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VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
Which term describes the play activity of the preschool aged child?
A. Cooperative B.Associative C. Parallel D. Solitary B (Associative) (Play of the preschool aged child is described as associative. At this stage, children are more interested in playing with other children than they are with playing with toys. The child may talkto other children and exchange toys or play games without any rules. Answer A describes the play of a school-aged child. Answer C describes the play of an infant.) The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly on hismother's lap. Which should the nurse do first?
A. Check the Babinski reflex B. Listen to the heart and lung sounds C. Palpate the abdomen D. Check tympanic membranes B (Listen to the heart and lung sounds) (While the infant is quiet, the nurse should begin the exam by listening to the heart and lungs. Ifthe nurse elicits the Babinski reflex , palpates the abdomen, or checks the tympanic membranes,the infant may cry and it will be difficult to adequately listen to the heart and lungs; therefore answers A,C, and D are incorrect.) In terms of cognitive development, a three-year-old would be expected to:
A. Think abstractly B. Use magical thinking C. Understand conservation of matter D. See things from the perspective of others
B (Use magical thinking)
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
(A three-year-old is expected to use magical thinking, such as believing that a toy bear is a real bear. Answers A, C, and D are incorrect because of abstract thinking, conservation of matter, andthe ability to look at things from the perspective of others are cognitive abilities of an older child) Which of the following describes the language development of a two-year-old?
A. Doesn't understand yes and no B. Understands the meaning of all words C. Can combine three or four words D. Repeatedly asks "why?" C (can combine three or four words) (The two year old can combine three to four words. Answers A and B are incorrect because thetwo-year-old understands yes and no, but does not understand the meaning of all the words. Answer D is incorrect because seeking information and asking "why?" is typical of the three-year old) A client who has been receiving Urokinase (uPA) for deep vein thrombosis is noted to have darkbrown urine in the urine collection bag. Which action should the nurse take immediately?
A. Prepare an injection of vitamin K B. Irrigate the urinary catheter with 50 mL of normal saline C. Offer the client additional oral fluids D. Withhold the medication and notify the physician
D (Withhold the medication and notify the physician) (Urokinase is a thrombolytic agent used in the treatment of deep vein thrombosis, pulmonary embolus, or myocardial infarction. The presence of dark brown or rust-colored urine suggests bleeding. The nurse should withhold the medication, call the doctor immediately, and prepare toadminister Amicar. Answer A is correct because vitamin K is not the antidote for urokinase. Answers B and C are incorrect because they do not address the adverse
problem of bleeding)Which of the following can occur with the frequent use of
calcium based antacids?
A. Constipation
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
A client with a renal failure is prescribed a low potassium diet. Which food choice would be bestfor this client?
A.1 cup beef broth B.1 baked potato C. 1/2 cup raisins D.1 cup rice D (1 cup of rice) ( Answer D is correct because one cup of rice is considered a low-potassium food. The foods inanswer A, B, and C are incorrect because they contain higher amounts of potassium) An appropriate nursing intervention for the client with borderline personality disorder is:
A. Observing the client for signs of depression or suicidal thinking B.Allowing the client to lead unit group sessions C. Restricting the client's activity to the assigned unit of care throughout hospitalization D. Allowing the client to select a primary caregiver
A (observing the client for signs of depression or suicidal thinking) (Clients with borderline personality frequently suffer from depression and suicidal thinking and should be assessed for risk of self-injury. Answers B and D are incorrect choices because they allow the client too much control of the therapeutic environment. Answer C is incorrect becausethe client's activities do not have to be restricted to the unit after the level of depression has beendetermined )
Which of the following is an expected finding in the assessment of a client with bulimia nervosa
A. Extreme weight loss B.Presence of lanugo over body C. Erosion of tooth enamel D. Muscle wasting
C (Erosion of tooth enamel) (Erosion of tooth enamel caused by frequent self-induced vomiting is an expected finding in aclient with bulimia nervosa. Answers A, B, and D are expected findings in the client with anorexia nervosa; therefore, they are incorrect.)
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
Assuming that all have achieved normal cognitive and emotional development, which of thefollowing children is at greatest risk for accidental poisoning?
