Nursing Board Exam Quiz: Test Your Clinical Knowledge
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Are you ready for the nursing board exam questions with an answer? Take this broad nursing board exam quiz designed for all nursing aspirants who are preparing for the same exam and want some excellent practice exercises to crack the process. This nursing board exam quiz includes a variety of board exam nursing questions and answers to help you assess your knowledge and readiness. The quiz will cover critical topics essential for your exam, making it an invaluable resource for your study routine.
This practice test is particularly helpful for last-minute revision before the exam, allowing you to reinforce Read moreyour understanding and identify any areas that may need further review. If you find this quiz beneficial, don't hesitate to share it with your friends who are also preparing for the nursing licensure exam. With dedicated practice, you'll boost your confidence and enhance your chances of success on the exam day!
Note: Scope of this Nursing Test I is parallel to the NP1 NLE Coverage:
Foundation of Nursing
Nursing Research
Professional Adjustment
Leadership and Management
Board Exam Nursing Questions and Answers
- 1.
The registered nurse is planning to delegate tasks to Unlicensed Assistive Personnel (UAP). Which of the following tasks could the registered nurse safely assign to a UAP?
- A.
Monitor the I&O of a comatose toddler client with salicylate poisoning
- B.
Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall
- C.
Check the IV of a preschooler with Kawasaki disease
- D.
Give an oatmeal bath to an infant with eczema
Correct Answer
D. Give an oatmeal bath to an infant with eczemaExplanation
Delegating tasks involves considering the complexity of the task, the stability of the patient, and the competency of the person to whom the task is delegated. Giving an oatmeal bath to an infant with eczema is a routine and non-complex task that can be safely performed by a UAP. However, tasks such as monitoring the intake and output of a comatose toddler with salicylate poisoning, performing a complete bed bath on a 2-year-old with multiple injuries, and checking the IV of a preschooler with Kawasaki disease are more complex and require nursing judgment, making them less suitable for delegation to a UAP.Rate this question:
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- 2.
A nurse manager assigned a registered nurse from telemetry unit to the pediatrics unit. There were three patients assigned to the RN. Which of the following patients should not be assigned to the floated nurse?
- A.
A 9-year-old child diagnosed with rheumatic fever
- B.
A young infant after pyloromyotomy
- C.
A 4-year-old with VSD following cardiac catheterization
- D.
A 5-month-old with Kawasaki disease
Correct Answer
B. A young infant after pyloromyotomyExplanation
Pyloromyotomy is a surgical procedure involving the pylorus, and caring for an infant post-operatively may require specialized knowledge in pediatric surgical nursing. The floated nurse from the telemetry unit may not have the specific expertise in caring for an infant after pyloromyotomy. The other patients might be more within the floated nurse's general pediatric nursing knowledge. Patient assignments are complex decisions that take into consideration various factors, including the nurse's competencies, patient needs, and available resources. Always consult with the nursing supervisor or manager when making patient assignments in a healthcare setting.Rate this question:
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- 3.
A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager safely assign to the float nurse?
- A.
A child who had multiple injuries from a serious vehicle accident
- B.
A child diagnosed with Kawasaki disease and with cardiac complications
- C.
A child who has had a nephrectomy for Wilm’s tumor
- D.
A child receiving an IV chelating therapy for lead poisoning
Correct Answer
C. A child who has had a nepHrectomy for Wilm’s tumorExplanation
The correct assignment for a float nurse from the obstetrics unit in the pediatric unit would be a child who has had a nephrectomy for Wilms tumor. This postoperative care involves routine tasks such as pain management and wound care, aligning with the float nurse's experience. However, patients with complex needs like multiple injuries from a vehicle accident, Kawasaki disease with cardiac complications, or IV chelating therapy for lead poisoning should not be assigned, as these demand specialized pediatric care beyond the float nurse's expertise. Consultation with the nursing supervisor ensures appropriate patient assignments.Rate this question:
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- 4.
The registered nurse is planning to delegate tasks to a certified nursing assistant. Which of the following clients should not be assigned to a CNA?
- A.
A client diagnosed with diabetes and who has an infected toe
- B.
A client who had a CVA in the past two months
- C.
A client with Chronic renal failure
- D.
