Performance
Exit
Week 1 (2 of 2)
Due May 12, 2024 by 11:59 pm
Final Score
100%
622 out of 638 questions answered correctly
Completed on May 6, 2024 7:40 pm
Incorrect (16)
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Which stage of the human immunodeficiency virus (HIV) would a client with a
CD4+ T cell count of 325 cells/mm 3 be classified?
Stage 1
Stage 2
Stage 3
Stage 4
Rationale
Stage 2 describes a client with a CD4+ T cell count between 200 and 499 cells/mm 3. Stage 1
describes a client with a CD4+ T cell count of greater than 500 cells/mm 3. Stage 3 describes a
client with a CD4+ T cell count of less than 200 cells/mm 3. Stage 4 describes a client with a
confirmed HIV infection but no information regarding CD4+ T cell counts is available.
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Which issue related to antibiotic use is an increased risk for the older adult?
Allergy
Toxicity
Resistance
Superinfection
Rationale
The older adult is at increased risk for toxicity related to antibiotic use because of reduced
metabolism and excretion of medications. Allergy, resistance, and superinfection are a risk for all
antibiotic recipients but not an increased risk in the older adult population.
Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they
will recognize the right answer when they see it or that the right answer will somehow stand out
from the other choices. This is a dangerous misconception. The more carefully the question is
constructed, the more each of the choices will seem like the correct response.
Report content error
Which adolescent behavior increases the risk of injury? Select all that apply. One,
some, or all responses may be correct.
Poor diet
Substance use
Unprotected sex
Sedentary lifestyle
Increased screen time
Rationale
Behaviors that increase an adolescent’s risk for injury include substance use and unprotected
sexual intercourse. Poor diet, sedentary lifestyle, and increased screen time increase the risk for
obesity, not injury.
Report content error
Which protective equipment would the nurse use when caring for an infant
admitted with gastroenteritis? Select all that apply. One, some, or all responses
may be correct.
Mask
Gown
Face shield
Pair of gloves
Hair cap
Rationale
Contact precautions, including gown and gloves, should be worn with diarrheal illness to prevent
spread of the infection. A mask, face shield, and hair cap are not required unless the vomiting is
projectile in nature.
Report content error
Which color disaster triage tag would lead the emergency department nurse to
believe that some clients will remain in a stable condition even after delaying
treatment for 3 hours?
Red
Black
Green
Yellow
Rationale
Green-tagged clients have minor injuries, for which treatment can be delayed, generally for more
than 2 hours. Clients with red tags require immediate treatment. Clients who are dead or
expected to die are given black tags. Clients with yellow tags need treatment within 30 minutes to
2 hours.
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Which parental statement would the nurse recognize as a concern?
"My baby likes several different types of pacifiers."
"The mouth guard for the pacifier was too big so I had to alter the size."
"I allow my baby to fall asleep with the pacifier during day naps and at night."
"I have clipped the pacifier to my baby’s clothing so that it does not fall on the floor."
Rationale
Altering the size of a pacifier poses a safety risk. There is no problem with an infant using different
types of pacifiers as long as they are appropriate for the infant’s age. The use of a pacifier is
associated with a reduced risk of sudden infant death syndrome (SIDS). There are clips available
that are safe to use to secure a pacifier.
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Which medication therapy lowers a child’s resistance to varicella?
Anticonvulsant
Systemic steroid
Antihypertensive
Topical antibiotic
Rationale
Individuals who are taking steroids have lowered resistance and may become fatally ill if exposed
to the varicella virus. Anticonvulsants and antihypertensives do not lower body resistance;
therefore, they do not increase susceptibility. Topical antibiotics do not affect body resistance
because topical antibiotics do not have systemic effects.
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Which action would the nurse take first for a client on intravenous medication
who experiences an anaphylactic reaction?
Stop the intravenous medication.
Administer epinephrine (adrenaline).
Start a normal saline infusion immediately.
Report to the primary health care provider immediately.
Rationale
Intravenous medications can cause an anaphylactic reaction. During anaphylactic reactions, the
nurse would immediately stop the intravenous medication and then administer epinephrine
(adrenaline). The nurse can start a normal saline infusion and report to the primary health care
provider, but only after stopping the intravenous medication and administering epinephrine
(adrenaline).
Test-Taking Tip: Multiple-choice questions can be challenging because students think that they
will recognize the right answer when they see it or that the right answer will somehow stand out
from the other choices. This is a dangerous misconception. The more carefully the question is
constructed, the more each of the choices will seem like the correct response.
Report content error
Which priority emergency assessment would the nurse perform on a client with
bomb blast injuries? Select all that apply. One, some, or all responses may be
correct.
Some correct answers were not selected
Airway
Breathing
Circulation
Provide comfort measures
Facilitate family presence
Exposure or environmental control
Rationale
The primary survey focuses on airway-breathing-circulation (ABC) and environmental control.
These are surveyed during emergency assessments in a primary survey to identify life-threatening
conditions and to analyze the appropriate interventions. Giving comfort measures and facilitating
family presence are performed in a secondary survey of emergency assessment followed by a
primary survey.
Test-Taking Tip: Key words or phrases in the question stem such as first, primary, early, or best
are important. Similarly, words such as only, always, never, and all in the alternatives are
frequently evidence of a wrong response. No real absolutes exist in life; however, every rule has its
exceptions, so answer with care.
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In which order would the nurse perform interventions for the jaw-thrust
maneuver on an unconscious client admitted in the emergency unit with
traumatic injuries and a suspected a spinal injury?
1. Stand or kneel at the top of the client’s head.
2. Place one hand on each side of the client’s head.
3. Rest elbows on the surface.
4. Lay the client in the supine position.
5. Grasp the client’s lower jaw and lift forward with both hands
without tilting the head.
Rationale
Jaw-thrust maneuver is performed to open the airway of an unconscious client with possible
spinal or neck injury. The client should be laid in supine position and the nurse would kneel at the
top of the client’s head to initiate the procedure. This position allows access to the peritoneal,
thoracic, and pericardial regions. This should be followed by resting the elbows on the surface and
placing one hand on each side of the client’s head. Grasping the client’s lower jaw and lifting
forward with both hands without tilting the head helps lift of the epiglottis and enlarge the
laryngeal inlet and the pharynx, thereby resulting in improved ventilation.
Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options
presented. For example, you might be asked the steps of performing an action or skill such as
those involved in medication administration.
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A client with acquired immunodeficiency syndrome (AIDS) and cryptococcal
pneumonia frequently is incontinent of feces and urine and produces copious
sputum. When giving this client a bath, which protective equipment would the
nurse use? Select all that apply. One, some, or all responses may be correct.
Goggles
Surgical mask
Shoe covers
Gown
Gloves
N95 HEPA mask
Rationale
A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other
body fluids during intimate body care. Goggles would be important only if the client was on
mechanical ventilation to avoid contact with sputum. Shoe covers are designed for protecting a
sterile environment such as a surgery suite and are not necessary for giving client care at the
bedside. An N95 HEPA mask would be necessary if the client had tuberculosis, but not for
cryptococcal pneumonia alone.
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The nurse is working with victims who were exposed to mustard gas. Which
action by the nurse requires correction?
Administers antidote
Brushes dry substances from skin
Rinses exposed areas with water
Uses personal protective equipment
Rationale
When a victim is exposed to mustard gas, the nurse will refrain from rinsing exposed areas with
water. Water combined with mustard gas causes the release of chlorine gas. Antidotes can be
administered, dry substances can be brushed off the skin, and the nurse must put on appropriate
personal protective equipment before treating clients.
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Which information would the nurse document in the medical record regarding a
client’s reported allergies? Select all that apply. One, some, or all responses may
be correct.
Medication names
Date of allergic reaction
Type of allergic reaction
Family history of allergies
Epinephrine (EpiPen) use for allergic reaction
Rationale
When documenting client allergies, the nurse will include the names of the medications, type of
allergic reactions experienced, and any use of an EpiPen to manage symptoms of allergic
reactions. Documenting this information in a client’s medical record provides communication to
other members of the health care team to prevent administration of these medications. It is not
necessary for the nurse to record the date the reaction occurred or the client’s family history of
allergies.
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Which statements made by the parent indicate further teaching is needed about
the care of circumcision for a 3-day-old newborn? Select all that apply. One,
some, or all responses may be correct.
Some correct answers were not selected
"I will avoid using any baby wipes until the penis has healed."
"My baby should have at least four wet diapers in a 24-hour period."
"I can expect a yellow exudate to form over the penis after 24 hours."
"I can wash the circumcised area with soap and water if it becomes soiled."
"I should apply the diaper snugly over the penis to help prevent bleeding."
Rationale
Baby wipes should be avoided until the site is healed because they may contain alcohol. A yellow
exudate is normal after 24 hours and should not be wiped off. A 3-day-old newborn should have at
least six to eight wet diapers within a 24-hour period. The circumcised area should be washed
with warm water only, and the diaper should be applied loosely over the penis to prevent pressure
on the circumcised area.
Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type,
you are asked to select all options that apply to a given situation or client. All options likely relate
to the situation, but only some of the options may relate directly to the situation.
Report content error
Which precaution would the nurse take when restarting the intravenous (IV) line
after it infiltrates and needs restarting on a client diagnosed with acquired
immunodeficiency syndrome (AIDS)? Select all that apply. One, some, or all
responses may be correct.
Mask
Gown
Gloves
Face shield
Hand hygiene
Rationale
Wearing gloves protects the nurse from potential contamination. Gloves are appropriate when
there is a risk of the hands coming into contact with a client’s blood or body fluids. Hand hygiene
is the most effective way to prevent the spread of microorganisms. Wearing a mask is necessary
for procedures where splashing of body fluids is anticipated or a risk. Wearing a gown is necessary
for procedures where splashing of body fluids is anticipated or a risk. Wearing a face shield is
necessary for procedures where splashing of body fluids is anticipated.
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Upon finding a client is restless at night, has muscle spasms, and is at risk of
falling out of bed, the nurse obtains a provider's prescription for restraints. In
which order would the nurse apply the prescribed restraints?
1. Adjust the bed to a proper height and lowering the side rail on the
side of client contact
2. Pad any skin and bony prominences that will be under the restraint
3. Apply a proper-sized restraint according to the manufacturer’s
direction
4. Secure the restraint with a quick-release tie without making a knot
5. Attach restraint straps to the portion of the bed frame that moves
while raising or lowering the head of the bed
6. Assess proper placement of the restraint, skin integrity, pulses,
skin temperature, color, and sensation of body parts
Rationale
To apply a restraint properly, the nurse would first adjust the bed to a proper height and lower the
side rail on the side of client contact. Next, the nurse would pad the skin and bony prominences
that will be under the restraint. The restraint would be applied according to the manufacturer’s
directions. The nurse would then attach restraint straps to the portion of the bed frame that
moves when the head of the bed is raised or lowered. The restraint would then be secured with a
quick-release tie. Finally, the nurse would check proper placement of the restraint, skin integrity,
pulses, skin temperature, color, and sensation of the body part that is restrained.
Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options
presented. For example, you might be asked the steps of performing an action or skill such as
those involved in medication administration.
Correct (622)
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Which required noninvasive assessment and management skills certification
would the nurse need to perform airway maintenance and cardiopulmonary
resuscitation (CPR)?
Basic Life Support (BLS)
Certified Emergency Nurse (CEN)
Advanced Cardiac Life Support (ACLS)
Pediatric Advanced Life Support (PALS)
Rationale
BLS is the certification for emergency nursing that includes assessment and management skills
for airway maintenance and CPR. CEN is emergency nursing certification that validates the core
emergency nursing knowledge base. ACLS involves invasive airway management skills,
pharmacology, electrical therapies, and special resuscitation. PALS involves neonatal and pediatric
resuscitation.
Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a
wrong answer.
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The nurse explains to the parents of a 6-year-old child with a pinworm infestation
how pinworms are transmitted. Which statement indicates that the teaching has
been understood?
"We need to keep the cat off the bed."
"She needs to wash her hands before eating anything."
"She needs to cover her mouth whenever she coughs."
"We need to tell the school so that the cafeteria can be cleaned."
Rationale
Pinworm infestation is transferred by way of the oral-anal route, and effective hand washing is the
best way to prevent transmission. Cats do not transmit pinworms. The hands should be kept away
from the nose and mouth; the child should be taught to cough into a tissue or the inside elbow of
the arm. Pinworms are not transmitted by coughing. Cleaning the cafeteria is not an effective
means of preventing the transmission of pinworms.
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Which information would the nurse share with an adolescent girl with a seizure
disorder refusing to wear a medical alert bracelet that may help her wear the
bracelet consistently?
Hide the bracelet under long-sleeved clothes.
Wear the bracelet when engaging in contact sports.
Ask her friends to wear bracelets that look like hers.
Select a bracelet similar to bracelets worn by her peers.
Rationale
Because adolescents have a developmental need to conform to their peers, the teenager should be
able to select a bracelet of a design similar to that of those worn by her peers. Hiding the bracelet
under long-sleeved clothes might be acceptable in cool weather, but not when it is warm and
friends are wearing T-shirts. The bracelet should be worn at all times when the girl is not with
responsible family members. Asking friends to wear a similar bracelet may be difficult, especially if
the girl does not wish to tell her friends why she needs the bracelet.
Report content error
Which team member acts as a liaison between the health care facility and the
media?
Triage officer
Public information officer
Medical command physician
Hospital incident commander
Rationale
The public information officer acts as a liaison between the health care facility and the media. The
triage officer applies disaster triage tags after evaluating the client’s condition. The medical
command physician decides the number, acuity, and resource needs of clients. The hospital
incident commander assumes overall leadership for implementing the emergency plan.
Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for
a moment, close your eyes, take a few deep breaths, and resume review of the question.
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Which hospital department plays a primary role in disaster preparedness?
Medical department
Surgical department
Emergency department
Mental health department
Rationale
The emergency department plays a primary role in emergency disaster preparedness. Although all
departments in the hospital contribute to disaster planning, the only department that plays a
primary role is the emergency department.
Report content error
,Which age group has the highest incidence of lead poisoning?
Adult
Toddler
Adolescent
School-age child
Rationale
The incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage
explore the environment and because of their increased level of oral activity, put objects into their
mouths. Adults have a greater risk of cardiovascular or pulmonary disease. Drowning and motor
vehicle accidents are more common among adolescents. Bicycle accidents are more common
among school-aged children.
Test-Taking Tip: If you can eliminate any responses as incorrect based on your knowledge, you
will not be guessing randomly but will be exercising "informed guessing."
Report content error
For which client illness would airborne precautions be implemented?
Influenza
Chickenpox
Pneumonia
Respiratory syncytial virus
Rationale
Chickenpox is known or suspected to be transmitted by air. Diseases that are known or suspected
to be transmitted by droplet include influenza and pneumonia. A disease that is known or
suspected to be transmitted by direct contact is respiratory syncytial virus.
Test-Taking Tip: Identifying content and what is being asked about that content is critical to your
choosing the correct response. Be alert for words in the stem of the item that are the same or
similar in nature to those in one or two of the options.
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Which antibody forms first, after exposure to an antigen?
Immunoglobulin A (IgA)
Immunoglobulin E (IgE)
Immunoglobulin G (IgG)
Immunoglobulin M (IgM)
Rationale
IgM is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low
circulating levels and is responsible for preventing infection in the upper and lower respiratory
tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the
blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily
expressed on second and subsequent exposures to antigens to provide sustained, long-term
immunity against invading microorganisms.
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Which product would the nurse instruct intravenous drug users (IDUs) to use for
cleaning of needles and syringes between uses?
Bleach
Hot water
Ammonia
Rubbing alcohol
Rationale
IDUs should be instructed to fill syringes with household bleach and shake the syringe for 30 to
60 seconds. Hot water, ammonia, or rubbing alcohol is not used to disinfect used syringes.
Report content error
Which reaction is an example of a type I hypersensitivity reaction?
Anaphylaxis
Serum sickness
Contact dermatitis
Blood transfusion reaction
Rationale
An example of a type I hypersensitivity reaction is anaphylaxis. Serum sickness is a type III
immune complex reaction. Contact dermatitis is a type IV delayed hypersensitivity reaction. A
blood transfusion reaction is a type II cytotoxic reaction.
Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under
ordinary circumstances and that the action can be carried out in the given situation.
Report content error
Which term describes the practice of placing clients with the same infection in a
semi-private room?
Isolating
Cohorting
Colonizing
Cross-referencing
Rationale
Cohorting is the practice of grouping clients who are colonized or infected with the same
pathogen. Isolating is limiting the exposure to individuals with an infection. Colonizing refers to
the development of an infection in the body. Cross-referencing has nothing to do with an
infectious process.
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Which manifestation indicates tertiary syphilis?
Chancre
Alopecia
Gummas
Condylomata lata
Rationale
Gummas are chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes
occur during tertiary syphilis. A chancre appears during primary syphilis. Alopecia and
condylomata lata occur during secondary syphilis.
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Which sexually transmitted infection (STI) is most commonly reported?
Syphilis
Chlamydia
Gonorrhea
Human immunodeficiency virus
Rationale
Chlamydial infections are the most commonly reported STIs. Syphilis, gonorrhea, and human
immunodeficiency virus are not the most commonly reported STIs.
Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there
usually is no pattern to the answers.
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Which sexually transmitted infection causes condylomata acuminate?
Chlamydia
Gonorrhea
Herpes simplex
Human papillomavirus (HPV)
Rationale
Condylomata acuminate are genital warts that are caused by HPV. Genital warts are not caused by
chlamydia, gonorrhea, or herpes simplex.
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Which criteria would the nurse consider when determining if an infection is a
health care–associated infection?
Originated primarily from an exogenous source
Is associated with a medication-resistant microorganism
Occurred in conjunction with treatment for an illness
Still has the infection despite completing the prescribed therapy
Rationale
Health care–associated infections are classified as those that are contracted within a health care
environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery,
medications). Originating primarily from an exogenous source is not a criterion for identifying a
health care–associated infection. The source of health care–associated infections may be
endogenous (originate from within the client) or exogenous (originate from the health care
environment or service personnel providing care); most health care–associated infections stem
from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus.
Association with a medication-resistant microorganism is not a criterion for identifying a health
care–associated infection. A health care–associated infection may or may not be caused by a
medication-resistant microorganism. Still having the infection despite completing the prescribed
therapy is not a criterion for identifying a health care–associated infection.
Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an
educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it
blank, you will certainly be wrong and lose precious points.
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Which action would the nurse take when a client who had a total hip replacement
states that the plan is to go swimming at the community pool the day after
discharge?
Tell the client to take a friend along for safety.
Encourage participation in this activity because it provides excellent range-of-motion
exercise.
Explain that the incision should not be immersed in water until it has healed.
Let the client know that swimming can substitute for the prescribed physical therapy.
Rationale
Because of the risk for infection, the client should avoid tub baths, hot tubs, pools, and immersion
in other bodies of water until after the wound has healed and these activities are approved by the
primary health care provider. Immersion in water for a prolonged period interferes with wound
healing, because water may macerate tissue. Having a friend along does not change the fact that
immersion in water for a prolonged period will interfere with wound healing. The client needs to
continue physical therapy after discharge whether or not the client goes swimming.
Report content error
An 8-year-old girl who is hospitalized for intravenous (IV) antibiotic therapy tells
the nurse that she is bored. The nurse has a discussion with the parent about
appropriate activities. Which activity suggested by the parent would indicate a
need for further teaching?
"I’ll bring a radio and CD player."
"I’ll bring homework and school supplies."
"She’ll enjoy having a rubber baseball and plastic bat."
"She’ll enjoy rubber stamps and a pretty box to keep them in."
Rationale
Playing with a bat and ball is an unsafe activity in a hospital setting; the IV catheter could be
dislodged, and boisterous activity is dangerous to the other children on the unit. A radio and CD
player, homework and school supplies, and rubber stamps and a collection box are all appropriate
for the school-aged child.
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Which nursing action would be included in the plan of care for a child with acute
poststreptococcal glomerulonephritis?
Encouraging fluids
Monitoring for seizures
Measuring abdominal girth
Checking for pupillary reactions
Rationale
Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures.
Increasing fluid intake may lead to an increase in blood pressure and edema. Measuring
abdominal girth is appropriate for children with nephrotic syndrome, in which the child has
hypoalbuminemia that causes fluid to shift from plasma to the abdominal cavity.
Glomerulonephritis will not alter pupillary reactions.
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The school nurse is planning to teach the importance of hand washing to the
children in first grade. Which is the most effective approach for this age group?
Showing a video of the correct hand-washing technique
Demonstrating hand washing and asking for return demonstrations
Involving them in a discussion about the importance of hand washing
Describing how germs cause illness and how hand washing prevents disease
Rationale
Six-year-old children are still in the perceptual phase of cognitive development. They base
judgments on what they see rather than on what they reason; reasoning begins around age 7.