A. One-year-old B.Four-year-old C. Eight-year-old D. Twelve-year-old
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
action should be to:
A. Report the findings to the physician B.Recheck the vital signs in one hour C. Ask the patient if he is in pain D. Compare the current vital signs with those on admission A (Report the findings to the physician)
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
(The client is exhibiting a widened pulse pressure, tachycardia, tachypnea. The first nursing action after obtaining these vital signs is to notify the physician for additional orders. Answers B,C, and D can be done after the physician is notified; therefore, they are incorrect choices as a first action.) The nurse is preparing s client with an axillopopliteal bypass graft for discharge. The clientshould be taught to avoid:
A. Using a recliner to rest B.Resting in supine position C. Sitting in a straight chair D. Sleeping in right Sim's position
C (Sitting in a straight chair) (The client with the axillo-popliteal graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Answers A, B, and D are incorrect because resting in a supine position, resting in a recliner, andsleeping in the right Sim's position are allowed.) The doctor has ordered antithrombotic stockings to be applied to the legs of a client with peripheral vascular disease. The nurse knows the antithrombotic stockings should be applied:
A. Before the client arises in the morning B.With the client in a standing position C. After the client has bathed and applied lotion to the legs D. Before the client retires in the evening
A (Before the client arises in the morning) (The best time to apply antithrombotic stockings to the client is in the morning before the clientarises. If the physician orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings. Answers B, C, and D are incorrect because there is likely )
The nurse has just received the change of shift report and is preparing to make rounds. Whichclient should the nurse assess first?
A. A client recovering from a stroke with an oxygen saturation rate of 99% B.A client three days port-coronary artery bypass graft with an oral
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
A. Hypothyroidism B.Diabetic ulcers C. Gastroenteritis D. Bacterial pneumonia
A (Hypothyroidism) The nurse is teaching the client regarding use of sodium warfarin. Which statement made by theclient would require further teaching?
A."I will have blood drawn every month." B."I will assess my skin for rash." C."I take aspirin for a headache." D."I will use an electric razor to shave." C ("I take aspirin for a headache.") The client returns to the recovery room following repair of an abdominal aneurysm. Whichfinding would require further investigation?
A. Pedal pulses regular B.Urinary output 20mL in the past hour C. Blood pressure 108/ D. Oxygen saturation 97%
B (Urinary output 20mL in the past hour) The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of thefollowing is not a factor for the nurse to consider?
A. Diet pattern B.Mobility C. Fluid intake D. Sexual function
D (Sexual function) The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) statfor an adult client. What is the least amount of time that the nurse can safely administer this medication?
- 1 minute
- 2 minutes
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
- 5 minutes
- 10 minutes
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
- Incorrect: The primary purpose of the NG tube to suction is to keep the stomach empty anddry to decrease pancreatic enzyme production, not to relieve nausea.
- Incorrect: Because gastric contents are removed, the NG tube to suction may lead to fluid andelectrolyte disturbances rather than helping to control them.
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
- Incorrect: Although the food in the stomach causes the pancreatic enzymes to becomeactivated in the pancreas due to the obstruction, the food is not considered an irritant. Precipitating irritants are not a part of the pathophysiology occurring with pancreatitis. The nurse is working with a committee at the local school to develop an emergency preparednessplan for tornados. What should be included in the plan?
- Identification of safe zones.
- Methods for accounting for all people present in the building.
- Warning system activation.
- Identification of the gymnasium as the routine safe place.
- Regular practice protocols. 1., 2., 3. & 5. Correct: Everyone should be aware of safe zones within the school. Personnel should be given this information and signs posted in safe zones. There must be systems in placeto accurately determine the number of people in the building at any given time. There also mustbe a system in place to alert personnel and students of tornado warnings. Regular practice prepares everyone for an actual event.
- Incorrect: Gymnasiums are not considered safe places due to wide expanse of roof. Safe zonesshould be on interior walls, no windows, and a strong concrete floor if possible.
What should a nurse teach family members prior to them entering the room of a client who hasagranulocytosis?
- Meticulous hand washing is needed.
- Do not visit if you have any infection.
- The client must wear a mask.
- Children under 12 may not visit.
- Flowers are not allowed in the room.
