NURSING ASSESSMENT QUESTIONS AND ANSWERS

NURSING ASSESSMENT QUESTIONS AND ANSWERS 1- After listening to the parent’s reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting? a. 1-year-old with dyspnea, drooling, and a swollen tongue after eating part of a houseplant. b. 2-year-old who is crying and has a large forehead hematoma after falling out of a chair. c. 3-year-old with second-degree burns on the face after pulling a cup of hot tea off the table. d. 5-year-old whose x-ray reveals 1 new and 2 healed humerus fractures after falling from a tree. 2- The nurse on an inpatient mental health unit is caring for a client with paranoid delusions who is refusing to eat. The client states that all the food and drinks have been poisoned. Which intervention by the nurse is appropriate? a. Contact the client’s family and ask then to bring prepared food from home b. Inform the client that tube feedings will be initiated if the client refuses to ear c. Offer to taste the client’s food and drinks while the client observes d. Provide the client food in unopened single-serving packages. 3- The nurse caring for a male client prepares to insert an indwelling urinary catheter. The nurse assesses for allergies, explains the procedure to the client, and asks unlicensed personnel to perform perineal care while equipment is gathered. Placed in order the steps the nurse should take when inserting the urinary catheter. a. Perform hand hygiene and open sterile urinary catheterization kit b. Apply sterile gloves and place fenestrated drape with shinny side down c. Use nondominant hand to grasp penis below glans d. Use dominant hand to cleanse meatus with cotton balls or swab sticks e. Use dominant hand to insert catheter until urine return is observed. f. Advance catheter to tubing bifurcation and inflate balloon. 4- A client in cardiac arrest, and resuscitation efforts are in progress when the client’s spouse arrives. The client’s spouse insists on coming into the room. How should the nurse respond? a. Allow the spouse into the room and provide a chair b. Call the chaplain to sit with the spouse outside the room c. Have the unit secretary escort the spouse to the waiting room d. Tell the spouse that the resuscitation is too graphic to be witnessed. 5- The nurse is caring for a client with a central venous catheter (CVC) who reports feeling nauseated and chilled. The nurse notes that the CVC insertion site is red and inflamed and that the client has a temperature of 102 F (38.8 C) which new prescription from the health care provider should the nurse implement first? a. Administer ondansetron 4mg IV push PRN for nausea or vomiting b. Document the occurrence and notify the hospital’s epidemiology team c. Initiate the first dose of IV piperacillin/tazobactam via a new peripheral IV d. Obtain blood cultures and discontinue the CVC. CVC’s are used in the treatement of clients who require long-term IV access or are prescribed hypertoni solutions (TPN) or vesicant medications. CVC’s can serve as a portal of entry for bacteria, which increases the risk of developing serious bloodstream infections. Symptoms are consistent with possible sepsis. 6- The charge nurse is responsible for making room assignments for multiple clients. Which pair of client assignments to a shared room is appropriate? a. Client with blood loss anemia and client with intractable diarrhea b. Client with gastroenteritis and client with chemotherapy-induced nausea and vomiting c. Client who has a bowel resection 1 day ago and a client with asthma exacerbation d. Client who had a total hip arthroplasty 2 days ago with client with influeza 7- The nurse cares for a client with a terminal disease who has an advance directive supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client’s adult child states, “I changed my mind. DO whatever you can to save him!” Which intervention is most appropriate at this time? a. Call for help to initiate cardiopulmonary resuscitation b. Call the health care provider to confirm the DNR status c. Explain the client’s wishes to the client’s child d. Offer to call the hospital chaplain to provide support 8- The clinic nurse is assessing a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide? a. “I lost my imipramine prescription. Could I have a refill? b. “I plan to attend my granddaughter’s graduation next month” c. “I Seem to have a lot more energy since I started therapy” d. “I will sign a ‘no-suicide’ contract at today’s appointment 9- The nurse is preparing to administer acetaminophen to a 4-year-old client weighing 43lb. Based on the prescription, what is the volume in milliliters (mL) that the child should receive with each dose? Medication prescription Acetaminophen: 15mg/kg/dose PO q6h PRN for temperature 101 F Acetaminophen 160mg/5mL oral suspension 43lb/2.2 = 19.5kg 15mg x 19.5 kg = 292.5 292.5 x 5mL = 9.1 mL 160mg 10- The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which findings as MOST likely to hinder healing? a. BMI of 29.5 kh/m^2 b. Family history of osteoporosis c. History of a daily glass of wine d. Peripheral arterial disease Bone healing depends on multiple factors, including nutrition, adequate circulation and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. 11- Based on the nursing assessment progress notes, what is the correct staging of the client’s pressure injury? Progress notes Shallow, open area with clean, dark pink wound bed about 1cm in diameter noted on coccyx. 1300 Surrounding area is slightly hard and warm to touch with erythema. Foam dressing clean, dry and intact. No drainage noted. Enterostomal consult made. a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4