EXAM WITH NGN
A nurse is assessing the heart sounds of a client who has acute
pericarditis. Which of the following clinical manifestations is an expected
finding for this client?
a. Report of occipital headache
b. Scratchy, high pitched sound upon chest auscultation
c. ECG demonstrates a depressed ST segment
d. White, diffuse peritonsillar pustules - ANSWER-b. Scratchy, high pitched
sound upon chest auscultation
A community health nurse is teaching a client who has type 1 diabetes
mellitus and is 10 weeks of gestation about managing diabetes during
pregnancy. Which of the following statements by the client indicates an
understanding of the teaching?
a. "I will decrease my protein intake during the third trimester"( increase
protein for basic growth)
b. "I will need to increase my insulin doses later in my pregnancy"
,c. "I will increase my carbs at breakfast and limit them the rest of the
day"
d. "I will decrease my calorie consumption during the first
trimester"(increase calorie) - ANSWER-b. "I will need to increase my
insulin doses later in my pregnancy"
A home health nurse is preparing to assess a client who reports tingling
around the mouth and laxative use at least once daily. Which of the
following assessments should the nurse perform first?
a. Test the client for Trousseau's sign
b. Assess the client's skin turgor
c. Check the client's motor strength
d. Measure the client's pupil size - ANSWER-a. Test the client for
Trousseau's sign
A nurse is teaching a client who has an ileostomy about the care of his
stoma site. Which of the following statements by the client requires
further teaching?
,a. "I should clean my stoma with warm water"( can use low ph soap and
water)
b. " My stoma should be bright pink or red"(pink,red and moist)
c. "I should change the stoma pouch every day"
d. "I should cut my pouch opening ⅛ inch larger than my stoma"(allow
expansion) - ANSWER-c. "I should change the stoma pouch every day
Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty
at ¼ or ½ full.
A nurse is assessing a client who is receiving magnesium sulfate by
continuous IV infusion. Which of the following findings should the nurse
recognize as a result of magnesium sulfate toxicity?
a. Hyporeflexia
b. Tachypnea( bradypnea, less than 12/min) c. Pruritus( sign of allergic
reaction)
d. Polyuria (oliguria, less than 30 ml/hr) - ANSWER-a. Hyporeflexia
, A nurse is reviewing the medical record of a client who has schizophrenia
and is taking clozapine. Which of the following findings should the nurse
identify as a contraindication to the administration of clozapine?
A. HR 58
B. Fasting blood glucose 100
C. Hgb 14
D. WBC 2900 - ANSWER-D. WBC 2900
A nurse is developing an in service about personality disorders. Which of
the following information should the nurse include when discussing
borderline personality disorder?
A. The clients exhibits impulse behavior
B. The client might act seductively
C. The client is exceptionally clingy to others
D. The client is overly concerned about minor details - ANSWER-A. The
clients exhibits impulse behavior
Intra-dermal Injections areas.
A. Buttocks
B. Upper back