A nurse in the emergency department is caring for a 2-year- old child who was
found by his parents crying and holding a container of toilet bowl cleaner. The
child's lips are edematous and inflamed, and he is drooling. Which of the following
is the priority action by the nurse?
Remove the child's contaminated clothing. Check the child's respiratory status.
Administer an antidote to the child. Establish IV access for the child.
Rationale: The nurse should apply the ABC priority-setting
Check the child's respiratory status.
A nurse is teaching a parent of a 12-month old child about development during the
toddler years. Which of the following statements should the nurse include?
"Your child should be referring to himself using the appropriate pronoun by 18
months of age."
"A toddler's interest in looking at pictures occurs at 20 months
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of age."
C. "A toddler should have davtime control of his bowel and bladder by 24 months of
age.
d. "Your child should be able to scribble spontaneously using a crayon at the age of
15 months."
d. "Your child should be able to scribble spontaneously using a crayon at the age of
15 months."
A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride
100 mL IV to infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL.
The nurse should set the manual IV infusion to deliver how many gtt/min? (Round
the answer to the nearest whole number. Use a leading zero if it applies. Do not use
a trailing zero.)
25 GTT
4. A nurse in a pediatric clinic is assessing a toddler at a well- child visit. Which
of the following actions should the nurse take?
a. Perform the assessment in a head to toe sequence.
b. Minimize physical contact with the child initially.
c. Explain procedures using medical terminology.
d. Stop the assessment if the child becomes uncooperative.
b. Minimize physical contact with the child initially.
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,4. A nurse is caring for an 18-year-old adolescent who is up-to- date on
immunizations and is planning to attend college. The nurse should inform the client
that he should receive which of the following immunizations prior to moving into a
campus dormitory?
a. Pneumococcal polysaccharide
b. Meningococcal polysaccharide
c. Rotavirus
d. Herpes zoster
b. Meningococcal polysaccharide
A nurse is providing discharge instructions to a Chinese client regarding prescribed
dietary modifications. During the teaching session the client continually turns away
from the nurse. Which of the following nursing actions is most appropriate?
1.
Continue with the instructions, verifying client understanding. 2.
Identify the importance of the instructions for the maintenance of health care.
3.
Walk around the client so that the nurse continually faces the client.
4.
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Give the client a dietary booklet and return later to continue with the instructions. -
100% correct answer is 1
A nurse is assisting in preparing a plan of care for a client who is a Jehovah's
Witness. The client has been told that surgery is necessary. Considering the client's
religious preferences, the nurse documents that:
1.
Surgery is prohibited in this religious group. 2.
The administration of blood and blood products is forbidden. 3.
Medication administration is not allowed. 4.
Faith healing is primarily practiced. - 100% correct answer is 2
A nurse is preparing to deliver a food tray to a client whose religion is Judaism. The
nurse checks the food on the tray and notes that the client has received a roast
beef dinner with whole milk as a beverage. Which of the following actions will the
nurse take?
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1.
Deliver the food tray to the client. 2.
Call the dietary department and ask for a new meal tray. 3.
Replace the whole milk with fat-free milk. 4.
,Ask the dietary department to replace the roast beef with pork. - 100% correct
answer is 2
A nurse educator is describing the yin and yang theory of the ancient Chinese
philosophy of Tao to a group of nursing students. The nurse explains that foods are
classified as hot and cold in this theory and are transformed into yin and yang
energy when metabolized by the body. The nursing student understands this theory
when the student verbalizes that a client who practices this belief:
1.
Consumes cold foods when a "hot" illness is present 2.
Consumes hot foods when a "hot" illness is present 3.
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Believes that yin foods are hot foods 4.
Believes that yang foods are cold foods - 100% correct answer is 1
A nurse is planning to instruct the Hispanic-American client about nutrition and
dietary restrictions. When developing the plan for the instructions, the nurse is
aware that this ethnic group:
1.
Enjoys foods that lack color, flavor, and texture 2.
Primarily eats raw fish 3.
Enjoys eating red meat 4.
Views food as a primary form of socialization - 100% correct answer is 4
A nursing student is discussing cultural issues in a clinical conference. The nursing
instructor asks the student to describe ethnocentrism. Which of the following if
stated by
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the student indicates a lack of understanding of the issue of ethnocentrism?
1.
"It is a tendency to view one's own ways as best." 2.
"It is acting in a manner that is superior to other cultures." 3.
"It is believing that one's own ways are the only acceptable way."
4.
"It is imposing one's beliefs on individuals from another culture." - 100% correct
answer is 4
A nurse is assigned to collect data from a Hispanic-American client during the
hospital admission. On initial meeting of the client, the nurse should plan to:
1.
Greet the client with a handshake. 2.
Avoid touching the client. 3.
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Avoid any affirmative nods during the conversations with the client.
4.
Smile and use humor throughout the entire admission process. - 100% correct
answer is 1
A nurse is providing care to a Cuban-American client who is terminally ill.
Numerous family members are present most of the time, and many of the family
members are very emotional. The most appropriate nursing plan is to:
1.
Restrict the number of family members visiting at one time. 2.
Inform the family that emotional outbursts are to be avoided. 3.
Request permission to move the client to a private room, and allow the family
members to visit.
4.
Contact the physician to speak to the family regarding their behavior. - 100%
correct answer is 3
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A nurse is instructing a Native-American client regarding the procedure for
collecting a urine sample. The nurse observes that the client continually stares at
the floor during the instructional session. The nurse interprets this behavior as:
1.
Rude 2.
Disinterest 3.
Embarrassment 4.
Indicative that the client is paying close attention - 100% correct answer is 4
A nurse who works on the night shift enters the medication room and finds a co-
worker with a tourniquet wrapped around the upper arm. The co-worker is about to
insert a needle, attached to a syringe containing a clear liquid, into the antecubital
area. The appropriate initial action by the nurse is which of the following?
1.
Call the police.
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2.