Effective Teaching in Nursing: Observing Patient Responses, Exams of Nursing

Download Effective Teaching in Nursing: Observing Patient Responses and more Exams Nursing in PDF only on Docsity! Nursing Exam Predictor Version 2 Question with Answers 1. The nurse shows a teenager how to use a metered dose inhaler of ipratropium (Atrovent). Which statement, if made by the client to the nurse, indicates teaching is effective? 1. “I should use this medicine to stop the coughing that leads to an asthma attack” 2. “I should use this medicine if I begin to have an asthma attack” 3. “I should use this medicine right after I have an asthma attack” 4. “I should use this medicine to prevent an asthma attack” Answer#2 2. An older client is scheduled for a magnetic resonance imaging MRI procedure. Which of the following statements, if made by the client to the nurse, should be reported to the technician before the test? 1. “I take medication to control my blood pressure” 2. “I have had diabetes for about 10 years now” 3. “I had a knee replacement 5 years ago” 4. “I am allergic to penicillin and sulfa medications” Answer#3 3. The nurse makes the following observations of a 6 hour old newborn: axillary temperature 96.4 F (35.8 C), apical pulse 148, respirations irregular at 48/minute, black sticky stool, blood glucose 60mg/dL. It is most important for the nurse to take which action? 1. Feed the newborn 30mL of infant formula 2. Administer low flow oxygen to the newborn 3. Wrap the newborn in a warmed blanket 4. Perform a guaiac test on the newborns stool Answer#3 4. A client is returned to the unit at 10AM after laparoscopic gallbladder surgery. The nurse plans to get the patient out of bed for the first time at 4PM. It is MOST important for the nurse to take which of the following actions? 1. Turn the patient from side to side at 2 PM 2. Offer pain medication to the patient at 3:30PM 3. Encourage the patient to use the incentive spirometer at 3PM 4. Cough and deep-breathe the patient at 2:30PM Answer#1 5. The activity therapy staff takes a group of psychiatric patients on a trip to the zoo. The nurse should intervene with which of the following patients before their departure? 1. A 50 year old female who is having difficulty with sleeping, eating, and social interaction. 2. A 40 year old male who just received his third dose of trazodone (Desyrel) and is 20 pounds overweight. 3. A 42 year old female who has problems with decision making who paces continuously, wringing her hands. 4. A 38 year old female who is receiving chlorpromazine (Thorazine) and is wearing a sundress without a hat or sunglasses. Answer#4 (photosensitivity;causes sensitivity to sun) 6. A patient experiences skin eruptions due to an allergic reaction to a medication. The nurse demonstrates the BEST documentation with which of the following? 1. “Patient complains of rash and itching over most of his body. Patient is concerned about how it looks” 2. “Multiple red welts noted over trunk and both arms. Patient states that welts itch” 3. “Allergic skin reaction to medication experienced by patient. Started several hours ago” 4. “Vital signs stable. Patient scratching arms and chest area frequently” Answer#2 7. An older client diagnosed with emphysema is admitted to the psychiatric unit for treatment of bipolar disorder. The client receives oxygen per nasal cannula. The client expresses concern to the nurse that someone will come in and change the amount of oxygen the client is receiving. INITIALLY, the nurse should take which of the following actions? 1. Schedule an in-service with the staff about emphysema 2. Place a sign above the patient’s bed stating that the oxygen level is not to be changed 3. Tell the patient she will be well cared for in the hospital 4. Convey the patient’s concern to the nursing staff Answer#2 8. A teenager has a positive home pregnancy test and comes to the prenatal clinic. The girl is uncertain of the date of her last menstrual period. The nurse palpates the uterine fundus midway between the symphysis pubis and the umbilicus. Which statement by the nurse is BEST? 1. “You are 24 weeks pregnant. It is good that you came in for prenatal care” 2. “You are 30 weeks pregnant. Prenatal care is important for you and your baby” 3. “You are 16 weeks pregnant. Let’s talk about what that means” 4. “You are 8 weeks pregnant. Are your periods usually irregular?” Answer#3 9. A client is admitted to the psychiatric unit with complaints of fatigue, inability to concentrate, lack of appetite, and repetitive thoughts. The client is reluctant to take the prescribed medications, fearing that they are harmful. After the nurse gives the client the medication, the nurse should take which of the following actions? 1. Instruct the client to open her mouth and move her tongue up and down and to each side while the nurse looks inside. 2. Ask the client if she has swallowed the medication completely. 3. Watch the client’s behavior to see if the medication is having its desired effect. 19. The nurse observes the nursing assistant giving morning care to an elderly client who has an area of warm, reddened skin on the sacrum that does not blanch with pressure. Which action by the nursing assistant requires an intervention by the nurse? 1. The aide cleanses and then applies A and D ointment to the reddened area 2. The aide firmly massages the reddened area in a circular motion 3. The aide placed a piece of sheepskin under the patients sacrum 4. The aide positions the patient on the left side with head of the bed flat Answer#2 (Stage I pressure ulcer, do not massage can damage capillary beds and cause tissue necrosis) 20. The school nurse identifies several children who have food allergies. Which sequence should the nurse teach the staff to follow if an allergic reaction is observed in a child? 