Text Mode – Text version of the exam
1. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- Document the finding
- Report the finding to the doctor
- Prepare the client for a C-section
- Continue primary care as prescribed
2. A client with a diagnosis of HPV is at risk for which of the following?
- Hodgkin’s lymphoma
- Cervical cancer
- Multiple myeloma
- Ovarian cancer
3. During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
4. A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
- Venereal Disease Research Lab (VDRL)
- Rapid plasma reagin (RPR)
- Florescent treponemal antibody (FTA)
- Thayer-Martin culture (TMC)
5. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
- Elevated blood glucose
- Elevated platelet count
- Elevated creatinine clearance
- Elevated hepatic enzymes
6. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
- The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
- The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.
- The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
- The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
7. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?
- Magnesium sulfate 4gm (25%) IV
- Brethine 10mcg IV
- Stadol 1mg IV push every 4 hours as needed prn for pain
- Ancef 2gm IVPB every 6 hours
8. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is:
- The infant is at low risk for congenital anomalies.
- The infant is at high risk for intrauterine growth retardation.
- The infant is at high risk for respiratory distress syndrome.
- The infant is at high risk for birth trauma.
9. Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
10. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
- Decreased urinary output
- Absence of knee jerk reflex
- Decreased respiratory rate
11. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:
- Place her in Trendelenburg position
- Decrease the rate of IV infusion
- Administer oxygen per nasal cannula
- Increase the rate of the IV infusion
12. A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
- Alteration in nutrition
- Alteration in bowel elimination
- Alteration in skin integrity
- Ineffective individual coping
13. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
- Inspection of the abdomen for enlargement
- Bimanual palpation for hepatomegaly
- Daily measurement of abdominal girth
- Assessment for a fluid wave
14. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?
- Alteration in cerebral tissue perfusion
- Fluid volume deficit
- Ineffective airway clearance
- Alteration in sensory perception
15. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
- Likes to play football
- Drinks several carbonated drinks per day
- Has two sisters with sickle cell tract
- Is taking acetaminophen to control pain
16. The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
- Allow the client to keep the fruit
- Place the fruit next to the bed for easy access by the client
- Offer to wash the fruit for the client
- Tell the family members to take the fruit home
17. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse’s action should be to:
- Place the client in Trendelenburg position
- Increase the infusion of Dextrose in normal saline
- Administer atropine intravenously
- Move the emergency cart to the bedside
18. The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
- Order a chest x-ray
- Reinsert the tube
- Cover the insertion site with a Vaseline gauze
- Call the doctor
19. A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
- ssess for signs of abnormal bleeding
- Anticipate an increase in the Coumadin dosage
- Instruct the client regarding the drug therapy
- Increase the frequency of neurological assessments
20. Which selection would provide the most calcium for the client who is 4 months pregnant?
- A granola bar
- A bran muffin
- A cup of yogurt
- A glass of fruit juice
21. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?
- The nurse places a sign over the bed not to check blood pressure in the right arm.
- The nurse places a padded tongue blade at the bedside.
- The nurse inserts a Foley catheter.
- The nurse darkens the room.
22. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child’s mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?
- Ask the mother to leave while the blood transfusion is in progress
- Encourage the mother to reconsider
- Explain the consequences without treatment
- Notify the physician of the mother’s refusal
23. A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
- Laryngeal edema
24. The nurse is evaluating nutritional outcomes for an elderly client with bulimia. Which data best indicates that the plan of care is effective?
- The client selects a balanced diet from the menu.
- The client’s hemoglobin and hematocrit improve.
- The client’s tissue turgor improves.
- The client gains weight.
25. The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
- Pain beneath the cast
- Warm toes
- Pedal pulses weak and rapid
- Paresthesia of the toes
26. A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply.
- Scant mucus
- Early onset cough
- Marked weight loss
- Purulent mucus production
- Mild episodes of dyspnea
27. A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client’s efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?
