Q&A Random Selection #8

1. While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for
hyperbilirubinemia. Which of the following should be reported immediately?
A) Jaundice evident at 26 hours
B) Hematocrit of 55%
C) Serum bilirubin of 12mg
D) Positive Coombs' test

2. A young adult male has been diagnosed with testicular cancer. Which of these statements by this client would
need to be explored by the nurse to clarify his understanding?
A) "This surgical procedure involves removing one or both testicles through a cut in the groin. My lymph nodes in
my lower belly also may be removed."
B) "I have a good chance to regain my fertility later. However if I am concerned, I can have my sperm frozen and
preserved (cryopreserved) before chemotherapy."
C) "If I have cancer at stage 3 it means I have less involvement of the cancer."
D) "After the surgical removal of a testicle, I can have an artificial testicle (prosthesis) placed inside my scrotum. This
artificial implant has the weight and feel of a normal testicle."

3. During the beginning shift assessment of a client with asthma who is receiving oxygen per nasal cannula at 2 liters
per minute, the nurse would be most concerned about which unreported finding?
A) Pulse oximetry reading of 89%
B) Crackles at the base of the lungs on auscultation
C) Rapid shallow respirations with intermittent wheezes
D) Excessive thirst with a dry cracked tongue

4. A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the "evil eye." The
nurse should communicate to other personnel that the appropriate approach is to
A) touch the baby after looking at him
B) talk very slowly while speaking to him
C) avoid touching the child
D) look only at the parents

5. The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will
avoid hypoxia by
A) inserting a fenestrated catheter with a whistle tip without suction
B) completing suction pass in 30 seconds with pressure of 150 mm Hg
C) hyperoxygenation with 100% O2 for 1 to 2 minutes before and after each suction pass
D) minimizing suction pass to 60 seconds while slowly rotating the lubricated catheter

6. A client is admitted for COPD. Which findings would require the nurse's immediate attention?
A) Nausea and vomiting
B) Restlessness and confusion
C) Low-grade fever and cough
D) Irritating cough and liquefied sputum

7. A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed
by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the
child is
A) high risk for infection related to vomiting
B) altered family processes related to chronic illness
C) fluid volume deficit related to vomiting
D) risk for aspiration related to loss of consciousness

8. A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica
cast. The nurse should teach the parents to
A) gently rub the skin with a cotton swab to relieve itching
B) place the favorite books and push-pull toys in the crib
C) check every few hours for the next day or 2 for swelling in the baby's feet
D) turn the baby with the abduction stabilizer bar every 2 hours

9. The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the
correct pathway of blood flow through the heart?
A) Right ventricle, left ventricle, right atrium, left atrium
B) Left ventricle, right ventricle, left atrium, right atrium
C) Right atrium, right ventricle, left atrium, left ventricle
D) Right atrium, left atrium, right ventricle, left ventricle
10. Which of these tests would the nurse expect to monitor for the evaluation of clients aged 18 and older with poor
glycemic control?
A) A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up
assessments, which should occur at no longer than 3-month intervals
B) A glycosylated hemoglobin is to be obtained at least twice a year
C) A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial
assessment
D) A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-monthintervals
after the initial assessment

11. The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate?
A) Non-intention tremors and urgency with voiding
B) Echolalia and a shuffling gait
C) Muscle spasm and a bent over posture
D) Intention tremor and jerky movement of the elbows

12. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate
attention?
A) Pleuritic pain on inspiration
B) Dry mucus membranes in the mouth
C) A decrease in respiratory rate from 34 to 24
D) Decrease in chest wall expansion

13. Which finding would be the most characteristic of an acute episode of reactive airway disease?
A) auditory gurgling
B) inspiratory laryngeal stridor
C) auditory expiratory wheezing
D) frequent dry coughing

14. The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth
of a 9 year old child has been avulsed ("knocked out"). After recovering the tooth, the initial response should be to
A) rinse the tooth in water before placing it in the socket
B) place the tooth in a clean plastic bag for transport to the dentist
C) hold the tooth by the roots until reaching the emergency room
D) ask the child to replace the tooth even if the bleeding continues

15. At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She
asks about preconception diet changes. Which of the statements made by the nurse is best?
A) "Include fibers in your daily diet."
B) "Increase green leafy vegetable intake."
C) "Drink a glass of milk with each meal."
D) "Eat at least 1 serving of fish weekly."

16. A 67 year-old client is admitted with substernal chest pain with that radiates to the jaw. The admitting diagnosis is
acute myocardial infraction (MI). The priority nursing diagnosis for this client during the first 24 hours is
A) constipation related to immobility
B) high risk for infection
C) impaired gas exchange
D) fluid volume deficit

17. The nurse is caring for a client with status epilepticus. The most important nursing assessment(s) of this client
is/are
A) intravenous drip rate
B) level of consciousness
C) pulse and respiration
D) injuries to the extremities

18. Which tasks, if delegated by the new charge nurse to a unlicensed assistive personnel (UAP), would require
intervention by the nurse manager?
A) To help an elderly client to the bathroom
B) To empty a Foley catheter bag
C) To bathe a woman with internal radon seeds
D) To feed a 2 year-old with a broken arm

19. The nurse is assessing a newborn the day after birth. A high pitched cry, irritability and lack of interest in feeding
are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing
care?
A) Reduce the environmental stimuli
B) Offer formula every 2 hours
C) Talk to the newborn while feeding
D) Rock the baby frequently

20. An 82 year-old client is prescribed eye drops for treatment of glaucoma. What assessment is needed before the
nurse begins teaching proper administration of the medication?
A) Determine third party payment plan for this treatment
B) The client’s manual dexterity
C) Proximity to health care services
D) Ability to use visual assistive devices