These children are at the developmental stage when they want to show off their accomplishments;
just watching the technique without feedback is not sufficient at this age. These children are too
young to understand the abstract concepts involved in a discussion of the cause and effect
regarding pathogens or to understand why hand washing is so important in preventing illness.
Report content error
The nurse is planning to teach the four-point alternate crutch gait to a 9-year-old
child with cerebral palsy. How would the nurse explain this choice to the parent?
The child has minimal step ability in the lower extremities.
It provides for two points of support on the floor at all times.
It provides for equal but partial weight bearing on each limb.
The child has more power in the upper extremities than in the lower extremities.
Rationale
The four-point alternate crutch gait is a simple, slow, stable gait because there are always three
points of support on the floor, with equal but partial weight bearing on each limb. The child has
the ability to move, but the movement in the lower extremities is uncoordinated. The four-point
gait provides for three points of support, not two, at all times. A four-point gait divides weight
bearing equally among the limbs.
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Which intervention would the nurse encourage the parent of a child with
plumbism (lead poisoning) to do?
Discourage the child’s pica by providing nutritious snacks.
Move the family away from areas that are next to gas stations.
Assess the family’s home environment for lead sources and have them removed.
Have the child take repeat x-rays of the wrist and forearm for signs of a lead line.
Rationale
All sources of lead must be removed from the home if the problem is to be controlled. Sources
include lead-painted surfaces and old plumbing that has lead solder. Although pica must be
controlled if it is present, this alone will not eliminate the environmental risks. The data do not
indicate that the child is engaging in pica. Leaded gasoline is no longer used in the United States.
Chelation therapy is based on the blood lead level; changes in bone take longer to evaluate.
Report content error
Which parental statement would the nurse recognize as indicating the need for
further education about bicycle safety for a school-aged client?
"My child should be able to place both feet on the ground while seated."
"My child should be able to easily grasp the brake handles and squeeze them."
"My child will be required to wear a bicycle helmet if he or she wants to ride a bike."
"My child should be able to safely ride after being supervised for a couple of days."
Rationale
Children may not safely be able to ride their bike after a couple of days of learning. The child
should be able to place the balls of both feet on the ground while sitting on the bike. The child
should easily be able to grasp the brake handles and squeeze them. The child should always wear
the appropriate safety equipment while riding his or her bike.
Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them
will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number
of response choices by one and improved the odds. Continue to analyze the options. If you can
eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While
you are eliminating the wrong choices, recall often occurs. One of the options may serve as a
trigger that causes you to remember what a few seconds ago had seemed completely forgotten.
Report content error
After the nurse provides education about all-terrain vehicle (ATV) safety for a
parent of a 11-year-old child, which statement made by the parent indicates an
understanding of the information?
"I will have my child ride with an adult."
"I will make sure my child wears a helmet."
"I will make sure my child does not get on an ATV."
"I will make sure my child has had safety training before he or she rides."
Rationale
The American Academy of Pediatrics recommends that children under 16 years of age not ride in
or operate an ATV. The child should not ride with another adult. When the child is 16 years of age
and begins riding an ATV, safety gear such as a helmet should be worn and proper safety training
should be implemented.
Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the
options are very similar. This can be very helpful, because it may mean that one of these look-alike
answers is the best choice and the other is a very good distractor. Test both of these options
against the stem. Ask yourself which one completes the incomplete statement grammatically and
which one answers the question more fully and completely. The option that best completes or
answers the stem is the one you should choose. Here, too, pause for a few seconds, give your
brain time to reflect, and recall may occur.
Report content error
Which response would the nurse provide the parent of a 15-month-old child who
expresses feelings of guilt when their child was hospitalized after ingesting toilet
bowl cleaner?
"Anyone could make a mistake. Don’t dwell on it."
"Let’s not worry about the past. Your child is going to get better."
"It was an accident, but you should consider special locks on your closets."
"That was careless of you. Please make sure that you poison-proof your house."
Rationale
Describing the incident as an accident and recommending locks on closets accepts the parent’s
statement and helps the parent express their guilt while providing directions to safeguard the
child. Poisoning is not an everyday occurrence; teaching should be incorporated to protect the
child. Telling the parent that the child will get better is false reassurance; the child’s condition is
still in question. Calling the parent careless only increases the parent’s guilt and provides nothing
more than a vague suggestion of how to remedy the problem.
Report content error
In which way do toddlers learn self-protection?
Through trial-and-error strategies
By imitating playmates and siblings
By obeying orders from their parent
By playing with age-appropriate toys and puzzles
Rationale
The toddler is developing autonomy, is curious, and learns self-protection from experience.
Toddlerhood play is parallel, not interactive. The struggle for autonomy at this age limits learning
from siblings, even though the toddler attempts to copy their behavior. The toddler is still
learning from experiences, not from others. The toddler is still attempting to distinguish the self
as separate from their parent; the struggle for autonomy limits learning from parents. Toddlers
learn gross and fine motor skills as they play with their toys, not self-protection.
Report content error
A child becomes cyanotic during a generalized tonic-clonic seizure. Which action
would the nurse take?
Insert an oral airway
Administer oxygen (O 2) by mask
Continue to observe the seizure
Notify the health care provider immediately
Rationale
The child’s status and the progression of the seizure should be monitored; the child will not
breathe until the seizure is over, and cyanosis should subside at that time. Attempting to open a
clenched jaw may result in injury to the child. O 2 is useless until the child breathes when the
seizure is over. The health care provider may be notified later; provisions for the child’s safety and
observation are the priorities.
Report content error
Which action would the nurse take first if an allergic reaction to a blood
transfusion occurs?
Shut off the infusion.
Slow the rate of flow.
Administer an antihistamine.
Call the health care provider (HCP).
Rationale
The client is experiencing an allergic reaction, and the infusion must be stopped immediately to
prevent serious complications. Slowing the rate of infusion will not halt the allergic reaction to the
transfused blood. Administering an antihistamine is dangerous as an initial action because the
degree of allergic reaction cannot be determined at this time. Also, it requires an HCP’s
prescription. The HCP should be notified after the infusion has been stopped.
Report content error
Which action would the nurse take when caring for an older adult with a history
of recent memory loss?
Instruct the client to move slowly when changing positions.
Remind the client to look where he or she places the feet while walking.
Adjust the daily schedule to accommodate sleep pattern.
Employ electronic devices that provide alerts.
Rationale
Providing electronic devices that give alerts can help an older adult who has developed recent
memory loss. Instructing the client to move slowly when changing positions can prevent dizziness
and falls caused by orthostatic blood pressure changes or altered balance/coordination.
Reminding the client to check where the feet are placed can help older adults with a decreased
sensory perception of touch. Adjusting the daily schedule can aid older adults who have changes
in their sleep pattern.
Report content error
Which nursing intervention would the nurse take for an older adult with delirium
who begins acting out while in the dayroom?
Instructing the client to be quiet
Allowing the client to act out until fatigue sets in
Immediately guiding the client from the room by gently holding the client’s arm
Giving the client one simple direction at a time in a firm, low-pitched voice
Rationale
Clients with delirium typically respond to simple directions stated one at a time in a firm, low-
pitched voice. "Be quiet" is a nontherapeutic order; furthermore, it is demeaning to the client.
Allowing the client to act out until fatigue sets in will not help the client gain control and might be
frightening to other clients in the dayroom. Guiding the client from the room by gently holding
the client’s arm is done only after giving simple directions and attempting to calm the client has
failed. Touch should also be used cautiously in clients who have delirium because the client may
misinterpret the gesture as aggressive.
Report content error
In which order would clients receive care based on triage tag color?
1. Red
2. Yellow
3. Green
4. Black
, Rationale
Clients with a red tag generally have life-threatening conditions involving airway obstruction and
shock. Red-tagged clients should be seen immediately. Clients who are dead or expected to die
are labeled with black tags, are classified as expectant, and are given the lowest priority. Green-
tagged clients have minor injuries that can receive treatment within 2 hours and are classified as
nonurgent. Clients with yellow tags have injuries or conditions that need treatment within 30
minutes to 2 hours and who can be treated after red-tagged clients.
Report content error
Which type of needs would the nurse identify as a high priority in the
prioritization of client care?
Developmental needs
Long-term care needs
Potential needs in care
Needs that affect safety
Rationale
Needs related to survival and safety are the highest priority because these are an immediate threat
to client health. Developmental needs and long-term care needs are low priority when prioritizing
care because they are not an immediate threat to health. Potential needs in care are intermediate
priority because they are best addressed before complications follow.
Report content error
Which condition would the nurse monitor for in the client on aminoglycoside
therapy and skeletal muscle relaxants?
Stroke
Respiratory arrest
Myocardial infarction
Abdominal discomfort
Rationale
Aminoglycosides can intensify the effect of skeletal muscle relaxants, placing the client at risk for
respiratory arrest. Aminoglycoside therapy with muscle relaxants does not increase the risk of
stroke, myocardial infarction, or abdominal discomfort.
Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or
five consecutive questions have the same letter or number for the correct answer.
Report content error
Which effect has resulted in the avoidance of tetracycline use in children under 8
years old?
Birth defects
Allergic responses
Severe nausea and vomiting
Permanent tooth discoloration
Rationale
Tetracycline use in children under the age of 8 years has been discontinued because it causes
permanent tooth discoloration. Birth defects, allergic responses, and severe nausea and vomiting
are not prevalent reasons for the discontinuation of tetracycline medications in children under 8
years old.
Report content error
Which medication for treatment of gastroesophageal reflux disease would be
contraindicated in the pregnant client?
Ranitidine
Misoprostol
Esomeprazole
Calcium carbonate
Rationale
Misoprostol is contraindicated in pregnancy because it can cause uterine contractions, expelling
the developing fetus. Ranitidine, esomeprazole, and calcium carbonate are not contraindicated
during pregnancy.
Report content error
Which sexually transmitted infection is caused by bacteria? Select all that apply.
One, some, or all responses may be correct.
Syphilis
Hepatitis
Gonorrhea
Herpes simplex
Trichomoniasis
Rationale
Syphilis is caused by Treponema pallidum, a motile spirochete bacterium. Gonorrhea is caused by
a bacteria called Neisseria gonorrhoeae. Hepatitis A and herpes simplex are caused by viruses.
Trichomoniasis is caused by a protozoan.
Report content error
Which activity would the nurse manager complete during an emergency event
when acting as the triage officer according to the Hospital Incident Command
System (HICS)?
Facilitating client movement through the system
Bringing in personnel and supply resources to meet needs
Rapidly evaluating each person who comes to the hospital
Identifying the need for and call in specialty providers
Rationale
In the role of triage officer, the nurse would rapidly evaluate each person who comes to the
hospital, including those triaged in the field. The hospital incident commander facilitates client
movement through the system and brings in personnel and resources to meet needs. The medical
command physician identifies the need for and calls in needed specialty providers.
