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QN 1:
A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these
points is most important to be reinforced by the nurse?
A) "Until the health care provider has determined that your ejaculate doesn't
contain sperm, continue to use another form of contraception."
B) "This procedure doesn't impede the production of male hormones or the
production of sperm in the testicles. The sperm can no longer
enter your semen and no sperm are in your ejaculate."
C) "After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If
your work doesn't
involve hard physical labor, you can return to your job as soon as you
feel to it. The stitches
generally dissolve in 7-10 days."
D) "The health care provider at this clinic recommends rest, ice, an athletic
supporter or over-the-counter pain medication to relieve any discomfort."
A : All of these options are correct information. The most important point to reinforce is the
continuing need to take additional action for birth control.
II. A female client talks to the nurse in the provider’s office about uterine fibroids, also called
leiomyomas or myomas. What statement by the woman indicates more education is needed?
A) "I am the one out of every 4 women that get fibroids, and of women my age
- between the 30s or 40s, fibroids occur more frequently."
B) "My fibroids are noncancerous tumors that grow slowly."
C) "My associated problems I have had are pelvic pressure and pain, urinary
incontinence,and constipation."
D) "Fibroids that cause no problems still need to be taken out."
D : Fibroids that cause no findings may require only "watchful waiting" with no treatment. Only
when the client’s findings become disturbing to them would surgical interventions be
considered.
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III. A client has an indwelling catheter with continuous bladder irrigation after undergoing a
transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time
should be reported to the health care provider?
A) light, pink urine
B) occasional suprapubic cramping
C) minimal drainage into the urinary collection bag
D) reports of the feeling of pulling on the urinary catheter
C : Options A, B, and D are expected complaints after this procedure. Option C needs to be
reported immediately since minimal urinary drainage puts the client at risk for bladder rupture.
The flow rate of the continuous irrigation would need to be slowed until the provider is notified.
If an order to irrigate the system is written, sterile technique would be used.
IV. Which order can be associated with the prevention of atelectasis and pneumonia in a
client with amyotrophic lateral sclerosis (ALS)?
A) Active and passive range of motion exercises twice a day
B) Use incentive spirometer every 4 hours
C) Chest physiotherapy twice a day
D) Repositioning every 2 hours around the clock
C : Chest physiotherapy twice a day. These clients have potential inability to have voluntary and
involuntary muscle movement or activity. Thus, options A and B may not be feasible for the
immobilized client. Option D is not specific for prevention of complications associated with the
lung.
1.A client has been hospitalized after an automobile accident. A full leg cast was applied in the
emergency room. The most important reason for the nurse to elevate the casted leg is to
A) Promote the client's comfort
B) Reduce the drying time
C) Decrease irritation to the skin
D) Improve venous return
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A) Comatose, breathing unlabored
B) Glascow Coma Scale 8, respirations regular
C) Appears to be sleeping, vital signs stable
D) Glascow Coma Scale 13, no ventilator required
B : Glascow Coma Scale 8, respirations regular. The Glascow Coma Scale provides a standard
reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a
neurological impairment. Using the term comatose provides too much room for interpretation
and is not very precise.
- When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse
monitor to determine therapeutic response to the drug?
A) Bleeding time
B) Coagulation time
C) Prothrombin time
D) Partial thromboplastin time
C : Prothrombin time. Coumadin is ordered daily, based on the client''s prothrombin time (PT).
This test evaluates the adequacy of the extrinsic system and common pathway in the clotting
cascade; Coumadin affects the Vitamin K dependent clotting factors.
- A client with moderate persistent asthma is admitted for a minor surgical procedure. On
admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is
complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the
nurse do first?
A) Notify both the surgeon and provider
B) Administer the prn dose of albuterol
C) Apply oxygen at 2 liters per nasal cannula
D) Repeat the peak flow reading in 30 minutes
B : Administer the prn dose of albuterol. Peak flow monitoring during exacerbations of asthma is
recommended for clients with moderate-to-severe persistent asthma to determine the severity of
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the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client''s
baseline reading is a medical alert condition and a short-acting beta-agonist must be taken
immediately.
- A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse
to include at the change of shift report?
A) The client lost 2 pounds in 24 hours
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at this time?
A) leave a book about relaxation techniques
B) write out a daily exercise routine for them to assist the client to do
C) list actions to improve the client's daily nutritional intake
D) suggest communication strategies
D : suggest communication strategies. Alzheimer''s disease, a progressive chronic illness, greatly
challenges caregivers. The nurse can be of greatest assistance in helping the family to use
communication strategies to enhance their ability to relate to the client. By use of select verbal
and nonverbal communication strategies the family can best support the client’s strengths and
cope with any aberrant behavior.
