What is the best explanation for the nurse to give the client about the therapeutic effects of this medication? a. b. c. d. It will reduce serum calcium The drug is taken to control gastric acid secretion Amphojel increases urine output It decreases serum phosphate

16. The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit with a diagnosis of schizophrenia. The client's symptoms have been managed for several months with fluphenazine (Prolixin). Which should be the initial focus of the questioning during the admission assessment? a. What is your medication routine of what and when do you take it? b. How much alcohol in the form of beer, wine or hard liquor do you use each day?

c. How long have you been outside in the hot weather this prior week? d. What stressors do you have living in your home by yourself? 17. Which findings of a client who is admitted for COPD would require a nurse's immediate attention? a. b. c. d. Low-grade fever and cough Restlessness and confusion Frequent cough and liquefied sputum Nausea and vomiting

18. A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority? a. b. c. d. Apply support stockings Elevate the leg on two pillows Apply warm compresses Maintain complete bed rest

19. A nurse is assessing a client with delayed wound healing. Which risk factor is most important in this situation? a. b. c. d. Diet high in carbohydrates Long term steroid usage History of myocardial infarction Glucose level of 120

20. A client days, It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland. What should the nurse document this behavior as? a. b. c. d. Flight of ideas Neologisms Circumstantiality Perseveration

ANSWER KEY: 1. CORRECT: B. Diffuse auditory expiratory wheezing Rationale: Learning Objective: Lesson 8 Physiological Adaptation In asthma, two situations are of concern. First the airways are narrowed ,making it difficult to get air into the lungs, resulting in wheezing. An auditory wheeze is one that is heard with normal hearing of the ear without a stethoscope. This is an emergency situation. The second concern is thick, tenacious secretions. A forced expiratory volume is of concern if it is 50% or less. Fever and chills are not consistent with asthma attacks. 2. CORRECT: B. A middle-aged client diagnosed with hemiplegia is fed by a nasogastric tube and a client with a left leg below the knee amputation (BKA) in rehabilitation Rationale: Learning Objective: Lesson 1 Management of Care This client requires supportive care and interventions within the scope of practice of a PN. This client is the most stable with a minimal risk of complications or instability. In the other options some of the clients would require the RN care. The clues are: newly admitted, newly diagnosed and current alcohol withdrawal. All of these clients would have a high risk of instability. 3. CORRECT: Rationale: When caring for a client with bronchiolitis related to RSV, the primary nursing interventions are aimed at promoting oxygenation. Assessing respiratory distress and promoting adequate oxygenation address basic physiologic needs. Instituting droplet precautions is required to prevent transmission of the disease to others. Administering prescribed medications will alleviate symptoms such as wheezing and promote healing. It is important to maintain fluid and electrolyte balance by promoting fluid intake. Even though the infant has not eaten for a long time, this is less important than the respiratory status. Finally, the nurse will need to provide support to the parents, who may have a lot of anxiety and concern about their child. They will need to be taught about their infant's diagnosis and treatments so they can care for the child at home. Involving them in the care while the child is hospitalized will facilitate this learning process while alleviating anxiety. 4. CORRECT: D. Nursing the twins will help contract the uterus and reduce the risk of bleeding. Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important to enhance the prevention of hemorrthage. 5. CORRECT: D. Alteration in comfort Rationale: Learning Objective: Lesson 5 Basic Care and Comfort Relief of the pain is the priority objective for a client in an exacerbation of the rheumatoid arthritis. The second nursing diagnosis of importance is self care deficit. Then the risk for an alteration in mobility and injury would follow with both being associated with each other. 6. CORRECT: D. A middle aged client with a seven year history of being ventilator dependent and who was admitted with bacterial pneumonia five days ago

Rationale: Learning Objective: Lesson 2 Safety and Infection Control The best candidate for discharge is one who has a chronic condition and has an established a plan of care. The client who has been on the ventilator for years is most likely stable and could continue medication therapy at home. The other clients have a risk for instability or are unstable. 7. CORRECT: D. It is not caught but is a response to a previous B-hemolytic strep infection Rationale: Learning Objective: Lesson 8 Physiological Adaptation AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of four to six weeks prior, and is considered as a noninfectious renal disease 8. CORRECT: Rationale: Learning Objective: Lesson 8 Physiological Adaptation A positive Chvostek's sign is a finding in severe hypocalcemia, (low calcium level) which frequently occurs after thyroid surgery due to incidental parathyroid tissue removal druing the surgery.A positive Chvostek's sign is twitching of the mouth lips and or cheek with stimulation of the facial nerve. Perform this test by tapping about 2 centimeters anterior to the earlobe, just below the zygomatic arch on the cheek. 9. CORRECT: A. Maintain and preserve function Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance To maintain quality of life, the plan for care must emphasize the preservation of function. Proper body positioning and posture as well as active and passive range of motion exercises are important interventions for maintaining function of the affected joints 10. CORRECT: D. Cardizem SR tablet (diltiazem) Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Cardizem SR is a sustained-release drug form. Sustained release (controlled release; long-acting) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The health care provider must substitute another medication. 11. CORRECT: A. taking the blood pressure in the left arm Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential Clients who have had a unilateral mastectomy should not have their blood pressure measured on the affected extremity. This helps avoid the possibility of lymphedema and tissue trauma postoperatively and in the future. 12. CORRECT: Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Auscultation of heart sounds is a key component of the physical assessment. It is important that the nurse is able to identify the are on the chest that corresponds to each of the four valves. The mitral area or apex of the heart is located at the fifth intercostal space, left midclavicular line. 13. CORRECT: B. Do not eat or drink anything but water for 12 hours before the test. Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential Serum lipid levels should be obtained from clients who have been fasting for at least 12 hours 14. CORRECT: C. Sliced bananas cut vertically Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Finger foods should be bite-size pieces of soft food such as banana at his stage. Hot dogs it cut horizontally and grapes can accidentally be swallowed whole and can occlude the airway. Popcorn is too difficult to chew at this age and can irritate the airway of swallowed. 15. CORRECT: D. It decreases serum phosphate Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Aluminum binds phosphates that tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel or Basogel are commonly used to accomplish a decreased serum phosphate. 16. CORRECT: A. What is your medication routine of what and when do you take it? Rationale: Learning Objective: Lesson 4 Psychosocial Integrity Medication compliance is a priority to investigate in the initial part of the admission assessment. Prolixin is an antipsychotic/neuroleptic medication useful in the management of the symptoms of schizophrenia. Noncompliance with daily doses should be conveyed to the health care provider as priority information since it may be associated with the need for admission to an inpatient unit. 17. CORRECT: B. Restlessness and confusion Rationale: Learning Objective: Lesson 8 Physiological Adaptation Respiratory failure may be signaled by excessive somnolence, restless, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, arterial blood gases (ABGs) should be obtained with peripheral pulse oximetry. 18. CORRECT: B. Elevate the leg on two pillows Rationale: Learning Objective: Lesson 8 Physiological Adaptation The first goal of nonpharmacologic interventions is to minimize edema of the affected extremity by leg elevation 19. CORRECT: B. Long term steroid usage Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Steroid dependency tends to delay wound healing. If the client also smokes or has diabetes mellitus, the risk is increased. 20. CORRECT: A. Flight of ideas Rationale: Learning Objective: Lesson 4 Psychosocial Integrity Flight of ideas is characterized by over productivity of talk and verbally skipping from one idea to another. It is classic with patients diagnosed with bipolar disorder and occurs in the manic state of the disease. Flight of ideas can also occur with

the diagnosis of schizophrenia and in clients who are intoxicated with psychoactive substances.