Report content error
Which emergency medical service agency offers service such as first aid stations
and special-need shelters during a disaster or pandemic disease outbreak?
Medical Reserve Corps (MRC)
National Disaster Medical System (NDMS)
Disaster Medical Assistance Team (DMAT)
Federal Emergency Management Agency (FEMA)
Rationale
The MRC may help staff hospitals or community health settings that face shortages and provide
first aid stations or special-need shelters. The NDMS manages mass fatalities, emergency animal
care, and establishes fully functional field surgical facilities. A DMAT is a medical relief team
deployed to a disaster area with enough medical equipment and supplies to sustain operations for
72 hours. FEMA provides Community Emergency Response Team (CERT) training so that people
are better prepared for disasters and hazard situations in their own communities.
Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one
answer may be correct, but one answer may contain more information or more important
information than another answer.
Report content error
To which disaster triage class would the nurse infer a client with a green triage tag
belongs?
Class I
Class II
Class III
Class IV
Rationale
The green disaster triage tag is issued to nonurgent or "walking-wounded" clients who belong to
class III. A red disaster triage tag is issued to clients who require immediate treatment and belong
to class I. Clients with yellow and black tags belong to class II and IV respectively.
Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a
wrong answer.
Report content error
Which color tag would the nurse use to triage a victim of a train derailment who
is able to walk independently to the first aid station?
Red
Black
Green
Yellow
Rationale
An emergency triage system uses colored tags to designate both the seriousness of the injury and
the likelihood of survival. Green would be used for minor injuries such as the victim who is able to
ambulate independently. Red indicates life-threatening injuries requiring immediate attention.
Black indicates that the victim is expected to die. Yellow indicates urgent but not life-threatening
injuries.
Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a
wrong answer.
Report content error
Which is the minimum number of disaster drills the hospital disaster plan
committee must plan and implement each year?
Two
Three
Four
Five
Rationale
Although it is appropriate to have more than the minimum number of disaster drills each year,
the minimum that must be implemented per The Joint Commission (TJC) requirements is twice
per calendar year. Three, four, and five are too many.
Report content error
Which agent of terrorism can cause death within a few minutes?
Sarin gas
Uranium
Iodine-131
Mustard gas
Rationale
Sarin gas is an agent for bioterrorism that can cause death within minutes of exposure by
paralyzing respiratory muscles. Uranium and iodine-131 can be dangerous in close proximities
but are not as harmful as sarin gas. Mustard gas causes blisters on the skin but does not cause
death within a few minutes.
Report content error
Which object would the nurse teach the client with a newly implanted pacemaker
to avoid?
Strong magnet
Microwave oven
Mobile telephone
Remote control device
Rationale
The client with a newly implanted pacemaker is taught to avoid strong magnets because they can
change the settings and function of the pacemaker. Microwave oven use is not a concern for a
client with a pacemaker. Mobile phones should be used in the ear opposite the
pacemaker. Remote control devices are not contraindicated for the client with a pacemaker.
Report content error
Which threats included in the term "NBC" led to the implementation of improved
emergency medical services (EMS) and hospital safety programs? Select all that
apply. One, some, or all responses may be correct.
Nuclear
Biological
Botulism
Chemical
Nipah virus
Rationale
The term "NBC" was coined to describe nuclear, biological, and chemical threats. In response,
EMS agencies and hospitals improved safety by upgrading their decontamination facilities,
equipment, and all levels of personal protective equipment to better protect staff. Botulism and
Nipah virus are two specific examples of biological threats.
Report content error
Which method of delivering client care works well in disaster situations?
Team nursing
Primary nursing
Functional nursing
Total client care nursing
Rationale
The functional method of delivering care works well in emergency and disaster situations. Each
care provider knows the expectations of the assigned role and completes the tasks quickly and
efficiently. Team nursing, primary nursing, and total client care nursing are not the ideal models
for delivering client care during disaster situations.
Report content error
Which team would be mobilized to manage the deceased at the earthquake zone
where many people lost their lives?
Medical Reserve Corps (MRC)
National Veterinary Response Teams (NVRTs)
International Medical-Surgical Response Teams (IMSRTs)
Disaster Mortuary Operational Response Teams (DMORTs)
Rationale
DMORTs are a team deployed under NDMS. This team is specialized in managing mass fatalities
during a disaster. The MRC helps staff hospitals or community health care settings that face
shortages of nurses. They establish first aid stations and special-needs shelters in disasters.
NVRTs provide emergency care to animals. IMSRTs provide fully functional field surgical facilities
all over the world, wherever it is required.
Report content error
Which action would the nurse implement when caring for a client reporting a
recent bee sting presenting with localized redness, swelling, intense localized
pain, and itching?
Applying cold compresses to the affected area
Ensuring the client keeps the skin clean and dry
Monitoring for neurological and cardiac symptoms
Advising the client to launder all clothes with bleach
Rationale
A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic
reaction. The nurse would apply cold compresses to the affected area to reduce the pain and
edema at the sting site. A client with Candida albicans infection should keep his or her skin clean
and dry to prevent further fungal infections. A client with a Borrelia burgdorferi infection may
suffer from cardiac, arthritic, and neurological manifestations, which requires monitoring by the
nurse. Direct contact may transmit a Sarcoptes scabiei infection; the nurse should make sure the
client bleaches his or her clothes to prevent the transmission of the infection.
Test-Taking Tip: Read the question carefully before looking at the answers: (1) determine what the
question is really asking; look for key words; (2) read each answer thoroughly and see if it
completely covers the material asked by the question; (3) narrow the choices by immediately
eliminating answers you know are incorrect.
Report content error
Who is responsible for triaging the victims of a multiple motor vehicle crash on a
major interstate?
Emergency first responders
Nurses in the acute care areas
Nurses in the emergency department
Health care providers in the emergency department
Rationale
For a mass casualty incident, triaging will occur in the field or at the site of the incident. In this
case, the emergency first responders will triage the victims of the crash. Nurses in the acute care
areas may or may not have victims admitted for care. The victims should be triaged before arriving
in the emergency department, so it would be incorrect to expect the nurses and health care
providers in the emergency department to perform triage.
Report content error
Which action would the nurse implement when providing care for a client with
acquired immunodeficiency syndrome (AIDS)?
Use standard precautions.
Employ airborne precautions.
Plan interventions to limit direct contact.
Discourage long visits from family members.
Rationale
The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) states
that standard precautions should be used for all clients; these precautions include wearing of
gloves, gown, mask, and goggles when there is risk for exposure to blood or body secretions.
There is no indication that airborne precautions are necessary. Planning interventions to limit
direct contact or discouraging long visits from family members will unnecessarily isolate the
client.
Report content error
Which response by the nurse is best when a client expresses concern regarding
the lack of annual flu vaccines because of a supply and demand problem?
"This is an unfortunate situation, but there was such a limited supply available."
"There are many others who were unable to obtain a flu vaccine this month."
"The limited supply doesn’t really matter because the vaccine is for one particular strain."
"There are other things you and your family can do to prevent the flu, such as hand
washing."
Rationale
The statement "There are other things you can do to prevent the flu, such as hand washing" is a
teaching opportunity of which the nurse can take advantage and show the client the things that
can be done to avoid infection. The response "It’s unfortunate, but there was such a limited supply
available" is empathic, but it does not address the client’s concern of vulnerability. The response
"There are many others who also were unable to get a flu vaccine" belittles the client for being
concerned. The response "It doesn’t matter because the vaccine is for just one particular strain"
may be true, but it belittles the client’s concern.
Report content error
Which event would the nurse state is an example of a natural disaster?
Floods
Terrorism
Fire explosion
Building collapse
Rationale
External disasters can be natural, such as floods, earthquakes, or tornadoes. Acts of terrorism are
external disasters that use technology such as explosive devices or a malfunction of a nuclear
reactor. A fire explosion is an internal disaster. A building collapse is a consequence of internal or
external disaster.
Report content error
Which action would the nurse identify as a potential contributor to staff post-
traumatic stress disorder (PTSD) during a mass casualty assessment?
Working less than 12 hours
Encouraging and motivating team members
Working continuously without any breaks
Discussing feelings with the team members
Rationale
Working continuously without any breaks will result in increased stress. Working less than 12
hours may reduce stress. By motivating team members, PTSD can be prevented. By discussing
feelings with team members or nurse managers, stress can be reduced.
Report content error
Which event would the nurse describe as an example of an internal disaster?
Tornado
Hurricanes
Fire or explosion
Terrorism attacks
Rationale
An internal disaster refers to an event that impairs the hospital’s normal functioning and disrupts
normal client care activities. Examples include a fire or explosion and the loss of critical utilities.
Tornado, hurricanes, and terrorist attacks are external disasters that result in the loss of lives and
property.
Report content error
Which statement would the nurse include in the teaching plan of a client
anticipating discharge with acquired immunodeficiency syndrome (AIDS)?
"Wash used dishes in hot, soapy water."
"Let dishes soak in hot water for 24 hours before washing."
"You should boil the client’s dishes for 30 minutes after use."
"Have the client eat from paper plates so they can be discarded."
Rationale
A person cannot contract human immunodeficiency virus (HIV) by eating from dishes previously
used by an individual with AIDS; routine care is adequate. Washing used dishes in hot, soapy
water is sufficient care for dishes used by the AIDS client. Dishes do not need to soak for 24 hours
before being washed. The client’s dishes do not need to be boiled for 30 minutes after use. Paper
plates are fine to use but are not indicated to prevent the spread of AIDS.
Report content error
How often should a health care facility that is Joint Commission accredited plan
to test the emergency preparedness plan?
Annually
Twice a year
Every 2 years
Every 3 months
Rationale
The Joint Commission mandates that hospitals have an emergency preparedness plan that is
tested through drills or actual participation in a real event at least twice yearly. Annually or every 2
years is not frequent enough to test the emergency preparedness plan. It is not necessary to test
the plan as frequently as every 3 months.
Report content error
When caring for a client who is receiving enteral feedings, the nurse would take
which measure to prevent aspiration?
Elevate the head of the bed between 30 and 45 degrees.
Decrease flow rate at night.
Check for residual daily.
Irrigate regularly with warm tap water.
Rationale
To prevent aspiration, the nurse would keep the head of the bed elevated between 30 and 45
degrees. Elevating the head any higher causes increased sacral pressure and increases the risk of
skin breakdown. Decreasing flow rate, checking for residual, and irrigating regularly will not
Exit
Week 1 (2 of 2)
Due May 12, 2024 by 11:59 pm
Final Score
100%
622 out of 638 questions answered correctly
Completed on May 6, 2024 7:40 pm
Incorrect (16)
Report content error
Which stage of the human immunodeficiency virus (HIV) would a client with a
CD4+ T cell count of 325 cells/mm 3 be classified?
