ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
The nurse is called to the waiting room of a paediatric clinic. The frantic mother
states, "I think my 4-month-old baby is choking!" What steps will the nurse
take? (Select all that apply.)
A.
Compress the chest once between the nipples with two fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep. -answer- B, C, D
Rationale: The fingers are placed at the same location on an infant as chest
compressions for CPR; however, the nurse must deliver five chest thrusts, after
the five back slaps. Blind sweeps are not used as this action may push the
object deeper into the throat. The remaining steps are correct.
Which fluid will the nurse select to administer with the prescribed blood
transfusion?
A.
,5% Dextrose and water
B.
Normal saline
C.
Lactated Ringer's solution
D.
5% Dextrose and Lactated Ringer's -answer- B
Rationale: Normal saline solution is the only solution that is compatible with
blood.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her
child is often awake until midnight playing and is then very difficult to awaken
in the morning for school. Which assessment data should the nurse obtain in
response to the mother's concern?
A.
The occurrence of any episodes of sleep apnoea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is experiencing
D.
Description of the family's home environment -answer- D
Rationale: School-age children often resist bedtime. The nurse should begin by
assessing the environment of the home to determine factors that may not be
conducive to the establishment of bedtime rituals that promote sleep. Option
,A often causes daytime fatigue rather than resistance to going to sleep. Option
B is unlikely to provide useful data. The nurse cannot determine option C.
The nurse identifies a potential for infection in a client with partial-thickness
(second-degree) and full-thickness (third-degree) burns. What action has the
highest priority in decreasing the client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns -answer- B
Rationale: Careful handwashing technique is the single most effective
intervention for the prevention of contamination of all clients. Option A
reverses the hypovolemia that initially accompanies burn trauma but is not
related to decreasing the proliferation of infectious organisms. Options C and D
are recommended by various burn centers as possible ways to reduce the
chance of infection. Option B is a proven technique to prevent infection.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that
the peripheral IV rate by gravity has slowed, even though the venous access
site is healthy. What should the nurse do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
, C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate. -answer- B
Rationale: The nurse should first check the tubing and height of the bag on the
IV pole, which are common factors that may slow the rate. Gravity infusion
rates are influenced by the height of the bag, tubing clamp closure or kinks,
needle size or position, fluid viscosity, client blood pressure (crying in the
paediatric client), and infiltration. Veno spasm can slow the rate and often
responds to warmth over the vessel, but the nurse should first adjust the IV
pole height. The nurse may need to adjust the stabilizing tape on a positional
needle or flush the venous access with normal saline, but less invasive actions
should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is instructing UPAs on
ways to prevent complications of immobility. Which action should be included
in this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. -answer- A
Rationale: Performing range-of-motion exercises is beneficial in reducing
contractures around joints. Options B, C, and D are all potentially harmful
practices that place the immobile client at risk of complications.