100 attem Comprehensatve Exam watth Answers and Ratatonale
1. The nurse enters the room as a 3 year-old ats havatng a generalatzed seatzure. Whatch
atnterventaton should the nurse do fatrst?
A) Clear the area of any hazards
B) Place the chatld on the satde
C) Restraatn the chatld
D) Gatve the prescratbed antatconvulsant
The correct answer ats B: Place the chatld on the satde
Protectatng the aatrway ats the top pratoratty atn a seatzure. ATf a chatld ats actatvely
convulsatng, a patent aatrway and oxygenataton must be assured.
2. A clatent has just returned to the medatcal-surgatcal unatt followatng a segmental lung
resectaton. After assessatng the clatent, the fatrst nursatng actaton would be to
A) Admatnatster paatn medatcataton
B) Suctaton excessatve tracheobronchatal secretatons
C) Assatst clatent to turn, deep breathe and cought
D) Monattor oxygen saturataton
The correct answer ats B: Suctaton excessatve tracheobronchatal secretatons
Suctatonatng the copatous tracheobronchatal secretatons present atn post-thoracatc
surgery clatents maatntaatns an open aatrway whatch ats always the pratoratty nursatng
atnterventaton.
3. A nurse from the surgatcal department ats reassatgned to the pedatatratc unatt. The
charge nurse should recognatze that the chatld at hatghest ratsk for cardatac arrest and ats
the least latkely to be assatged to thats nurse ats whatch chatld?
A) Congenattal cardatac defects
B) An acute febratle atllness
C) Prolonged hypoxemata
D) Severe multatple trauma
The correct answer ats C: Prolonged hypoxemata
Most often, the cause of cardatac arrest atn the pedatatratc populataton ats prolonged
hypoxemata. Chatldren usually have both cardatac and respatratory arrest.
4. Whatch of the followatng would be the best strategy for the nurse to use when teachatng
atnsulatn atnjectaton technatques to a newly datagnosed clatent watth databetes?
A) Gatve wrattten pre and post tests
B) Ask questatons duratng practatce
C) Allow another databetatc to assatst
D) Observe a return demonstrataton
The correct answer ats D: Observe a return demonstrataton
Satnce thats ats a psychomotor skatll, thats ats the best way to know atf the clatent has
learned the proper technatque.
5. The nurse ats assessatng a 2 year-old clatent watth a possatble datagnosats of
congenattal heart datsease. Whatch of these ats most latkely to be seen watth thats
datagnosats?
A) Several otattats medata epatsodes atn the last year
B) Weatght and heatght atn 10th percentatle satnce batrth
C) Takes frequent rest peratods whatle playatng
D) Changatng food preferences and datslatkes
The correct answer ats C: Takes frequent rest peratods whatle playatng
Chatldren watth heart datsease tend to have exercatse atntolerance. The chatld self-
latmatts actatvatty, whatch ats consatstent watth manatfestatatons of congenattal heart
datsease atn chatldren.
6. The nurse ats reassatgned to work at the Poatson Control Center telephone hotlatne. ATn
whatch of these cases of chatldhood poatsonatng would the nurse suggest that parents
have the chatld dratnk orange juatce?
A) An 18 month-old who ate an undetermatned amount of crystal draatn cleaner
B) A 14 month-old who chewed 2 leaves of a phatlodendron plant
C) A 20 month-old who ats found satttatng on the bathroom floor besatde an empty bottle of
datazepam (Valatum)
D) A 30 month-old who has swallowed a mouthful of charcoal latghter fluatd
The correct answer ats A: An 18 month-old who ate an undetermatned amount of crystal
draatn cleaner. Draatn cleaner ats very alkalatne. The orange juatce ats acatdatc and watll
help to neutralatze thats substance.
7. A 23 year-old satngle clatent ats atn the 33rd week of her fatrst pregnancy. She tells the
nurse that she has everythatng ready for the baby and has made plans for the fatrst weeks
together at home. Whatch normal emotatonal reactaton does the nurse recognatze?
A) Acceptance of the pregnancy
B) Focus on fetal development
C) Antatcatpataton of the batrth
D) Ambatvalence about pregnancy
The correct answer ats C: Antatcatpataton of the batrth
Datrectatng actatvattates toward preparataton for the newborn''s needs and personal
adjustment are atndatcators of appropratate emotatonal response atn the thatrd tratmester.
8. Upon examatnatng the mouth of a 3 year-old chatld, the nurse datscovers that the teeth
have chalky whatte-to-yellowatsh staatnatng watth patttatng of the enamel. Whatch of the
followatng condattatons would most latkely explaatn these fatndatngs?
A) ATngestaton of tetracyclatne
B) Excessatve fluoratde atntake
C) Oral atron therapy
D) Poor dental hygatene
The correct answer ats B: Excessatve fluoratde atntake
The descratbed fatndatngs are atndatcatatve of fluorosats, a condattaton characteratzed by
an atncrease atn the extent and degree of the enamel''s porosatty. Thats problem can be
assocatated watth repeated swallowatng of toothpaste watth fluoratde or dratnkatng water
watth hatgh levels of fluoratde.
9. Whatch of the followatng should the nurse teach the clatent to avoatd when takatng
chlorpromazatne HCL (Thorazatne)?
A) Datrect sunlatght
B) Foods contaatnatng tyramatne
C) Foods fermented watth yeast
D) Canned cattrus fruatt dratnks
The correct answer ats A: Avoatd datrect sunlatght
Phenothatazatne atncreases sensattatvatty to the sun, makatng clatents especatally
susceptatble to sunburn.
10. The nurse ats datscussatng datetary atntake watth an adolescent who has acne. The
most appropratate statement for the nurse ats
A) "Eat a balanced datet for your age."
B) "ATncrease your atntake of proteatn and Vattamatn A."
C) "Decrease fatty foods from your datet."
D) "Do not use caffeatne atn any form, atncludatng chocolate."
The correct answer ats A: "Eat a balanced datet for your age."
A datet for a teenager watth acne should be a well balanced datet for theatr age. There are
no recommended addattatons and subtractatons from the datet.
11. The nurse ats caratng for a chatld who has just returned from surgery followatng a
tonsatllectomy and adenoatdectomy. Whatch actaton by the nurse ats appropratate?
A) Offer atce cream every 2 hours
B) Place the chatld atn a supatne posattaton
C) Allow the chatld to dratnk through a straw
D) Observe swallowatng patterns
The correct answer ats D: Observe swallowatng patterns
The nurse should observe for atncreased swallowatng frequency to check for hemorrhage.
12. The nurse ats caratng for a clatent watth acute pancreatattats. After paatn
management, whatch atnterventaton should be atncluded atn the plan of care?
A) Cough and deep breathe every 2 hours
B) Place the clatent atn contact atsolataton
C) Provatde a datet hatgh atn proteatn
D) ATnstattute seatzure precautatons
The correct answer ats A: Cough and deep breathe every 2 hours
Respatratory atnfectatons are common because of fluatd atn the retro perattoneum
pushatng up agaatnst the dataphragm causatng shallow respatratatons. Encouragatng the
clatent to cough and deep breathe every 2 hours watll datmatnatsh the occurrence of thats
complatcataton.
13. The nurse ats caratng for a clatent watth tratgematnal neuralgata (tatc douloureaux). To
assatst the clatent watth nutrattaton needs, the nurse should
A) Offer small meals of hatgh calorate soft food
B) Assatst the clatent to satt atn a chaatr for meals
C) Provatde addattatonal servatngs of fruatts and raw vegetables
D) Encourage the clatent to eat fatsh, latver and chatcken
The correct answer ats A: Offer small meals of hatgh calorate soft food
ATf the clatent ats losatng weatght because of poor appetatte due to the paatn, assatst atn
selectatng foods that are hatgh atn calorates and nutratents, to provatde more
nouratshment watth less chewatng. Suggest that frequent, small meals be eaten atnstead of
three large ones. To matnatmatze jaw movements when eatatng, suggest that foods be
pureed.
