QUESTION BANK #1 CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) GRADED A+
The nurse is caring for a client with a long history of emphysema. Which clinical
signs/symptoms, if noted by the nurse, would support a history of emphysema?
1. Atelectasis
2. Increased AP diameter
3. Breathlessness
4. Use of accessory muscles with respiration.
5. Leans backwards to breathe.
6. Clubbing of fingernails - Right Ansa -2., 3., 4., & 6. Correct: Emphysema is described
as a permanent hyperinflation of lung beyond the bronchioles with destruction of
alveolar walls. Airway resistance is increased, especially on expiration. Inspection
reveals dyspnea on exertion, barrel chest, tachypnea, and use of accessory muscles
with respiration. Clubbing of fingernails is due to decreased oxygen levels.
1. Incorrect: Atelectasis is collapse of alveolar lung tissue, and findings reflect presence
of a small, airless lung. This condition is caused by complete obstruction of a draining
bronchus by a tumor, thick secretions, or an aspirated foreign body, or by compression
of lung.
5. Incorrect: Client tends to lean forward and uses accessory muscles of respiration to
breathe.
A term male infant was just delivered vaginally. Which of the following actions by the
nurse has priority?
1. Apply identification bands
2. Apply eye ointment
3. Dry the baby
4. Obtain footprints - Right Ansa -3. Correct: Cold stress is the biggest danger to a
newborn. A newborn is wet and evaporation will rapidly cool the baby which can cause
hypoglycemia and respiratory distress.
1. Incorrect: A task that needs to be accomplished before the baby leaves the delivery
room, but is not immediate priority.
2. Incorrect: Eye prophylaxis can safely be delayed up to two hours.
,4. Incorrect: A task that needs to be accomplished before the baby leaves the delivery
room, but is not immediate priority.
A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg
intramuscularly (IM). The newborn weighs 6 pounds (2.7 kg). The dispensed dose is
25,000 units per 1 mL. What should the nurse do?
1. Administer the drug intravenously (IV) since a large volume is required.
2. Choose three injection sites and give the medication as prescribed.
3. Consult with the pharmacy for a different medication concentration.
4. Read the available drug information to determine how to administer the medication. -
Right Ansa -3. Correct: The nurse must consult with the pharmacy to receive further
instructions. The dose is greater than the allowed volume to be given IM, which
warrants clarification by the pharmacy.
1. Incorrect: Since the drug is prescribed IM, the route should not be changed to IV
administration because this violates the order as written.
2. Incorrect: The dose is greater than the allowed volume to be given IM, which
warrants clarification by the pharmacy. You want to avoid having to give three
injections.
4. Incorrect: The concern is not drug information on administration, it is the available
concentration which can only be provided by the pharmacy.
Which interventions should the nurse include for a client with sickle cell crisis who is
experiencing pain?
1. Apply cold compresses to affected joints.
2. Massage affected areas gently.
3. Support and elevate swollen joints.
4. Monitor pain level by looking for BP, respiratory, and heart rate elevation.
5. Administer acetacylic acid 325 mg every 4 hours in order to thin the blood. - Right
Ansa -2. & 3. Correct: Apply local massage gently to affected areas which helps reduce
muscle tension. This helps to decrease swelling thus decreasing pain.
1. Incorrect: Apply warm, moist compresses to affected joints or other painful areas.
Avoid use of ice or cold compresses. Rationale: Warmth causes vasodilation and
, increases circulation to hypoxic areas. Cold causes vasoconstriction and compounds
the crisis.
4. Incorrect: Although pain can cause vital signs to elevate, it does not always occur.
The nurse should assess pain with an objective scale such as having the client rate the
pain on a scale of 1-10. Remember that pain is what the client says it is.
5. Incorrect: Acetacylic acid should be avoided because it alters blood pH and can make
cells sickle more easily.
The nurse is instructing a client in the use of cane. Which is the best description of
correct cane technique?
1. Place the cane on weaker side of body to support weaker leg. Using the cane for
support, step forward with good leg, and then move weaker leg and cane forward to the
good leg.
2. Place the cane on stronger side of body. Place cane forward 6 to 10 inches while
client stands with body weight divided between two legs. Weaker leg is advanced to
cane, with body weight divided between good leg and the cane.
3. Place cane on weaker side of body. Cane is placed forward 6 to 10 inches while
client stands with body weight divided between two legs. Weaker leg is advanced to
cane, with the body weight divided between good leg and cane.
4. Place cane on stronger side of body to help support weaker leg. Using cane for
support, step forward with good leg and then move weaker leg and cane forward to
good leg. - Right Ansa -2. Correct: Place the cane on the stronger side of the body. The
cane is placed forward 6 to 10 inches while the client stands with the body weight
divided between the two legs. The weaker leg is then advanced to the cane, with the
body weight divided between the good leg and the cane. Finally the stronger leg is
advanced past the cane and the weaker leg, with the body weight divided between the
cane and the weaker leg.
1. Incorrect: The cane should be on the stronger side of the body to create a wider base
for balance as the client advances the good leg and must use the weaker leg for
support with the cane. If the cane is placed on the weaker side of the body, this would
create a narrower base for support and balance and increase the risk of falling.
3. Incorrect: The cane should be on the stronger side of the body to create a wider base
for balance as the client advances the good leg and must use the weaker leg for
support with the cane. If the cane is placed on the weaker side of the body, this would
create a narrower base for support and balance and increase the risk of falling.