- Identifying the client’s ability to function
- Identifying the client’s potential for self-harm
- Inquiring about the client’s feelings that may affect coping
- Inquiring about the client’s perception of the cause of the neighbor’s death
28. A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client’s hospital gown?
- Using a hospital gown with snaps at the sleeves
- Disconnecting the IV tubing from the catheter in the vein
- Checking the IV flow rate immediately after changing the hospital gown
- Putting the bag and tubing through the sleeve, followed by the client’s arm
29. A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first?
- A client on a ventilator
- A client in skeletal traction
- A postoperative client preparing for discharge
- A client admitted on the previous shift who has a diagnosis of gastroenteritis
30. A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection?
31. A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply.
- Wearing gloves when emptying the client’s bedpan
- Keeping all linens in the room until the implant is removed
- Wearing a film (dosimeter) badge when in the client’s room
- Wearing a lead apron when providing direct care to the client
- Placing the client in a semiprivate room at the end of the hallway
32. The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.
- On the left side
- With the neck flexed
- Supine on the left side
- With extreme hip flexion
- In a semi-Fowler’s position
- With the head in a midline position
33. A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to:
- Treat thyroid storm.
- Prevent cardiac irritability.
- Treat hypocalcemic tetany.
- Stimulate the release of parathyroid hormone.
34. A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure?
- Gloves and a gown
- Gloves and goggles
- Gloves, a gown, and goggles
- Gloves, a gown, and shoe protectors
35. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?
- Metabolic acidosis
- Metabolic alkalosis
- Respiratory acidosis
- Respiratory alkalosis
36. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse most likely observe?
- Respirations that cease for several seconds
- Respirations that are regular but abnormally slow
- Respirations that are labored and increased in depth and rate
- Respirations that are abnormally deep, regular, and increased in rate
37. Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.
- Monitor for hemorrhage.
- Administer eye medications.
- Maintain the eye patch or shield.
- Assist with activities of daily living.
- Encourage coughing and deep breathing.
- Educate regarding symptoms of retinal detachment.
38. A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?
- Intense thirst
- Slow bounding pulse
- Dry mucous membranes
- Postural blood pressure changes
39. A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications?
- A 60-year-old male client with rhinitis
- A 24-year-old male client with a lower back injury
- A 10-year-old female client with a urinary tract infection
- A 45-year-old female client with a history of migraine headaches
40. A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.
- Call a code blue.
- Notify the registered nurse.
- Place the infant in a prone position.
- Prepare to administer morphine sulfate.
- Prepare to administer intravenous fluids.
- Prepare to administer 100% oxygen by face mask.
Answers and Rationales
- Answer B. Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect.
- Answer B . The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect.
- Answer B . A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Condylomata lesions are painless warts, so answer D is incorrect. In answer C, gonorrhea does not present as a lesion, but is exhibited by a yellow discharge.
- Answer C . Florescent treponemal antibody (FTA) is the test for treponema pallidum. VDRL and RPR are screening tests done for syphilis, so answers A and B are incorrect. The Thayer-Martin culture is done for gonorrhea, so answer D is incorrect.
- Answer D . The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. In answer A, an elevated blood glucose level is not associated with HELLP. Platelets are decreased, not elevated, in HELLP syndrome as stated in answer B. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome so answer C is incorrect.
- Answer A . Answer B elicits the triceps reflex, so it is incorrect. Answer C elicits the patella reflex, making it incorrect. Answer D elicits the radial nerve, so it is incorrect.
- Answer B . Brethine is used cautiously because it raises the blood glucose levels. Answers A, C, and D are all medications that are commonly used in the diabetic client, so they are incorrect.
- Answer C. When the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma, so answer D is incorrect. The L/S ratio does not indicate congenital anomalies, as stated in answer A, and the infant is not at risk for intrauterine growth retardation, making answer B incorrect.
- Answer C . Jitteriness is a sign of seizure in the neonate. Crying, wakefulness, and yawning are expected in the newborn, so answers A, B, and D are incorrect.