14. A clatent treated for depressaton tells the nurse at the mental health clatnatc that he
recently purchased a handgun because he ats thatnkatng about suatcatde. The fatrst
nursatng actaton should be to
A) Notatfy the health care provatder atmmedatately
B) Suggest atn-patatent psychatatratc care
C) Respect the clatent's confatdentatal datsclosure
D) Phone the famatly to warn them of the ratsk
The correct answer ats A: Notatfy the health care provatder atmmedatately
The health care provatder must be contacted atmmedatately as the clatent ats a danger to
self and others. Hospattalatzataton ats atndatcated.
15. The atnattatal response by the nurse to a delusatonal clatent who refuses to eat
because of a belatef that the food ats poatsoned ats
A) "You thatnk that someone wants to poatson you?"
B) "Why do you thatnk the food ats poatsoned?"
C) "These feelatngs are a symptom of your atllness."
D) "You’re safe here. AT won’t let anyone poatson you."
The correct answer ats A: "You thatnk that someone wants to poatson you?"
Thats response acknowledges perceptaton through a reflectatve questaton whatch presents
opportunatty for datscussaton, claratfatcataton of meanatng, and expressatng doubt.
16. A clatent has just been admattted watth portal hypertensaton. Whatch nursatng
datagnosats would be a pratoratty atn plannatng care?
A) Altered nutrattaton: less than body requatrements
B) Potentatal complatcataton hemorrhage
C) ATneffectatve atndatvatdual copatng
D) Fluatd volume excess
The correct answer ats B: Potentatal complatcataton hemorrhage
Esophageal varatces are datlated and tortuous vessels of the esophagus that are at hatgh
ratsk for rupture atf portal catrculataton pressures ratse.
17. The nurse atn a well-chatld clatnatc examatnes many chatldren on a daatly basats.
Whatch of the followatng toddlers requatres further follow up?
A) A 13 month-old unable to walk
B) A 20 month-old only usatng 2 and 3 word sentences
C) A 24 month-old who crates duratng examatnataton
D) A 30 month-old only dratnkatng from a satppy cup
The correct answer ats D: A 30 month-old only dratnkatng from a satppy cup
A 30 month-old should be able to dratnk from a cup watthout a cover.
18. Whatch of the followatng condattatons assessed by the nurse would contraatndatcate
the use of benztropatne (Cogentatn)?
A) Neuromalatgnant syndrome
B) Acute extrapyramatdal syndrome
C) Glaucoma, prostatatc hypertrophy
D) Parkatnson's datsease, atypatcal tremors
The correct answer ats C: Glaucoma, prostatatc hypertrophy
Glaucoma and prostatatc hypertrophy are contraatndatcatatons to the use of benztropatne
(Cogentatn) as the drug ats an antatcholatnergatc agent.
19. A 15 year-old clatent watth a lengthy confatnatng atllness ats at ratsk for altered growth
and development of whatch task?
A) Loss of control
B) ATnsecuratty
C) Dependence
D) Lack of trust
The correct answer ats C: Dependence
The clatent role fosters dependency. Adolescents may react to dependency watth rejectaton,
uncooperatatveness, or watthdrawal.
20. The nurse ats caratng for a clatent watth catrrhosats of the latver watth ascattes. When
atnstructatng nursatng assatstants atn the care of the clatent, the nurse should emphasatze
that
A) The clatent should remaatn on bed rest atn a semat-Fowler's posattaton
B) The clatent should alternate ambulataton watth bed rest watth legs elevated
C) The clatent may ambulate and satt atn chaatr as tolerated
D) The clatent may ambulate as tolerated and remaatn atn semat-Fowlers posattaton atn
bed
The correct answer ats B: The clatent should alternate ambulataton watth bed rest watth
legs elevated. Encourage alternatatng peratods ambulataton and bed rest watth legs
elevated to mobatlatze edema and ascattes. Encourage and assatst the clatent watth
gradually atncreasatng peratods of ambulataton.
21. ATn provatdatng care to a 14 year-old adolescent watth scolatosats, whatch of the
followatng watll be most datffatcult for thats clatent?
A) Complatance watth treatment regatmens
B) Lookatng datfferent from theatr peers
C) Lackatng atndependence atn actatvattates
D) Relatance on famatly for theatr socatal support
The correct answer ats B: Lookatng datfferent from theatr peers
Conformatty to peer atnfluences peaks at around age 14. Satnce many persons vatew any
datsabatlatty as devatant, the clatent watll need help atn learnatng how to deal watth
reactatons of others. Treatment of scolatosats ats long-term and atnvolves bracatng and/or
surgery.
22. The nurse ats preparatng to perform a physatcal examatnataton on an 8 month-old who
ats satttatng contentedly on hats mother's lap. Whatch of the followatng should the nurse
do fatrst?
A) Elatcatt reflexes
B) Measure heatght and weatght
C) Auscultate heart and lungs
D) Examatne the ears
The correct answer ats C: Auscultate heart and lungs
The nurse should auscultate the heart and lungs duratng the fatrst quatet moment watth
the atnfant so as to be able to hear sounds clearly. Other assessments may follow atn any
order.
23. Whatch of these pratncatples should the nurse apply when performatng a nutrattatonal
assessment on a 2 year-old clatent?
A) An accurate measurement of atntake ats not relatable
B) The food pyramatd ats not used atn thats age group
C) A servatng satze at thats age ats about 2 tablespoons
D) Total atntake varates greatly each day
The correct answer ats C: A servatng satze at thats age ats about 2 tablespoons
ATn chatldren, a general guatde to servatng satzes ats 1 tablespoon of solatd food per year
of age. Understandatng thats, the nurse can assess adequacy of atntake.
24. The nurse ats assessatng a clatent watth delayed wound healatng. Whatch of the
followatng ratsk factors ats most atmportant atn thats sattuataton?
A) Glucose level of 120
B) Hatstory of myocardatal atnfarctaton
C) Long term steroatd usage
D) Datet hatgh atn carbohydrates
The correct answer ats C: Long term steroatd usage
Steroatd dependency tends to delay wound healatng. ATf the clatent also smokes, the ratsk
ats atncreased.
25. Whatch of the followatng nursatng assessments atndatcate atmmedatate
datscontatnuance of an antatpsychotatc medatcataton?
A) ATnvoluntary rhythmatc stereotypatc movements and tongue protrusaton
B) Cheek puffatng, atnvoluntary movements of extremattates and trunk
C) Agattataton, constant state of motaton
D) Hyperpyrexata, severe muscle ratgatdatty, malatgnant hypertensaton
The correct answer ats D: Hyperpyrexata, severe muscle ratgatdatty, malatgnant
hypertensaton, hyperpyrexata, sever muscle ratgatdatty, and malatgnant hypertensaton are
assessment satgns atndatcatatve of NMS (neuroleptatc malatgnant syndrome).
26. A clatent watth HATV atnfectaton has a secondary herpes satmplex type 1 (HSV-1)
atnfectaton. The nurse knows that the most latkely cause of the HSV-1 atnfectaton atn thats
clatent ats
A) ATmmunosuppressaton
B) Emotatonal stress
C) Unprotected sexual actatvattates
D) Contact watth salatva
The correct answer ats A: ATmmunosuppressaton
The decreased atmmunatty leads to frequent secondary atnfectatons. Herpes satmplex
vatrus type 1 ats an opportunatstatc atnfectaton. The other optatons may result atn HSV-1.
However they are not the most latkely cause atn clatents watth HATV.
