Cat exam 1 Questions and Answers
correctly verified
A client is comatose upon arrival to the emergency department after falling a roof. The client flexes with
painful stimuli, and the nurse determines the client's Glasgow Coma Scale (GCS) is 6. Which intervention
should the nurse prepare to implement to maintain the client's airway? - Answer A nasopharyngeal tube
A client is receiving a continuous half strength tube feeding at 50 ml/hr. To prepare enough of the
solution for eight hours, how many ml of full strength feeding will the nurse need? - Answer Answer:
200
25 ml x 8hrs = 200
The alarm of a client's pulse oximeter sounds and the nurse notes that the oxygen saturation rate is
indicated at 85%. What action should the nurse take first? - Answer Check the probe position
A client is known to have an irregular respiratory rate with periods of apnea lasting 10 to 15 seconds.
Currently, the nurse counts 22 respiratory cycles in a 30-second interval followed by an apneic period.
What intervention should the nurse implement? - Answer Reassess the respiratory rate, counting for
one full minute
A retiree with depression complains of feeling "lonely and having no purpose" in life.Based on Erikson's
developmental theory, which questions suggest that the nurse understands the client's most important
emotional need? - Answer "What about your life makes you proud?"
Following a precipitous labor, a client has a continuous trickling of bright red blood from her vagina. Her
uterus is firm and her vital signs are within normal limits. The
nurse determines that the client's symptoms may indicate which condition? - Answer A cervical
laceration
In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical
nurse? - Answer An elderly client with Alzheimer's disease complicated by dysphagia
,The healthcare provider prescribes oxygen per nasal cannula at 2 L/min. Which action has the highest
priority when the nurse implements this prescription? - Answer Set the flow meter
9. A nurse who is new to the pediatric unit is positioning a 6-month-old for an injection of penicillin V
(Pen V) in the dorsogluteal muscle. Which action should the nurse-manager who is supervising this
nurse take first? - Answer C. Instruct the nurse to select another injection site
10. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the nurse provides
home care instructions to the mother. Which statement by the child's mother indicates that she
understands home care treatment to promote pulmonary function? - Answer "Chest physiotherapy
should be performed at least twice a day"
The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in
preventing bone loss and promoting bone formation? - Answer Encourage physical activity
The nurse reviews the signs of hypoglycemia with the parents of a child with Type 1 diabetes mellitus.
The parents correctly understands signs of hypoglycemia if they include which symptom? - Answer
Sweating
The nurse observes a 2 cm area nonblanchable erythema on the sacrum of an immobile client. What
documentation of this finding is best for the nurse to enter into the client's record? - Answer Stage 1
pressure ulcer on sacrum
When assessing a 7-year-old girl, the nurse notes that she has multiple bruises on her back and upper
arms. The child's aunt tells the nurse that the child's parents abuse drugs and alcohol. What intervention
is most essential for the nurse to implement? - Answer Report assessment findings to the proper legal
authorities
15. A 14-year-old male client arrives at the emergency room in status epilepticus. He was diagnosed
with a seizure disorder in childhood. What is the most likely cause of his present condition? - Answer
Acute withdrawal from anticonvulsant medication
A Chinese-American client who just delivered a baby states that she will not be able to take the
prescribed sitz baths to help heal her episiotomy incision because this will cause an unhealthy balance of
, cold and hot forces. When planning nursing care, what nursing diagnosis has the highest priority? -
Answer Impaired tissue integrity related to episiotomy
17. A 2-year-old with sickle cell anemia has an axillary temperature of 102 F. In planning care for this
child, which nursing diagnosis has the highest priority? - Answer High risk for fluid volume deficit related
to temperature elevation
During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir
(Zovirax) prior to this pregnancy tells the nurse that she is experiencing an episode of genital herpes.
Which nursing intervention has the highest priority? - Answer Determine if the client has taken acyclovir
(Zovirax) for this outbreak of genital herpes
The nurse is obtaining a medication history for a client with a new prescription for paroxetine (Paxil).
The client reports current use of the MAO inhibitor isocarboxazid
(Marplan). What intervention is most important for the nurse to implement? - Answer Notify the
healthcare provider that the client is currently taking Marplan
While performing a skin inspection on a newborn, the nurse finds a small dimple and a dark tuft of hair
in the lumbosacral area of the infant's back. What is the most likely indication of this finding? - Answer
External manifestation of a spinal abnormality
What action should the nurse implement first when delegating nursing activities to an unlicensed
assistive personnel (UAP)? - Answer Evaluate the experience of the UAP
A female resident of a long-term care facility is being admitted to the medical department. The client
has a fractured hip and has methicillin-resistant
staphylococcus aureus (MRSA). Which room should the charge nurse assign this client? - Answer A semi-
private room with a client who also has methicillin-resistant staphylococcus
aureus (MRSA)
The nurse is preparing a client for surgery. Which finding indicates that the client is ready to proceed to
the operating room (OR) for a scheduled surgical procedure? - Answer Hemoglobin 10.1 grams
correctly verified
A client is comatose upon arrival to the emergency department after falling a roof. The client flexes with
painful stimuli, and the nurse determines the client's Glasgow Coma Scale (GCS) is 6. Which intervention
should the nurse prepare to implement to maintain the client's airway? - Answer A nasopharyngeal tube
A client is receiving a continuous half strength tube feeding at 50 ml/hr. To prepare enough of the
solution for eight hours, how many ml of full strength feeding will the nurse need? - Answer Answer:
200
25 ml x 8hrs = 200
The alarm of a client's pulse oximeter sounds and the nurse notes that the oxygen saturation rate is
indicated at 85%. What action should the nurse take first? - Answer Check the probe position
A client is known to have an irregular respiratory rate with periods of apnea lasting 10 to 15 seconds.
