Pre-Board Nursing Exam for December 2013 NLE
by Admin · November 15, 2013
This Pre-Board Nursing Exam contains 100 questions. Both questions and answers were arranged randomly.
Topics that are included were: Foundation of Nursing, Nursing Research, Professional Adjustment, Leadership and Management, Maternal and Child Health, Community Health Nursing, Communicable Diseases, Integrated Management of Childhood Illness, Medical and Surgical Nursing and Psychiatric Nursing.

Pre-Board Exam for December 2013 NLE
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Question 1 |
What should the nurse advice when a mother of a 3-month-old infant calls the clinic and states that her child has a diaper rash?
A | “Switch to cloth diapers until the rash is gone” |
B | “Use baby wipes with each diaper change.” |
C | “Leave the diaper off while the infant sleeps.” |
D | “Offer extra fluids to the infant until the rash improves.” |
Question 1 Explanation:
ANSWER: “Leave the diaper off while the infant sleeps.” ; RATIONALE: Leaving the diaper off while the infant sleeps helps to promote air circulation to the area, improving the condition. Switching to cloth diapers isn’t necessary; in fact, that may make the rash worse. Baby wipes contain alcohol, which may worsen the condition. Extra fluids won’t make the rash better.
Question 2 |
Chris, has been hospitalized, is diagnosed to have meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause:
A | Cerebral edema |
B | Dehydration |
C | Heart failure |
D | Hypovolemic shock |
Question 2 Explanation:
ANSWER: Cerebral edema ; RATIONALE: Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increase intracranial pressure. Fluid overload won’t cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration is extreme. Hypovolemic shock would occur with an extreme loss of fluid of blood.
Question 3 |
When educating a new mother who has some questions about (PKU), which of the following statements made by a nurse is not correct regarding PKU?
A | A Guthrie test can check the necessary lab values. |
B | The urine has a high concentration of phenylpyruvic acid |
C | Mental deficits are often present with PKU. |
D | The effects of PKU are reversible. |
Question 3 Explanation:
ANSWER: The effects of PKU are reversible. ; RATIONALE: The effects of PKU stay with the infant throughout their life.
Question 4 |
Piolo is diagnosed with “strep throat.” Which clinical manifestation would be expectedfrom the client?
A | A fiery red pharyngeal membrane and fever |
B | Pain over the sinus area and purulent nasal secretions |
C | Foul-smelling breath and noisy respirations |
D | Weak cough and high-pitched noise on respirations |
Question 4 Explanation:
ANSWER: A fiery red pharyngeal membrane and fever ; RATIONALE: Strep throat, or acute pharyngitis, results in a red throat, edematous lymphoid tissues, enlarged lymph nodes, fever, and sore throat. Pain over the sinus area and purulent nasal secretions would be evident with sinusitis. Foul-smelling breath and respirations indicate adenoiditis. A weak cough and high-pitched noisy respirations are associated with foreign-body aspiration.
Question 5 |
In today’s lecture, meningitis is discussed. Which of the following microorganisms has not been linked to meningitis in humans?
A | S. pneumonia |
B | H. influenza |
C | N. meningitis |
D | Cl. difficile |
Question 5 Explanation:
ANSWER: Cl. difficile ; RATIONALE: Cl. difficile has not been linked to meningitis.
Question 6 |
What should Nurse Ivy answer when a patient asks her, “My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acids?”
A | Green vegetables and liver |
B | Yellow vegetables and red meat |
C | Carrots |
D | Milk |
Question 6 Explanation:
ANSWER: Green vegetables and liver ; RATIONALE: Green vegetables and liver are a great source of folic acid.
Question 7 |
You are preparing for the discharge of a patient who has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breathe easily. Which of the following would be the best instruction for this patient?
A | Deep breathing techniques to increase O2 levels. |
B | Cough regularly and deeply to clear airway passages. |
C | Cough following bronchodilator utilization |
D | Decrease CO2 levels by increase oxygen take output during meals. |
Question 7 Explanation:
ANSWER: Cough following bronchodilator utilization ; RATIONALE: The bronchodilator will allow a more productive cough.
Question 8 |
Which intervention would the Nurse Leo perform to prevent systemic adverse effects from drug absorption during eyedrop instillation?
A | Applying pressure on the eyelid rim |
B | Having the client close his eyes tightly |
C | Placing the client in the supine position for a few minutes |
D | Applying pressure on the inner canthus |
Question 8 Explanation:
ANSWER: Applying pressure on the inner canthus ; RATIONALE: Systemic absorption and subsequent adverse effects may occur if the medication enters the nasolacrimal canal. The nurse therefore applies pressure to the inner canthus, causing occlusion of this canal and minimizing the risk for systemic adverse effects. Applying pressure on the eyelid rim would not occlude this canal. Having the client close his eyes tightly may cause some of the medication to be expelled. Positioning has no effect on the blood flow of medication into the nasolacrimal canal and subsequent absorption.
Question 9 |
The mother of a 22-month-old child conveys her desire to begin toilet training. The most important factor for the nurse to stress to the mother is:
A | Developmental readiness of the child |
B | Consistency in approach |
C | The mother’s positive attitude |
D | Developmental level of the child’s peers |
Question 9 Explanation:
ANSWER: Developmental readiness of the child ; RATIONALE: If the child isn’t developmentally ready, child and parent will become frustrated. Consistency is important once toilet training has already started. The mother’s positive attitude is important when the child is ready. Developmental levels of children are individualized and comparison to peers isn’t useful.
Question 10 |
Nurse Lina is busy checking the emergency cart when a female patient arrives at the emergency department complaining of midsternal chest pain. Which of the following nursing action should take priority?
A | A complete history with emphasis on preceding events. |
B | An electrocardiogram. |
C | Careful assessment of vital signs. |
D | Chest exam with auscultation. |
Question 10 Explanation:
ANSWER: Careful assessment of vital signs. ; RATIONALE: The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. A thorough medical history, including onset of symptoms, will be necessary and it is likely that an electrocardiogram will be performed as well, but these are not the first priority. Similarly, chest exam with auscultation may offer useful information after vital signs are assessed.
Question 11 |
Nurse Gummy knows that screening for lead poisoning should begin when a child reaches which age?
A | 6 months |
B | 12 months |
C | 18 months |
D | 24 months |
Question 11 Explanation:
ANSWER: 18 months ; RATIONALE: The nurse should start screening a child for lead poisoning at age 18 months and perform repeat screening at age 24, 30, and 36 months. High-risk infants, such as premature infants and formula-fed infants not receiving iron supplementation, should be screened for iron-deficiency anemia at 6 months. Regular dental visits should begin at age 24 months.
Question 12 |
A nurse is administering blood to a patient who has a low hemoglobin count. Based on what she knows, the RBC’s life span is?
A | 45 days. |
B | 60 days. |
C | 90 days. |
D | 120 days. |
Question 12 Explanation:
ANSWER: 120 days. ; RATIONALE: RBC’s last for 120 days in the body.
Question 13 |
Alvin is scanning through his notes about the concept of pain. Which term refers to the pain that has a slower onset, is diffuse, radiates, and is marked by somatic pain from organs in any body activity?
A | Acute pain |
B | Chronic pain |
C | Superficial pain |
D | Deep pain |
Question 13 Explanation:
ANSWER: Deep pain ; RATIONALE: Deep pain has a slow onset, is diffuse, and radiates, and is marked by somatic pain from organs in any body activity. Acute pain is rapid in onset, usually temporary (less than 6 months), and subsides spontaneously. Chronic pain is marked by gradual onset and lengthy duration (more than 6 months). Superficial pain has abrupt onset with sharp, stinging quality.
Question 14 |
Lyme disease has been discussed in class today. Which of the following strategies is NOT effective for prevention of Lyme disease?