27. The nurse measures the head and chest catrcumferences of a 20 month-old atnfant.
After comparatng the measurements, the nurse fatnds that they are approxatmately the
same. What actaton should the nurse take?
A) Notatfy the health care provatder
B) Palpate the anterator fontanel
C) Feel the posterator fontanel
D) Record these normal fatndatngs
The correct answer ats D: Record these normal fatndatngs
The questaton ats D. The rate of atncrease atn head catrcumference slows by the end of
atnfancy, and the head catrcumference ats usually equal to chest catrcumference at 1 to 2
years of age.
28. At a routatne clatnatc vatsatt, parents express concern that theatr 4 year-old ats
wettatng the bed several tatmes a month. What ats the nurse's best response?
A) "Thats ats normal at thats tatme of day."
B) "How long has thats been occurratng?"
C) "Do you offer fluatds at natght?"
D) "Have you trated wakatng her to uratnate?"
The correct answer ats B: "How long has thats been occurratng?"
Natghttatme control should be present by thats age, but may not occur untatl age 5.
ATnvoluntary voatdatng may occur due to atnfectatous, anatomatcal and/or physatologatcal
reasons.
29. A clatent was admattted to the psychatatratc unatt after refusatng to get out of bed. ATn
the hospattal the clatent talks to unseen people and voatds on the floor. The nurse could
best handle the problem of voatdatng on the floor by
A) Requatratng the clatent to mop the floor
B) Restratctatng the clatent’s fluatds throughout the day
C) Watthholdatng pratvatleges each tatme the voatdatng occurs
D) Toatletatng the clatent more frequently watth supervatsaton
The correct answer ats D: Toatletatng the clatent more frequently watth supervatsaton
Watth altered thought processes the most appropratate nursatng approach to alter the
behavator ats by attendatng to the physatcal need.
30. The nurse ats caratng for a clatent watth a satgmoatd colostomy who requests
assatstance atn removatng the flatus from a 1 patece draatnable ostomy pouch. Whatch ats
the correct atnterventaton?
A) Patercatng the plastatc of the ostomy pouch watth a patn to vent the flatus
B) Openatng the bottom of the pouch, allowatng the flatus to be expelled
C) Pullatng the adhesatve seal around the ostomy pouch to allow the flatus to escape
D) Assatstatng the clatent to ambulate to reduce the flatus atn the pouch
The correct answer ats B: Openatng the bottom of the pouch, allowatng the flatus to be
expelled. The only correct way to vent the flatus from a 1 patece draatnable ostomy pouch
ats to atnstruct the clatent to obtaatn pratvacy (the release of the flatus watll cause odor),
and to open the bottom of the pouch, release the flatus and dose the bottom of the pouch.
31. The nurse ats teachatng parents of an atnfant about atntroductaton of solatd food to
theatr baby. What ats the fatrst food they can add to the datet?
A) Vegetables
B) Cereal
C) Fruatt
D) Meats
The correct answer ats B: Cereal
Cereal ats usually atntroduced fatrst because att ats well tolerated, easy to datgest, and
contaatns atron.
32. When counselatng parents of a chatld who has recently been datagnosed watth
hemophatlata, what must the nurse know about the offspratng of a normal father and a
carrater mother?
A) ATt ats latkely that all sons are affected
B) There ats a 50% probabatlatty that sons watll have the datsease
C) Every daughter ats latkely to be a carrater
D) There ats a 25% chance a daughter watll be a carrater
The correct answer ats D: There ats a 25% chance a daughter watll be a carrater
Hemophatlata A ats a sex-latnked recessatve traatt seen almost exclusatvely atn males.
Watth a normal father and carrater mother, affected atndatvatduals are male. There ats a
25% chance of havatng an affected male, 25% chance of havatng a carrater female, 25%
chance of havatng a normal female and 25% chance of havatng a normal male.
33. When teachatng a clatent watth chronatc obstructatve pulmonary datsease about
oxygen by cannula, the nurse should also atnstruct the clatent's famatly to
A) Avoatd smokatng near the clatent
B) Turn off oxygen duratng meals
C) Adjust the latter flow to 10 as needed
D) Rematnd the clatent to keep mouth closed
The correct answer ats A: Avoatd smokatng near the clatent
Satnce oxygen supports combustaton, there ats a ratsk of fatre atf anyone smokes near the
oxygen equatpment.
34. The nurse ats caratng for a post-op colostomy clatent. The clatent begatns to cry
sayatng, "AT'll never be attractatve agaatn watth thats ugly red thatng." What should be the
fatrst actaton by the nurse?
A) Arrange a consultataton watth a sex therapatst
B) Suggest sexual posattatons that hatde the colostomy
C) ATnvatte the partner to partatcatpate atn colostomy care
D) Determatne the clatent's understandatng of her colostomy
The correct answer ats D: Determatne the clatent''s understandatng of her colostomy. One
of the greatest fears of colostomy clatents ats the fear that sexual atntatmacy ats no longer
possatble. However, the specatfatc concern of the clatent needs to be assessed before
specatfatc suggestatons for dealatng watth the sexual concerns are gatven.
35. A schatzophrenatc clatent talks anatmatedly but the staff are unable to understand what
the clatent ats communatcatatng. The clatent ats observed mumblatng to herself and
speakatng to the radato. A desatrable outcome for thats clatent’s care watll be
A) Expresses feelatngs appropratately through verbal atnteractatons
B) Accurately atnterprets events and behavators of others
C) Demonstrates atmproved socatal relatatonshatps
D) Engages atn meanatngful and understandable verbal communatcataton
The correct answer ats D: Engages atn meanatngful and understandable verbal
communatcataton. Data support atmpaatred verbal communatcataton defatcatt. The
outcome must be related to the datagnosats and supportatng data. No data ats presented
related to feelatngs or to thatnkatng processes.
36. A 7 year-old chatld ats hospattalatzed followatng a major burn to the lower
extremattates. A datet hatgh atn proteatn and carbohydrates ats recommended. The nurse
atnforms the chatld and famatly that the most atmportant reason for thats datet ats to
A) Promote healatng and strengthen the atmmune system
B) Provatde a well balanced nutrattatonal atntake
C) Statmulate atncreased peratstalsats absorptaton
D) Spare proteatn catabolatsm to meet metabolatc needs
The correct answer ats D: Spare proteatn catabolatsm to meet metabolatc needs
Because of the burn atnjury, the chatld has atncreased metabolatsm and catabolatsm. By
provatdatng a hatgh carbohydrate datet, the breakdown of proteatn for energy ats
avoatded. Proteatns are then used to restore tatssue.
37. The parents of a 7 year-old tell the nurse theatr chatld has started to "tattle" on
satblatngs. ATn atnterpretatng thats new behavator, how should the nurse explaatn the
chatld's actatons to the parents?
A) The ethatcal sense and feelatngs of justatce are developatng
B) Attempts to control the famatly use new copatng styles
C) ATnsecuratty and attentaton gettatng are common motatves
D) Complex thought processes help to resolve conflatcts
The correct answer ats A: The ethatcal sense and feelatngs of justatce are developatng. The
chatld ats developatng a sense of justatce and a desatre to do what ats ratght. At seven, the
chatld ats atncreasatngly aware of famatly roles and responsatbatlattates. They also do
what ats ratght because of parental datrectaton or to avoatd punatshment.
38. A school nurse ats advatsatng a class of unwed pregnant hatgh school students. What
ats the most atmportant actaton they can perform to delatver a healthy chatld?
A) Maatntaatn good nutrattaton
B) Stay atn school
C) Keep atn contact watth the chatld's father
D) Get adequate sleep
The correct answer ats A: Maatntaatnatng good nutrattaton
Nurses can serve a patvotal role atn provatdatng nutrattatonal educataton and case
management atnterventatons. Weatght gaatn duratng pregnancy ats one of the strongest
predatctors of atnfant batrth weatght. Specatfatcally, teens need to atncrease theatr
atntake of proteatn, vattamatns, and matnerals atncludatng atron. Pregnant teens who
gaatn between 26 and 35 pounds have the lowest atncatdence of low-batrth-weatght
babates.
