NSG 4800 QUESTIONS AND ANSWERS SET A+
✔✔The nurse is caring for 4 pediatric clients. After receiving reports from the night shift,
which child should the nurse assess first? (Scroll for Answer)
A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic
treatment
A 6-week-old infant admitted to the hospital for decreased level of consciousness;
shaken baby syndrome is suspected
A 2-year-old child with cerebral palsy being admitted to the hospital for surgical
placement of a gastrostomy feeding tube the next day
A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for
hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and
ready for a computed tomography (CT) scan of the head - ✔✔2, The infant or child who
is the most unstable should be assessed first. A 6-week-old infant with an altered level
of consciousness suspected to have resulted from shaken baby syndrome is the most
unstable client because the infant could be developing increased intracranial pressure
(ICP) and require interventions for the complications associated with increased ICP.
The 6-year-old child on day 10 of antibiotics for bacterial meningitis is a stable client.
The 2-year-old child with cerebral palsy being admitted for surgical placement of a
gastrostomy tube will need an admission assessment, but this child is stable. The 16-
year-old with a possible shunt malfunction could become unstable, but because this
child is older and ready for the CT scan, he or she is stable at this time.
✔✔The nurse is reviewing the client's arterial blood gas (ABG) results and notes the
following values:
pH: 7.35; PaO2: 80 mm Hg; PaCO2: 55mmHg; HCO: 30mEq/L.
The nurse should recognize that this result is suggestive of which acid base imbalance?
(Scroll for Answer)
A.Compensated metabolic acidosis
B.Compensated respiratory acidosis
C.Compensated metabolic alkalosis
D.Compensated metabolic alkalosis - ✔✔B - the pH is within normal range while the
carbon dioxide level is increased indicating compensated respiratory acidosis
, ✔✔When educating a patient about inject-able influenza immunization, the registered
nurse considers the following...
It is contraindicated during pregnancy.
Its use is limited to children older than 6 years old.
It contains a live virus.
Its use is recommended for virtually all children age 6 months to 18 years old. - ✔✔4
This vaccine can be given to infants 6 months and older.
✔✔A miotic medication has been prescribed for the client with glaucoma and the client
asks the nurse about the purpose of the medication. Which response should the nurse
provide to the client?
A. "The medication will help dilate the eye to prevent pressure from occurring."
B. "The medication will relax the muscles of the eyes and prevent blurred vision."
C. "The medication causes the pupil to constrict and will lower the pressure in the eye."
D. "The medication will help block the responses that are sent to the muscles in the
eye." - ✔✔C
Miotic medications cause constriction of the pupil. This will allow the extra fluid to drain
from the eye and relieve the pressure.
✔✔The nurse is caring for a client who has had spinal fusion, with the insertion of
hardware. The nurse would be most concerned with which assessment finding? (Scroll
for Answer)
Temperature of 101.6°F (38.7°C) orally
Complaints of discomfort during repositioning
Old bloody drainage outlined on the surgical dressing
Discomfort during coughing and deep-breathing exercises - ✔✔1, The nursing
assessment conducted after spinal surgery is similar to that done after other surgical
procedures. For this specific type of surgery, the nurse assesses the neurovascular
status of the lower extremities, watches for signs and symptoms of infection, and
inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear
and tests positive for glucose). A mild temperature is expected after insertion of
hardware, but a temperature of 101.6°F (38.7°C) should be reported.
✔✔The nurse is planning care for a client who has amyotrophic lateral sclerosis (ALS).
Which of the following interventions is most important for the nurse to include?
1.Increase periods of exercise
2.Establish alternative methods of communication
3.Coughing every two hours
4.Verbalization of feelings about the diagnosis - ✔✔3- protect airway
✔✔The nurse is assessing a client who has been admitted to the coronary care unit.
The client seems to fluctuate in the ability to focus during the day. On the basis of this
assessment, which client problem should the nurse suspect?
