100 Item Comprehensive Nursing Exam With Answers Graded A!!!

1. The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first? A) Clear the area of any hazards B) Place the child on the side C) Restrain the child D) Give the prescribed anticonvulsant - ANS The correct answer is B: Place the child on the side Protecting the airway is the top priority in a seizure. If a child is actively convulsing, a patent airway and oxygenation must be assured. 2. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to A) Administer pain medication B) Suction excessive tracheobronchial secretions C) Assist client to turn, deep breath and cough D) Monitor oxygen saturation - ANS The correct answer is B: Suction excessive tracheobronchial secretions Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway which is always the priority nursing intervention. 3. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child? A) Congenital cardiac defects B) An acute febrile illness C) Prolonged hypoxemia D) Severe multiple trauma - ANS The correct answer is C: Prolonged hypoxia Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia. Children usually have both cardiac and respiratory arrest. 4. Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes? A) Give written pre and posttests B) Ask questions during practice C) Allow another diabetic to assist D) Observe a return demonstration - ANS The correct answer is D: Observe a return demonstration Since this is a psychomotor skill, this is the best way to know if the client has learned the proper technique. 5. The nurse is assessing a 2-year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis? A) Several otitis media episodes in the last year B) Weight and height in 10th percentile since birth C) Takes frequent rest periods while playing D) Changing food preferences and dislikes - ANS The correct answer is C: Takes frequent rest periods while playing. Children with heart disease tend to have exercise intolerance. The child self-limits activity, which is consistent with manifestations of congenital heart disease in children. 6. The nurse is reassigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice? A) An 18 month-old who ate an undetermined amount of crystal drain cleaner B) A 14 month-old who chewed 2 leaves of a philodendron plant C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium) D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid - ANS The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain cleaner. Drain cleaner is very alkaline. The orange juice is acidic and will help to neutralize this substance. 7. A 23-year-old single client is in the 33rd week of her first pregnancy. She tellsthe nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? A) Acceptance of the pregnancy B) Focus on fetal development C) Anticipation of the birth D) Ambivalence about pregnancy - ANS The correct answer is C: Anticipation of the birth Directing activities toward preparation for the newborn's needs and personal adjustment are indicators of appropriate emotional response in the third trimester. 8. Upon examining the mouth of a 3-year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most likely explain these findings? A) Ingestion of tetracycline B) Excessive fluoride intake C) Oral iron therapy D) Poor dental hygiene - ANS Thterm-1e correct answer is B: Excessive fluoride intake The described findings are indicative of fluorosis, a condition characterized by an increase in the extent and degree of the enamel's porosity. This problem can be associated with repeated swallowing of toothpaste with fluoride or drinking water with high levels of fluoride. 9. Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)? A) Direct sunlight B) Foods containing tyramine C) Foods fermented with yeast D) Canned citrus fruit drinks - ANS The correct answer is A: Avoid direct sunlight Phenothiazine increases sensitivity to the sun, making clients especially susceptible to sunburn 10. The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is A) "Eat a balanced diet for your age." B) "Increase your intake of protein and Vitamin A." C) "Decrease fatty foods from your diet." D) "Do not use caffeine in any form, including chocolate." - ANS The correct answer is A: "Eat a balanced diet for your age."