A client with chronic venous insufficiency
Correct Answer
B. A client who had a CVA in the past two monthsExplanation
This client may have complex care needs due to potential complications and recovery requirements following a recent stroke, including the need for frequent assessments, monitoring for changes in neurological status, and potential complications that may require skilled nursing judgment. Such tasks are beyond the typical scope of practice for a CNA and require the skills and assessment capabilities of a registered nurse.Rate this question:
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- 5.
The nurse in the medication unit passes the medications to all the clients in the nursing unit. The head nurse is making rounds with the physician and coordinates clients’ activities with other departments. The nurse assistant changes the bed lines and answers call lights. A second nurse is assigned to change wound dressings; a licensed practitioner nurse takes vital signs and bathes the clients. This illustrates what method of nursing care.
- A.
Case management method
- B.
Primary nursing method
- C.
Team method
- D.
Functional method
Correct Answer
D. Functional methodExplanation
In the functional method, nursing tasks are divided among the team members based on their skills and scope of practice. Each member is assigned specific duties rather than being responsible for all the care needs of a particular group of patients. For example, the medication nurse handles medications, the head nurse coordinates care, the nurse assistant changes bed linens and answers call lights, another nurse changes wound dressings, and the licensed practical nurse takes vital signs and bathes the clients. This approach emphasizes task efficiency and specialization.Rate this question:
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- 6.
A registered nurse has been assigned to six clients on the 12-hour shift. The RN is responsible for every aspect of care, such as executing the care plan, and intervention, and evaluating the care during her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. What kind of method does this nursing care illustrate?
- A.
Primary nursing method
- B.
Case method
- C.
Team method
- D.
Functional method
Correct Answer
A. Primary nursing methodExplanation
In the primary nursing method, a registered nurse (RN) is responsible for the comprehensive care of a specific group of patients during their shift. The RN plans, implements, and evaluates all aspects of the patients' care and maintains continuity of care by handing over to the next RN at the end of the shift. This approach ensures that one nurse oversees all care activities and provides a high level of accountability and personalized care for the patients.Rate this question:
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- 7.
A newly hired nurse on an adult medicine unit with 3 months of experience was asked to float to pediatrics. The nurse hesitates to perform pediatric skills and receives an interesting assignment that feels overwhelming. The nurse should:
- A.
Resign on the spot from the nursing position and apply for a position that does not require floating
- B.
Inform the nursing supervisor and the charge nurse on the pediatric floor about the nurse’s lack of skill and feelings of hesitations and request assistance
- C.
Ask several other nurses how they feel about pediatrics and find someone else who is willing to accept the assignment
- D.
Refuse the assignment and leave the unit requesting a vacation a day
Correct Answer
B. Inform the nursing supervisor and the charge nurse on the pediatric floor about the nurse’s lack of skill and feelings of hesitations and request assistanceExplanation
The nurse is ethically obligated to inform the person responsible for the assignment and the person responsible for the unit about the nurse’s skill level. The nurse therefore avoids a situation of abandoning clients and exposing them to greater risksRate this question:
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- 8.
An experienced nurse who voluntarily trained a less experienced nurse to enhance the skills and knowledge and promote professional advancement to the nurse is called a:
- A.
Mentor
- B.
Team leader
- C.
Case manager
- D.
Change agent
Correct Answer
A. MentorExplanation
In the nursing profession, a mentor is an experienced and knowledgeable nurse who voluntarily guides, supports, and trains a less experienced nurse, often referred to as a mentee or protégé. Mentorship is a key component in fostering professional growth and development within the nursing field. It helps bridge the gap between theoretical knowledge and practical application, ensuring that new nurses are well-prepared to deliver high-quality patient care. Additionally, mentorship contributes to the retention of nursing staff by creating a supportive and nurturing work environment.Rate this question:
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- 9.
The pediatrics unit is understaffed and the nurse manager informs the nurses in the obstetrics unit that she is going to assign one nurse to float in the pediatric units. Which statement by the designated float nurse may put her job at risk?
- A.
“I do not get along with one of the nurses on the pediatrics unit”
- B.
“I have a vacation day coming and would like to take that now”
- C.
“I do not feel competent to go and work on that area”
- D.
“ I am afraid I will get the most serious clients in the unit”
Correct Answer
C. “I do not feel competent to go and work on that area”Explanation
This statement may put the nurse's job at risk because it demonstrates a lack of responsibility and willingness to adapt to different assignments, which is an important aspect of nursing practice. Instead, the nurse should attempt to negotiate with the nurse manager to express concerns and seek appropriate support or training if needed.Rate this question:
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- 10.
