|ACTUAL QUESTIONS AND VERIFIED
Question 1
A nurse is caring for a client who has gastroenteritis and reports diarrhea and vomiting for
3 days. Which of the following findings should the nurse recognize as a manifestation of
this inflammatory bowel disease?
-Hiccups
-Rebound tenderness of abdomen
-Orthostatic hypotension
-Shoulder pain
CORRECT ANSWER
Orthostatic hypotension (The nurse should identify that a client who has gastroenteritis
can exhibit orthostatic hypotension caused by dehydration from fluid loss and electrolyte
imbalance)
-Hiccups (The nurse should identify that a client who has peritonitis can exhibit hiccups
caused by inflammation of the diaphragm.)
-Rebound tenderness of abdomen (The nurse should identify that a client who has
peritonitis can exhibit rebound tenderness of the abdomen.)
-Shoulder pain (The nurse should identify that a client who has peritonitis can exhibit
referred shoulder or chest pain.)
Question 2
A nurse is reviewing the medical record of a 9-month-old infant. Which of the following
findings should the nurse report to the provider?
1
,-WBC count
-Hert rate
-Gross motor skills
-Respiratory rate
CORRECT ANSWER
Gross motor skills (The nurse should identify that the infant's gross motor skills indicate a
possible developmental delay. A 9-month-old infant should be able to sit unsupported for
up to 10 min at a time.)Res
-WBC count (The nurse should identify that a WBC count of 12,000/mm3 is within the
expected reference range for a 9-month-old infant.)
-Heart rate (The nurse should identify that a heart rate of 110/min is within the expected
reference range for a 9-month-old infant.
-Respiratory rate (The nurse should identify that a respiratory rate of 28/min is within the
expected reference range for a 9-month-old infant.)
Question 3
A nurse is teaching a client who has chronic pain about biofeedback. Which of the
following information should the nurse include about this complementary therapy?
-Biofeedback provides audio and visual signals to induce a physiological change.
-Biofeedback involves manipulating soft tissue to increase circulation.
-Biofeedback uses a variety of body movements to strengthen muscles.
-Biofeedback uses digital pressure to reduce pain and improve function.
CORRECT ANSWER
Biofeedback provides audio and visual signals to induce a physiological change.
(Biofeedback is a technique that uses audio and visual signals that allow clients to reduce
muscle tension by gaining control over autonomic physiological functions.)
2
, -Biofeedback involves manipulating soft tissue to increase circulation. (Massage therapy
involves manipulating soft tissue to increase circulation and induce muscle relaxation.)
-Biofeedback uses a variety of body movements to strengthen muscles. (Yoga and Pilates
use a variety of body movements and poses to strengthen core muscles and improve
control of muscle groups.
-Biofeedback uses digital pressure to reduce pain and improve function. (Acupuncture uses
digital pressure on specific areas of the body to reduce pain and improve function.)
Question 4
A nurse is preparing to administer phenytoin via intermittent IV bolus to a client who is
having a tonic-clonic seizure caused by epilepsy. Which of the following factors should the
nurse consider when administering IV phenytoin?
-Mix the phenytoin with 5% dextrose in water.
-Discard phenytoin in precipitate occurs when refrigerated.
-Administer phenytoin at a rate no greater than 50 mg/min.
-Monitor for hypertension while infusing the phenytoin.
CORRECT ANSWER
Administer phenytoin at a rate no greater than 50 mg/min.(The nurse should administer
phenytoin intermittent IV bolus at a rate of no greater than 50 mg/min to prevent the
client from developing hypotension and bradycardia.)
-Mix the phenytoin with 5% dextrose in water. (The nurse should mix the phenytoin with
no more than 50 mL of 0.9% sodium chloride. The nurse should also flush the intravenous
primary tubing with 0.9% sodium chloride before and after administering the medication.)
-Discard phenytoin in precipitate occurs when refrigerated. (Phenytoin can develop a
precipitate when refrigerated, but the precipitate dissolves at room temperature and does
not affect the potency of the medication. The nurse should check and discard the
phenytoin if it is cloudy or precipitate remains present at room temperature.)
