ANSWERS
1.A LPN complains to the charge nurse that an unlicensed assistive person
(UAP) consistently leaves the work area untidy and does not restock
supplies. What is the best initial response by the charge nurse?
1Write down potential solutions to the problems today by shift's end
2Add this concern to the agenda of the next unit meeting
3Assure the staff nurse that the complaint will be investigated
4Explore for further identification about the nature of the problem
ANS 4 Explore for further identification about the nature of the problem
2.The nurse assists with the reinforcement of information about breast
self-examination to a group of college students. A female student asks when
to perform the monthly exam. The appropriate reply by the nurse should
include which statement?
1"Ovulation, or midcycle is the best time to detect changes."
2"Do the exam at the same time every month."
3"Right after the period, when your breasts are less tender."
4"The first of every month, because it will be easiest to remember."
ANS 3
3.The nurse is caring for a 75 year-old client with type 2 diabetes mellitus.
The client should be instructed to contact the outpatient clinic immediately
if which findings are present?
1An open wound on the heel with minimal discomfort
2Occasional hiccups and sneezing
3Sustained insomnia and daytime fatigue
4Persistent dryness and itching of the perineal area
ANS 1An open wound on the heel with minimal discomfort-
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,4.A pregnant woman has been advised to alter her diet during pregnancy by
increasing the intake of protein and vitamin C to meet the needs of the
growing fetus. Which diet choice would best meet the woman's needs?
1. 1 cup of macaroni, three-fourths cup of peas, glass whole milk, medium
pear
2. Scrambled egg, hash browned potatoes, one-half glass of buttermilk,
large nectarine
3. 3 oz. chicken, one-half cup of corn, lettuce salad, small banana
4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of
strawberries
ANS 4. Beef, one-half cup of lima beans, glass of skim milk, three-
fourths cup of strawberries –
5.A nurse is taking a health history from parents of a child admitted with
possible Reye's syndrome. Which recent illness should the nurse recognize
as being associated with an increased the risk for the development of
Reye's syndrome?
1. Varicella
2. Meningitis
3. Hepatitis
4. Rubeola
ANS 1. Varicella –
6.A Native American chief visits his newborn son and performs a traditional
ceremony that involves feathers and chanting. The nurse comments to a
colleague "I wonder if he has any idea how ridiculous he looks - he's a
grown man!" The nurse's comment is an example of what type of attitude?
1. Prejudice
2. Ethnocentrism
3. Discrimination
4. Stereotyping
ANS 1. Prejudice-
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,7.A nursing student asks the licensed practical nurse (LPN) to explain the
forces that drive health care reform. When responding to the student's
ques- tion, what information should the nurse emphasize?
1. Increased competition between health care insurers
2. Increase in health care spending that's growing faster than the economy
3. Increase in the population who have health insurance
4. Increase in spending for end-of-life treatment
ANS 2
8.A child is admitted to the unit with the suspected diagnosis of pertussis
(whooping cough). What is the priority nursing intervention for this child?
1. Maintain hydration and encourage fluids
2. Implement droplet precautions
3. Monitor respiratory rate and oxygen saturation
4. Anti- infective therapy
ANS 2
9.A client has an indwelling catheter with continuous bladder irrigation
after undergoing a transurethral resection of the prostate (TURP) 12 hours
ago. Which finding at this time should be reported to the registered nurse
(RN) charge nurse?
1Complaints for the feeling of pulling on the urinary catheter
2Light, pink to clear urine
3Occasional suprapubic cramping
4Minimal drainage into the urinary collection bag
ANS 4Minimal drainage into the urinary collection bag
10.A nurse is caring for a woman two hours after a vaginal delivery.
Documen- tation indicates that the membranes ruptured 36 hours prior to
delivery. Which of these nursing diagnoses should the nurse expect the
charge nurse to list as a priority at this time?
1Risk for fluid volume deficit
2Risk for excessive bleeding
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, 3Risk for infection -
4Altered tissue perfusion
ANS 3
11.A 14 month-old child ingests a half a bottle of baby aspirin (81 mg)
tablets. Which finding should a nurse expect to see in the child?
1Hypothermia
2Nausea and vomiting
3Hypoventilation
4Bradycardia
ANS 2
12.A school nurse monitors a child with a history of tonic-clonic seizures.
The school nurse should inform teachers that if the child falls to the floor
and experiences a seizure while in the classroom, which of the following
would be the most important action to take during the seizure?
1Place the hands or a folded blanket under the head of the child
2Provide privacy as much as possible to minimize frightening the other chil-
dren
3Move any chairs or desks at least three feet away from the child
4Note the sequence of movements with the time lapse of the event
ANS 1Place the hands or a folded blanket under the head of the child –
13.A client is admitted with diagnosis of a right upper lobe infiltrate and to
rule out active tuberculosis (TB). Which type of precautions will be needed
for this client?
1Droplet
2Contact
3Standard
4Airborne
ANS 4
14.A client has had a positive reaction to purified protein derivative
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