Q&A Random Selection #13

1. The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is
A) pain
B) impaired gas exchange
C) cardiac output altered: decreased
D) fluid volume excess

2. In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good
healing?
A) White patches
B) Green drainage
C) Reddened tissue
D) Eschar development

3. The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a
priority to assess for findings of heart conduction disturbance?
A) Arterial septal defect
B) Patent ductus arteriosus
C) Aortic stenosis
D) Ventricular septal defect

4. When an autistic client begins to eat with her hands, the nurse can best handle the problem by
A) placing the spoon in the client’s hand and stating, "Use the spoon to eat your food."
B) commenting, "I believe you know better than to eat with your hand."
C) jokingly stating, "Well I guess fingers sometimes work better than spoons."
D) removing the food and stating, "You can’t have anymore food until you use the spoon."

5. A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he
tells the nurse "I’ve made some decisions about my life." What should be the nurse’s initial response?
A) "You’ve made some decisions."
B) "Are you thinking about killing yourself?"
C) "I’m so glad to hear that you’ve made some decisions."
D) "You need to discuss your decisions with your therapist."

6. The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a
mental status examination when
A) an individual displays restlessness
B) there are obvious signs of depression
C) conducting any health assessment
D) the resident reports memory lapses

7. The nurse asks a client with a history of alcoholism about recent drinking behavior. The client states "I didn’t hurt
anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense
mechanism?
A) Denial
B) Projection
C) Intellectualization
D) Rationalization

8. When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations
are 12/minute. Which action should the nurse take first?
A) Try to vigorously stimulate normal breathing
B) Ask the RN to assess the vital signs
C) Measure the pulse oximetry
D) Continue to monitor respirations

9. A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When
planning
client teaching, what is most important for the nurse to emphasize?
A) Maintain a low sodium diet
B) Take a diuretic with lithium and avoid excessive fluids
C) Don't be overly concerned if feelings of depression occur
D) Come in for evaluation of serum lithium levels regularly
10. Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called
A) craving
B) crashing
C) outward bound
D) nodding out

11. What is the best way for the nurse to obtain the health history of a 14 year-old client?
A) Have the mother present to verify information
B) Allow an opportunity for the teen to express feelings
C) Use the same type of language as the adolescent
D) Focus the discussion of risk factors in the peer group

12. The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output
has
dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to
A) dehydration
B) diminished blood volume
C) decreased cardiac output
D) renal failure

13. When a client is having a general tonic clonic seizure, the nurse should
A) hold the client's arms at their side
B) place the client on their side
C) insert a padded tongue blade in client's mouth
D) elevate the head of the bed

14. The nursing intervention that best describes treatment to deal with the behaviors of clients with personality
disorders include
A) pointing out inconsistencies in speech patterns to correct thought disorders
B) accepting client and the client's behavior unconditionally
C) encouraging dependency in order to develop ego controls
D) consistent limit-setting enforced 24 hours per day

15. After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second
day on the unit the client states to the nurse, "My husband told me to get treatment or he would divorce me. I don’t
believe I really need treatment, but I don’t want my husband to leave me." Which response by the nurse would assist
the client?
A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people can’t get well."
B) "In early recovery, it’s quite common to have mixed feelings, but I didn’t know you had been pressured to come."
C) "In early recovery it’s quite common to have mixed feelings, perhaps it would be best to seek treatment on an
outpatient basis."
D) "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you."

16. The nurse understands that one reason domestic violence remains extensively undetected is
A) few battered victims seek medical care
B) there is typically a series of minor, vague complaints
C) expenses due to police and court costs are prohibitive
D) very little knowledge is currently known about batterers and battering relationships

17. The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest
drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the
chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to
A) check for subcutaneous emphysema in the upper torso
B) reposition the client to improve the level of comfort
C) call the provider as soon as possible
D) check for any increase in the amount of thoracic drainage

18. While teaching a client about their medications, the client asks how long it will take before the therapeutic effects
of lithium occur. What is the best response of the nurse?
A) Immediately
B) Several days
C) 2 weeks
D) 1 month

19. A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse
expect to find?
A) S3 heart sound
B) Thready pulse
C) Flattened neck veins
D) Hypoventilation

20. The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the
provider?
A) Lifts head from the prone position
B) Rolls from abdomen to back
C) Responds to parents' voices
D) Falls forward when sitting

21. Clients with mitral stenosis would likely manifest findings associated with congestion in the
A) pulmonary circulation
B) descending aorta
C) superior vena cava
D) bundle of His

22. The nurse is assessing a client on admission to a community mental health center. The client discloses that she
has been thinking about ending her life. The nurse's best response would be
A) "Do you want to discuss this with your pastor?"
B) "We will help you deal with those thoughts."
C) "Is your life so terrible that you want to end it?"
D) "Have you thought about how you would do it?"

