The parent of a preschooler with chickenpox asks the Correct Answer: 3
nurse about measures to make the child comfortable.
The nurse instructs the parent to avoid administering RATIONALES: Research shows a correlation between the use of aspirin during
aspirin or any other product that contains salicylates. chickenpox and the development of Reye's syndrome (a disorder characterized
When given to children with chickenpox, aspirin has by brain and liver toxicity). Therefore, the nurse should instruct the parents to
been linked to which disorder? avoid administering aspirin or other products that contain salicylates and to
consult the physician or pharmacist before administering any medication to a
child with chickenpox. No research has found a link between aspirin use,
chickenpox, and the development of Guillain-Barré syndrome, rheumatic fever, or
1. Guillain-Barré syndrome scarlet fever.
2. Rheumatic fever
3. Reye's syndrome
4. Scarlet fever
A client is to have an epidural block to relieve labor pain. Correct Answer: 3
The nurse anticipates that the anesthesiologist will inject
the anesthetic agent into the: RATIONALES: For an epidural block, the nurse should anticipate that the
anesthesiologist will inject a local anesthetic agent into the epidural space,
located between the dura mater and the ligamentum flavum in the lumbar region
of the spinal column. When administering a spinal block, the anesthesiologist
1. subarachnoid space. injects the anesthetic agent into the subarachnoid space. The ligamentum flavum
and the area between the subarachnoid space and the dura mater are
inappropriate injection sites.
2. area between the subarachnoid space and the dura
mater.
3. area between the dura mater and the ligamentum
flavum.
4. ligamentum flavum.
The physician prescribes penicillin potassium oral Correct Answer: 14
suspension 56 mg/kg/day in four divided doses for a
client with anorexia nervosa who weighs 25 kg. The RATIONALES: To determine the total daily dosage, set up the following
medication dispensed by the pharmacy contains a proportion:
dosage strength of 125 mg/5 ml. How many milliliters of 25 kg/X = 1 kg/56 mg
solution should the nurse administer with each dose? X = 1,400 mg.
Next, divide the daily dosage by four doses to determine the dose to administer
every 6 hours:
X = 1,400 mg/4 doses
X = 350 mg/dose.
The adolescent should receive 350 mg every 6 hours.
Lastly, calculate the volume to give for each dose by setting up this proportion:
X/350 mg = 5 ml/125 mg
X = 14 ml.
,The nurse must irrigate a gaping abdominal incision with Correct Answer: 1
sterile normal saline, using a piston syringe. How should
the nurse proceed? RATIONALES: To wash away tissue debris and drainage effectively, the nurse
should irrigate the wound until the solution becomes clear or all of the solution
has been used. After the irrigation, the nurse should dry the area around the
wound; moistening it promotes microorganism growth and skin irritation. When
1. Irrigate continuously until the solution becomes clear the area is dry, the nurse should apply a sterile dressing, rather than awet-to-dry
or all of the solution has been used. dressing. The nurse always should instill the irrigating solution gently; rapid or
forceful instillation can damage tissues.
2. Moisten the area around the wound with normal saline
after the irrigation.
3. Apply a wet-to-dry dressing to the wound after the
irrigation.
4. Rapidly instill a stream of irrigating solution into the
wound.
As an adolescent is receiving care, he's inadvertently Correct Answer: 2
injured with a warm compress. The nurse completes an
incident report based on the knowledge that identification RATIONALES: The purpose of an incident report is threefold: to identify ways to
of which of the following is a goal of the report? prevent incident recurrences, to identify patterns of care problems, and to identify
facts surrounding each incident. Incident reports aren't used to hold people
accountable for their actions, to punish those involved in the incident, or to
punish the nurse-manager responsible for the unit.