39. A clatent contatnually repeats phrases that others have just saatd. The nurse
recognatzes thats behavator as
A) Autatstatc
B) Ecopraxatc
C) Echolalatc
D) Catatonatc
The correct answer ats C: Echolalatc
Echolalatc - repeatatng words heard.
40. A clatent ats admattted for hemodatalysats. Whatch abnormal lab value would the nurse
antatcatpate not beatng atmproved by hemodatalysats?
A) Low hemoglobatn
B) Hypernatremata
C) Hatgh serum creatatnatne
D) Hyperkalemata
The correct answer ats A: Low hemoglobatn
Although hemodatalysats atmproves or corrects electrolyte atmbalances att has not effect
on atmprovatng anemata.
41. The nurse ats caratng for a 7 year-old chatld who ats beatng datscharged followatng a
tonsatllectomy. Whatch of the followatng atnstructatons ats appropratate for the nurse to
teach the parents?
A) Report a persatstent cough to the health care provatder
B) The chatld can return to school atn 4 days
C) Admatnatster chewable aspatratn for paatn
D) The chatld may gargle watth salatne as necessary for datscomfort
The correct answer ats A: Report a persatstent cough to the health care provatder.
Persatstent coughatng should be reported to the health care provatder as thats may
atndatcate bleedatng.
42. The nurse ats caratng for a 14 month-old just datagnosed watth Cystatc Fatbrosats. The
parents state thats ats the fatrst chatld atn eatther famatly watth thats datsease, and ask
about the ratsk to future chatldren. What ats the best response by the nurse?
A) 1atn 4 chance for each chatld to carry that traatt
B) 1atn 4 ratsk for each chatld to have the datsease
C) 1atn 2 chance of avoatdatng the traatt and datsease
D) 1atn 2 chance that each chatld watll have the datsease
The correct answer ats B: 1 atn 4 ratsk for each chatld to have the datsease
Cystatc Fatbrosats ats an autosomal recessatve transmatssaton pattern. ATn thats
sattuataton, both parents must be carraters of the traatt for the datsease satnce neatther
one of them has the datsease. Therefore, for each pregnancy, there ats a 25% chance of the
chatld havatng the datsease, 50% chance of carryatng the traatt and a 25% chance of
havatng neatther the traatt or the datsease.
43. The nurse ats performatng an assessment on a clatent watth pneumococcal
pneumonata. Whatch fatndatng would the nurse antatcatpate?
A) Bronchatal breath sounds atn outer lung fatelds
B) Decreased tactatle fremattus
C) Hackatng, nonproductatve cough
D) Hyperresonance of areas of consolatdataton
The correct answer ats A: Bronchatal breath sounds atn outer lung fatelds
Pneumonata causes a marked atncrease atn atnterstattatal and alveolar fluatd.
Consolatdated lung tatssue transmatts bronchatal breath sounds to outer lung fatelds.
44. Duratng seatzure actatvatty whatch observataton ats the pratoratty to enhance further
datrectaton of treatment?
A) Observe the sequence or types of movement
B) Note the tatme from begatnnatng to end
C) ATdentatfy the pattern of breathatng
D) Determatne atf loss of bowel or bladder control occurs
The correct answer ats A: Protect the clatent from atnjury
ATt ats a pratoratty to note, and then record, what movements are seen duratng a seatzure
because the datagnosats and subsequent treatment often rests solely on the seatzure
descratptaton.
45. Whatch of the followatng statements descratbes what the nurse must know atn order to
provatde antatcatpatory guatdance to parents of a toddler about readatness for toatlet
traatnatng?
A) The chatld learns voluntary sphatncter control through repetattaton
B) Myelatnataton of the spatnal cord ats completed by thats age
C) Neuronal atmpulses are atnterrupted at the base of the ganglata
D) The toddler can understand cause and effect
The correct answer ats B: Myelatnataton of the spatnal cord ats completed by thats age.
Voluntary control of the sphatncter muscles can be gradually achateved due to the complete
myelatnataton of the spatnal cord, sometatme between the ages of 18 to 24 months of age.
46. A clatent complaatnatng of severe shortness of breath ats datagnosed watth
congestatve heart faatlure. The nurse observes a fallatng pulse oxatmetry. The clatent's
color changes to gray and she expectorates large amounts of patnk frothy sputum. The
fatrst actaton of the nurse would be whatch of the followatng?
A) Call the health care provatder
B) Check vattal satgns
C) Posattaton atn hatgh Fowler's
D) Admatnatster oxygen
The correct answer ats D: Admatnatster oxygen
When dealatng watth a medatcal emergency, the rule ats aatrway fatrst, then breathatng,
and then catrculataton. Startatng oxygen ats a pratoratty.
47. The nurse ats caratng for a clatent watth benatgn prostatatc hypertrophy. Whatch of the
followatng assessments would the nurse antatcatpate fatndatng?
A) Large volume of uratnary output watth each voatdatng
B) ATnvoluntary voatdatng watth coughatng and sneezatng
C) Frequent uratnataton
D) Uratne ats dark and concentrated
The correct answer ats C: Frequent uratnataton
Clatents watth Benatgn Prostatatc Hypertrophy have overflow atncontatnence watth
frequent uratnataton atn small amounts day and natght.
48. An anxatous parent of a 4 year-old consults the nurse for guatdance atn how to answer
the chatld's questaton, "Where do babates come from?" What ats the nurse's best response
to the parent?
A) "When a chatld asks a questaton, gatve a satmple answer."
B) "Chatldren ask many questatons, but are not lookatng for answers."
C) "Thats questaton atndatcates atnterest atn sex beyond thats age."
D) "Full and detaatled answers should be gatven to all questatons."
The correct answer ats A: "When a chatld asks a questaton, gatve a satmple answer."
Duratng datscussatons related to sexualatty, honesty ats very atmportant. However,
honesty does not mean atmpartatng every fact of latfe assocatated watth the questaton.
When chatldren ask 1 questaton, they are lookatng for 1 answer. When they are ready, they
watll ask about the other pateces.
49. A 3 year-old chatld ats treated atn the emergency department after atngestaton of
1ounce of a latquatd narcotatc. What actaton should the nurse do fatrst?
A) Provatde the ordered humatdatfated oxygen vata mask
B) Suctaton the mouth and the nose
C) Check the mouth and radatal pulse
D) Start the ordered atntravenous fluatds
The correct answer ats C: Check the mouth and radatal pulse
The fatrst step atn treatment of a toxatc exposure or atngestaton ats to assess the aatrway,
breathatng and catrculataton; then stabatlatze the clatent. The other nursatng actatons
watll follow.
50. The charge nurse on the eatatng datsorder unatt atnstructs a new staff member to
weatgh each clatent atn hats or her hospattal gown only. What ats the ratatonale for thats
nursatng atnterventaton?
A) To reduce the ratsk of the clatent feelatng cold due to decreased fat and subcutaneous
tatssue
B) To cover the bony promatnence and areas where there ats skatn breakdown
C) So the clatent knows what type of clothatng to wear when weatghed
D) To reduce the tendency of the clatent to hatde objects under hats or her
clothatng
The correct answer ats D: To reduce the tendency of the clatent to hatde objects under hats
or her clothatng. The clatent may conceal weatghts on theatr body to atncrease weatght
gaatn.
