Page | 1
The nurse is teaching a continuing education course regarding vaccines and
pregnancy. It would be appropriate for the nurse to state which vaccines are
not recommended to be administered during pregnancy? Select all that apply.
A. MMR
B. Varicella
C. Hepatitis A
D. Inactivated Influenza
E. TDAP (Tetanus, Diphtheria, Pertussis)
F. Human Papillomavirus (HPV)
A, B, F
The nurse is teaching a client about the newly prescribed medication,
sevelamer. Which statement, if made by the client, would indicate a correct
understanding of the teaching?
A. "This medication will help lower my calcium level."
B. "I should take this medication with my meal."
C. "I may experience bad diarrhea with this medication."
D. "My blood pressure may increase while I take this medication."
B; Sevelamer is a phosphate binder that is indicated for individuals with
chronic kidney disease (CKD). This medication inhibits phosphorus
absorption, thereby increasing the calcium level. Hyperphosphatemia and
hypocalcemia are common laboratory abnormalities found in CKD.
Phosphorus and calcium have a reciprocal relationship; therefore, lowering
phosphorus levels through phosphate binders is a standard treatment for
CKD. The nurse should ensure these medications are given with meals and
advise the client to mitigate the common effect of constipation through stool
softeners and laxatives.
The nurse assesses an infant who sustained a traumatic brain injury (TBI).
Which assessment finding requires follow-up?
Select all that apply.
, A. Bulging fontanel
B. Tachycardia
C. Bradycardia
Page | 2 D. Ptosis
E. Distended scalp veins
For an infant with a TBI, the nurse must assess the newborn for increased
intracranial pressure. Manifestations of increased ICP in newborns and infants
include a high-pitched cry, bulging fontanels that may also have distended
scalp veins, irritability, bradycardia, and an irregular breathing pattern.
The nurse is caring for a client who has a factitious disorder. The client reports
chest pain. Which of the following actions should the nurse take? Select all that
apply.
A. Provide reassurance that this is part of the disorder
B. Notify the primary healthcare physician (PHCP)
C. Obtain a 12-lead Electrocardiogram
D. Disregard the symptom as it may be unreliable
E. Assess vital signs
B, C, E; Chest pain is a worrisome manifestation as it may be a clinical finding
associated with myocardial infarction, pulmonary embolism, or other
pathology. Despite the client having factitious disorder, which is characterized
by the client feigning their symptoms, the nurse should intervene by notifying
the PHCP, obtaining a 12-lead Electrocardiogram, and assessing vital signs.
This is the standard of care for any client reporting an acute change such as
angina.
Your client has continuous intravenous fluid replacement at 75 mL per hour. At
2 pm, the client complains about the intravenous line and states, "The IV is
hurting me." You assess the site and note that it is red with a streak. You palpate
the area and you can barely feel a venous cord. What would you suspect and
what is the first thing that you would do?
A. Grade 3 phlebitis: You would immediately stop the intravenous fluid
infusion.
B. Grade 4 phlebitis: You would immediately place a cool compress on the site.
C. Infiltration: You would immediately stop the intravenous fluid infusion.
D. Catheter embolus: You would immediately tourniquet the area distal to the
site.
, A; You would suspect a grade 3 phlebitis and you would immediately stop the
intravenous fluid. Grade 3 phlebitis is characterized by pain, a visible streak,
site redness, and a palpable venous cord less than 1 inch. Grade 4 phlebitis is
characterized by pain, a visible streak, site redness, a palpable venous cord
Page | 3 more than 1 inch, and possible drainage. Lastly, as with all intravenous
therapy, any suspicion of a complication is immediately addressed with the
discontinuation of the intravenous line
The nurse is caring for a client that is hypothermic and receiving warmed IV
fluids. The nurse understands that rewarming must be done slowly due to
which primary reason?
A. To prevent burns in the patient.
B. To prevent ventricular fibrillation and cardiovascular collapse.
C. To prevent frostbite.
D. To avoid muscle spasms.
B; Rewarming must be done slowly because the hypothermic client is
especially susceptible to the development of ventricular fibrillation and
cardiovascular collapse if warmed blood is returned rapidly to a cold heart.
The nurse is caring for a child with nephroblastoma. The nurse plans to take
which action?
