Download Nursing Misc Practice Exam Questions and Answers for 2024 and more Exams Nursing in PDF only on Docsity!
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- A nurse is instilling an otic solution into the adult client’s left ear. The nurse avoids doing which of the following as part of this procedure? Options: A) Warming the solution to room temperature B) Placing the client in a side-lying position with the ear facing up C) Pulling the auricle backward and upward D) Placing the tip of the dropper on the edge of the ear canal Correct Answer is: D Explanation : The dropper is not allowed to touch any object or any part of the client’s skin. The solution is warmed before use. The client is placed on the side with the affected ear upward. The nurse pulls the auricle backward and upward and instills the medication by holding the dropper about 1 cm above the ear canal.
- Levothyroxine sodium (Synthroid) is administered to a hospitalized child with congenital hypothyroidism. The child vomits 10 minutes after administration of the dose. The most appropriate nursing action is to: Options: A) Repeat the prescribed dose B) Give two doses of the prescribed medicine on the next day C) Contact the physician immediately D) Hold the dose for today Correct Answer is: A Explanation : Levothyroxine sodium (Synthroid) is the medication of choice for hypothyroidism. The most
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significant factor adversely affecting the eventual intelligence of children born with congenital hypothyroidism is inadequate treatment. Therefore, compliance with the medication regimen is essential. If the infant or child vomits within 1 hour of taking medication, the dose should be administered again. 3 A client diagnosed as having catatonic excitement has been pacing rapidly non-stop for several hours and is not eating or drinking. The nurse recognizes that in this situation: Options: A) There is an urgent need for physical and medical control B) There is an urgent need for restraint C) There is a need to encourage verbalization of feelings D) The client will soon become catatonic stuporous Correct Answer is: A Explanation : Catatonic excitement is manifested by a state of extreme psychomotor agitation. Clients urgently require physical and medical control because they are often destructive and violent to others, and their excitement can cause them to injure themselves or to collapse from complete exhaustion. Options 2, 3, and 4 are incorrect. 4A 52-year-old male client is seen in the physician’s office for a physical examination after experiencing unusual fatigue over the last several weeks. The client’s height is 5 feet, 8 inches, and weight is 220 pounds. Vital signs are temperature 98o F orally, pulse 86 beats per minute, and respirations 18 breaths per minute. The blood pressure (BP) is 184/100 mmHg. Random blood glucose is 122 mg/dL. Which of the following questions should the nurse ask the client first? Options: A) Do you exercise regularly? B) Are you considering trying to lose weight? C) Is there a history of diabetes mellitus in your family? D) When was the last time you had your blood pressure checked?
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Correct Answer is: A Explanation : The nurse provides supportive care by encouraging the client to participate in care. The nurse should not avoid discussing the client’s problem with the client, and communication with family members in important. Counselling needs to continue after the infant is born. 7A client in the second trimester of pregnancy is being assessed at the health care clinic. The nurse performing the assessment notes that the fetal heart rate is 100 beats per minute. Which nursing action would be most appropriate? Options: A) Document the findings B) Inform the mother that the assessment is normal and everything is fine C) Notify the physician D) Instruct the mother to return to the clinic in 1 week for reevaluation of the fetal heart rate Correct Answer is: C Explanation : The fetal heart rate should be between 120 to 160 beats per minute during pregnancy. A fetal heart rate of 100 beats per minute would require that the physician be notified and the client be further evaluated. Although the nurse would document the findings, the most appropriate nursing action is to notify the physician. Options 2 and 4 are inaccurate nursing actions. 8A client is admitted to the hospital with a diagnosis of a leaking cerebral aneurysm and is scheduled for surgery. The nurse implements which of the following during the preoperative period? Options: A) Encourages the client to be up at least twice per day B) Allows the client to ambulate to the bathroom C) Obtains a bedside commode for the client’s use D) Places the client on strict bed rest
