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2024/2025 Nursing exam 5 questions
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Results for item 1. 1 0 / 1 point The nurse is caring for a client who had skin traction applied 30 minutes ago to the left leg. Which of the following actions would be a priority for the nurse to take? Check the clients peripheral pulses and temperature of the toes. , Not Selected Inspect the client's skin under the traction. , Not Selected Incorrectanswer: Reposition the client frequently. Correct Answer: Check the clients peripheral pulses and temperature of the toes. Monitor the client's pain level. , Not Selected Feedback General Feedback Rationale: Monitoring the client's circulation by checking skin temperature and peripheral pulses should be the priority intervention 30 minutes after skin traction application. The other actions should be completed but would not be a priority over circulation. deWit 2017, pg. 742- Results for item 2. 2
r 1 / 1 point The nurse is to administer prescribed estradiol 0.45 mg, po, daily to a client in menopause. The nurse has 0.9 mg tablets. How many tablets should the nurse administer with each dose? Do not round your answer. Enter numeric value only. Correctanswe 0. 5 Results for item 3.
diaphoresis and personality changes, and postoperative pain must be managed, but it is not as critical as identifying and treating hypoglycemia because hypoglycemia immediately threatens the client’s life. DeWit 2017, pp. 868-879, pp. 696-698, pp. 847- Results for item 4. 4 1 / 1 point The nurse in an outpatient clinic is reinforcing teaching with the parents of an infant regarding introduction of solid foods. Which of the following information should the nurse recommend including in the teaching? “Begin solid foods while the extrusion reflex is still present to prevent choking.” , Not Selected Correctanswer: “Introduce solid foods one at a time, for 4 to 7 day intervals.” “Solid foods can be mixed in an infant feeder to make feeding easier.” , Not Selected “Solid foods should begin with fruits and vegetables.” , Not Selected Feedback General Feedback Rationale: Solid foods should be added to the diet one at a time, for 4 to 7 day intervals between new foods. The extrusion reflex completely disappears around 4 to 6 months of age which would be the appropriate time to start solid foods. Solids should not be added to the bottle and the use of infant feeders is discouraged. The first food added to the infant’s diet should be rice cereal. Leifer, p. 401 Results for item 5. 5
1 / 1 point The nurse received change of shift report about assigned clients. Which of the following clients should the nurse assess first? The client with a serum potassium level of 5.0 mEq/L who is reporting abdominal cramping. , Not Selected The client with a serum sodium level of 145 mEq/L who reports dry mouth and is asking for water. , Not Selected Correctanswer: The client with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. The client with a serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates. , Not Selected Feedback General Feedback Rationale: The client with low magnesium needs to be seen first because hypomagnesemia can lead to cardiac dysrhythmias. The client with a high phosphorus is just barely high and has manifestations that are expected and not life threatening. The client with a high normal potassium level is experiencing expected symptoms of abdominal cramping and also does not have life-threatening symptoms. Finally, the client whose sodium is 145 is within normal limits and so would not be the priority. DeWitt 2017, p. 40- Results for item 6. 6 1 / 1 point The nurse is administering prescribed heparin 4,000 units, subcutaneous to an assigned client after surgery. Using the label shown below, how many mL should the nurse administer to the client? Do not round your answer. Enter numeric value only.
Feedback General Feedback Rationale: When collecting data during a physical exam for different age groups, the nurse needs to be aware of the client’s developmental stage. All of the options are correct except for checking the infant’s ears and eyes first during a physical. The nurse should perform invasive procedures last because it may cause the infant to cry or be fearful of the nurse. Therefore, it is better to obtain the history first and then do less invasive procedures like heart and lung sounds while the infant is calm and quiet. Potter & Perry 2017, pg. 537 Results for item 8. 8 1 / 1 point The nurse is collecting data from a client admitted with hyperphosphatemia. Which of the following history would be the most important information for the nurse to obtain? Correctanswer: thyroid surgery gastric surgery , Not Selected physical activity , Not Selected food preferences , Not Selected Feedback General Feedback Rationale: The nurse should ask first about a history of thyroid surgery.
During a thyroidectomy parathyroid tissue can accidentally be removed or destroyed which can then lead to a deficiency of parathormone
1 / 1 point The nurse is caring for a client who had a bowel resection surgery 4 hours ago. The client has a nasogastric tube in place that is attached to low intermittent suction. The nurse should document which of the following findings as an indication that the nasogastric tube is working properly? Correctanswer: soft abdomen intact swallow reflex , Not Selected positive bowel sounds , Not Selected abdominal dressing is dry and intact , Not Selected Feedback General Feedback Rationale: The nurse should document that the nasogastric tube is working because the suction decompresses the stomach and leaves the abdomen soft and non-distended. The other options do not indicate that the suction is working. DeWitt 2017, pg. 677- Results for item 11. 11 1 / 1 point The nurse is assisting with performing a non-stress test for a client who is 2 days past her expected delivery time. Which of the following information about the test should the nurse explain to the client? “You will need to have a full bladder while the test is performed.” , Not Selected
“The test will provide information about how well you will handle a vaginal delivery.” , Not Selected Correctanswer: “The results provide information about the functioning of the placenta and oxygenation of the fetus.” “You will need to have induced contractions during this test, if the fetus’ heart rate accelerates during fetal movement.” , Not Selected Feedback General Feedback The NST evaluates FHR and provides information that the placenta is functioning properly and the fetus is well oxygenated. The bladder does not need to be full. This test does not provide information about the mother and handling vaginal delivery. Induced contractions is part of the contraction stress test (CST). Leifer 2015, pg. 81 Results for item 12. 12 1 / 1 point The nurse is caring for a client who has bronchitis and has a sudden change in breath sounds from diminished to rhonchi. Which of the following actions would be most appropriate? administer prescribed oxygen via nasal canula , Not Selected Correctanswer: suction the client’s airway reposition the client to a high-Fowlers position , Not Selected encourage the client to increase oral fluid intake , Not Selected
the client’s heel and then slide the remaining portion of sticking over the client’s foot and leg. Applying lotion to the legs prior to applying stockings is not recommended, as this would make it very difficult to apply the stockings. The nurse can use powder if there are no contraindications with the client. The client should be in a comfortable position lying down with the head flat or elevated when applying stockings. Reverse Trendelenburg’s position is not necessary. The stockings should be removed at least once per shift. Perry/Potter 2017, pg. 425- Results for item 14. 14 1 / 1 point The nurse is collecting data from a female client before having a prescribed computed tomography (CT) scan. Which of the following information is important for the nurse to obtain prior to the procedure? date of last menstrual period , Not Selected Correctanswer: history of claustrophobia shellfish allergies , Not Selected history of sensory deafness , Not Selected Feedback General Feedback Rationale: Asking about claustrophobia is important because of the enclosed/confined environment of the scanner. There is no contraindication to a CT scan being done during pregnancy. A shellfish allergy does not automatically mean the client is allergic to contrast media, that is a myth, and the client should be asked if they have ever had a reaction to contrast.