Stage 1
Stage 2
Stage 3
Stage 4
Rationale
Stage 2 describes a client with a CD4+ T cell count between 200 and 499 cells/mm 3. Stage 1
describes a client with a CD4+ T cell count of greater than 500 cells/mm 3. Stage 3 describes a
client with a CD4+ T cell count of less than 200 cells/mm 3. Stage 4 describes a client with a
confirmed HIV infection but no information regarding CD4+ T cell counts is available.
Report content error
Which issue related to antibiotic use is an increased risk for the older adult?
Allergy
Toxicity
Resistance
Superinfection
Rationale
The older adult is at increased risk for toxicity related to antibiotic use because of reduced
metabolism and excretion of medications. Allergy, resistance, and superinfection are a risk for all
antibiotic recipients but not an increased risk in the older adult population.
Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they
will recognize the right answer when they see it or that the right answer will somehow stand out
from the other choices. This is a dangerous misconception. The more carefully the question is
constructed, the more each of the choices will seem like the correct response.
Report content error
Which adolescent behavior increases the risk of injury? Select all that apply. One,
some, or all responses may be correct.
Poor diet
Substance use
Unprotected sex
Sedentary lifestyle
Increased screen time
Rationale
Behaviors that increase an adolescent’s risk for injury include substance use and unprotected
sexual intercourse. Poor diet, sedentary lifestyle, and increased screen time increase the risk for
obesity, not injury.
Report content error
Which protective equipment would the nurse use when caring for an infant
admitted with gastroenteritis? Select all that apply. One, some, or all responses
may be correct.
Mask
Gown
Face shield
Pair of gloves
Hair cap
Rationale
Contact precautions, including gown and gloves, should be worn with diarrheal illness to prevent
spread of the infection. A mask, face shield, and hair cap are not required unless the vomiting is
projectile in nature.
Report content error
Which color disaster triage tag would lead the emergency department nurse to
believe that some clients will remain in a stable condition even after delaying
treatment for 3 hours?
Red
Black
Green
Yellow
Rationale
Green-tagged clients have minor injuries, for which treatment can be delayed, generally for more
than 2 hours. Clients with red tags require immediate treatment. Clients who are dead or
expected to die are given black tags. Clients with yellow tags need treatment within 30 minutes to
2 hours.
Report content error
Which parental statement would the nurse recognize as a concern?
"My baby likes several different types of pacifiers."
"The mouth guard for the pacifier was too big so I had to alter the size."
"I allow my baby to fall asleep with the pacifier during day naps and at night."
"I have clipped the pacifier to my baby’s clothing so that it does not fall on the floor."
Rationale
Altering the size of a pacifier poses a safety risk. There is no problem with an infant using different
types of pacifiers as long as they are appropriate for the infant’s age. The use of a pacifier is
associated with a reduced risk of sudden infant death syndrome (SIDS). There are clips available
that are safe to use to secure a pacifier.
Report content error
Which medication therapy lowers a child’s resistance to varicella?
Anticonvulsant
Systemic steroid
Antihypertensive
Topical antibiotic
Rationale
Individuals who are taking steroids have lowered resistance and may become fatally ill if exposed
to the varicella virus. Anticonvulsants and antihypertensives do not lower body resistance;
therefore, they do not increase susceptibility. Topical antibiotics do not affect body resistance
because topical antibiotics do not have systemic effects.
Report content error
Which action would the nurse take first for a client on intravenous medication
who experiences an anaphylactic reaction?
Stop the intravenous medication.
Administer epinephrine (adrenaline).
Start a normal saline infusion immediately.
Report to the primary health care provider immediately.
Rationale
Intravenous medications can cause an anaphylactic reaction. During anaphylactic reactions, the
nurse would immediately stop the intravenous medication and then administer epinephrine
(adrenaline). The nurse can start a normal saline infusion and report to the primary health care
provider, but only after stopping the intravenous medication and administering epinephrine
(adrenaline).
Test-Taking Tip: Multiple-choice questions can be challenging because students think that they
will recognize the right answer when they see it or that the right answer will somehow stand out
from the other choices. This is a dangerous misconception. The more carefully the question is
constructed, the more each of the choices will seem like the correct response.
Report content error
Which priority emergency assessment would the nurse perform on a client with
bomb blast injuries? Select all that apply. One, some, or all responses may be
correct.
Some correct answers were not selected
Airway
Breathing
Circulation
Provide comfort measures
Facilitate family presence
Exposure or environmental control
Rationale
The primary survey focuses on airway-breathing-circulation (ABC) and environmental control.
These are surveyed during emergency assessments in a primary survey to identify life-threatening
conditions and to analyze the appropriate interventions. Giving comfort measures and facilitating
family presence are performed in a secondary survey of emergency assessment followed by a
primary survey.
Test-Taking Tip: Key words or phrases in the question stem such as first, primary, early, or best
are important. Similarly, words such as only, always, never, and all in the alternatives are
frequently evidence of a wrong response. No real absolutes exist in life; however, every rule has its
exceptions, so answer with care.
Report content error
In which order would the nurse perform interventions for the jaw-thrust
maneuver on an unconscious client admitted in the emergency unit with
traumatic injuries and a suspected a spinal injury?
1. Stand or kneel at the top of the client’s head.
2. Place one hand on each side of the client’s head.
3. Rest elbows on the surface.
4. Lay the client in the supine position.
5. Grasp the client’s lower jaw and lift forward with both hands
without tilting the head.
Rationale
Jaw-thrust maneuver is performed to open the airway of an unconscious client with possible
spinal or neck injury. The client should be laid in supine position and the nurse would kneel at the
top of the client’s head to initiate the procedure. This position allows access to the peritoneal,
thoracic, and pericardial regions. This should be followed by resting the elbows on the surface and
placing one hand on each side of the client’s head. Grasping the client’s lower jaw and lifting
forward with both hands without tilting the head helps lift of the epiglottis and enlarge the
laryngeal inlet and the pharynx, thereby resulting in improved ventilation.
Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options
presented. For example, you might be asked the steps of performing an action or skill such as
those involved in medication administration.
Report content error
A client with acquired immunodeficiency syndrome (AIDS) and cryptococcal
pneumonia frequently is incontinent of feces and urine and produces copious
sputum. When giving this client a bath, which protective equipment would the
nurse use? Select all that apply. One, some, or all responses may be correct.
Goggles
Surgical mask
Shoe covers
Gown
Gloves
N95 HEPA mask
Rationale
A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other
body fluids during intimate body care. Goggles would be important only if the client was on
mechanical ventilation to avoid contact with sputum. Shoe covers are designed for protecting a
sterile environment such as a surgery suite and are not necessary for giving client care at the
bedside. An N95 HEPA mask would be necessary if the client had tuberculosis, but not for
cryptococcal pneumonia alone.
Report content error
The nurse is working with victims who were exposed to mustard gas. Which
action by the nurse requires correction?
Administers antidote
Brushes dry substances from skin
Rinses exposed areas with water
Uses personal protective equipment
Rationale
When a victim is exposed to mustard gas, the nurse will refrain from rinsing exposed areas with
water. Water combined with mustard gas causes the release of chlorine gas. Antidotes can be
administered, dry substances can be brushed off the skin, and the nurse must put on appropriate
personal protective equipment before treating clients.
Report content error
Which information would the nurse document in the medical record regarding a
client’s reported allergies? Select all that apply. One, some, or all responses may
be correct.
Medication names
Date of allergic reaction
Type of allergic reaction
Family history of allergies
Epinephrine (EpiPen) use for allergic reaction
Rationale
When documenting client allergies, the nurse will include the names of the medications, type of
allergic reactions experienced, and any use of an EpiPen to manage symptoms of allergic
reactions. Documenting this information in a client’s medical record provides communication to
other members of the health care team to prevent administration of these medications. It is not
necessary for the nurse to record the date the reaction occurred or the client’s family history of
allergies.
Report content error
Which statements made by the parent indicate further teaching is needed about
the care of circumcision for a 3-day-old newborn? Select all that apply. One,
some, or all responses may be correct.
Some correct answers were not selected
"I will avoid using any baby wipes until the penis has healed."
"My baby should have at least four wet diapers in a 24-hour period."
"I can expect a yellow exudate to form over the penis after 24 hours."
"I can wash the circumcised area with soap and water if it becomes soiled."
"I should apply the diaper snugly over the penis to help prevent bleeding."
Rationale
Baby wipes should be avoided until the site is healed because they may contain alcohol. A yellow
exudate is normal after 24 hours and should not be wiped off. A 3-day-old newborn should have at
least six to eight wet diapers within a 24-hour period. The circumcised area should be washed
with warm water only, and the diaper should be applied loosely over the penis to prevent pressure
on the circumcised area.
Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type,
you are asked to select all options that apply to a given situation or client. All options likely relate
to the situation, but only some of the options may relate directly to the situation.
Report content error
Which precaution would the nurse take when restarting the intravenous (IV) line
after it infiltrates and needs restarting on a client diagnosed with acquired
immunodeficiency syndrome (AIDS)? Select all that apply. One, some, or all
responses may be correct.
Mask
Gown
Gloves
Face shield
Hand hygiene
Rationale
Wearing gloves protects the nurse from potential contamination. Gloves are appropriate when
there is a risk of the hands coming into contact with a client’s blood or body fluids. Hand hygiene
is the most effective way to prevent the spread of microorganisms. Wearing a mask is necessary
for procedures where splashing of body fluids is anticipated or a risk. Wearing a gown is necessary
for procedures where splashing of body fluids is anticipated or a risk. Wearing a face shield is
necessary for procedures where splashing of body fluids is anticipated.
Report content error
Upon finding a client is restless at night, has muscle spasms, and is at risk of
falling out of bed, the nurse obtains a provider's prescription for restraints. In
which order would the nurse apply the prescribed restraints?
1. Adjust the bed to a proper height and lowering the side rail on the
side of client contact
2. Pad any skin and bony prominences that will be under the restraint
3. Apply a proper-sized restraint according to the manufacturer’s
direction
4. Secure the restraint with a quick-release tie without making a knot
5. Attach restraint straps to the portion of the bed frame that moves
while raising or lowering the head of the bed
6. Assess proper placement of the restraint, skin integrity, pulses,
skin temperature, color, and sensation of body parts
Rationale
To apply a restraint properly, the nurse would first adjust the bed to a proper height and lower the
side rail on the side of client contact. Next, the nurse would pad the skin and bony prominences
that will be under the restraint. The restraint would be applied according to the manufacturer’s
directions. The nurse would then attach restraint straps to the portion of the bed frame that
moves when the head of the bed is raised or lowered. The restraint would then be secured with a
quick-release tie. Finally, the nurse would check proper placement of the restraint, skin integrity,
pulses, skin temperature, color, and sensation of the body part that is restrained.
Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options
presented. For example, you might be asked the steps of performing an action or skill such as
those involved in medication administration.
Correct (622)
Report content error
Which required noninvasive assessment and management skills certification
would the nurse need to perform airway maintenance and cardiopulmonary
resuscitation (CPR)?
Basic Life Support (BLS)
Certified Emergency Nurse (CEN)
Advanced Cardiac Life Support (ACLS)
Pediatric Advanced Life Support (PALS)
Rationale
BLS is the certification for emergency nursing that includes assessment and management skills
for airway maintenance and CPR. CEN is emergency nursing certification that validates the core
emergency nursing knowledge base. ACLS involves invasive airway management skills,
pharmacology, electrical therapies, and special resuscitation. PALS involves neonatal and pediatric
resuscitation.
Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a
wrong answer.
Report content error
The nurse explains to the parents of a 6-year-old child with a pinworm infestation
how pinworms are transmitted. Which statement indicates that the teaching has
been understood?
"We need to keep the cat off the bed."
"She needs to wash her hands before eating anything."
"She needs to cover her mouth whenever she coughs."
"We need to tell the school so that the cafeteria can be cleaned."
Rationale
Pinworm infestation is transferred by way of the oral-anal route, and effective hand washing is the
best way to prevent transmission. Cats do not transmit pinworms. The hands should be kept away
from the nose and mouth; the child should be taught to cough into a tissue or the inside elbow of
the arm. Pinworms are not transmitted by coughing. Cleaning the cafeteria is not an effective
means of preventing the transmission of pinworms.
Report content error
Which information would the nurse share with an adolescent girl with a seizure
disorder refusing to wear a medical alert bracelet that may help her wear the
bracelet consistently?
Hide the bracelet under long-sleeved clothes.
Wear the bracelet when engaging in contact sports.
Ask her friends to wear bracelets that look like hers.
Select a bracelet similar to bracelets worn by her peers.
Rationale
Because adolescents have a developmental need to conform to their peers, the teenager should be
able to select a bracelet of a design similar to that of those worn by her peers. Hiding the bracelet
under long-sleeved clothes might be acceptable in cool weather, but not when it is warm and
friends are wearing T-shirts. The bracelet should be worn at all times when the girl is not with
responsible family members. Asking friends to wear a similar bracelet may be difficult, especially if
the girl does not wish to tell her friends why she needs the bracelet.
Report content error
Which team member acts as a liaison between the health care facility and the
media?
Triage officer
Public information officer
Medical command physician
Hospital incident commander
Rationale
The public information officer acts as a liaison between the health care facility and the media. The
triage officer applies disaster triage tags after evaluating the client’s condition. The medical
command physician decides the number, acuity, and resource needs of clients. The hospital
incident commander assumes overall leadership for implementing the emergency plan.
Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for
a moment, close your eyes, take a few deep breaths, and resume review of the question.
Report content error
Which hospital department plays a primary role in disaster preparedness?
Medical department
Surgical department
Emergency department
Mental health department
Rationale
The emergency department plays a primary role in emergency disaster preparedness. Although all
departments in the hospital contribute to disaster planning, the only department that plays a
primary role is the emergency department.
Report content error
,Which age group has the highest incidence of lead poisoning?
Adult
Toddler
Adolescent
School-age child
Rationale
The incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage
explore the environment and because of their increased level of oral activity, put objects into their
mouths. Adults have a greater risk of cardiovascular or pulmonary disease. Drowning and motor
vehicle accidents are more common among adolescents. Bicycle accidents are more common
among school-aged children.
Test-Taking Tip: If you can eliminate any responses as incorrect based on your knowledge, you
will not be guessing randomly but will be exercising "informed guessing."
Report content error
For which client illness would airborne precautions be implemented?
Influenza
Chickenpox
Pneumonia
Respiratory syncytial virus
Rationale
Chickenpox is known or suspected to be transmitted by air. Diseases that are known or suspected
to be transmitted by droplet include influenza and pneumonia. A disease that is known or
suspected to be transmitted by direct contact is respiratory syncytial virus.
Test-Taking Tip: Identifying content and what is being asked about that content is critical to your
choosing the correct response. Be alert for words in the stem of the item that are the same or
similar in nature to those in one or two of the options.
Report content error
Which antibody forms first, after exposure to an antigen?
Immunoglobulin A (IgA)
Immunoglobulin E (IgE)
Immunoglobulin G (IgG)
Immunoglobulin M (IgM)
Rationale
IgM is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low
circulating levels and is responsible for preventing infection in the upper and lower respiratory
tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the
blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily
expressed on second and subsequent exposures to antigens to provide sustained, long-term
immunity against invading microorganisms.
Report content error
Which product would the nurse instruct intravenous drug users (IDUs) to use for
cleaning of needles and syringes between uses?
Bleach
Hot water
Ammonia
Rubbing alcohol
Rationale
IDUs should be instructed to fill syringes with household bleach and shake the syringe for 30 to
60 seconds. Hot water, ammonia, or rubbing alcohol is not used to disinfect used syringes.
Report content error
Which reaction is an example of a type I hypersensitivity reaction?
Anaphylaxis
Serum sickness
Contact dermatitis
Blood transfusion reaction
Rationale
An example of a type I hypersensitivity reaction is anaphylaxis. Serum sickness is a type III
immune complex reaction. Contact dermatitis is a type IV delayed hypersensitivity reaction. A
blood transfusion reaction is a type II cytotoxic reaction.
Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under
ordinary circumstances and that the action can be carried out in the given situation.
Report content error
Which term describes the practice of placing clients with the same infection in a
semi-private room?
Isolating
Cohorting
Colonizing
Cross-referencing
Rationale
Cohorting is the practice of grouping clients who are colonized or infected with the same
pathogen. Isolating is limiting the exposure to individuals with an infection. Colonizing refers to
the development of an infection in the body. Cross-referencing has nothing to do with an
infectious process.
Report content error
Which manifestation indicates tertiary syphilis?
Chancre
Alopecia
Gummas
Condylomata lata
Rationale
Gummas are chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes
occur during tertiary syphilis. A chancre appears during primary syphilis. Alopecia and
condylomata lata occur during secondary syphilis.
Report content error
Which sexually transmitted infection (STI) is most commonly reported?
Syphilis
Chlamydia
Gonorrhea
Human immunodeficiency virus
Rationale
Chlamydial infections are the most commonly reported STIs. Syphilis, gonorrhea, and human
immunodeficiency virus are not the most commonly reported STIs.
Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there
usually is no pattern to the answers.
Report content error
Which sexually transmitted infection causes condylomata acuminate?
Chlamydia
Gonorrhea
Herpes simplex
Human papillomavirus (HPV)
Rationale
Condylomata acuminate are genital warts that are caused by HPV. Genital warts are not caused by
chlamydia, gonorrhea, or herpes simplex.
Report content error
Which criteria would the nurse consider when determining if an infection is a
health care–associated infection?
Originated primarily from an exogenous source
Is associated with a medication-resistant microorganism
Occurred in conjunction with treatment for an illness
Still has the infection despite completing the prescribed therapy
Rationale
Health care–associated infections are classified as those that are contracted within a health care
environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery,
medications). Originating primarily from an exogenous source is not a criterion for identifying a
health care–associated infection. The source of health care–associated infections may be
endogenous (originate from within the client) or exogenous (originate from the health care
environment or service personnel providing care); most health care–associated infections stem
from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus.
Association with a medication-resistant microorganism is not a criterion for identifying a health
care–associated infection. A health care–associated infection may or may not be caused by a
medication-resistant microorganism. Still having the infection despite completing the prescribed
therapy is not a criterion for identifying a health care–associated infection.
Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an
educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it
blank, you will certainly be wrong and lose precious points.
Report content error
Which action would the nurse take when a client who had a total hip replacement
states that the plan is to go swimming at the community pool the day after
discharge?
Tell the client to take a friend along for safety.
Encourage participation in this activity because it provides excellent range-of-motion
exercise.
Explain that the incision should not be immersed in water until it has healed.
Let the client know that swimming can substitute for the prescribed physical therapy.
Rationale
Because of the risk for infection, the client should avoid tub baths, hot tubs, pools, and immersion
in other bodies of water until after the wound has healed and these activities are approved by the
primary health care provider. Immersion in water for a prolonged period interferes with wound
healing, because water may macerate tissue. Having a friend along does not change the fact that
immersion in water for a prolonged period will interfere with wound healing. The client needs to
continue physical therapy after discharge whether or not the client goes swimming.
Report content error
An 8-year-old girl who is hospitalized for intravenous (IV) antibiotic therapy tells
the nurse that she is bored. The nurse has a discussion with the parent about
appropriate activities. Which activity suggested by the parent would indicate a
need for further teaching?
"I’ll bring a radio and CD player."
"I’ll bring homework and school supplies."
"She’ll enjoy having a rubber baseball and plastic bat."
"She’ll enjoy rubber stamps and a pretty box to keep them in."
Rationale
Playing with a bat and ball is an unsafe activity in a hospital setting; the IV catheter could be
dislodged, and boisterous activity is dangerous to the other children on the unit. A radio and CD
player, homework and school supplies, and rubber stamps and a collection box are all appropriate
for the school-aged child.
Report content error
Which nursing action would be included in the plan of care for a child with acute
poststreptococcal glomerulonephritis?
Encouraging fluids
Monitoring for seizures
Measuring abdominal girth
Checking for pupillary reactions
Rationale
Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures.
Increasing fluid intake may lead to an increase in blood pressure and edema. Measuring
abdominal girth is appropriate for children with nephrotic syndrome, in which the child has
hypoalbuminemia that causes fluid to shift from plasma to the abdominal cavity.
Glomerulonephritis will not alter pupillary reactions.
Report content error
The school nurse is planning to teach the importance of hand washing to the
children in first grade. Which is the most effective approach for this age group?
Showing a video of the correct hand-washing technique
Demonstrating hand washing and asking for return demonstrations
Involving them in a discussion about the importance of hand washing
Describing how germs cause illness and how hand washing prevents disease
Rationale
Six-year-old children are still in the perceptual phase of cognitive development. They base
judgments on what they see rather than on what they reason; reasoning begins around age 7.
