Comprehensive Test #1

Question 1

Under which circumstance may a nurse communicate medical information without the client’s consent?

1. when certifying the client’s absence from work
2. when requested by the client’s family
3. when treating the client with a sexually transmitted infection
4. when prescribed by another HCP

Answer 1

3. when treating the client with a sexually transmitted infection

STI are communicable disease that must be reported.

Question 2

The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which interventions? SATA

1. Ask the client to rub lotion over the hands every day after bathing
2. Encourage physical activity, such as ambulation
3. Provide frequent contacts for communication and socialization
4. Provide family education
5. Encourage involvement of family and friends

Answer 2

2. Encourage physical activity, such as ambulation
3. Provide frequent contacts for communication and socialization
4. Provide family education
5. Encourage involvement of family and friends

Socialization and communication, in addition to increased activity, are all means to aid in prevention of self-injury. Education of family members may foster development of strategies to prevent self-injury; hence, mitten restraints could be avoided. Applying lotion after bathing may not be appropriate when the skin is broken and not intact.

Question 3

The nurse is planning care for an older adult with a stage 2 pressure ulcer. What should the nurse do? SATA

1. Elevate the HOB to 50 degrees
2. Obtain daily cultures
3. Cover with protective dressing
4. Reposition the client every 2 hours
5. Request an alternating pressure mattress

Answer 3

3. Cover with protective dressing
4. Reposition the client every 2 hours
5. Request an alternating pressure mattress

The nurse should take measures to relieve the pressure, treat the local infection, and protect the wound.

Question 4

A client takes hydrochlorothiazide for treatment of hypertension. The nurse should instruct the client to report which effects? SATA

1. muscle twitching
2. abdominal cramping
3. diarrhea
4. confusion
5. lethargy
6. muscle weakness

Answer 4

2. abdominal cramping
3. lethargy
4. muscle weakness

HCTZ is a thiazide diuretic used in the management of mild to moderate hypertension and in the treatment of edema associated with heart failure, renal dysfunction, cirrhosis, corticosteroid therapy, and estrogen therapy. It increases the excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule of the kidneys. It promotes the excretion of chloride, potassium, magnesium, and bicarbonate. Side effects include drowsiness, lethargy, and muscle weakness but not muscle twitching. Although there may be abdominal cramping, there is no diarrhea. The client does not become confused as a result of taking this drug.

Question 5

Assessment of a client starting on lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, what should the nurse do next?

1. Withhold the lithium, and obtain a STAT lithium level
2. Continue the lithium, and immediately notify the HCP about the assessment findings
3. Continue the lithium, and reassure the client that these temporary side effects will subside.
4. Withhold the lithium, and monitor the client for signs & symptoms of increasing toxicity.

Answer 5

3. Continue the lithium, and reassure the client that these temporary side effects will subside.

The client is exhibiting temporary side effects associated with beginning lithium therapy.

Question 6

A client admitted with gastric ulcer has been vomiting bright red blood. The hemoglobin level is 5.11 g/dL, and bp is 100/50 mm Hg. The client and family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse should collaborate with the hcp and family to plan to take which action next?

1. Discontinue all measures
2. Notify the hospital attorney
3. Attempt to stabilize the client through the use of fluid replacement
4. Give enough blood to keep the client from dying

Answer 6

3. Attempt to stabilize the client through the use of fluid replacement

The most appropriate response is to continue all treatments and attempt to stabilize the client using fluid replacement without administering blood or blood products. It is imperative that the health care team respects the client’s religious beliefs and wishes, even if they are not those of the health care team.

Question 7

When a client with alcohol dependency begins to talk about not having a problem with alcohol, what is the best approach for the nurse to use?

1. Question the client about how much alcohol the client consumes each day
2. Confront the client about being intoxicated 2 days ago
3. Point out how alcohol has gotten the client into trouble
4. Ask the client about his or her reasons for not staying sober

Answer 7

3. Point out how alcohol has gotten the client into trouble

When a client talks about not having a problem with alcohol, the nurse needs to point out how alcohol has gotten the client into trouble. Concrete facts are helpful in decreasing the client’s denial that alcohol is a problem. The other approaches allow the client to use defense mechanisms.

