1) 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
Your response was "A". The correct answer is D: A hospitalized middle aged client receiving clindamycin Hospitalized patients, especially those receiving antibiotic therapy, are primary targets for C. difficile. Of patients receiving antibiotics, 5-38% experience antibiotic-associated diarrhea; C. difficile causes 15 to 20% of the cases. Several antibiotic agents have been associated with C. difficile. Broad-spectrum agents, such as clindamycin, ampicillin, amoxicillin, and cephalosporins, are the most frequent sources of C. difficile. Also, C. difficile infection has been caused by the administration of agents containing beta-lactamase inhibitors (ie, clavulanic acid, sulbactam, tazobactam) and intravenous agents that achieve substantial colonic intraluminal concentrations (ie, ceftriaxone, nafcillin, oxacillin). Fluoroquinolones, aminoglycosides, vancomycin, and trimethoprim are seldom associated with C. difficile infection or pseudomembranous colitis.
2) The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse do 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
Your response was "B". The correct answer is D: Permit handling the equipment before putting the cuff in place The best way to gain the toddler''s cooperation is to encourage handling the equipment. Detailed explanations are not helpful.
3) The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is
A) A firm touch to the trapezius muscle or arm
B) Pinching any body part
C) Sternal rub
D) Gentle pressure on eye orbit
The correct answer is D: Gentle pressure on eye orbit This is an acceptable stimuli only after progressing from lighter to stimuli to more obnoxious.
4) 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
The correct answer is B: Nausea Because the client with Hodgkin''s disease is usually healthy when therapy begins, the nausea is especially troubling
5) A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these mediations would the nurse anticipate the health care 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
The correct answer is D: Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value Several studies have been conducted in pregnant women where oral anticoagulation agents are contraindicated. Warfarin (Coumadin) is known to cross the placenta and is therefore reported to be teratogenic.
6) 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
The correct answer is D: The loss is within normal limits A newborn is expected to lose 5-10% of the birth weight in the first few days because of changes in elimination and feeding.
7) A client is receiving Total Parenteral Nutrition (TPN) via 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
The correct answer is B: Apply a pressure dressing to the site The client is at risk of bleeding or the development of an air embolus if the catheter exit site is not covered immediately
8) A client with a panic disorder has a new prescription for Xanax (Alpazolam). 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
The correct answer is A: Short-term relief can be expected Xanax is a short-acting benzodiazepine useful in controlling panic symptoms quickly.
9) 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 changes would require the nurse's immediate attention?
A) Increased restlessness
B) Tachycardia
C) Tracheal deviation
D) Tachypnea
The correct answer is C: Tracheal deviation The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency.
10) 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."
The correct answer is C: "This drug will decrease the workload on his heart." One action of beta-blockers is to decrease systemic vascular resistance by dilating arterioles. This is useful for the client with coronary artery disease, and will reduce the risk of another MI or sudden death
11) 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
The correct answer is D: Avoid eating2 hours before going to sleep Eating before sleeping enhances the regurgitation of stomach contents which have increased acidity into the esophagus. Maintaining an upright posture should be for about 2 hours after eating to allow for the stomach emptying. The options A and C are interventions for clients with swallowing difficulties
12) 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
The correct answer is C: Repeat the test in two hours This blood sugar is within the normal range for a full-term newborn. Normal values are: Premature infant: 20-60 mg/dl or 1.1-3.3 mmol/L, Neonate: 30-60 mg/dl or 1.7-3.3 mmol/L, Infant: 40-90 mg/dl or 2.2-5.0 mmol/L. Critical values are: Infant: <40 mg/dl and in a Newborn: <30 and >300 mg/dl. Because of the increased birth weight which can be associated with diabetes mellitus, repeated blood sugars will be drawn.
13) 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
The MMR vaccine should be given now, prior to the transplant MMR is a live virus vaccine, and should be given at this time. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the compromised immune system.
14) A nurse admits a client transferred from the emergency room. The client, diagnosed with a myocardial infarction, is complaining of substernal chest pain, diaphoresis and nausea. The first action by the nurse should be
A) Order an EKG
B) Administer morphine sulphate
C) Start an IV
D) Measure vital signs
Your response was "A". The correct answer is B: Administer pain medication as ordered Decreasing the clients pain is the most important priority at this time. As long as pain is present there is danger in extending the infarcted area. Morphine will decrease the oxygen demands of the heart and act as a mild diuretic as well.
15) 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
The correct answer is C: Altered parenting The cocaine abusing mother puts her newborn and other children at risk for neglect and abuse. Continuing to use drugs has the potential to impact parenting behaviors. Social service referrals are indicated
16) 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."
The correct answer is B: "He has had an ear infection for the past 2 days." Contributing factors to seizures in children include those such as age (more common in first 2 years), infections (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention
17) Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy?
A) Benzodiazephines
B) Chlorpromazine (Thorazine)
C) Succinylcholine (Anectine)
D) Thiopental sodium (Pentothal Sodium)
The correct answer is C: Succinylcholine (Anectine) Succinylcholine is given intravenously to promote skeletal relaxation
18) A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediatley report which of these?
A) Double vision and visual halos
B) Extremity tingling and numbness
C) Confusion and lightheadedness
D) Sensitivity of sunlight
The correct answer is B: Extremity tingling and numbness Peripheral neuropathy is the most common side effect of INH and should be reported to the health care provider; it can be reversed.
19) 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
The correct answer is A: Encourage child to engage in activities in the playroom According to Erikson, the school age child is in the stage of industry versus inferiority. To help them achieve industry, the nurse should encourage them to carry out tasks and activities in their room or in the playroom
20) 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
The correct answer is A: The client''s self-report is the most important consideration Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but not the priority.
source: NCSBN
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