These children are at the developmental stage when they want to show off their accomplishments;
just watching the technique without feedback is not sufficient at this age. These children are too
young to understand the abstract concepts involved in a discussion of the cause and effect
regarding pathogens or to understand why hand washing is so important in preventing illness.
Report content error
The nurse is planning to teach the four-point alternate crutch gait to a 9-year-old
child with cerebral palsy. How would the nurse explain this choice to the parent?
The child has minimal step ability in the lower extremities.
It provides for two points of support on the floor at all times.
It provides for equal but partial weight bearing on each limb.
The child has more power in the upper extremities than in the lower extremities.
Rationale
The four-point alternate crutch gait is a simple, slow, stable gait because there are always three
points of support on the floor, with equal but partial weight bearing on each limb. The child has
the ability to move, but the movement in the lower extremities is uncoordinated. The four-point
gait provides for three points of support, not two, at all times. A four-point gait divides weight
bearing equally among the limbs.
Report content error
Which intervention would the nurse encourage the parent of a child with
plumbism (lead poisoning) to do?
Discourage the child’s pica by providing nutritious snacks.
Move the family away from areas that are next to gas stations.
Assess the family’s home environment for lead sources and have them removed.
Have the child take repeat x-rays of the wrist and forearm for signs of a lead line.
Rationale
All sources of lead must be removed from the home if the problem is to be controlled. Sources
include lead-painted surfaces and old plumbing that has lead solder. Although pica must be
controlled if it is present, this alone will not eliminate the environmental risks. The data do not
indicate that the child is engaging in pica. Leaded gasoline is no longer used in the United States.
Chelation therapy is based on the blood lead level; changes in bone take longer to evaluate.
Report content error
Which parental statement would the nurse recognize as indicating the need for
further education about bicycle safety for a school-aged client?
"My child should be able to place both feet on the ground while seated."
"My child should be able to easily grasp the brake handles and squeeze them."
"My child will be required to wear a bicycle helmet if he or she wants to ride a bike."
"My child should be able to safely ride after being supervised for a couple of days."
Rationale
Children may not safely be able to ride their bike after a couple of days of learning. The child
should be able to place the balls of both feet on the ground while sitting on the bike. The child
should easily be able to grasp the brake handles and squeeze them. The child should always wear
the appropriate safety equipment while riding his or her bike.
Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them
will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number
of response choices by one and improved the odds. Continue to analyze the options. If you can
eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While
you are eliminating the wrong choices, recall often occurs. One of the options may serve as a
trigger that causes you to remember what a few seconds ago had seemed completely forgotten.
Report content error
After the nurse provides education about all-terrain vehicle (ATV) safety for a
parent of a 11-year-old child, which statement made by the parent indicates an
understanding of the information?
"I will have my child ride with an adult."
"I will make sure my child wears a helmet."
"I will make sure my child does not get on an ATV."
"I will make sure my child has had safety training before he or she rides."
Rationale
The American Academy of Pediatrics recommends that children under 16 years of age not ride in
or operate an ATV. The child should not ride with another adult. When the child is 16 years of age
and begins riding an ATV, safety gear such as a helmet should be worn and proper safety training
should be implemented.
Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the
options are very similar. This can be very helpful, because it may mean that one of these look-alike
answers is the best choice and the other is a very good distractor. Test both of these options
against the stem. Ask yourself which one completes the incomplete statement grammatically and
which one answers the question more fully and completely. The option that best completes or
answers the stem is the one you should choose. Here, too, pause for a few seconds, give your
brain time to reflect, and recall may occur.
Report content error
Which response would the nurse provide the parent of a 15-month-old child who
expresses feelings of guilt when their child was hospitalized after ingesting toilet
bowl cleaner?
"Anyone could make a mistake. Don’t dwell on it."
"Let’s not worry about the past. Your child is going to get better."
"It was an accident, but you should consider special locks on your closets."
"That was careless of you. Please make sure that you poison-proof your house."
Rationale
Describing the incident as an accident and recommending locks on closets accepts the parent’s
statement and helps the parent express their guilt while providing directions to safeguard the
child. Poisoning is not an everyday occurrence; teaching should be incorporated to protect the
child. Telling the parent that the child will get better is false reassurance; the child’s condition is
still in question. Calling the parent careless only increases the parent’s guilt and provides nothing
more than a vague suggestion of how to remedy the problem.
Report content error
In which way do toddlers learn self-protection?
Through trial-and-error strategies
By imitating playmates and siblings
By obeying orders from their parent
By playing with age-appropriate toys and puzzles
Rationale
The toddler is developing autonomy, is curious, and learns self-protection from experience.
Toddlerhood play is parallel, not interactive. The struggle for autonomy at this age limits learning
from siblings, even though the toddler attempts to copy their behavior. The toddler is still
learning from experiences, not from others. The toddler is still attempting to distinguish the self
as separate from their parent; the struggle for autonomy limits learning from parents. Toddlers
learn gross and fine motor skills as they play with their toys, not self-protection.
Report content error
A child becomes cyanotic during a generalized tonic-clonic seizure. Which action
would the nurse take?
Insert an oral airway
Administer oxygen (O 2) by mask
Continue to observe the seizure
Notify the health care provider immediately
Rationale
The child’s status and the progression of the seizure should be monitored; the child will not
breathe until the seizure is over, and cyanosis should subside at that time. Attempting to open a
clenched jaw may result in injury to the child. O 2 is useless until the child breathes when the
seizure is over. The health care provider may be notified later; provisions for the child’s safety and
observation are the priorities.
Report content error
Which action would the nurse take first if an allergic reaction to a blood
transfusion occurs?
Shut off the infusion.
Slow the rate of flow.
Administer an antihistamine.
Call the health care provider (HCP).
Rationale
The client is experiencing an allergic reaction, and the infusion must be stopped immediately to
prevent serious complications. Slowing the rate of infusion will not halt the allergic reaction to the
transfused blood. Administering an antihistamine is dangerous as an initial action because the
degree of allergic reaction cannot be determined at this time. Also, it requires an HCP’s
prescription. The HCP should be notified after the infusion has been stopped.
Report content error
Which action would the nurse take when caring for an older adult with a history
of recent memory loss?
Instruct the client to move slowly when changing positions.
Remind the client to look where he or she places the feet while walking.
Adjust the daily schedule to accommodate sleep pattern.
Employ electronic devices that provide alerts.
Rationale
Providing electronic devices that give alerts can help an older adult who has developed recent
memory loss. Instructing the client to move slowly when changing positions can prevent dizziness
and falls caused by orthostatic blood pressure changes or altered balance/coordination.
Reminding the client to check where the feet are placed can help older adults with a decreased
sensory perception of touch. Adjusting the daily schedule can aid older adults who have changes
in their sleep pattern.
Report content error
Which nursing intervention would the nurse take for an older adult with delirium
who begins acting out while in the dayroom?
Instructing the client to be quiet
Allowing the client to act out until fatigue sets in
Immediately guiding the client from the room by gently holding the client’s arm
Giving the client one simple direction at a time in a firm, low-pitched voice
Rationale
Clients with delirium typically respond to simple directions stated one at a time in a firm, low-
pitched voice. "Be quiet" is a nontherapeutic order; furthermore, it is demeaning to the client.
Allowing the client to act out until fatigue sets in will not help the client gain control and might be
frightening to other clients in the dayroom. Guiding the client from the room by gently holding
the client’s arm is done only after giving simple directions and attempting to calm the client has
failed. Touch should also be used cautiously in clients who have delirium because the client may
misinterpret the gesture as aggressive.
Report content error
In which order would clients receive care based on triage tag color?
1. Red
2. Yellow
3. Green
4. Black
, Rationale
Clients with a red tag generally have life-threatening conditions involving airway obstruction and
shock. Red-tagged clients should be seen immediately. Clients who are dead or expected to die
are labeled with black tags, are classified as expectant, and are given the lowest priority. Green-
tagged clients have minor injuries that can receive treatment within 2 hours and are classified as
nonurgent. Clients with yellow tags have injuries or conditions that need treatment within 30
minutes to 2 hours and who can be treated after red-tagged clients.
Report content error
Which type of needs would the nurse identify as a high priority in the
prioritization of client care?
Developmental needs
Long-term care needs
Potential needs in care
Needs that affect safety
Rationale
Needs related to survival and safety are the highest priority because these are an immediate threat
to client health. Developmental needs and long-term care needs are low priority when prioritizing
care because they are not an immediate threat to health. Potential needs in care are intermediate
priority because they are best addressed before complications follow.
Report content error
Which condition would the nurse monitor for in the client on aminoglycoside
therapy and skeletal muscle relaxants?
Stroke
Respiratory arrest
Myocardial infarction
Abdominal discomfort
Rationale
Aminoglycosides can intensify the effect of skeletal muscle relaxants, placing the client at risk for
respiratory arrest. Aminoglycoside therapy with muscle relaxants does not increase the risk of
stroke, myocardial infarction, or abdominal discomfort.
Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or
five consecutive questions have the same letter or number for the correct answer.
Report content error
Which effect has resulted in the avoidance of tetracycline use in children under 8
years old?
Birth defects
Allergic responses
Severe nausea and vomiting
Permanent tooth discoloration
Rationale
Tetracycline use in children under the age of 8 years has been discontinued because it causes
permanent tooth discoloration. Birth defects, allergic responses, and severe nausea and vomiting
are not prevalent reasons for the discontinuation of tetracycline medications in children under 8
years old.
Report content error
Which medication for treatment of gastroesophageal reflux disease would be
contraindicated in the pregnant client?
Ranitidine
Misoprostol
Esomeprazole
Calcium carbonate
Rationale
Misoprostol is contraindicated in pregnancy because it can cause uterine contractions, expelling
the developing fetus. Ranitidine, esomeprazole, and calcium carbonate are not contraindicated
during pregnancy.
Report content error
Which sexually transmitted infection is caused by bacteria? Select all that apply.
One, some, or all responses may be correct.
Syphilis
Hepatitis
Gonorrhea
Herpes simplex
Trichomoniasis
Rationale
Syphilis is caused by Treponema pallidum, a motile spirochete bacterium. Gonorrhea is caused by
a bacteria called Neisseria gonorrhoeae. Hepatitis A and herpes simplex are caused by viruses.
Trichomoniasis is caused by a protozoan.
Report content error
Which activity would the nurse manager complete during an emergency event
when acting as the triage officer according to the Hospital Incident Command
System (HICS)?