Question 8

A client with newly diagnosed type 1 DM has a finger stick blood sugar of 483 dL/mL. What should the nurse do first?

1. Start an IV infusion
2. Repeat the finger stick in 30 mins
3. Notify HCP of the results
4. Obtain a serum glucose level as prescribed

Answer 8

4. Obtain a serum glucose level as prescribed

The nurse should first obtain a serum glucose level for a more accurate information about the client’s blood sugar level.

Question 9

A female client who has diagnosis of border-line personality disorder is manipulative and very disruptive on the hospital unit. She is not dangerous to herself or others but is clearly not making any therapeutic progress. She consistently refuses any medications. The nurse realizes that legally, this client has which option?

1. Refuse treatment
2. Receive forced treatment if the nursing team concurs
3. Be medicated if her family signs permission for treatment
4. Be guided to accept treatment recommendations by threatening loss of privileges

Answer 9

1. Refuse treatment

A client who has not been deemed a danger to self or others or who has not been declared incompetent retains the right to refuse treatment.

Question 10

An older adult who is to be on bed rest has become incontinent of urine. To prevent pressure ulcers, the nurse should do which tasks? SATA

1. Use a sanitary napkin to absorb urine
2. Institute a turning schedule
3. Inspect the groin for wetness
4. Have client wear incontinence briefs
5. Anchor a Foley catheter

Answer 10

2. Institute a turning schedule
3. Inspect the groin for wetness
4. Have client wear incontinence briefs

This client is at risk for pressure ulcers because of age, being on bed rest, and being incontinent.

Question 11

A mother tells the nurse that her 10 yr old daughter has an increase in hair growth and breast enlargement. The nurse explains to the mother and daughter that after the symptoms of puberty are noticed, menstruation typically occurs within which time frame?

1. 6 months
2. 12 months
3. 30 months
4. 36 months

Answer 11

3. 30 months

Question 12

A nurse is teaching a new mother how to prevent burns in the home. Which statement by the mother indicates more teaching is required?

1. “I will set my hot water heater to 49 C”
2. “I will not hold my infant while drinking coffee”
3. “I will heat my infant’s formula in the microwave”
4. “I will keep loose appliance cords tied up on the counter”

Answer 12

3. “I will heat my infant’s formula in the microwave”

Infant formula should never be heated in the microwave; the formula may heat at different temperatures and can burn the infant’s mouth.

Question 13

The HCP has prescribed IV chemotherapy to be administered to a client every day for the next week. The nurse assigned to the client has not been trained to handle chemotherapy agents. What is the nurse’s most appropriate response?

1. Send the client to the oncology floor for administration of the medication
2. Ask a nurse from the oncology floor to come to the client and administer the medication
3. Ask another nurse to help mix the chemotherapy agent
4. Ask the pharmacy to mix the chemotherapy agent and administer it.

Answer 13

1. Send the client to the oncology floor for administration of the medication

The nurse handling chemotherapy agents should be specially trained.

Question 14

A nurse has been exposed to hep B through a needlestick injury. Which actions should be included in the postexposure management plan? SATA

1. Wash the injection site with soap and water
2. Wipe the site with undiluted bleach solution
3. Administer hep B immune globulin
4. Administer hep B vaccine
5. Notify the nurse’s supervisor

Answer 14

1. Wash the injection site with soap and water
2. Administer hep B immune globulin
3. Administer hep B vaccine
4. Notify the nurse’s supervisor

Question 15

When instilling ear drops on a 2 yr old child, the nurse should pull the pinna in which directions?

1. down and back
2. down and slightly forward
3. up and back
4. up and forward

Answer 15

1. down and back

This helps open the ear canal to ensure drops reach the tympanic membrane. For an older child, the nurse should pull the pinna up and back

Question 16

An older adult alert and oriented client is admitted to the hospital for treatment of cellulitis of the left shoulder. Which fall prevention strategy is most appropriate for this client?