A | Insect repellant on the skin and clothes when in a Lyme endemic area. |
B | Long sleeved shirts and long pants. |
C | Prophylactic antibiotic therapy prior to anticipated exposure to ticks. |
D | Careful examination of skin and hair for ticks following anticipated exposure. |
Question 14 Explanation:
ANSWER: Prophylactic antibiotic therapy prior to anticipated exposure to ticks. ; RATIONALE: Prophylactic use of antibiotics is not indicated to prevent Lyme disease. Antibiotics are used only when symptoms develop following a tick bite. Insect repellant should be used on skin and clothing when exposure is anticipated. Clothing should be designed to cover as much exposed area as possible to provide an effective barrier. Close examination of skin and hair can reveal the presence of a tick before a bite occurs.
Question 15 |
Patient X in Room 4, who has been diagnosed with pneumonia is ordered for discharge. A nurse provides discharge instructions to both the patient and his family. Which misunderstanding by the family indicates the need for more detailed information?
A | The patient may resume normal home activities as tolerated but should avoid physical exertion and get adequate rest. |
B | The patient should resume a normal diet with emphasis on nutritious, healthy foods. |
C | The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved. |
D | The patient should continue use of the incentive spirometer to keep airways open and free of secretions. |
Question 15 Explanation:
ANSWER: The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved. ; RATIONALE: It is always critical that patients being discharged from the hospital take prescribed medications as instructed. In the case of antibiotics, a full course must be completed even after symptoms have resolved to prevent incomplete eradication of the organism and recurrence of infection. The patient should resume normal activities as tolerated, as well as a nutritious diet. Continued use of the incentive spirometer after discharge will speed recovery and improve lung function.
Question 16 |
Which of the following information is important to communicate when it comes to conducting nutrition counseling for a patient with cholecystitis?
A | The patient must maintain a low calorie diet. |
B | The patient must maintain a high protein/low carbohydrate diet. |
C | The patient should limit sweets and sugary drinks. |
D | The patient should limit fatty foods. |
Question 16 Explanation:
ANSWER: The patient should limit fatty foods. ; RATIONALE: Cholecystitis, inflammation of the gallbladder, is most commonly caused by the presence of gallstones, which may block bile (necessary for fat absorption) from entering the intestines. Patients should decrease dietary fat by limiting foods like fatty meats, fried foods, and creamy desserts to avoid irritation of the gallbladder.
Question 17 |
Which findings best indicates that a 15-month old child recovering from surgery to remove Wilms’ tumor is free from pain?
A | Decreased appetite |
B | Increased heart rate |
C | Decreased urine output |
D | Increased interest in play |
Question 17 Explanation:
ANSWER: Increased interest in play ; RATIONALE: One of the most valuable clues to pain is a behavior change: A child who’s pain-free likes to play. A child in pain is less likely to consume food or fluids. An increased heart rate may indicate increased pain; decreased urine output may signify dehydration.
Question 18 |
Which intervention takes top priority prior to ending Nurse Lydia’s shift on the pediatric unit?
A | Changing the linens on the clients’ beds |
B | Restocking the bedside supplies needed for a dressing change on the upcoming shift |
C | Documenting the care provided during her shift |
D | Emptying the trash cans in the assigned client room |
Question 18 Explanation:
ANSWER: Documenting the care provided during her shift ; RATIONALE: Documentation should take top priority. Documentation is the only way the nurse can legally claim that interventions were performed. The other three options would be appreciated by the nurses on the oncoming shift but aren’t mandatory and don’t take priority over documentation.
Question 19 |
Nurse Chia is a mother of a 6-year old who will begin school in the fall. She understands that a child of this age:
A | Still depends on the parents |
B | Rebels against scheduled activities |
C | Is highly sensitive to criticism |
D | Loves to tattle |
Question 19 Explanation:
ANSWER: Is highly sensitive to criticism ; RATIONALE: In a 6-year-old child, a precarious sense of self causes overreaction to criticism and a sense of inferiority. By age 6, most children no longer depend on the parents for daily tasks and love the routine of a schedule. Tattling is more common at age 4 to 5, by age 6, the child wants to make friends and be a friend.
Question 20 |
Upon reviewing the nursing unit’s refrigerator, which of the following drugs in the refrigerator should be removed from the refrigerator’s contents?
A | Corgard |
B | Humulin (injection) |
C | Urokinase |
D | Epogen (injection) |
Question 20 Explanation:
ANSWER: Corgard ; RATIONALE: Corgard could be removed from the refrigerator.
Question 21 |
Which of the following is a contraindication to the study for a patient who is scheduled for and MRI scan and is suspected to have lung cancer?
A | The patient is allergic to shellfish. |
B | The patient has a pacemaker. |
C | The patient suffers from claustrophobia. |
D | The patient takes antipsychotic medication. |
Question 21 Explanation:
ANSWER: The patient has a pacemaker. ; RATIONALE: The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and may be deactivated by them. Shellfish/iodine allergy is not a contraindication because the contrast used in MRI scanning is not iodine-based. Open MRI scanners and anti-anxiety medications are available for patients with claustrophobia. Psychiatric medication is not a contraindication to MRI scanning.
Question 22 |
The nurse should expect which of the following assessment data the client scheduled for surgical correction of chronic open-angle glaucoma to report during nursing history?
A | Seeing flashes of lights and floaters |
B | Recent motor vehicle crash while changing lanes |
C | Complaints of headaches, nausea, and redness of the eyes |
D | Increasingly frequent episodes of double vision |
Question 22 Explanation:
ANSWER: Recent motor vehicle crash while changing lanes ; RATIONALE: Typically, the client with chronic open-angle glaucoma experiences a gradual loss in peripheral vision leading to tunnel vision. Being involved in a motor vehicle crash while changing lanes suggests the disorder. The client may experience insidious blurring, decreased accommodation, mild aching eyes and, eventually, halos around the lights as intraocular pressure increases. Flashes of light and floaters are characteristic of retinal detachment. Nausea, headache, and eye redness are seen with an episode of acute (sudden) closed-angle closure. Double vision occurs when one eye has a lens and other is aphakic.
Question 23 |
A mother plans to discontinue breast-feeding after 5 months. In client teaching, the nurse should advise her to include which foods in her infant’s diet?
A | Iron-rich formula and baby food |
B | Whole milk and baby food |
C | Skim milk and baby food |
D | Iron-rich formula only |
Question 23 Explanation:
ANSWER: Iron-rich formula only ; RATIONALE: The American Academy of Pediatrics recommends that infants at age 5 months receive iron-rich formula and that they shouldn’t receive solid food – even baby food – until age 6 months. The Academy doesn’t recommend whole milk until age 12 months, and skim milk until after age 2 years.
Question 24 |
Nurse Gigi is the school nurse, while checking the records, a preschooler is brought to the clinic due to an ear problem. Which assessment data would cause the nurse to suspect serous otitis media?
A | Bright red, bulging or retracted tympanic membrane and fever. |
B | Inflammation of the external ear and crust formation on the auditory canal |
C | Sensorineural hearing loss and complaints of tinnitus |
D | Plugged feeling in the ear and reverberation of the client’s own voice. |
Question 24 Explanation:
ANSWER: Plugged feeling in the ear and reverberation of the client’s own voice. ; RATIONALE: Serous otitis media is manifested by a plugged feeling in the ear, reverberation of the client’s own voice, and hearing loss. A bright red, bulging or retracted tympanic membrane and fever suggest suppurative otitis media. Inflammation of the external ear and crust formation on the auditory canal suggest external otitis media. Sensorineural hearing loss and tinnitus indicate otosclerosis.
Question 25 |
Diego is assisting the staff nurse assigned to a patient aged 68-year-old, a widower, and has been stricken with cataracts about year ago. Which assessment date would the nurse expect when collecting the nursing history from the client?
