Pre-board Exam For November 2009 NLE (Practice Mode)
Mark the letter of the letter of choice then click on the next button. Answer will be revealed after each question. No time limit to finish the exam. Good luck!
- 1.
A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time?
- A.
Timing and recording length of contractions.
- B.
Monitoring.
- C.
Preparing for an emergency cesarean birth.
- D.
Checking the perineum for bulging.
Correct Answer
A. Timing and recording length of contractions.Explanation
The oxytocic effect of Pitocin increases the intensity and durations of contractions; prolonged contractions will jeopardize the safety of the fetus and necessitate discontinuing the drug.Rate this question:
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- 2.
A client who hallucinates is not in touch with reality. It is important for the nurse to:
- A.
Isolate the client from other patients.
- B.
Maintain a safe environment.
- C.
Orient the client to time, place, and person
- D.
Establish a trusting relationship.
Correct Answer
B. Maintain a safe environment.Explanation
It is of paramount importance to prevent the client from hurting himself or herself or others.Rate this question:
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- 3.
The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. Which of the following would the nurse give to the child?
- A.
Cola with ice
- B.
Yellow noncitrus Jello
- C.
Cool cherry Kool-Aid
- D.
A glass of milk
Correct Answer
B. Yellow noncitrus JelloExplanation
After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding.Rate this question:
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- 4.
The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client. The nurse caring to the client provides instructions that the nasal spray must be used exactly as directed to prevent the development of:
- A.
Increased nasal congestion.
- B.
Nasal polyps
- C.
Bleeding tendencies.
- D.
Tinnitus and diplopia.
Correct Answer
B. Nasal polypsExplanation
Phenylephrine, with frequent and continued use, can cause rebound congestion of mucous membranes.Rate this question:
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- 5.
A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should:
- A.
Place the client in a private room.
- B.
Wear an N 95 respirator when caring for the client.
- C.
Put on a gown every time when entering the room.
- D.
Don a surgical mask with a face shield when entering the room.
Correct Answer
B. Wear an N 95 respirator when caring for the client.Explanation
The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator.Rate this question:
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- 6.
Which of the following is the most frequent cause of noncompliance to the medical treatment of open-angle glaucoma?
- A.
The frequent nausea and vomiting accompanying use of miotic drug.
- B.
Loss of mobility due to severe driving restrictions.
- C.
Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
- D.
The painful and insidious progression of this type of glaucoma.
Correct Answer
C. Decreased light and near-vision accommodation due to miotic effects of pilocarpine.Explanation
The most frequent cause of noncompliance to the treatment of chronic, or open-angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal accommodation, making night driving difficult and hazardous, reducing the client’s ability to read for extended periods and making participation in games with fast-moving objects impossible.Rate this question:
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- 7.
In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a client’s room and notes that the client’s tube has become disconnected from the Pleurovac. What would be the initial nursing action?
- A.
Apply pressure directly over the incision site.
- B.
Clamp the chest tube near the incision site.
- C.
Clamp the chest tube closer to the drainage system.
- D.
Reconnect the chest tube to the Pleurovac.
Correct Answer
B. Clamp the chest tube near the incision site.Explanation
This stops the sucking of air through the tube and prevents the entry of contaminants. In addition, clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube.Rate this question:
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- 8.
Which of the following complications during a breech birth the nurse needs to be alarmed?
- A.
Abruption placenta.
- B.
Caput succedaneum.
- C.
Pathological hyperbilirubinemia.
- D.
Umbilical cord prolapse
Correct Answer
D. Umbilical cord prolapseExplanation
Because umbilical cord’s insertion site is born before the fetal head, the cord may be compressed by the after-coming head in a breech birth.Rate this question:
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- 9.
The nurse is caring to a client diagnosed with severe depression. Which of the following nursing approach is important in depression?
- A.
Protect the client against harm to others.
- B.
Provide the client with motor outlets for aggressive, hostile feelings.
- C.
Reduce interpersonal contacts.
- D.
Deemphasizing preoccupation with elimination, nourishment, and sleep.
Correct Answer
B. Provide the client with motor outlets for aggressive, hostile feelings.Explanation
It is important to externalize the anger away from self.Rate this question:
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- 10.
A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting that the baby may have hypothyroidism when mother states that her baby does not:
- A.
Sit up.
- B.
Pick up and hold a rattle.
- C.
Roll over.
- D.
Hold the head up.
