A day-shift nurse on the pediatric neurologic unit has just received a report from the
previous shift. Which infant should the nurse assess first? - Answer-A restless infant
with a high-pitched cry who was transferred from the intensive care unit (ICU) the
previous evening
Explanation:
An infant's restlessness and high-pitched cry can indicate increased intracranial
pressure (ICP). Because the infant was transferred from the ICU the previous night,
assessing for increased ICP should be a nursing priority. The infant with a pulse of 140-
160 bpm exhibits normal parameters. Although the nurse must assess a low-grade
fever on the third postoperative day, this stable infant isn't the priority at this time.
Decreased respirations are indicative of increased intracranial pressure, but this infant's
respirations of 38 breaths per minute would not be a priority concern.
During the immediate postpartum period, the nurse is caring for a primipara who gave
birth to a postterm neonate after an oxytocin induction. When developing the client's
plan of care, which problem should the nurse expect to assess for frequently? - Answer-
uterine atony
Uterine atony is more common in clients who have received oxytocin during labor
because the uterine muscle becomes fatigued and does not contract effectively to
compress the vessels at the placental site.
Respiratory depression, not typically associated with oxytocin induction, may occur with
narcotic overdose or excessive magnesium sulfate administration.
Increased pulse rate and hypertension are not typically associated with oxytocin
induction during labor.
When preparing discharge instructions for a client after an abdominal hysterectomy, the
nurse should first: - Answer-assess the client's available social supports.
Explanation:
Assessment is the first step in planning client education. Assessing social support
resources is a key aspect of discharge planning that begins when the client is admitted
to the hospital. It is imperative to know what assistance and support the client has at
home. Assessment includes obtaining data about any family or home responsibilities
the client is concerned with during the recovery period. It is within the scope of nursing
practice to provide discharge instructions. A social worker is not needed at this time.
1|Page
,The nurse should assess the client's needs before determining whether using a video or
reading instructions to the client is appropriate.
A nurse is caring for a client that received a colostomy 2 days ago. Which is the priority
intervention? - Answer-Assess the drainage from the stoma.
Explanation:
Assessing the stoma is important because of the potential for surgical site infection.
Teaching on irrigation and dietary planning should be performed before discharge. The
client should be encouraged to look at the stoma, but this is not the priority.
A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline
solution to a 6-month-old infant. The nurse should select which tubing to safely
administer the solution? - Answer-I.V. tubing with a volume-control chamber
Explanation:
Because infants have a small circulating blood volume, inadvertent administration of
extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing
with a volume-control chamber should always be used for infants and children to closely
regulate the amount of fluid infused. The volume-control chamber should be filled only
with enough I.V. fluid for the next two 2 hours. A microdrip chamber that allows for 60
drops/ml (as opposed to a macrodrip chamber, which allows for 10 to 20 drops/ml,
depending on the manufacturer) should be used to infuse the smaller amounts of I.V.
fluids an infant needs. A filter is typically used only for the administration of total
parenteral nutrition and certain blood products. Standard I.V. tubing for adults should be
avoided for infants because of the inability to closely regulate the amount of fluid
infused.
A client in the emergency department is diagnosed with a communicable disease. When
complications of the disease are discovered, the client is admitted to the hospital and
placed in respiratory isolation. Which infection warrants airborne isolation? - Answer-
Measles
Explanation:
Measles warrants airborne isolation, which aims to prevent transmission of disease by
airborne nuclei droplets. Other infections necessitating respiratory isolation include
varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact
isolation; and cholera, enteric isolation.
The nurse observes a family member of a client who is on contact precautions enter
and exit the client's room without performing hand hygiene. What is the nurse's most
appropriate action? - Answer-Offer to show family members how to perform hand
hygiene using soap and water or alcohol rub.
Explanation:
2|Page
,The nurse should address the family member's oversight and promote infection control,
but in a way that is nonconfrontational. Offering to show the family members how to
perform hand hygiene achieves these goals. Moving signage may not result in a
behavior change. Speaking about hospital-acquired infections may not result in
improved hand hygiene.
A healthy client comes to the clinic for a routine examination. When auscultating his
lower lung lobes, the nurse should expect to hear which type of breath sound? -
Answer-Vesicular
Explanation:
Vesicular breath sounds are soft, low-pitched sounds normally heard over the lower
lobes of the lung. They're prolonged on inhalation and shortened on exhalation.
Bronchial breath sounds are loud, high-pitched sounds normally heard next to the
trachea; discontinuous, they're loudest during expiration. Tracheal breath sounds are
harsh, discontinuous sounds heard over the trachea during inhalation or exhalation.
Bronchovesicular breath sounds are medium-pitched, continuous sounds that occur
during inhalation or exhalation. They're best heard over the upper third of the sternum
and between the scapulae.
The nurse advises a client recovering from a myocardial infarction to decrease fat and
sodium intake. Which foods should the nurse instruct the client to avoid? Select all that
apply. - Answer--Pepperoni pizza
-Bacon
-Cheese
-Soft drinks
Explanation:
Foods high in sodium include cheese, processed meats such as pepperoni and bacon,
and soft drinks. Bacon and cheese also have a high fat content.
