Q & A Random Selection #3

1. The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula
following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dl. Which of
the following would the nurse anticipate?
A) Additional potassium will be given IV
B) Blood for coagulation studies will be drawn
C) Total parenteral nutrition (TPN) will be started
D) Serum lipase levels will be evaluated

2. The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments
requires an immediate response from the nurse?
A) Decreased breath sounds in right lower lobe
B) Aspiration of a residual of 100cc of formula
C) Decrease in bowel sounds
D) Urine output of 250 cc in past 8 hours

3. The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the
nurse perform first?
A) Explain that the procedure will help him to get well
B) Show a cartoon character with a blood pressure cuff
C) Explain that the blood pressure checks the heart pump
D) Permit handling the equipment before putting the cuff in place

4. A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states, “I
refuse both radiation and chemotherapy because they are 'hot.'” The next action for the nurse to take is to
A) document the situation in the notes
B) report the situation to the health care provider
C) talk with the client's family about the situation
D) ask the client to talk about concerns regarding "hot" treatments

5. Which of the following drugs should the nurse anticipate administering to a client before they are to receive
electroconvulsive therapy?
A) Benzodiazepines
B) Chlorpromazine (Thorazine)
C) Succinylcholine (Anectine)
D) Thiopental sodium (Pentothal Sodium)

6. Which statement made by a nurse about the goal of total quality management or continuous quality improvement
in a health care setting is correct?
A) It is to observe reactive service and product problem solving
B) Improvement of the processes in a proactive, preventive mode is paramount
C) A chart audits to finds common errors in practice and outcomes associated with goals
D) A flow chart to organize daily tasks is critical to the initial stages

7. The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent
would be important in determining the etiology of the seizure?
A) "He has been taking long naps for a week."
B) "He has had an ear infection for the past 2 days."
C) "He has been eating more red meat lately."
D) "He seems to be going to the bathroom more frequently."

8. The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse
recognizes that, as a result of the radiation therapy, the client is most likely to experience
A) high fever
B) nausea
C) face and neck edema
D) night sweats

9. A client with a panic disorder has a new prescription for Xanax (alprazolam). In teaching the client about the drug's
actions and side effects, which of the following should the nurse emphasize?
A) Short-term relief can be expected
B) The medication acts as a stimulant
C) Dosage will be increased as tolerated
D) Initial side effects often continue
10. While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the
radial pulsecan be accurately assessed at about what age?
A) 1 year of age
B) 2 years of age
C) 3 years of age
D) 4 years of age

11. As a part of a 9 pound full-term newborn's assessment, the nurse performs a dextro-stick at 1 hour post birth. The
serum glucose reading is 45 mg/dl. What action by the nurse is appropriate at this time?
A) Give oral glucose water
B) Notify the pediatrician
C) Repeat the test in 2 hours
D) Check the pulse oximetry reading

12. The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an appropriate
finger food?
A) Hot dog pieces
B) Sliced bananas
C) Whole grapes
D) Popcorn

13. During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results
indicate a level of 11%. Based on this result, what teaching should the nurse emphasize?
A) Rotation of injection sties
B) Insulin mixing and preparation
C) Daily blood sugar monitoring
D) Regular high protein diet

14. A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds
the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss?
A) The newborn needs additional assessments
B) The mother should breast feed more often
C) A change to formula is indicated
D) The loss is within normal limits

15. A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving
aminophylline, 25mg/hour. Which one of the following findings by the nurse would require immediate intervention?
A) Decreased blood pressure and respirations
B) Flushing and headache
C) Restlessness and palpitations
D) Increased heart rate and blood pressure

16. A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client’s medication administration
record. The nurse should notify the health care provider if the client received which medication during the preceding
24 hours?
A) Digoxin (Lanoxin)
B) Diltiazem (Cardizem)
C) Nitroglycerine ointment
D) Metoprolol (Toprol XL)

17. A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client
should be instructed to immediately report which of these?
A) Double vision and visual halos
B) Extremity tingling and numbness
C) Confusion and lightheadedness
D) Sensitivity of sunlight

18. Which of these clients would the nurse monitor for the complication of C. difficile diarrhea?
A) An adolescent taking medications for acne
B) An elderly client living in a retirement center taking prednisone
C) A young adult at home taking a prescribed aminoglycoside
D) A hospitalized middle aged client receiving clindamycin

19. The clinic nurse is counseling a substance-abusing post partum client on the risks of continued cocaine use. In
order to provide continuity of care, which nursing diagnosis is a priority?
A) Social isolation
B) Ineffective coping
C) Altered parenting
D) Sexual dysfunction
20. An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the
nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps,
rubella (MMR) immunization. The nurse understands that which of the following is true in regards to giving
immunizations to this child?
A) Live vaccines are withheld in children with renal chronic illness
B) The MMR vaccine should be given now, prior to the transplant
C) An inactivated form of the vaccine can be given at any time
D) The risk of vaccine side effects precludes giving the vaccine

21. A client is receiving Total Parenteral Nutrition (TPN) via a Hickman catheter. The catheter accidentally becomes
dislodged from the site. Which action by the nurse should take priority?
A) Check that the catheter tip is intact
B) Apply a pressure dressing to the site
C) Monitor respiratory status
D) Assess for mental status changes