Correct Answer
D. Hold the head up.Explanation
Development normally proceeds cephalocaudally; so the first major developmental milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks of life. In hypothyroidism, the infant’s muscle tone would be poor and the infant would not be able to achieve this milestone.Rate this question:
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- 11.
The physician calls the nursing unit to leave an order. The senior nurse had conversation with the other staff. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not know the physician or the client to whom the order pertains. The nurse should:
- A.
Ask the physician to call back after the nurse has read the hospital policy manual.
- B.
Take the telephone order.
- C.
Refuse to take the telephone order.
- D.
Ask the charge nurse or one of the other senior staff nurses to take the telephone order.
Correct Answer
D. Ask the charge nurse or one of the other senior staff nurses to take the telepHone order.Explanation
Get a senior nurse who know s the policies, the client, and the doctor. Generally speaking, a nurse should not accept telephone orders. However, if it is necessary to take one, follow the hospital’s policy regarding telephone orders. Failure to follow hospital policy could be considered negligence. In this case, the nurse was new and did not know the hospital’s policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the nurse should not take the order unless a) no one else is available and b) it is an emergency situation.Rate this question:
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- 12.
The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition complicated by hypertension. A new pregnant woman in active labor is admitted in the same unit. The nurse manager assigned the same nurse to the second client. The nurse feels that the client with hypertension requires one-to-one care. What would be the initial action of the nurse?
- A.
Accept the new assignment and complete an incident report describing a shortage of nursing staff.
- B.
Report the incident to the nursing supervisor and request to be floated.
- C.
Report the nursing assessment of the client in transitional labor to the nurse manager and discuss misgivings about the new assignment.
- D.
Accept the new assignment and provide the best care.
Correct Answer
C. Report the nursing assessment of the client in transitional labor to the nurse manager and discuss misgivings about the new assignment.Explanation
The nurse is obligated to inform the nurse manager about changes in the condition of the client, which may change the decision made by the nurse manager.Rate this question:
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- 13.
A newborn infant with Down syndrome is to be discharged today. The nurse is preparing to give the discharge teaching regarding the proper care at home. The nurse would anticipate that the mother is probably at the:
- A.
40 years of age
- B.
20 years of age.
- C.
35 years of age.
- D.
20 years of age.
Correct Answer
A. 40 years of ageExplanation
Perinatal risk factors for the development of Down syndrome include advanced maternal age, especially with the first pregnancy.Rate this question:
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- 14.
The emergency department has shortage of staff. The nurse manager informs the staff nurse in the critical care unit that she has to float to the emergency department. What should the staff nurse expect under these conditions?
- A.
The float staff nurse will be informed of the situation before the shift begins.
- B.
The staff nurse will be able to negotiate the assignments in the emergency department.
- C.
Cross training will be available for the staff nurse.
- D.
Client assignments will be equally divided among the nurses.
Correct Answer
B. The staff nurse will be able to negotiate the assignments in the emergency department.Explanation
Assignments should be based on scope of practice and expertise.Rate this question:
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- 15.
The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is receiving digoxin. Which of the following questions will be asked by the nurse to the parents of the child in order to assess the client’s risk for digoxin toxicity?
- A.
“Has he been exposed to any childhood communicable diseases in the past 2-3 weeks?”
- B.
“Has he been taking diuretics at home?”
- C.
“Do any of his brothers and sisters have history of cardiac problems?”
- D.
“Has he been going to school regularly?”
Correct Answer
B. “Has he been taking diuretics at home?”Explanation
The child who is concurrently taking digoxin and diuretics is at increased risk for digoxin toxicity due to the loss of potassium. The child and parents should be taught what foods are high in potassium, and the child should be encouraged to eat a high-potassium diet. In addition, the child’s serum potassium level should be carefully monitored.Rate this question:
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- 16.
The nurse noticed that the signed consent form has an error. The form states, “Amputation of the right leg” instead of the left leg that is to be amputated. The nurse has administered already the preoperative medications. What should the nurse do?
- A.
Call the physician to reschedule the surgery.
- B.
Call the nearest relative to come in to sign a new form.
- C.
Cross out the error and initial the form.
- D.
Have the client sign another form.
Correct Answer
A. Call the pHysician to reschedule the surgery.Explanation
The responsible for an accurate informed consent is the physician. An exception to this answer would be a life-threatening emergency, but there are no data to support another response.Rate this question:
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- 17.
The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a closed chest drainage system. The fluctuation has stopped, the nurse would:
- A.