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Correct Answer is: D Explanation : The client’s activity is kept to a minimum to prevent Valsalva maneuver. Clients often hold their breath and strain while pulling up to get out of bed. This exertion may cause a rise in blood pressure, which increases bleeding. Clients who have bleeding aneurysms in any vessel will have activity curtailed. Therefore, options 1, 2, and 3 are incorrect actions. 9A physician calls a nurse to obtain the daily laboratory results of a client receiving total parenteral nutrition (TPN). Which laboratory result would the nurse obtain from the client’s record because it would provide the most valuable information regarding the client’s status related to the TPN? Options: A) Serum electrolyte levels B) Arterial blood gas (ABG) levels C) White blood cell count (WBC) D) Complete blood cell count (CBC) Correct Answer is: A Explanation : TPN solutions contain amino acid and dextrose solutions, with electrolyte and trace elements added. The physician uses the electrolyte values to determine whether changes are needed in the composition of the TPN solutions that will be administered over the next 24 hours. This prevents the client from developing electrolyte imbalance, Options 2, 3, and 4 are not directly related to evaluating client status regarding TPN. 10A client who has episodes of bronchospasm and a history of tachydysrhythmias is admitted to the hospital. The nurse reviews the physician’s orders and contacts the physician to verify which medication, if prescribed by the physician? Options: A) Metaproterenol (Alupent) B) Albuterol (Proventil) C) Epinephrine (Primatene Mist)
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Correct Answer is: C Explanation : A client with a history of tachydysrhythmias should not be given bronchodilators that contain catecholamines, such as epinephrine and isoproterenol hydrochloride (Isuprel). Other sympathomimetics that are noncatecholamines should be used instead. These include metaproterenol, albuterol, and salmeterol. 11A client has a compulsive bed-making ritual in which the client makes and remakes a bed numerous times. The client often misses breakfast and some of the morning activities because of the ritual. Which nursing action would be most helpful? Options: A) Verbalize tactful, mild disapproval of the behavior B) Help the client to make the bed so that the task can be finished quicker C) Discuss the ridiculousness of the behavior D) Offer reflective feedback, such as “I see you have made your bed several times.” Correct Answer is: D Explanation : Verbalizing minimal disapproval would increase the client’s anxiety and reinforce the need to perform the ritual. Helping with the ritual is nontherapeutic and also reinforce the behavior. The client is usually aware of the irrationality (ridiculousness) of the behavior. Reflective feedback acknowledges the client’s behavior. 12An older client who has undergone internal fixation after fracturing a left hip as developed a reddened left heel. The nurse obtains which of the following as a priority item to manage this problem? Options: A) Bed cradle B) Sheepskin C) Trapeze D) Draw sheet
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Correct Answer is: B Explanation : The reddened heel results from pressure of the foot against the mattress. The nurse obtains a sheepskin, heel protectors, or an alternating pressure. The bed cradle will keep the linens off the client’s lower extremities but not assist in managing a reddened heel. A draw sheet and trapeze are of general use for this client but are not specific in dealing with the reddened heel. 13A nurse is caring for an infant following pyloromyotomy to treat hypertropic pyloric stenosis. The nurse places the infant in which position following surgery? Options: A) Flat on the unoperative side B) Flat on the operative side C) Prone with head of the bed elevated D) Supine with head of the bed elevated Correct Answer is: C Explanation : Following pyloromyotomy, the head of the bed is elevated and the infant is placed prone to reduce the risk of aspiration. Options 1, 2, and 4 are incorrect positions following this type of surgery. 14A mother if a child with mumps calls the health clinic to tell the nurse that the child has been lethargic and vomiting. The nurse most appropriately tells the mother: Options: A) To continue to monitor the child B) That lethargy and vomiting are normal manifestations of mumps C) To bring the child to the clinic to be seen by the physician D) That as long as there is no fever, there is nothing to be concerned about Correct Answer is: C
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Explanation : The prone position with the neck hyper extended improves the child’s breathing. Options 1,2 and 3 are not appropriate positions. 17A nurse in the newborn nursery prepares to admit a newborn infant with spina bifida, meningomyelocele type. Which nursing action is most important in the care for this infant? Options: A) Monitoring blood pressure B) Monitoring specific gravity of the urine C) inspecting the anterior fontanel for bulging D) Monitoring temperature Correct Answer is: C Explanation : Intracranial pressure is complication associated with spina bifida. A sign of intracranial pressure in the newborn infant with spina bifida is a bulging anterior fontanel. The newborn infant is at risk for infection before the surgical procedure and closure of the gibbus, and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is most important. A normal saline dressing is placed over the affected site to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of skin integrity at the site. Blood pressure is difficult to assess during the newborn period, and it is not the best indicator of infection or a potential complication. Urine concentration is not well developed in the newborn stage of development. 18On assessment of a child, a nurse notes that the child’s genitals are swollen. The nurse suspects that the child is being sexually abused. Which action by the nurse is of primary importance? Options: A) Document the child’s physical findings B) Report the case in which the abuse is suspected C) Refer the family to appropriate support groups D) Assist the family in identifying resources and support systems