A | Blurred vision |
B | Eye pain |
C | Floaters |
D | Eye redness |
Question 25 Explanation:
ANSWER: Blurred vision ; RATIONALE: Cataracts lead to progressive worsening and blurring of vision. Eye pain and redness, common with glaucoma, are not present with cataracts. Floaters are characteristics of retinal detachment.
Question 26 |
A non-pharmacologic pain-relief intervention for chronic pain includes:
A | Referring the client for hypnosis |
B | Administering pain medication as prescribed |
C | Removing all glaring lights and excessive noise |
D | Using transcutaneous electric nerve stimulation |
Question 26 Explanation:
ANSWER: Using transcutaneous electric nerve stimulation ; RATIONALE: Nonpharmacologic pain relief interventions include cutaneous stimulation, back rubs, biofeedback, acupuncture, transcutaneous electric nerve stimulation, and more. Hypnosis is considered an alternative therapy. Medications are pharmacologic measures. Although removing glaring lights and excessive noise help to reduce or remove noxious stimuli, it is not specific to pain relief.
Question 27 |
In the assessment of a patient with a diagnosis of hepatitis A, which of the following is the most likely route of transmission?
A | Sexual contact with an infected partner. |
B | Contaminated food. |
C | Blood transfusion. |
D | Illegal drug use. |
Question 27 Explanation:
ANSWER: Contaminated food. ; RATIONALE: Hepatitis A is the only type that is transmitted by the fecal-oral route through contaminated food. Hepatitis B, C, and D are transmitted through infected bodily fluids.
Question 28 |
Nurse Kim is acting as the charge nurse on the cardiac unit today and is currently planning assignments. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery?
A | A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge. |
B | A suspected myocardial infarction patient on telemetry, just admitted from the Emergency Department and scheduled for an angiogram. |
C | A patient with unstable angina being closely monitored for pain and medication titration. |
D | A postoperative valve replacement patient who was recently admitted to the unit because all surgical beds were filled. |
Question 28 Explanation:
ANSWER: A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge. ; RATIONALE: The charge nurse planning assignments must consider the skills of the staff and the needs of the patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the least acute needs. The patient who is one-week post-operative and nearing discharge is likely to require routine care. A new patient admitted with suspected MI and scheduled for angiography would require continuous assessment as well as coordination of care that is best carried out by experienced staff. The unstable patient requires staff that can immediately identify symptoms and respond appropriately. A postoperative patient also requires close monitoring and cardiac experience.
Question 29 |
Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm in a patient with a complaint of abdominal pain. Which of the following actions should the nurse expect?
A | The patient will be admitted to the medicine unit for observation and medication. |
B | The patient will be admitted to the day surgery unit for sclerotherapy. |
C | The patient will be admitted to the surgical unit and resection will be scheduled. |
D | The patient will be discharged home to follow-up with his cardiologist in 24 hours. |
Question 29 Explanation:
ANSWER: The patient will be admitted to the surgical unit and resection will be scheduled. ; RATIONALE: A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and should be resected as soon as possible. No other appropriate treatment options currently exist.
Question 30 |
Prior to the discharge an 8-month-old infant who is recovering from gastroenteritis and dehydration, the Nurse Florie teaches the parents about their infant’s dietary and fluid requirements. The nurse should include which other topic in the teaching session?
A | Nursery schools |
B | Toilet Training |
C | Safety guidelines |
D | Preparation for surgery |
Question 30 Explanation:
ANSWER: Safety guidelines ; RATIONALE: The nurse always should reinforce safety guidelines when teaching parents how to care for their child. By giving anticipatory guidance the nurse can help prevent many accidental injuries. For parents of a 9-month-old infant, it is too early to discuss nursery schools or toilet training. Because surgery is not used gastroenteritis, this topic is inappropriate.
Question 31 |
An elderly Vietnamese patient in the terminal stages of lung cancer is under the care of Nurse Valerie. She notices that many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which of the following actions should the nurse take?
A | Restrict visiting hours and ask the family to limit visitors to two at a time. |
B | Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed. |
C | If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family. |
D | Contact the physician to report the unusual rituals and activities. |
Question 31 Explanation:
ANSWER: If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family. ; RATIONALE: When a family member is dying, it is most helpful for nursing staff to provide a culturally sensitive environment to the degree possible within the hospital routine. In the Vietnamese culture, it is important that the dying be surrounded by loved ones and not left alone. Traditional rituals and foods are thought to ease the transition to the next life. When possible, allowing the family privacy for this traditional behavior is best for them and the patient. Answers A, B, and D are incorrect because they create unnecessary conflict with the patient and family.
Question 32 |
Nurse Benny has just finished instructing the patient who is due for discharge. Which statement by a client diagnosed with Ménière’s disease who has had a labyrinthectomy of the left ear indicates that he understands the discharge teaching concerning the surgery?
A | “I should be able to hear fairly well after the edema in my ear subsides.” |
B | “I will be totally deaf in my left ear, but the dizziness will be gone.” |
C | “I should remove the inner ear packing in exactly 3 days.” |
D | “I should lubricate the skin around my stoma with petroleum jelly.” |
Question 32 Explanation:
ANSWER: “I will be totally deaf in my left ear, but the dizziness will be gone.” ; RATIONALE: A labyrinthectomy is the most radical procedure for Ménière’s disease. It involves resection of the vestibular nerve or total removal of the labyrinth by the transcanal route. Although this procedure controls the disorder, it results in deafness in the affected ear. With this procedure, inner ear packing is not used, and a stoma is not created.
Question 33 |
What’s the nurse’s best recommendation for helping the mother of a 4-year old child who is known to be a poor eater, increase the child’s nutritional intake?
A | Allow the child to feed herself |
B | Use specially designed dishes for children – for example, a plate with the child’s favorite cartoon character |
C | Only serve the child’s favorite foods |
D | Allow the child to eat at a small table and chair by herself |
Question 33 Explanation:
ANSWER: Allow the child to feed herself ; RATIONALE: The best recommendation is to allow the child to feed herself because the child’s stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. The child should be offered new foods and choices, not just served her favorite foods. Using a small table and chair would also enhance the primary recommendation.
Question 34 |
Who is authorized to give written, informed consent for blood transfusion to an infant who has been in foster care since birth?
A | The foster mother |
B | The social worker who placed the infant in the foster home |
C | The registered nurse caring for the infant |
D | The nurse-manager |
Question 34 Explanation:
ANSWER: The foster mother ; RATIONALE: When children are minors and aren’t emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion. The social workers, the nurse, and the nurse-manager have no legal rights to give consent in this scenario.
Question 35 |
Which nursing intervention should take the highest priority when caring for a 4-month-old with meningococcal meningitis?
A | Instituting droplet precautions |
B | Administering acetaminophen (Tylenol) |
C | Obtaining history information from the parents |
D | Orienting the parents to the pediatric unit |
Question 35 Explanation:
ANSWER: Instituting droplet precautions ; RATIONALE: Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn’t take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don’t take priority.
Question 36 |
Robert is studying about congenital heart defect. Which of the following clinical signs would most likely be present in the infant with CHD?
A | Slow pulse rate |
B | Weight gain |
C | Decreased systolic pressure |
D | Irregular WBC lab values |
Question 36 Explanation:
ANSWER: Weight gain ; RATIONALE: Weight gain is associated with CHF and congenital heart deficits.
Question 37 |
A preschooler with spina bifida has been said to sneeze and get a rash when playing with brightly colored balloons. The mother also says that her daughter recently had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to:
A | Bananas |
B | Latex |
C | Kiwifruit |
D | Color dyes |
Question 37 Explanation:
ANSWER: Latex ; RATIONALE: Children with spina bifida often develop an allergy to latex and shouldn’t be exposed to it. If a child is sensitive to bananas, kiwifruit, and chestnuts, then she’s likely to be allergic to latex. Some children are allergic to dyes in foods and other products but dyes aren’t a factor in a latex allergy.
Question 38 |
Bob fell in a touch football game and is rushed to the Emergency room because of severe leg pain. Following routine triage, which of the following is the appropriate next step in assessment and treatment?