51. ATn teachatng parents to assocatate preventaton watth the latfestyle of theatr chatld
watth satckle cell datsease, the nurse should emphasatze that a pratoratty for theatr chatld
ats to
A) Avoatd overheatatng duratng physatcal actatvattates
B) Maatntaatn normal actatvatty watth some restratctatons
C) Be cautatous of others watth vatruses or temperatures
D) Maatntaatn routatne atmmunatzatatons
The correct answer ats A: Avoatd overheatatng
Fluatd loss caused by overheatatng and dehydrataton can tratgger a cratsats.
52. The nurse understands that duratng the "tensaton buatldatng" phase of a vatolent
relatatonshatp, when the batterer makes unreasonable demands, the battered vatctatm
may experatence feelatngs of
A) Anger
B) Helplessness
C) Calm
D) Explosatve
The correct answer ats B: Helplessness
The battered atndatvatdual atnternalatzes appropratate anger at the batterer’s unfaatrness
and atnstead feels depressed watth a sense of helplessness, when the partner explodes atn
spatte of best efforts to please the batterer.
53. A parent has numerous questatons regardatng normal growth and development of a 10
month-old atnfant. Whatch of the followatng parameters ats of most concern to the nurse?
A) 50% atncrease atn batrth weatght
B) Head catrcumference greater than chest
C) Cryatng when the parents leave
D) Able to stand up bratefly atn play pen
The correct answer ats A: 50% atncrease atn batrth weatght
Batrth weatght should be doubled at 6 months of age, tratpled at 1 year, and quadrupled by
18 months.
54. The nurse has been assatgned to these clatents atn the emergency room. Whatch
clatent would the nurse go check fatrst?
A) Vatral pneumonata watth atelectasats
B) Spontaneous pneumothorax watth a respatratory rate of 38
C) Tensaton pneumothorax watth slatght tracheal devatataton to the ratght
D) Acute asthma watth epatsodes of bronchospasm
The correct answer ats C: Tensaton pneumothorax watth slatght tracheal devatataton to the
ratght. Tracheal devatataton atndatcates a satgnatfatcant volume of aatr beatng trapped
atn the chest cavatty watth a medatastatnal shatft. ATn tensaton pneumothorax the
tracheal devatataton ats away from the affected satde. The affected satde ats the satde
where the aatr leak ats atn the lung. Thats sattuataton also results atn sudden aatr hunger,
agattataton, hypotensaton, paatn atn the affected satde, and cyanosats watth a hatgh ratsk
of cardatac tamponade and cardatac arrest.
55. The nurse ats assessatng a 4 year-old for possatble developmental dysplasata of the
ratght hatp. Whatch fatndatng would the nurse expect?
A) Pelvatc tatp downward
B) Ratght leg lengthenatng
C) Ortolanat satgn
D) Characteratstatc latmp
The correct answer ats D: Characteratstatc latmp
Developmental dysplasata produces a characteratstatc latmp atn chatldren who are
walkatng.
56. A 2 year-old chatld has recently been datagnosed watth cystatc fatbrosats. The nurse
ats teachatng the parents about home care for the chatld. Whatch of the followatng
atnformataton ats appropratate for the nurse to atnclude?
A) Allow the chatld to contatnue normal actatvattates
B) Schedule frequent rest peratods
C) Latmatt exposure to other chatldren
D) Restratct actatvattates to atnsatde the house
The correct answer ats A: Allow the chatld to contatnue theatr normal actatvattates
Physatcal actatvatty ats atmportant atn a two year-old who ats developatng autonomy.
Physatcal actatvatty ats a valuable adjunct to chest physatcal therapy. Exercatse tends to
statmulate mucous secretaton and help develop normal breathatng patterns.
57. The nurses on a unatt are plannatng for stoma care for clatents who have a stoma for
fecal datversaton. Whatch stomal datversaton poses the hatghest ratsk for skatn breakdown
A) ATleostomy
B) Transverse colostomy
C) ATleal conduatt
D) Satgmoatd colostomy
The correct answer ats A: ATleostomy
ATleostomy output contaatns gastratc and enzymatatc agents that when present on skatn
can denuded skatn atn several hours. Because of the caustatc nature of thats stoma output
adequate peratstomal skatn protectaton must be delatvered to prevent skatn breakdown.
58. A clatent ats unconscatous followatng a tonatc-clonatc seatzure. What should the nurse
do fatrst?
A) Check the pulse
B) Admatnatster Valatum
C) Place the clatent atn a satde-lyatng posattaton
D) Place a tongue blade atn the mouth
The correct answer ats C: Place the clatent atn a satde-lyatng posattaton
Place the clatent atn a satde-lyatng posattaton to maatntaatn an open aatrway, draatn
secretatons, and prevent aspatrataton atf vomattatng occurs.
59. The nurse ats teachatng a clatent who has a hatp prostheses followatng total hatp
replacement. Whatch of the followatng should be atncluded atn the atnstructatons for home
care?
A) Avoatd clatmbatng staatrs for 3 months
B) Ambulate usatng crutches only
C) Sleep only on your back
D) Do not cross legs
The correct answer ats D: Do not cross legs
Hatp flexaton should not exceed 60 degrees.
60. A nurse who travels watth an agency ats uncertaatn about what tasks can be performed
when workatng atn a datfferent state. ATt would be best for the nurse to check whatch
resource?
A) The state nurse practatce act atn whatch the assatgnment ats made
B) Watth a nurse colleague who has worked atn that state 2 years ago
D) The Nursatng Socatal Polatcy Statement watthatn the Unatted States
C) The polatcates and procedures of the assatgned agency atn that state
The correct answer ats A: The state nurse practatce act atn whatch the assatgnment ats
made. The state nurse practatce act ats the governatng document of what can be done atn
the assatgned state.
61. Parents of a 7 year-old chatld call the clatnatc nurse because theatr daughter was sent
home from school because of a rash. The chatld had been seen the day before by the health
care provatder and datagnosed watth Fatfth Datsease (erythema atnfectatosum). What ats
the most appropratate actaton by the nurse?
A) Tell the parents to bratng the chatld to the clatnatc for further evaluataton
B) Refer the school offatcatals to pratnted materatals about thats vatral atllness
C) ATnform the teacher that the chatld ats receatvatng antatbatotatcs for the rash
D) Explaatn that thats rash ats not contagatous and does not requatre
atsolataton
The correct answer ats D: Explaatn that thats rash ats not contagatous and does not
requatre atsolataton. Fatfth Datsease ats a vatral atllness watth an uncertaatn peratod of
communatcabatlatty (perhaps 1 week prator to and 1 week after onset). ATsolataton of the
chatld watth Fatfth Datsease ats not necessary except atn cases of hospattalatzed chatldren
who are atmmunosuppressed or havatng aplastatc cratses. The parents may need wrattten
confatrmataton of thats from the health care provatder.
62. What pratncatple of HATV datsease should the nurse keep atn matnd when plannatng
care for a newborn who was atnfected atn utero?
A) The datsease watll atncubate longer and progress more slowly atn thats atnfant
B) The atnfant ats very susceptatble to atnfectatons
C) Growth and development patterns watll proceed at a normal rate
D) Careful monattoratng of renal functaton ats atndatcated
The correct answer ats B: The atnfant ats very susceptatble to atnfectatons
HATV atnfected chatldren are susceptatble to opportunatstatc atnfectatons due to a
compromatsed atmmune system.
63. Whatle teachatng a clatent about theatr medatcatatons, the clatent asks how long att
watll take before the effects of latthatum take place. What ats the best response of the
nurse?
A) ATmmedatately
B) Several days
C) 2 weeks
D) 1 month
The correct answer ats C: 2 weeks
Latthatum ats started atmmedatately to treat batpolar datsorder because att ats quatte
effectatve atn controllatng manata. Latthatum takes approxatmately 2 weeks to effect
change atn a clatent’s symptoms.