11.An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a
blood pressure from 160/100 to 180/110 over the past 2 hours. The nurse has also noted
increased lethargy. Which assessment finding should the nurse report immediately to the
provider?
A) Slurred speech
B) Incontinence
C) Muscle weakness
D) Rapid pulse
A : Slurred speech. Changes in speech patterns and level of conscious can be indicators of
continued intracranial bleeding or extension of the stroke. Further diagnostic testing may be
indicated.
- A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago.
Which statement from the parent indicates that teaching has been inadequate?
A) "I will keep the cast uncovered for the next day to prevent burning of the skin."
B) "I can apply an ice pack over the area to relieve itching inside the cast."
C) "The cast should be propped on at least 2 pillows when my child is lying down."
D) "I think I remember that my child should not stand until after 72 hours."
D : "I think I remember that my child should not stand until after 72 hours.". Synthetic casts
will typically set up in 30 minutes and dry in a few hours. Thus, the client may stand within the
initial 24 hours. With plaster casts, the set up and drying time, especially in a long leg cast which
is thicker than an arm cast, can take up to 72 hours. Both types of casts give off a lot of heat
when drying and it is preferable to keep the cast uncovered for the first 24 hours. Clients may
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complain of a chill from the wet cast and therefore can simply be covered lightly with a sheet or
blanket. Applying ice is a safe method of relieving the itching.
- Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that immediate
action is required?
A) pH below 7.
B) Potassium of 5.
C) HCT of 60
D)
Pa O 2
of 79%
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A) a tissue bank."
B) a pig."
C) my thigh."
D) synthetic skin."
C : my thigh.". Autografts are done with tissue transplanted from the client''s own skin.
- A client is admitted to the emergency room following an acute asthma attack. Which of the
following assessments would be expected by the nurse?
A) Diffuse expiratory wheezing
B) Loose, productive cough
C) No relief from inhalant
D) Fever and chills
A : Diffuse expiratory wheezing. In asthma, the airways are narrowed, creating difficulty getting
air in. A wheezing sound results.
- A client has been admitted with a fractured femur and has been placed in skeletal traction.
Which of the following nursing interventions should receive priority?
A) Maintaining proper body alignment
B) Frequent neurovascular assessments of the affected leg
C) Inspection of pin sites for evidence of drainage or inflammation
D) Applying an over-bed trapeze to assist the client with movement in bed
B : Frequent neurovascular assessments of the affected leg. The most important activity for the
nurse is to assess neurovascular status. Compartment syndrome is a serious complication of
fractures. Prompt recognition of this neurovascular problem and early intervention may prevent
permanent limb damage.
- The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The
client has many questions about this condition. What area is a priority for the nurse to discuss at
this time?
A) Daily needs and concerns
B) The overview cardiac rehabilitation
C) Medication and diet guideline
D) Activity and rest guidelines
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A : Daily needs and concerns. At 2 days post-MI, the client’s education should be focused on the
immediate needs and concerns for the day.
- A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his
bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess
for which problem?
A) allergies
B) scabies
C) regression
D) pinworms
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B : Metabolic alkalosis. Vomiting causes loss of acid from the stomach. Prolonged vomiting can
result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability,
increased activity, hyperactive reflexes, muscle twitching and elevated pulse. Options C and D
are correct answers but not the best answers since they are too general.
- A two year-old child is brought to the provider's office with a chief complaint of mild
diarrhea for two days. Nutritional counseling by the nurse should include which statement?
A) Place the child on clear liquids and gelatin for 24 hours
B) Continue with the regular diet and include oral rehydration fluids
C) Give bananas, apples, rice and toast as tolerated
D) Place NPO for 24 hours, then rehydrate with milk and water
B : Continue with the regular diet and include oral rehydration fluids. Current recommendations
for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate.
- The nurse is teaching parents about the appropriate diet for a 4 month-old infant with
gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should
include
A) formula or breast milk
B) broth and tea
C) rice cereal and apple juice
D) gelatin and ginger ale
A : formula or breast milk. The usual diet for a young infant should be followed.