Practice Bank 6
1. A nurse is assessing a four year-old for possible developmental dysplasia of the right hip. Which finding should a nurse expect? a. b. c. d. Pelvic tip downward Ortolani sign Right leg lengthening Characteristic limp

2. Which action should be planned in a child's care for an 18 month-old child? a. b. c. d. Encourage the child to feed self with finger foods Hold and cuddle the child frequently Engage the child in games with other children Allow the child to walk independently on the nursing unit

3. To assist the client diagnosed with trigeminal neuralgia (tic doloureux) for the nutrition needs, a nurse should recommend which approach? a. b. c. d. Encourage the client to eat fish, liver and chicken Offer small meals of high calorie soft food Provide additional servings of fruits and raw vegetables Assist the client to sit in a chair for meals

4. An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for a diagnosis of tracheoesophageal fistula. The mother asks: When can the tube be used for feeding? A nurse should respond with which of these comments? a. b. c. d. The feeding tube can be used immediately. Healing of the incision must be complete before feeding. The stomach contents and air must be drained first. Feedings can begin in five to seven days.

5. A nurse is planning care for a two year-old hospitalized child. Which issue will produce the most stress at this age? a. b. c. d. Loss of control Separation anxiety Bodily injury Fear of pain

6. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice (Pediculus Humanus Capitis) in the school. The information that would be most important to include is reflected in which of these statements? a. b. c. d. The treatment medication requires reapplication in eight to ten days. Nit combs are necessary to comb lice eggs (nits) out of children's hair. Children should not share hats, scarves and combs. Bedding and clothing can be boiled or steamed to kill lice.

7. A nurse is to administer diltiazem (Cardizem) to a client. Prior to administration, the nurse should assess which parameter? a. b. c. d. Temperature Blood pressure Vision Bowel sounds

8. The charge nurse sends a nursing assistant to help an RN with an admission of a client with multiple health problems. Which of the following tasks would be appropriate to delegate to the nursing assistant? (Select all that apply) a. Collect a urine specimen

b. c. d. e.

Obtain routine vital signs (temperature, pulse, respirations, blood pressure) Assist the client to change into a gown Orient the client to the room Observe and document the client's responses to ambulation to the bathroom

9. The client has been recently diagnosed with gastroesophageal reflux disease (GERD) and is reviewing
information about the disease with the nurse. The nurse identifies which are of the gastrointestinal tract as the cause of GERD?

10. A nurse is caring for a client with a serum potassium of 3.5 mEq/L. The client is placed on a cardiac monitor and receives via IV therapy 40 mEq KCL in 1000 mL of 5% dextrose in water. Which ECG patterns indicates that the infusions should be stopped and discontinued? a. b. c. d. Narrowed QRS complex Tall peaked T waves Prominent U waves Shortened PR interval

11. To prevent keratitis in an unconscious client, a nurse should apply moisturizing ointment to which area? a. b. c. d. Perianal area Eyes Finger and toenail quicks External ear canals

12. A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? a. b. c. d. Smoking cessation Weight reduction Stress management Physical exercise

13. A charge nurse of a long term care (LTC) facility is making out assignments. Which assignment made to an unlicensed assistive personnel (UAP) requires intervention by the nursing director of the LTC facility? a. b. c. d. Bathe and feed client who is on bed and chair rest Provide decubitus ulcer care and apply a dry dressing to the site Oral suctioning as needed of an unresponsive older adult client Review with family members the procedure of intermittent (bolus) feedings via G-tube

14. Which intervention demonstrates a nurse's sensitivity to an adolescent's need for autonomy? a. b. c. d. Provides opportunity to discuss concerns without presence of any parent Explores feelings of resentment to identify causes for behaviors Allows young siblings to visit the client whenever they want to Alertness for the adolescent's feelings about body image

15. A nurse is assessing a client during a visit to a community mental health center. The client discloses that I have

been thinking about ending my life. The nurse's best response should be which statement? a. b. c. d. Is your life do terrible that you want to end it? Do you want to discuss this with your pastor? We will help you deal with those thoughts. have you thought about how you would do it?

16. The nurse is assessing the uterine fundus of a client who delivered a healthy neonate 10 hours ago. Identify the area where the nurse would expect to feel the fundus.

17. A client is receiving total parenteral nutrition (TPN) via a Hickman catheter. The catheter accidentally becomes dislodged out of the site. Which action by a nurse should take priority? a. b. c. d. Check that the catheter tip is intact Apply pressure dressing to the site Monitor respiratory status Assess for mental status changes

18. A newly admitted client has a diagnosis of depression. The client complaints of twitching muscles and a racing heart, and states that: I stopped taking Zoloft a few days ago because it was not helping my depression. Instead, I began to take my partner's Parnate. A nurse should immediately assess for which of these adverse reactions? a. b. c. d. Mental status changes Muscle weakness Pulmonary edema Atrial fibrillation

19. What is the best way that caregivers of a preschooler can begin teaching their child about injury prevention? a. b. c. d. Protect their child from outside influences Set good examples themselves Make sure their child understand the safety rules Discuss the consequences of not wearing protective devices

20. When suctioning a client's tracheostomy, a nurse should instill saline for what purpose? a. b. c. d. Reduce the viscosity of secretions Facilitate the removal of mucus plugs Prevent client aspiration from secretions decrease the client's discomfort

ANSWER KEY: 1. CORRECT: D. Characteristic limp Rationale: Learning Objective: Lesson 8 Physiological Adaptation Developmental dysplasia produces a characteristic limp in children who are walking. 2. CORRECT: A. Encourage the child to feed self with finger foods Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living that allow the toddlers to assert their budding sense of control. 3. CORRECT: B. Offer small meals of high calorie soft food Rationale: Learning Objective: Lesson 5 Basic care and Comfort If the client is losing weight because of poor appetite due to the pain in the jaw, a nurse needs to teach them about foods that are high in calories and nutrients and requires less chewing. Suggest that frequent, small meals be eaten every two hours instead of three large meals per day. To minimize jaw movements when eating, foods could also be pureed. 4. CORRECT: C. The stomach contents and air must be drained first

