Final NUR 103 Questions With Complete Solutions
A 1-year-old infant is pale, but the physical examination is
normal. Blood studies reveal a hematocrit of 24% (0.24). Which
question by the nurse to the parents would be most useful in
helping to establish a diagnosis of anemia?
A. "Is the infant on any medications?"
B. "What's the infant's usual daily diet?"
C. "Did the infant receive phototherapy for jaundice?"
D. "What's the pattern and appearance of bowel movements?"
Correct Answer B. "What's the infant's usual daily diet?"
A 33-year-old client who tested positive for the human
immunodeficiency virus (HIV) is admitted to the medical unit
with pancreatitis. A nurse director from another unit comes into
the medical unit nurses' station and begins reading the client's
chart. The staff nurse questions the director, who says that the
client is her neighbor's son. What should the nurse do to protect
the client's right to privacy?
A. Inform the nurse director that she's violating the client's right
to privacy and ask her to return the chart.
B. Remind the nurse director not to share the client's medical
information with anyone because of his HIV status.
C. Report the incident to the medical director.
D. Ask the nurse director if she has permission to read the
client's chart, and if not, tell her she needs to obtain it. Correct
Answer A. Inform the nurse director that she's violating the
client's right to privacy and ask her to return the chart.
A 75-year-old client who was admitted to the hospital with a
stroke informs the nurse that he doesn't want to be kept alive
,with machines. He wants to make sure that everyone knows his
wishes. Which action should the nurse take?
A. Contact the social services department to make arrangements
for the client to complete a living will.
B. Notify the physician so that he can place a do-not-resuscitate
order on the client's medical record.
C. Make arrangements for the client to receive information
about advance directives.
D. Explain that his condition is stable, so he doesn't need to be
concerned at this time. Correct Answer C. Make arrangements
for the client to receive information about advance directives.
A child has just returned to the pediatric unit following
ventriculoperitoneal shunt placement for hydrocephalus. Which
intervention would the nurse perform first?
A. Monitor intake and output.
B. Place the child on the side opposite the shunt.
C. Offer fluids because the child has a dry mouth.
D. Administer pain medication by mouth as ordered. Correct
Answer B. Place the child on the side opposite the shunt.
A child is admitted to the hospital for an asthma exacerbation.
The nursing history reveals this client was exposed to
chickenpox 1 week ago. When would this client require isolation
if he or she were to remain hospitalized?
A. isolation isn't required
B. immediate isolation is required
C. 10 days after exposure
D. 12 days after exposure Correct Answer B. immediate
isolation is required
,A child tests positive for the sickle cell trait, and the parents ask
the nurse what this means. Which response by the nurse would
be most appropriate?
A. "Your child has sickle cell anemia."
B. "Your child is a carrier but doesn't have the disease."
C. "Your child is a carrier and will pass the disease to any
offspring."
D. "Your child doesn't have the disease now but may develop
the disease as he gets older." Correct Answer B. "Your child is
a carrier but doesn't have the disease."
A child with sickle cell anemia is being treated for a vase-
occlusive crisis and reports significant discomfort. Which
actions can promote increased levels of comfort for the child?
Select all that apply.
A. cluster care interventions
B. encourage fluid intake
C. perform passive range of motion
D. oxygen therapy as prescribed
E. assist to knee-chest position Correct Answer A. cluster care
interventions
B. encourage fluid intake
D. oxygen therapy as prescribed
A child with weakness in the legs and a history of influenza is
admitted with a diagnosis of Guillain-Barre syndrome. Which
symptom, indicative of a possible serious complication, would
the nurse report immediately to the primary health care
provider?
A. tingling in the hands
B. increased hoarseness
, C. weak muscle tone in the arms
D. weak muscle tone in the legs Correct Answer B. increased
hoarseness
A client accidentally splashes chemicals into his eye. The nurse
knows that eye irrigation with plain tap water should begin
immediately and continue for 15 to 20 minutes. What is the
primary purpose of this first-aid treatment?
A. To hasten formation of scar tissue
B. To prevent vision loss
C. To eliminate the need for medical care
D. To serve as a stopgap measure until help arrives Correct
Answer B. To prevent vision loss
A client admitted with a cerebral contusion is confused,
disoriented, and restless. Which nursing diagnosis takes highest
priority?
A. Disturbed sensory perception (visual) related to neurologic
trauma
B. Feeding self care deficit: related to neurologic trauma
C. Impaired verbal communication related to confusion
D. Risk for injury related to neurologic deficit Correct Answer
D. Risk for injury related to neurologic deficit
A client arrives at the clinic requesting testing for HIV. Which
response by the nurse is best?
A. "Did you have sex with multiple partners?"
B. "The test results won't be back for a while."
C. "You will need to sign a consent form prior to testing."
D. "We will call you with the results." Correct Answer C. "You
will need to sign a consent form prior to testing."