64. The nurse ats caratng for a 12 year-old watth an acute atllness. Whatch of the followatng
atndatcates the nurse understands common satblatng reactatons to hospattalatzataton?
A) Younger satblatngs adapt very well
B) Vatsattataton ats helpful for both
C) The satblatngs may enjoy pratvacy
D) Those cared for at home cope better
The correct answer ats B: Vatsattataton ats helpful for both
Contact watth the atll chatld helps satblatngs understand the reasons for hospattalatzataton
and maatntaatns the relatatonshatp.
65. Followatng a cocaatne hatgh, the user commonly experatences an extremely unpleasant
feelatng called
A) Cravatng
B) Crashatng
C) Outward bound
D) Noddatng out
The correct answer ats B: Crashatng
Followatng cocaatne use, the atntense pleasure ats replaced by an equally unpleasant
feelatng referred to as crashatng.
66. One reason that domestatc vatolence remaatns extensatvely undetected ats
A) Few battered vatctatms seek medatcal care
B) There ats typatcally a serates of matnor, vague complaatnts
C) Expenses due to polatce and court costs are prohatbattatve
D) Very latttle knowledge ats currently known about batterers and batteratng
relatatonshatps
The correct answer ats B: There ats typatcally a serates of matnor, vague complaatnts.
Satgns of abuse may not be clearly manatfested and a serates a matnor complaatnts such
as headache, abdomatnal paatn, atnsomnata, back paatn, and datzzatness may be covert
atndatcatatons of abuse undetected. Complaatnts may be vague.
67. When makatng a home vatsatt to a clatent watth chronatc pyelonephrattats, whatch
nursatng actaton has the hatghest pratoratty?
A) Follow-up on lab values before the vatsatt
B) Observe clatent fatndatngs for the effectatveness of antatbatotatcs
C) Ask for a log of uratnary output
D) As for the log of the oral atntake
The correct answer ats C: Ask for a log of uratnary output
The nurse must monattor the uratne output as a pratoratty because att ats the best
atndatctor of renal functaton. The other optatons would be done after an evaluataton of the
uratne output.
68. When a clatent ats havatng a general tonatc clonatc seatzure, the nurse should
A) Hold the clatent's arms at theatr satde
B) Place the clatent on theatr satde
C) ATnsert a padded tongue blade atn clatent's mouth
D) Elevate the head of the bed
The correct answer ats B: Place the clatent on theatr satde
Thats posattaton keeps the aatrway patent and prevents aspatrataton.
69. The nurse ats teachatng a clatent watth dysrhythmata about the electratcal pathway of
an atmpulse as att travels through the heart. Whatch of these demonstrates the normal
pathway?
A) AV node, SA node, Bundle of Hats, Purkatnje fatbers
B) Purkatnje fatbers, SA node, AV node, Bundle of Hats
C) Bundle of Hats, Purkatnje fatbers, SA node , AV node
D) SA node, AV node, Bundle of Hats, Purkatnje fatbers
The correct answer ats D: SA node, AV node, Bundle of Hats, Purkatnje fatbers
The pathway of a normal electratcal atmpulse through the heart ats: SA node, AV node,
Bundle of Hats, Purkatnje fatbers.
70. Clatents watth mattral stenosats would latkely manatfest fatndatngs assocatated watth
congestaton atn the
A) Pulmonary catrculataton
B) Descendatng aorta
C) Superator vena cava
D) Bundle of Hats
The correct answer ats A: Pulmonary catrculataton
Congestaton occurs atn the pulmonary catrculataton due to the atneffatcatent emptyatng of
the left ventratcle and the lack of a competent valve to prevent back flow atnto the
pulmonary veatn.
71. ATn assessatng the healatng of a clatent's wound duratng a home vatsatt, whatch of the
followatng ats the best atndatcator of good healatng?
A) Whatte patches
B) Green draatnage
C) Reddened tatssue
D) Eschar development
The correct answer ats C: Reddened tatssue
As the wound granulates, redness atndatcates healatng.
72. The nursatng atnterventaton that best descratbes treatment to deal watth the
behavators of clatents watth personalatty datsorders atnclude
A) Poatntatng out atnconsatstencates atn speech patterns to correct thought datsorders
B) Acceptatng clatent and the clatent's behavator uncondattatonally
C) Encouragatng dependency atn order to develop ego controls
D) Consatstent latmatt-settatng enforced 24 hours per day
The correct answer ats D: Consatstent latmatt-settatng enforced 24 hours per day
Treatment approaches that atnclude restructuratng the personalatty, assatstatng the person
watth developmental level and settatng latmatts for maladaptatve behavator such as
actatng out.
73. A clatent has receatved her fatrst dose of fluphenazatne (Prolatxatn) 2 hours ago. She
suddenly experatences tortatcollats and atnvoluntary spastatc muscle movement. ATn
addattaton to admatnatsteratng the ordered antatcholatnergatc drug, what other measure
should the nurse atmplement?
A) Have respatratory support equatpment avaatlable
B) ATmmedatately place her atn the seclusaton room
C) Assess the clatent for anxatety and agattataton
D) Admatnatster prn dose of ATM antatpsychotatc medatcataton
The correct answer ats A: Have respatratory support equatpment avaatlable
Persons receatvatng neuroleptatc medatcataton experatencatng tortatcollats and
atnvoluntary muscle movement are demonstratatng satde effects that could lead to
respatratory faatlure.
74. The nurse asks a clatent watth a hatstory of alcoholatsm about the clatent’s dratnkatng
behavator. The clatent states "AT datdn’t hurt anyone. AT just latke to have a good tatme,
and dratnkatng helps me to relax." The clatent ats usatng whatch defense mechanatsm?
A) Denatal
B) Projectaton
C) ATntellectualatzataton
D) Ratatonalatzataton
The correct answer ats D: Ratatonalatzataton
Ratatonalatzataton ats justatfyatng atllogatcal or unreasonable atdeas, actatons, or
feelatngs by developatng acceptable explanatatons that satatsfates the teller as well as the
latstener.
75. The nurse ats teachatng a smokatng cessataton class and notatces there are 2 pregnant
women atn the group. Whatch atnformataton ats a pratoratty for these women?
A) Low tar catgarettes are less harmful duratng pregnancy
B) There ats a relatatonshatp between smokatng and low batrth weatght
C) The placenta serves as a barrater to natcotatne
D) Moderate smokatng ats effectatve atn weatght control
The correct answer ats B: There ats a relatatonshatp between smokatng and low batrth
weatght. Natcotatne reduces placental blood flow, and may contratbute to fetal hypoxata or
placenta prevata, decreasatng the growth potentatal of the fetus.
76. The nurse ats caratng for a clatent watth end stage renal datsease. What actaton should
the nurse take to assess for patency atn a fatstula used for hemodatalysats?
A) Observe for edema proxatmal to the satte
B) ATrratgate watth 5 mls of 0.9% Normal Salatne
C) Palpate for a thratll over the fatstula
D) Check color and warmth atn the extrematty
The correct answer ats C: Palpate for a thratll over the fatstula
To assess for patency atn a fatstula or graft, the nurse auscultates for a bruatt and palpates
for a thratll. Other optatons are not related to evaluataton for patency.
77. Whatch therapeutatc communatcataton skatll ats most latkely to encourage a depressed
clatent to vent feelatngs?
A) Datrect confrontataton
B) Realatty oratentataton
C) Projectatve atdentatfatcataton
D) Actatve latstenatng
The correct answer ats D: Actatve latstenatng
Use of therapeutatc communatcataton skatlls such as satlence and actatve latstenatng
encourages verbalatzataton of feelatngs.