Rationale: Learning Objective: Lesson 8 Physiological Adaptation After surgery for gastrostomy tube placement, the catheter is left open and attached to gravity drainage for 24 hours or more. 5. CORRECT: B. Separation anxiety Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance While a toddler will experience all of the stresses, separation from parents is the major stressor. Separation anxiety peaks in the toddler years. 6. CORRECT: C. Children should not share hats, scarves and combs. Rationale: Learning Objective: Lesson 2 Safety and Infection Control Head lice live only on human beings and can be spread easily by sharing hats, combs, scarves, coats and other items of clothing that touch the hair. All of the options are correct statements. However they do not best answer the question of how to prevent the spread of lice in a school setting. 7. CORRECT: B. Blood pressure Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Diltiazem (Cardiazem) is a calcium channel blocker that causes systemic vasodilation with a potential outcome of a decreased blood pressure 8. CORRECT: A.,B.,C., and D. Rationale: Learning Objective: Lesson 1 Management of Care Obtaining routine vital signs and answering call lights are universal activities that a nursing assistant can perform, regardless of the setting. A nursing assistant may help with activities of daily living (ADLs) and can collect basic specimens, e.g., urine for urinalysis. Although nursing assistants can document information, they cannot assess clients. 9. CORRECT: Rationale: Learning Objective: Lesson 8 Physiological Adaptation In most people diagnosed with GERD, the pathophysiology involves a relaxation of the lower esopahgeal sphincter (LES). This allows reflux of stomach acid into the esophagus, which produces the symptoms and damage to the esophagus. The LES is a ring of smooth muscle fibers located at the junction of the stomach and the esophagus. 10. CORRECT: B. Tall peaked T waves Rationale: Learning Objective: Lesson 8 Physiological Adaptation A tall peaked T wave is a finding in hyperkalemia. The health care provider should be notified that the medication drip was stopped and a serum potassium should be done to verify the serum levels. 11. CORRECT: B. Eyes Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential Keratitis is eye inflammation from a corneal ulcer or abrasion. Keratitis is caused by exposure to the air without the normal blink. It requires regular applications of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch. 12. CORRECT: A. Smoking cessation Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be addressed at some time. 13. CORRECT: D. Review with family members the procedure of intermittent (bolus) feedings via G-tube Rationale: Learning Objective: Lesson 1 Management of Care Neither initial teaching nor a review of teaching can be delegated to a UAP. PNs can reinforce teaching and RNs do the initial teaching. The other tasks can be performed by UAPs in LTC facilities. 14. CORRECT: A. Provides opportunity to discuss concerns without presence of any parent Rationale: Learning Objective: Lesson 4 Psychosocial Integrity This intervention provides the teen with the opportunity to have a control and encourages decision making through talking with a neutral person. Body image has no connection to the asked question. The other two options introduce new content into the situation of visiting of siblings and resentment feelings and are unlikely to be the correct answer. 15. CORRECT: D. Have you thought about how you would do it? Rationale: Learning Objective: Lesson 4 Psychosocial Integrity This response provides an opening to discuss the intent and means of committing suicide. It helps in assessing the severity of the risk. Clients who have formulated a suicide plan are closer to suicidal behavior than those who have had vague, non-specific thoughts. 16. CORRECT: Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance The uterus should be felt at the level of the umbilicus from about 1 to 24 hours after birth. The fundus (top of the uterus) will fall approximately 1 centimeter (or 1 fingerbreadth) each day for the next 10 days 17. CORRECT: B. Apply pressure dressing to the site Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies The client is at risk of bleeding or developing an air embolus if the catheter exit is not covered with a pressure and occlusive dressing. An occlusive dressing is one that is totally covered by adhesive tape around the edges as well as over the entire dressing. 18. CORRECT: A. Mental status changes Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Use of serotonergic agents may result in serotonin syndrome with confusion, nausea, palpitations, increased muscle tone with twitching muscles, and agitation. Serotonin syndrome is most often reported in clients taking two or more medications that increase CNS serotonin levels by different mechanisms. The most common drug combinations associated with serotonin syndrome involve the MAOIs, SSRIs, and thr tricyclic antidepressants.

19. CORRECT: B. Set good example themselves Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance The preschool years are the time for caregivers to begin emphasizing safety principles as well as providing protection. Setting a good example themselves is crucial because of the imitative behaviors of preschoolers. They are quick to notice discrepancies between what they see and what they are told. 20. CORRECT: B. Facilitate the removal of mucus plugs Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential According to evidence-based practice, the use of saline is no longer recommended during routine suctioning. However, if a client is suspected to have a mucous plug in the larger bronchials or in an artificial airway (such as tracheostomy tube), the nurse can instill sterile normal saline to thin and loosen the plug.

Practice Bank 7
1. The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach should a nurse use when dealing with the parents' comments? a. b. c. d. Explain the cause of the child's illness Accept their feelings without judgment Focus on the child's needs and recovery Acknowledge that early care would have been better

2. During the plan of care for a 12 year-old child diagnosed with sickle cell disease in a vaso-occlusive crisis of the elbow a nurse should include item? a. b. c. d. Cold compresses to elbow Patient-controlled analgesia (PCA) Fluid restriction Passive range of motion exercise

3. The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be proper to delegate these tasks to? a. b. c. d. Unlicensed assistive personnel (UAP) Registered Nurse (RN) Practical Nurse (PN) Volunteer

4. A nurse is teaching parents about the treatment plan for a two week-old newborn with Tetralogy of Fallot. While awaiting future surgery, a nurse instructs the parents to immediately report what finding? a. b. c. d. Changes in level of consciousness Fatigue with crying Poor weight gain Feeding problems

5. A nurse reviews the history of a client diagnosed with depression from an earlier administration. Documentation of anhedonia is noted. What should the nurse understand about this note in the client's history? a. b. c. d. A lack of enjoyment in usual pleasures in life A reduced sense of taste and smell A report of difficulty falling and staying asleep An expression of persistent suicidal thoughts

6. The registered nurse (RN) is making decisions regarding client room assignments on a pediatric unit. Which possible roommate would be appropriate for a three year-old child diagnosed with minimal change nephrotic syndrome? a. b. c. d. Six year-old admitted with a diagnosis of a sickle cell anemia crisis Three year-old admitted with fractured arm whose sibling has chickenpox Four year-old who had a bilateral inguinal hernia repair Two year-old diagnosed with a respiratory infection

7. During an assessment on a client in heart failure a nurse should expect on auscultation of the heart which sound? a. Split S2

b. Ventricular gallop of S3 c. Systolic murmur d. Apical click 8. The registered nurse (RN) is making staffing assignments at the start of a new shift. The RN can delegate the care of which of these clients to the licensed practical nurse (LPN)? a. b. c. d. A new admission with a history of diagnosis of transient ischemic attacks and syncope An older adult client with a diagnosis of hypertension and sel-reported noncompliance. A client with a diagnosis of peripheral vascular disease with an ulceration of the lowe leg. A preoperative client with a history of asthma awaiting an adrenalectomy.