A 1-year-old infant is pale, but the physical examination is
normal. Blood studies reveal a hematocrit of 24% (0.24). Which
question by the nurse to the parents would be most useful in
helping to establish a diagnosis of anemia?
A. "Is the infant on any medications?"
B. "What's the infant's usual daily diet?"
C. "Did the infant receive phototherapy for jaundice?"
D. "What's the pattern and appearance of bowel movements?"
Correct Answer B. "What's the infant's usual daily diet?"
A 33-year-old client who tested positive for the human
immunodeficiency virus (HIV) is admitted to the medical unit
with pancreatitis. A nurse director from another unit comes into
the medical unit nurses' station and begins reading the client's
chart. The staff nurse questions the director, who says that the
client is her neighbor's son. What should the nurse do to protect
the client's right to privacy?
A. Inform the nurse director that she's violating the client's right
to privacy and ask her to return the chart.
B. Remind the nurse director not to share the client's medical
information with anyone because of his HIV status.
C. Report the incident to the medical director.
D. Ask the nurse director if she has permission to read the
client's chart, and if not, tell her she needs to obtain it. Correct
Answer A. Inform the nurse director that she's violating the
client's right to privacy and ask her to return the chart.
A 75-year-old client who was admitted to the hospital with a
stroke informs the nurse that he doesn't want to be kept alive
,with machines. He wants to make sure that everyone knows his
wishes. Which action should the nurse take?
A. Contact the social services department to make arrangements
for the client to complete a living will.
B. Notify the physician so that he can place a do-not-resuscitate
order on the client's medical record.
C. Make arrangements for the client to receive information
about advance directives.
D. Explain that his condition is stable, so he doesn't need to be
concerned at this time. Correct Answer C. Make arrangements
for the client to receive information about advance directives.
A child has just returned to the pediatric unit following
ventriculoperitoneal shunt placement for hydrocephalus. Which
intervention would the nurse perform first?
A. Monitor intake and output.
B. Place the child on the side opposite the shunt.
C. Offer fluids because the child has a dry mouth.
D. Administer pain medication by mouth as ordered. Correct
Answer B. Place the child on the side opposite the shunt.
A child is admitted to the hospital for an asthma exacerbation.
The nursing history reveals this client was exposed to
chickenpox 1 week ago. When would this client require isolation
if he or she were to remain hospitalized?
A. isolation isn't required
B. immediate isolation is required
C. 10 days after exposure
D. 12 days after exposure Correct Answer B. immediate
isolation is required
,A child tests positive for the sickle cell trait, and the parents ask
the nurse what this means. Which response by the nurse would
be most appropriate?
A. "Your child has sickle cell anemia."
B. "Your child is a carrier but doesn't have the disease."
C. "Your child is a carrier and will pass the disease to any
offspring."
D. "Your child doesn't have the disease now but may develop
the disease as he gets older." Correct Answer B. "Your child is
a carrier but doesn't have the disease."
A child with sickle cell anemia is being treated for a vase-
occlusive crisis and reports significant discomfort. Which
actions can promote increased levels of comfort for the child?
Select all that apply.
A. cluster care interventions
B. encourage fluid intake
C. perform passive range of motion
D. oxygen therapy as prescribed
E. assist to knee-chest position Correct Answer A. cluster care
interventions
B. encourage fluid intake
D. oxygen therapy as prescribed
A child with weakness in the legs and a history of influenza is
admitted with a diagnosis of Guillain-Barre syndrome. Which
symptom, indicative of a possible serious complication, would
the nurse report immediately to the primary health care
provider?
A. tingling in the hands
B. increased hoarseness
, C. weak muscle tone in the arms
D. weak muscle tone in the legs Correct Answer B. increased
hoarseness
A client accidentally splashes chemicals into his eye. The nurse
knows that eye irrigation with plain tap water should begin
immediately and continue for 15 to 20 minutes. What is the
primary purpose of this first-aid treatment?
A. To hasten formation of scar tissue
B. To prevent vision loss
C. To eliminate the need for medical care
D. To serve as a stopgap measure until help arrives Correct
Answer B. To prevent vision loss
A client admitted with a cerebral contusion is confused,
disoriented, and restless. Which nursing diagnosis takes highest
priority?
A. Disturbed sensory perception (visual) related to neurologic
trauma
B. Feeding self care deficit: related to neurologic trauma
C. Impaired verbal communication related to confusion
D. Risk for injury related to neurologic deficit Correct Answer
D. Risk for injury related to neurologic deficit
A client arrives at the clinic requesting testing for HIV. Which
response by the nurse is best?
A. "Did you have sex with multiple partners?"
B. "The test results won't be back for a while."
C. "You will need to sign a consent form prior to testing."
D. "We will call you with the results." Correct Answer C. "You
will need to sign a consent form prior to testing."