1. Call 911, call the physician, administer EpiPen, call the parents 2. Administer the EpiPen, call 911, call the physician, call the parents 3. Call the physician, administer the EpiPen, call 911, call the parents 4. Call the parents, administer the EpiPen, call the physician Answer#2 21. A client comes to the ER complaining of shortness of breath, fatigue, insomnia, and weight loss. The client states that the client’s company forced the client into early retirement. The client says that the client has been sick ever since the client stopped working. The nurse should take which of the following actions first? 1. Encourage the patient to find outlets for his job skills in a consultative or volunteer basis in the community 2. Help the client see a connection between his symptoms and emotions, while investigating each symptom 3. Tell the client that anger is an unacceptable reason to something being taken away 4. Explain to the client what retirement should be like, and contrast this with what he has experienced Answer#2 22. The nurse teaches the woman diagnosed with type 1 diabetes who is pregnant for the first time. The nurse teaches the client that as the pregnancy advances, the client may require which implementation? 1. Decreased amounts of insulin 2. Increased amounts of insulin 3. Decreased amounts of carbohydrates in her diet 4. Increased amounts of protein in her diet Answer#2 23. The nurse cares for a patient after a colon resection. The patient has a Salem sump tube connected to intermittent suction. The patient asks the nurse, “When will I be able to eat?” Which is the BEST response by the nurse? 1. “You will be given a high-calorie, high-fiber diet in a few days” 2. “You will be started on clear liquids when we hear your stomach make noises” 3.”You can eat food when the NG tube is removed in about 5 to 6 days” 4. A soft diet will be given to you after you have your first bowel movement” Answer#2 24. The nurse supervises care provided for a client immediately after cardioversion. Which observation, if made by the nurse, indicates the need for an intervention? 1. A cold cloth has been applied to the paddle sites on the patient’s chest 2. The patient’s dentures remain in a cup at the bedside 3. There is an NPO sign above the patients bed 4. The oxygen the patient was receiving before the procedure remains disconnected Answer#4 25. The nurse cares for a client diagnosed with bursitis of the right shoulder. The nurse expects the client to experience which of the following? 1. Pain and numbness in the first two fingers and thumb of her right hand 2. Spasms of the right hand when a blood pressure cuff is initiated and left in place for 2 minutes 3. A constant dull ache originating in the neck and radiating down the right arm 4. Pain with extension, flexion, and internal rotation of the right arm Answer#4 26. The nurse supervises care provided by the nursing assistive personnel (NAP) to the older client in the convalescent phase after a stroke. The nurse should intervene if which action is observed? 1. The client is supine with a pillow under the head 2. The client is positioned laterally on the left side with the head of the bed flat 3. The client sits with the head of the bed elevated and the knee gatch up 4. The client is positioned laterally on the right side with the head of the bed flat Answer#1 (Brain attack or CVA; keep head unaffected side, no neck flexion or extension, head of bed flat) 27. The nurse cares for a client who is receiving amitriptyline (Elavil) 25 mg q A.M. and 100 mg at HS. The nurse understands that the medication schedule will accomplish which of the following? 1. Make therapeutic use of an expected side effect of the medication 2. Decrease interference between digestion of food and absorption of medication 3. Utilize the increased permeability of the blood-brain barrier that occurs during sleep 4. Reduce the side effects experienced by the client Answer#4 (Antidepressant, tryciclic; it has a sedative effect, administer larger dose at night it causes increased sedation) 28. An older patient falls on the floor of the psychiatric unit. To determine the cause of the fall, it is MOST important for the nurse to do which of the following? 1. Check the patients eyeglasses 2. Examine the condition of the patients shoes 3. Monitor the patients’ blood pressure 4. Evaluate the floor where the patient fell Answer#4 29. The nurse instructs a prenatal class for first-time mothers. A group of mothers state they are afraid because they have heard that babies often die in their sleep before their first birthday. The mothers ask what they can do to prevent this. It is BEST for the nurse to make which of the following responses? 1. it’s important for you to focus on your pregnancy and upcoming labor and not to focus on negative things that may happen in the future 2. This does not happen very often. With good nutrition and loving care your babies should thrive and develop normally 3. Unfortunately, the cause of this condition is not definitely known, so there is little you can do to prevent this from happening 4. It’s best to position the baby on its back or side in bed. There seems to be an increase in this condition when babies are put to sleep on their stomach Answer#4 30. A client attends a support group for incest survivors at the community mental health center. The client tells the nurse, “I don’t get it. People keep telling me I talk just like my father. He’s the last person I’d want to act like!” which response by the nurse is BEST? 1. Genetically, you are like your father 2. You need to be more open-minded. I’m sure your father had some good qualities 3. Don’t worry about what everyone else is saying 4. Sometimes people unconsciously take on the characteristics of people who exert power over them Answer#4 To exert is to apply or use. Waleska=mami 31. The family of a patient admitted to the psychiatric unit 3 days ago arrives for a visit carrying two suitcases. The nurse informs the family that before they can proceed into the unit, the suitcases need to be searched. The family asks why this needs to be done. Which is the BEST response by the nurse? 