ALL 180 QUESTIONS AND CORRECT DETAILED ANSWERS
A nurse is assessing a client who has acute angle-closure glaucoma. Which of the following findings
should the nurse expect?
A. Increased light perception
B. Reddened cornea
C. Severe periocular pain
D. Gray cast sclera - ANSWER-C. Severe periocular pain
A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last 5 days. The
client's laboratory values this morning are the following: WBC 10,000/mm3, RBC 5.2 million/mm3,
platelets 250,000mm3, BUN 32 mg/dL, and serum creatinine 2.1 mg/dL. The nurse should report these
findings to which of the following members of the interdisciplinary team? And
A Dietitian
B Infection control nurse
C Nephrologist
D. Cardiologist - ANSWER-C Nephrologist
A nurse is caring for a toddler who has retinoblastoma. Which of the following
100.findings should the nurse expect?
AHyphema
bOpacity of the lens
c Nystagmus
dWhite eye reflex - ANSWER-dWhite eye reflex
101.a client who does not speak the same language as the nurse. The nurse is communicating with the
client using an interpreter. Which of the following actions should the nurse take?
,a. Use gestures to convey meaning
b. Speak directly to the client
c. Pause in the middle of sentences
d. Speak slowly when talking to the interpreter - ANSWER-b. Speak directly to the client
102. A nurse is providing teaching about exercise to a client who is at 28 weeks of gestation. Which of
the following statements by the client indicates an understanding of the teaching?
a. "I can continue to do exercises that require the supine position" X
b. "I should check my pulse rate once every hour while exercising"
c. "I should increase my exercise level to prepare for labor" X
d. "I should drink 16 to 24 ounces of water after I exercise" - ANSWER-d. "I should drink 16 to 24 ounces
of water after I exercise"
A nurse is providing discharge teaching to the parents of toddler who has cystic fibrosis. What should
nurse include?
a. "Use a nebulizer to administer a bronchodilator following airway clearance therapy"
b."Restrict intake of foods that contain gluten"
c.Perform chest percussion and postural drainage at least twice daily"
d." "Administer pancreatic enzymes on an empty stomach"- X with meal - ANSWER-c.Perform chest
percussion and postural drainage at least twice daily"
Plan of care for client who has preeclapsia and is to receive magnesium sulfate via continuous IV
infusion. Which of the following actions should the nurse include in the plan?
a. Monitor the FHR via Doppler every 30 min
b. Restrict the client's total fluid intake to 250 mL/hr
c. Give the client protamine if signs of magnesium sulfate toxicity occur
d Measure the client's urine output every hour - ANSWER-d Measure the client's urine output every
hour
A nurse is planning discharge teaching for a client who is to start a new .prescription for metoprolol. For
which of the following should the nurse instruct the client to monitor and report to the provider?
,a. Tinnitus
b. Polyuria
c. Hyperglycemia
d. Bradycardia - ANSWER-d.Bradycardia
A nurse is providing teaching to the parents of a newborn who has been circumcised. Which of the
following instructions should the nurse include in the teaching?
a. "Remove yellow exudate around the penis"
b. "Wrap sterile gauze around the penis if bleeding occurs"
c. "Use soap to cleanse the site"
d, "Apply petroleum jelly to the glans with diaper changes" - ANSWER-d, "Apply petroleum jelly to the
glans with diaper changes"
Care plan for bucks traction and is scheduled for surgery for a fractured femur of the right leg. Which of
the following interventions should the nurse delegate to an assistive personnel?
a. Remind the client to use the incentive spirometer
b. Ask the client to describe her pain
c. Observe the position of the suspended weight
d. Check the client's pedal pulse on the right leg - ANSWER-a. Remind the client to use the incentive
spirometer
A nurse is assessing the growth and development of a 3-year-old child. Which of the following questions
should the nurse ask the parent to determine if the child exhibiting typical developmental expectations?
a. "Can your child catch and throw a small ball?"
b. "Can your child ride a tricycle?"
c. "Can your child name give colors?"
d. "Can your child draw a stick figure?" - ANSWER-b. "Can your child ride a tricycle?"
A nurse is caring for a newborn whose mother was taking methadone during her
109.pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal?
, a. Bradycardia
b. Acrocyanosis
c. Hypertonicity
d. Bulging fontanels - ANSWER-c. Hypertonicity
A charge nurse is admitting four clients to an acute care unit. Which of the following clients should the
nurse place near the nurses' station?
A. A client who is on fluid restriction
B. A client who is in Buck's traction
C A client who has orthostatic hypotension
D A client who has an open wound - ANSWER-C A client who has orthostatic hypotension
A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant is sitting on
my chest." The client is weak and unable to walk. After the nurse initiates chest pain protocol, which of
the following is the priority diagnostic test?
a. Serum potassium
b. 12-lead ECG
c. PT and INR
d. Chest x-ray - ANSWER-b. 12-lead ECG
A charge nurse on a medical- surgical unit is assisting with the emergency response plan following an
external disaster in the community. In anticipation of multiple client admissions, which of the following
current clients should the nurse recommend for early discharge?
a. A client who has COPD and a respiratory rate of 44/min
b. A client who has cancer with a sealed implant for radiation therapy
c. A client who is receiving heparin for deep-vein thrombosis
d. A client who is 1 day postoperative following a vertebroplasty - ANSWER-d. A client who is 1 day
postoperative following a vertebroplasty
A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate
action for the nurse to take?