9. Which statement made by a client to an admission nurse suggests that the client is experiencing a manic episode? a. b. c. d. I have powers to get you whatever you wish, no matter the cost. I think all children should have their heads shaved. I think all of my contacts last week have attempted to poison me. I have been restricted in thought and harmed.

10. The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted with a connection to a ventilator. Which finding should the nurse take immediate action to resolve the issue? a. b. c. d. Client is unable to speak Breath sounds are heard bilaterally Mist is visible in the T-Pierce of the ventilator circuit Pulse oximetry of 86% saturation

11. When counseling parents of a child who has recently been diagnosed with hemophilia, what should a nurse know about the offspring of an unaffected father and a carrier mother? a. b. c. d. There is a 25% probability that sons will have the disease It is likely that all sons are affected There is a 50% chance a daughter with be a carrier Every daughter is likely to be a carrier

12. A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention should be to a. b. c. d. administer oxygen by mask as ordered initiate continuous blood pressure monitoring begin the ordered intravenous therapy institute continuous cardiac monitoring

13. After a client has an enteral feeding tube inserted, what is the most accurate method for verification of placement? a. b. c. d. Auscultation with air insertion Aspiration for gastric contents Abdominal x-ray Flushing tube with saline

14. Which assessment finding requires an immediate action from the nurse if found during the care of a client who is unconscious and in receipt of gastric tube feedings? a. b. c. d. Urine output of 250 mL in the past eight hours Decrease in bowel sounds in all quadrants Decreased breath sounds in the right lower lobe Aspiration for a formula residual of 100 mL

15. A nurse is caring for a postoperative client who develops an abdominal wound evisceration. The priority nursing intervention to prevent further complications should be to a. b. c. d. place the client in dorsal recumbent position medicate the client for pain with PRN order call the health care provider within the hour cover the wound with sterile saline dressing

16. The nurse is caring for a 10 year-old child who is diagnosed with diabetes insipidus (DI) and is receiving vasopressin (Pitressin). What is the priority for the nurse to teach the child and the family members about this prescribed medication? a. b. c. d. The family must observe the child for dehydration The child will need intravenous therapy for several weeks The family must monitor the child for arrhythmias Parents should administer the daily intramuscular injections

17. A nurse is teaching a child and the family about the medication phenytoin (Dilantin) prescribed for seizure control. Which side effect is most likely to occur? a. b. c. d. Gingival hyperplasia Vomiting Vertigo Drowsiness

18. Using a vibrating tuning fork, the nurse will perform the Rinne test to assess the client's hearing. Where will the nurse place the tuning fork to assess for bone conduction of sound?

19. The nurse is using the image below to explain and clarify information about the client's colostomy. Based on the
image, which of the following statements about the consistency of the drainage is correct?

a. b. c. d.

The feces are semiformed to formed The feces have a normal, formed consistency The feces are liquid to semiliquid and the discharge is often irritating to the skin around the stoma The feces are mushy (liquid to semiformed)

20. When teaching parents about sickle cell disease, a nurse should discuss with them that their child's anemia is defined by which information? a. Reduced oxygen capacity of cells from a lack of iron b. A depression of the platelets and the red and white blood cells c. An inability of sickle shaped cells to regenerate

d. An imbalance between red cell destruction and production ANSWER KEY: 1. CORRECT: B. Accept their feelings without judgment Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Parents often blame themselves for their child's illness. Feeling helpless and angry is normal and these feelings must be accepted. The other actions are inappropriate at this time. 2. CORRECT: B. Patient-controlled analgesia (PCA) Rationale: Learning Objective: Lesson 5 Basic Care and Comfort Management of a sickle cell crisis is directed towards support and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, patient-controlled analgesia promotes maximum comfort. Fluid are usually increased and range of motion exercises are avoided in the acute phase of the crisis. Cold is voided since it constricts the vessels and may result in increased pain. 3. CORRECT: A. Unlicensed assistive personnel (UAP) Rationale: Learning Objective: Lesson 1 Management of Care The measurement and recording of vital signs may be delegated to UAP. This falls under the umbrella of routine tasks with expected outcomes for stable clients. Other considerations for delegation of care would be: Who is capable and is the least expensive worker to do each task? 4. CORRECT: A. Changes in level of consciousness Rationale: Learning Objective: Lesson 8 Physiological Adaptation While parents should report any of these findings, they need to call the health care provider immediately if the level of alertness changes to a diminished or agitated presentation. This indicates anoxia, which may lead to death. The structural defects associated with Tetralogy of Fallot include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy and overriding of the aorta. Surgery is often delayed, or may be performed in stages. 5. CORRECT: A. A lack of enjoyment in usual pleasures in life Rationale: Learning Objective: Lesson 4 Psychosocial Integrity All of the responses could be associated with a diagnosis of depression, including anhedonia, which means the i nability to experience pleasure or the loss of interest in previously rewarding or enjoyable activities. Anhedonia is one of the main symptoms of major depressive disorder (MDD). 6. CORRECT: C. Four year-old who had a bilateral inguinal hernia repair Rationale: Learning Objective: Lesson 2 Safety and Infection Control Children diagnosed with nephrotic syndrome are at risk for development of infections. This risk results from the standard use of immunosuppressant therapy. Therefore, these children must be protected from sources of possible infection. The child diagnosed with a sickle cell crisis, which may be from an infectious process, would not be a proper choice of roommate. 7. CORRECT: B. Ventricular gallop of S3 Rationale: Learning Objective: Lesson 8 Physiological Adaptation A ventricular gallop, S3 is caused by blood flowing rapidly into a distended non-compliant ventricle. This is the most common sound with left-sided heart failure. 8. CORRECT: C. A client with a diagnosis of peripheral vascular disease with an ulceration of the lower leg Rationale: Learning Objective: Lesson 1 Management of Care The client with PVD is stable with no risk of instability as compared to the other clients. This client also has a chronic condition that needs supportive care. The clues in the other options include a risk of instability, including: awaiting surgery, hypertension...noncompliance, and new admission. 9. CORRECT: A. I have powers to get you whatever you wish, no matter the cost. Rationale: Learning Objective: Lesson 4 Psychosocial Integrity This statement reflects grandiosity which is characteristic of a manic episode. Thinking that someone has been attempted to be poisoned is a paranoid thought. 10. CORRECT: D. Pulse oximetry of 86% saturation Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential Pulse oximetry should not be lower than 90% saturation. Breath sounds are heard bilaterally so the placement of an ET is most likely in proper position. The ventricular settings will need to be rechecked. A client with an ET tube in pace will not be able to talk when the ET tube balloon is inflated. 11. CORRECT: C. There is a 50% chance a daughter will be a carrier Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. With an unaffected father and carrier mother, there is a 50% chance of having an affected male (hemophilia XY), a 25% chance of having an affected female, and a 50% chance of having a carrier female (hemophilia XX). 12. CORRECT: A. administer oxygen by mask as ordered Rationale: Learning Objective: Lesson 8 Physiological Adaptation Early findings of shock is associated with hypoxia and exhibited by a rapid heart rate and rapid respirations. Oxygen is the most critical initial intervention. The other interventions are secondary to oxygen therapy 13. CORRECT: C. Abdominal x-ray Rationale: Learning Objective: Lesson 5 Basic Care and Comfort Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways. This is the most objective approach. The others are often used and are subjective approaches. Another objective approach is to check the pH of the aspirated gastric contents. 14. CORRECT: C. Decreased breath sounds in the right lower lobe

Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential The most common problem associated with enteral feedings is aspiration with resulting atelectasis and pneumonia. A nursing action should be to maintain clients at a minimuim of 30 degrees of head elevation during feedings an up to two hours afterwards. Tube placement should be done prior to each feeding or every four to eight hours if the client receives a continuous feeding. 15. CORRECT: D. cover the wound with sterile saline dressing Rationale: Learning Objective: Lesson 8 Physiological Adaptation When evisceration occurs, the wound should first be quickly covered by sterile saline soaked dressings. This prevents tissue damage and drying of the area until a surgical repair can de done. 16. CORRECT: C. The family must monitor the child for arrhythmias Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Diabetes insipidus is characterized by a decreased secretion of antidiuretic hormone (ADH). Decreased ADH results in polyuria and polydipsia; the person is unable to concentrate urine. Vasopressin is the drug of choice to treat central DI. At home, it can be administered 2-3 times a day, either IM, subQ, or intranasally. Not drinking enough fluids can cause arrhythmias, fatigue and muscle pain. Other serious side effects include chest pain, skin discoloration and paresthesia. 17. CORRECT: A. Gingival hyperplasia Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized. Bleeding gums indicate a problem and is not to be considered normal in any condition except pregnancy, when the condition is called epulis. 18. CORRECT: Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance The Rinne test helps distinguish between conductive and sensorineural hearing loss. To assess for bone conduction of sound, the nurse holds the tip of a vibrating tuning fork against the mastoid bone. Normally, air conduction is audible longer than bone conduction, but the reverse is true for someone with conductive hearing loss. 19. CORRECT: A. The feces are semiformed to formed Rationale: Learning Objective: Lesson 8 Physiological Adaptation This is an image of a descending colostomy. The feces will be semiformed to formed because much of the water had already been absorbed. 20. CORRECT: D. An imbalance between red cell destruction and production Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential Anemia results when the rate of cell destruction exceeds the rate of production through stimulated erythropoiesis in bone marrow. The red cell life span is shortened from 120 days to 12-20 days.

Practice Bank 8
1. The client who is receiving intermittent enteral nutrition through a gastrostomy tube has had four diarrhea stools in the past 24 hours. The nurse should a. b. c. d. attach a rectal bag to protect the skin increase the amount of water used to flush the tube review the medications the client is receiving increase the formula infusion rate when running

2. The school nurse is preparing information to present to parents about mandated health assessments for all students. Based on the image below, which of the following statements should be included in the presentation? ( Select all that apply )

a. b. c. d.

More cases occur in girls than boys Treatment for this condition always involves surgery This is an image of lordosis This is an image of scoliosis

e. Screening for this condition is typically mandated for students in the 6 grade 3. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, a nurse should emphasize which point? a. b. c. d. This rare problems is always hereditary Administration of thyroid hormone will prevent problems Physical growth development will be delayed They can expect the child will be mentally retarded

th

4. A client is admitted with the diagnosis of meningitis. Which findings should a nurse expect when assessing the client? a. b. c. d. Hyperflexion of the neck with rebound flexion of the legs Flexion of the legs with rebound tenderness Hyperextension of the neck with passive shoulder flexion Flexion of the hip and knees with passive flexion of the neck

5. Which statement by a client would require the most immediate action by a nurse? a. b. c. d. When I take in a deep breath, it stabs like a knife. When I turn in bed to reach the remote for the TV, my chest hurts. I feel pressure in the middle of my chest like an elephant is sitting on my chest. The pain came on after dinner. That soup seemed very spicy.

6. In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize which approach? a. b. c. d. Learning relaxation techniques Avoiding passive smoke Eat smaller meals Limiting alcohol use

7. A nurse has been assigned to four clients in the emergency room, with each client experiencing one of those conditions. Which client should the nurse check first? a. b. c. d. Acute asthma with episodes of bronchospasm Tension pneumothorax with slight tracheal deviation to the right Spontaneous pneumothorax with a respiratory rate of 38 Viral pneumonia with atelectasis

8. The RN has just admitted a client newly diagnosed with severe depression. What domain should be a priority focus as the nurse identifies the applicable nursing diagnoses? a. b. c. d. Activity Safety Nutrition Elimination

9. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and lipids. What is the priority nursing action on every eight hour shift? a. b. c. d. Monitor blood pressure, temperature and weight Check serum glucose level Change the tubing under sterile conditions Adjust the infusion rate to provide for total volume

10. A client visits a community clinic for the treatment of recurrent pelvic inflammatory disease (PID). The nurse should plan to teach with the knowledge that this condition most frequently follows which type of infection? a. b. c. d. Syphilis Chlamydia Trichomoniasis Herpes simplex 2

11. A nurse is speaking to a group of parents and elementary school teachers about care for children with rheumatic fever. The nurse should emphasize which priority point?

a. b. c. d.

Children may remain strep carriers for years Clumsiness and behavior changes should be reported Home schooling is preferred to classroom instruction Most play activities will be restricted indefinitely

12. An unlicensed assistive personnel (UAP), who usually works in pediatrics is reassigned to work on an adult medical-surgical unit. Which of these questions should the charge nurse ask prior to making delegation decision? a. b. c. d. Do you have your complementary checklist that we can review? How comfortable are you to care for adults? How long have you been a UAP? What type of client care did you give in pediatrics?