1. “We know what is best for our patients” 2. “We have to make sure you’re not bringing contraband” 3. “Were just following the rules established by administration” 4. “Things that you may not think of as being harmful may be used for harm by the patient Answer#4 32. The nurse asks the nursing assistant to obtain morning vital signs on several patients. It is best for the nurse to make which of the following statements? 1. “Go check the vital signs for the patient in rooms 321 and 322. Record your findings on this sheet and then return it to me” 2. “Today you’ll check patient’s vitals. Please start with rooms 321 and 322. Be sure to Answer#4 Assess client’s physical needs FIRST, MASLOW. 42. At the bedside of a patient, the nurse is preparing for insertion of a percutaneous intravenous catheter (PICC) line. The patient holds out the left arm and says, “Please put it in this arm; I’m right handed.” Which response by the nurse is best? 1. The placement of the line won’t affect the use of your hand. The line is always placed on the left side, near the heart 2. The line needs to go into your right arm. It is important for you to move your arm while the line is in place 3. That is helpful to know. We will put the line in your left arm as you wish 4. The line won’t go into either of your arms. The line will go through a spot under your collarbone Answer#4 43. The nurse is caring for a client undergoing internal radiation therapy to treat cervical cancer. The client is receiving Osmolite half-strength at 100 ml/h per Salem sump tube. Before hanging a new container of Osmolite, the nurse aspirates the residual gastric contents. The nurse should take which of the following actions? 1. Reinsert the solution into the Salem sump tube before starting the feeding 2. Discard the solution in a lead-lined container in the patients room 3. Flush the solution down the sink in the dirty utility room 4. Replace the solution into the Salem sump tube after completing the feeding Answer#1 44. A patient diagnosed with schizophrenia approaches the nurse and reports a very sore throat, feeling hot, and experiencing aches. It is flu season, and several patients and staff have been ill. Which is the BEST action for the nurse to take? 1. Move the patient to a private room so she is less likely to infect others 2. Check to see when the patient last received her antipsychotic medication 3. Tell the patient she is probably getting the flu and will feel better in a few days 4. Notify the physician so appropriate blood work can be ordered Answer#4 45. The nurse cares for a client scheduled to begin continuous ambulatory peritoneal dialysis (CAPD). Which statement, if made by the client, is MOST important for the nurse to communicate to the physician? 1. I’m so glad to be going on dialysis. Maybe now the backaches I’ve had for so long will go away 2. I know I have to be careful not to gain weight, but it is good to have my appetite back 3. The last thing I want to do is die, so I’ll put whatever I have to do to make this dialysis work 4. I like the idea of being independent with my own care. I just hope I do the procedure correctly Answer#2 (Main cause of insufficient outflow is a full colon; encourage a high fiber diet because constipation can cause inflow and outflow problems.) 46. The physician order phenytoin (Dilantin) 200 mg PO daily for a teenager. It is MOST important for the nurse to include which of the following instructions when teaching the client? 1. Visit your dentist frequently 2. If you miss a dose, take an extra one the next day 3. Avoid contact sports for the next several weeks 4. Be sure to take the medication between meals Answer#1 (causes gingival hyperplasia and bleeding). 47. The nurse evaluates a patient in the emergency department for admission to the psychiatric unit. The nurse is MOST concerned if the patient’s history reveals which of the following? 1. Past episodes of violence and alcohol ingestion 2. Lack of a support system and family friction 3. Current unemployment and lack of pleasurable activities 4. Presence of a chronic illness and recent death of a parent Answer#1 (alcohol withdrawal) 48. The nurse visits a 24-hour –old newborn at home. The nurse notes the newborns axillary temperature is 96.1 F (35.6 C). The nurse notes the newborn is pink with a small amount of jaundice on the nose. The mother states that the newborn has been spitting up most feedings and has been “too sleepy to eat” since early that morning. The newborn does not awake during the nurse’s exam and has decreased muscle tone. The nurse should prepare implementations for which medical diagnosis? 1. Erythroblastosis fetalis 2. Neonatal sepsis 3. Physiologic jaundice 4. Hypoglycemia Answer#2 (newborns decrease temperature with infection, pallor, anorexia, poor feeding) 49. The nurse expects a ventilator-perfusion (V/Q) scan to be ordered for which client? 1. A client diagnosed with asthma 2. A client diagnosed with emphysema 3. A client diagnosed with cystic fibrosis 4. A client diagnosed with a pulmonary embolism Answer#4 50. If reported in a 24-hour diet recall, which action is the BEST indication that the client understands the nurse’s teaching regarding a high-fiber diet? 1. The client sprinkles granola over vanilla ice cream for dessert 2. The client munches on pork rinds between meals 3. The client peels and mashes potatoes with whole milk 4. The client removes skin from the chicken before cooking it Answer#1 51. The physician’s office nurse checks the incision of a client 48 hours after a hernia repair. Which finding, if observed by the nurse, is unexpected? 1. There is slight swelling under each individual suture 2. There is crusting around the incision line 3. The incision line is bright red 4. The incision line is approximated Answer#3 52. An agitated patient grabs another patient’s hair from behind and begins to pull on it. INITIALLY, the nurse should take which of the following actions? 