Currently, the nurse counts 22 respiratory cycles in a 30-second interval followed by an apneic period.
What intervention should the nurse implement? - Answer Reassess the respiratory rate, counting for
one full minute
A retiree with depression complains of feeling "lonely and having no purpose" in life.Based on Erikson's
developmental theory, which questions suggest that the nurse understands the client's most important
emotional need? - Answer "What about your life makes you proud?"
Following a precipitous labor, a client has a continuous trickling of bright red blood from her vagina. Her
uterus is firm and her vital signs are within normal limits. The
nurse determines that the client's symptoms may indicate which condition? - Answer A cervical
laceration
In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical
nurse? - Answer An elderly client with Alzheimer's disease complicated by dysphagia
,The healthcare provider prescribes oxygen per nasal cannula at 2 L/min. Which action has the highest
priority when the nurse implements this prescription? - Answer Set the flow meter
9. A nurse who is new to the pediatric unit is positioning a 6-month-old for an injection of penicillin V
(Pen V) in the dorsogluteal muscle. Which action should the nurse-manager who is supervising this
nurse take first? - Answer C. Instruct the nurse to select another injection site
10. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the nurse provides
home care instructions to the mother. Which statement by the child's mother indicates that she
understands home care treatment to promote pulmonary function? - Answer "Chest physiotherapy
should be performed at least twice a day"
The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in
preventing bone loss and promoting bone formation? - Answer Encourage physical activity
The nurse reviews the signs of hypoglycemia with the parents of a child with Type 1 diabetes mellitus.
The parents correctly understands signs of hypoglycemia if they include which symptom? - Answer
Sweating
The nurse observes a 2 cm area nonblanchable erythema on the sacrum of an immobile client. What
documentation of this finding is best for the nurse to enter into the client's record? - Answer Stage 1
pressure ulcer on sacrum
When assessing a 7-year-old girl, the nurse notes that she has multiple bruises on her back and upper
arms. The child's aunt tells the nurse that the child's parents abuse drugs and alcohol. What intervention
is most essential for the nurse to implement? - Answer Report assessment findings to the proper legal
authorities
15. A 14-year-old male client arrives at the emergency room in status epilepticus. He was diagnosed
with a seizure disorder in childhood. What is the most likely cause of his present condition? - Answer
Acute withdrawal from anticonvulsant medication
A Chinese-American client who just delivered a baby states that she will not be able to take the
prescribed sitz baths to help heal her episiotomy incision because this will cause an unhealthy balance of
, cold and hot forces. When planning nursing care, what nursing diagnosis has the highest priority? -
Answer Impaired tissue integrity related to episiotomy
17. A 2-year-old with sickle cell anemia has an axillary temperature of 102 F. In planning care for this
child, which nursing diagnosis has the highest priority? - Answer High risk for fluid volume deficit related
to temperature elevation
During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir
(Zovirax) prior to this pregnancy tells the nurse that she is experiencing an episode of genital herpes.
Which nursing intervention has the highest priority? - Answer Determine if the client has taken acyclovir
(Zovirax) for this outbreak of genital herpes
The nurse is obtaining a medication history for a client with a new prescription for paroxetine (Paxil).
The client reports current use of the MAO inhibitor isocarboxazid
(Marplan). What intervention is most important for the nurse to implement? - Answer Notify the
healthcare provider that the client is currently taking Marplan
While performing a skin inspection on a newborn, the nurse finds a small dimple and a dark tuft of hair
in the lumbosacral area of the infant's back. What is the most likely indication of this finding? - Answer
External manifestation of a spinal abnormality
What action should the nurse implement first when delegating nursing activities to an unlicensed
assistive personnel (UAP)? - Answer Evaluate the experience of the UAP
A female resident of a long-term care facility is being admitted to the medical department. The client
has a fractured hip and has methicillin-resistant
staphylococcus aureus (MRSA). Which room should the charge nurse assign this client? - Answer A semi-
private room with a client who also has methicillin-resistant staphylococcus
aureus (MRSA)
The nurse is preparing a client for surgery. Which finding indicates that the client is ready to proceed to
the operating room (OR) for a scheduled surgical procedure? - Answer Hemoglobin 10.1 grams