A | Apply heat to the painful area. |
B | Apply an elastic bandage to the leg. |
C | X-ray the leg. |
D | Give pain medication. |
Question 38 Explanation:
ANSWER: X-ray the leg. ; RATIONALE: Following triage, an x-ray should be performed to rule out fracture. Ice, not heat, should be applied to a recent sports injury. An elastic bandage may be applied and pain medication given once fracture has been excluded.
Question 39 |
Mr. Smith who has osteoarthritis is preparing for discharge. Which of the following information is correct.
A | Increased physical activity and daily exercise will help decrease discomfort associated with the condition. |
B | Joint pain will diminish after a full night of rest. |
C | Nonsteroidal anti-inflammatory medications should be taken on an empty stomach. |
D | Acetaminophen (Tylenol) is a more effective anti-inflammatory than ibuprofen (Motrin). |
Question 39 Explanation:
ANSWER: Increased physical activity and daily exercise will help decrease discomfort associated with the condition. ; RATIONALE: Physical activity and daily exercise can help to improve movement and decrease pain in osteoarthritis. Joint pain and stiffness are often at their worst during the early morning after several hours of decreased movement. Acetaminophen is a pain reliever, but does not have anti-inflammatory activity. Ibuprofen is a strong anti-inflammatory, but should always be taken with food to avoid GI distress.
Question 40 |
Patient Y, who has undergone abdominal surgery 3 days earlier complains of sharp, throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain). Which intervention should the nurse implement first?
A | Assessing the client to rule out possible complications secondary to surgery |
B | Checking the client’s chart to determine when pain medication was last administered |
C | Explaining to the client that the pain should not be this severe 3 days postoperatively |
D | Obtaining an order for a stronger pain medication because the client’s pain has increased |
Question 40 Explanation:
ANSWER: Assessing the client to rule out possible complications secondary to surgery ; RATIONALE: The nurse immediate action should be assess the client in an attempt to exclude possible complications that may be causing the client’s complaints. The health care provider ordered the pain medication for routine postoperative pain that is expected after abdominal surgery, not for such complications as hemorrhage, infection, or dehiscence. The nurse should never administer pain medication without assessing the client first. Obtaining an order for a strong medication may be appropriate after the nurse assesses the client and checks the chart to see whether the current analgesic is infective. Checking the client’s chart is appropriate after the nurse determines that the client is not experiencing complications from surgery. Pain is subjective, and each person has his own level of pain tolerance. The nurse must always believe the client’s complaint of pain.
Question 41 |
Lydia, a mother of a young child conveys her fears regarding poisoning. If the child ingests poison, what should the nurse instruct the mother to do first?
A | Administer ipecac syrup |
B | Call an ambulance immediately |
C | Call the poison control center |
D | Punish the child for being bad |
Question 41 Explanation:
ANSWER: Call the poison control center ; RATIONALE: Before interviewing in any way, the parents should call the poison control center for specific directions. Ipecac syrup is no longer recommended. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn’t appropriate because the parents are responsible for making the environment safe.
Question 42 |
Nurse Mark is about to change the IV bottle of the patient when he saw her choking and unable to speak. Which intervention should the nurse implement first for the client?
A | Calling for help immediately |
B | Leaving the client alone to clear his throat. |
C | Telling the client to adequately humidify the room |
D | Trying to determine what the client is choking on |
Question 42 Explanation:
ANSWER: Calling for help immediately ; RATIONALE: Because the client cannot speak, a total airway obstruction has occurred. The client is in acute distress and requires emergency treatment. Leaving the client alone to clear the throat would be appropriate for a client with partial airway obstruction, as evidenced by choking but with an ability to speak. Adequate humidification is appropriate for the client with recurrent epistaxis or nasal congestion. It does not matter what the client is choking on.
Question 43 |
Kelly, a 10-year-old patient contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear to protect herself while providing care?
A | Gloves |
B | Gown and gloves |
C | Gown, gloves, and mask |
D | Gown, gloves, mask, and eye goggles or eye shield |
Question 43 Explanation:
ANSWER: Gown, gloves, mask, and eye goggles or eye shield ; RATIONALE: The transmission of SARS isn’t fully understood. Therefore, all modes of transmission must be considered possible, including airborne, droplet, and direct contact with the virus. For protection from contracting SARS, any health care worker providing care for a client with SARS should wear a gown, gloves, mask, and eye goggles or an eye shield.
Question 44 |
Nurse Eva is caring for a thirty five year old male, who has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would she most likely suspects?
A | Atherosclerosis |
B | Diabetic nephropathy |
C | Autonomic neuropathy |
D | Somatic neuropathy |
Question 44 Explanation:
ANSWER: Autonomic neuropathy ; RATIONALE: Autonomic neuropathy can cause inability to urinate.
Question 45 |
Rocky sustained a tibia fracture in a motor vehicle accident, has a cast and complains of itching. What should the nurse do to help relieve the itching?
A | Apply cool air under the cast with a blow-dryer |
B | Use sterile applicators to scratch the itch |
C | Apply cool water under the cast |
D | Apply hydrocortisone cream under the cast using sterile applicator. |
Question 45 Explanation:
ANSWER: Apply cool air under the cast with a blow-dryer ; RATIONALE: Itching underneath a cast can be relieved by directing blow-dryer, set, on the cool setting, toward the itchy area. Skin breakdown can occur if anything is placed under the cast. Therefore, the client should be cautioned not to put any object down the cast in an attempt to scratch.
Question 46 |
Which of the following nursing actions is most important in the care of acancer patient who is receiving subcutaneous morphine sulfate for pain?
A | Monitor urine output. |
B | Monitor respiratory rate. |
C | Monitor heart rate. |
D | Monitor temperature. |
Question 46 Explanation:
ANSWER: Monitor respiratory rate. ; RATIONALE: Morphine sulfate can suppress respiration and respiratory reflexes, such as cough. Patients should be monitored regularly for these effects to avoid respiratory compromise. Morphine sulfate does not significantly affect urine output, heart rate, or body temperature.
Question 47 |
Patient X in cubicle 3, who has been diagnosed with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?
A | Slow, deep respirations. |
B | Stridor. |
C | Bradycardia. |
D | Air hunger. |
Question 47 Explanation:
ANSWER: Air hunger. ; RATIONALE: Patients with pulmonary edema experience air hunger, anxiety, and agitation. Respiration is fast and shallow and heart rate increases. Stridor is noisy breathing caused by laryngeal swelling or spasm and is not associated with pulmonary edema.
Question 48 |
Upon arriving the cardiac unit, Nurse Ben is told that one patient is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure?
A | A patient admitted for myocardial infarction without cardiac muscle damage. |
B | A post-operative coronary bypass patient, recovering on schedule. |
C | A patient with a history of ventricular tachycardia and syncopal episodes. |
D | A patient with a history of atrial tachycardia and fatigue. |
Question 48 Explanation:
ANSWER: A patient with a history of ventricular tachycardia and syncopal episodes. ; RATIONALE: An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary in a patient with significant ventricular symptoms, such as tachycardia resulting in syncope. A patient with myocardial infarction that resolved with no permanent cardiac damage would not be a candidate. A patient recovering well from coronary bypass would not need the device. Atrial tachycardia is less serious and is treated conservatively with medication and cardioversion as a last resort.
Question 49 |
Bea is reading all about epistaxis tonight. According to her readings, which intervention would be included in the care plan for a patient diagnosed with epistaxis?