During the evening shift on the day of a client's bowel resection surgery, the nasogastric
(NG) tube drains 500 mL of green-brown fluid. The nurse should: - Answer-record the
amount of drainage on the client's chart.
Explanation:
Because peristalsis has not been reestablished, this amount of gastric drainage would
be expected. The green-brown color would also be expected. The appropriate nursing
action is to chart the amount and color of output and continue monitoring the client.
There is no need to notify the health care provider or to provide additional IV fluids.
A patent NG tube does not require irrigation.
3|Page
, The nurse is instructing a client about skin care while receiving radiation therapy to the
chest. What should the nurse instruct the client to do? - Answer-Wash the area with
tepid water and mild soap.
Explanation:
Clients receiving radiation experience dryness or redness in the area of the radiation.
The nurse instructs the client to wash the area with soap and water and keep the area
dry. The client does not apply lotion, shave, or cover the area.
Which night clothes would the nurse recommend for an infant with atopic dermatitis? -
Answer-one-piece cotton pajamas with long sleeves
Explanation:
Atopic dermatitis results in pruritus. The infant's skin should be covered as completely
as possible to keep him from scratching himself. Cotton is the preferred material
because it allows the skin to breathe and moisture to evaporate.A short-sleeved shirt
would be inappropriate because the infant could scratch the uncovered arms,
exacerbating the condition.
Flannel may be too warm, causing the child to perspire, which will aggravate the
condition.
Because atopic dermatitis is commonly associated with allergies, wool garments should
be avoided.
A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and
discovers that the client is difficult to arouse. The client's morning ammonia level is 110
mcg/dl. The nurse should suspect which situation? - Answer-The client's hepatic
function is decreasing.
Explanation:
The decreased level of consciousness caused by an increased serum ammonia level
indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he
wouldn't have elevated ammonia levels and decreased level of consciousness this
soon. These assessment findings are not indicative of reduced renal filtration.
A client who is very depressed exhibits psychomotor retardation, a flat affect, and
apathy. The nurse observes the client to be in need of grooming and hygiene. Which
nursing action is most appropriate? - Answer-stating to the client that it is time for him to
take a shower
Explanation:
The client with depression is preoccupied, has decreased energy, and cannot make
decisions, even simple ones. Therefore, the nurse presents the situation, "It is time for a
shower," and assists the client with personal hygiene to preserve his dignity and self-
esteem. Explaining the importance of good hygiene to the client is inappropriate
4|Page
previous shift. Which infant should the nurse assess first? - Answer-A restless infant
with a high-pitched cry who was transferred from the intensive care unit (ICU) the
previous evening
Explanation:
An infant's restlessness and high-pitched cry can indicate increased intracranial
pressure (ICP). Because the infant was transferred from the ICU the previous night,
assessing for increased ICP should be a nursing priority. The infant with a pulse of 140-
160 bpm exhibits normal parameters. Although the nurse must assess a low-grade
fever on the third postoperative day, this stable infant isn't the priority at this time.
Decreased respirations are indicative of increased intracranial pressure, but this infant's
respirations of 38 breaths per minute would not be a priority concern.
During the immediate postpartum period, the nurse is caring for a primipara who gave
birth to a postterm neonate after an oxytocin induction. When developing the client's
plan of care, which problem should the nurse expect to assess for frequently? - Answer-
uterine atony
Uterine atony is more common in clients who have received oxytocin during labor
because the uterine muscle becomes fatigued and does not contract effectively to
compress the vessels at the placental site.
Respiratory depression, not typically associated with oxytocin induction, may occur with
narcotic overdose or excessive magnesium sulfate administration.
Increased pulse rate and hypertension are not typically associated with oxytocin
induction during labor.
When preparing discharge instructions for a client after an abdominal hysterectomy, the
nurse should first: - Answer-assess the client's available social supports.
Explanation:
Assessment is the first step in planning client education. Assessing social support
resources is a key aspect of discharge planning that begins when the client is admitted
to the hospital. It is imperative to know what assistance and support the client has at
home. Assessment includes obtaining data about any family or home responsibilities
the client is concerned with during the recovery period. It is within the scope of nursing
practice to provide discharge instructions. A social worker is not needed at this time.
1|Page
,The nurse should assess the client's needs before determining whether using a video or
reading instructions to the client is appropriate.
A nurse is caring for a client that received a colostomy 2 days ago. Which is the priority
intervention? - Answer-Assess the drainage from the stoma.
Explanation:
Assessing the stoma is important because of the potential for surgical site infection.
Teaching on irrigation and dietary planning should be performed before discharge. The
client should be encouraged to look at the stoma, but this is not the priority.