1. Keep all the lights on in the room at all times
2. Use a night-light in the morning
3. Keep all 4 side rails up at all times
4. Use a medical alert system

Answer 16

2. Use a night-light in the morning

Many falls occur when older clients attempt to get to the bathroom at night. The risk is greater in an unfamiliar environment.

Question 17

A client has been prescribed hydrochlorothiazide to treat heart failure. What adverse effect should the nurse instruct the client to report to the HCP?

1. urinary retention
2. muscle weakness
3. confusion
4. diaphoresis

Answer 17

2. muscle weakness

Hydrochlorothiazide is a thiazide diuretic. Muscle weakness can be an indication of hypokalemia.

Question 18

The nurse is developing an education plan for clients with hypertension. The nurse should emphasize which long-term goal for the clients?

1. Develop a plan to limit stress
2. Participate in a weight reduction program
3. Commit to lifelong therapy
4. Monitor bp regularly

Answer 18

3. Commit to lifelong therapy

Question 19

Which measure should be implemented promptly after a client’s NG tube has been removed?

1. Provide the client with oral hygiene
2. Offer the client liquids to drink
3. Encourage the client to cough & DB
4. Auscultate the client’s bowel sounds

Answer 19

1. Provide the client with oral hygiene

Question 20

The nurse is making a home visit to an older adult who is living with his son’s family. The client has scald burns on the hands, both forearms, and on the neck (10% first and second-degree burns). What should the nurse do? SATA

1. Cleanse the wounds with cool water
2. Apply antibiotic cream
3. Remove clothing near the area
4. Call for transport to a hospital
5. Cover the burns with sterile dressing
6. Investigate the possibility of elder abuse

Answer 20

1. Cleanse the wounds with cool water
2. Remove clothing near the area
3. Call for transport to a hospital
4. Investigate the possibility of elder abuse

Question 21

An infant is to receive the DTaP and IPV immunizations. The child is recovering from a cold and is afebrile. The child’s sibling has cancer and is receiving chemotherapy. Which action is most appropriate?

1. Give the DTaP and withhold the IPV
2. Administer the DTaP and IPV immunizations
3. Postpone both immunizations until the sibling is in remission
4. Withhold both immunizations until the infant is well

Answer 21

2. Administer the DTaP and IPV immunizations

The fact that the child’s sibling is immunosuppressed because of chemotherapy is not a reason to withhold the vaccines. The fact that the child has a cold also is not a reason.

Question 22

The nurse creates a program to decrease the primary cause of disability and death in children. What is the most important action to include in the plan?

1. Encourage legislators to draft legislation to promote prenatal care.
2. Require all children to be immunized
3. Teach accident prevention and safety practices to children and their parents
4. Hire a nurse practitioner for each of the schools in the community

Answer 22

3. Teach accident prevention and safety practices to children and their parents

Question 23

The nurse teaches the parents of an infant who has had surgery to correct imperforate anus how to position the infant to prevent tension on the perineum. The nurse determines more teaching is needed when the parents put the infant in which position?

1. abdomen, with legs pulled up under the body
2. back, with legs suspended at a 90 degree angle
3. left side, with hips elevated
4. right side, with hips elevated

Answer 23

1. abdomen, with legs pulled up under the body

Question 24

A 14 months old child has a severe diaper rash. Which recommendation should the nurse provide to the parents?

1. Continue to use the baby wipes
2. Change the diaper every 4 to 6 hours
3. Wash the buttocks using mild soap
4. Apply powder to the diaper area

Answer 24

3. Wash the buttocks using mild soap

Question 25

What should be the nurse’s priority assessment after an epidural anesthetic has been given to a nulligravid client in active labor?

1. LOC
2. BP
3. cognitive function
4. contraction pattern

Answer 25

2. BP

Question 26

After abdominal surgery 3 days ago the client continues to have pain every 4 to 6 hours ranging from 3 to 7 on a 10 point scale. The client has prescriptions for morphine 10 mg IM every 3 to 4 hours and acetaminophen with codeine 30 mg every 3 to 4 hours as needed for pain. The client has been taking the morphine every 4 hours for the past 3 days but tells the nurse that the morphine is no longer lasting 4 hours and wants to receive pain medication every 3 hours. The nurse reviews the progress notes that indicate the client has obtained pain relief for 5 to 6 hours after receiving the morphine. What should the nurse do to help the client manage the pain?

