Q&A Random Selection #9

1. The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client
would be
A) Reduce fear and protect self-esteem
B) Minimize anxiety and delay apprehension
C) Avoid conflict and leave unpleasant situations
D) Increase independence and communicate more often

2. A child with tetralogy of Fallot visits the clinic several weeks before planned surgery. The nurse should give
priority
attention to
A) assessment of oxygenation
B) observation for developmental delays
C) prevention of infection
D) maintenance of adequate nutrition

3. The registered nurse (RN) is planning care at a team meeting for a 2 month-old child in bilateral leg casts for
congenital clubfoot. Which of these outcomes suggested by the practical nurse (PN) should be considered the
priority nursing goal following cast application?
A) The infant will experience minimal pain
B) Muscle spasms will be relieved
C) Mobility will be managed as tolerated
D) Tissue perfusion will be maintained

4. At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up,
the nurse manager should initially
A) Allow the staff to change assignments
B) Clarify reasons for current assignments
C) Help staff see the complexity of issues
D) Facilitate creative thinking on staffing

5. A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize
the client, and is aware that gradual emptying is preferred over complete emptying because it reduces the
A) potential for renal collapse
B) potential for shock
C) intensity of bladder spasms
D) chance of bladder atrophy

6. The nurse is assessing a 12 year-old who has hemophilia A. Which finding would the nurse anticipate?
A) An excess of red blood cells
B) An excess of white blood cells
C) A deficiency of clotting factor VIII
D) A deficiency of clotting factors VIII and IX

7. The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early
indication of inadequate oxygen transport?
A) crackles in the lungs
B) confusion and restlessness
C) distended neck veins
D) use of accessory muscles

8. A 6 year-old female is diagnosed with recurrent urinary tract infections (UTIs). Which one of the following
instructions
would be best for the nurse to tell the caregiver?
A) Increase bladder tone by delaying voiding
B) When laundering clothing, rinse several times
C) Use plain water for the bath, shampooing hair last
D) Have the child use antibacterial soaps while bathing

9. While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip
dislocation. Which of the following is most suggestive of the abnormality?
A) Flexion of lower extremities
B) Negative Ortolani response
C) Lengthened leg of affected side
D) Irregular hip symmetry
10. In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of
the following after a water deprivation test?
A) Increased edema and weight gain
B) Unchanged urine specific gravity
C) Rapid protein excretion
D) Decreased blood potassium

11. The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled
therapies. What is the most appropriate action for the nurse to take in this situation?
A) Ask family members to dress the client
B) Encourage the client to dress more quickly
C) Allow the client the time needed to dress
D) Demonstrate methods on how to dress more quickly

12. When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority?
A) risk for injury: hemorrhage
B) risk for injury related to peripheral neuropathy
C) altered nutrition: less than body requirements
D) fluid volume excess: ascites

13. A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The
nurse
knows that pain related to an MI is due to
A) insufficient oxygenation of the cardiac muscle
B) potential circulatory overload
C) left ventricular overload
D) electrolyte imbalance

14. On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the
registered nurse (RN) anticipate?
A) Periorbital edema, absent light reflex and translucent tympanic membrane
B) Irritability, rhinorrhea, and bulging tympanic membrane
C) Diarrhea, retracted tympanic membrane and enlarged parotid gland
D) Vomiting, pulling at ears and pearly white tympanic membrane

15. Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery
pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. The purpose of these
actions by the nurse is to assess
A) right ventricular pressure
B) left ventricular end-diastolic pressure
C) acid-base balance
D) coronary artery stability

16. A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following
interventions would be appropriate?
A) Determine that adequate mist is supplied
B) Inspect the nares and ears for skin breakdown
C) Lubricate the tips of the cannula before insertion
D) Maintain sterile technique when handling cannula

17. The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which
information about prevention of asthma episodes would be the most helpful to include during the teaching?
A) Change the pillow covers every month
B) Wash bed linens in warm water with a cold rinse
C) Wash and rinse the bed linens in hot water
D) Use air filters in the furnace system

18. A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is
the best initial response by the nurse?
A) Call a chaplain
B) Deny the feelings
C) Cite recovery statistics
D) Listen to the client

19. The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client
finding calls for immediate nursing action?
A) Diaphoresis and shakiness
B) Reduced lower leg sensation
C) Intense thirst and hunger
D) Painful hematoma on thigh

20. A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this
person brings what to situations of illness?
A) Holistic healing
B) Spiritual advising
C) Herbal preparations
D) Witchcraft potions

21. You are teaching a client about the patient controlled analgesia (PCA) planned for post-operative care. Which
statement indicates further teaching may be needed by the client?
A) "I will be receiving continuous doses of medication."
B) "I should call the nurse before I take additional doses."
C) "I will call for assistance if my pain is not relieved."
D) "The machine will prevent an overdose."