- A child is injured on the school playground and appears to have a fractured leg. The first action
the school nurse should take is
A) call for emergency transport to the hospital
B) immobilize the limb and joints above and below the injury
C) assess the child and the extent of the injury
D) apply cold compresses to the injured area
C : assess the child and the extent of the injury. When applying the nursing process, assessment is
the first step in providing care. The "5 Ps" of vascular impairment can be used as a guide (pain,
pulse, pallor, paresthesia, paralysis).
- The mother of a 3 month-old infant tells the nurse that she wants to change from formula to
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whole milk and add cereal and meats to the diet. What should be emphasized as the nurse
teaches about infant nutrition?
A) Solid foods should be introduced at 3-4 months
B) Whole milk is difficult for a young infant to digest
C) Fluoridated tap water should be used to dilute milk
D) Supplemental apple juice can be used between feedings
B : Whole milk is difficult for a young infant to digest. Cow''s milk is not given to infants younger
than 1 year because the tough, hard curd is difficult to digest. In addition, it contains little iron and
creates a high renal solute load.
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- What finding signifies that children have attained the stage of concrete operations (Piaget)?
A) Explores the environment with the use of sight and movement
B) Thinks in mental images or word pictures
C) Makes the moral judgment that "stealing is wrong"
D) Reasons that homework is time-consuming yet necessary
C : Makes the moral judgment that "stealing is wrong". The stage of concrete operations is
depicted by logical thinking and moral judgments.
- The mother of a child with a neural tube defect asks the nurse what she can do to decrease the
chances of having another baby with a neural tube defect. What is the best response by the
nurse?
A) "Folic acid should be taken before and after conception."
B) "Multivitamin supplements are recommended during pregnancy."
C) "A well balanced diet promotes normal fetal development."
D) "Increased dietary iron improves the health of mother and fetus."
A : "Folic acid should be taken before and after conception.". The American Academy of
Pediatrics recommends that all childbearing women increase folic acid from dietary sources
and/or supplements. There is evidence that increased amounts of folic acid prevents neural tube
defects.
- The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which
of these foods would the nurse reinforce for the client to eat at least daily?
A) Spaghetti
B) Watermelon
C) Chicken
D) Tomatoes
B : Watermelon. Watermelon is high in potassium and will replace potassium lost by the diuretic.
The other foods are not high in potassium.
- While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure
control, it is most important for the nurse to teach them about which of the following actions?
A) Maintain good oral hygiene and dental care
B) Omit medication if the child is seizure free
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C) Administer acetaminophen to promote sleep
D) Serve a diet that is high in iron
A : Maintain good oral hygiene and dental care. Swollen and tender gums occur often with use of
phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized.
- The nurse is offering safety instructions to a parent with a four month-old infant and a four
year-old child. Which statement by the parent indicates understanding of appropriate
precautions to take with the children?
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- The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would
emphasize that pancreatic enzymes should be taken
A) once each day
B) 3 times daily after meals
C) with each meal or snack
D) each time carbohydrates are eaten
C : Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of
all foods that are eaten.
- A nurse is providing a parenting class to individuals living in a community of older homes. In
discussing formula preparation, which of the following is most important to prevent lead
poisoning?
A) Use ready-to-feed commercial infant formula
B) Boil the tap water for 10 minutes prior to preparing the formula
C) Let tap water run for 2 minutes before adding to concentrate
D) Buy bottled water labeled "lead free" to mix the formula
C : Let tap water run for 2 minutes before adding to concentrate. Use of lead-contaminated water
to prepare formula is a major source of poisoning in infants. Drinking water may be
contaminated by lead from old lead pipes or lead solder used in sealing water pipes. Letting tap
water run for several minutes will diminish the lead contamination.
- Which of the following manifestations observed by the school nurse confirms the presence of
pediculosis capitis in students?
A) Scratching the head more than usual
B) Flakes evident on a student's shoulders
C) Oval pattern occipital hair loss
D) Whitish oval specks sticking to the hair
D : Whitish oval specks sticking to the hair. Diagnosis of pediculosis capitis is made by
observation of the white eggs (nits) firmly attached to the hair shafts. Treatment can include
application of a medicated shampoo with lindane for children over 2 years of age, and
meticulous combing and removal of all nits.
- When interviewing the parents of a child with asthma, it is most important to assess the child's
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environment for what factor?
A) Household pets
B) New furniture
C) Lead based paint
D) Plants such as cactus
A: Household pets. Animal dander is a very common allergen affecting persons with asthma.
Other triggers may include pollens, carpeting and household dust.
- The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B
and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as
long as 3 hours, and has had several shaking spells. In addition to referring her 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 the infant is displaying?