The newly hired staff nurse has been working on a medical unit for 3 weeks. The nurse manager has posted the team leader assignments for the following week. The new staff knows that a major responsibility of the team leader is to:
- A.
Provide care to the most acutely ill client on the team
- B.
Know the condition and needs of all the patients on the team
- C.
Document the assessments completed by the team members
- D.
Supervise direct care by nursing assistants
Correct Answer
B. Know the condition and needs of all the patients on the teamExplanation
The team leader is responsible for the overall management of all clients and staff on the team. Knowing the condition and needs of all the patients is essential for coordinating care and ensuring that all team members are providing appropriate and effective care.Rate this question:
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- 11.
A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. The nurse prepared the consent form and it should be signed by:
- A.
The Physician
- B.
The Registered Nurse caring for the client
- C.
The 15-year-old mother of the baby boy
- D.
The mother of the girl
Correct Answer
C. The 15-year-old mother of the baby boyExplanation
Even though the mother is a minor, she is legally able to sign consent for her own child. The law generally recognizes the rights of minor parents to make medical decisions for their childrenRate this question:
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- 12.
A nurse caring for a client with Alzheimer’s disease overheard a family member say to the client, “if you pee one more time, I won’t give you any more food and drinks”. What initial action is best for the nurse to take?
- A.
Take no action because it is the family member saying that to the client
- B.
Talk to the family member and explain that what she/he has said is not appropriate for the client
- C.
Give the family member the number for an Elder Abuse Hot line
- D.
Document what the family member has said
Correct Answer
B. Talk to the family member and explain that what she/he has said is not appropriate for the clientExplanation
This response is the most direct and immediate. It addresses the inappropriate behavior directly with the family member, which is a case of potential need for advocacy and patient’s rights. It also provides an opportunity to educate the family member on appropriate ways to communicate with the client.Rate this question:
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- 13.
Which is true about informed consent?
- A.
A nurse may accept the responsibility of signing a consent form if the client is unable.
- B.
Obtaining consent is not the responsibility of the physician.
- C.
A physician will not subject himself to liability if he withholds any facts that are necessary to form the basis of intelligent consent.
- D.
If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the signature is that of the purported person and that the person’s condition is as indicated at the time of signing.
Correct Answer
D. If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the signature is that of the purported person and that the person’s condition is as indicated at the time of signing.Explanation
The nurse who witnesses a consent for treatment or surgery is witnessing only that the client signed the form and that the client’s condition is as indicated at the time of signing. The nurse is not witnessing that the client is “informed”.Rate this question:
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- 14.
A mother in labor told the nurse that she was expecting that her baby has no chance to survive and expects that the baby will be born dead. The mother accepts the fate of the baby and informs the nurse that when the baby is born and requires resuscitation, the mother refuses any treatment to her baby and expresses hostility toward the nurse while the pediatric team is taking care of the baby. The nurse is legally obligated to:
- A.
Notify the pediatric team that the mother has refused resuscitation and any treatment for the baby and take the baby to the mother
- B.
Get a court order making the baby a ward of the court
- C.
Record the statement of the mother, notify the pediatric team, and observe carefully for signs of impaired bonding and neglect as a reasonable suspicion of child abuse
- D.
Do nothing except record the mother’s statement in the medical record
Correct Answer
C. Record the statement of the mother, notify the pediatric team, and observe carefully for signs of impaired bonding and neglect as a reasonable suspicion of child abuseExplanation
Although the statements by the mother may not create a suspicion of neglect, when they are coupled with observations about impaired bonding and maternal attachment, they may impose the obligation to report child neglect. The nurse is further obligated to notify caregivers of refusal to consent to treatmentRate this question:
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- 15.
The hospitalized client with a chronic cough is scheduled for a bronchoscopy. The nurse is tasked to bring the informed consent document into the client’s room for a signature. The client asks the nurse for details of the procedure and demands an explanation of why the process of informed consent is necessary. The nurse responds that informed consent means:
- A.
The patient releases the physician from all responsibility for the procedure.
- B.
The immediate family may make decisions against the patient’s will.
- C.
The physician must give the client or surrogates enough information to make health care judgments consistent with their values and goals.
- D.
