1. A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child?
A) Riding in a car
B) Falling off a bed
C) Electrical outlets
D) Eating peanuts
The correct answer is D: Eating peanuts Asphyxiation by foreign materials in the respiratory tract is the leading cause of death in children less than 6 years of age
2. The nurse is attending a workshop about caring for persons infected with Hepatitis. Which statement is correct when referring to the incidence rate for Hepatitis?
A) The number of persons in a population who develop Hepatitis B during a specific period of time
B) The total number of persons in a population who have Hepatitis B at a particular time
C) The percentage of deaths resulting from Hepatitis B during a specific time
D) The occurrence of Hepatitis B in the population at a particular time
The correct answer is A: The number of persons in a population who develop Hepatitis B during a specific period of time This is the correct definition of incidence of the disease.
3. Which of these women in the labor and delivery unit would the nurse check first when the water breaks for all of them within a 2 minute period?
A) A multigravida with station at +2, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 7 cm, and 50% effacement
B) A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement
C) A primapara with station at 0, contractions at 20 minutes apart with duration of 20 seconds, cervix dilated at 2 cm and 10% effacement
D) A primapara with station at 1, contractions at 15 minutes apart with duration of 35 seconds, cervix dilated at 5 cm and 50% effacement
The correct answer is B: A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement When the station of -1 or -2 is present and the water breaks, the risk is greater for a prolapsed cord.
4. 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
5. 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.
6. While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what pyschosocial skill?
A) Stubborn behavior
B) Rejection of parents
C) Frustration with adults
D) Assertion of control
The correct answer is D: Assertion of control Negativism is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child''s progress from dependency to autonomy and independence.
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 providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care?
A) Impaired skin integrity related to dependent edema
B) Activity intolerance related to oxygen supply and demand imbalance
C) Constipation related to immobility
D) Risk for infection related to ineffective mobilization of secretions
The correct answer is B: Activity Intolerance related to oxygen supply and demand imbalance This is the primary problem due to decreased cardiac output related to heart failure. There is a reduction of oxygen and complaints of dyspnea and fatigue.
9. A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?
A) Capillary refill less than 3 seconds
B) Pale mucous membranes
C) Respirations 36 breaths per minute
D) Complaints of fatigue when ambulating
The correct answer is A: Capillary refill less than 3 seconds Since the hemoglobin and hematocrit are normal for an adult female, addition assessments should be normal. Capillary refill is "normal" assessment data.
10. 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
11. 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
12. 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.
13. The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?
A) Complaints of numbness and tingling in feet
B) Wheezing noted when lung sound auscultated
C) Excessive perspiration
D) Difficulty sleeping
The correct answer is A: Complaints of numbness and tingling in feet
A child who has unusual neurologic signs or symptoms, neuropathy, footdrop, or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This most often occurs when a child ingests or inhales paint chips from lead-based paint or dust from remodeling in older buildings.
14. After the shift report in a labor and delivery unit which of these clients would the nurse check first?
A) A middle aged woman with asthma and diabetes mellitus Type 1 has a BP of 150/94
B) A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
C) A young woman wo is a grand multipara has cervical dilation of 4 cm and 50% effaced
D) An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
The correct answer is D: An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum This client has an actual complication. The others present with findings of potential complications
15. An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by
B) Acidic byproducts
C) Vomiting and dehydration
The correct answer is A: Tachypnea Stimulation of respiratory center leads to hyperventilation, thus decreasing CO2 levels which causes respiratory alkalosis
16. The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: “We are concerned about the possible occurrence of sudden infant death syndrome (SIDS).” In order to take appropriate action, the nurse must understand that
A) The child is within the age group most susceptible to SIDS
B) The peak age for occurrence of SIDS is 8 to 12 months of age
C) The apnea monitor is not effective on a child in this age group
D) 95% of SIDS cases occur before 6 months of age
The correct answer is D: 95% percent of all SIDS cases occur before 6 months
Peak age of SIDS occurrence is 2 to 4 months and 95% of cases occur by 6 months of age. It is the leading cause of death in infants 1 month to 1 year of age.
17. The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be
A) High calorie, low fat, low sodium
B) High protein, low fat, low carbohydrate
C) High protein, high calorie, unrestricted fat
D) High carbohydrate, low protein, moderate fat
The correct answer is C: High protein, high calorie, unrestricted fat. The child with Cystic Fibrosis needs a well balanced diet that is high in protein and calories. Fat does not need to be restricted.
18. A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child?
A) Riding in a car
B) Falling off a bed
C) Electrical outlets
D) Eating peanuts
The correct answer is D: Eating peanuts Asphyxiation by foreign materials in the respiratory tract is the leading cause of death in children less than 6 years of age.
19. A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client?
A) Moist mucous membranes
B) Urinary frequency
C) Poor skin turgor
D) Increased blood pressure
The correct answer is C: Poor skin turgor
The specific gravity value is high, indicating dehydration. Poor skin turgor (tenting of the skin) is consistent with this problem
20. The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB?
A) Tuberculin skin testing
B) Sputum culture
C) White blood cell count
D) Chest x-ray
The correct answer is B: Sputum culture The sputum culture is the most accurate method for determining the presence of active TB.