1. Pull the other patients head and body away from the patient that is pulling the hair 2. Stabilize the patient’s hand against the other patient’s head 3. Twist the patient’s fingers off the other patient’s head 4. Quickly get help to separate the two patients Answer#2 53. The nurse cares for a client after abdominal surgery for a gunshot wound. The large abdominal dressing is to be changed every 4 hours. While changing the dressing, the nurse notes that the area surrounding the dressing is edematous and red. The nurse should take which of the following actions? 1. Apply tape to the dressing lightly 2. Allow the wound to air-dry 3. Use Montgomery straps 4. Apply a tubular elastic dressing Answer#3 For frequent dressing changes to prevent skin irritation from frequent tape removal. 54. A patient is admitted to the psychiatric unit with depression and suicidal ideation. Which action is MOST important for the nurse to take? 1. Instruct the patient to check in with the staff every 15 minutes, and encourage her to comply 2. Ask the staff to assess the patient’s suicidal thoughts every 30 minutes 3. Observe the patient every 15 minutes, and add several unscheduled observations 4. Establish a schedule for the staff to check the patient every 15 minutes Answer#3 55. A client diagnosed with malnutrition secondary to AIDS prepares for total parenteral nutrition (TPN). The client says to the nurse “I know glucose is sugar. I can’t see how giving me sugar is going to help me.” Which is the BEST response by the nurse? 1. This will give you enough calories so that your body won’t have to use protein stores for energy 2. It will all be explained to you when the dietician comes to see you and talks about how TPN works 3. Glucose is the building block of protein, and your disease has caused a serious deficit 3. Suction machine 4. Tracheostomy set Answer#1 carotid endarterectomy: to remove plaque from artery 65. The nurse cares for a client undergoing radiation therapy of the right breast and axilla after lumpectomy. Which statement, if made by the client, indicates to the nurse that teaching is effective? 1/. I should apply body cream to the area to keep it lubricated 2. I should wear a loose fitting bra made of 100% cotton to prevent irritation 3. I will apply cold compresses to the area to prevent swelling 4. I will expose the area to air and sun once daily to help it heal Answer#2 66. The nurse cares for patient on the psychiatric unit. A patient becomes verbally abusive and begins swinging arms and kicking anyone who approaches the patient. An order is obtained for mechanical restraints. The nursing team is able to get the patient to the floor and under their physical control. Before being lifted and taken to the patient’s room for restraint application, the patient’s body relaxes and the patient says “I’m sorry. Ill cooperates. I’ll walk to my room. Please don’t hold me down anymore.” Which response by the nurse is BEST? 1. Negotiate an agreement with the patient for nonaggressive behavior 2. Ask the patient if he is sincere 3. Tell the patient that he will be transported as planned 4. Instruct the staff to release their hold on the patient Answer#3 67. The nurse cares for a 3,000 gram newborn who receives ampicillin (Omnipen). The dosage is 100 mg/kg/day with doses divided, and it is administered every 12 hours. How many milligrams should the nurse administer to the newborn every 12 hours? 1. 300 mg 2. 100 mg 3. 15 mg 4. 150 mg Answer#4 100 mg *3 kg=300 mg/2=150 mg 68. The registered nurse leads a patient care team that consists of one LPN/LVN and one nursing assistant. It is considered appropriate for the RN to assign which of the following patient to the LPN/LVN? 1. A 30 year old quadriplegic and ventilator dependent man admitted for skin grafting 2. A 47 year old woman transferred from the intensive care unit 3 hours ago after a coronary artery bypass graft (CABG) 3. A 79 year old man diagnosed with Alzheimer’s disease who is rubbing his chest and has a respiratory rate of 22 4. A 64 year old woman diagnosed with cirrhosis of the liver who vomited bright red blood two hours ago Answer#3 69. The registered nurse delegates insertion of a Foley catheter to an LPN/LVN. Before the LPN/LVN begins the procedure, it is MOST important for the registered nurse to take which of the following actions? 1. Verify that the LPN/LVN is competent to insert a Foley catheter 2. Demonstrate to the LPN/LVN how to perform a sterile catheterization 3. Ask the patient’s permission for the LPN/LVN to perform the procedure 4. Show confidence in the LPN/LVN’s ability to perform the procedure Answer#3 70. A nurse has lunch in the hospital cafeteria with a nursing assistant from the unit. The nurse asks how the nursing assistant is doing, knowing that the nursing assistant is in nursing school, has three young children, works 30 hours a week, and looks worried. The nursing assistant replies, “I’m okay, just stressed out with finals.” The BEST response by the nurse is which of the following? 1. You’ll be fine. You grades have always been good 2. Maybe you shouldn’t try to do so much next semester 3. Sounds like you feel you’re managing most things fine, but will be relieved when finals are over 4. I know what you mean. Nursing school is harder now than when I went to school Answer#3 71. The nurse administers fentanyl 100 mcg IM to a patient after an appendectomy. After administering the medication, is most important for the nurse to take which of the following actions? 1. Ask the patients family to wait in the hall until the medication takes effect 2. Position the patient on his right side with left leg extended 3. Elevate the head of the patient’s bed 30 to 45 degrees 4. Turn the television off and darken the patient’s room Answer#3 Opioid analgesic: Fentanyl (sublimaze) can cause respiratory depression, dizziness, drowsiness, hypotension, urinary retention, fetal necrosis and distress. 