The patient agrees to a procedure ordered by the physician even if the client does not understand what the outcome will be.
Correct Answer
C. The pHysician must give the client or surrogates enough information to make health care judgments consistent with their values and goals.Explanation
This response best explains what informed consent is and provides for the legal rights of the patient. Informed consent involves ensuring that the patient or their surrogate has enough information to make an informed decision about their healthcare, in alignment with their values and goals.Rate this question:
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- 16.
A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an amputation. The client tells the nurse that he will not sign the consent form and he does not want any surgery or treatment because of religious beliefs about reincarnation. What is the role of the RN?
- A.
Call a family meeting
- B.
Discuss the religious beliefs with the physician
- C.
Encourage the client to have the surgery
- D.
Inform the client of other options
Correct Answer
B. Discuss the religious beliefs with the pHysicianExplanation
The physician may not be aware of the role that religious beliefs play in the client's decision about surgery. It is important for the RN to communicate this to the physician so that the healthcare team can address the client's concerns appropriately and consider alternative treatments or approaches.Rate this question:
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- 17.
While in the hospital lobby, the RN overhears the three staff discussing the health condition of her client. What would be the appropriate nursing action for the RN to take?
- A.
Tell them it is not appropriate to discuss the condition of the client
- B.
Ignore them, because it is their right to discuss anything they want to
- C.
Join in the conversation, giving them supportive input about the case of the client
- D.
Report this incident to the nursing supervisor
Correct Answer
A. Tell them it is not appropriate to discuss the condition of the clientExplanation
The behavior should be stopped immediately to prevent any breach of confidentiality. The first step is to remind the staff that discussing a client's health condition in public places is inappropriate and violates privacy regulations.Rate this question:
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- 18.
A staff nurse has had a serious issue with her colleague. In this situation, it is best to:
- A.
Discuss this with the supervisor
- B.
Not discuss the issue with anyone. It will probably resolve itself
- C.
Try to discuss with the colleague about the issue and resolve it when both are calmer
- D.
Tell other members of the network what the team member did
Correct Answer
C. Try to discuss with the colleague about the issue and resolve it when both are calmerExplanation
Waiting for emotions to dissipate and sitting down with the colleague to discuss the issue calmly is the first rule of conflict resolution. Direct communication can help resolve misunderstandings and promote a healthy working relationship.Rate this question:
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- 19.
The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose confidential information when:
- A.
The nurse discusses the condition of the client in a clinical conference with other nurses
- B.
The client asks the nurse to discuss the her condition with the family
- C.
The father of a woman who just delivered a baby is on the phone to find out the sex of the baby
- D.
A researcher from an institutionally approved research study reviews the medical record of a patient
Correct Answer
C. The father of a woman who just delivered a baby is on the pHone to find out the sex of the babyExplanation
The nurse has no idea who the person is on the phone and therefore may not share the information, even if the patient gives permission. This is to protect the confidentiality and privacy of the client.Rate this question:
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- 20.
A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes that consent has not been signed after preoperative medications were given. What should the nurse do?
- A.
Call the surgeon
- B.
Ask the spouse to sign the consent
- C.
Obtain a consent from the client as soon as possible
- D.
Get a verbal consent from the parents of the client
Correct Answer
A. Call the surgeonExplanation
The priority is to let the surgeon know, who in turn may ask the husband to sign the consent. It is important to address the lack of consent immediately to ensure that the surgery proceeds with proper authorization.Rate this question:
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- 21.
A 12-year-old client is admitted to the hospital. The physician ordered Dilantin for the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be most correct in mixing it with:
- A.
Normal Saline
- B.
Heparinized normal saline
- C.
5% dextrose in water
- D.
Lactated Ringer’s solution
Correct Answer
A. Normal SalineExplanation
Phenytoin (Dilantin) can cause venous irritation due to its alkalinity and should be mixed with normal saline. Mixing it with other solutions like dextrose or Lactated Ringer’s can cause precipitation of the drug.Rate this question:
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- 22.
The nurse is caring for a client who is hypotensive. Following a large hematemesis, how should the nurse position the client?
- A.
Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow
- B.
Low Fowler’s with knees at 30 degrees
- C.
Supine with the head turned to the left
- D.