22. The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan.
Which response made by the nurse would be best?
A) "What is your reason for wanting such a plan?"
B) "Have you talked with your provider about this?"
C) "Let us discuss your rights as a couple"
D) "Write your ideal plan for the next class"

23. The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment,
the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath
in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this
assessment data?
A) Impaired gas exchange related to acute infection and sputum production
B) Ineffective airway clearance related to sputum production and ineffective cough
C) Ineffective breathing pattern related to acute infection
D) Anxiety related to hospitalization and role conflict

24. A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her
second child. Which of the following shows proper documentation of the client's obstetric history by the nurse?
A) Para 2, Gravida 1
B) Nulligravida 2, Para 1
C) Primigravida 1, Para 1
D) Gravida 2, Para 1

25. When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should
the nurse determine to be the priority for long term mobility?
A) digestive problems
B) amenorrhea
C) Electrolyte imbalance
D) blood disorders

26. A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse
hears
inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What other finding would the
nurse expect?
A) Flushed skin
B) Bradycardia
C) Mental confusion
D) Hypotension

27. The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding
that the child has
A) achieved developmental milestones at an erratic rate
B) delay in musculoskeletal development
C) displayed difficulty with speech development
D) delay in achievement of most developmental milestones

28. The nurse would expect which eating disorder to cause the greatest fluctuations in potassium?
A) binge eating disorder
B) anorexia nervosa
C) bulimia
D) purge syndrome
29. The nurse is planning care for a client with increased intracranial pressure. The best position for this client is
A) Trendelenburg
B) Prone
C) Semi-Fowlers
D) Side-lying with head flat

30. The nurse is assessing a client with a deep vein thrombosis. Which of the following signs and/or symptoms would
the nurse anticipate finding?
A) Rapid respirations
B) Diaphoresis
C) Swelling of lower extremity
D) Positive Babinski's sign

31. The nurse is assessing a newborn infant and observes low set ears, short palpebral fissures, flat nasal bridge and
indistinct philtrum. A priority maternal assessment by the nurse should be to ask about
A) alcohol use during pregnancy
B) usual nutritional intake
C) family genetic disorders
D) maternal and paternal ages

32. A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after
discharge. Which lunch is the best example of an appropriate meal?
A) Hot dog, carrot sticks, gelatin, milk
B) Soup, blenderized soft foods, ice cream, milk
C) Peanut butter and jelly sandwich, chips, pudding, milk
D) Baked chicken, applesauce, cookie, milk

33. In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to
show loss of ability in
A) Hearing, speech, and sight
B) Endurance, strength, and mobility
C) Learning, creativity, and judgment
D) Balance, flexibility, and coordination

34. A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's
immediate attention?
A) Lethargy
B) Agitation
C) Ataxia
D) Hearing loss

35. A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of
chronic lead poisoning is
A) central nervous system damage
B) moderate anemia
C) renal tubule damage
D) growth impairment

36. The new graduate nurse interviews for a position in a nursing department of a large health care agency,
described by the interviewer as having shared governance. Which of these statements best illustrates the shared
governance model?
A) An appointed board oversees any administrative decisions
B) Nursing departments share responsibility for client outcomes
C) Staff groups are appointed to discuss nursing practice and client education issues
D) Non-nurse managers supervise nursing staff in groups of units

37. In a long term rehabilitation care unit, a client with spinal cord injury complains of a pounding headache. The
client is sitting in a wheelchair watching television. Further assessment by the nurse reveals excessive sweating, a
splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should
perform which action next?
A) Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
B) Place the client into the bed and administer the ordered PRN analgesic
C) Check the client for bladder distention and the client's urinary catheter for kinks
D) Turn the television off and then assist client to use relaxation techniques
38. A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate
postoperative period for a cleft lip repair, which nursing approach should be the priority?
A) Remove protective arm devices one at a time for short periods with supervision
B) Initiate by mouth feedings when alert, with the return of the gag reflex
C) Introduce to the parents how to cleanse the suture line with the prescribed protocol
D) Position the infant on the back after feedings throughout the day

39. When teaching new parents prevention of sudden infant death syndrome (SIDS) what is the most important
practice the nurse should instruct them to do?
A) Place the infant in a supine or side lying position for sleep
B) Do not allow anyone to smoke in the home
C) Follow recommended immunization schedule
D) Be sure to check infant every one hour

40. A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be
consistent with this diagnosis
A) Low serum albumin
B) High serum cholesterol
C) Abnormally low white blood cell count
D) Elevated creatinine phosphokinase (CPK)