13. An RN from the women's wellness health clinic is temporarily reassigned to an adult medical-surgical unit. Which of these client assignments would be appropriate for this nurse? a. b. c. d. A newly diagnosed client with type 2 diabetes mellitus who is learning foot care A client admitted for a barium swallow after a transient ischemic attack (TIA) A newly admitted client with a diagnosis of pancreatic cancer and severe dehydration A client from a motor vehicle accident with an external fixation device on the leg

14. A nurse is conduction a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning? a. b. c. d. A nine month-old who stays with a sitter five days a week A 10 year-old who occasionally stays at home unattended A 15 year-old who likes to repair bicycles A 20 month-old who has just learned to climb stairs

15. Based on principles of teaching and learning, what is the best initial approach by a nurse to pre-op teaching for a client scheduled for coronary artery bypass? a. b. c. d. Mail a video tape to the home Assess the client's learning style Tour the coronary intensive unit Administer a written pre-test

16. When administering enteral feeding to a client via a jejunostomy tube, a nurse should administer the formula with which frequency? a. b. c. d. In a bolus Continuously Every hour Every four to six hours

17. A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparation. What is the initial action a nurse should take? a. b. c. d. Explain the importance of the medication to the client Contact the client's primary care provider Report the behavior to the charge nurse Talk with the client to find out about the preferred herbal preparation

18. At 40 weeks gestation, a client in active labor is admitted to the labor and delivery unit. Based on the ongoing assessment of the cervical examinations listed in the table below, what would the nurse anticipate as a result of these findings? a. b. c. d. Fetal hypoxia Neonatal APGAR score of 9 at one minute Maternal episiotomy Maternal elation and anticipation

19. A nurse is caring for a 13 year-old after a spinal fusion to treat scoliosis. Which nursing intervention is appropriate in the immediate postoperative period? a. Raise the head of the bed at least 30 degrees b. Maintain in a flat position with logrolling as needed c. Encourage ambulation within 24 hours

d. Encourage leg contraction and relaxation after 48 hours 20. A health care provider has written Morphine sulfate 2 mg IV every three to four hours prn for pain on the chart of a child weighing twenty two pounds (10 kg). What should be a nurse's action? a. b. c. d. Hold the medication and contact the provider Check with the pharmacist Give the dose every six to eight hours Administer the prescribed dose as ordered

ANSWER KEY: 1. CORRECT: C. review the medications the client is receiving Rationale: Learning Objective: Lesson 5 Basic Care and Comfort Antibiotics and medications containing sorbitol may induce diarrhea. An increased rate often results in increased peristalsis and diarrhea. Attaching a rectal bag may be needed. However, it does not address the problem. 2. CORRECT: A., D., and E. Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance This is an image of scoliosis, which typically becomes more apparent during growth spurts, especially at the onset of adolescence. During the assessment the nurse stands behind the child and observes for differences in height of the shoulders or iliac crest. Treatment is determined by the many factors and may involve the use of a brace or surgery. 3. CORRECT: B. Administration of thyroid hormone will prevent problems Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Early identification and continues treatment with hormone replacement corrects this condition. 4. CORRECT: D. Flexion of the hip and knees with passive flexion of the neck Rationale: Learning Objective: Lesson 8 Physiological Adaptation This is known as a positive Brudzinski's sign (flexion of hip and knees with passive flexion of the neck). A positive Kernig's sign, the inability to extend the knee to move more than 135 degrees without pain behind the knee while the hip is flexed, usually established the diagnosis of meningitis. 5. CORRECT: C. I feel pressure in the meddle of my chest like an elephant is sitting on my chest. Rationale: Learning Objective: Lesson 8 Physiological Adaptation This is a classic description of chest pain in men caused by myocardial infarction. Women experience vague feeling of fatigue and back and jaw pain. Pain after spicy food is often the result of irritation and gastric indigestion. The pain with a deep breath is typically from an inflammation of the pleural covering of the lung, called pleurisy. 6. CORRECT: A. Learning relaxation techniques Rationale: Learning Objective: Lesson 4 Psychosocial Integrity The only factor that can enhance the client's response to pain medication for angina is reduction of anxiety through relaxation methods. Anxiety may increase intensity whereas pain medication outcomes are totally ineffective. 7. CORRECT: B. Tension pneumothorax with slight tracheal deviation to the right. Rationale: Learning Objective: Lesson 8 Physiological Adaptation Tracheal deviation indicates a significant volume of air being trapped ion the chest cavity with a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side, and cyanosis with a high risk of cardiac tamponade and cardiac arrest. 8. CORRECT: B. Safety Rationale: Learning Objective: Lesson 2 Safety and Infection Control\ Safety is a priority for all inpatient clients, and a depressed client is at acute risk for self-destructive behavior. Precautions to prevent suicide must be a part of the nursing care plan. Note that the client has 'severe' depression which requires higher safety 9. CORRECT: B. Check serum glucose level Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Because of high dextrose (about 4 to 5 mg/kg/day) content in parenteral nutrition, plasma glucose should be monitored every 6 to 8 hours. Fluid intake and output should also be monitored continuously. Plasma proteins and prothrombin time, plasma and urine osmolality, and calcium magnesium and phosphate levels should be measured about twice a week. 10. CORRECT: B. Chlamydia Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential Chlamydial infections are the more frequent cause of salpinghitis or pelvic inflammatory disease. An unwanted outcome of recurrent infections is the obstruction and scarring of the fallopian tubes, resulting in partial or total sterility. This infection is subtle in its findings and thus not frequently diagnosed early on before it is transmitted to others during sexual activity. 11. CORRECT: B. Clumsiness and behavior changes should be reported Rationale: Learning Objective: Lesson 8 Physiological Adaptation A major manifestation of rheumatic fever that reflects central nervous system involvement is chorea. Early symptoms of chorea include behavior changes and clumsiness. Chorea is characterized by sudden, amiss, irregular movements of the extremities, involuntary facial grimaces, speech disturbances, emotional liability, and muscle weakness. Chorea is transitory and all manifestations will eventually disappear. 12. CORRECT : A. Do you have your competency checklist that we can review? Rationale: Learning Objective: Lesson 1 Management of Care The UAP must be competent to accept the delegated task. The use of a check list is the most comprehensive approach to