A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline
solution to a 6-month-old infant. The nurse should select which tubing to safely
administer the solution? - Answer-I.V. tubing with a volume-control chamber
Explanation:
Because infants have a small circulating blood volume, inadvertent administration of
extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing
with a volume-control chamber should always be used for infants and children to closely
regulate the amount of fluid infused. The volume-control chamber should be filled only
with enough I.V. fluid for the next two 2 hours. A microdrip chamber that allows for 60
drops/ml (as opposed to a macrodrip chamber, which allows for 10 to 20 drops/ml,
depending on the manufacturer) should be used to infuse the smaller amounts of I.V.
fluids an infant needs. A filter is typically used only for the administration of total
parenteral nutrition and certain blood products. Standard I.V. tubing for adults should be
avoided for infants because of the inability to closely regulate the amount of fluid
infused.
A client in the emergency department is diagnosed with a communicable disease. When
complications of the disease are discovered, the client is admitted to the hospital and
placed in respiratory isolation. Which infection warrants airborne isolation? - Answer-
Measles
Explanation:
Measles warrants airborne isolation, which aims to prevent transmission of disease by
airborne nuclei droplets. Other infections necessitating respiratory isolation include
varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact
isolation; and cholera, enteric isolation.
The nurse observes a family member of a client who is on contact precautions enter
and exit the client's room without performing hand hygiene. What is the nurse's most
appropriate action? - Answer-Offer to show family members how to perform hand
hygiene using soap and water or alcohol rub.
Explanation:
2|Page
,The nurse should address the family member's oversight and promote infection control,
but in a way that is nonconfrontational. Offering to show the family members how to
perform hand hygiene achieves these goals. Moving signage may not result in a
behavior change. Speaking about hospital-acquired infections may not result in
improved hand hygiene.
A healthy client comes to the clinic for a routine examination. When auscultating his
lower lung lobes, the nurse should expect to hear which type of breath sound? -
Answer-Vesicular
Explanation:
Vesicular breath sounds are soft, low-pitched sounds normally heard over the lower
lobes of the lung. They're prolonged on inhalation and shortened on exhalation.
Bronchial breath sounds are loud, high-pitched sounds normally heard next to the
trachea; discontinuous, they're loudest during expiration. Tracheal breath sounds are
harsh, discontinuous sounds heard over the trachea during inhalation or exhalation.
Bronchovesicular breath sounds are medium-pitched, continuous sounds that occur
during inhalation or exhalation. They're best heard over the upper third of the sternum
and between the scapulae.
The nurse advises a client recovering from a myocardial infarction to decrease fat and
sodium intake. Which foods should the nurse instruct the client to avoid? Select all that
apply. - Answer--Pepperoni pizza
-Bacon
-Cheese
-Soft drinks
Explanation:
Foods high in sodium include cheese, processed meats such as pepperoni and bacon,
and soft drinks. Bacon and cheese also have a high fat content.
During the evening shift on the day of a client's bowel resection surgery, the nasogastric
(NG) tube drains 500 mL of green-brown fluid. The nurse should: - Answer-record the
amount of drainage on the client's chart.
Explanation:
Because peristalsis has not been reestablished, this amount of gastric drainage would
be expected. The green-brown color would also be expected. The appropriate nursing
action is to chart the amount and color of output and continue monitoring the client.
There is no need to notify the health care provider or to provide additional IV fluids.
A patent NG tube does not require irrigation.
3|Page
, The nurse is instructing a client about skin care while receiving radiation therapy to the
chest. What should the nurse instruct the client to do? - Answer-Wash the area with
tepid water and mild soap.
Explanation:
Clients receiving radiation experience dryness or redness in the area of the radiation.
The nurse instructs the client to wash the area with soap and water and keep the area
dry. The client does not apply lotion, shave, or cover the area.
Which night clothes would the nurse recommend for an infant with atopic dermatitis? -
Answer-one-piece cotton pajamas with long sleeves
Explanation:
Atopic dermatitis results in pruritus. The infant's skin should be covered as completely
as possible to keep him from scratching himself. Cotton is the preferred material
because it allows the skin to breathe and moisture to evaporate.A short-sleeved shirt
would be inappropriate because the infant could scratch the uncovered arms,
exacerbating the condition.
Flannel may be too warm, causing the child to perspire, which will aggravate the
condition.
Because atopic dermatitis is commonly associated with allergies, wool garments should
be avoided.
A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and
discovers that the client is difficult to arouse. The client's morning ammonia level is 110
mcg/dl. The nurse should suspect which situation? - Answer-The client's hepatic
function is decreasing.
Explanation:
The decreased level of consciousness caused by an increased serum ammonia level
indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he
wouldn't have elevated ammonia levels and decreased level of consciousness this
soon. These assessment findings are not indicative of reduced renal filtration.
A client who is very depressed exhibits psychomotor retardation, a flat affect, and
apathy. The nurse observes the client to be in need of grooming and hygiene. Which
nursing action is most appropriate? - Answer-stating to the client that it is time for him to
take a shower
Explanation:
The client with depression is preoccupied, has decreased energy, and cannot make
decisions, even simple ones. Therefore, the nurse presents the situation, "It is time for a
shower," and assists the client with personal hygiene to preserve his dignity and self-
esteem. Explaining the importance of good hygiene to the client is inappropriate
4|Page
