ARCHER EXAM 2 [ANSWERS
SHEET PROVIDED]
EMAIL US FOR ANY ENQUIRY
,1. Your client is expressing feelings of dread and impending danger. As you allow
the client to freely express these feelings, you attempt to determine the cause of
these feelings but are unable to identify the source. What is the most likely
nursing diagnosis for this client?
A. Fear related to an unidentifiable source
B. Anxiety related to an unidentifiable source
C. Ineffective coping related to a source that is not based on reality
D. Maladaptive coping related to a source that is based on reality
2. You are caring for a 12-year-old patient with a history of seizures. During her
stay, you notice that she begins staring blankly. During this period, you are
unable to get her attention, and she does not speak. You suspect that this is a:
A. Petit mal seizure
B. Simple partial seizure
C. Grand mal seizure
D. Myoclonic seizure
3. You are caring for a patient with a new order for nitroglycerin ointment one
inch applied to the skin twice a day to prevent angina. To use nitroglycerin
correctly, you know to:
A. Apply it only to the upper chest
B. Rub the ointment into the skin until it disappears
C. Rotate the application sites
D. Cover the application site with a gauze dressing
4. The nurse is transfusing one unit of packed red blood cells (PRBCs) to a
client. The nurse initiated the transfusion at 1400. After completing the 1545
vital signs, the nurse should take which action? See the image below.
, A. Stop the transfusion
B. Verify the blood product with another nurse
C. Apply nasal cannula oxygen
D. Document the findings and continue the transfusion
5. The nurse is caring for a 3-year-old newly diagnosed with acute lymphoblastic
leukemia (ALL). While talking to the family, which of the following educational
points does the nurse know to reinforce based on the child’s
diagnosis? Select all that apply.
A. Bleeding precautions
B. Contact precautions
C. Neutropenic precautions
D. Sternal precautions
6. While working in the resuscitation area of the emergency department, EMS
notifies you that a 7-year-old male with an avulsion fracture to the left tibia is
20 minutes out. You know to expect which of the following?
A. A fracture that pulls a part of the bone from the tendon or ligament.
B. A fracture with which the whole cross-section of the bone is fractured.
C. A fracture that results from an underlying disease or disorder, not physical
trauma or stressors.
D. A fracture that affects only one side of the bone.
7. You receive the change-of-shift report for an infant whose family has just
been informed of the infant's cystic fibrosis diagnosis. As the nurse caring for
, this pediatric client and the family, which of the following should
you prioritize?
A. Arrange and schedule a follow-up appointment with a pediatric
pulmonologist
B. Provide emotional support for the family
C. Arrange for financial assistance
D. Arrange for parental genetic testing, as the parents mention they want
another child soon
8. The nurse is teaching a client about ambulating with a cane. It would indicate
effective teaching if the nurse observes the client
A. position the cane on their weaker side.
B. advances their weaker leg first, then the cane.
C. measures the height of the cane from their wrist crease.
D. advances the cane 12-16 inches with each step.
9. The emergency department (ED) triage nurse is assigned to see the following
clients. Which of the following clients requires the most rapid action in the
ED?
A. A travel blogger who needs tuberculosis testing after exposure to a person
with TB during his trip.
B. An elderly woman who has a history of a methicillin-resistant
Staphylococcus aureus (MRSA) leg wound infection.
C. A pregnant woman with a blister-like rash on the face who possibly has
varicella.
D. An infant with a runny nose and whose older brother has pertussis.
SHEET PROVIDED]
EMAIL US FOR ANY ENQUIRY
,1. Your client is expressing feelings of dread and impending danger. As you allow
the client to freely express these feelings, you attempt to determine the cause of
these feelings but are unable to identify the source. What is the most likely
nursing diagnosis for this client?
A. Fear related to an unidentifiable source
B. Anxiety related to an unidentifiable source
C. Ineffective coping related to a source that is not based on reality
D. Maladaptive coping related to a source that is based on reality
2. You are caring for a 12-year-old patient with a history of seizures. During her
stay, you notice that she begins staring blankly. During this period, you are
unable to get her attention, and she does not speak. You suspect that this is a:
A. Petit mal seizure
B. Simple partial seizure
C. Grand mal seizure
D. Myoclonic seizure
3. You are caring for a patient with a new order for nitroglycerin ointment one
inch applied to the skin twice a day to prevent angina. To use nitroglycerin
correctly, you know to:
A. Apply it only to the upper chest
B. Rub the ointment into the skin until it disappears
C. Rotate the application sites
D. Cover the application site with a gauze dressing
4. The nurse is transfusing one unit of packed red blood cells (PRBCs) to a
client. The nurse initiated the transfusion at 1400. After completing the 1545
vital signs, the nurse should take which action? See the image below.
, A. Stop the transfusion
B. Verify the blood product with another nurse
C. Apply nasal cannula oxygen
D. Document the findings and continue the transfusion
5. The nurse is caring for a 3-year-old newly diagnosed with acute lymphoblastic
leukemia (ALL). While talking to the family, which of the following educational
points does the nurse know to reinforce based on the child’s
diagnosis? Select all that apply.
A. Bleeding precautions
B. Contact precautions
C. Neutropenic precautions
D. Sternal precautions
6. While working in the resuscitation area of the emergency department, EMS
notifies you that a 7-year-old male with an avulsion fracture to the left tibia is
20 minutes out. You know to expect which of the following?
A. A fracture that pulls a part of the bone from the tendon or ligament.
B. A fracture with which the whole cross-section of the bone is fractured.
C. A fracture that results from an underlying disease or disorder, not physical
trauma or stressors.
D. A fracture that affects only one side of the bone.
7. You receive the change-of-shift report for an infant whose family has just
been informed of the infant's cystic fibrosis diagnosis. As the nurse caring for
, this pediatric client and the family, which of the following should
you prioritize?
A. Arrange and schedule a follow-up appointment with a pediatric
pulmonologist
B. Provide emotional support for the family
C. Arrange for financial assistance
D. Arrange for parental genetic testing, as the parents mention they want
another child soon
8. The nurse is teaching a client about ambulating with a cane. It would indicate
effective teaching if the nurse observes the client
A. position the cane on their weaker side.
B. advances their weaker leg first, then the cane.
C. measures the height of the cane from their wrist crease.
D. advances the cane 12-16 inches with each step.
9. The emergency department (ED) triage nurse is assigned to see the following
clients. Which of the following clients requires the most rapid action in the
ED?
A. A travel blogger who needs tuberculosis testing after exposure to a person
with TB during his trip.
B. An elderly woman who has a history of a methicillin-resistant
Staphylococcus aureus (MRSA) leg wound infection.
C. A pregnant woman with a blister-like rash on the face who possibly has
varicella.
D. An infant with a runny nose and whose older brother has pertussis.