3
Question 1
A nurse is caring for a client who has gastroenteritis and reports diarrhea and vomiting for
3 days. Which of the following findings should the nurse recognize as a manifestation of
this inflammatory bowel disease?
-Hiccups
-Rebound tenderness of abdomen
-Orthostatic hypotension
-Shoulder pain
CORRECT ANSWER
Orthostatic hypotension (The nurse should identify that a client who has gastroenteritis
can exhibit orthostatic hypotension caused by dehydration from fluid loss and electrolyte
imbalance)
-Hiccups (The nurse should identify that a client who has peritonitis can exhibit hiccups
caused by inflammation of the diaphragm.)
-Rebound tenderness of abdomen (The nurse should identify that a client who has
peritonitis can exhibit rebound tenderness of the abdomen.)
-Shoulder pain (The nurse should identify that a client who has peritonitis can exhibit
referred shoulder or chest pain.)
Question 2
A nurse is reviewing the medical record of a 9-month-old infant. Which of the following
findings should the nurse report to the provider?
1
,-WBC count
-Hert rate
-Gross motor skills
-Respiratory rate
CORRECT ANSWER
Gross motor skills (The nurse should identify that the infant's gross motor skills indicate a
possible developmental delay. A 9-month-old infant should be able to sit unsupported for
up to 10 min at a time.)Res
-WBC count (The nurse should identify that a WBC count of 12,000/mm3 is within the
expected reference range for a 9-month-old infant.)
-Heart rate (The nurse should identify that a heart rate of 110/min is within the expected
reference range for a 9-month-old infant.
-Respiratory rate (The nurse should identify that a respiratory rate of 28/min is within the
expected reference range for a 9-month-old infant.)
Question 3
A nurse is teaching a client who has chronic pain about biofeedback. Which of the
following information should the nurse include about this complementary therapy?
-Biofeedback provides audio and visual signals to induce a physiological change.
-Biofeedback involves manipulating soft tissue to increase circulation.
-Biofeedback uses a variety of body movements to strengthen muscles.
-Biofeedback uses digital pressure to reduce pain and improve function.
CORRECT ANSWER
Biofeedback provides audio and visual signals to induce a physiological change.
(Biofeedback is a technique that uses audio and visual signals that allow clients to reduce
muscle tension by gaining control over autonomic physiological functions.)
2
, -Biofeedback involves manipulating soft tissue to increase circulation. (Massage therapy
involves manipulating soft tissue to increase circulation and induce muscle relaxation.)
-Biofeedback uses a variety of body movements to strengthen muscles. (Yoga and Pilates
use a variety of body movements and poses to strengthen core muscles and improve
control of muscle groups.
-Biofeedback uses digital pressure to reduce pain and improve function. (Acupuncture uses
digital pressure on specific areas of the body to reduce pain and improve function.)
Question 4
A nurse is preparing to administer phenytoin via intermittent IV bolus to a client who is
having a tonic-clonic seizure caused by epilepsy. Which of the following factors should the
nurse consider when administering IV phenytoin?
-Mix the phenytoin with 5% dextrose in water.
-Discard phenytoin in precipitate occurs when refrigerated.
-Administer phenytoin at a rate no greater than 50 mg/min.
-Monitor for hypertension while infusing the phenytoin.
CORRECT ANSWER
Administer phenytoin at a rate no greater than 50 mg/min.(The nurse should administer
phenytoin intermittent IV bolus at a rate of no greater than 50 mg/min to prevent the
client from developing hypotension and bradycardia.)
-Mix the phenytoin with 5% dextrose in water. (The nurse should mix the phenytoin with
no more than 50 mL of 0.9% sodium chloride. The nurse should also flush the intravenous
primary tubing with 0.9% sodium chloride before and after administering the medication.)
-Discard phenytoin in precipitate occurs when refrigerated. (Phenytoin can develop a
precipitate when refrigerated, but the precipitate dissolves at room temperature and does
not affect the potency of the medication. The nurse should check and discard the
phenytoin if it is cloudy or precipitate remains present at room temperature.)
3
