Q&A Random Selection #17

1. A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal
preparations. What is the initial action the nurse should take?
A) Report the behavior to the charge nurse
B) Talk with the client to find out about the preferred herbal preparation
C) Contact the client's primary care provider
D) Explain the importance of the medication to the client

2. During the two-month well-baby visit, the mother complains that formula seems to stick to her baby's mouth and
tongue. Which of the following would provide the most valuable data for nursing assessment?
A) Inspect the baby's mouth and throat
B) Obtain cultures of the mucous membranes
C) Flush both sides of the mouth with normal saline
D) Use a soft cloth to attempt to remove the patches

3. Dual diagnosis indicates that there is a substance abuse problem as well as a

A) cross addiction
B) mental disorder
C) disorder of any type
D) medical problem

4. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification
program. The nurse must understand that a priority during withdrawal is
A) avoiding alcohol use during this time
B) observing the client for hypotension
C) abrupt discontinuation of the drug
D) assessing for mild physical symptoms

5. To obtain data for the nursing assessment, the nurse should:

A) observe carefully the client’s nonverbal behaviors
B) adhere to pre-planned interview goals and structure
C) allow clients to talk about whatever they want
D) elicit clients' description of their experiences, thoughts and behaviors

6. A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the
following to prevent aspirin toxicity?
A) Serum potassium
B) Protein intake
C) Lactose tolerance
D) Serum albumin

7. The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an
understanding of the diet by stating
A) "I will increase sodium and fluids and restrict potassium."
B) "I will increase potassium and sodium and restrict fluids."
C) "I will increase sodium, potassium and fluids."
D) "I will increase fluids and restrict sodium and potassium."

8. A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by
the nurse?
A) Suggest isometric exercises
B) Maintain the client on bed rest
C) Ambulate for several minutes
D) Apply ice to the extremity

9. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?
A) Allow the infant to drink the liquid from a medicine cup
B) Administer the medication with a syringe next to the tongue
C) Mix the medication with the infant's formula in the bottle
D) Hold the child upright and administer the medicine by spoon

10. A mother telephones the clinic and says “I am worried because my breast-fed 1 month-old infant has soft, yellow
stools after each feeding.” The nurse's best response would be which of these?
A) "This type of stool is normal for breast fed infants. Keep doing as you have."
B) "The stool should have turned to light brown by now. We need to test the stool."
C) "Formula supplements might need to be added to increase the bulk of the stools."
D) "Water should be offered several times each day in addition to the breast feeding."
11. A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected
planning
committee has approved the change, yet the staff are not receptive to the plan. As a change agent, the nurse
manager should first
A) support the planning committee and post the new schedule
B) explore how the planning committee evaluated barriers to the plan
C) design a different approach to deliver care with fewer staff
D) retain the previous staffing pattern for another 6 months

12. What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?
A) Acceptance of the pregnancy
B) Acceptance of the termination of the pregnancy
C) Acceptance of the fetus as a separate and unique being
D) Satisfactory resolution of fears related to giving birth

13. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is
important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?
A) Skin irritation
B) Drug tolerance
C) Severe headaches
D) Postural hypotension

14. The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?
A) Heart rate
B) Muscle tone
C) Cry
D) Color

15. The nurse is caring for a depressed client with a new prescription for a selective serotonin reuptake inhibitor
(SSRI)
antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about
the safety of this medication?
A) History of obesity
B) Prescribed use of a monoamine oxidase (MAO) inhibitor
C) Diagnosis of vascular disease
D) Takes antacids frequently

16. The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to
prevent skin breakdown?
A) Massage legs frequently
B) Frequent turning
C) Moisten skin with lotions
D) Apply moist heat to reddened areas

17. A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a
sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be
which of these statements?
A) "Touching the abdomen could cause cancer cells to spread."
B) "Examining the area would cause difficulty to the child."
C) "Pushing on the stomach might lead to the spread of infection."
D) "Placing any pressure on the abdomen may cause an abnormal experience."

18. In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider
before administering which of the following drugs through the tube?
A) Cardizem SR tablet (diltiazem)
B) Lanoxin liquid
C) Os-cal tablet (calcium carbonate)
D) Tylenol liquid (acetaminophen)

19. A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English
speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when
working with an interpreter is to
A) promote verbal and nonverbal communication with both the client and the interpreter
B) speak only a few sentences at a time and then pause for a few moments
C) plan that the encounter will take more time than if the client spoke English
D) ask the client to speak slowly and to look at the person spoken to
20. A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another
person. This seems to be a recent pattern of behavior. What is the appropriate initial action?
A) Report this immediately to the nurse manager
B) Confront the nurse about the suspected drug use
C) Sign the narcotic sheet and document the event in an incident report
D) Counsel the colleague about the risky behaviors

21. A mother calls the clinic, concerned that her 5 week-old infant is "sleeping more than her brother did." What is the
best initial response?
A) "Do you remember his sleep patterns?"
B) "How old is your other child?"
C) "Why do you think this a concern?"
D) "Does the baby sleep after feeding?"