23. The nurse is caring for a newborn who has just been diagnosed with hypospadias. When discussing the defect
with the parents, the nurse should communicate that
A) circumcision can be performed at any time
B) initial repair is delayed until 6-8 years of age
C) post-operative appearance will be normal
D) surgery will be performed in stages

24. A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose, for acute otitis media.
The child weighs 30 lb. (15 kg) and the daily dose range is 20-40 mg/kg of body weight, in three divided doses every
8 hours. Using
principles of safe drug administration, what should the nurse do next?
A) Give the medication as ordered
B) Call the provider to clarify the dose
C) Recognize that antibiotics are over-prescribed
D) Hold the medication as the dosage is too low

25. While planning care for a preschool aged child, the nurse takes developmental needs into consideration. Which of
the following would be of the most concern to the nurse?
A) Playing imaginatively
B) Expressing shame
C) Identifying with family
D) Exploring the playroom

26. The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which
information is a priority for these women?
A) Low tar cigarettes are less harmful during pregnancy
B) There is a relationship between smoking and low birth weight
C) The placenta serves as a barrier to nicotine
D) Moderate smoking is effective in weight control

27. In order to enhance a client's response to medication for chest pain from acute angina, the nurse should
emphasize
A) learning relaxation techniques
B) limiting alcohol use
C) eating smaller meals
D) avoiding passive smoke

28. When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority?
A) follow-up on lab values before the visit
B) observe client findings for the effectiveness of antibiotics
C) ask for a log of urinary output
D) ask for the log of the oral intake

29. A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new
nurse is surprised when one of the nurses states: "The manager makes all decisions and rarely asks for our input."
The best description of the nurse manager's management style is
A) Participative or democratic
B) Ultraliberal or communicative
C) Autocratic or authoritarian
D) Laissez faire or permissive
30. Clients taking which of the following drugs are at risk for depression?
A) Steroids
B) Diuretics
C) Folic acid
D) Aspirin

31. The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the
heart. Which of these describes the normal pathway?
A) AV node, SA node, Bundle of His, Purkinje fibers
B) Purkinje fibers, SA node, AV node, Bundle of His
C) Bundle of His, Purkinje fibers, SA node , AV node
D) SA node, AV node, Bundle of His, Purkinje fibers

32. A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and
slight tremors. The newborn passed one loose, watery stool. Which of these is a nursing priority?
A) Hold the infant at frequent intervals.
B) Assess for neonatal withdrawal syndrome
C) Offer fluids to prevent dehydration
D) Administer paregoric to stop diarrhea

33. A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis
and
involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other
measure
should the nurse implement?
A) Have respiratory support equipment available
B) Immediately place her in the seclusion room
C) Assess the client for anxiety and agitation
D) Administer prn dose of IM antipsychotic medication

34. What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected
in utero?
A) The disease will incubate longer and progress more slowly in this infant
B) The infant is very susceptible to infections
C) Growth and development patterns will proceed at a normal rate
D) Careful monitoring of renal function is indicated

35. The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands
common
sibling reactions to hospitalization?
A) Younger siblings adapt very well
B) Visitation is helpful for both
C) The siblings may enjoy privacy
D) Those cared for at home cope better

36. Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a
rash. The child had been seen the day before by the provider and diagnosed with Fifth Disease (erythema
infectiosum). What is the most appropriate action by the nurse?
A) Tell the parents to bring the child to the clinic for further evaluation
B) Refer the school officials to printed materials about this viral illness
C) Inform the teacher that the child is receiving antibiotics for the rash
D) Explain that this rash is not contagious and does not require isolation

37. Which therapeutic communication skill used by the nurse is most likely to encourage a depressed client to vent
feelings?
A) Direct confrontation
B) Reality orientation
C) Projective identification
D) Active listening

38. The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first
A) assess the client's airway
B) call for help
C) establish that the client is unresponsive
D) see if anyone saw the client fall
39. The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for
patency in a fistula used for hemodialysis?
A) observe for edema proximal to the site
B) irrigate with 5 ml of 0.9% Normal Saline
C) palpate for a thrill over the fistula
D) check color and warmth in the extremity

40. The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing
basketball. In understanding his behavior and in planning care for this client, the nurse should understand that
adolescents with hemophilia
_______.
A) must have structured activities
B) often take part in active sports
C) explain limitations to peer groups
D) avoid risks after bleeding episodes