Sensory deafness is not a contraindication to having a CT scan. Potter/Perry 2017, pg. 1114
1 / 1 point The nurse working on an oncology unit is caring for a client with a white blood cell count of 800 cells/μL and a platelet count of 150 , 000 cells/μL. During visiting hours, the nurse notes that one of the client’s visitors is coughing and sneezing. Which of the following would be the most appropriate action by the nurse? Ask the visitor to do hand washing before entering the room. , Not Selected Limit visitation time for this particular visitor. , Not Selected Correctanswer: Request the visitor come back when symptom free. Provide the visitor with a mask and gown. , Not Selected Feedback General Feedback The client’s platelet count is stable, but the white blood cell count is very low leaving the client at risk for infection. Therefore, the nurse should ask this visitor to return when they are symptom free to protect the client. Hand washing before entering the room is appropriate, but would not protect the client from the visitor’s coughing and sneezing. Limiting the visit and giving the visitor a mask and gown is not the most appropriate action to help protect the client from possible infection. The client should avoid any persons with cold symptoms. DeWitt 2017, pg. 110-111, 213- Results for item 18. 18 1 / 1 point The nurse is developing the plan of care for a middle aged adult. Which of the following should the nurse implement to promote lifespan development? Cluster nursing care to promote visitation with friends. , Not Selected
Correctanswer: Allow the client access to a computer to check work email. Provide cross word puzzle books. , Not Selected Create a cluster free environment. , Not Selected Feedback General Feedback Rationale: The middle aged adult is in the Erikson's stage of development of generativity versus stagnation, where the client focuses on career and requires a need of feeling productive. Clients in the identity versus role confusion (adolescents) are developing who they are and require contact with friends. Providing cross word puzzles and create a cluster free environment would be appropriate for older adults to promote ego integrity and independence. Perry and Potter 2017, pg. 168- Results for item 19. 19 1 / 1 point The nurse is monitoring the serum laboratory results for an assigned client. Which of the following results would indicate that the client is dehydrated? Correctanswer: blood urea nitrogen, 30 mg/dL hematocrit level, 29% , Not Selected sodium level, 125 mEq/L , Not Selected urine specific gravity, 1. , Not Selected
The nurse is contributing to the plan of care for prevention of deep vein thrombosis for a client who had a pneumonectomy 48 hours ago. Which of the following nursing interventions should the nurse recommend including in the client’s care plan? Encourage the client to use an incentive spirometer. , Not Selected Administer prescribed thrombolytic medication. , Not Selected Remind the client to turn and perform deep breathing exercises. , Not Selected Correctanswer: Encourage the client to ambulate as soon as possible. Feedback General Feedback Rationale: Ambulating the client as soon as possible after surgery prevents venous stasis and helps to prevent embolus formation. Deep breathing and incentive spirometer use are designed to increase the effectiveness of respirations and help to prevent pneumonia and pulmonary embolism. Administering a thrombolytic medication is a treatment to break up an existing embolus. deWit 2017, pg. 415,312- Results for item 22. 22 1 / 1 point The nurse is assisting with developing a plan of care for a newborn client with physiologic jaundice who is receiving phototherapy. Which of the following interventions should the nurse recommend including in the client’s plan of care? Correctanswer: Provide the newborn with 2 ounces of sterile water in between feedings.
Apply emollient to the newborn’s skin every 2 hours. , Not Selected Wear a gown, gloves, and mask while caring for the newborn. , Not Selected Place the newborn in a private room for enteric isolation. , Not Selected Feedback General Feedback Providing additional fluids will help the newborn eliminate excess bilirubin in the stool and urine. Oils and lotions should not be used with phototherapy. Physiologic jaundice is not associated with infection, so there is no need for isolation precautions or PPE. Leifer 2015, pg. 343 Results for item 23. 23 1 / 1 point The nurse is reinforcing information about precautions needed for a client with breast cancer who is being treated with brachytherapy. Which of the following information should the nurse reinforce? “Children 6-years-old and older may be allowed to visit.” , Not Selected Correctanswer: “You should remain on bed rest while receiving the treatment.” “Increased amounts of fluids will be required while receiving the treatment.” , Not Selected “You are allowed out of the room for 15 minutes per day.” , Not Selected Feedback General