evaluation of the UAPs skill set. Further assessment of the qualifications of the UAP is important in order to assign the correct type of tasks. The length of time in a position does not endure competency. Client care in pediatrics is irrelevant on an adult unit. And the UAPs feelings are not priority for delegation of assignments. Feelings are important for the charge nurse to be aware of for approaches of moral support to the UAP. 13. CORRECT: D. A client from a motor vehicle accident with an external device on the leg. Rationale: Learning Objective: Lesson 1 Management of Care This client is the most stable, requires basic safety measures and has a predictable outcome. The clues in the other options not to delegate to a reassigned n urse are newly diagnosed, after a TIA, and newly admitted. All of these clients have an illness as compared to the client who is healthy except for a fracture from an accident. 14. CORRECT: D. A 20 month-old who has just learned to climb stairs Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Toddlers, aged one to three years, are at the highest risk for poisoning because they are increasingly mobile, need to explore and engage in autonomous behavior. 15. CORRECT: B. Assess the client's learning style Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance As with any anticipatory teaching, assessment of the client's level of knowledge and learning style should occur first. If possible the three senses of hearing, seeing and touching should be used during any teaching to enhance recall. 16. CORRECT: B. Continuously Rationale: Learning Objective: Lesson 5 Basic Care and Comfort Usually small intestinal feedings such as jejunostomy feedings are given continuously to ensure proper absorption. However, initial feedings may be given by bolus to assess the client's tolerance to formula. Gastric feedings are more often in a bolus every so many hours. 17. CORRECT: D. Talk with the client to find out about the preferred herbal preparation Rationale: Learning Objective: Lesson 4 Psychosocial Integrity All the options are correct, but the questions asks for an initial action. The correct answer is further assessment of the situation; it is the first action to be taken. The other options may be implemented afterwards. The challenge for the health care provider is to understand the client's perspective and to support, facilities or enable cultural values that can help the client recover from illness or to cope with any handicaps and/or death. 18. CORRECT: A. Fetal hypoxia Rationale: Learning Objective: Lesson 8 Physiological Adaptation This labor is precipitous labor (active labor lasting less than 3 hours). Since the contractions are coming rapidly, with little time in between contractions, fetal hypoxia would be expected. Maternal episiotomy is incorrect since there is no time. Due to the potential for fetal hypoxia, the APGAR score would probably be lower than 9. Extremely rapid delivery can be anxiety-provoking for the client. When the actual birth event is not what is expected, other reactions may include hostility, fear, and disappointment. 19. CORRECT: B. Maintain in a flat position with logrolling as needed Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential The bed should remain flat for at least the first 24 hours to prevent injury. Logrolling is the best way to turn the client who is on bed rest. 20. CORRECT: A. Hold the medication and contact the provider Rationale: Learning Objective: Lesson 6 Pharmacological Adaptation The usual pediatric dose of morphine is 0.1 mg/kg every three to four hours. At 10 kg, this child typically should receive 1 mg every three to four hours.

Practice Bank 9
1. The nurse walks into a client's room and finds someone lying still and silent on the floor. What should the nurse do first? a. b. c. d. Call for help Assess the airway Establish that the person is unresponsive Determine if anyone saw the person fall

2. A newborn premature baby is to be fed breast milk through a nasogastric tube. Breast milk is preferred over formula for premature infants because of what substance? a. b. c. d. Has less fatty acid Is higher in calories/ounce Contains less lactose Provides antibodies

3. A client who is terminally ill has been receiving high doses of an opioid analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli, what orders should a nurse expect from the health care provider?

a. b. c. d.

Continue the same analgesic dosage Discontinue the analgesic Prescribe a less potent drug Decrease the analgesic dosage by half

4. A nurse is teaching a client to select foods rich in potassium to prevent digitalis toxicity. Which choice indicates the client understands this dietary requirement for the highest potassium food? a. b. c. d. Naval orange Three apricots Small banana Baked potato

5. A nursing care plan for a toddler diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem? a. b. c. d. Coronary artery aneurysms Chronic vessel plaque formation Pulmonary embolism Occlusions at the vessel bifurcations

6. A client with anemia has a new prescription for ferrous sulfate. In teaching the client about diet and iron supplements, a nurse should emphasize that absorption of iron is enhanced if taken with which substance? a. b. c. d. Orange juice An antacid Acetaminophen Low fat milk

7. A nurse is teaching a class on human immunodeficiency virus (HIV) prevention. Which activity should be cautioned against since it is shown to increase the risk of HIV? a. b. c. d. Physical touch of a person with autoimmune deficiency syndrome (AIDS) Engagement in unprotected sexual encounters Use of public bathrooms in any city Donation of blood to the state agencies

8. A client is admitted to a psychiatric unit with reports of delusions. What behaviors if observed by a nurse would be consistent with delusional thought patterns? a. b. c. d. Suspiciousness and resistance to therapy Flight of ideas and hyperactivity Anorexia and hopelessness Panic and multiple physical complaints

9. A child is brought to the emergency department with suspected ingestion of a toxic substance. Number the following actions according to priority. ___ ___ ___ ___ Stabilize the child Start an IV infusion Reverse or eliminate the toxic substance Obtain a history of the ingestion 10. During discharge teaching to a client who has a total hip prosthesis implanted, a nurse should include which content in the instructions for home care? a. b. c. d. Do not cross your legs at the ankles or knees Avoid climbing stairs for three months Sleep only on your back and not on your side Ambulate using crutches only

11. An immobile hospitalized client is eating less than 25% of served meals. The client gains 5 pounds (2.27 kg) in two days. The most likely explanation for this is the retention of how many milliliters of fluid? _________ mL. 12. A nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?

a. b. c. d.

Have you talked with your provider about this? Write your ideal plan for the next class? What is your reason for wanting such a plan? Let us discuss your rights as a couple.

13. A client is admitted with a tentative diagnosis of heart failure. Which assessment should a nurse expect to be consistent with this problem? a. b. c. d. Chest pain Inspiratory crackles Cyanosis Heart murmur

14. In a child with a suspected diagnosis of coarctation of the aorta, a nurse would expect which finding? a. b. c. d. Normal femoral pulses Strong pedal pulses Bounding pulses in the arms Diminishing carotid pulses

15. The nurse is caring for a client admitted with a diagnosis of Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in which substance? a. b. c. d. Fiber Calcium Sodium Carbohydrates

16. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first? a. b. c. d. Cefotaxime IV 50 mg/kg/day divided every six hours Initiate droplet precautions Monitor neurologic status every hour Institute seizure precautions

17. A nurse admits a two year-old child who has had a seizure. Which statement by the child's parent would be important in the determination of the etiology of the seizure? a. b. c. d. In the past week the naps have been getting longer and longer. An ear infection has been present for the past 2 days. Red meat has been his favorite food lately. He seems to be going to the bathroom more frequently.

