Q&A Random Selection #15

1. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is
asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next
action?
A) Leave the room and return five minutes later and give the medicine
B) Explain to the child that the medicine must be taken now
C) Give the medication to the father and ask him to give it
D) Mix the medication with ice cream or applesauce

2. During the evaluation phase for a client, the nurse should focus on
A) All finding of physical and psychosocial stressors of the client and in the family
B) The client's status, progress toward goal achievement, and ongoing re-evaluation
C) Setting short and long-term goals to insure continuity of care from hospital to home
D) Select interventions that are measurable and achievable within selected timeframes

3. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which
statement by the mother indicates the need for additional instruction?
A) "I should position my baby completely facing me with my baby's mouth in front of my nipple."
B) "The baby should latch onto the nipple and areola areas."
C) "There may be times that I will need to manually express milk."
D) " I can switch to a bottle if I need to take a break from breast feeding."

4. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the
nurse?
A) "Do you want to take this pretty red medicine?"
B) "You will feel better if you take your medicine."
C) "This is your medicine, and you must take it all right now."
D) "Would you like to take your medicine from a spoon or a cup?"

5. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day
care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse
assess for in this child?
A) All lesions crusted
B) Elevated temperature
C) Rhinorrhea and coryza
D) Presence of vesicles

6. The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse
anticipate?
A) Retractions in the intercostal tissues of the thorax
B) Chest pain aggravated by respiratory movement
C) Cyanosis and mottling of the skin
D) Rapid, shallow respirations

7. A nurse is assigned to a client who is newly admitted for treatment of a frontal lobe brain tumor. Which history
offered by the family members would be recognized by the nurse as associated with the diagnosis, and
communicated to the provider?
A) "My partner's breathing rate is usually below 12."
B) "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."
C) "It seems our sex life is nonexistent over the past 6 months."
D) "In the morning and evening I hear complaints that reading is next to impossible from blurred print."

8. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic
lab value should the nurse monitor when a client is receiving this medication?
A) Potassium level
B) Arterial blood gasses
C) Blood urea nitrogen
D) Thiocyanate

9. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in
diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
A) transparent film dressing
B) wet dressing with debridement granules
C) wet to dry with hydrogen peroxide
D) moist saline dressing
10. The school nurse suspects that a third grade child might have attention deficit hyperactivity disorder (ADHD).
Prior to referring the child for further evaluation, the nurse should
A) observe the child's behavior on at least 2 occasions
B) consult with the teacher about how to control impulsivity
C) compile a history of behavior patterns and developmental accomplishments
D) compare the child's behavior with classic signs and symptoms

11. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would
expect to find elevation in which of the following values?
A) Blood urea nitrogen
B) Acid phosphatase
C) Bilirubin
D) Sedimentation rate

12. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse
recognize as the cause of the findings?
A) Decreased cardiac output
B) Tissue hypoxia
C) Cerebral edema
D) Reduced oxygen saturation

13. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which
initial response by the nurse would be best?
A) "A recovering person has to be very careful not to lose control, therefore, confine your drinking only to family
gatherings."
B) "At your next AA meeting discuss the possibility of limited drinking with your sponsor."
C) "A recovering person needs to get in touch with their feelings. Do you want a drink?"
D) "A recovering person cannot return to drinking without starting the addiction process over."

14. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet
A) high in carbohydrates and proteins
B) low in carbohydrates and proteins
C) high in carbohydrates, low in proteins
D) low in carbohydrates, high in proteins

15. A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by
the nurse is to
A) have the unlicensed assistive personnel (UAP) reheat the food if the client wishes
B) ask the client what foods are acceptable or are unacceptable
C) encourage her to eat for healing and strength
D) schedule the dietitian to meet with the client as soon as possible

16. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client
develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing
intervention should be performed first?
A) Take the client's vital signs
B) Place the client in a sitting position with legs dangling
C) Contact the health care provider
D) Administer the PRN antianxiety agent

17. Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client
scheduled for coronary artery bypass?
A) Touring the coronary intensive unit
B) Mailing a video tape to the home
C) Assessing the client's learning style
D) Administering a written pre-test

18. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in
the infant?
A) Increased 10% in height
B) 2 deciduous teeth
C) Tripled the birth weight
D) Head > chest circumference
19. A nurse is doing preconception counseling with a woman who is planning a pregnancy. Which of the following
statements suggests that the client understands the connection between alcohol consumption and fetal alcohol
syndrome?
A) "I understand that a glass of wine with dinner is healthy."
B) "Beer is not really hard alcohol, so I guess I can drink some."
C) "If I drink, my baby may be harmed before I know I am pregnant."
D) "Drinking with meals reduces the effects of alcohol."