Vigorously strip the tube to dislodge a clot.
- B.
Raise the apparatus above the chest to move fluid.
- C.
Increase wall suction above 20 cm H2O pressure.
- D.
Ask the client to cough and take a deep breath.
Correct Answer
D. Ask the client to cough and take a deep breath.Explanation
Asking the client to cough and take a deep breath will help determine if the chest tube is kinked or if the lungs has reexpanded.Rate this question:
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- 18.
The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother in the hospital room is wrong. The nurse determines that two babies were placed in the wrong cribs. The most appropriate nursing action would be to:
- A.
Determine who is responsible for the mistake and terminate his or her employment.
- B.
Record the event in an incident/variance report and notify the nursing supervisor.
- C.
Reassure both mothers, report to the charge nurse, and do not record.
- D.
Record detailed notes of the event on the mother’s medical record.
Correct Answer
B. Record the event in an incident/variance report and notify the nursing supervisor.Explanation
Every event that exposes a client to harm should be recorded in an incident report, as well as reported to the appropriate supervisors in order to resolve the current problems and permit the institution to prevent the problem from happening again.Rate this question:
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- 19.
Before the administration of digoxin, the nurse completes an assessment to a toddler client for signs and symptoms of digoxin toxicity. Which of the following is the earliest and most significant sign of digoxin toxicity?
- A.
Tinnitus
- B.
Nausea and vomiting
- C.
Vision problem
- D.
Slowing in the heart rate
Correct Answer
D. Slowing in the heart rateExplanation
One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart rate that falls below the norm of about 100-120 bpm would indicate Bradycardia and would necessitate holding the medication and notifying the physician.Rate this question:
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- 20.
Which of the following treatment modality is appropriate for a client with paranoid tendency?
- A.
Activity therapy.
- B.
Individual therapy.
- C.
Group therapy.
- D.
Family therapy.
Correct Answer
B. Individual therapy.Explanation
This option is least threatening.Rate this question:
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- 21.
The client with rheumatoid arthritis is for discharge. In preparing the client for discharge on prednisone therapy, the nurse should advise the client to:
- A.
Wear sunglasses if exposed to bright light for an extended period of time.
- B.
Take oral preparations of prednisone before meals.
- C.
Have periodic complete blood counts while on the medication.
- D.
Never stop or change the amount of the medication without medical advice.
Correct Answer
D. Never stop or change the amount of the medication without medical advice.Explanation
In preparing the client for discharge that is receiving prednisone, the nurse should caution the client to (a) take oral preparations after meals; (b) remember that routine checks of vital signs, weight, and lab studies are critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication in a light-resistant container.Rate this question:
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- 22.
A pregnant client tells the nurse that she is worried about having urinary frequency. What will be the most appropriate nursing response?
- A.
“Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife.
- B.
“Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes.”
- C.
“Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily.”
- D.
“Frequency is due to bladder irritation from concentrate urine and is normal in pregnancy. Increase your daily fluid intake to 3L.”
Correct Answer
A. “Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife.Explanation
Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding.Rate this question:
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- 23.
Which of the following will help the nurse determine that the expression of hostility is useful?
- A.
Expression of anger dissipates the energy.
- B.
Energy from anger is used to accomplish what needs to be done.
- C.
Expression intimidates others.
- D.
Degree of hostility is less than the provocation.
Correct Answer
B. Energy from anger is used to accomplish what needs to be done.Explanation
This is the proper use of anger.Rate this question:
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- 24.
The nurse is providing an orientation regarding case management to the nursing students. Which characteristics should the nurse include in the discussion in understanding case management?
- A.
Main objective is a written plan that combines discipline-specific processes used to measure outcomes of care.
- B.
Main purpose is to identify expected client, family and staff performance against the timeline for clients with the same diagnosis.
- C.
Main focus is comprehensive coordination of client care, avoid unnecessary duplication of services, improve resource utilization and decrease cost.
- D.
Primary goal is to understand why predicted outcomes have not been met and the correction of identified problems.
Correct Answer
C. Main focus is comprehensive coordination of client care, avoid unnecessary duplication of services, improve resource utilization and decrease cost.Explanation
There are several models of case management, but the commonality is comprehensive coordination of care to better predict needs of high-risk clients, decrease exacerbations and continually monitor progress overtime.Rate this question:
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- 25.
The physician orders a dose of IV phenytoin to a child client. In preparing in the administration of the drug, which nursing action is not correct?