Bed sloped at a 45 degree angle with the head lowest and the legs highest
Correct Answer
A. Feet and legs elevated 20 degrees, trunk horizontal, head on small pillowExplanation
To maximize blood flow to the brain and vital organs in a hypotensive patient who has experienced significant blood loss, the modified Trendelenburg position (feet and legs elevated 20 degrees, trunk horizontal, head on a small pillow) is optimal as it promotes venous return while maintaining an open airway.Rate this question:
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- 23.
The client is brought to the emergency department after a serious accident. What would be the initial nursing action of the nurse to the client?
- A.
Assess the level of consciousness and circulation
- B.
Check respirations, circulation, neurological response
- C.
Align the spine, check pupils, check for hemorrhage
- D.
Check respiration, stabilize spine, check circulation
Correct Answer
D. Check respiration, stabilize spine, check circulationExplanation
In an emergency situation, the nurse's initial action is to check respiration, circulation, and neurological response. This rapid assessment, often remembered by the acronym ABC (Airway, Breathing, Circulation), helps identify and prioritize life-threatening conditions. Ensuring the patient has a patent airway, is breathing adequately, and has sufficient blood circulation is crucial for immediate survival. While spinal stabilization and pupil checks are important, they are secondary to ensuring basic life functions.Rate this question:
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- 24.
A nurse is assigned to care for a client with Parkinson’s disease. What interventions are important if the nurse wants to improve nutrition and promote effective swallowing of the client?
- A.
Eat solid food
- B.
Give liquids with meals
- C.
Feed the client
- D.
Sit in an upright position to eat
Correct Answer
D. Sit in an upright position to eatExplanation
Clients with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing and helps prevent choking.Rate this question:
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- 25.
During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implement?
- A.
Limit suction pressure to 150-180 mmHg
- B.
Suction for 15-20 seconds
- C.
Wear eye goggles
- D.
Remove the inner cannula
Correct Answer
C. Wear eye gogglesExplanation
To prevent the spread of infection during tracheal suctioning, the nurse must wear eye goggles to protect their eyes from potential contact with bodily fluids. Other measures, like appropriate suction pressure and duration, are also crucial for patient safety.Rate this question:
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- 26.
The nurse is giving discharge instructions to a client diagnosed with diabetes. What signs of hypoglycemia should be taught to a client?
- A.
Warm, flushed skin
- B.
Hunger and thirst
- C.
Increase urinary output
- D.
Palpitation and weakness
Correct Answer
D. Palpitation and weaknessExplanation
Hypoglycemia can cause symptoms such as palpitations and weakness due to low blood sugar levels. Recognizing these signs early is crucial for a client with diabetes to take corrective actions promptly.Rate this question:
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- 27.
A client was admitted to the hospital and diagnosed with Addison’s disease. What would be the appropriate nursing action for the client?
- A.
Administering insulin-replacement therapy
- B.
Providing a low-sodium diet
- C.
Restricting fluids to 1500 ml/day
- D.
Reducing physical and emotional stress
Correct Answer
D. Reducing pHysical and emotional stressExplanation
Because the client’s ability to react to stress is decreased, maintaining a quiet environment becomes a nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial.Rate this question:
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- 28.
The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is essential to prevent hypoxemia?
- A.
Auscultating the lungs to determine the baseline data to assess the effectiveness of suctioning.
- B.
Removing oral and nasal secretions.
- C.
Encourage the patient to breathe deeply and cough to facilitate the removal of upper-airway secretions.
- D.
Administering 100% oxygen to reduce the effects of airway obstruction during suctioning.
Correct Answer
D. Administering 100% oxygen to reduce the effects of airway obstruction during suctioning.Explanation
Pre-Suctioning and post-suctioning ventilation with 100% oxygen is important in reducing hypoxemia, which occurs when the flow of gasses in the airway is obstructed by the suctioning catheter.Rate this question:
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- 29.
An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the swollen face resembling a handprint. The nurse does a further assessment of the client. How would the nurse document the findings?
- A.
Facial edema with ecchymosis and handprint mark: crackles and wheezes
- B.
Facial edema, with red marks; crackles in the lung
- C.
Facial edema with ecchymosis that looks like a handprint
- D.
Red bruise mark and ecchymosis on face
Correct Answer
C. Facial edema with ecchymosis that looks like a handprintExplanation
This documentation provides a clear, objective description of the findings. It notes the presence of facial swelling (edema) and bruising (ecchymosis) in a pattern resembling a handprint, which is essential for accurate medical records and potential follow-up on the cause of the injury.Rate this question:
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- 30.