A | Performing several abdominal thrust (Heimlich) maneuvers |
B | Compressing the nares to the septum for 5 to 10 minutes |
C | Applying an ice collar to the neck area |
D | Encouraging warm saline throat gargles |
Question 49 Explanation:
ANSWER: Compressing the nares to the septum for 5 to 10 minutes ; RATIONALE: When a client experiences epistaxis, the nurse should compress the soft outer portion of the nares against the septum for approximately 5 to 10 minutes. the client should sit upright, breathe through the mouth, and refrain from talking. Performing abdominal thrusts is appropriate for the client with a foreign-body aspiration. Applying an ice collar to the neck is commonly done for a client after a tonsillectomy. Warm saline throat gargles are appropriate for the client with pharyngitis.
Question 50 |
Rhogam is most often used to treat____ mothers that have a ____ infant.
A | RH positive, RH positive |
B | RH positive, RH negative |
C | RH negative, RH positive |
D | RH negative, RH negative |
Question 50 Explanation:
ANSWER: RH negative, RH positive ; RATIONALE: Rhogam prevents the production of anti-RH antibodies in the mother that has a Rh positive fetus.
Question 51 |
Which nursing action is most appropriate for an infanthospitalized for treatment of nonorganic failure to thrive?
A | Encouraging the infant to hold a bottle |
B | Keeping the infant on bed rest to conserve energy |
C | Rotating caregivers to provide more stimulation |
D | Maintaining a consistent, structured environment |
Question 51 Explanation:
ANSWER: Maintaining a consistent, structured environment ; RATIONALE: The nurse caring for an infant with nonorganic failure to thrive should maintain a consistent, structured environment that provides interaction with the infant to promote growth and development. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.
Question 52 |
Allopurinol is included in the regimen of a child who is undergoing remission induction therapy to treat leukemia. The main reason for administering allopurinol as part of the client’s chemotherapy regimen is to:
A | Prevent metabolic breakdown of xanthine to uric acid |
B | Prevent uric acid from precipitating in the ureters |
C | Enhance the production of uric acid to ensure adequate excretion of urine |
D | Ensure that the chemotherapy doesn’t adversely affect the bone marrow |
Question 52 Explanation:
ANSWER: Prevent metabolic breakdown of xanthine to uric acid ; RATIONALE: The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid. Allopurinol doesn’t act in the manner described in the other options.
Question 53 |
Which of the following donor medical conditions would prevent a relative of a leukemia patient from donating blood for transfusion?
A | A history of hepatitis C five years previously. |
B | Cholecystitis requiring cholecystectomy one year previously. |
C | Asymptomatic diverticulosis. |
D | Crohn’s disease in remission. |
Question 53 Explanation:
ANSWER: A history of hepatitis C five years previously. ; RATIONALE: Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis (gallbladder disease), diverticulosis, and history of Crohn’s disease do not preclude blood donation.
Question 54 |
Nurse Verna is conducting health teaching to a newly diagnosed 8-year-old child with type I diabetes mellitus and his mother education prior to discharge. The physician has prescribed Glucagon for emergency use. The mother asks the purpose of this medication. Which of the following statements by the nurse is correct?
A | Glucagon enhances the effect of insulin in case the blood sugar remains high one hour after injection. |
B | Glucagon treats hypoglycemia resulting from insulin overdose. |
C | Glucagon treats lipoatrophy from insulin injections. |
D | Glucagon prolongs the effect of insulin, allowing fewer injections. |
Question 54 Explanation:
ANSWER: Glucagon treats hypoglycemia resulting from insulin overdose. ; RATIONALE: Glucagon is given to treat insulin overdose in an unresponsive patient. Following Glucagon administration, the patient should respond within 15-20 minutes at which time oral carbohydrates should be given. Glucagon reverses rather than enhances or prolongs the effects of insulin. Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat.
Question 55 |
In caring for a patient who has arthritis and remains in bed too long because it hurts to get started, which intervention should the nurse plan?
A | Telling the client to strictly limit the amount of movement of his inflamed joints |
B | Teaching the client’s family how to transfer the client into a wheelchair |
C | Teaching the client the proper method for massaging inflamed, sore joints |
D | Encouraging gentle range-of-motion exercises after administering aspirin and before rising |
Question 55 Explanation:
ANSWER: Encouraging gentle range-of-motion exercises after administering aspirin and before rising ; RATIONALE: Aspirin raises the pain threshold and, although range-of-motion exercises hurt, mild exercise can relieve pain on rising. Strict limitation of motion only increases the client’s pain. Having others transfer the client into a wheelchair does not increase his feelings of dependency. Massage increases inflammation and should be avoided with this client.
Question 56 |
Nurse Ezra is administering 2 drops of medication in OS prior to ophthalmic surgery. Which interventions should he implement? (Select all that apply.)
A | Instructing the client to look up prior to administering the medication |
B | Administering the medication into the right eye |
C | Administering the medication into the upper conjunctiva |
D | Pulling the left ear up and back prior to administering the medication |
E | Wiping the excess medication from the inner to the outer canthus |
F | Pressing on the nasal-lacrimal canal |
Question 56 Explanation:
ANSWER: Instructing the client to look up prior to administering the medication ; Wiping the excess medication from the inner to the outer canthus ; Pressing on the nasal-lacrimal canal ; RATIONALE: The nurse is administering medication into the left eye (OS) for ophthalmic surgery, which includes instructing the client to look up, administering the medication into the lower conjunctiva, pressing on the nasal-lacrimal canal to prevent systemic drug absorption, and wiping excess secretions with a sterile cotton ball from the inner to outer canthus. The abbreviation for the right eye is OD and both eyes is OU.
Question 57 |
A toddler, age 19 months, is brought to the clinic for a regular check-up. When palpating the toddler’s fontanels, what should the nurse expects to find?
A | Closed anterior fontanel and open posterior fontanel |
B | Open anterior and fontanel and closed posterior fontanel |
C | Closed anterior and posterior fontanels |
D | Open anterior and posterior fontanels |
Question 57 Explanation:
ANSWER: Closed anterior and posterior fontanels ; RATIONALE: By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.
Question 58 |
Which technique is most important in recognizing possible hydrocephalus in an infant diagnosed with spina bifida?
A | Measuring head circumference |
B | Obtaining skull X-ray |
C | Performing a lumbar puncture |
D | Magnetic resonance imaging (MRI) |
Question 58 Explanation:
ANSWER: Measuring head circumference ; RATIONALE: Measuring head circumference is the most important assessment technique for recognizing possible hydrocephalus, and is a key part of routine infant screening. Skull X-rays and MRI may be used to confirm the diagnosis. A lumbar puncture isn’t appropriate.
Question 59 |
When performing cardiopulmonary resuscitation (CPR) to a child, age 4. Nurse Gina should:
A | Compress the sternum with both hands at a depth of 1½ to 2” (4 to 5 cm) |
B | Deliver 12 breaths/minute |
C | Perform only two-person CPR |
D | Use the heel of one hand for sternal compressions |
Question 59 Explanation:
ANSWER: Use the heel of one hand for sternal compressions ; RATIONALE: The nurse should use the heel of one hand and compress 1” to 1½ “. The nurse should use the heels of both hands clasped together and compress the sternum 1½ “to 2” for an adult. For a small child, two-person rescue may be inappropriate. For a child, the nurse should deliver 20 breaths/minute instead of 12.
Question 60 |
You are assigned to care for a child with down syndrome, which of the following characteristics is not associated with Down’s syndrome?
A | Simian crease |
B | Brachycephaly |
C | Oily skin |
D | Hypotonicity |
Question 60 Explanation:
ANSWER: Oily skin ; RATIONALE: The skin would be dry and not oily.
Question 61 |
Which of the following symptoms has the nurse most likely observed upon suspecting that a patient has developed pulmonary embolism?
A | The patient is somnolent with decreased response to the family. |
B | The patient suddenly complains of chest pain and shortness of breath. |
C | The patient has developed a wet cough and the nurse hears crackles on auscultation of the lungs. |
D | The patient has a fever, chills, and loss of appetite. |
Question 61 Explanation:
ANSWER: The patient suddenly complains of chest pain and shortness of breath. ; RATIONALE: Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. A patient with pulmonary embolism will not be sleepy or have a cough with crackles on exam. A patient with fever, chills and loss of appetite may be developing pneumonia.