- A.
Infuse the phenytoin into a smaller vein to prevent purple glove syndrome.
- B.
Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy.
- C.
Plan to give phenytoin over 30-60 minutes, using an in-line filter.
- D.
Flush the IV tubing with normal saline before starting phenytoin.
Correct Answer
A. Infuse the pHenytoin into a smaller vein to prevent purple glove syndrome.Explanation
Phenytoin should be infused or injected into larger veins to avoid the discoloration know as purple glove syndrome; infusing into a smaller vein is not appropriate.Rate this question:
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- 26.
The pregnant woman visits the clinic for check –up. Which assessment findings will help the nurse determine that the client is in 8-week gestation?
- A.
Leopold maneuvers.
- B.
Fundal height.
- C.
Positive radioimmunoassay test (RIA test).
- D.
Auscultation of fetal heart tones.
Correct Answer
C. Positive radioimmunoassay test (RIA test).Explanation
Serum radioimmunoassay (RIA) is accurate within 7days of conception. This test is specific for HCG, and accuracy is not compromised by confusion with LH.Rate this question:
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- 27.
Which of the following nursing intervention is essential for the client who had pneumonectomy?
- A.
Medicate for pain only when needed.
- B.
Connect the chest tube to water-seal drainage.
- C.
Notify the physician if the chest drainage exceeds 100mL/hr.
- D.
Encourage deep breathing and coughing.
Correct Answer
D. Encourage deep breathing and coughing.Explanation
Surgery and anesthesia can increase mucus production. Deep breathing and coughing are essential to prevent atelectasis and pneumonia in the client’s only remaining lung.Rate this question:
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- 28.
The nurse is providing a health teaching to a group of parents regarding Chlamydia trachomatis. The nurse is correct in the statement, “Chlamydia trachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause:
- A.
Discoloration of baby and adult teeth.
- B.
Pneumonia in the newborn.
- C.
Snuffles and rhagades in the newborn.
- D.
Central hearing defects in infancy.
Correct Answer
B. Pneumonia in the newborn.Explanation
Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and conjunctivitis from Chlamydia.Rate this question:
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- 29.
The nurse is assigned to care to a 17-year-old male client with a history of substance abuse. The client asks the nurse, “Have you ever tried or used drugs?” The most correct response of the nurse would be:
- A.
“Yes, once I tried grass.”
- B.
“No, I don’t think so.”
- C.
“Why do you want to know that?”
- D.
“How will my answer help you?”
Correct Answer
D. “How will my answer help you?”Explanation
The client may perceive this as avoidance, but it is more important to redirect back to the client, especially in light of the manipulative behavior of drug abusers and adolescents.Rate this question:
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- 30.
Which of the following describes a health care team with the principles of participative leadership?
- A.
Each member of the team can independently make decisions regarding the client’s care without necessarily consulting the other members.
- B.
The physician makes most of the decisions regarding the client’s care.
- C.
The team uses the expertise of its members to influence the decisions regarding the client’s care.
- D.
Nurses decide nursing care; physicians decide medical and other treatment for the client.
Correct Answer
C. The team uses the expertise of its members to influence the decisions regarding the client’s care.Explanation
It describes a democratic process in which all members have input in the client’s care.Rate this question:
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- 31.
A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby. Which hormone, normally secreted during the postpartum period, influences both the milk ejection reflex and uterine involution?
- A.
Oxytocin.
- B.
Estrogen.
- C.
Progesterone.
- D.
Relaxin.
Correct Answer
A. Oxytocin.Explanation
Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland.Rate this question:
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- 32.
One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse is responsible for the overall planning, giving and evaluating care during the entire shift. After the shift, same responsibility will be endorsed to the next nurse in charge. This describes nursing care delivered via the:
- A.
Primary nursing method.
- B.
Case method.
- C.
Functional method.
- D.
Team method.
Correct Answer
B. Case method.Explanation
In case management, the nurse assumes total responsibility for meeting the needs of the client during the entire time on duty.Rate this question:
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- 33.
The ambulance team calls the emergency department that they are going to bring a client who sustained burns in a house fire. While waiting for the ambulance, the nurse will anticipate emergency care to include assessment for:
- A.
Gas exchange impairment
- B.
Hypoglycemia.
- C.
Hyperthermia.
- D.
Fluid volume excess.
Correct Answer
A. Gas exchange impairmentExplanation
Smoke inhalation affects gas exchange.Rate this question:
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- 34.