- , 2., 4., & 5. Correct: Protective isolation is needed for this client because of the presence of a low white blood cell count. We are protecting the client from acquiring an infection. So any visitors will need to have meticulous hand washing prior to entering. The visitor should not enterif he or she has any type of infection. To decrease the risk of infection, small children should notvisit. Even the mildest symptom of infection could be detrimental to the client. Flowers have bacteria and should not be brought into the room.
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
- Are you having trouble sleeping at night?
- Do you have periods of muscle jerking?
- Are you having any sexual dysfunction?
- Is your mood improving?
- Correct: Myoclonus, high body temperature, shaking, chills, and mental confusion are some ofthe symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal.
- Incorrect: Sleep disturbances are common with depression. Selective serotonin reuptake inhibitors (SSRIs) may cause insomnia; however, there is a more pertinent question needed forassessment of this client. You should be concerned with the more serious or life-threatening issue.
- Incorrect: Sexual dysfunction may occur with the SSRIs; however, the client is exhibitingsignificant symptoms of an adverse reaction which would take priority.
- Incorrect: The response to the SSRI medications is important; however, there is a more significant issue in this case. The possible serotonin syndrome is a serious situation that would bethe priority for the nurse to address. A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expecton assessment?
- Fever and shivering
- Agitation
- Decreased body temperature
- Constipation
- Increased heart rate
- , 2. & 5. Correct: Serotonin syndrome is a group of symptoms that can result from the use of certain serotonin reuptake inhibitors. These symptoms can range from mild to severe and includehigh body temperature, agitation, increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likely to experience shivering with fever. Increased heart rate and blood pressure are also commonly experienced. More severe symptoms, including muscle rigidity and seizures, can occur. If not treated, serotonin syndrome can be fatal.
- Incorrect: Increased body temperature is expected as is increased diaphoresis.
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
- Incorrect: Diarrhea, not constipation, is a symptom of serotonin syndrome. The emergency department nurse is assessing a client who presents with severe epigastric pain. The client reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation?
- pH - 7.49, pCO2 - 40, HCO3 - 30
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
protective environments such aswhen immunocompromised clients require protection from potential infectious agents outside ofthe room.
A healthy newborn has just been delivered and placed in the care of the nurse. What nursingactions should the nurse initiate?
Place in the correct priority order.
Assess newborn's airway and
breathing.
VERIFIED 600 QUESTIONS AND ANSWERS WITH
RATIONALES
Bulb suction excessive mucus.Assess newborn's heart rate. Place identification bands on newborn and mom. Administer sterile ophthalmic ointment containing 0.5% erythromycin. Remember Maslow's hierarchy of needs will guide your assessment. First, Assess newborn's airway and breathing. The most critical change that a newborn must make physiologically is the initiation of breathing. The nurse should assess the newborn's crying. If the cry is weak, it may indicate a respiratory disturbance. Other signs of respiratory compromise may include: stridor, grunting, retractions, apnea or diminished breath sounds. Normal respiration are 30 - 60 breaths aminute.
Second, Bulb suction excessive mucus. It is important to assure that the throat and nose are keptclean of secretions to prevent respiratory distress.
Third, Assess newborn's heart rate. If there is no respiratory distress, the nurse continues theassessment by checking the heart rate and other vital signs.
Fourth, Place identification bands on newborn and mom. These are critical for ensuring babies and moms will be appropriately matched at all times but does not take priority over respirationand circulation.
Fifth, Administer sterile ophthalmic ointment containing 0.5% erythromycin. This is a legally required prophylactic eye treatment to prevent Neisseria gonorrhea. However, this would neverbe a priority over Maslow's hierarchy of needs. What information should a nurse include when educating a client regarding buccaladministration of a medication?
- This route allows the medication to get into the bloodstream faster than the oral route.
- Stinging may occur after placing the medication in the cheek.
- If swallowed, the medication may be inactivated by gastric secretions.
- The buccal dose of medication will need to be increased from the oral dose.
- Remove the tablet from buccal area after 15 seconds. 1., 2., & 3. Correct: These are correct statements about buccal administration of medication. Buccal administration involves the medication being placed between the gums and cheek, where it dissolves and becomes absorbed into the