Dementia as a result of isolation
✔✔The nurse is caring for 4 pediatric clients. After receiving reports from the night shift,
which child should the nurse assess first? (Scroll for Answer)
A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic
treatment
A 6-week-old infant admitted to the hospital for decreased level of consciousness;
shaken baby syndrome is suspected
A 2-year-old child with cerebral palsy being admitted to the hospital for surgical
placement of a gastrostomy feeding tube the next day
A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for
hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and
ready for a computed tomography (CT) scan of the head - ✔✔2, The infant or child who
is the most unstable should be assessed first. A 6-week-old infant with an altered level
of consciousness suspected to have resulted from shaken baby syndrome is the most
unstable client because the infant could be developing increased intracranial pressure
(ICP) and require interventions for the complications associated with increased ICP.
The 6-year-old child on day 10 of antibiotics for bacterial meningitis is a stable client.
The 2-year-old child with cerebral palsy being admitted for surgical placement of a
gastrostomy tube will need an admission assessment, but this child is stable. The 16-
year-old with a possible shunt malfunction could become unstable, but because this
child is older and ready for the CT scan, he or she is stable at this time.
✔✔The nurse is reviewing the client's arterial blood gas (ABG) results and notes the
following values:
pH: 7.35; PaO2: 80 mm Hg; PaCO2: 55mmHg; HCO: 30mEq/L.
The nurse should recognize that this result is suggestive of which acid base imbalance?
(Scroll for Answer)
A.Compensated metabolic acidosis
B.Compensated respiratory acidosis
C.Compensated metabolic alkalosis
D.Compensated metabolic alkalosis - ✔✔B - the pH is within normal range while the
carbon dioxide level is increased indicating compensated respiratory acidosis
, ✔✔When educating a patient about inject-able influenza immunization, the registered
nurse considers the following...
It is contraindicated during pregnancy.
Its use is limited to children older than 6 years old.
It contains a live virus.
Its use is recommended for virtually all children age 6 months to 18 years old. - ✔✔4
This vaccine can be given to infants 6 months and older.
✔✔A miotic medication has been prescribed for the client with glaucoma and the client
asks the nurse about the purpose of the medication. Which response should the nurse
provide to the client?
A. "The medication will help dilate the eye to prevent pressure from occurring."
B. "The medication will relax the muscles of the eyes and prevent blurred vision."
C. "The medication causes the pupil to constrict and will lower the pressure in the eye."
D. "The medication will help block the responses that are sent to the muscles in the
eye." - ✔✔C
Miotic medications cause constriction of the pupil. This will allow the extra fluid to drain
from the eye and relieve the pressure.
✔✔The nurse is caring for a client who has had spinal fusion, with the insertion of
hardware. The nurse would be most concerned with which assessment finding? (Scroll
for Answer)
Temperature of 101.6°F (38.7°C) orally
Complaints of discomfort during repositioning
Old bloody drainage outlined on the surgical dressing
Discomfort during coughing and deep-breathing exercises - ✔✔1, The nursing
assessment conducted after spinal surgery is similar to that done after other surgical
procedures. For this specific type of surgery, the nurse assesses the neurovascular
status of the lower extremities, watches for signs and symptoms of infection, and
inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear
and tests positive for glucose). A mild temperature is expected after insertion of
hardware, but a temperature of 101.6°F (38.7°C) should be reported.
✔✔The nurse is planning care for a client who has amyotrophic lateral sclerosis (ALS).
Which of the following interventions is most important for the nurse to include?
1.Increase periods of exercise
2.Establish alternative methods of communication
3.Coughing every two hours
4.Verbalization of feelings about the diagnosis - ✔✔3- protect airway
✔✔The nurse is assessing a client who has been admitted to the coronary care unit.
The client seems to fluctuate in the ability to focus during the day. On the basis of this
assessment, which client problem should the nurse suspect?
Dementia as a result of isolation