18. A practical nurse (PN) from the pediatric unit is reassigned to work in an adult critical care unit. Which client assignment would be appropriate for this staff member? a. b. c. d. A client admitted with multiple trauma with a history of a newly implanted pacemaker A 53 year-old who had a cardiac arrest and was diagnosed with suspected myocardial infarction (MI) A 35 year-old client in balanced traction admitted six days ago after a motor vehicle accident A new admission diagnosed with left-sided weakness from a stroke and mild confusion

19. A two year-old child is being treated with amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 33 lb (15 kg) and the daily dose range is 20-40 mg/kg of body weight, in three divided doses every eight hours. Using principles of safe drug administration, what should a nurse do next? a. b. c. d. Call the health care provider to clarify the dose Recognize that antibiotics are over-prescribed Hold the medication as the dosage is too low Give the medication as ordered

20. An important goal in the development of a therapeutic inpatient milieu is which of these items? a. b. c. d. Provide a testing ground for new patterns of behavior while clients take responsibility for their own actions Offer a businesslike atmosphere where clients can work on individual goals Discourage expressions of anger such as feelings can be disruptive to other clients Form a group forum in which clients decide on unit rules, regulations, and policies

ANSWER KEY: 9 1. CORRECT: C. Establish that the person is unresponsive Rationale: Learning Objective: Lesson 8 Physiological Adaptation According to the American Heart Association's basic life support, the first step after determining a victim is unresponsive is to call for help. The next step is to check for a pulse. If there is no pulse, the rescuer should begin CPR (30 chest compressions followed by 2 ventilations). 2. CORRECT: D. Provides antibodies Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest. Therefore, less residual is left in the infant's stomach. 3. CORRECT: A. Continue the same analgesic dosage Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Dying clients who have been in chronic pain will probably continue to experience pain even though they cannot communicate their experience. Pain medication should be continued at the same dose, if it is effective at that dosage level. 4. CORRECT: D. Baked potato Rationale: Learning Objective: Lesson 5 Basic Care and Comfort A baked potato contains 610 milligrams of potassium. Apricots, orange and bananas do have higher potassium content. However, because of the size they are not the highest in potassium. A baked potato is the highest in potassium of the given options. 5. CORRECT: A. Coronary artery aneurysms Rationale: Learning Objective: Lesson8 Physiological Adaptation Kawasaki disease involves all the small and medium-sized blood vessels. There is progressive inflammation of the small vessels which progresses to the medium-sized muscular arteries, potentially damaging the walls and leading to coronary artery aneurysms. 6. CORRECT: A Orange juice Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Ascorbic acid enhances the absorption of iron. 7. CORRECT: B. Engagement in unprotected sexual encounters Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Because HIV is spread through exposure to body fluids, unprotected intercourse and shared drug paraphernalia remain the highest risks for this infection. The other actions are not at risk behaviors for HIV. 8. CORRECT: A. Suspiciousness and resistance to therapy Rationale: Learning Objective: Lesson 4 Psychosocial Integrity Clinical features of paranoid delusional disorder include extreme suspiciousness, jealousy, distrust, and a belief that others intend to invoke harm. Panic, multiple physical complaints, anorexia and hopelessness may be associated with depression. Flight of ideas and hyperactivity are associated with mania. 9. CORRECT: Rationale: The first priority is to assess the ABC's, provide supplemental oxygen. Next, an IV fusion is started using a large bore hole; this will allow for blood to be drawn for a toxicology screen as well as IV therapy. Then a history of the ingestion is needed to guide the provider in planning care. Once the substance is identified or there is a high index of suspicion, then treatment to reverse or eliminate the toxic substance is begun. 10. CORRECT: A. Do not cross your legs at the ankles or knees Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential These clients should avoid the bringing of the knees together. Clients are to use a pillow between their legs when lying down and can lie on the back or side. Crossing the legs or bringing the knees together results in a strain on the hip joint. This increases the risk of a malfunction of the prosthesis where the ball may pop out. A walker or crutches may be used as assistive devices. These and other precautions are minimally followed for 6 weeks postoperative and sometimes longer as indicated. 11. CORRECT: 2500, 2270 Rationale: 454 = 1 lb (1g ~ 1mL) or 500 mL = 1 lb. 1 kg ~ 1 liter. However, you don't really need to do any math to calculate the answer to this question if you remember this saying: a pint is a pound the world around. 12. CORRECT: D. Let us discuss your rights as a couple Rationale: Learning Objective: Lesson 3 Health Promotion and Maintenance Discussion of the provider's role and the couple's rights and limitations in selecting birth options must precede development of a plan. To write an ideal is not a realistic nor the best approach since this approach does not often allow for complications 13. CORRECT: B. Inspiratory crackles Rationale: Learning Objective: Lesson 8 Physiological Adaptation In heart failure, fluid backs up into the lungs as a result of inefficient cardiac pumping. The fluid is manifested in breath sounds as crackles which may be on inspiration or expiration. The other findings are more consistent with the condition of a myocardial infarction. 14. CORRECT: C. Bounding pulses in the arms Rationale: Learning Objective: Lesson 8 Physiological Adaptation Coarctation the aorta, a narrowing of the descending aorta, causes increased blood flow to the upper extremities and this results in an increased pressure and pulses 15. CORRECT: C. Sodium

Rationale: Learning Objective: Lesson 5 Basic Care and Comfort The client with Meniere's disease has an alteration in the balance of the fluid in the inner ear. A low sodium diet will aid in reduction of the fluid. Sodium restriction is commonly ordered as adjunct to diuretic therapy in the acute and chronic treatment. 16. CORRECT: B. Initiate droplet precautions Rationale: Learning Objective: Lesson 2 Safety and Infection Control Meningococcal meningitis is a bacterial infection that can be communicated to others. The initial therapeutic management of acute bacterial meningitis includes droplet precautions, initiation of antimicrobial therapy, monitoring neurological status along with vital signs,instituting seizure precautions and, lastly, maintaining optimum hydration. The first action is to initiate any necessary precautions to protect themselves and others from the potential infection. Viral meningitis usually does not require protective measures of isolation and these clients often return home to recover. 17. CORRECT: B. An ear infection has been present for the past 2 days Rationale: Learning Objective: Lesson 7 Reduction of Risk Potential Contributing factors to seizures in children include those such as age, infections associated with febrile seizures (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention. 18. CORRECT: C. A 35 year-old client in balanced traction admitted six days ago after motor vehicle accident Rationale: Learning Objective: Lesson 1 Management of Care This client is the most stable with a predictable outcome. The other options contain key words that suggest a risk of instability multiple trauma...newly implanted, new admission...stroke, and cardiac arrest...MI 19. CORRECT: D. Give the medication as ordered Rationale: Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Amoxicillin continues to be the drug of choice in the treatment of acute otitis media. The dose range is 20-40 mg'kg/day divided every eight hours. 15 kg x 40 mg = 600 mg, divided by 3 = 200 mg per dose. The prescribed dose is correct and should be given as ordered. 20. CORRECT: A. Provide a testing ground foe new patterns of behavior while clients take responsibility for their actions Rationale: Learning Objective: Lesson 4 Psychosocial Integrity A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. The other approaches may be part of other types of therapies.