Question 62 |
Upon endorsement, Nurse Allie reviews the medications of the patient assigned to her. Which of the following medication would be contraindicated if the patient were pregnant? (More than one answer may be correct)
A | Coumadin |
B | Finasteride |
C | Celebrex |
D | Catapres |
E | Habitrol |
F | Clofazimine |
Question 62 Explanation:
ANSWER: Coumadin ; Finasteride ; RATIONALE: are both contraindicated with pregnancy.
Question 63 |
A patient with peripheral vascular disease (PVD complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?
A | Inadequate tissue perfusion leading to nerve damage. |
B | Fluid overload leading to compression of nerve tissue. |
C | Sensation distortion due to psychiatric disturbance. |
D | Inflammation of the skin on the hands and feet. |
Question 63 Explanation:
ANSWER: Inadequate tissue perfusion leading to nerve damage. ; RATIONALE: Patients with peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are secondary to decreased tissue perfusion rather than primary inflammation.
Question 64 |
Viel is reading all about total parental nutrition (TPN) today. When administering TPN through a peripheral I.V. line to a school-age child, what’s the smallest amount of glucose that’s considered safe and not caustic to small veins, while also providing adequate TPN?
A | 5% glucose |
B | 10% glucose |
C | 15% glucose |
D | 17% glucose |
Question 64 Explanation:
ANSWER: 10% glucose ; RATIONALE: The amount of glucose that’s considered safe for peripheral veins while still providing adequate parenteral nutrition is 10%. Five percent glucose isn’t sufficient nutritional replacement, although it’s sake for peripheral veins. Any amount above 10% must be administered via central venous access.
Question 65 |
Your cousin, Anna tells you that her urine is starting to look discolored. If you, as a nurse, believe this change is due to medication, which of the following patient’s medication does not cause urine discoloration?
A | Sulfasalazine |
B | Levodopa |
C | Phenolphthalein |
D | Aspirin |
Question 65 Explanation:
ANSWER: Aspirin ; RATIONALE: All of the others can cause urine discoloration.
Question 66 |
Nurse Pauline should expect to see which of the following when caring for an 11-month-old infant with dehydration and metabolic acidosis?
A | A reduced white blood cell count |
B | A decreased platelet count |
C | Shallow respirations |
D | Tachypnea |
Question 66 Explanation:
ANSWER: Tachypnea ; RATIONALE: The body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations, altered white blood cell or platelet counts are not specific signs of metabolic imbalance.
Question 67 |
Robert is researching about diuretic therapy. He has heard that term earlier and is curious. When it comes to an infant with congestive heart failure, who is receiving diuretic therapy at home, which of the following symptoms would indicate that the dosage may need to be increased?
A | Sudden weight gain. |
B | Decreased blood pressure. |
C | Slow, shallow breathing. |
D | Bradycardia. |
Question 67 Explanation:
ANSWER: Sudden weight gain. ; RATIONALE: Weight gain is an early symptom of congestive heart failure due to accumulation of fluid. When diuretic therapy is inadequate, one would expect an increase in blood pressure, tachypnea, and tachycardia to result.
Question 68 |
Today, you are the charge nurse. Which of the following is your primary responsibility when caring for a fifty-year-old blind and deaf patient who has been admitted to your floor?
A | Let others know about the patient’s deficits. |
B | Communicate with your supervisor your patient safety concerns. |
C | Continuously update the patient on the social environment. |
D | Provide a secure environment for the patient. |
Question 68 Explanation:
ANSWER: Provide a secure environment for the patient. ; RATIONALE: This patient’s safety is your primary concern.
Question 69 |
Patient Y is complainingperiocular aching after a surgical repair of a detached retina. Which medication would be the most appropriate analgesic?
A | Acetaminophen |
B | Codeine |
C | Meperidine |
D | Morphine |
Question 69 Explanation:
ANSWER: Acetaminophen ; RATIONALE: Because the discomfort is typically mild after surgery to repair a detached retina, a mild analgesic such as acetaminophen would be used. Codeine is constipating and may lead to straining and increased intraocular pressure (IOP). Meperidine often causes nausea and vomiting, further adding to the client’s level of discomfort, and vomiting may lead to increased IOP. Morphine causes nausea, vomiting, and constipation, which should be avoided after surgery.
Question 70 |
The history of Patient X indicates photosensitive reactions to medications. Which of the following drugs has not been associated with photosensitive reactions? (More than one answer may be correct)
A | Cipro |
B | Sulfonamide |
C | Noroxin |
D | Bactrim |
E | Accutane |
F | Nitro-dur |
Question 70 Explanation:
ANSWER: Nitro-dur ; RATIONALE: All of the others have can cause photosensitivity reactions.
Question 71 |
Coco is reading about tuberculosis intradermal skin test in detecting tuberculosis infectio. How long after the test is administered should the result be evaluated?
A | Immediately |
B | Within 24 hours |
C | In 48 to 72 hours |
D | After 5 days |
Question 71 Explanation:
ANSWER: In 48 to 72 hours ; RATIONALE: Tuberculin skin tests of delayed hypersensitivity. If the test results are positive, a reaction should appear in 48 to 72 hours. Immediately after the test and within 24 hours are both too soon to observe a reaction. Waiting more than 5 days to evaluate the test is too long because any reaction may no longer be visible.
Question 72 |
Diego is hurrying to get ready for school. While going down the stairs, he trips, falls, grabs his wrist, and cries, “Oh, my wrist! Help! The pain is so sharp, I think I broke it.” Based on this data, the pain the student is experiencing is caused by impulses traveling from receptors to the spinal cord along which type of nerve fibers?
A | Type A-delta fibers |
B | Autonomic nerve fibers |
C | Type C fibers |
D | Somatic efferent fibers |
Question 72 Explanation:
ANSWER: Type A-delta fibers ; RATIONALE: Type A-delta fibers conduct impulses at a very rapid rate and are responsible for transmitting acute sharp pain signals from the peripheral nerves to the spinal cord. Only type A-delta fibers transmit sharp, piercing pain. Somatic efferent fibers affect the voluntary movement of skeletal muscles and joints. Type C fibers transmit sensory input at a much slower rate and produce a slow, chronic type of pain. The autonomic system regulates involuntary vital functions and organ control such as breathing.
Question 73 |
James is listening to the lecture about glomerulonephritis. Which of the following conditions most commonly causes acute glomerulonephritis?
A | A congenital condition leading to renal dysfunction. |
B | Prior infection with group A Streptococcus within the past 10-14 days. |
C | Viral infection of the glomeruli. |
D | Nephrotic syndrome. |
Question 73 Explanation:
ANSWER: Prior infection with group A Streptococcus within the past 10-14 days. ; RATIONALE: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.
Question 74 |
Which teaching topic should take priority when teaching the parents of a school-age child?
A | Prevent accidents |
B | Keeping a night light on to allay fears |
C | Explaining normalcy of fears about body integrity |
D | Encouraging the child to dress without help |
Question 74 Explanation:
ANSWER: Prevent accidents ; RATIONALE: Accidents are the major cause of death and disability during the school-age years. Therefore, accident prevention should take priority when teaching parents of school-age children. Preschool (not school-age) children are afraid of the dark, have fears concerning body integrity, and should be encouraged to dress without help (with the exception of tying shoes).
Question 75 |
Which of the following medications would be contraindicated for a patient who has been diagnosed with acute gastritis?
A | Naproxen sodium (Naprosyn). |
B | Calcium carbonate. |
C | Clarithromycin (Biaxin). |
D | Furosemide (Lasix). |
Question 75 Explanation:
ANSWER: Naproxen sodium (Naprosyn). ; RATIONALE: Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. Calcium carbonate is used as an antacid for the relief of indigestion and is not contraindicated. Clarithromycin is an antibacterial often used for the treatment of Helicobacter pylori in gastritis. Furosemide is a loop diuretic and is contraindicated in a patient with gastritis.