On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which of the following clients should receive the highest priority?
- A.
An elderly woman complaining of a loss of appetite and fatigue for the past week
- B.
A football player limping and complaining of pain and swelling in the right ankle
- C.
A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw
- D.
A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon
Correct Answer
C. A 50-year-old man, diapHoretic and complaining of severe chest pain radiating to his jawExplanation
The 50-year-old man with severe chest pain radiating to his jaw and diaphoresis (sweating) should receive the highest priority. This presentation strongly suggests a potential cardiac event, such as a heart attack, which requires immediate medical attention. The other cases, while needing assessment, are less likely to be immediately life-threatening.Rate this question:
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- 31.
A 80-year-old female client is brought to the emergency department by her caregiver, on the nurse’s assessment; the following are the manifestations of the client: anorexia, cachexia and multiple bruises. What would be the best nursing intervention?
- A.
check the laboratory data for serum albumin, hematocrit, and hemoglobin
- B.
talk to the client about the caregiver and support system
- C.
Complete a police report on elder abuse
- D.
Complete a gastrointestinal and neurological assessment
Correct Answer
D. Complete a gastrointestinal and neurological assessmentExplanation
Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, and the bruises may be attributed to ataxia, frequent falls, vertigo or medication.Rate this question:
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- 32.
The night shift nurse is making rounds. When the nurse enters a client’s room, the client is on the floor next to the bed. What would be the initial action of the nurse?
- A.
Chart that the patient fell
- B.
Call the physician
- C.
Chart that the client was found on the floor next to the bed
- D.
Fill out an incident report
Correct Answer
B. Call the pHysicianExplanation
The initial action should be to assess the client and ensure their safety. After assessing the client and providing any necessary immediate care, the nurse should inform the physician about the incident. This prioritizes the client’s immediate health needs before documentation and paperwork.Rate this question:
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- 33.
The nurse on the night shift is about to administer medication to a preschooler client and notes that the child has no ID bracelet. The best way for the nurse to identify the client is to ask:
- A.
The adult visiting, “The child’s name is ____________________?”
- B.
The child, “Is your name____________?”
- C.
Another staff nurse to identify this child
- D.
The other children in the room what the child’s name is
Correct Answer
C. Another staff nurse to identify this childExplanation
The only acceptable way to identify a preschooler client is to have a parent or another staff member who is familiar with the child verify their identity. This ensures accuracy and safety when administering medications.Rate this question:
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- 34.
The nurse caring for a client has completed the assessment. Which of the following will be considered to be the most accurate charting of a lump felt in the right breast?
- A.
“abnormally felt area in the right breast, drainage noted”
- B.
“hard nodular mass in right breast nipple”
- C.
“firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’
- D.
“mass in the right breast 4cmx1cm
Correct Answer
C. “firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’Explanation
This charting describes the mass in the greatest detail, including the location, size, and quadrant. This level of detail is crucial for accurate medical records and for guiding further assessments or interventions.Rate this question:
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- 35.
The physician instructed the nurse that intravenous pyelogram will be done to the client. The client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to:
- A.
Outline the kidney vasculature
- B.
Determine the size, shape, and placement of the kidneys
- C.
Test renal tubular function and the patency of the urinary tract
- D.
Measure renal blood flow
Correct Answer
C. Test renal tubular function and the patency of the urinary tractExplanation
Intravenous pyelogram tests both the function and patency of the kidneys. After the intravenous injection of a radiopaque contrast medium, the size, location, and patency of the kidneys can be observed by roentgenogram, as well as the patency of the urethra and bladder as the kidneys function to excrete the contrast medium.Rate this question:
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- 36.
A client visits the clinic for screening of scoliosis. The nurse should ask the client to:
- A.
Bend all the way over and touch the toes
- B.
Stand up as straight and tall as possible
- C.
Bend over at a 90-degree angle from the waist
- D.
Bend over at a 45-degree angle from the waist
Correct Answer
C. Bend over at a 90-degree angle from the waistExplanation
To screen for scoliosis, the nurse should ask the client to bend over at a 90-degree angle from the waist. This is the standard position for the Adam's Forward Bend Test, which is used to check for spinal curvature and asymmetry. It allows the nurse to observe the spine's alignment and identify any potential signs of scoliosis, such as uneven shoulder blades or a prominent rib hump.Rate this question:
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- 37.