20. In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the
relationship between edema formation and
A) increased retention of albumin in the vascular system
B) decreased colloidal osmotic pressure in the capillaries
C) fluid shift from interstitial spaces into the vascular space
D) reduced tubular reabsorption of sodium and water

21. Which of these parents’ comments about a newborn would most likely reveal an initial finding of a suspected
pyloric stenosis?
A) "I noticed a little lump a little above the belly button."
B) "The baby seems hungry all the time."
C) "Mild vomiting turned into vomiting that shot across the room."
D) "We notice irritation and spitting up immediately after feedings."

22. Which of the actions suggested to the registered nurse (RN) by the practical nurse (PN) during a planning
conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the
plan of care?
A) measure head circumference
B) place in airborne isolation
C) provide passive range of motion
D) provide an over-the-crib protective top

23. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these
statements about milk consumption is correct?
A) May drink as much milk as desired
B) Can have milk mixed with other foods
C) Will benefit from fat-free cow's milk
D) Should be limited to 3-4 cups of milk daily

24. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested
in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers,
not fathers." The nurse's initial intervention should be what focus?
A) Discuss with the mother sharing parenting responsibilities
B) Set time aside to get the mother to express her feelings and concerns
C) Arrange for the parents to attend infant care classes
D) Talk with the father and help him accept the wife's decision

25. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the
moon. Walking is a good health habit." The client’s remarks most likely indicate
A) neologisms
B) flight of ideas
C) loose associations
D) word salad

26. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse
emphasize as normal at this age?
A) Jumping rope
B) Tying shoelaces
C) Riding a tricycle
D) Playing hopscotch

27. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00
A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?
A) 14 minutes
B) 10 minutes
C) 15 minutes
D) Nine minutes
28. A client who has been drinking for five years states that he drinks when he gets upset about "things" such as
being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol
as a way to deal with
A) recreational and social needs
B) feelings of anger
C) life’s stressors
D) issues of guilt and disappointment

29. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious
and concerned about the child's reaction to impending surgery. Which nursing intervention would best prepare the
child?
A) Introduce the child to all staff the day before surgery
B) Explain the surgery 1 week prior to the procedure
C) Arrange a tour of the operating and recovery rooms
D) Encourage the child to bring a favorite toy to the hospital

30. The nurse should recognize that physical dependence is accompanied by what findings when alcohol
consumption is first reduced or ended?
A) Seizures
B) Withdrawal
C) Craving
D) Marked tolerance

31. The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24
hours. The nurse should
A) review the medications the client is receiving
B) increase the formula infusion rate
C) increase the amount of water used to flush the tube
D) attach a rectal bag to protect the skin

32. The nurse, assisting in applying a cast to a client with a broken arm, knows that the
A) cast material should be dipped several times into the warm water
B) cast should be covered until it dries
C) wet cast should be handled with the palms of hands
D) casted extremity should be placed on a cloth-covered surface

33. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary
contraindication for breast feeding?
A) Age 40 years
B) Lactose intolerance
C) Family history of breast cancer
D) Use of cocaine on weekends

34. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the
partner’s injuries by
A) seeking medical help for the victim's injuries
B) minimizing the episode and underestimating the victim’s injuries
C) contacting a close friend and asking for help
D) being very remorseful and assisting the victim with medical care

35. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that
the client should
A) eat foods high in sodium to increase sputum liquefaction
B) use oxygen during meals to improve gas exchange
C) perform exercise after respiratory therapy to enhance appetite
D) cleanse the mouth of dried secretions to reduce risk of infection

36. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the
batterer might respond?
A) With acceptance and views the victim’s comment as an indication that their marriage is in trouble
B) With fear of rejection causing increased rage toward the victim
C) With a new commitment to seek counseling to assist with their marital problems
D) With relief, and welcomes the separation as a means to have some personal time
37. An 18 month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin, and
increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional
findings of
A) septicemia
B) dehydration
C) hypokalemia
D) hypercalcemia

38. The nurse prepares for a Denver Screening of a 3 year-old child in the clinic. The mother asks the nurse to
explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver?
A) "It measures a child’s intelligence."
B) "It assesses a child's development."
C) "It evaluates psychological responses."
D) " It helps to determine problems."

39. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to
A) Dress the child warmly to avoid chilling
B) Keep the child away from other children for the duration of the rash
C) Clean the affected areas with tepid water and detergent
D) Wrap the child's hand in mittens or socks to prevent scratching

40. The father of an 8 month-old infant asks the nurse if his child's vocalizations are normal for his age. Which of the
following would the nurse expect at this age?
A) Cooing
B) Imitation of sounds
C) Throaty sounds
D) Laughter