72. After a patient receives naloxone hydrochloride (Narcan) 0.2 mg IV, which of the following actions is essential for the nurse to perform? 1. Encourage fluids 2. Decrease external stimuli 3/. Place the patient in lateral recumbent position 4. Monitor the patient’s rate of respirations Answer#4 73. A client who is 5 feet 1 inch tall and 115 pounds recovers from an abdominal perineal resection. The nurse notes that when the head of the bed is elevated, the client slips down in bed. The nurse should take which of the following actions? 1. Move the patient up in bed frequently and keep firm pillows between the patient’s feet and the foot of the bed 2. Instruct the patient to pull up in bed using the side rails after sliding to the foot of the bed 3. Raise the knee gatch and the side rails, and place the call light within reach 4. Lower the head of the bed and place the patient on back, keeping both legs extended Answer#3 74. A 36 hour old newborn is receiving phototherapy. The infant’s mother asks why this is being done. Which response by the nurse is BEST? 1. This treatment changes the nature of circulating anti bodies in the body 2. This treatment prevents the formation of antibodies in the body 3. This treatment converts bilirubin to a form that can be removed from the body 4. This treatment prevents the formation of bilirubin in the body Answer#3 75. The school nurse is demonstrating how to wash hands to a group of first grade children. The MOST important behavior by the nurse is which of the following? 1. The school nurse dries the hands from the fingers to the wrist 2. The school nurse rubs the hands together briskly 3. The school nurse uses warm water and liberal amount of liquid soap 4. The school nurse rinses the hands from the fingers to the wrists Answer#2 76. The nurse cares for a client receiving enalapril (Vasotec) 40mg PO for several weeks. The client returns to the outpatient clinic for a bimonthly visit. Which statement, if made by the client to the nurse, indicates a problem with this medication? 1. “I have this cough that keeps me up at night, and I can’t seem to shake it.” 2. “ My joints ache, and I am stiff when I get out of bed in the morning. 3. “ I seem to get sunburned if I spend to much time outside without wearing sunscreen.” 4. “ My bowel movements have become less frequent and more difficult to pass.” Answer#4 Gastric irritation 77. The clinic nurse plans to perform a physical assessment of a 15-year-old girl. To initiate the interview, the nurse should take which of the following actions? 1. Ask if the client has had any symptoms during the past 2 weeks. 2. Use silence to encourage the client to talk about her physical health. 3. Request that the client’s mother be present for the exam. 4. Chat informally about the client’s friends, school, and family. 78. The nurse plans an in service on safety for LPN/ LVNs and nursing assistants. During the presentation, it is MOST important for the nurse to make which of the following recommendations? 1. The patient is alert and oriented to time, place, and person. 2. The patient has an active gag reflex. 3. The patient’s blood pressure and pulse have returned to the presurgical levels. 4. The patient can feel the nurse touching his feet. Answer#4 88. The nurse cares for a patient just returned from the urology department after a needle biopsy of the left kidney. It is MOST important for the nurse to take which of the following actions? 1. Position the patient in a supine position 2. Position the patient on the right side. 3. Position the patient on the left side. 4. Position the patient in a prone position. Answer#1 89. A father brings his adult child diagnosed with chronic schizophrenia back to the hospital for the fifth admission in 2 years. The father asks the nurse, “When will this ever end? What did we do wrong?” Which is the BEST response for the nurse to make? 1. “ Your son has a chronic disease that may require frequent hospitalizations. It is hard on you and your son.” 2. “ What you are feeling is very common. You should join a support group of families that are in the same position.” 3. “Don’t feel that this is your fault. You did nothing wrong. Things just happen.” 4. “ Let’s talk about this. Tell me what you think you did wrong and we can problem- solve what to do next time.” Answer#2 90. While working with a team to restrain a physically combative patient, it is MOST important for the nurse to remember which of the following? 1. Leadership should be shared equally among all team members. 2. Team members should not talk to other team members while in front of the patient. 3. All team members should communicate with the patient. 4. Each team member should maintain an assigned role throughout the restraining process. Answer#4 91. The nurse cares for a client diagnosed with type 1 diabetes. The client has experienced problems related to gastrointestinal neuropathies for some time, with an increase in severity over the past 12 months. Which test, if ordered by the physician, should the nurse question? 1. CT Scan 2. Upper GI 3. MRI 4. Endoscopic ultrasound Answer#2 92. The nurse cares for a patient recovering from a carotid endarterectomy. Which is an EXPECTED outcome after this surgery? 1. The client has 2+ deep tendon reflexes. 2. The client says it is difficult to shallow. 3. The client’s vital signs are BP 180/96, pulse 96, respiration’s 18. 4. The client’s voice is low and raspy. Answer#4 93. The clinic nurse cares for a teacher receiving naproxen 500 mg BID for 3 weeks. The client reports to the clinic nurse that she has had a fever and a rash on her trunk for a week. The skin is now flaking off, leaving the underlying skin red and flaky. Which statement by the nurse is BEST? 1. “This may be a reaction to the medication you are taking. I’ll notify your physician right away.” 2. “ We’ll watch this rash carefully. You may need ointment for the rash.” 3. “ I know you work with children. Have you noticed more absences than usual in your school over the past few weeks?” 