A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42%
following a D&C. Which of the following would the nurse expect to find when
assessing this client?
A) Capillary refill less than 3 seconds
B) Pale mucous membranes
C) Respirations 36 breaths per minute
D) Complaints of fatigue when ambulating
A
The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the
following diagnostic tests is essential for determining the presence of active TB?
The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the
following diagnostic tests is essential for determining the presence of active TB?
A) Tuberculin skin testing
B) Sputum culture
C) White blood cell count
D) Chest x-ray
B
The nurse has been teaching an apprehensive primipara who has difficulty in initial
nursing of the newborn. What observation at the time of discharge suggests that
initial breast feeding is effective?
A) The mother feels calmer and talks to the baby while nursing
B) The mother awakens the newborn to feed whenever it falls asleep
C) The newborn falls asleep after 3 minutes at the breast
D) The newborn refuses the supplemental bottle of glucose water
,A
The mother of a burned child asks the nurse to clarify what is meant by a third
degree burn. The best response by the nurse is
A) "The top layer of the skin is destroyed."
B) "The skin layers are swollen and reddened."
C) "All layers of the skin were destroyed in the burn."
D) "Muscle, tissue and bone have been injured."
C
The nurse is taking a health history from a Native American client. It is critical that
the nurse must remember that eye contact with such clients is considered
A) Expected
B) Rude
C) Professional
D) Enjoyable
B
A nurse is instructing a class for new parents at a local community center. The nurse
would stress that which activity is most hazardous for an 8 month-old child?
A) Riding in a car
B) Falling off a bed
C) Electrical outlets
D) Eating peanuts
D
When teaching parents about sickle cell disease, the nurse should tell them that
their child's anemia is caused by
A) Reduced oxygen capacity of cells due to lack of iron
B) An imbalance between red cell destruction and production
,C) Depression of red and white cells and platelets
D) Inability of sickle shaped cells to regenerate
B
The nurse is assessing a newborn delivered at home by an admitted heroin addict.
Which of the following would the nurse expect to observe?
A) Hypertonic neuro reflex
B) Immediate CNS depression
C) Lethargy and sleepiness
D) Jitteriness at 24-48 hours
D
The nurse is caring for a client with congestive heart failure. Which finding requires
the nurse's immediate attention?
A) Pulse oximetry of 85%
B) Nocturia
C) Crackles in lungs
D) Diaphoresis
A
The nurse is assessing a young child at a clinic visit for a mild respiratory infection.
Koplik spots are noted on the oral mucous membranes. The nurse should then
assess which area of the body?
A) Inspect the skin
B) Auscultate breath sounds
C) Evaluate muscle strength
D) Investigate elimination patterns
A
Which action is most likely to ensure the safety of the nurse while making a home
visit?
, A) Observation during the visit of no evidence of weapons in the home
B) Prior to the visit, review client's record for any previous entries about violence
C) Remain alert at all times and leave if cues suggest the home is not safe
D) Carry a cell phone, pager and/or hand held alarm for emergencies
C
An adolescent client is admitted in respiratory alkalosis following aspirin overdose.
The nurse recognizes that this imbalance was caused by
A) Tachypnea
B) Acidic byproducts
C) Vomiting and dehydration
D) Hyperpyrexia
A
The nurse discovers that the parents of a 2 year-old child continue to use an apnea
monitor each night. The parents state: "We are concerned about the possible
occurrence of sudden infant deathsyndrome (SIDS)." In order to take appropriate
action, the nurse must understand that
A) The child is within the age group most susceptible to SIDS
B) The peak age for occurrence of SIDS is 8 to 12 months of age
C) The apnea monitor is not effective on a child in this age group
D) 95% of SIDS cases occur before 6 months of age
D
As a client is being discharged following resolution of a spontaneous pneumothorax,
he tells the nurse that he is now going to Hawaii for a vacation. The nurse would
warn him to avoid
A) Surfing
B) Scuba diving