- Answer B. The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations indicate toxicity, so answers A, C, and D are incorrect.
- Answer D. If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration. Answer A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down and ventilate the client. In answer B, the IV rate should be increased, not decreased. In answer C, the oxygen should be applied by mask, not cannula.
- Answer A . Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition. The other problems are of lesser concern; thus, answers B, C, and D are incorrect.
- Answer C. Measuring with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspecting and checking for fluid waves are more subjective, so answers A and B are incorrect. Palpation of the liver will not tell the amount of ascites; thus, answer D is incorrect.
- Answer B. The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, so answers A, C, and D are incorrect.
- Answer A. The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise, especially in warm weather, can exacerbate the condition. Answers B, C, and D are not factors for concern.
- Answer D. The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. He should also not eat foods grown on or in the ground or eat from the salad bar. The nurse should remove potted or cut flowers from the room as well. Any source of bacteria should be eliminated, if possible. Answers A, B, and C will not help prevent bacterial invasions.
- Answer B. In clients who have not had surgery to the face or neck, the answer would be answer A; however, in this situation, this could further interfere with the airway. Increasing the infusion and placing the client in supine position would be better. Answers C is incorrect because it is not necessary at this time and could cause hyponatremia and further hypotension. Answer D is not necessary at this time.
- Answer C. If the client pulls the chest tube out of the chest, the nurse’s first action should be to cover the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube. Answers A, B, and D are not the first action to be taken.
- Answer A. The normal Protime is 12–20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode. Answers B, C, and D may be needed at a later time but are not the most important actions to take first.
- Answer C. The food with the most calcium is the yogurt. Answers A, B, and D are good choices, but not as good as the yogurt, which has approximately 400mg of calcium.
- Answer C. The client receiving magnesium sulfate should have a Foley catheter in place, and hourly intake and output should be checked. There is no need to refrain from checking the blood pressure in the right arm. A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion. Darkening the room is unnecessary, so answers A, B, and D are incorrect.
- Answer D. If the client’s mother refuses the blood transfusion, the doctor should be notified. Because the client is a minor, the court might order treatment. Answer A is incorrect. Because it is not the primary responsibility for the nurse to encourage the mother to consent or explain the consequences, so answers B and C are incorrect.
- Answer B. The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be answer A, as well as hyponatremia and hypokalemia in C and D, but these answers are not of primary concern so are incorrect.
- Answer D. The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet does little good if the client will not eat, so answer A is incorrect. The hematocrit might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition; therefore, answer B is incorrect. The tissue turgor indicates fluid stasis, not improvement of anorexia, so answer C is incorrect.
- Answer D. At this time, pain beneath the cast is normal. The client’s toes should be warm to the touch, and pulses should be present. Paresthesia is not normal and might indicate compartment syndrome. Therefore, Answers A, B, and C are incorrect.
- Answers: B, D, and E. Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea.
- Answer: C. The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis.Inquiring about the client’s feelings that may affect coping pertains directly to the client’s feelings. Other answer choices do not directly address the client’s feelings.
- Answer: B. The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection.Using a hospital gown with snaps at the sleeves and putting the bag and tubing through the sleeve, followed by the client’s arm are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change.
- Answer: A. The airway is always a high priority, and the nurse first checks the client on a ventilator. The clients described in remaining options have needs that would be identified as intermediate priorities.
- Answer: B. The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that would be the priority.
- Answer: A, B, C, and D. A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device.
- Answers: E and F. Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.
- Answer: C.
- Answer: C. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.
- Answer: B. The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition.Respiratory acidosis and respiratory alkalosis deal with respiratory problems. Metabolic acidosis relates to acidosis.
- Answer: D. Kussmaul’s respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.
- Answers: A, B, C, D, and F. An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse’s assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.
- Answer: D. Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.
- Answer: C. Children should not be given herbal therapies, especially in the home and without professional supervision. There are no general contraindications for the clients described in the remaining options.
- Answers: B, D, E, and F. The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.