22. A diabetic client asks the nurse why the provider ordered a glycosylated hemoglobin (HbA) measurement, since a
blood glucose reading was just performed. You will explain to the client that the HbA test:
A) Provides a more precise blood glucose value than self-monitoring
B) Is performed to detect complications of diabetes
C) Measures circulating levels of insulin
D) Reflects an average blood sugar for several months

23. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate
attention?
A) Temperature of 102 degrees Fahrenheit
B) Pulse rate of 98 beats per minute
C) Respiratory rate of 32
D) Blood pressure of 90/50

24. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress
at this age?
A) Separation anxiety
B) Fear of pain
C) Loss of control
D) Bodily injury

25. During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small,
circular,
ecchymotic areas on the client's knees. The best action for the nurse to take is to
A) Ask the client for more information about the nature of the bruises
B) Ask the client and then the family about the findings
C) Report the bruising to social services to follow-up
D) Document the findings on the admission sheet

26. Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin
damage?
A) Ninety-ninety
B) Buck's
C) Bryant
D) Russell

27. A client with considerable pain asks, “What is your opinion regarding acupuncture as a drug-free method for
alleviating pain?” The nurse responds, "I'd forget about it as those weird non-Western treatments can be scary." The
nurse's response is an example of
A) prejudice
B) discrimination
C) ethnocentrism
D) cultural insensitivity

28. The nurse is speaking to a group of parents and elementary school teachers about care for children with
rheumatic fever. It is a priority to emphasize that
A) home schooling is preferred to classroom instruction
B) children may remain strep carriers for years
C) most play activities will be restricted indefinitely
D) clumsiness and behavior changes should be reported

29. A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing anorexia, moderate edema and
elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. What would the
nurse's best response to this request?
A) "That's a good choice, and I know it is your favorite. You can have it today."
B) "I'm sorry, that is not a good choice, but you could have pasta."
C) "I know that is your favorite, but let me help you pick another lunch."
D) "You cannot have the peanut butter until you are feeling better."

30. A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have
A) scrotal discoloration
B) sustained painful erection
C) inability to achieve erection
D) heaviness in the affected testicle

31. Which statement describes factors that help build personal power in an organization?
A) Longevity in an organization, social ties to people in power, and a history as someone who does not back down in
conflict ends with success
B) Goals are met with the use of networking, mentoring, and coalition building
C) High visibility and formal power are maintained with a confrontational style
D) Credibility to one's position is enhanced when professional dress and demeanor are employed

32. Which statement describes the advantage of using a decision grid for decision making?
A) It is both a visual and a quantitative method of decision making
B) It is the fastest way for group decision making
C) It allows the data to be graphed for easy interpretation
D) It is the only truly objective way to make a decision in a group

33. A nurse is caring for a client with peripheral arterial insufficiency of the lower extremities. Which intervention
should be included in the plan of care to reduce leg pain?
A) elevate the legs above the heart
B) increase ingestion of caffeine products
C) apply cold compresses
D) lower the legs to a dependent position

34. The nurse is caring for a client with COPD who becomes dyspneic. The nurse should
A) instruct the client to breathe into a paper bag
B) place the client in a high Fowler's position
C) assist the client with pursed lip breathing
D) administer oxygen at 6L/minute via nasal cannula

35. After successful alcohol detoxification, a client remarked to a friend, "I’ve tried to stop drinking but I just can’t. I
can’t even work without having a drink." The client’s belief that he needs alcohol indicates his dependence is primarily
A) psychological
B) physical
C) biological
D) social-cultural

36. The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result
in metabolic acidosis?
A) Severe diarrhea for 24 hours
B) Nausea with anorexia
C) Alternating constipation and diarrhea
D) Vomiting for over 48 hours

37. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the
appropriate nursing action?
A) Pack the nose and ears with sterile gauze
B) Apply pressure to the injury site
C) Apply bulky, loose dressing to nose and ears
D) Apply an ice pack to the back of the neck

38. Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy (ECT)?
A) Permission to videotape
B) Salivary pH
C) Mini-mental status exam
D) Pre-anesthesia work-up