Facilitating client movement through the system
Bringing in personnel and supply resources to meet needs
Rapidly evaluating each person who comes to the hospital
Identifying the need for and call in specialty providers
Rationale
In the role of triage officer, the nurse would rapidly evaluate each person who comes to the
hospital, including those triaged in the field. The hospital incident commander facilitates client
movement through the system and brings in personnel and resources to meet needs. The medical
command physician identifies the need for and calls in needed specialty providers.
Report content error
Which emergency medical service agency offers service such as first aid stations
and special-need shelters during a disaster or pandemic disease outbreak?
Medical Reserve Corps (MRC)
National Disaster Medical System (NDMS)
Disaster Medical Assistance Team (DMAT)
Federal Emergency Management Agency (FEMA)
Rationale
The MRC may help staff hospitals or community health settings that face shortages and provide
first aid stations or special-need shelters. The NDMS manages mass fatalities, emergency animal
care, and establishes fully functional field surgical facilities. A DMAT is a medical relief team
deployed to a disaster area with enough medical equipment and supplies to sustain operations for
72 hours. FEMA provides Community Emergency Response Team (CERT) training so that people
are better prepared for disasters and hazard situations in their own communities.
Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one
answer may be correct, but one answer may contain more information or more important
information than another answer.
Report content error
To which disaster triage class would the nurse infer a client with a green triage tag
belongs?
Class I
Class II
Class III
Class IV
Rationale
The green disaster triage tag is issued to nonurgent or "walking-wounded" clients who belong to
class III. A red disaster triage tag is issued to clients who require immediate treatment and belong
to class I. Clients with yellow and black tags belong to class II and IV respectively.
Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a
wrong answer.
Report content error
Which color tag would the nurse use to triage a victim of a train derailment who
is able to walk independently to the first aid station?
Red
Black
Green
Yellow
Rationale
An emergency triage system uses colored tags to designate both the seriousness of the injury and
the likelihood of survival. Green would be used for minor injuries such as the victim who is able to
ambulate independently. Red indicates life-threatening injuries requiring immediate attention.
Black indicates that the victim is expected to die. Yellow indicates urgent but not life-threatening
injuries.
Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a
wrong answer.
Report content error
Which is the minimum number of disaster drills the hospital disaster plan
committee must plan and implement each year?
Two
Three
Four
Five
Rationale
Although it is appropriate to have more than the minimum number of disaster drills each year,
the minimum that must be implemented per The Joint Commission (TJC) requirements is twice
per calendar year. Three, four, and five are too many.
Report content error
Which agent of terrorism can cause death within a few minutes?
Sarin gas
Uranium
Iodine-131
Mustard gas
Rationale
Sarin gas is an agent for bioterrorism that can cause death within minutes of exposure by
paralyzing respiratory muscles. Uranium and iodine-131 can be dangerous in close proximities
but are not as harmful as sarin gas. Mustard gas causes blisters on the skin but does not cause
death within a few minutes.
Report content error
Which object would the nurse teach the client with a newly implanted pacemaker
to avoid?
Strong magnet
Microwave oven
Mobile telephone
Remote control device
Rationale
The client with a newly implanted pacemaker is taught to avoid strong magnets because they can
change the settings and function of the pacemaker. Microwave oven use is not a concern for a
client with a pacemaker. Mobile phones should be used in the ear opposite the
pacemaker. Remote control devices are not contraindicated for the client with a pacemaker.
Report content error
Which threats included in the term "NBC" led to the implementation of improved
emergency medical services (EMS) and hospital safety programs? Select all that
apply. One, some, or all responses may be correct.
Nuclear
Biological
Botulism
Chemical
Nipah virus
Rationale
The term "NBC" was coined to describe nuclear, biological, and chemical threats. In response,
EMS agencies and hospitals improved safety by upgrading their decontamination facilities,
equipment, and all levels of personal protective equipment to better protect staff. Botulism and
Nipah virus are two specific examples of biological threats.
Report content error
Which method of delivering client care works well in disaster situations?
Team nursing
Primary nursing
Functional nursing
Total client care nursing
Rationale
The functional method of delivering care works well in emergency and disaster situations. Each
care provider knows the expectations of the assigned role and completes the tasks quickly and
efficiently. Team nursing, primary nursing, and total client care nursing are not the ideal models
for delivering client care during disaster situations.
Report content error
Which team would be mobilized to manage the deceased at the earthquake zone
where many people lost their lives?
Medical Reserve Corps (MRC)
National Veterinary Response Teams (NVRTs)
International Medical-Surgical Response Teams (IMSRTs)
Disaster Mortuary Operational Response Teams (DMORTs)
Rationale
DMORTs are a team deployed under NDMS. This team is specialized in managing mass fatalities
during a disaster. The MRC helps staff hospitals or community health care settings that face
shortages of nurses. They establish first aid stations and special-needs shelters in disasters.
NVRTs provide emergency care to animals. IMSRTs provide fully functional field surgical facilities
all over the world, wherever it is required.
Report content error
Which action would the nurse implement when caring for a client reporting a
recent bee sting presenting with localized redness, swelling, intense localized
pain, and itching?
Applying cold compresses to the affected area
Ensuring the client keeps the skin clean and dry
Monitoring for neurological and cardiac symptoms
Advising the client to launder all clothes with bleach
Rationale
A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic
reaction. The nurse would apply cold compresses to the affected area to reduce the pain and
edema at the sting site. A client with Candida albicans infection should keep his or her skin clean
and dry to prevent further fungal infections. A client with a Borrelia burgdorferi infection may
suffer from cardiac, arthritic, and neurological manifestations, which requires monitoring by the
nurse. Direct contact may transmit a Sarcoptes scabiei infection; the nurse should make sure the
client bleaches his or her clothes to prevent the transmission of the infection.
Test-Taking Tip: Read the question carefully before looking at the answers: (1) determine what the
question is really asking; look for key words; (2) read each answer thoroughly and see if it
completely covers the material asked by the question; (3) narrow the choices by immediately
eliminating answers you know are incorrect.
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Who is responsible for triaging the victims of a multiple motor vehicle crash on a
major interstate?
Emergency first responders
Nurses in the acute care areas
Nurses in the emergency department
Health care providers in the emergency department
Rationale
For a mass casualty incident, triaging will occur in the field or at the site of the incident. In this
case, the emergency first responders will triage the victims of the crash. Nurses in the acute care
areas may or may not have victims admitted for care. The victims should be triaged before arriving
in the emergency department, so it would be incorrect to expect the nurses and health care
providers in the emergency department to perform triage.
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Which action would the nurse implement when providing care for a client with
acquired immunodeficiency syndrome (AIDS)?
Use standard precautions.
Employ airborne precautions.
Plan interventions to limit direct contact.
Discourage long visits from family members.
Rationale
The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) states
that standard precautions should be used for all clients; these precautions include wearing of
gloves, gown, mask, and goggles when there is risk for exposure to blood or body secretions.
There is no indication that airborne precautions are necessary. Planning interventions to limit
direct contact or discouraging long visits from family members will unnecessarily isolate the
client.
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Which response by the nurse is best when a client expresses concern regarding
the lack of annual flu vaccines because of a supply and demand problem?
"This is an unfortunate situation, but there was such a limited supply available."
"There are many others who were unable to obtain a flu vaccine this month."
"The limited supply doesn’t really matter because the vaccine is for one particular strain."
"There are other things you and your family can do to prevent the flu, such as hand
washing."
Rationale
The statement "There are other things you can do to prevent the flu, such as hand washing" is a
teaching opportunity of which the nurse can take advantage and show the client the things that
can be done to avoid infection. The response "It’s unfortunate, but there was such a limited supply
available" is empathic, but it does not address the client’s concern of vulnerability. The response
"There are many others who also were unable to get a flu vaccine" belittles the client for being
concerned. The response "It doesn’t matter because the vaccine is for just one particular strain"
may be true, but it belittles the client’s concern.
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Which event would the nurse state is an example of a natural disaster?
Floods
Terrorism
Fire explosion
Building collapse
Rationale
External disasters can be natural, such as floods, earthquakes, or tornadoes. Acts of terrorism are
external disasters that use technology such as explosive devices or a malfunction of a nuclear
reactor. A fire explosion is an internal disaster. A building collapse is a consequence of internal or
external disaster.
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Which action would the nurse identify as a potential contributor to staff post-
traumatic stress disorder (PTSD) during a mass casualty assessment?
Working less than 12 hours
Encouraging and motivating team members
Working continuously without any breaks
Discussing feelings with the team members
Rationale
Working continuously without any breaks will result in increased stress. Working less than 12
hours may reduce stress. By motivating team members, PTSD can be prevented. By discussing
feelings with team members or nurse managers, stress can be reduced.
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Which event would the nurse describe as an example of an internal disaster?
Tornado
Hurricanes
Fire or explosion
Terrorism attacks
Rationale
An internal disaster refers to an event that impairs the hospital’s normal functioning and disrupts
normal client care activities. Examples include a fire or explosion and the loss of critical utilities.
Tornado, hurricanes, and terrorist attacks are external disasters that result in the loss of lives and
property.
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Which statement would the nurse include in the teaching plan of a client
anticipating discharge with acquired immunodeficiency syndrome (AIDS)?
"Wash used dishes in hot, soapy water."
"Let dishes soak in hot water for 24 hours before washing."
"You should boil the client’s dishes for 30 minutes after use."
"Have the client eat from paper plates so they can be discarded."
Rationale
A person cannot contract human immunodeficiency virus (HIV) by eating from dishes previously
used by an individual with AIDS; routine care is adequate. Washing used dishes in hot, soapy
water is sufficient care for dishes used by the AIDS client. Dishes do not need to soak for 24 hours
before being washed. The client’s dishes do not need to be boiled for 30 minutes after use. Paper
plates are fine to use but are not indicated to prevent the spread of AIDS.
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How often should a health care facility that is Joint Commission accredited plan
to test the emergency preparedness plan?
Annually
Twice a year
Every 2 years
Every 3 months
Rationale
The Joint Commission mandates that hospitals have an emergency preparedness plan that is
tested through drills or actual participation in a real event at least twice yearly. Annually or every 2
years is not frequent enough to test the emergency preparedness plan. It is not necessary to test
the plan as frequently as every 3 months.
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When caring for a client who is receiving enteral feedings, the nurse would take
which measure to prevent aspiration?
Elevate the head of the bed between 30 and 45 degrees.
Decrease flow rate at night.
Check for residual daily.
Irrigate regularly with warm tap water.
Rationale
To prevent aspiration, the nurse would keep the head of the bed elevated between 30 and 45
degrees. Elevating the head any higher causes increased sacral pressure and increases the risk of
skin breakdown. Decreasing flow rate, checking for residual, and irrigating regularly will not