Question 76 |
The patient in cubicle 3, a 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid intake?
A | Worsening dyspnea |
B | Gastric distension |
C | Nausea and vomiting |
D | Temperature of 102°F (38.9° C) |
Question 76 Explanation:
ANSWER: Worsening dyspnea ; RATIONALE: Dyspnea and other signs of respiratory distress signify fluid volume excess (overload), which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention may suggest excessive oral fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit.
Question 77 |
Mr. Dennis has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered to this patient?
A | Streptokinase |
B | Atropine |
C | Acetaminophen |
D | Coumadin |
Question 77 Explanation:
ANSWER: Streptokinase ; RATIONALE: Streptokinase is a clot busting drug and the best choice in this situation.
Question 78 |
Nurse Vivian is assigned at the pediatric unit. Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe asthma exacerbation?
A | Oxygen saturation of 95% |
B | Mild work of breathing |
C | Absence of intercostals or substernal retractions |
D | History of steroid-dependent asthma |
Question 78 Explanation:
ANSWER: History of steroid-dependent asthma ; RATIONALE: A history of steroid-dependent asthma, a contributing factor to this client’s high-risk status, requires the nurse to treat the situation as a severe exacerbation regardless of the severity of the current episode. An oxygen saturation of 95%, mild work of breathing, and absence of intercostals or substernal retractions are all normal findings.
Question 79 |
Which of the following should a nurse most closely monitor for during acute management of a patient who has taken an overdose of aspirin?
A | Onset of pulmonary edema |
B | Metabolic alkalosis |
C | Respiratory alkalosis |
D | Parkinson’s disease type symptoms |
Question 79 Explanation:
ANSWER: Parkinson’s disease type symptoms ; RATIONALE: Aspirin overdose can lead to metabolic acidosis and cause pulmonary edema development.
Question 80 |
When caring for a client with a retinal detachment at the inner aspect of the right eye, into which position would Nurse Albie place the client?
A | Fowler’s position |
B | Supine with a small pillow |
C | Right-side lying |
D | Left-side lying |
Question 80 Explanation:
ANSWER: Left-side lying ; RATIONALE: When retinal detachment occurs, the client is positioned so that the area of detachment is dependent. For this client, the left-side lying position is used. Positioning the client in the Fowler, supine, or right-side lying position would not place the detached area in a dependent position.
Question 81 |
While checking the Ecart for its contents, a 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most likely suspect?
A | Diverticulosis |
B | Hypercalcaemia |
C | Hypocalcaemia |
D | Irritable bowel syndrome |
Question 81 Explanation:
ANSWER: Hypercalcaemia ; RATIONALE: Hypercalcaemia can cause polyuria, severe abdominal pain, and confusion.
Question 82 |
Patient X in cubicle 4 who is orderedwith Dilantin (phenytoin) for a seizure disorder is experiencing breakthrough seizures. A blood sample is taken to determine the serum drug level. Which of the following would indicate a sub-therapeutic level?
A | 15 mcg/mL. |
B | 4 mcg/mL. |
C | 10 mcg/dL. |
D | 5 mcg/dL. |
Question 82 Explanation:
ANSWER: 4 mcg/mL. ; RATIONALE: The therapeutic serum level for Dilantin is 10 – 20 mcg/mL. A level of 4 mcg/mL is subtherapeutic and may be caused by patient non-compliance or increased metabolism of the drug. A level of 15 mcg/mL is therapeutic. Choices C and D are expressed in mcg/dL, which is the incorrect unit of measurement.
Question 83 |
You accidentally suffered a needlestickinjury while working with a patient that is positive for AIDS. Which of the following is the most important action that you should take?
A | Immediately see a social worker |
B | Start prophylactic AZT treatment |
C | Start prophylactic Pentamidine treatment |
D | Seek counseling |
Question 83 Explanation:
ANSWER: Start prophylactic AZT treatment ; RATIONALE: AZT treatment is the most critical intervention.
Question 84 |
A CBC (complete blood count) reveals a platelet count of 25,000/microliter in a patient with leukemia and is receiving chemotherapy. Knowing that chemotherapy is known to depress bone marrow, which of the following actions related specifically to the platelet count should be included on the nursing care plan?
A | Monitor for fever every 4 hours. |
B | Require visitors to wear respiratory masks and protective clothing. |
C | Consider transfusion of packed red blood cells. |
D | Check for signs of bleeding, including examination of urine and stool for blood. |
Question 84 Explanation:
ANSWER: Check for signs of bleeding, including examination of urine and stool for blood. ; RATIONALE: A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the initiation of bleeding precautions, including monitoring urine and stool for evidence of bleeding. Monitoring for fever and requiring protective clothing are indicated to prevent infection if white blood cells are decreased. Transfusion of red cells is indicated for severe anemia.
Question 85 |
Nurse Ave is caring for a patient who has been diagnosed with Ménière’s disease, which diet would be most appropriate to discuss with her?
A | Low-fiber |
B | Low-potassium |
C | Low-sodium |
D | Low-protein |
Question 85 Explanation:
ANSWER: Low-sodium ; RATIONALE: It is taught that Ménière’s disease is caused by edema of the semicircular canals. A low-sodium diet is often prescribed in conjunction with diuretic therapy. Protein intake should have no relation to Ménière’s disease, but hypoproteinemia may aggravate edema. FIber and potassium have not been identified as instrumental in the development of Ménière’s disease.
Question 86 |
You are assigned to take the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect?
A | Multiple sclerosis |
B | Anorexia nervosa |
C | Bulimia |
D | Systemic sclerosis |
Question 86 Explanation:
ANSWER: Anorexia nervosa ; RATIONALE: All of the clinical signs and symptoms point to a condition of anorexia nervosa.
Question 87 |
When planning care for a 8-year-old boy with Down syndrome, Nurse Fifishould:
A | Plan interventions according to the developmental level of a 7-year-old child because that’s the child’s age |
B | Plan interventions according to the developmental levels of a 5-year-old because the child will have developmental delays |
C | Assess the child’s current developmental level and plan care accordingly |
D | Direct all teaching to the parents because the child can’t understand |
Question 87 Explanation:
ANSWER: Assess the child’s current developmental level and plan care accordingly ; RATIONALE: Nursing care plan should be planned according to the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually assessed. A child with Down syndrome is capable of learning, especially a child with mild limitations.
Question 88 |
Lea has been reading all about osteoporosis. Based on what she has learned, which patient should NOT be prescribed alendronate (Fosamax) for osteoporosis?
A | A female patient being treated for high blood pressure with an ACE inhibitor. |
B | A patient who is allergic to iodine/shellfish. |
C | A patient on a calorie restricted diet. |
D | A patient on bed rest who must maintain a supine position. |
Question 88 Explanation:
ANSWER: A patient on bed rest who must maintain a supine position. ; RATIONALE: Alendronate can cause significant gastrointestinal side effects, such as esophageal irritation, so it should not be taken if a patient must stay in supine position. It should be taken upon rising in the morning with 8 ounces of water on an empty stomach to increase absorption. The patient should not eat or drink for 30 minutes after administration and should not lie down. ACE inhibitors are not contraindicated with alendronate and there is no iodine allergy relationship.
Question 89 |
Mrs Beck, a 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?
A | IgA |
B | IgD |
C | IgE |
D | IgG |
Question 89 Explanation:
ANSWER: IgG ; RATIONALE: IgG is the only immunoglobulin that can cross the placental barrier.
Question 90 |
In the assessment of a patient who is experiencing an acute exacerbation of Ménière’s disease, which assessment data would the nurse expect as the chief complaint?