22. The nurse is preparing to administer a tube feeding to a postoperative client. To accurately assess for a
gastrostomy tube placement, the priority is to
A) auscultate the abdomen while instilling 10 cc of air into the tube
B) place the end of the tube in water to check for air bubbles
C) retract the tube several inches to check for resistance
D) measure the length of tubing from nose to epigastrium

23. A nurse admits a client transferred from the emergency room (ER). The client, diagnosed with a myocardial
infarction, is complaining of substernal chest pain, diaphoresis and nausea. The first action by the nurse should be to
A) order an EKG
B) administer morphine sulfate
C) start an IV
D) measure vital signs

24. The nurse is planning care for an 8 year-old child. Which of the following should be included in the plan of care?
A) Encourage child to engage in activities in the playroom
B) Promote independence in activities of daily living
C) Talk with the child and allow him to express his opinions
D) Provide frequent reassurance and cuddling

25. A client being discharged from the cardiac step-down unit following a myocardial infarction (MI), is given a
prescription for a beta-blocking drug. A nursing student asks the charge nurse why this drug would be used by a
client who is not hypertensive. What is an appropriate response by the charge nurse?
A) "Most people develop hypertension following an MI."
B) "A beta-Blocker will prevent orthostatic hypotension."
C) "This drug will decrease the workload on his heart."
D) "Beta-blockers increase the strength of heart contractions."

26. To prevent drug resistance from developing, the nurse is aware that which of the following is a characteristic of
the typical treatment plan to eliminate the tuberculosis bacilli?
A) An anti-inflammatory agent
B) High doses of B complex vitamins
C) Aminoglycoside antibiotics
D) Administering two anti-tuberculosis drugs

27. Which of these questions is priority when assessing a client with hypertension?
A) "What over-the-counter medications do you take?"
B) "Describe your usual exercise and activity patterns."
C) "Tell me about your usual diet."
D) "Describe your family's cardiovascular history."

28. The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is
A) touching the trapezius muscle or arm firmly
B) pinching any body part
C) shaking a limb vigorously
D) rubbing the sternum

29. Which approach is a priority for the nurse who works with clients from many different cultures?
A) Speak at least 2 other languages of clients in the neighborhood
B) Learn about the cultures of clients who are most often encountered
C) Have a list of persons for referral when interaction with these clients occur
D) Recognize personal attitudes about cultural differences and real or expected biases
30. A client has gastroesophageal reflux. Which recommendation made by the nurse would be most helpful to the
client?
A) Avoid liquids unless a thickening agent is used
B) Sit upright for at least 1 hour after eating
C) Maintain a diet of soft foods and cooked vegetables
D) Avoid eating 2 hours before going to sleep

31. A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half
hour after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate
attention?
A) increased restlessness
B) tachycardia
C) tracheal deviation
D) tachypnea

32. During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the
nurse?
A) The client's self-report is the most important consideration
B) Cultural sensitivity is fundamental to pain management
C) Clients have the right to have their pain relieved
D) Nurses should not prejudge a client's pain using their own values

33. When teaching a client about the side effects of fluoxetine (Prozac), which of the following will the nurse include?
A) Tachycardia blurred vision, hypotension, anorexia
B) Orthostatic hypotension, vertigo, reactions to tyramine-rich foods
C) Diarrhea, dry mouth, weight loss, reduced libido
D) Photosensitivity, seizures, edema, hyperglycemia

34. The nurse is talking with the family of an 18 months-old newly diagnosed with retinoblastoma. A priority in
communicating with the parents is
A) Discuss the need for genetic counseling
B) Inform them that combined therapy is seldom effective
C) Prepare for the child's permanent disfigurement
D) Suggest that total blindness may follow surgery

35. The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting
a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This
affirms the ethical
principle of
A) Anonymity
B) Beneficence
C) Justice
D) Autonomy

36. Which of these clients, all of whom have the findings of a board-like abdomen, would the nurse suggest that the
provider examine first?
A) An elderly client who stated, "My awful pain in my right side suddenly stopped about 3 hours ago."
B) A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy
C) A middle-aged client admitted with diverticulitis who has taken only clear liquids for the past week
D) A teenager with a history of falling off a bicycle without hitting the handle bars

37. The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after hearing
the report?
A) The client with asthma who is now ready for discharge
B) The client with a peptic ulcer who has been vomiting all night
C) The client with chronic renal failure returning from dialysis
D) The client with pancreatitis who was admitted yesterday

38. The nurse is teaching about nonsteroidal anti-inflammatory drugs (NSAIDs) to a group of arthritic clients. To
minimize the side effects, the nurse should emphasize which of the following actions?
A) Reporting joint stiffness in the morning
B) Taking the medication 1 hour before or 2 hours after meals
C) Using alcohol in moderation unless driving
D) Continuing to take aspirin for short term relief
39. A client is prescribed warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included
in the nurse’s discharge instruction?
A) Maintain a consistent intake of green leafy foods
B) Report any nose or gum bleeds
C) Take Tylenol for minor pains
D) Use a soft toothbrush

40. A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these
medications would the nurse anticipate the provider ordering?
A) Oral Coumadin therapy
B) Heparin 5000 units subcutaneously B.I.D.
C) Heparin infusion to maintain the PTT at 1.5-2.5 times the control value
D) Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value