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1. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment
parameter that will indicate that the child has adequate fluid replacement
is
2. A registered nurse (RN) is assigned to work at the Poison Control Center telephone hotline.
In which of these cases of childhood poisoning would the nurse
suggest that parents have the child drink orange juice?
The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain
cleaner
Drain cleaner is very alkaline. Orange juice is acidic and will help to neutralize this substance.
3. Which of the following conditions assessed by them nurse would contraindicate the use of
benztropine (Cogentin)?
A) Compulsive behavior
B) Sense of impending doom
C) Fear of flying
D) Predictable episodes
5. The nursing care plan for a client with decreased adrenal function should include
A) encouraging activity
B) placing client in reverse isolation
C) limiting visitors
D) measures to prevent constipation
The correct answer is C: limiting visitors
Any exertion, either physical or emotional, places additional stress on the adrenal glands which
could precipitate an Addisonian crisis. The plan of care should protect this client from the
physical and emotional exertion of visitors.
6. A client is in the third month of her first pregnancy. During the interview, she tells the nurse
that she has several sex partners and is unsure of the identity of the baby's father. Which of
the following nursing interventions is a priority?
7. A client has developed thrombophlebitis of the left leg. Which nursing intervention should
be given the highest priority?
8. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart
disease. Which of these is most likely to be seen with this diagnosis?
9. The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention
should the nurse perform first?
10. While planning care for a 2 year-old hospitalized child, which situation would the nurse
expect to most likely affect the behavior?
A) Nutrition
B) Elimination
C) Activity
D) Safety
12. When using an interpreter to teach a client about a procedure to do in the home, the nurse
should take which approach?
A) Speak directly to the interpreter while presenting information and use pauses
for questions
B) Talk to the interpreter in advance and leave the client and interpreter alone
C) Include a family member and direct communications to that person
D) Face the client while presenting the information as the interpreter talks in the
native language
The correct answer is D: Face the client whilepresenting the information as the interpreter
talks in the native language
Communication is the cornerstone of an effective teaching plan, especially when the nurse and
client do not share the same cultural heritage. Even if the nurse uses an interpreter, it is critical
that the nurse use conversational style and spacing, personal space, eye contact, touch, and
orientation to time strategies that are acceptable to the client. Therefore, face the client and
present the information to the client, allow the interpreter to translate the content. Facing the
client allows non-verbal communication to take place between the client and nurse.
13. The nurse is planning care for a client with pneumococcal pneumonia. Which of the
following would be most effective in removing respiratory secretions?
The correct answer is B: Increasing oral fluid intake to 3000 cc per day
Secretion removal is enhanced with adequate hydration which thins and liquefies secretions.
14. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that
she has everything ready for the baby and has made plans for the first weeks together at
home. Which normal emotional reaction does the nurse recognize?
15. The nurse in a well-child clinic examines many children on a daily basis. Which of the
following toddlers requires further follow up?
16. Which of the following would be the best strategy for the nurse to use when teaching
insulin injection techniques to a newly diagnosed client with diabetes?
17. The nurse is caring for a client with acute pancreatitis. After pain management, which
intervention should be included in the plan of care?
18. A nurse who is evaluating a developmentally challenged 2 year-old should stress which goal
when talking to the child's mother?
19. A client has just been admitted with portal hypertension. Which nursing diagnosis would be
a priority in planning care?
20. A client is discharged following hospitalization for congestive heart failure. The nurse
teaching the family suggests they encourage the client to rest frequently in which of the
following positions?
A) High Fowler's
B) Supine
C) Left lateral
D) Low Fowler's
The correct answer is A: "You think that someone wants to poison you?"
This response acknowledges perception through a reflective question which presents
opportunity for discussion, clarification of meaning, and expressing doubt.
22. Which of the following should the nurse teach the client to avoid when taking
chlorpromazine HCL (Thorazine)?
A) Direct sunlight
B) Foods containing tyramine
C) Foods fermented with yeast
D) Canned citrus fruit drinks
23. The nurse is caring for a client in the coronarycare unit. The display on the cardiac
monitorindicates ventricular fibrillation. What should the nurse do first?
A) perform defibrillation
B) administer epinephrine as ordered
C) assess for presence of pulse
D) institute CPR
24. The nurse is caring for a child who has just returned from surgery following a tonsillectomy
and adenoidectomy. Which action by the nurse is
appropriate?
25. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse
should recognize that the child at highest risk for cardiac arrest and is the least likely to be
assigned to this nurse is which child?
26. A client has just returned to the medical-surgical unit following a segmental lung resection.
After assessing the client, the first nursing action would be to
27. The nurse is performing physical assessments on adolescents. What finding would the nurse
anticipate concerning female growth spurts?
28. The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing
nursing assistants in the care of the client, the nurse should emphasize that the client
The correct answer is B: should alternate ambulation with bed rest with legs elevated
Encourage alternating periods ambulation and bed rest with legs elevated to mobilize edema
and ascites. Encourage and assist the client with gradually increasing periods of ambulation.
29. A client treated for depression tells the nurse at the mental health clinic that he recently
purchased a handgun because he is thinking about suicide. The first nursing action should be to
30. The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the
nurse about how it is determined that a person has AIDS other than a positive HIV test. The
nurse responds:
The correct answer is A: Offer small meals of high calorie soft food
If the client is losing weight because of poor appetite due to the pain, assist in selecting foods
that are high in calories and nutrients, to provide more nourishment with less chewing.
Suggest that frequent, small meals be eaten instead of three large
ones. To minimize jaw movements when eating, suggest that foods be pureed.
32. A 2 month-old child has had a cleft lip repair. The selection of which restraint would require
no further action by the charge nurse?
A) elbow
B) mummy
C) jacket
D) clove hitch
33. The nurse is reviewing a depressed client's history from an earlier admission.
Documentation ofanhedonia is noted. The nurse understands that this finding refers to
34. The nurse is discussing dietary intake with an adolescent who has acne. The most
appropriate statement for the nurse is
35. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the
cognitive development at this age?
The correct answer is B: They are able to think logically in organizing facts
The child in the concrete operations stage, according to Piaget, is capable of mature thought
when allowed to manipulate and organize objects.
36. Which of these variations in the newborn results from the presence of maternal hormones?
37. A 15 year-old client with a lengthy confining illness is most at risk for altered psycho-
emotional growth and development due to
A) loss of control
B) insecurity
C) dependence
D) lack of trust
38. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this
child enters the hospital room for the first time, the toddler runs to the mother, clings to her
and begins to cry. What would be the initial action by the nurse?
39. Which playroom activities should the nurse organize for a small group of 7 year-old
hospitalized children?
40. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have
chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions
would most likely explain these findings?
A) Ingestion of tetracycline
B) Excessive fluoride intake
C) Oral iron therapy
D) Poor dental hygiene