A | Vertigo |
B | Dizziness |
C | Severe ear pain |
D | Sudden deafness |
Question 90 Explanation:
ANSWER: Vertigo ; RATIONALE: Ménière’s disease is characterized by sudden, severe episodes of vertigo during which the client has a sensation of spinning. Dizziness is not vertigo and must be distinguished from true rotational vertigo. A feeling of pressure but not pain is also characteristic, and hearing loss os progressive, not sudden.
Question 91 |
Nurse Via is evaluating a postoperative patient and notes a moderate amount of serous drainage on the dressing 24 hours after surgery. Which of the following is the appropriate nursing action?
A | Notify the surgeon about evidence of infection immediately. |
B | Leave the dressing intact to avoid disturbing the wound site. |
C | Remove the dressing and leave the wound site open to air. |
D | Change the dressing and document the clean appearance of the wound site. |
Question 91 Explanation:
ANSWER: Change the dressing and document the clean appearance of the wound site. ; RATIONALE: A moderate amount of serous drainage from a recent surgical site is a sign of normal healing. Purulent drainage would indicate the presence of infection. A soiled dressing should be changed to avoid bacterial growth and to examine the appearance of the wound. The surgical site is typically covered by gauze dressings for a minimum of 48-72 hours to ensure that initial healing has begun.
Question 92 |
Chloe, 17 years old, is rushed to the hospital and is suspected to have a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Note: More than one answer may be correct.
A | Urine specific gravity of 1.040. |
B | Urine output of 350 ml in 24 hours. |
C | Brown (“tea-colored”) urine. |
D | Generalized edema. |
Question 92 Explanation:
ANSWER: Urine specific gravity of 1.040. ; Urine output of 350 ml in 24 hours. ; Brown (“tea-colored”) urine. ; RATIONALE: Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark “tea colored” urine caused by large amounts of red blood cells. There is periorbital edema, but generalized edema is seen in nephrotic syndrome, not acute glomerulonephritis.
Question 93 |
Which statement by the parents of a child with celiac disease indicates effective teaching when it comes to dietary restrictions?
A | “Well follow these instructions until our child’s symptoms disappear.” |
B | “Our child must maintain these dietary restrictions until adulthood.” |
C | “Our child must maintain these dietary restrictions lifelong.” |
D | “We’ll follow these instructions until our child has completely grown and developed.” |
Question 93 Explanation:
ANSWER: “Our child must maintain these dietary restrictions lifelong.” ; RATIONALE: A patient with celiac disease must maintain dietary restrictions lifelong to avoid recurrence of clinical manifestations of the disease. The other options are incorrect because signs and symptoms will reappear if the patient eats prohibited foods.
Question 94 |
Jace is scanning his notes tonight in preparation for next week’s exam. Tonight, he is reading all about Wilms tumor. Which of the following statements most accurately describes Wilms tumor, stage II?
A | The tumor is less than 3 cm. in size and requires no chemotherapy. |
B | The tumor did not extend beyond the kidney and was completely resected. |
C | The tumor extended beyond the kidney but was completely resected. |
D | The tumor has spread into the abdominal cavity and cannot be resected. |
Question 94 Explanation:
ANSWER: The tumor extended beyond the kidney but was completely resected. ; RATIONALE: The staging of Wilms tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual non hematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.
Question 95 |
Patient H is diagnosed with an acute exacerbation of Meniere;s disease. Which intervention would be included in the care plan for this client?
A | Instructing the client on the correct way to remove impacted cerumen |
B | Speaking slowly and distinctly in a low-pitched, clear voice without yelling |
C | Providing a safe, quiet, dimly lit environment with enforced bed rest |
D | Instructing the client to pull the top of the ear and back to instill eardrops |
Question 95 Explanation:
ANSWER: Providing a safe, quiet, dimly lit environment with enforced bed rest ; RATIONALE: Ménière’s disease is a chronic disorder of the inner ear involving sensorineural hearing loss, severe vertigo, and tinnitus. Typically, the client experiences sudden episodes of od severe whirling vertigo with an inability to stand or walk, buzzing tinnitus that worsens before and during an episode, nausea, vomiting, and diaphoresis. The client’s safety must be ensured along with decreasing exposure to extraneous stimuli. This is accompanied by providing the client with a quiet, dimly lit environment and bed rest. Instructions about removing cerumen are appropriate for a client with cerumen impaction. Speaking slowly and distinctly in a low-pitched, clear voice without yelling is appropriate for clients experiencing a hearing loss. Clients with Ménière’s disease are not deaf during acute exacerbations. However, hearing loss may occur after repeated episodes. Ear drops are not the treatment of choice for an acute attack of Ménière’s disease.
Question 96 |
Mr. Pinkerton has just undergone nasal surgery with posterior packing in place, which assessment data would alert the Nurse Venus to the possibility of active bleeding?
A | Appearance of anxiety |
B | Discoloration around the eyes |
C | Frequent swallowing |
D | Black, tarry stool |
Question 96 Explanation:
ANSWER: Frequent swallowing ; RATIONALE: After nasal surgery, drainage tricking down the posterior pharynx (seen with a flashlight) accompanied by frequent swallowing, belching, or hematemesis indicate continued bleeding. Anxiety is common because of the necessity to breathe through the mouth. Discoloration around the eyes occurs with surgical trauma and is to be expected. Tarry stools indicate previous, but not current bleeding.
Question 97 |
Nurse Hillary is assigned to care for an infant with hydrocele, who is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?
A | Massaging the groin area twice a day until the fluid is gone. |
B | Referral to a surgeon for repair. |
C | No treatment is necessary; the fluid is reabsorbing normally. |
D | Keeping the infant in a flat, supine position until the fluid is gone. |
Question 97 Explanation:
ANSWER: No treatment is necessary; the fluid is reabsorbing normally. ; RATIONALE: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the area or placing the infant in a supine position would have no effect. Surgery is not indicated.
Question 98 |
Nurse Abby is catering a who patient arrived at the emergency department complaining of back pain. He reports taking at least 3 acetaminophen tablets every three hours for the past week without relief. Which of the following symptoms suggests acetaminophen toxicity?
A | Tinnitus. |
B | Diarrhea. |
C | Hypertension. |
D | Hepatic damage. |
Question 98 Explanation:
ANSWER: Hepatic damage. ; RATIONALE: Acetaminophen in even moderately large doses can cause serious liver damage that may result in death. Immediate evaluation of liver function is indicated with consideration of N-acetylcysteine administration as an antidote. Tinnitus is associated with aspirin overdose, not acetaminophen. Diarrhea and hypertension are not associated with acetaminophen.
Question 99 |
Leo returns to the emergency department less than 24 hours after having a fiberglass cast applied for a fractured right radius. Which of the following complaints from the patient would cause the nurse to be concerned about impaired perfusion to the limb?
A | Severe itching under the cast. |
B | Severe pain in the right shoulder. |
C | Severe pain in the right lower arm. |
D | Increased warmth in the fingers. |
Question 99 Explanation:
ANSWER: Severe pain in the right lower arm. ; RATIONALE: Impaired perfusion to the right lower arm as a result of a closed cast may cause neurovascular compromise and severe pain, requiring immediate cast removal. Itching under the cast is common and fairly benign. Neurovascular compromise in the arm would not cause pain in the shoulder, as perfusion there would not be affected. Impaired perfusion would cause the fingers to be cool and pale. Increased warmth would indicate increased blood flow or infection.
Question 100 |
Nurse Clary is caring for a child who has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes priority?
A | Ineffective airway clearance related to edema |
B | Disturbed body image related to physical appearance |
C | Impaired urinary elimination related to fluid loss |
D | Risk for infection related to epidermal disruption |
Question 100 Explanation:
ANSWER: Ineffective airway clearance related to edema ; RATIONALE: Initially, when a preschool client is admitted to the hospital for burns, the primary focus is on assessing and managing an effective airway. Body image disturbance, impaired urinary elimination, and infection are all integral parts of burn management but aren’t the first priority.
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