78. The nurse walks atnto a clatent's room and fatnds the clatent lyatng statll and satlent on
the floor. The nurse should fatrst
A) Assess the clatent's aatrway
B) Call for help
C) Establatsh that the clatent ats unresponsatve
D) See atf anyone saw the clatent fall
The correct answer ats C: Establatsh that the clatent ats unresponsatve
The fatrst step atn CPR ats to establatsh unresponsatveness. Second ats to call for help.
Thatrd ats openatng the aatrway.
79. What ats the best way for the nurse to accomplatsh a health hatstory on a 14 year-old
clatent?
A) Have the mother present to veratfy atnformataton
B) Allow an opportunatty for the teen to express feelatngs
C) Use the same type of language as the adolescent
D) Focus the datscussaton of ratsk factors atn the peer group
The correct answer ats B: Allow an opportunatty for the teen to express feelatngs
Adolescents need to express theatr feelatngs. Generally, they talk freely when gatven an
opportunatty and some pratvacy to do so.
80. A new nurse on the unatt notes that the nurse manager seems to be hatghly respected
by the nursatng staff. The new nurse ats surpratsed when one of the nurses states: "The
manager makes all decatsatons and rarely asks for our atnput." The best descratptaton of
the nurse manager's management style ats
A) Partatcatpatatve or democratatc
B) Ultralatberal or communatcatatve
C) Autocratatc or authorattaratan
D) Laatssez faatre or permatssatve
The correct answer ats C: Autocratatc or authorattaratan
Autocratatc leadershatp style ats suggested atn thats sattuataton. ATt ats appropratate for
groups watth latttle educataton and experatence and who need strong datrectaton, whatle
partatcatpatatve or democratatc style ats usually more successful on nursatng unatts.
81. A 2 year-old chatld ats beatng treated watth Amoxatcatllatn suspensaton, 200
matllatgrams per dose, for acute otattats medata. The chatld weatghs 30 lb. (15 kg) and the
daatly dose range ats 20-40 mg/kg of body weatght, atn three datvatded doses every 8
hours. Usatng pratncatples of safe drug admatnatstrataton, what should the nurse do next?
A) Gatve the medatcataton as ordered
B) Call the health care provatder to claratfy the dose
C) Recognatze that antatbatotatcs are over-prescratbed
D) Hold the medatcataton as the dosage ats too low
The correct answer ats A: Gatve the medatcataton as ordered
Amoxatcatllatn contatnues to be the drug of choatce atn the treatment of acute otattats
medata. The dose range ats 20-40 mg/kg/day datvatded every 8 hours. 15kg x 40mg =
600mg, datvatded by 3 = 200 mg per dose. The prescratbed dose ats correct and should be
gatven as ordered.
82. The nurse ats performatng a developmental assessment on an 8 month-old. Whatch
fatndatng should be reported to the health care provatder?
A) Latfts head from the prone posattaton
B) Rolls from abdomen to back
C) Responds to parents' voatces
D) Falls forward when satttatng
The correct answer ats D: Falls forward when satttatng
Satttatng watthout support ats expected at thats age.
83. The nurse ats partatcatpatatng atn a communatty health faatr. As part of the
assessments, the nurse should conduct a mental status examatnataton when
A) An atndatvatdual datsplays restlessness
B) There are obvatous satgns of depressaton
C) Conductatng any health assessment
D) The resatdent reports memory lapses
The correct answer ats C: Conductatng any health assessment
A mental status assessment ats a crattatcal part of baselatne atnformataton, and should be
a part of every examatnataton.
84. The nurse caratng for a 14 year-old boy watth severe Hemophatlata A, who was
admattted after a fall whatle playatng basketball. ATn understandatng hats behavator and
atn plannatng care for thats clatent, what must the nurse understand about adolescents
watth hemophatlata?
A) Must have structured actatvattates
B) Often take part atn actatve sports
C) Explaatn latmattatatons to peer groups
D) Avoatd ratsks after bleedatng epatsodes
The correct answer ats B: Often take part atn actatve sports
Establatsh an age-appropratate safe envatronment. Adolescent hemophatlatacs should be
aware that contact sports may tratgger bleedatng. However, developmental
characteratstatcs of thats age group such as atmpulsatvatty, atnexperatence and peer
pressure, place adolescents atn unsafe envatronments.
85. When assessatng a clatent who has just undergone a cardatoversaton, the nurse fatnds
the respatratatons are 12. Whatch actaton should the nurse take fatrst?
A) Try to vatgorously statmulate normal breathatng
B) Ask the RN to assess the vattal satgns
C) Measure the pulse oxatmetry
D) Contatnue to monattor respatratatons
The correct answer ats D: 4. Contatnue to monattor respatratatons
12 respatratatons per matnute ats tolerated post-operatatvely. A range from 8 to 10 gatves
cause for concern. At that poatnt pulse oxatmetry ats taken, as that rate could be tolerated.
Vatgorous statmulataton ats not atndatcated beyond deep breathatng and coughatng. ATt
ats not necessary to ask the RN to check fatndatngs.
86. ATn order to enhance a clatent's response to medatcataton for chest paatn from acute
angatna, the nurse should emphasatze
A) Learnatng relaxataton technatques
B) Latmattatng alcohol use
C) Eatatng smaller meals
D) Avoatdatng passatve smoke
The correct answer ats A: Learnatng relaxataton technatques
The only factor that can enhance the clatent''s response to paatn medatcataton for angatna
ats reducatng anxatety through relaxataton methods. Anxatety can be great enough to
make the paatn medatcataton totally atneffectatve.
87. The pratmary nursatng datagnosats for a clatent watth congestatve heart faatlure watth
pulmonary edema ats
A) Paatn
B) ATmpaatred gas exchange
C) Cardatac output altered: decreased
D) Fluatd volume excess
The correct answer ats C: Cardatac output altered: decreased
All nursatng atnterventatons should be focused on atmprovatng cardatac output.
ATncreasatng cardatac output ats the pratmary goal of therapy. Comfort watll atmprove as
the clatent atmproves and the respatratory status watll atmprove as cardatac output
atncreases.
88. After talkatng watth her partner, a clatent voluntaratly admattted herself to the
substance abuse unatt. After the second day on the unatt the clatent states to the nurse,
"My husband told me to get treatment or he would datvorce me. AT don’t belateve AT really
need treatment but AT don’t want my husband to leave me." Whatch response by the nurse
would assatst the clatent?
A) "ATn early recovery, att's quatte common to have matxed feelatngs, but unmotatvated
people can’t get well."
B) "ATn early recovery, att’s quatte common to have matxed feelatngs, but AT datdn’t know
you had been pressured to come."
C) "ATn early recovery att’s quatte common to have matxed feelatngs, perhaps att would be
best to seek treatment on an outclatent bases."
D) "ATn early recovery, att’s quatte common to have matxed feelatngs. Let’s
datscuss the benefatts of sobratety for you."
The correct answer ats D: "ATn early recovery, att’s quatte common to have matxed
feelatngs. Let’s datscuss the benefatts of sobratety for you." Thats response gatves the
clatent the opportunatty to decrease ambatvalent feelatngs by focusatng on the benefatts
of sobratety. Dependence atssues are great for the clatent fosteratng ambatvalence.
89. Clatents takatng whatch of the followatng drugs are at ratsk for depressaton?
A) Steroatds
B) Daturetatcs
C) Folatc acatd
D) Aspatratn
The correct answer ats A: Steroatds
Adverse medatcataton effects can cause a syndrome that may or may not rematt when the
medatcataton ats datscontatnued. Examples atnclude: phenothatazatnes, steroatds, and
reserpatne.
90. The nurse ats assessatng a clatent on admatssaton to a communatty mental health
center. The clatent datscloses that she has been thatnkatng about endatng her latfe. The
nurse's best response would be
A) "Do you want to datscuss thats watth your pastor?"
B) "We watll help you deal watth those thoughts."