21. A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence
or absence of an infection, it is most important for all family members to have a
A) chest x-ray
B) blood culture
C) sputum culture
D) PPD intradermal test

22. A client comes into the community health center upset and crying stating “I will die of cancer now that I have this
disease.” And then the client hands the nurse a paper with one word written on it: "Pheochromocytoma." Which
response should the nurse state initially?
A) "Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in
other endocrine glands such as the thyroid (medullary carcinoma of the thyroid)"
B) This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline
C) "Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor"
D) "You probably have had episodes of sweating, heart pounding and headaches"

23. On admission to the hospital a client with an acute asthma episode has intermittent nonproductive coughing and
a pulse oximeter reading of 88%. The client states, “I feel like this is going to be a bad time this admission. I wish I
would not have gone into that bar with all those people who smoke last night.” Which nursing diagnoses would be
most important for this client?
A) Anxiety related to hospitalization
B) Ineffective airway clearance related to potential thick secretions
C) Altered health maintenance related to preventative behaviors associated with asthma
D) Impaired gas exchange related to bronchoconstriction and mucosal edema

24. A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced
manager should the new manager implement initially?
A) Set daily goals and establish priorities for each hour and each day.
B) Ask for additional assistance when you feel overwhelmed.
C) Keep a time log of your day in hourly blocks for at least 1 week.
D) Complete each task before beginning another activity in selected instances.

25. The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the
parents, the best statement by the nurse should be that,
A) "A child's bone is more flexible and can be bent 45 degrees before breaking."
B) "Bones of children are more porous than adults’ and often have incomplete breaks."
C) "Compression of porous bones produces a buckle or torus type break."
D) "Bone fragments often remain attached by a periosteal hinge."

26. While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism.
Which of the following assessment findings suggests this complication?
A) Positive Homan's sign
B) Fever and chills
C) Dyspnea and cough
D) Sensory impairment

27. The nurse uses the DRG (Diagnosis Related Group) manual to
A) classify nursing diagnoses from the client's health history
B) identify findings related to a medical diagnosis
C) determine reimbursement for a medical diagnosis
D) implement nursing care based on case management protocol

28. The nurse would teach a client with Raynaud's phenomenon that, after smoking cessation, it is most important to
A) avoid caffeine
B) keep feet dry
C) reduce stress
D) wear gloves
29. A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how
would the nurse position the client?
A) Prone
B) Dorsal recumbent
C) Semi-Fowler
D) Supine

30. A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations
28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of
digoxin. Which finding is most indicative of digoxin toxicity?
A) Bradycardia
B) Lethargy
C) Irritability
D) Vomiting

31. The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To
assist staff in this change process, the nurse manager is preparing for the "unfreezing" phase of change. With this
approach the nurse manager should:
A) discuss with the staff how to deal with any defensive behavior
B) explain to the unit staff why change is necessary
C) assist the staff during the acceptance of the new changes
D) clarify what the changes mean to the community and hospital

32. Which of these statements by the nurse is incorrect if the nurse has the goal to reinforce information about
cancers to a group of young adults?
A) "You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting
all meat, and avoiding nitrate-containing foods."
B) "Prostate cancer is the most common cancer in American men with results to threaten sexuality and life."
C) "Colorectal cancer is the second-leading cause of cancer-related deaths in the United States."
D) "Lung cancer is the leading cause of cancer deaths in the United States. Yet it's the most preventable of all
cancers."

33. The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers.
Which of these comments by the student indicates a need for clarification of information?
A) "The infant will get the hepatitis B vaccine and the hepatitis B immune globulin within 12 hours at birth at separate
injection sites."
B) "The second dose can be given at 1 to 2 months of age."
C) "The third dose should be given at least 16 weeks from the second dose."
D) "The last dose in the series is not to be given before age 24 weeks."

34. A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia,
leukorrhea and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to
A) suggest 3 to 4 warm sitz baths per day
B) cleanse the genitalia twice a day with soap and water
C) spray warm water over genitalia after urination
D) apply heat or cold to lesions as desired

35. The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which
intervention would be the best approach by the nurse manager?
A) Confront the nurse about the suspicions in a private meeting
B) Schedule a staff conference, without the nurse present, to collect information
C) Consult the human resources department about the issue and needed actions
D) Counsel the employee to resign to avoid investigation

36. A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the
nurse would expect to note
A) high protein
B) clear color
C) elevated sed rate
D) increased glucose

37. A client with chronic congestive heart failure should be instructed to contact the home health nurse if which
finding occurs?
A) Weight gain of 2 pounds or more in a 48 hour period
B) Urinating 4 to 5 times each day
C) A significant decrease in appetite
D) Appearance of non-pitting ankle edema
38. A 74 year-old male is admitted due to inability to void. He has a history of an enlarged prostate and has not
voided in 14 hours. When assessing for bladder distention, the best method for the nurse to use is to assess for
A) rebound tenderness
B) left lower quadrant dullness
C) rounded swelling above the pubis
D) urinary discharge

39. With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are
potential
discharges within the next hour. Which client should the charge nurse select?
A) An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago
B) An adolescent admitted the prior night with Tylenol intoxication
C) A middle-aged client with an internal automatic defibrillator and complaints of “passing out at unknown times”
admitted yesterday
D) A school-aged child diagnosed with suspected bacterial meningitis and was admitted at the change of shifts

40. Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has
been effective?
A) "I may experience seizures if I stop the medication abruptly."
B) "I may experience an increase in my heart rate for a few weeks."
C) ”I can expect to feel nervousness the first few weeks."
D) “I can have a heart attack if I stop this medication suddenly."