A. Post a sign that states, "Do not palpate abdomen"
B. Recommend foods low in protein
C. Insert an indwelling urinary catheter
D. Initiate fluid restrictions
A; Nephroblastoma (Wilms tumor) is the most common childhood cancer.
Common treatments include surgical removal followed by chemotherapy.
Nursing care involves minimal manipulation of the abdomen (no palpation)
and a posted sign. It is essential to keep the encapsulated tumor intact.
The nurse is discussing infection control with a group of nursing students. It
would be correct to state that droplet precautions are used for which
condition?
Select all that apply.
A. Influenza
B. Viral meningitis
C. Pertussis
D. Hepatitis C
E. Lyme disease
, A,C
While caring for a patient who has recently suffered from a fracture, the nurse
sees that the patient's injured extremity will be placed in traction. Which of the
following actions should the nurse refrain from performing?
Page | 4
A. Keeping the pulley system tightened so that they may not move freely
B. Check the ropes for fraying or break
C. Keep the weights above the floor
D. Ensure proper body alignment
A; The nurse caring for a patient in traction should avoid keeping the pulley
system tight. The pulley system should move freely uninhibited by knots or
tension. Traction is used to reduce and immobilize a fracture.
The nurse educates a family with a child with phenylketonuria (PKU). It would
be appropriate for the nurse to recommend that the child avoid which foods?
Select all that apply.
A. Pork tenderloin
B. Green beans
C. Cheese omelets
D. Pears
E. Almond milk
A, C; In phenylketonuria (PKU), there is impaired metabolism of an essential
amino acid named phenylalanine. When clients eat foods containing this
amino acid, they cannot break it down, and levels of this amino acid can
become toxic.
The nurse is performing an assessment on a term newborn four hours after
delivery. Which assessment findings require follow-up? Select all that apply.
A. Head circumference of 34 cm
B. Chest is 2 cm smaller than the head
C. Vernix caseosa in the skin folds
D. Positive Babinski reflex
E. Asymmetrical gluteal folds
F. Jaundice noted in the head
E,F; Jaundice may be classified as pathologic or physiologic. Jaundice with an
onset of less than 24-hours is pathologic and concerning as this may indicate
hemolysis. Asymmetrical gluteal folds are not an expected finding because this
suggests developmental dysplasia of the hip.
The nurse is teaching a continuing education course regarding vaccines and
pregnancy. It would be appropriate for the nurse to state which vaccines are
not recommended to be administered during pregnancy? Select all that apply.
A. MMR
B. Varicella
C. Hepatitis A
D. Inactivated Influenza
E. TDAP (Tetanus, Diphtheria, Pertussis)
F. Human Papillomavirus (HPV)
A, B, F
The nurse is teaching a client about the newly prescribed medication,
sevelamer. Which statement, if made by the client, would indicate a correct
understanding of the teaching?
A. "This medication will help lower my calcium level."
B. "I should take this medication with my meal."
C. "I may experience bad diarrhea with this medication."
D. "My blood pressure may increase while I take this medication."
B; Sevelamer is a phosphate binder that is indicated for individuals with
chronic kidney disease (CKD). This medication inhibits phosphorus
absorption, thereby increasing the calcium level. Hyperphosphatemia and
hypocalcemia are common laboratory abnormalities found in CKD.
Phosphorus and calcium have a reciprocal relationship; therefore, lowering
phosphorus levels through phosphate binders is a standard treatment for
CKD. The nurse should ensure these medications are given with meals and
advise the client to mitigate the common effect of constipation through stool
softeners and laxatives.
The nurse assesses an infant who sustained a traumatic brain injury (TBI).
Which assessment finding requires follow-up?
Select all that apply.
, A. Bulging fontanel
B. Tachycardia
C. Bradycardia
Page | 2 D. Ptosis
E. Distended scalp veins
For an infant with a TBI, the nurse must assess the newborn for increased
intracranial pressure. Manifestations of increased ICP in newborns and infants
include a high-pitched cry, bulging fontanels that may also have distended
scalp veins, irritability, bradycardia, and an irregular breathing pattern.
The nurse is caring for a client who has a factitious disorder. The client reports
chest pain. Which of the following actions should the nurse take? Select all that
apply.