4. “ This is part of the healing process. As toxins are released from your body, they come out through the skin.” Answer#1 94. A patient is discharged after being treated for injuries sustained in an auto accident. The client has two dressings, one on the left forearm and one on the right knee that need to be changed daily. Which statement, if made by the patient, indicates to the nurse that further teaching is necessary? 1. “ I will put the tape in the center of the dressing and press it toward both sides.” 2. “ I will apply tape to the edges of the dressings to hold them in place.” 3. “ I will pull the tape off quickly when I change the dressing.” 4. “ I will use paper tape to secure the dressing.” Answer#4 95. The home health nurse explains the use of transcutaneous electrical nerve stimulation (TENS) to a client. Which action, if performed by the client, indicates to the nurse that further teaching is necessary? 1. The client places the electrodes on the side of the body opposite to the painful area. 2. The client applies a conducting gel before applying the electrodes. 3. The client adjusts the voltage based on the relief of pain she experiences. 4. The client increases the voltage until she feels a prickly, “pins-and-needles” sensation. Answer#4 96. The nurse plans care for a patient with carpal tunnel syndrome. The nurse should question which of the following orders? 1. Indomethacin (Indocin) 25 mg PO TID 2. Electromyography (EMG) today 3. Hydrocortisone acetate (Cortef) 25 mg IM 4. Active ROM twice daily Answer#4 97. The nurse in the same-day surgery department cares for an elderly client after a colonoscopy. The nurse is MOST concerned if the nursing assistant reports which of the following findings 30 minutes after the procedure? 1. “The client is complaining of grogginess and thirst.” 2. “The client is complaining of lightheadedness and dizziness.” 3. “The client is complaining of fullness and pressure of the abdomen.” 4. “The client is complaining of mild pain and cramping in her abdomen.” Answer#2 Electrolyte imbalance? 98. A client has received gavage feeding though a Levin tube for 2 weeks. This method of feeding is to be discontinued. The nurse should take which of the following actions? 1. Flush the tube with 10 ml of normal saline before removing it. 2. Withdraw the tube quickly, using intermittent suction. 3. Show the tube to the patient after it is withdrawn to confirm that it came out intact. 4. Instruct the patient to exhale and bear down as the tube is removed. Answer#4 99. The psychiatric nursing team consists of one registered nurse and three nursing assistants. Which patient should be assigned to the registered nurse? 1. A 56-year-old male alcoholic who will attend his first Alcoholics Anonymous meeting tomorrow. 2. A 16-year-old girl with anorexia nervosa who is showing a daily weight gain. 3. A 40-year-old man receiving clozapine (Clozaril) who is complaining of a sore throat and fine hand tremors. 4. A 50-year-old woman with a history of depression who received her third dose of amitriptyline (Elavil) yesterday. Answer#3 Akathisia (motor restlessness) and agranulocytosis (low WBC’s) 100. A 9-month-old infant receives intramuscular injections every 12 hours. It is MOST important for the nurse to take which of the following actions? 1. Administer each the injection into the ventral gluteal muscle using the “Z” track method. 2. Administer one injection into the right vastus lateralis and the next injection into the left vastus lateralis muscle. 3. Administer one injection into the right deltoid and the next injection into the left deltoid muscle. 4. Administer each injection into the gluteal medius muscle using a 25-gauge, 5/8- inch needle. Answer#4 101. The nurse teaches the client about albuterol 2 inhalations every 6 hours by metered dose inhaler. Which statement, if made by the client, indicates to the nurse that further teaching is necessary? 111. A college student is brought to the emergency department after taking 200 mg of methylphenidate (Ritalin). After gastric lavage is completed, it is MOST important for the nurse to take which of the following actions? 1. Ask the patient to hold his breath as the tube is removed. 2. Clamp the tubing and leave it in place for 1 hour. 3. Instruct the patient to hold his breath and bear down as the lavage tube is withdrawn. 4. Maintain suction as the lavage tube is withdrawn. Answer#1 112. The clinic nurse evaluates a client for tendonitis of the elbow. Which statement, if made by the client, indicates to the nurse a predisposition to this condition? 1. “My sister has had rheumatoid arthritis for several years.” 2. “I recently changed jobs and now work as an apprentice carpenter.” 3. “My mother had symptoms very similar to mine before she died.” 4. “I was in an accident several years ago and dislocated my shoulder. “ Answer#2 113. The clinic nurse recommends a high-fiber diet for the older client reporting constipation. The client asks the nurse how this will help. Which statement by the nurse is best? 1. “Fiber makes the stool firmer.” 2. “Fiber decreases gas production in the gastrointestinal tract.” 3. “Fiber increases the water content of your stool.” 4. “Fiber stretches your internal sphincters.” Answer#3 114. A newborn receives an Apgar score of 3 at 1 minute after birth. The nurse knows that a score of 3 indicates which of the following? 1. The newborn has a congenital defect. 2. The newborn is in a state of acidosis. 3. The newborn requires resuscitation. 4. The newborn has a life-threatening anomaly. Answer#4 0-3 poor 4-6 fair 7-10 excellent 115. A young adult is brought to the emergency department for ingestion of 40 5-grain tablets of acetaminophen (Tylenol). The patient’s roommate reports that the patient took the pills 2 days ago after a break up with a significant other, but the patient refused to go to the hospital at that time. Today the roommate found the patient in bed, confused and gripping the upper abdominal area. The nurse expects to see which of the following tests given the HIGHEST priority? 