Most couples are using “natural” family planning methods. Most accidental pregnancies in couples preferred to use this method have been related to unprotected intercourse before ovulation. Which of the following factor explains why pregnancy may be achieved by unprotected intercourse during the preovulatory period?
- A.
Ovum viability.
- B.
Tubal motility.
- C.
Spermatozoal viability.
- D.
Secretory endometrium.
Correct Answer
C. Spermatozoal viability.Explanation
Sperm deposited during intercourse may remain viable for about 3 days. If ovulation occurs during this period, conception may result.Rate this question:
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- 35.
An older adult client wakes up at 2 o’clock in the morning and comes to the nurse’s station saying, “I am having difficulty in sleeping.” What is the best nursing response to the client?
- A.
“I’ll give you a sleeping pill to help you get more sleep now.”
- B.
“Perhaps you’d like to sit here at the nurse’s station for a while.”
- C.
“Would you like me to show you where the bathroom is?”
- D.
“What woke you up?”
Correct Answer
B. “Perhaps you’d like to sit here at the nurse’s station for a while.”Explanation
This option shows acceptance (key concept) of this age-typical sleep pattern (that of waking in the early morning).Rate this question:
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- 36.
The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, her membranes ruptured spontaneously 2 hours ago. While auscultating for the point of maximum intensity of fetal heart tones before applying an external fetal monitor, the nurse counts 100 beats per minute. The immediate nursing action is to:
- A.
Start oxygen by mask to reduce fetal distress.
- B.
Examine the woman for signs of a prolapsed cord.
- C.
Turn the woman on her left side to increase placental perfusion.
- D.
Take the woman’s radial pulse while still auscultating the FHR.
Correct Answer
D. Take the woman’s radial pulse while still auscultating the FHR.Explanation
Taking the mother’s pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal Bradycardia.Rate this question:
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- 37.
The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications like:
- A.
Antihistamines.
- B.
NSAIDs.
- C.
Antacids.
- D.
Salicylates.
Correct Answer
A. Antihistamines.Explanation
Antihistamines cause pupil dilation and should be avoided with glaucoma.Rate this question:
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- 38.
A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when:
- A.
Client is oriented when aroused from sleep, and goes back to sleep immediately.
- B.
Blood pressure is decreased from 160/90 to 110/70.
- C.
Client refuses dinner because of anorexia.
- D.
Pulse is increased from 88-96 with occasional skipped beat.
Correct Answer
A. Client is oriented when aroused from sleep, and goes back to sleep immediately.Explanation
This suggests that the level of consciousness is decreasing.Rate this question:
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- 39.
The nurse is conducting a lecture to a class of nursing students about advance directives to preoperative clients. Which of the following statement by the nurse js correct?
- A.
“The spouse, but not the rest of the family, may override the advance directive.”
- B.
“An advance directive is required for a “do not resuscitate” order.”
- C.
“A durable power of attorney, a form of advance directive, may only be held by a blood relative.”
- D.
“The advance directive may be enforced even in the face of opposition by the spouse.”
Correct Answer
D. “The advance directive may be enforced even in the face of opposition by the spouse.”Explanation
An advance directive is a form of informed consent, and only a competent adult or the holder of a durable power of attorney has the right to consent or refuse treatment. If the spouse does not hold the power of attorney, the decisions of the holder, even if opposed by the spouse, are enforced.Rate this question:
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- 40.
A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside, saying, “I need to go to an appointment.” What is the appropriate nursing intervention?
- A.
Tell the client that he cannot bang on the door.
- B.
Ignore this behavior.
- C.
Escort the client going back into the room.
- D.
Ask the client to move away from the door.
Correct Answer
C. Escort the client going back into the room.Explanation
Gentle but firm guidance and nonverbal direction is needed to intervene when a client with schizophrenic symptoms is being disruptive.Rate this question:
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- 41.
Which of the following action is an accurate tracheal suctioning technique?
- A.
25 seconds of continuous suction during catheter insertion.
- B.
20 seconds of continuous suction during catheter insertion.
- C.
10 seconds of intermittent suction during catheter withdrawal.
- D.
15 seconds of intermittent suction during catheter withdrawal.
Correct Answer
C. 10 seconds of intermittent suction during catheter withdrawal.Explanation
Suctioning is only done for 10 seconds, intermittently, as the catheter is being withdrawn.Rate this question:
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- 42.