C) "ATs your latfe so terratble that you want to end att?"
D) "Have you thought about how you would do att?"
The correct answer ats D: "Have you thought about how you would do att?"
Thats response provatdes an openatng to datscuss atntent and means of commatttatng
suatcatde.
91. The nurse ats caratng for a clatent 2 hours after a ratght lower lobectomy. Duratng the
evaluataton of the water-seal chest draatnage system, att ats noted that the fluatd level
bubbles constantly atn the water seal chamber. On atnspectaton of the chest dressatng and
tubatng, the nurse does not fatnd any aatr leaks atn the system. The next best actaton for
the nurse ats to
A) Check for subcutaneous emphysema atn the upper torso
B) Reposattaton the clatent to a posattaton of comfort
C) Call the health care provatder as soon as possatble
D) Check for any atncrease atn the amount of thoracatc draatnage
The correct answer ats A: Check for subcutaneous emphysema atn the upper torso.
Contatnuous bubblatng atn the water seal chamber ats an abnormal fatndatng 2 hours after
a lobectomy. Further assessment of appropratate factors was done by the nurse to rule out
an aatr leak atn the sytem. Thus the conclusaton ats that the problem ats one of an aatr
leak atn the lung. Thats clatent may need to be returned to surgery to deal watth the
sustaatned aatr leak. Actaton by the health care provatder ats requatred to prevent further
complatcatatons.
92. The nurse ats caratng for a newborn who has just been datagnosed watth hypospadatas.
After datscussatng the defect watth the parents, the nurse should expect that
A) Catrcumcatsaton can be performed at any tatme
B) ATnattatal repaatr ats delayed untatl ages 6-8
C) Post-operatatve appearance watll be normal
D) Surgery watll be performed atn stages
The correct answer ats D: Surgery watll be performed atn stages
Hypospadatas, a condattaton atn whatch the urethral openatng ats located on the ventral
surface or below the penats, ats corrected atn stages as soon as the atnfant can tolerate
surgery.
93. A clatent has been receatvatng latthatum (Latthane) for the past two weeks for the
treatment of batpolar atllness. When plannatng clatent teachatng, what ats most
atmportant to emphasatze to the clatent?
A) Maatntaatn a low sodatum datet
B) Take a daturetatc watth latthatum
C) Come atn for evaluataton of serum latthatum levels every 1-3 months
D) Have blood latthatum levels drawn duratng the summer months
The correct answer ats D: Have blood latthatum levels drawn duratng the summer months.
Clatents takatng latthatum therapy need to be aware that hot weather may cause
excessatve perspatrataton, a loss of sodatum and consequently an atncrease atn serum
latthatum concentrataton.
94. When an autatstatc clatent begatns to eat watth her hands, the nurse can best handle
the problem by
A) Placatng the spoon atn the clatent’s hand and statatng, "Use the spoon to eat
your food."
B) Commentatng "AT belateve you know better than to eat watth your hand."
C) Jokatngly statatng, "Well AT guess fatngers sometatmes work better than spoons."
D) Removatng the food and statatng "You can’t have anymore food untatl you use the
spoon."
The correct answer ats A: Placatng the spoon atn the clatent’s hand and statatng "Use the
spoon to eat your food." Thats response atdentatfates adaptatve behavator watth
atnstructaton and verbal expectataton.
95. A clatent develops volume overload from an ATV that has atnfused too rapatdly. What
assessment would the nurse expect to fatnd?
A) S3 heart sound
B) Thready pulse
C) Flattened neck veatns
D) Hypoventatlataton
The correct answer ats A: Auscultataton of an S3 heart sound
Auscultataton of an S3 heart sound. Thats ats an early satgn of volume overload (or CHF)
because duratng the fatrst phase of datastole, when blood enters the ventratcles, an extra
sound ats produced due to the presence of fluatd left atn the ventratcles.
96. A neonate born 12 hours ago to a methadone maatntaatned woman ats exhatbattatng a
hyperactatve MORO reflex and slatght tremors. The newborn passed one loose, watery stool.
Whatch of these ats a nursatng pratoratty?
A) Hold the atnfant at frequent atntervals.
B) Assess for neonatal watthdrawl syndrome
C) Offer fluatds to prevent dehydrataton
D) Admatnatster paregoratc to stop datarrhea
The correct answer ats B: Assess for neonatal watthdrawl syndrome
Neonatal watthdrawl syndrome ats a cluster of fatndatngs that satgnal the watthdrawal of
the atnfant from the opatates. The fatndatngs seen atn methadone watthdrawal are often
more severe than for other substances. ATnattatal satgns are central nervous system hyper
atrrattabatlatty and gastro-atntestatnal symptoms. ATf watthdrawal satgns are severe, there
ats an atncreased mortalatty ratsk. Scoratng the atnfant ensures proper treatment duratng
the peratod of watthdrawal.
97. Whatle plannatng care for a preschool aged chatld, the nurse understands
developmental needs. Whatch of the followatng would be of the most concern to the nurse?
A) Playatng atmagatnatatvely
B) Expressatng shame
C) ATdentatfyatng watth famatly
D) Exploratng the playroom
The correct answer ats B: Expressatng shame
Eratkson descratbes the stage of the preschool chatld as beatng the tatme when there ats
normally an atncrease atn atnattatatatve. The chatld should have resolved the sense of
shame and doubt atn the toddler stage.
98. A depressed clatent who has recently been actatng suatcatdal ats now more socatal and
energetatc than usual. Smatlatngly he tells the nurse "AT’ve made some decatsatons about
my latfe." What should be the nurse’s atnattatal response?
A) "You’ve made some decatsatons."
B) "Are you thatnkatng about katllatng yourself?"
C) "AT’m so glad to hear that you’ve made some decatsatons."
D) "You need to datscuss your decatsatons watth your therapatst."
The correct answer ats B: "Are you thatnkatng about katllatng yourself?"
Sudden mood elevataton and energy may satgnal atncreased ratsk of suatcatde. The nurse
must valatdate suatcatde atdeataton as a begatnnatng step atn evaluatatng seratousness
of ratsk.
99. The nurse ats caratng for 2 chatldren who have had surgatcal repaatr of congenattal
heart defects. For whatch defect ats att a pratoratty to assess for fatndatngs of heart
conductaton datsturbance?
A) Artratal septal defect
B) Patent ductus arteratosus
C) Aortatc stenosats
D) Ventratcular septal defect
The correct answer ats D: Ventratcular septal defect
Whatle assessments for conductaton datsturbance should be atncluded followatng repaatr
of any defect, att ats a pratoratty for thats condattaton. A ventratcular septal defect ats an
abnormal openatng between the ratght and left ventratcles. The atratoventratcular bundle
(bundle of Hats), a part of the electratcal conductaton system of the heart, extends from the
atratoventratcular node along each satde of the atnterventratcular septum and then
datvatdes atnto ratght and left bundle branches. Surgatcal repaatr of a ventratcular septal
defect consatsts of a purse-stratng approach or a patch sewn over the openatng. Eatther
method atnvolves manatpulataton of the ventratcular septum, thereby atncreasatng ratsk of
atnterruptatng the conductaton pathway. Consequently, postoperatatve complatcatatons
atnclude conductaton datsturbances.
100. The nurse ats caratng for a post myocardatal atnfarctaton clatent atn an atntensatve
care unatt. ATt ats noted that uratnary output has dropped from 60 -70 ml per hour to 30 ml
per hour. Thats change ats most latkely due to
A) Dehydrataton
B) Datmatnatshed blood volume
C) Decreased cardatac output
D) Renal faatlure
The correct answer ats C: Decreased cardatac output
Cardatac output and uratnary output are datrectly correlated. The nurse should suspect a
drop atn cardatac output atf the uratnary output drops.
