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A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained
from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which
information should the nurse provide to the parents?
A. A retraining program will need to be initiated when the child returns home.
B. Diapering will be provided since hospitalization is stressful to preschoolers
C. A potty chair should be brought from home so he can maintain his toileting skills
D. Children usually resume their toileting behaviors when they leave the hospital
Answer:
D. Children usually resume their toileting behaviors when they leave the hospital
A 7-year old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low
intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare
provider?
A. Shift intake of 640mL IV fluids plus 30mL PO ice chips
B. Serum pH of 7.45
C. Gastric output of 100 mL in the last 8 hours
D. Serum potassium of 3.0 mg/dL
Answer:
D. Serum potassium of 3.0 mg/dL
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A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which
information is most important for the nurse to provide the parents prior to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family
Answer:
A. Instructions about how much fluid the child should drink daily
A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia
(BPH). Which information should the nurse provide?
A. Consume a high protein diet
B. Increase physical activity
C. Take vitamin supplements
D. Obtain a prostate-specific antigen blood level test
Answer:
B. Increase physical activity
A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis
gravidarum. Which action is most important for the nurse to implement?
A. Obtain the client's 24-hour dietary recall
B. Document mucosal membrane status
C. Schedule a consult with a nutritionist
D. Initiate prescribed intravenous fluids
Answer:
D. Initiate prescribed intravenous fluids
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A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum
hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare
provider's attention?
A. Esinapril
B. Allopurinol
C. Furosemide
D. Aspirin, low dose
Answer:
B. Allopurinol
A client fell in the bathroom when left unattended by the unlicensed assistive personnel (UAP). Which
information should the nurse include in the client's health record?
A. The UAP left the client to assist another client
B. The last time client was assisted to the bathroom
C. The unit was understaffed when the client fell
D. The client fell sustaining a fracture to the left hip
Answer:
D. The client fell sustaining a fracture to the left hip
A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only
three hours during the past 48 hours. Based on these findings, it is most important for the nurse to review
the laboratory value for which medication?
A. Lorazepam
B. Fluoxetine
C. Divalproex
D. Olanzapine
Answer:
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C. Divalproex
A client in the third trimester of pregnancy reports that she fells some "lumpy places" in her breasts and
that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider
in two weeks. What action should the nurse take?
A. Tell the client to begin nipple stimulation to prepare for breast feeding.
B. Reschedule the client's prenatal appointment for the following day
C. Explain that this normal secretion can be assessed at the next visit
D. Recommend that the client start wearing a supportive brassiere
Answer:
C. Explain that this normal secretion can be assessed at the next visit
A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse to report
to the healthcare provider?
A. Volume of each voiding is more than 300mL
B. Serum potassium that is elevated
C. Relief of flank pain that radiated into the groin
D. Hematuria that is beginning to turn pink
Answer:
D. Hematuria that is beginning to turn pink
A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important
in the plan of care?
A. Risk for ineffective self-health management related to deficient knowledge
B. Ineffective coping related to personal vulnerability
C. Risk for injury related to vertigo
D. Anxiety related to disruption of lifestyle
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A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained
from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which
information should the nurse provide to the parents?
A. A retraining program will need to be initiated when the child returns home.
B. Diapering will be provided since hospitalization is stressful to preschoolers
C. A potty chair should be brought from home so he can maintain his toileting skills
D. Children usually resume their toileting behaviors when they leave the hospital
Answer:
D. Children usually resume their toileting behaviors when they leave the hospital
A 7-year old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low
intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare
provider?
A. Shift intake of 640mL IV fluids plus 30mL PO ice chips
B. Serum pH of 7.45
C. Gastric output of 100 mL in the last 8 hours
D. Serum potassium of 3.0 mg/dL
Answer:
D. Serum potassium of 3.0 mg/dL
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A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which
information is most important for the nurse to provide the parents prior to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family
Answer:
A. Instructions about how much fluid the child should drink daily
A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia
(BPH). Which information should the nurse provide?
A. Consume a high protein diet
B. Increase physical activity
C. Take vitamin supplements
D. Obtain a prostate-specific antigen blood level test
Answer:
B. Increase physical activity
A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis
gravidarum. Which action is most important for the nurse to implement?
A. Obtain the client's 24-hour dietary recall
B. Document mucosal membrane status
C. Schedule a consult with a nutritionist
D. Initiate prescribed intravenous fluids
Answer:
D. Initiate prescribed intravenous fluids
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A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum
hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare
provider's attention?
A. Esinapril
B. Allopurinol
C. Furosemide
D. Aspirin, low dose
Answer:
B. Allopurinol
A client fell in the bathroom when left unattended by the unlicensed assistive personnel (UAP). Which
information should the nurse include in the client's health record?
A. The UAP left the client to assist another client
B. The last time client was assisted to the bathroom
C. The unit was understaffed when the client fell
D. The client fell sustaining a fracture to the left hip
Answer:
D. The client fell sustaining a fracture to the left hip
A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only
three hours during the past 48 hours. Based on these findings, it is most important for the nurse to review
the laboratory value for which medication?
A. Lorazepam
B. Fluoxetine
C. Divalproex
D. Olanzapine
Answer:
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C. Divalproex
A client in the third trimester of pregnancy reports that she fells some "lumpy places" in her breasts and
that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider
in two weeks. What action should the nurse take?
A. Tell the client to begin nipple stimulation to prepare for breast feeding.
B. Reschedule the client's prenatal appointment for the following day
C. Explain that this normal secretion can be assessed at the next visit
D. Recommend that the client start wearing a supportive brassiere
Answer:
C. Explain that this normal secretion can be assessed at the next visit
A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse to report
to the healthcare provider?
A. Volume of each voiding is more than 300mL
B. Serum potassium that is elevated
C. Relief of flank pain that radiated into the groin
D. Hematuria that is beginning to turn pink
Answer:
D. Hematuria that is beginning to turn pink
A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important
in the plan of care?
A. Risk for ineffective self-health management related to deficient knowledge
B. Ineffective coping related to personal vulnerability
C. Risk for injury related to vertigo
D. Anxiety related to disruption of lifestyle
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