1. AST (SGOT) and ALT (SGPT) 2. Arterial blood gases (ABG) 3. Fasting blood sugar (FBS) 4. Erythrocyte sedimentation rate. (ESR) Answer#1 Elevated hepatic enzymes (liver) Antidote Nacetyl cysteine (mucomyst) 116. A client with a history of liver disease is brought to the hospital by her family. The family is frightened because the client has become increasingly drowsy, gets disoriented and agitated, and sleeps during the day and is awake at night. The nurse expects the physician to order which of the following? 1. Soapsuds enemas until clear in A.M. 2. A barium enema in A.M. 3. Magnesium hydroxide (Milk of Magnesia) 25 g PO daily 4. Lactulose (Chronulac) 200 g retention enema q 6 h. Answer#4 Hepatic portal hypertension (increase in pressure in portal vein) 117. The nurse supervises care provided by a nursing assistant to a client who is demonstrating aggressive behavior. The nurse should intervene if which of the following behaviors is observed? 1. The nursing assistant provides consistent and firm messages. 2. The nursing assistant portrays a calm and authoritative manner. 3. The nursing assistant verbalizes clear and concise expectations. 4. The nursing assistant demonstrates a friendly and conciliatory attitude. Answer#4 118. A psychiatric patient diagnosed with an anxiety disorder is known to pace in the hall as a method of calming himself down. After 20 minutes, the patient is usually able to engage in a one-to-one discussion of his feelings. When the nurse sees the patient begin to pace, it is MOST important for the nurse to take which of the following actions? 1. Ask the patient to join the nurse and several other patients in the day room for a game of cards. 2. Walk next to the patient as he paces in the hall, commenting occasionally on the patient’s behavior. 3. Suggest that the patient go to his room because his pacing may upset other patients. 4. Allow the patient to pace, remaining available for conversation and alert to the patient’s anxiety level. Answer#4 119. An adolescent (gravida 1, para 0) is admitted to the labor unit for induction of labor. With the Pitocin infusion at 20 milliunits/min, the patient’s uterine contractions occur every 2 to 3 minutes and last 90 seconds. During a contraction, the fetal heart tones initially drop to 160/min, and then remain between 180 and 190/min. It is MOST important for the nurse to take which of the following actions? 1. Stop the infusion of Pitocin 2. Change the patient’s position 3. Increase the IV infusion rate 4. Administer oxygen at 6 L/min. Answer#1 120. A 7 lb, 6 oz newborn is to receive vitamin K 9 (AquaMEPHYTON). It is MOST important for the nurse to take which of the following actions? 1. Administer the medication IM into the infant’s gluteal medius muscle using a 1- inch needle. 2. Administer the medication IM into the infant’s vastus lateralis muscle using a 25- gauge needle. 3. Administer the medication SQ into the infant’s deltoid muscle using a 20-guage needle. 4. Administer the medication SQ into the infant’s ventrogluteal muscle using a 1/2 – inch needle. Answer#2 121. The nurse asks the nursing assistant to provide A.M. care to a patient several days after a right total hip replacement. The nursing assistant says, “I haven’t bathed a patient with this problem before.” It is BEST for the nurse to take which of the following actions? 1. Bathe the patient and have the nursing assistant watch the procedure. 2. Review the bathing procedure for this patient with the nursing assistant, and observe the bath. 3. Reassign the patient’s A.M. care to an experienced LPN/VN 4. List the needs of a patient who has had a total hip replacement for the nursing assistant. Answer#2 122. The nurse plans to perform a physical assessment of a teenager. It is MOST important for the nurse to take which of the following actions? 1. Allow the mother to remain in the room unless the client objects to her presence. 2. Obtain the client’s medical history before asking the mother to leave the room. 3. Explain to the mother that the nurse needs to conduct the examination in private. 4. Tell the client that everything she says will be held in absolute confidence. Answer#4 123. The nurse has a conversation with a newly admitted patient on the psychiatric unit. Several times during their interaction the patient breaks eye contact and looks down at the floor. Which action by the nurse is MOST appropriate? 1. Request the patient pay attention to the conversation. 2. Ask the patient why he keeps looking away from the nurse during the conversation. 3. Tell the patient that he frequently looks away from the nurse. 4. Note the topics being discussed when the patient looks away. Answer#4 124. The RN supervises the care provided by a nursing assistant to a patient being weaned from a mechanical ventilator. It is MOST appropriate for the RN to make which of the following statements to the nursing assistant? 1. “Count his respiratory rate every 15 minutes, and notify me if the rate is less than 10 or greater than 30 breaths’ per minute.” 2. “Check the patient frequently and please notify me if he becomes anxious.” 2. Chinese. 3. Thai 4. African. Answer#1 135. A client undergoes a routine physical examination that reveals a severe hearing deficit in the left ear. The nurse conducts a Weber test. If the client has a conductive loss, the nurse would expect the client to report hearing the sound of the tuning fork in which of the following locations? 