Question 1
An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a diagnosis of
dehydration. A replacement bolus of normal saline at 20 mL/kg is ordered to be
administered intravenously over 40 minutes.
In mL/hour, what will be the setting for the IV delivery system?
CORRECT ANSWER
300
Using ratio proportion:First, convert 22 pounds to kilograms (22/2.2) = 10 kg20 mL/kg = 20 x
10 kg = 200 mL200 mL/40 minutes = x mL/60 minutes (in an hour)200 x 60 = 12000/40 = 300
mL/hrUsing dimensional analysis:20 mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x 1/40 min = 300
mL/hr
Question 2
The mother of a 2 month-old baby calls a pediatrician's nurse two days after the first DTaP,
inactivated polio vaccine (IPV), Hepatitis B and Haemophilus influenzae type B (HIB)
immunizations. She reports that the baby feels very warm, cries inconsolably for as long as
three hours, and has had several shaking spells. Which immunization would the nurse
expect to be primarily responsible with these findings?
A. DTaP
B. IPV
C. Hepatitis B
D. HIB
CORRECT ANSWER
A
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@THE STUDY VAULT
,DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis
(whooping cough). The majority of reactions described in this question occur with the
administration of the DTaP vaccination. Contraindications to giving repeat DTaP
immunizations include the occurrence of severe side effects after a previous dose, as well as
signs of encephalopathy within seven days of the immunization.
Question 3
A client diagnosed with angina has been instructed about the use of sublingual
nitroglycerin. Which statement made by the client is incorrect and indicates a need for
further teaching?
A. "I'll call the health care provider if pain continues after three tablets five minutes apart."
B. "I will rest briefly right after taking one tablet."
C. "I understand that the medication should be kept in the dark bottle."
D. "I can swallow two or three tablets at once if I have severe pain."
CORRECT ANSWER
D
Clients must understand that just one sublingual tablet should be taken at a time and placed
under the tongue. After rest and a five-minute interval, a second and then eventually a third
tablet may be necessary.
Question 4
The nurse is working with victims of domestic abuse. The nurse should understand which
of these factors is a reason why domestic violence or emotional abuse remains extensively
undetected?
A. The expenses due to police and court costs are prohibitive
B. Little knowledge is known about batterers and battering relationships
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@THE STUDY VAULT
,C. There are typically many series of minor, vague complaints
D. Few people who have been battered seek medical care
CORRECT ANSWER
C
Signs of domestic violence or emotional abuse may not be clearly manifested and include
many series of a minor complaints such as headache, abdominal pain, insomnia, back pain
and dizziness. These may be covert indications of violence or abuse that go undetected.
These complaints may be vague and reflect ambivalence about the disclosure of any
violence or abuse.
Question 5
The nurse is obtaining an aerobic wound culture from a client with stage two pressure
injury. The nurse first removes a gauze dressing and observes a moderate amount of
purulent drainage on the dressing and then the nurse performs hand hygiene. What is the
next correct step in the procedure?
A. Swab the gauze dressing that was removed from the wound
B. Irrigate the wound with normal saline
C. Obtain a culture by rotating a sterile swab in the open wound
D. Remove wound exudate from the wound edges with a cotton tip applicator
CORRECT ANSWER
B
After removing the dressing and performing hand hygiene, the wound needs to be irrigated
to remove surface pathogens before the nurse can obtain a wound culture. Cultures are not
obtained from wound exudate on the dressing or wounds that have not been irrigated since
the exudate may be contaminated with normal skin flora.
Question 6
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@THE STUDY VAULT
, The nurse is caring for a client who is experiencing frightening hallucinations that are
markedly increased at night. The client's partner asks to stay a few hours beyond the
visiting time, in the client's private room. What would be the best response by the nurse?
A. "Yes, staying with the client and orienting the client to the surroundings may decrease any
anxiety."
B. "No, your presence may cause the client to become more anxious."
C. "No, it would be best if you brought the client some reading material that the client could
read at night."
D. "Yes, would you like to spend the night when the client's behavior indicates that the client
is or will be frightened?"
CORRECT ANSWER
A
Encouragement of a family member or a close friend to stay with the client in a quiet
surrounding cannot only help increase orientation, but can also minimize confusion and
anxiety. The visitor could also report to the nurse any unusual findings of the client. This
would be the most supportive approach for this client.
Question 7
The RN, who is functioning as the charge nurse, needs to determine shift assignments.
How will the charge nurse determine which client assignments are appropriate for the
licensed practical nurse (LPN)?
A. Ask the LPN about prior experience caring for clients with similar diagnoses
B. Determine how many nursing assistants are available to help the LPN with client care
C. Refer to the list of technical tasks LPNs are trained to perform
D. Review the procedure manual with the LPN prior to making an assignment
CORRECT ANSWER
A
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@THE STUDY VAULT
An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a diagnosis of
dehydration. A replacement bolus of normal saline at 20 mL/kg is ordered to be
administered intravenously over 40 minutes.