A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s family members come to visit, they would be adhering to respiratory isolation precautions when they:
- A.
Wash their hands when leaving
- B.
Put on gowns, gloves and masks
- C.
Avoid contact with the client’s roommate
- D.
Keep the client’s room door open
Correct Answer
A. Wash their hands when leavingExplanation
Family members visiting a client with tuberculosis should adhere to respiratory isolation precautions by washing their hands when leaving and avoiding contact with the client's roommate. These actions help prevent the spread of tuberculosis bacteria, which can be transmitted through the air.Rate this question:
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- 38.
An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following would be the best nursing response of the nurse?
- A.
“Your baby eats too rapidly and overfills the stomach, which causes vomiting
- B.
“Your baby can’t empty the formula that is in the stomach into the bowel”
- C.
“The vomiting is due to the nausea that accompanies pyloric stenosis”
- D.
“Your baby needs to be burped more thoroughly after feeding”
Correct Answer
B. “Your baby can’t empty the formula that is in the stomach into the bowel”Explanation
Pyloric stenosis is an anomaly of the upper gastrointestinal tract. The condition involves a thickening, or hypertrophy, of the pyloric sphincter located at the distal end of the stomach. This causes a mechanical intestinal obstruction, which leads to vomiting after feeding the infant. The vomiting associated with pyloric stenosis is described as being projectile in nature. This is due to the increasing amounts of formula the infant begins to consume coupled with the increasing thickening of the pyloric sphincter.Rate this question:
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- 39.
A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An intradermal tuberculosis test is scheduled to be done. The client asks the nurse what the purpose of the test is. Which of the following would be the best rationale for this?
- A.
Reactivation of an old tuberculosis infection
- B.
Increased incidence of new cases of tuberculosis in persons over 65 years old
- C.
Greater exposure to diverse health care workers
- D.
Respiratory problems are characteristic in this population
Correct Answer
B. Increased incidence of new cases of tuberculosis in persons over 65 years oldExplanation
Increased incidence of TB has been seen in the general population with a high incidence reported in hospitalized elderly clients. Immunosuppression and lack of classic manifestations because of the aging process are just two of the contributing factors of tuberculosis in the elderly.Rate this question:
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- 40.
The nurse is conducting a health lesson with the client's parent. In teaching parents how to measure the area of induration in response to a PPD test, the nurse would be most accurate in advising the parents to measure:
- A.
Both the areas that look red and feel raised
- B.
The entire area that feels itchy to the child
- C.
Only the area that looks reddened
- D.
Only the area that feels raised
Correct Answer
D. Only the area that feels raisedExplanation
Parents should be taught to feel the area that is raised and measure only that. The induration is the palpable, raised, hardened area or swelling, and this is what is measured, not the redness or itchy areas.Rate this question:
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- 41.
A community health nurse is schedule to do home visit. She visits to an elderly person living alone. Which of the following observation would be a concern?
- A.
Picture windows
- B.
Unwashed dishes in the sink
- C.
Clear and shiny floors
- D.
Brightly lit rooms
Correct Answer
C. Clear and shiny floorsExplanation
Shiny floors can be a safety hazard because they can cause falls, especially for elderly individuals. It is important to ensure that the living environment is safe and reduces the risk of accidents.Rate this question:
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- 42.
After a birth, the physician cut the cord of the baby, and before the baby is given to the mother, what would be the initial nursing action of the nurse?
- A.
Examine the infant for any observable abnormalities
- B.
Confirm identification of the infant and apply bracelet to mother and infant
- C.
Instill prophylactic medication in the infant’s eyes
- D.
Wrap the infant in a prewarmed blanket and cover the head
Correct Answer
D. Wrap the infant in a prewarmed blanket and cover the headExplanation
The first priority, besides maintaining a newborn’s patent airway, is body temperature. Wrapping the infant in a prewarmed blanket and covering the head helps prevent hypothermia.Rate this question:
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- 43.
A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck and arms. The client is scratching the affected areas. What would be the best nursing intervention to prevent the client from scratching the affected areas?
- A.
Elbow restraints to the arms
- B.
Mittens to the hands
- C.
Clove-hitch restraints to the hands
- D.