The client’s jaw and cheekbone is sutured and wired. The nurse anticipates that the most important thing that must be ready at the bedside is:
- A.
Suture set.
- B.
Tracheostomy set.
- C.
Suction equipment.
- D.
Wire cutters.
Correct Answer
D. Wire cutters.Explanation
The priority for this client is being able to establish an airway.Rate this question:
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- 43.
A mother is in the third stage of labor. Which of the following signs will help the nurse determine the signs of placental separation?
- A.
The uterus becomes globular.
- B.
The umbilical cord is shortened.
- C.
The fundus appears at the introitus.
- D.
Mucoid discharge is increased.
Correct Answer
A. The uterus becomes globular.Explanation
Signs of placental separation include a change in the shape of the uterus from ovoid to globular.Rate this question:
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- 44.
After therapy with the thrombolytic alteplase (t-PA), what observation will the nurse report to the physician?
- A.
3+ peripheral pulses.
- B.
Change in level of consciousness and headache.
- C.
Occasional dysrhythmias.
- D.
Heart rate of 100/bpm.
Correct Answer
B. Change in level of consciousness and headache.Explanation
This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any gastrointestinal or internal bleeding.Rate this question:
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- 45.
A client who undergone left nephrectomy has a large flank incision. Which of the following nursing action will facilitate deep breathing and coughing?
- A.
Push fluid administration to loosen respiratory secretions.
- B.
Have the client lie on the unaffected side.
- C.
Maintain the client in high Fowler’s position.
- D.
Coordinate breathing and coughing exercise with administration of analgesics.
Correct Answer
D. Coordinate breathing and coughing exercise with administration of analgesics.Explanation
Because flank incision in nephrectomy is directly below the diaphragm, deep breathing is painful. Additionally, there is a greater incisional pull each time the person moves than there is with abdominal surgery. Incisional pain following nephrectomy generally requires analgesics administration every 3-4 hours for 24-48 hours after surgery. Therefore, turning, coughing and deep-breathing exercises should be planned to maximize the analgesic effects.Rate this question:
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- 46.
The community nurse is teaching the group of mothers about the cervical mucus method of natural family planning. Which characteristics are typical of the cervical mucus during the “fertile” period of the menstrual cycle?
- A.
Absence of ferning.
- B.
Thin, clear, good spinnbarkeit.
- C.
Thick, cloudy.
- D.
Yellow and sticky.
Correct Answer
B. Thin, clear, good spinnbarkeit.Explanation
Under high estrogen levels, during the period surrounding ovulation, the cervical mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.Rate this question:
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- 47.
A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care unit. The nurse placed the client in a semi-Fowler’s position primarily to:
- A.
Facilitate movement and reduce complications from immobility.
- B.
Fully aerate the lungs.
- C.
Splint the wound.
- D.
Promote drainage and prevent subdiaphragmatic abscesses.
Correct Answer
D. Promote drainage and prevent subdiapHragmatic abscesses.Explanation
After surgery for a ruptured appendix, the client should be placed in a semi-Fowler’s position to promote drainage and to prevent possible complications.Rate this question:
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- 48.
Which of the following will best describe a management function?
- A.
Writing a letter to the editor of a nursing journal.
- B.
Negotiating labor contracts.
- C.
Directing and evaluating nursing staff members.
- D.
Explaining medication side effects to a client.
Correct Answer
C. Directing and evaluating nursing staff members.Explanation
Directing and evaluation of staff is a major responsibility of a nursing manager.Rate this question:
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- 49.
The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye drops. The nurse is correct in advising the parents to place the drops:
- A.
In the middle of the lower conjunctival sac of the infant’s eye.
- B.
Directly onto the infant’s sclera.
- C.
In the outer canthus of the infant’s eye.
- D.
In the inner canthus of the infant’s eye.
Correct Answer
A. In the middle of the lower conjunctival sac of the infant’s eye.Explanation
The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conjunctival sac.Rate this question:
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- 50.
The nurse is assessing on the client who is admitted due to vehicle accident. Which of the following findings will help the nurse that there is internal bleeding?
- A.
Frank blood on the clothing.
- B.
Thirst and restlessness.
- C.
Abdominal pain.
- D.
Confusion and altered of consciousness.
Correct Answer
B. Thirst and restlessness.Explanation
Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is difficult to recognized and evaluate because it is not apparent.Rate this question:
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Mar 22, 2023Quiz Edited by
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May 13, 2012Quiz Created by
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