1. To reprimand the involved staff members for their
actions
2. To identify the learning needs of staff to prevent
incident recurrences
3. To reprimand the nurse-manager responsible for the
unit
4. To hold people accountable for their actions
As a client progresses through pregnancy, she develops Correct Answer: 4
constipation. What is the primary cause of this problem
during pregnancy? RATIONALES: During pregnancy, hormonal changes and mechanical pressure
reduce motility in the small intestine, enhancing water absorption and promoting
constipation. Although decreased appetite, inadequate fluid intake, and
prolonged gastric emptying may contribute to constipation, they aren't the
1. Decreased appetite primary cause.
2. Inadequate fluid intake
3. Prolonged gastric emptying
4. Reduced intestinal motility
, An adolescent with type 1 diabetes mellitus is Correct Answer: 2
experiencing a growth spurt. Which treatment approach
would be most effective for this client? RATIONALES: During an adolescent growth spurt, a regimen of multiple insulin
doses achieves better control of the blood glucose level because it more closely
simulates endogenous insulin release. A single daily dose of insulin wouldn't
control this client's blood glucose level as effectively. Limiting dietary fat intake
1. Administering insulin once per day wouldn't help the body use glucose at the cellular level. An adolescent with type
1 diabetes mellitus doesn't produce insulin and therefore can't receive an oral
antidiabetic agent instead of insulin.
2. Administering multiple doses of insulin
3. Limiting dietary fat intake
4. Substituting an oral antidiabetic agent for insulin
A client is admitted to the health care facility with bowel Correct Answer: 2
obstruction secondary to colon cancer. The nurse
obtains a health history, measures vital signs, and RATIONALES: During the data collection step of the nursing process, the nurse
auscultates for bowel sounds. Which step of the nursing obtains the client's health history, measures vital signs, and performs a physical
process is the nurse performing? examination to gather data for use in formulating the nursing diagnoses. During
the planning step, the nurse designs methods to help resolve client problems and
meet client needs. During evaluation, the nurse determines the effectiveness of
nursing interventions in achieving client goals. During implementation, the nurse
1. Planning takes actions to meet the client's needs.
2. Data collection
3. Evaluation
4. Implementation
The physician prescribes meperidine (Demerol), 1.1 Correct Answer: 3
mg/kg I.M., for a 16-month-old child who has just had
abdominal surgery. When administering this drug, the RATIONALES: For an infant, the nurse should use a needle with the smallest
nurse should use a needle of which size? appropriate gauge for the medication to be given. For an I.M. injection of
meperidine, a 25G to 22G needle is appropriate.
1. 18G
2. 20G
3. 23G
4. 27G
nurse about measures to make the child comfortable.
The nurse instructs the parent to avoid administering RATIONALES: Research shows a correlation between the use of aspirin during
aspirin or any other product that contains salicylates. chickenpox and the development of Reye's syndrome (a disorder characterized
When given to children with chickenpox, aspirin has by brain and liver toxicity). Therefore, the nurse should instruct the parents to
been linked to which disorder? avoid administering aspirin or other products that contain salicylates and to
consult the physician or pharmacist before administering any medication to a
child with chickenpox. No research has found a link between aspirin use,
chickenpox, and the development of Guillain-Barré syndrome, rheumatic fever, or
1. Guillain-Barré syndrome scarlet fever.
2. Rheumatic fever
3. Reye's syndrome
4. Scarlet fever
A client is to have an epidural block to relieve labor pain. Correct Answer: 3
The nurse anticipates that the anesthesiologist will inject
the anesthetic agent into the: RATIONALES: For an epidural block, the nurse should anticipate that the
anesthesiologist will inject a local anesthetic agent into the epidural space,
located between the dura mater and the ligamentum flavum in the lumbar region
of the spinal column. When administering a spinal block, the anesthesiologist
1. subarachnoid space. injects the anesthetic agent into the subarachnoid space. The ligamentum flavum
and the area between the subarachnoid space and the dura mater are
inappropriate injection sites.
2. area between the subarachnoid space and the dura
mater.
3. area between the dura mater and the ligamentum
flavum.
4. ligamentum flavum.
The physician prescribes penicillin potassium oral Correct Answer: 14
suspension 56 mg/kg/day in four divided doses for a
client with anorexia nervosa who weighs 25 kg. The RATIONALES: To determine the total daily dosage, set up the following
medication dispensed by the pharmacy contains a proportion:
dosage strength of 125 mg/5 ml. How many milliliters of 25 kg/X = 1 kg/56 mg
solution should the nurse administer with each dose? X = 1,400 mg.
Next, divide the daily dosage by four doses to determine the dose to administer
every 6 hours:
X = 1,400 mg/4 doses
X = 350 mg/dose.