A posey jacket to the torso
Correct Answer
B. Mittens to the handsExplanation
The purpose of restraints for this child is to keep the child from scratching the affected areas. Mittens would prevent scratching while allowing the most movement permissible.Rate this question:
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- 44.
The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric stenosis. The appropriate nursing response would be:
- A.
There is no way to determine this preoperatively
- B.
Their baby was born with this condition
- C.
Their baby developed this condition during the first few weeks of life
- D.
Their baby acquired it due to a formula allergy
Correct Answer
C. Their baby developed this condition during the first few weeks of lifeExplanation
Pyloric stenosis is not a congenital anatomical defect, but it develops during the first few weeks of life. The precise etiology is unknown, but it is not acquired due to a formula allergy or present at birth.Rate this question:
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- 45.
A male client comes to the clinic for a check-up. In doing a physical assessment, the nurse should report to the physician the most common symptom of gonorrhea, which is:
- A.
Pruritus
- B.
Pus in the urine
- C.
WBC in the urine
- D.
Dysuria
Correct Answer
B. Pus in the urineExplanation
Dysuria (painful urination) is usually the first and most common symptom of gonorrhea. While pus or discharge can occur, dysuria is often the initial symptom reported by patients.Rate this question:
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- 46.
Which of the following would be the most important goal in the nursing care of an infant client with eczema?
- A.
preventing infection
- B.
Maintaining the comfort level
- C.
providing for adequate nutrition
- D.
Decreasing the itching
Correct Answer
A. preventing infectionExplanation
Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection.Rate this question:
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- 47.
The nurse is making discharge instructions for a client receiving chemotherapy. The client is at risk for bone marrow suppression. The nurse gives instructions to the client about how to prevent infection at home. Which of the following health teaching would be included?
- A.
“Get a weekly WBC count”
- B.
“Do not share a bathroom with children or pregnant woman”
- C.
“Avoid contact with others while receiving chemotherapy”
- D.
“Frequent hand washing and maintain good hygiene”
Correct Answer
D. “Frequent hand washing and maintain good hygiene”Explanation
Frequent hand washing and maintaining good hygiene are the best means of preventing infection, especially for clients who are immunocompromised due to bone marrow suppression from chemotherapy. It helps reduce the risk of infection by minimizing exposure to harmful pathogens.Rate this question:
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- 48.
The nurse is assigned to care for a client with an infectious disease. The best antimicrobial agent for the nurse to use in handwashing is:
- A.
Isopropyl alcohol
- B.
Hexachlorophene (Phisohex)
- C.
Soap and water
- D.
Chlorhexidine gluconate (CHG) (Hibiclens)
Correct Answer
D. Chlorhexidine gluconate (CHG) (Hibiclens)Explanation
Chlorhexidine gluconate (CHG) is a highly effective antimicrobial ingredient, especially when it is used consistently over time. It provides a broad spectrum of antimicrobial activity and is effective against a wide range of pathogens.Rate this question:
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- 49.
The mother of the client tells the nurse, “ I’m not going to have my baby get any immunization”. What would be the best nursing response to the mother?
- A.
“You and I need to review your rationale for this decision”
- B.
“Your baby will not be able to attend day care without immunizations”
- C.
“Your decision can be viewed as a form of child abuse and neglect”
- D.
“You are needlessly placing other people at risk for communicable diseases”
Correct Answer
A. “You and I need to review your rationale for this decision”Explanation
The mother may have many reasons for such a decision. It is the nurse’s responsibility to review this decision with the mother and clarify any misconceptions regarding immunizations that may exist.Rate this question:
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- 50.
The nurse is teaching the client about breast self-examination. Which observation should the client be taught to recognize when examining the detection of breast cancer?
- A.
Tender, movable lump
- B.
Pain on breast self-examination
- C.
Round, well-defined lump
- D.
Dimpling of the breast tissue
Correct Answer
D. Dimpling of the breast tissueExplanation
Dimpling of the breast tissue can be a sign of breast cancer. It indicates that something beneath the skin is pulling the skin inward, which can occur with tumors. Other signs to be aware of include lumps that are hard, immovable, and not well-defined, changes in skin texture, and nipple discharge, but dimpling is particularly important to recognize during a self-examination.Rate this question:
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Nov 01, 2024Quiz Edited by
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Feb 23, 2010Quiz Created by
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