QUESTIONS AND CORRECT
ANSWERS GARANTEED PASS
The RN supervises the care provided by a nursing assistant to a patient
being weaned from a mechanical ventilator. It is MOST appropriate for the
RN to make which of the following statements to the nursing assistant?
1. "Count his respiratory rate every 15 minutes, and notify me if the rate is
less than 10 or greater than 30 breaths' per minute."
2. "Check the patient frequently and please notify me if he becomes
anxious."
3. "Call me if the patient's skin changes color or he begins to have difficulty
breathing."
4. "Stay with the patient to reassure him. Take his vital signs frequently."
1
A patient is admitted to the psychiatric unit for treatment of bipolar disorder.
During the admission interview, when asked by the nurse the reason for the
hospitalization, the patient responds, "I'm here for tests on my heart." The
nurse recognizes that the patient is most likely exhibiting which of the
following?
1. Substitution
2. Projection
3. Symbolization
4. Denial
4
,An LPN/LVN reports to the nurse that a client with a spinal cord injury at T2 is
complaining of a severe headache. The client's vital signs are BP 280/130,
pulse 60, respirations 24. The nurse should take which of the following
actions FIRST?
1. Perform a neurovascular check.
2. Assess his level of consciousness
3. Palpate the patient's bladder.
4. Listen for breath sounds.
3
The clinic nurse obtains a history from a client complaining of
gastrointestinal problems. If the client is experiencing irritable bowel
syndrome, which of the following symptoms are inconsistent with the
diagnosis?
1. Nausea and vomiting
2. Diarrhea.
3. Constipation
4. Abdominal distention
1
A patient with a history of substance abuse and a poor work history is
hospitalized for depression. The patient tries to manipulate the staff
members to get what the patient wants. Which approach by the nurse is
BEST?
,1. Meet the patient's demands, if possible.
2. Develop a strict schedule for the patient to follow while in the hospital.
3. Respond in a consistent manner to the patient's demands.
4. Tell the patient that his demands will not be met.
3
The nurse cares for a client with a Levin tube connected to intermittent low
suction. At 0630 the night nurse empties the suction container. At 1000 the
nurse charts there is 65 mL of greenish drainage in the suction container. At
1500 the nurse notes there is 210 mL of greenish drainage in the suction
container. Twice during the shift, the nurse irrigates the Levin tube with 30
mL of normal saline. Which is the amount of drainage from the Levin tube for
the 7 to 3 shift?
1. 270 mL
2. 210 mL
3. 180 mL
4. 150 mL
1
A woman (gravida 7, para 6) is in active labor. The client's last cervical exam
showed that she was 7 cm dilated and 100% effaced and that the fetus was
at 0 station. Which finding indicates to the nurse that delivery is imminent?
1. Spontaneous rupture of membrane occurs at the height of a contraction.
2. Strong uterine contractions occur every 2 minutes and last 60 seconds.
3. Fetal heart tones show early decelerations and decreased variability.
, 4. There is increasing bloody show and complaints of rectal pressure.
4
The outpatient nurse instructs a young adult diagnosed with primary syphilis.
Which statement, if made by the client, indicates to the nurse that teaching
is effective?
1. "I will stay at home in bed for 3 days to rest."
2. "I will always have a positive VDRL blood test."
3. "I will not have sexual contact with my partner until my partner has been
treated."
4. "I will wear disposable gloves when washing my genital area."
3
The clinic nurse teaches an elderly adult how to clean the ear mold of a
behind-the-ear hearing aid. Which statement, if made by the client to the
nurse, indicates teaching is successful?
1. "I will soak the ear mold in a solution of bleach and water for 5 minutes."
2. "I will allow the ear mold to dry thoroughly after I rinse it."
3. "I will use a small brush to clean the holes of the ear mold."
4. "I will keep the ear mold connected to the battery device while I clean it."
4