1. A 78 year-old client with pneumonia has a productive cough but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration?
a. Suction the client frequently while restrained
b. Secure all 4 restraints to 1 side of bed
c. Obtain a sitter for the client while restrained
d. Request an order for a cough suppressant
The correct answer is C: Obtain a sitter for the client while restrained
The plan to use safety devices (restraints) should be rethought. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These are to be provided by the facility in the event the family cannot do so. This client needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.
2. On daily cleaning of a tracheostomy, the client coughs and displaces the tracheostomy tube. The nurse could have avoided this by
A) placing an obturator at the client’s bedside
B) having another nurse assist with the procedure
C) fastening clean tracheostomy ties before removing old ties
D) Withdraw catheter in a circular motion
The correct answer is C: fastening clean tracheostomy ties before removing old ties
Fastening clean tracheostomy ties before removing old ones will ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the airway open only after the tracheostomy outer tube is coughed out. A second nurse is not needed. Changing the position may not prevent a dislodged tracheostomy.
3. Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
A) Venturi mask
B) Partial rebreather mask
C) Non-rebreather mask
D) Simple face mask
The correct answer is C: Non-rebreather mask
The non-rebreather mask has a one-way valve that prevents exhales air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of oxygen is available.
4. A newborn has hyperbilirubinemia and is undergoing phototherapy with a blanket. Which safety measure is most important during this process?
A) Regulate the neonate’s temperature using a radiant heater
B) Withhold feedings while under the phototherapy
C) Provide water feedings at least every 2 hours
D) Protect the eyes of neonate from the phototherapy lights
The correct answer is C: Provide water feedings at least every 2 hours
Since the blanket is used the protection of the eyes is inappropriate. Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights. It is recommended that the neonate remain under the lights for extended periods.The neonate’s skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin through the bowel in the stool
5. A newborn has hyperbilirubinemia and is undergoing phototherapy with a blanket. Which safety measure is most important during this process?
A) Regulate the neonate’s temperature using a radiant heater
B) Withhold feedings while under the phototherapy
C) Provide water feedings at least every 2 hours
D) Protect the eyes of neonate from the phototherapy lights
The correct answer is C: Provide water feedings at least every 2 hours
Since the blanket is used the protection of the eyes is inappropriate. Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights. It is recommended that the neonate remain under the lights for extended periods.The neonate’s skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin through the bowel in the stool
6. A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client’s greatest risk factors for osteoporosis?
A) Menopause at age 50
B) Has taken high doses of steroids for arthritis for many years
C) Maintains an inactive lifestyle for the past 10 years
D) Drinks 2 glasses of red wine each day for the past 30 years
The correct answer is B: Takes steroids for arthritis
The use of steroids especially high doses over time increases the risk for osteoporosis. Other risk factors are in each option, as well as low bone mass, poor calcium absorption and moderate to high alcohol ingestion
7. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
A) Drink small amounts of liquids frequently
B) Eat the evening meal just before retiring
C) Take sodium bicarbonate after each meal
D) Sleep with head propped on several pillows
The correct answer is D: Sleep with head propped on several pillows
Heartburn is a burning sensation caused by regurgitation of gastric contents that is best relieved by sleeping position, eating small meals, and not eating before bedtime.
8. A 16 year-old boy is admitted for Ewing's sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the initial treatment most often includes
A) Amputation just above the tumor
B) Surgical excision of the mass
C) Bone marrow graft in the affected leg
D) Radiation and chemotherapy
The correct answer is D: Radiation and chemotherapy
The initial treatment of choice for Ewing''s sarcoma is a combination of radiation and chemotherapy.
9. A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process?
A) Disruption of fetal glucose supply
B) Pancreatic insufficiency
C) Maternal insulin dependency
D) Reduced glycogen reserves
The correct answer is A: Disruption of fetal glucose supply
After delivery, the high glucose levels which crossed the placenta to the fetus are suddenly stopped. The newborn continues to secrete insulin in anticipation of glucose. When oral feedings begin, the newborn will adjust insulin production within a day or two.
