1. For which of the following mother-baby pairs should the nurse review the Coomb's test in preparation for administering RhO (D) immune globulin within 72 hours of birth?
A) Rh negative mother with Rh positive baby
B) Rh negative mother with Rh negative baby
C) Rh positive mother with Rh positive baby
D) Rh positive mother with Rh negative baby
The correct answer is A: Rh negative mother with Rh positive baby
An Rh- mother who delivers an Rh+ baby may develop antibodies to the fetal red cells to which she may be exposed during pregnancy or at placental separation. If the Coombs test is negative, no sensitization has occurred. The RhO(D) immune globulin is given to block antibody formation in the mother.
2. The nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's Syndrome?
The correct answer is C: Varicella
Varicella (chicken pox) and influenza are viral illnesses that have been identified as increasing the risk for Reye''s Syndrome. Use of aspirin is contraindicated for children with these infections
3. A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn assessments suggests to the nurse that the infant has fetal alcohol syndrome?
A) Growth retardation is evident
B) Multiple anomalies are identified
C) Cranial facial abnormalities are noted
D) Prune belly syndrome is suspected
The correct answer is C: Cranial facial abnormalities are noted
Characteristic facial abnormalities are seen in the newborn with fetal alcohol syndrome.
The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should
A) Irrigate it as ordered with distilled water
B) Irrigate it as ordered with normal saline
C) Place the end of the tube in water to see if the water bubbles
D) Withdraw the tube several inches and reposition it
The correct answer is B: Irrigate it as ordered with normal saline
Nasogastric tubes are only irrigated with normal saline to maintain patency
4. The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?
A) Fecal impaction
B) Infrequent voiding
C) Stress incontinence
D) Burning with urination
The correct answer is A: Fecal impaction
The nurse should report fecal impaction or constipation which can cause obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in the elderly.
5. Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach?
A) Consider a liquid supplement to increase calories
B) Discuss consequences of an unbalanced diet with the child
C) Provide fruit, vegetable and protein snacks
D) Encourage the child to keep a daily log of foods eaten
The correct answer is B: Discuss consequences of an unbalanced diet with the child It is important to educate the preadolescent as to appropriate diet, and the problems that might arise if diet is not adequate.
6. Which action is most likely to ensure the safety of the nurse while making a home visit?
A) Observation during the visit of no evidence of weapons in the home
B) Prior to the visit, review client's record for any previous entries about violence
C) Remain alert at all times and leave if cues suggest the home is not safe
D) Carry a cell phone, pager and/or hand held alarm for emergencies
The correct answer is C: Staying alert at all times and leaving if cues suggest the home is not safe .No person or equipment can guarantee nurses'' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards and sources of assistance. Become acquainted with neighbors. Be alert and confident while parking the car, walking to the client''s door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do so.
7. The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention?
A) Pulse oximetry of 85%
C) Crackles in lungs
The correct answer is A: Pulse oximetry of 85%
An oxygen saturation of 88% or less indicates hypoxemia and requires the nurse''s immediate attention.
8. The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor?
A) Sexually transmitted infection
B) Exposure to teratogens
C) Maternal hypertension
D) Chromosomal abnormalities
The correct answer is C: Maternal hypertension
Pregnancy induced hypertension is a common cause of late pregnancy fetal growth retardation. Vasoconstriction reduces placental exchange of oxygen and nutrients.
9. A client had arrived in the USA from a developing country 1 week prior. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS with a history of unintended weight loss, drug abuse, night sweats, productive cough and a "feeling of being hot all the time." The nurse should assign the client to share a room with a client with the diagnosis of
A) Acute tuberculosis with a productive cough of discolored sputum for over three months
B) Lupus and vesicles on one side of the middle trunk from the back to the abdomen
C) Pseudomembranous colitis and C. difficile.
D) Exacerbation of polyarthritis with severe pain
The correct answer is A: Acute tuberculosis with a productive cough of discolored sputum for over three months
The client for admission has classic findings of pulmonary tuberculosis. Of the choices the client in option A has the similar diagnosis and it is acceptable to put these types of clients in the same room when no other alternative exists. Clients are considered contagious until the cough is eliminated with medications which initially is a combination of 4 drugs simultaneously.
10. The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body?
A) Inspect the skin
B) Auscultate breath sounds
C) Evaluate muscle strength
D) Investigate elimination patterns
The correct answer is A: Inspect the skin.
A characteristic sign of rubeola is Koplik spots (small red spots with a bluish white center). These are found on the buccal mucosa about 2 days before and after the onset of the measles rash.
11. The nurse has been teaching an apprehensive primipara who has difficulty in initial nursing of the newborn. What observation at the time of discharge suggests that initial breast feeding is effective?
A) The mother feels calmer and talks to the baby while nursing
B) The mother awakens the newborn to feed whenever it falls asleep
C) The newborn falls asleep after 3 minutes at the breast
D) The newborn refuses the supplemental bottle of glucose water
The correct answer is A: The mother feels calmer and talks to the baby while nursing Early evaluation of successful breastfeeding can be measured by the client''s voiced confidence and satisfaction with the infant
12. The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in
The correct answer is C: Sodium The client with Meniere''s disease has an excess accumulation of fluid in the inner ear. A low sodium diet will aid in reducing the fluid. Sodium restriction is also ordered as adjunct to diuretic therapy
13. The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered
The correct answer is B; Rude
Native Americans consider direct eye contact to be impolite or aggressive among strangers.
14. As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid
B) Scuba diving
The correct answer is B: Scuba diving
The nurse would strongly emphasize the need for clients with history of spontaneous pneumothorax problems to avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressures could cause the lung to collapse again.
15. The parents of a child who has recently been diagnosed with asthma ask the nurse to explain the condition to them. The best response is "Asthma causes…
A) the airway to become narrow and obstructs airflow."
B) air to be trapped in the lungs because the airways are dilated."
C) the nerves that control respiration to become hyperactive."
D) a decrease in the stress hormones which prevents the airways from opening."
The correct answer is A: the airway to become narrow and obstructs airflow."
Asthma is defined as airway obstruction or a narrowing that is characterized by bronchial irritability after exposure to various stimuli
16. The nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. What action should the nurse do first?
A) Explain the stages of death and dying to the family
B) Recommend an easy-to-read book on grief
C) Assess the family's patterns for dealing with death
D) Ask about their religious affiliations
The correct answer is C: Assess the family''s patterns for dealing with death
When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that the client and their family''s needs are adequately identified in order to select the best nursing care approaches
17. A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be delayed?
The correct answer is A: MMR Medical management of Kawasaki involves administration of immunoglobulins. Measles, mumps, rubella (MMR) is a live virus vaccine. Following administration of immunoglobulins, live vaccines should be held due to possible interference with the body''s ability to form antibodies.
18. An unlicensed assistive staff member asks the nurse manager to explain the beliefs of a Christian Scientist who refuses admission to the hospital after a motor vehicle accident. The best response of the nurse would be which of these statements?
A) "Spiritual healing is emphasized and the mind contributes to the cure."
B) "The primary belief is that dietary practices result in health or illness."
C) "Fasting and prayer are initial actions to take in physical injury."
D) "Meditation is intensive in the initial 48 hours and daily thereafter."
The correct answer is A: "Spiritual healing is emphasized and the mind contributes to the cure." For the Christian Scientist, a mind cure uses spiritual healing methods. For the believer, medical treatments may interfere with drawing closer to God.