ANSWERS (VERIFIED ANSWERS) GRADED A+
The nurse is caring for a client with a long history of emphysema. Which clinical
signs/symptoms, if noted by the nurse, would support a history of emphysema?
1. Atelectasis
2. Increased AP diameter
3. Breathlessness
4. Use of accessory muscles with respiration.
5. Leans backwards to breathe.
6. Clubbing of fingernails - Right Ansa -2., 3., 4., & 6. Correct: Emphysema is described
as a permanent hyperinflation of lung beyond the bronchioles with destruction of
alveolar walls. Airway resistance is increased, especially on expiration. Inspection
reveals dyspnea on exertion, barrel chest, tachypnea, and use of accessory muscles
with respiration. Clubbing of fingernails is due to decreased oxygen levels.
1. Incorrect: Atelectasis is collapse of alveolar lung tissue, and findings reflect presence
of a small, airless lung. This condition is caused by complete obstruction of a draining
bronchus by a tumor, thick secretions, or an aspirated foreign body, or by compression
of lung.
5. Incorrect: Client tends to lean forward and uses accessory muscles of respiration to
breathe.
A term male infant was just delivered vaginally. Which of the following actions by the
nurse has priority?
1. Apply identification bands
2. Apply eye ointment
3. Dry the baby
4. Obtain footprints - Right Ansa -3. Correct: Cold stress is the biggest danger to a
newborn. A newborn is wet and evaporation will rapidly cool the baby which can cause
hypoglycemia and respiratory distress.
1. Incorrect: A task that needs to be accomplished before the baby leaves the delivery
room, but is not immediate priority.
2. Incorrect: Eye prophylaxis can safely be delayed up to two hours.
,4. Incorrect: A task that needs to be accomplished before the baby leaves the delivery
room, but is not immediate priority.
A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg
intramuscularly (IM). The newborn weighs 6 pounds (2.7 kg). The dispensed dose is
25,000 units per 1 mL. What should the nurse do?
1. Administer the drug intravenously (IV) since a large volume is required.
2. Choose three injection sites and give the medication as prescribed.
3. Consult with the pharmacy for a different medication concentration.
4. Read the available drug information to determine how to administer the medication. -
Right Ansa -3. Correct: The nurse must consult with the pharmacy to receive further
instructions. The dose is greater than the allowed volume to be given IM, which
warrants clarification by the pharmacy.
1. Incorrect: Since the drug is prescribed IM, the route should not be changed to IV
administration because this violates the order as written.
2. Incorrect: The dose is greater than the allowed volume to be given IM, which
warrants clarification by the pharmacy. You want to avoid having to give three
injections.
4. Incorrect: The concern is not drug information on administration, it is the available
concentration which can only be provided by the pharmacy.
Which interventions should the nurse include for a client with sickle cell crisis who is
experiencing pain?
1. Apply cold compresses to affected joints.
2. Massage affected areas gently.
3. Support and elevate swollen joints.
4. Monitor pain level by looking for BP, respiratory, and heart rate elevation.
5. Administer acetacylic acid 325 mg every 4 hours in order to thin the blood. - Right
Ansa -2. & 3. Correct: Apply local massage gently to affected areas which helps reduce
muscle tension. This helps to decrease swelling thus decreasing pain.
1. Incorrect: Apply warm, moist compresses to affected joints or other painful areas.
Avoid use of ice or cold compresses. Rationale: Warmth causes vasodilation and
, increases circulation to hypoxic areas. Cold causes vasoconstriction and compounds
the crisis.
4. Incorrect: Although pain can cause vital signs to elevate, it does not always occur.
The nurse should assess pain with an objective scale such as having the client rate the
pain on a scale of 1-10. Remember that pain is what the client says it is.
5. Incorrect: Acetacylic acid should be avoided because it alters blood pH and can make
cells sickle more easily.
The nurse is instructing a client in the use of cane. Which is the best description of
correct cane technique?
1. Place the cane on weaker side of body to support weaker leg. Using the cane for
support, step forward with good leg, and then move weaker leg and cane forward to the
good leg.
2. Place the cane on stronger side of body. Place cane forward 6 to 10 inches while
client stands with body weight divided between two legs. Weaker leg is advanced to
cane, with body weight divided between good leg and the cane.
3. Place cane on weaker side of body. Cane is placed forward 6 to 10 inches while
client stands with body weight divided between two legs. Weaker leg is advanced to
cane, with the body weight divided between good leg and cane.
4. Place cane on stronger side of body to help support weaker leg. Using cane for
support, step forward with good leg and then move weaker leg and cane forward to
good leg. - Right Ansa -2. Correct: Place the cane on the stronger side of the body. The
cane is placed forward 6 to 10 inches while the client stands with the body weight
divided between the two legs. The weaker leg is then advanced to the cane, with the
body weight divided between the good leg and the cane. Finally the stronger leg is
advanced past the cane and the weaker leg, with the body weight divided between the
cane and the weaker leg.
1. Incorrect: The cane should be on the stronger side of the body to create a wider base
for balance as the client advances the good leg and must use the weaker leg for
support with the cane. If the cane is placed on the weaker side of the body, this would
create a narrower base for support and balance and increase the risk of falling.
3. Incorrect: The cane should be on the stronger side of the body to create a wider base
for balance as the client advances the good leg and must use the weaker leg for
support with the cane. If the cane is placed on the weaker side of the body, this would
create a narrower base for support and balance and increase the risk of falling.
