ADN Level 3 Final Exam with Complete Solutions
A 32-year-old woman recently diagnosed with Hodgkin's disease is admitted for staging by
undergoing a bone marrow aspiration and biopsy. To obtain more information about the
client's nutrition status the nurse should review the results of which of the following tests?
a) Albumin level.
b) Reticulocyte count.
c) Red blood cell count.
d) Direct and indirect bilirubin levels. Correct Ans-A - Serum albumin levels help
determine whether protein intake is sufficient. Proteins are broken down into amino acids
during digestion. Amino acids are absorbed in the small intestine, and albumin is built from
amino acids. The red blood cell count, bilirubin levels, and reticulocyte count do not indicate
protein intake.
An infant underwent surgery to remove a myelomeningocele. The infant has bulging
fontanels. Which of the following is the nurse's best action?
a) Calm the infant
b) Teach parent about procedure
, ADN Level 3 Final Exam with Complete Solutions
c) Notify the healthcare provider
d) Reposition infant Correct Ans-C - Bulging fontanels in an infant may indicated increased
intracranial pressure, a possible postoperative complication. Calming the infant, teaching the
parent, and repositioning the infant will not address the underlying problem of increased
intracranial pressure within the skull. Calling the healthcare provider is indicated.
Which of the following is a common method of evaluating the urine output for newborns,
infants, and toddlers who are not potty trained.
a) Monitoring the amount of time for breast feeding
b) Measuring the formula before the child ingests it
c) Weighing the child before and after feeds
d) Weighing the diaper before and after micturition Correct Ans-D - Weighing the diaper
before applying it to the newborn, infant, or toddler, and then weighing it after micturition
will help evaluate the urine output. The difference between the wet diaper and the dry one
will give the amount of urine (1 g = 1 mL, so amounts may be recorded in milliliters). Weighing
the child or measuring the formula will not give an indication of evaluating the urine output
in this situation.
, ADN Level 3 Final Exam with Complete Solutions
According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the
initial assessment of the newborn and notes increased amounts of vernix. The mother asks
why the nurse seems concerned about the presence of the vernix. Which of the following
statements by the nurse is most appropriate?
a) "The vernix indicates a different gestational age than expected."
b) "The vernix is difficult and painful to remove from a newborn."
c) "The presence of vernix affects the newborn's immune system."
d) "The vernix should be a thicker coating for a newborn." Correct Ans-A - Vernix caseosa
is a whitish substance that serves as a protective covering over the fetal body throughout the
pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day post-
mature baby to have increased amounts of vernix. A discrepancy between EDC (estimated
date of conception) and gestational age by physical examination must have occurred.
a whitish substance that serves as a protective covering over the fetal body throughout the
pregnancy Correct Ans-VERNIX CASEOSA
, ADN Level 3 Final Exam with Complete Solutions
During the postoperative period after a modified radical mastectomy, the client confides in
the nurse that she thinks she got breast cancer because she had an abortion and she did not
tell her husband. The best response by the nurse is which of the following?
a) "You might feel better if you confided in your husband."
b) "Cancer is not a punishment; it is a disease."
c) "I can have the social worker talk to you if you would like."
d) "Tell me more about your feelings on this." Correct Ans-D - The nurse should respond
with an open-ended statement that elicits further exploration of the client's feelings. Women
with cancer may feel guilt or shame. Previous life decisions, sexuality, and religious beliefs
may influence a client's adjustment to a diagnosis of cancer. The nurse should not contradict
the client's feelings of punishment or offer advice such as confiding in the husband. A social
worker referral may be beneficial in the future, but is not the first response needed to elicit
exploration of the client's feelings.
A nurse is caring for an infant who is to be administered an enema. What spiritually oriented
interventions could the nurse follow with newborns and infants?
a) Encourage parents to be present during the treatment.
A 32-year-old woman recently diagnosed with Hodgkin's disease is admitted for staging by
undergoing a bone marrow aspiration and biopsy. To obtain more information about the
client's nutrition status the nurse should review the results of which of the following tests?
a) Albumin level.
b) Reticulocyte count.
c) Red blood cell count.
d) Direct and indirect bilirubin levels. Correct Ans-A - Serum albumin levels help
determine whether protein intake is sufficient. Proteins are broken down into amino acids
during digestion. Amino acids are absorbed in the small intestine, and albumin is built from
amino acids. The red blood cell count, bilirubin levels, and reticulocyte count do not indicate
protein intake.
An infant underwent surgery to remove a myelomeningocele. The infant has bulging
fontanels. Which of the following is the nurse's best action?
a) Calm the infant
b) Teach parent about procedure
, ADN Level 3 Final Exam with Complete Solutions
c) Notify the healthcare provider
d) Reposition infant Correct Ans-C - Bulging fontanels in an infant may indicated increased
intracranial pressure, a possible postoperative complication. Calming the infant, teaching the
parent, and repositioning the infant will not address the underlying problem of increased
intracranial pressure within the skull. Calling the healthcare provider is indicated.
Which of the following is a common method of evaluating the urine output for newborns,
infants, and toddlers who are not potty trained.
a) Monitoring the amount of time for breast feeding
b) Measuring the formula before the child ingests it
c) Weighing the child before and after feeds
d) Weighing the diaper before and after micturition Correct Ans-D - Weighing the diaper
before applying it to the newborn, infant, or toddler, and then weighing it after micturition
will help evaluate the urine output. The difference between the wet diaper and the dry one
will give the amount of urine (1 g = 1 mL, so amounts may be recorded in milliliters). Weighing
the child or measuring the formula will not give an indication of evaluating the urine output
in this situation.
, ADN Level 3 Final Exam with Complete Solutions
According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the
initial assessment of the newborn and notes increased amounts of vernix. The mother asks
why the nurse seems concerned about the presence of the vernix. Which of the following
statements by the nurse is most appropriate?
a) "The vernix indicates a different gestational age than expected."
b) "The vernix is difficult and painful to remove from a newborn."
c) "The presence of vernix affects the newborn's immune system."
d) "The vernix should be a thicker coating for a newborn." Correct Ans-A - Vernix caseosa
is a whitish substance that serves as a protective covering over the fetal body throughout the
pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day post-
mature baby to have increased amounts of vernix. A discrepancy between EDC (estimated
date of conception) and gestational age by physical examination must have occurred.
a whitish substance that serves as a protective covering over the fetal body throughout the
pregnancy Correct Ans-VERNIX CASEOSA
, ADN Level 3 Final Exam with Complete Solutions
During the postoperative period after a modified radical mastectomy, the client confides in
the nurse that she thinks she got breast cancer because she had an abortion and she did not
tell her husband. The best response by the nurse is which of the following?
a) "You might feel better if you confided in your husband."
b) "Cancer is not a punishment; it is a disease."
c) "I can have the social worker talk to you if you would like."
d) "Tell me more about your feelings on this." Correct Ans-D - The nurse should respond
with an open-ended statement that elicits further exploration of the client's feelings. Women
with cancer may feel guilt or shame. Previous life decisions, sexuality, and religious beliefs
may influence a client's adjustment to a diagnosis of cancer. The nurse should not contradict
the client's feelings of punishment or offer advice such as confiding in the husband. A social
worker referral may be beneficial in the future, but is not the first response needed to elicit
exploration of the client's feelings.
A nurse is caring for an infant who is to be administered an enema. What spiritually oriented
interventions could the nurse follow with newborns and infants?
a) Encourage parents to be present during the treatment.