A. Provide reassurance that this is part of the disorder
B. Notify the primary healthcare physician (PHCP)
C. Obtain a 12-lead Electrocardiogram
D. Disregard the symptom as it may be unreliable
E. Assess vital signs
B, C, E; Chest pain is a worrisome manifestation as it may be a clinical finding
associated with myocardial infarction, pulmonary embolism, or other
pathology. Despite the client having factitious disorder, which is characterized
by the client feigning their symptoms, the nurse should intervene by notifying
the PHCP, obtaining a 12-lead Electrocardiogram, and assessing vital signs.
This is the standard of care for any client reporting an acute change such as
angina.
Your client has continuous intravenous fluid replacement at 75 mL per hour. At
2 pm, the client complains about the intravenous line and states, "The IV is
hurting me." You assess the site and note that it is red with a streak. You palpate
the area and you can barely feel a venous cord. What would you suspect and
what is the first thing that you would do?
A. Grade 3 phlebitis: You would immediately stop the intravenous fluid
infusion.
B. Grade 4 phlebitis: You would immediately place a cool compress on the site.
C. Infiltration: You would immediately stop the intravenous fluid infusion.
D. Catheter embolus: You would immediately tourniquet the area distal to the
site.
, A; You would suspect a grade 3 phlebitis and you would immediately stop the
intravenous fluid. Grade 3 phlebitis is characterized by pain, a visible streak,
site redness, and a palpable venous cord less than 1 inch. Grade 4 phlebitis is
characterized by pain, a visible streak, site redness, a palpable venous cord
Page | 3 more than 1 inch, and possible drainage. Lastly, as with all intravenous
therapy, any suspicion of a complication is immediately addressed with the
discontinuation of the intravenous line
The nurse is caring for a client that is hypothermic and receiving warmed IV
fluids. The nurse understands that rewarming must be done slowly due to
which primary reason?
A. To prevent burns in the patient.
B. To prevent ventricular fibrillation and cardiovascular collapse.
C. To prevent frostbite.
D. To avoid muscle spasms.
B; Rewarming must be done slowly because the hypothermic client is
especially susceptible to the development of ventricular fibrillation and
cardiovascular collapse if warmed blood is returned rapidly to a cold heart.
The nurse is caring for a child with nephroblastoma. The nurse plans to take
which action?
A. Post a sign that states, "Do not palpate abdomen"
B. Recommend foods low in protein
C. Insert an indwelling urinary catheter
D. Initiate fluid restrictions
A; Nephroblastoma (Wilms tumor) is the most common childhood cancer.
Common treatments include surgical removal followed by chemotherapy.
Nursing care involves minimal manipulation of the abdomen (no palpation)
and a posted sign. It is essential to keep the encapsulated tumor intact.
The nurse is discussing infection control with a group of nursing students. It
would be correct to state that droplet precautions are used for which
condition?
Select all that apply.
A. Influenza
B. Viral meningitis
C. Pertussis
D. Hepatitis C
E. Lyme disease
, A,C
While caring for a patient who has recently suffered from a fracture, the nurse
sees that the patient's injured extremity will be placed in traction. Which of the
following actions should the nurse refrain from performing?
Page | 4
A. Keeping the pulley system tightened so that they may not move freely
B. Check the ropes for fraying or break
C. Keep the weights above the floor
D. Ensure proper body alignment
A; The nurse caring for a patient in traction should avoid keeping the pulley
system tight. The pulley system should move freely uninhibited by knots or
tension. Traction is used to reduce and immobilize a fracture.
The nurse educates a family with a child with phenylketonuria (PKU). It would
be appropriate for the nurse to recommend that the child avoid which foods?
Select all that apply.
A. Pork tenderloin
B. Green beans
C. Cheese omelets
D. Pears
E. Almond milk
A, C; In phenylketonuria (PKU), there is impaired metabolism of an essential
amino acid named phenylalanine. When clients eat foods containing this
amino acid, they cannot break it down, and levels of this amino acid can
become toxic.
The nurse is performing an assessment on a term newborn four hours after
delivery. Which assessment findings require follow-up? Select all that apply.
A. Head circumference of 34 cm
B. Chest is 2 cm smaller than the head
C. Vernix caseosa in the skin folds
D. Positive Babinski reflex
E. Asymmetrical gluteal folds
F. Jaundice noted in the head
E,F; Jaundice may be classified as pathologic or physiologic. Jaundice with an
onset of less than 24-hours is pathologic and concerning as this may indicate
hemolysis. Asymmetrical gluteal folds are not an expected finding because this
suggests developmental dysplasia of the hip.