10. Which of the following situations is most likely to produce sepsis in the neonate?
A) Maternal diabetes
B) Prolonged rupture of membranes
C) Cesarean delivery
D) Precipitous vaginal birth
The correct answer is B: Prolonged rupture of membranes
Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.
11. The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to
A) Restrict visitors to immediate family
B) Avoid arousal of the client except for family visits
C) Keep client's hips flexed at no less than 90 degrees
D) Apply a warming blanket for temperatures of 98 degrees Fahrenheit or less
The correct answer is A: Restrict visitors to immediate family
Maintaining a quiet environment will assist in minimizing cerebral rebleeding. When family visit the client should not be distrubed. However if the client is awake topics of a general nature are better choices for discussion than topics that result in emotional or physiological stimulation
12. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
A) Neurotoxicity
B) Hepatomegaly
C) Nephrotoxicity
D) Ototoxicity
The correct answer is C: Nephrotoxicity
Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general
13. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?
A) "I'm going to try feeding my baby some rice cereal."
B) "When he wakes at night for a bottle, I feed him."
C) "I dip his pacifier in honey so he'll take it."
D) "I keep formula in the refrigerator for 24 hours."
The correct answer is C: "I dip his pacifier in honey so he''ll take it."
Honey has been associated with infant botulism and should be avoided. Older children and adults have digestive enzymes that kill the botulism spores.
14. In addition to standard precautions, a nurse should implement contact precautions for which client?
A) 60 year-old with herpes simplex
A) B) 6 year-old with mononucleosis
B) 45 year-old with pneumonia
C) 3 year-old with scarlet fever
The correct answer is A: 60 year-old with herpes simplex
Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.
15. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering
A) Pulmonary embolectomy
B) Vena caval interruption
C) Increasing the coumadin therapy to an INR of 3-4
D) Thrombolytic therapy
The correct answer is B: Vena caval interruption
Clients with contraindications to heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.
16. The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When comparing findings to the Ballard scale, which situation may affect the score?
A) Birth weight
B) Racial differences
C) Fetal distress in labor
D) Birth trauma
The correct answer is C: Fetal distress in labor
The effects of earlier distress may alter the findings of reflex responses as measured on the Ballard tool. Other physical characteristics that estimate gestational age, such as amount of lanugo, sole creases and ear cartilage, are unaffected.
17. When suctioning a client's tracheostomy, the nurse should instill saline in order to
A) Decrease the client's discomfort
B) Reduce viscosity of secretions
C) Prevent client aspiration
D) Remove a mucus plug
The correct answer is D: Remove a mucus plug
Saline will thin and loosen secretions, making it easier to suction
18. The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information?
A) "I usually avoid driving at night since lights sometimes seem to make things blur."
B) "I take half of the usual dose for my sinuses to maintain my blood pressure."
C) "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem."
D) "I take extra fiber and drink lots of water to avoid getting constipated."
The correct answer is D: "I take extra fiber and drink lots of water to avoid getting constipated."
Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase intraocular pressure.
19. The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspect of this care is
".
A) Sedation as needed to prevent exhaustion
B) Antibiotic therapy for 10 to 14 days
C) Humidified air and increased oral fluids
D) Antihistamines to decrease allergic response
The correct answer is C: Humidified air and increased oral fluids
The most important aspect of home care for a child with acute spasmodic croup is to provide humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids is mucocillary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing.
20. Decentralized scheduling is used on a nursing unit. A cheif advantage of this management strategy is that it
A) Considers client and staff needs
B) Conserves time for planning
C) Frees the nurse manager to handle other priorities
D) Allows for requests about special privileges
The correct answer is A: Considers client and staff needs
Decentralized staffing takes into consideration specific client needs and staff interests and abilities.
source: NCSBN
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