FOUNDATIONS AND ADULT HEALTH NURSING

MULTIPLE CHOICE 1. A home health nurse has a patient who is taking lithium. What should be included in the teaching plan? a. Examine her skin closely for eruptions. b. Take her blood pressure twice a day to check for hypertension. c. Have her drug blood level checked every month. d. Avoid aged cheese and red wine. ANS: C Lithium has a very narrow therapeutic window. The drug blood levels should be closely monitored. DIF: Cognitive Level: Application REF: p. 1122 OBJ: 6 TOP: ...

MULTIPLE CHOICE 1. A patient with a history of rheumatic heart disease is being admitted to the labor and delivery unit. To prevent further stress on the heart, what should the nurse anticipate to be ordered? a. Oxygen administration b. Administering large amount of IV fluids c. Positioning the patient on her back d. Encouraging activity between contractions ANS: A Oxygen is administered to increase blood oxygen saturation and decrease the stress on the heart. IV fluid administrati...

MULTIPLE CHOICE 1. A child has developed a diaper rash, and the parents are using zinc oxide to treat it. What does the nurse suggest to aid in the removal of the zinc oxide? a. Mild soap and water b. A cotton ball c. Mineral oil d. Alcohol swabs ANS: C To completely remove ointment, especially zinc oxide, mineral oil should be used. DIF: Cognitive Level: Application REF: p. 1042 OBJ: 15 TOP: Diaper rash KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological In...

MULTIPLE CHOICE 1. Following a lumbar puncture of a 2-year-old, what should the nurse do? a. Keep the child flat for several hours. b. Allow the child to play quietly at will. c. Hold the child in a flexed position for 5 minutes. d. Stand the child upright immediately. ANS: B Children younger than 3 years of age are usually not affected by postlumbar headache. These children are allowed to play at will following a lumbar puncture. DIF: Cognitive Level: Comprehension REF: p. 966...

MULTIPLE CHOICE 1. What practice should be used by a pediatric nurse to remind parents of their responsibility in reducing the number of accidents involving children? a. Child awareness b. Good manners c. Anticipatory guidance d. Strict discipline ANS: C Anticipatory guidance has been the most widely used approach to educating parents in accident prevention. DIF: Cognitive Level: Application REF: p. 927 OBJ: 9 TOP: Injury prevention KEY: Nursing Process Step: Implementatio...

MULTIPLE CHOICE 1. When the nurse is developing a care plan for a terminally ill patient, what might be a realistic goal? a. The patient will remain pain-free. b. The patient will function optimally. c. The patient will spend time out of bed. d. The patient will demonstrate improved nutritional status. ANS: B The goal of the care plan for a terminally ill patient is to assist the patient to function optimally. The other options are not realistic. DIF: Cognitive Level: Application...

MULTIPLE CHOICE 1. Before initially feeding an infant, what reflex should the nurse assess? a. Moro reflex b. Rooting reflex c. Babinski reflex d. Swallow reflex ANS: D The nurse should verify that the infant is able to swallow normally before feeding. DIF: Cognitive Level: Application REF: p. 867 OBJ: 9 TOP: Postpartum KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 2. Following delivery of the newborn, which nursing intervention shoul...

MULTIPLE CHOICE 1. The patient’s membranes have just ruptured. What is the first priority of the nurse? a. Turn the patient on the left side. b. Perform a Nitrazine test. c. Check the fetal heart rate (FHR). d. Perform a vaginal examination. ANS: C The FHR should be assessed immediately after rupture of the membranes to determine the well-being of the baby. DIF: Cognitive Level: Application REF: p. 816 OBJ: 10 TOP: Ruptured membranes KEY: Nursing Process Step: Implementa...

MULTIPLE CHOICE 1. What does the increase in circulating blood volume during pregnancy cause in the mother? a. Shortness of breath b. Frontal headaches c. Decreased white blood cell count d. Decreased haemoglobin ANS: D Maternal circulating volume increases 30% to 40%, causing a virtual decrease in haemoglobin. DIF: Cognitive Level: Analysis REF: p. 785 OBJ: 2 TOP: Decreased Hgb KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. A woman e...

MULTIPLE CHOICE 1. The nurse is preparing to perform a dressing change on a patient following a total hip replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change? a. After the dressing change b. At least 15 minutes before the dressing change c. At least 30 minutes before the dressing change d. At least 1 hour before the dressing change ANS: C It may help to give an analgesic at least 30 minutes before exposi...