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Correct Answer is: B Explanation : The primary legal responsibility of the nurse when child abuse is suspected is to report to the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documentation of assessment findings, assisting the family, and referring the family to appropriate resources and support groups is important, the primary legal responsibility is to report the case. 19A nurse is planning care for an infant with a diagnosis of encephalocele located in the occipital area. Which item would the nurse use to assist in positioning the child to avoid pressure on the encephalocele? Options: A) Sheep skin B) Foam half donut C) Feather pillows D) Sand bags Correct Answer is: B Explanation : The infant is positioned to avoid pressure on the lesion. If the encephalocele is in the occipital area, a foam half donut may be useful in positioning to prevent this pressure. A sheepskin, feather pillow, or sandbag will not protect the enecephalocele from pressure. 20A nurse is caring for a child with a head injury. On review of the record, the nurse notes that the physician has documented that the physician has documented decorticate posturing. On assessment of the child, the nurse notes extension of the upper extremities and internal rotation of the upper arm and wrist. The nurse also notes that the lower extremities are noted at the knees and feet. Based on these findings, which of the following is the appropriate nursing action? Options: A) Document the findings B) Continue to monitor for posturing of the child C) Attempt to flex the child’s lower extremities D) Notify the physician
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D) 120 mmHg Correct Answer is: B Explanation : The suctioning procedure for pediatric clients varies from that which is used in adults. Suctioning in infants and children requires the use of a smaller suction catheter and lower suction settings that in the adult. Suction settings for a neonate is 60 to 80 mmHg, for an infant is 80 to 100 mmHg, and for larger children is 100 to 120 mmHg. 23A nurse is caring for a client who begins to experience seizure activity while in bed. The nurse implements which action to prevent aspiration? Options: A) Loosens restrictive clothing B) Removes the pillow and raises the padded side rails C) Raises the head of the bed D) Positions the client on the side if possible, with the head flexed forward Correct Answer is: D Explanation : Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitates drainage of secretions, which could help prevent aspiration. The nurse would also remove restrictive clothing and the pillow, and raise the padded side rails, if present, but these actions would not decrease the risk of aspiration. Rather, they are general safety measures to use during seizure activity. The nurse would not raise the client’s head of bed. 24A client with a cerebrovascular accident (CVA) has episodes of coughing while swallowing liquids. The client has developed a temperature of 101oF, oxygen saturation of 91% (down from 98% previously), slight confusion, and noticeable dyspnea. The nurse would take which most appropriate action? Options: A) Administer a bronchodilator ordered on a prn basis B) Administer an acetaminophen (Tylenol) suppository
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C) Encourage the client to cough and deep breathe D) Notify the physician Correct Answer is: D Explanation : The client is exhibiting clinical signs and symptoms of aspiration, which include fever, dyspnea, decreased arterial oxygen levels, and confusion. Other symptoms that occur with this complication are difficulty in managing own saliva, or coughing or choking while eating. Because the client has developed a complication requiring medical intervention, the most appropriate action is to contact the physician 25A nurse is providing care to the client following a bone biopsy. Which action would the nurse take as part of aftercare for this procedure? Options: A) Keep the area in a dependent position B) Monitor vital signs once per day C) Monitor the site for swelling, bleeding, or hematoma formation D) Administer intramuscular narcotic analgiesics Correct Answer is: C Explanation : Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, or hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain usually indicates that complications arising. 26A nurse is caring for a client who is going to have an arthrogram using a contrast medium. Which action by the nurse is the highest priority? Options: A) Determining the presence of client allergies B) Telling the client that he will need to remain still during the procedure