1. Administer the morphine every 3 hours
2. Suggest that the client take the acetaminophen with codeine every 3 hours
3. Continue to administer the morphine every 4 hours
4. Encourage the client to ambulate more frequently

Answer 26

2. Suggest that the client take the acetaminophen with codeine every 3 hours

Question 27

The nurse assesses a 7 months old infant’s growth and development. Which behavior should the nurse consider unusual?

1. drinking from a cup and spilling little of the liquid
2. raising the chest and upper abdomen off the bed with the hands
3. imitating sounds that the nurse makes
4. crying loudly in protest when the mother leaves the room

Answer 27

1. drinking from a cup and spilling little of the liquid

Question 28

A 13 yr old client is dying of cancer. When providing care for this client, the nurse should incorporate the developmental tasks for this age. According to Erikson’s developmental model, the child normally is expected to be working on which psychosocial issue?

1. lifetime vocation
2. social conscience
3. personal values
4. sense of competence

Answer 28

3. personal values

Question 29

The nurse is performing Leopold’s maneuvers on a woman who is in her 8th month of pregnancy. The nurse is palpating the uterus as shown below. Which maneuver is the nurse performing?

1. first
2. second
3. third
4. fourth

Answer 29

3. third

Question 30

A term primigravida was involved in a car accident 3 hours ago. She is having labor contractions every 4 mins, and her cervical exam is dilated 3 cm, 100% effaced, and station -1. She is crying uncontrollably and states her pain is constant and severe, rating it at 10/10. What is the nurse’s priority action?

1. Reassure the woman and assist with nonpharm pain interventions
2. Assess intensity of contractions and determine if she would like an epidural
3. Notify the provider of the pain and request an assessment for potential abruption
4. Perform a vaginal exam and coach the woman with breathing exercise for pain control.

Answer 30

3. Notify the provider of the pain and request an assessment for potential abruption

Question 31

Which statements made by a pregnant woman in the first trimester are consistent with this stage of pregnancy? SATA

1. “My husband told his friends we’ll have to give up the convertible for a minivan”
2. “Oh my, how did this happen? I don’t need this now”
3. “I can’t wait to see my baby. Do you think it will have my blond hair and blue eyes?”
4. “I wonder how it will feel to buy maternity clothes and be fat”
5. “I used a princess theme for decorating the room”
6. “We went to the mall yesterday to buy a crib and dressing table.”

Answer 31

1. “My husband told his friends we’ll have to give up the convertible for a minivan”
2. “Oh my, how did this happen? I don’t need this now”
3. “I wonder how it will feel to buy maternity clothes and be fat”

Question 32

A client comes to the ED with abdominal pain. This is the client’s 3rd visit to the ED in the past month with the same pain. When the nurse asks the client about taking prescribed medications, the nurse discovers the client has stopped taking the prescribed medication because of the cost of the medication. What would the nurse do first?

1. Refer the client to social services
2. Explain to the client the importance for taking the prescribed medication
3. Help the client make a budget that will include purchasing medication
4. Ask the health care to suggest a less costly medication

Answer 32

4. Ask the health care to suggest a less costly medication

Question 33

A client is admitted to the ED with crushing chest injuries sustained in a car accident. The nurse is assessing the client’s respiratory status. Which sign indicates a possible complication that the nurse should report to the hcp immediately?

1. oxygen saturation of 70% on room air
2. increased fremitus
3. absent breath sounds on the affected side
4. pain on the affected side of 6 on a scale of 1 to 10 when the client breathes

Answer 33

3. absent breath sounds on the affected side

Question 34

A primigravid client at 35 weeks’ gestation is scheduled for a biophysical profile. After instructing the client about the test, which client statement about what the test measures indicates effective teaching?

1. amniotic fluid volume
2. placement of the placenta
3. amniotic fluid color
4. fetal gestational age

Answer 34

4. fetal gestational age