The adolescent should receive 350 mg every 6 hours.
Lastly, calculate the volume to give for each dose by setting up this proportion:
X/350 mg = 5 ml/125 mg
X = 14 ml.
,The nurse must irrigate a gaping abdominal incision with Correct Answer: 1
sterile normal saline, using a piston syringe. How should
the nurse proceed? RATIONALES: To wash away tissue debris and drainage effectively, the nurse
should irrigate the wound until the solution becomes clear or all of the solution
has been used. After the irrigation, the nurse should dry the area around the
wound; moistening it promotes microorganism growth and skin irritation. When
1. Irrigate continuously until the solution becomes clear the area is dry, the nurse should apply a sterile dressing, rather than awet-to-dry
or all of the solution has been used. dressing. The nurse always should instill the irrigating solution gently; rapid or
forceful instillation can damage tissues.
2. Moisten the area around the wound with normal saline
after the irrigation.
3. Apply a wet-to-dry dressing to the wound after the
irrigation.
4. Rapidly instill a stream of irrigating solution into the
wound.
As an adolescent is receiving care, he's inadvertently Correct Answer: 2
injured with a warm compress. The nurse completes an
incident report based on the knowledge that identification RATIONALES: The purpose of an incident report is threefold: to identify ways to
of which of the following is a goal of the report? prevent incident recurrences, to identify patterns of care problems, and to identify
facts surrounding each incident. Incident reports aren't used to hold people
accountable for their actions, to punish those involved in the incident, or to
punish the nurse-manager responsible for the unit.
1. To reprimand the involved staff members for their
actions
2. To identify the learning needs of staff to prevent
incident recurrences
3. To reprimand the nurse-manager responsible for the
unit
4. To hold people accountable for their actions
As a client progresses through pregnancy, she develops Correct Answer: 4
constipation. What is the primary cause of this problem
during pregnancy? RATIONALES: During pregnancy, hormonal changes and mechanical pressure
reduce motility in the small intestine, enhancing water absorption and promoting
constipation. Although decreased appetite, inadequate fluid intake, and
prolonged gastric emptying may contribute to constipation, they aren't the
1. Decreased appetite primary cause.
2. Inadequate fluid intake
3. Prolonged gastric emptying
4. Reduced intestinal motility
, An adolescent with type 1 diabetes mellitus is Correct Answer: 2
experiencing a growth spurt. Which treatment approach
would be most effective for this client? RATIONALES: During an adolescent growth spurt, a regimen of multiple insulin
doses achieves better control of the blood glucose level because it more closely
simulates endogenous insulin release. A single daily dose of insulin wouldn't
control this client's blood glucose level as effectively. Limiting dietary fat intake
1. Administering insulin once per day wouldn't help the body use glucose at the cellular level. An adolescent with type
1 diabetes mellitus doesn't produce insulin and therefore can't receive an oral
antidiabetic agent instead of insulin.
2. Administering multiple doses of insulin
3. Limiting dietary fat intake
4. Substituting an oral antidiabetic agent for insulin
A client is admitted to the health care facility with bowel Correct Answer: 2
obstruction secondary to colon cancer. The nurse
obtains a health history, measures vital signs, and RATIONALES: During the data collection step of the nursing process, the nurse
auscultates for bowel sounds. Which step of the nursing obtains the client's health history, measures vital signs, and performs a physical
process is the nurse performing? examination to gather data for use in formulating the nursing diagnoses. During
the planning step, the nurse designs methods to help resolve client problems and
meet client needs. During evaluation, the nurse determines the effectiveness of
nursing interventions in achieving client goals. During implementation, the nurse
1. Planning takes actions to meet the client's needs.
2. Data collection
3. Evaluation
4. Implementation
The physician prescribes meperidine (Demerol), 1.1 Correct Answer: 3
mg/kg I.M., for a 16-month-old child who has just had
abdominal surgery. When administering this drug, the RATIONALES: For an infant, the nurse should use a needle with the smallest
nurse should use a needle of which size? appropriate gauge for the medication to be given. For an I.M. injection of
meperidine, a 25G to 22G needle is appropriate.
1. 18G
2. 20G
3. 23G
4. 27G