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B) Continue hydration and recheck the temperature 4 hours later C) Document the temperature D) Increased the intravenous fluids Correct Answer is: A Explanation : A temperature greater than 100.4 F in two consecutive reading is considered febrile, and the physician should be notified. Option 2, 3 and 4 are inappropriate actions at this time. 29A nurse is checking the fundus in a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially? Options: A) Massage the fundus gently until firm B) Document fundal position and consistency and height C) Encourage the mother to ambulate D) Notify the physician Correct Answer is: A Explanation : If the fundus is boggy (soft), it should massaged gently until firm, observing for increased bleeding or cots. Option 3 is an inappropriate action at this time. The nurse should document fundal position, consistency and height, the need to perform fundla massage, and the client’s response to the intervention. The physician will need to be notified if uterine massage is not helpful. 30A primipara is being evaluated in the clinic during her second trimester pregnancy. The nurse checks the fetal heart rate (FHR) and notes that it is 190 beats per minute. The appropriate nursing action would be to: Options: A) Document the finding B) Consult with the physician
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C) Tell the client that the FHR is normal D) Recheck the FHR with the client in the standing position Correct Answer is: B Explanation : The fetal heart rate should be 120 to 160 beats per minute throughout pregnancy. In this situation, the FHR is elevated from the normal range, and the nurse should consult with the physician. The GHR would be documented, but option 2 is appropriate action. The nurse would not tell the client that the FHR is normal because this is not true information. Option 4 is an inappropriate action. 31A female client tells the clinic nurse that her skin is very dry and irritated. Which product would the nurse suggest that the client apply to the dry skin? Options: A) Glycering emollient B) Aspercreme C) Myoflex D) Acetic acid solution Correct Answer is: A Explanation : Glycerin is an emollient that is used for dry, cracked, and irritated skin. Aspercreame and myoflex are used to treat muscular aches. Acetic acid solution is used for irrigating cleansing, and packing wounds infected by Pseudomonas aeruginosa. A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse provides information to the client about the medication and tells the client to avoid consuming which of the following fruits? Options: A) Apples B) Pears
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D) Cranberries Correct Answer is: C Explanation : Triamterene is a potassium-sparing diuretic, and the client should avoid foods high in potassium. Fruits that are naturally higher in potassium include avocado, bananas, fresh oranges, mangoes, nectarines, papayas, and dried prunes 32Breathing exercises and postural drainage is prescribed for a child with cystic fibrosis. A nurse implements these procedures by telling the child to: Options: A) Perform the postural drainage, then the breathing exercises B) Perform the breathing exercises, then the postural drainage C) Schedule the procedures so they are 4 hours apart D) Perform postural drainage in the morning and breathing exercises in the evening Correct Answer is: A Explanation : Breathing exercises are recommended for children with cystic fibrosis, even for those with minimal pulmonary involvement. The exercises are usually performed twice daily, and they are preceded with postural drainage. The postural drainage will mobilize secretions, and the breathing exercises will then assist with expectoration. Exercises to assist with posture and to mobilize the thorax are included, such as swinging the arms and bending and twisting the trunk. The ultimate aim of these exercises is to establish a good habitual breathing pattern. 33A nurse has been encouraging the intake of oral fluids in a woman in labor to improve hydration. Which of the following indicates a successful outcome of this action? Options: A) A urine specific gravity of 1. B) Continued leaking of amniotic fluid during labor C) Blood pressure of 150/90 mmHg.
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D) Ketones in the urine. Correct Answer is: A Explanation : Urine specific gravity measures the concentration of the urine. During the first stage of labor, the renal system has a tendency to concentrate urine. Labor and birth require hydration and caloric intake to replenish energy expenditure and promote efficient uterine function. An elevated blood pressure and ketones in the urine are not expected outcomes related to labor and hydration. Once membranes are ruptured, it is expected that amniotic fluid may continue to leak. 34A postpartum client has a nursing diagnosis of Risk for Infection. A goal has been developed that states: “The client will remain free of infection during her hospital stay. “Which assessment data would support that the goal has been met? Options: A) Presence of chills B) Abdominal tenderness C) Absence of fever D) Loss of appetite Correct Answer is: C Explanation : Fever is the first indication of an infection. Chills abdominal tenderness, and loss of appetite can indicate the presence of infection. Therefore, the absence of a fever indicates that an infection is not present. 35A nurse is monitoring the nutritional status of the client receiving enteral nutrition because of dysphagia that resulted from a head injury. The nurse monitors which of the following to best determine the effectiveness of the feedings for this client? Options: A) Calorie count B) Daily intake and output