1. In the right ear 2. In the left ear 3. In the middle of the head 4. Equally in both ears Answer#2 136. A client comes to the emergency department with complaints of a sore throat, chills, and abdominal pain. The spouse says the client became sick the day before but is worst today. The client has a temperature of 102F (38.8C).The client’s throat is red, and there is drainage from the oropharynx. Initially, the nurse would expect the physician to order which of the following? 1. A sputum analysis for AFB. 2. An abdominal ultrasound. 3. A throat culture. 4. A blood glucose. Answer#3 Do not start antibiotics until known causing organism. 137. A 79-year-old woman asks the clinic nurse which immunization she should have. It is BEST for the nurse to make which of the following responses? 1. “Mumps.” 2. “Influenza.” 3. “Measles.” 4. “Rubella.” Answer#2 138. A woman comes to the outpatient clinic because she believes that she has contracted genital herpes (HSV-2) from her sexual partner. If the diagnosis of genital herpes were to be confirmed, the nurse would expect to observe which of the following? 1. Dry, wartlike growths on her vulva, cervix, and rectum. 2. A papule-like lesion in her vaginal area. 3. A cluster of painful blisters in her genital area. 4. Abnormal cytology from the cells scraped from the cervix. Answer#3 139. The nurse administers succinylcholine (Anectine) to a patient before electroconvulsive treatment (ECT). The nurse knows that the medication is given for which of the following reasons? 1. Succinylcholine (Anectine) blocks the patien’s vagal stimulation and decreases production of secretions during the treatment. 2. Succinylcholine (Anectine) prevents the patient from having violent muscle contractions and developing possible fractures during the treatment. 3. Succinylcholine (Anectine) helps the patient fall asleep and ensures that the client will not feel the electric current during the treatment. 4. Succinylcholine (Anectine) enhances the patient’s response to the electric current and reduces the number of needed treatments. Answer#2 Muscle relaxant 140. The nurse interviews a client diagnosed with schizophrenia and with diabetes with severe hypoglycemic episodes. The client becomes increasingly restless, irritable, and belligerent. The client sees the food cart containing remains from clients’ lunches and immediately grabs and quickly eats food from the cart. After several minutes the client’s belligerence disappears. The nurse knows the client’s belligerence is caused by which of the following? 1. The client hears voices in his head. 2. The client is testing limits at the clinic. 3. The client feels self-destructive. 4. The client is hypoglycemic. Answer#4 Belligerence: hostility, aggressiveness 141. The nurse observes the respiratory therapist remove condensation from a patient’s ventilator tubing. The nurse should intervene if which of the following is observed? 1. The respiratory therapist returns the removed fluid to the heated water reservoir. 2. The respiratory therapist wears gloves and an eye shield during the procedure. 3. The respiratory therapist places the extra ventilator tubing in a dependent loop on the bed. 4. The respiratory therapist reduces the amount of humidification with the ventilator. Answer#1 142. A patient is admitted to the psychiatric unit complaining that the patient’s neighbors, boss and coworkers, and family are plotting against the patient. Which statement by the nurse is BEST? 1. “This is the room you will stay in while you are in the hospital.” 2. “We have a great unit here with friendly nurses who will provide you with good care.” 3. “Let me introduce you to all the patients on the unit.” 4. “What happened at work that made you suspicious?” Answer#3 143. A patient is scheduled for discharge 2 days after a colon resection. Which symptom, if observed by the nurse, suggests the patient is experiencing a pulmonary embolism? 1. The patient eructates frequently. 2. The patient’s heart rate changes from 92 to 74. 3. The patient has periods of apnea lasting 20 seconds. 4. The patient complains of tightness and pressure in his chest. Answer#4 Apprehension, restlessness, blood tinged or frothy sputum, chest pain, cough, crackles and wheezes, cyanosis, distended neck veins, feeling of impending doom petechiae over chest area and axilla. 144. A child who had abdominal surgery is scheduled to have the fourth postoperative dressing changed during the day shift. The patient says to the nurse during morning care, “I hate these dressing changes. I wish I didn’t have to have them.” Which response by the nurse is BEST? 1. “I’ll take care of it. It won’t be necessary for you to look at the scar or touch it.” 2. “I’ll come back to change your dressing around lunchtime instead of doing it now, if you would like.” 3. “You need your dressing changed to get well.” 4. “You sound upset. What is it that you dislike about the dressing changes?” Answer#4 145. A patient is observed to receive a soapsuds enema before surgery. The nurse delegates the procedure to a nursing assistant who was transferred from another unit. While the nursing assistant performs the procedure, the nurse should take which of the following actions? 1. Remain at the patient’s bedside and instruct the nursing assistant on how to administer the enema. 2. Perform care for the patient in the next bed while listening to the interaction between the patient receiving the enema and the nursing assistant. 3. Stay at the nurses’ station to demonstrate confidence in the nursing assistant’s ability to perform the procedure. 4. Supervise the nursing assistant while the enema is being given and help as necessary. Answer#4 146. A client has surgery for an obstructed bowel with creation of a colostomy. Six hours later, the client’s vital signs are BP 90/50, pulse 120 bpm, respirations 18/min, temperature 102.2F (39C). The nurse notes that the client’s muscles are rigid and the client’s jaw is clenched. Which action should the nurse take FIRST? 1. Evaluate the drainage from the colostomy. 2. Place the patient in Trendelenburg position. 3. Notify the physician. 4. Elevate the head of the bed 60 degrees. Answer#3