In mL/hour, what will be the setting for the IV delivery system?
CORRECT ANSWER
300
Using ratio proportion:First, convert 22 pounds to kilograms (22/2.2) = 10 kg20 mL/kg = 20 x
10 kg = 200 mL200 mL/40 minutes = x mL/60 minutes (in an hour)200 x 60 = 12000/40 = 300
mL/hrUsing dimensional analysis:20 mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x 1/40 min = 300
mL/hr
Question 2
The mother of a 2 month-old baby calls a pediatrician's nurse two days after the first DTaP,
inactivated polio vaccine (IPV), Hepatitis B and Haemophilus influenzae type B (HIB)
immunizations. She reports that the baby feels very warm, cries inconsolably for as long as
three hours, and has had several shaking spells. Which immunization would the nurse
expect to be primarily responsible with these findings?
A. DTaP
B. IPV
C. Hepatitis B
D. HIB
CORRECT ANSWER
A
1
@THE STUDY VAULT
,DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis
(whooping cough). The majority of reactions described in this question occur with the
administration of the DTaP vaccination. Contraindications to giving repeat DTaP
immunizations include the occurrence of severe side effects after a previous dose, as well as
signs of encephalopathy within seven days of the immunization.
Question 3
A client diagnosed with angina has been instructed about the use of sublingual
nitroglycerin. Which statement made by the client is incorrect and indicates a need for
further teaching?
A. "I'll call the health care provider if pain continues after three tablets five minutes apart."
B. "I will rest briefly right after taking one tablet."
C. "I understand that the medication should be kept in the dark bottle."
D. "I can swallow two or three tablets at once if I have severe pain."
CORRECT ANSWER
D
Clients must understand that just one sublingual tablet should be taken at a time and placed
under the tongue. After rest and a five-minute interval, a second and then eventually a third
tablet may be necessary.
Question 4
The nurse is working with victims of domestic abuse. The nurse should understand which
of these factors is a reason why domestic violence or emotional abuse remains extensively
undetected?
A. The expenses due to police and court costs are prohibitive
B. Little knowledge is known about batterers and battering relationships
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@THE STUDY VAULT
,C. There are typically many series of minor, vague complaints
D. Few people who have been battered seek medical care
CORRECT ANSWER
C
Signs of domestic violence or emotional abuse may not be clearly manifested and include
many series of a minor complaints such as headache, abdominal pain, insomnia, back pain
and dizziness. These may be covert indications of violence or abuse that go undetected.
These complaints may be vague and reflect ambivalence about the disclosure of any
violence or abuse.
Question 5
The nurse is obtaining an aerobic wound culture from a client with stage two pressure
injury. The nurse first removes a gauze dressing and observes a moderate amount of
purulent drainage on the dressing and then the nurse performs hand hygiene. What is the
next correct step in the procedure?
A. Swab the gauze dressing that was removed from the wound
B. Irrigate the wound with normal saline
C. Obtain a culture by rotating a sterile swab in the open wound
D. Remove wound exudate from the wound edges with a cotton tip applicator
CORRECT ANSWER
B
After removing the dressing and performing hand hygiene, the wound needs to be irrigated
to remove surface pathogens before the nurse can obtain a wound culture. Cultures are not
obtained from wound exudate on the dressing or wounds that have not been irrigated since
the exudate may be contaminated with normal skin flora.
Question 6
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@THE STUDY VAULT
, The nurse is caring for a client who is experiencing frightening hallucinations that are
markedly increased at night. The client's partner asks to stay a few hours beyond the
visiting time, in the client's private room. What would be the best response by the nurse?
A. "Yes, staying with the client and orienting the client to the surroundings may decrease any
anxiety."
B. "No, your presence may cause the client to become more anxious."
C. "No, it would be best if you brought the client some reading material that the client could
read at night."
D. "Yes, would you like to spend the night when the client's behavior indicates that the client
is or will be frightened?"
CORRECT ANSWER
A
Encouragement of a family member or a close friend to stay with the client in a quiet
surrounding cannot only help increase orientation, but can also minimize confusion and
anxiety. The visitor could also report to the nurse any unusual findings of the client. This
would be the most supportive approach for this client.
Question 7
The RN, who is functioning as the charge nurse, needs to determine shift assignments.
How will the charge nurse determine which client assignments are appropriate for the
licensed practical nurse (LPN)?
A. Ask the LPN about prior experience caring for clients with similar diagnoses
B. Determine how many nursing assistants are available to help the LPN with client care
C. Refer to the list of technical tasks LPNs are trained to perform
D. Review the procedure manual with the LPN prior to making an assignment
CORRECT ANSWER
A
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@THE STUDY VAULT
