Question 1

A nurse received four messages while she was out of the clinic. The nurse would call which of the following clients first?

Accepted Answer

A) A male client with a cast on his left leg, reporting that his injured leg feels numb 
B) A female client with osteoporosis, reporting low back pain 
C) A female client prescribed with an antidepressant a week ago, reporting that she does not feel any improvement 
D) A mother who gave birth a week ago, complaining of abdominal cramps during breastfeeding

Question 2

A physician orders ceftizoxime sodium, 1 mg in 50 ml normal saline to be infused over 30 minutes. The drop factor is 15 drops per ml. A nurse prepares the flow rate at how many drops per minute?

Accepted Answer

A) 20 drops 
B) 25 drops 
C) 30 drops 
D) 35 drops

Question 3

A nurse is caring for an eighty-year-old client who is visually impaired. The nurse would take which of the following actions to reduce sensory deprivation?

Accepted Answer

A) Use of night light 
B) Close the curtains on the windows 
C) Open the curtains during daytime 
D) Keep the overhead light on 24 hours a day, 7 days a week

Question 4

After the arterial blood gas test results are reviewed, a client with signs of diabetic ketoacidosis is diagnosed with metabolic acidosis. The nurse caring for the client expects to note which of the following laboratory results in the client's chart?

Accepted Answer

A) Low pH; low bicarbonate concentration 
B) High pH; high bicarbonate concentration 
C) Low pH; high PCO2 
D) High pH; low PCO2

Question 5

A nurse is alerted when she finds a 10-year-old child having seizures. Which of the following nursing actions is most appropriate?

Accepted Answer

A) Insert a padded tongue blade into the child's mouth and depress the tongue. 
B) Restrain the child's legs and arms. 
C) Pad the side rails of the bed with soft blankets. 
D) Ask assistance from the nursing assistant to hold the child still.

Question 6

A three-day-old full-term infant is observed with yellowish skin and sclera. Laboratory examination reveals a total serum bilirubin level of 15 mg/dl. The nurse determines that these symptoms suggest:

Accepted Answer

A) Jaundice of prematurity 
B) Physiological jaundice 
C) Pathological jaundice 
D) Breastfeeding jaundice

Question 7

A nurse is assessing a six-month-old child. On assessment, noting of which of the following findings should alert the nurse to a possible problem?

Accepted Answer

A) The posterior fontanel is not completely ossified. 
B) The anterior fontanel is not completely ossified. 
C) The tonic neck reflex is not demonstrated. 
D) The infant's birth weight doubled.

Question 8

A nurse is caring for Elaine, a 5-year-old child who was admitted due to a suspected case of brain tumor. Diagnostic tests reveal that the child has a brain tumor involving the cerebellum. A surgery is ordered. During the pre-operative period, which of the following is the most important nursing intervention for the client?

Accepted Answer

A) Initiate seizure precautions. 
B) Monitor the child's temperature every 2 hours. 
C) Measure the child's circumference every morning. 
D) Initiate fall precautions

Question 9

Which of the following should alert the labour nurse that her client has begun the second stage of labour?

Accepted Answer

A) The cervix is thin and fully dilated. 
B) The amniotic membranes have ruptured. 
C) The presenting part is below the ischial spines 
D) The woman tells you she needs to push.

Question 10

A male client with an obsessive-compulsive behavior is admitted to the mental health facility. He is unable to finish schoolbecause his repetitive behavior caused him to missmost of his classes. The nurse understands that the client's behavior is mainly caused by which of the following:

Accepted Answer

A) The client is responding to a psychologically traumatic event and re-experiencing intrusive dreams. 
B) The client is responding to auditory hallucinations and is attempting to overcome them. 
C) The client is constantly preoccupied with intrusive thoughts and ideas and he is unconsciously attempting to reduce his anxiety. 
D) The client has an altered self-perception in which his own reality is temporarily lost.

Question 11

Nikki, a female client who had an abdominal surgery a week ago, demonstrates separation of the wound edges at the suture line. Increased drainage and appearance of underlying tissues through the wound are noted. Which of the following is the most appropriate initial nursing intervention for the client?

Accepted Answer

A) Cover the wound with a sterile normal saline solution. 
B) Place the client in low Fowler's position with the knees bent. 
C) Instruct the client to splint the incision. 
D) Notify the physician.

Question 12

A physician orders a medication to a client with fluid volume deficit. The medication is ordered to be administered through the intravenous route. Which of the following actions by the nurse is the least appropriate when inserting an intravenous line?

Accepted Answer

A) Using sterile technique when inserting an intravenous line. 
B) Cleaning the skin using an inner to outer circular motion. 
C) Priming the tubing. 
D) Starting the intravenous infusion proximally.

Question 13

A client comes to the emergency department complaining of abrupt onset of midepigastric pain with radiation to the back. Cullen's sign, Turner's sign, abdominal guarding, decreased bowel sounds, and nausea and vomiting are documented. The client is diagnosed with acute pancreatitis. Which of the following medications is a physician most likely to prescibe to this client in order to relieve pain?

Accepted Answer

A) Morphine sulfate 
B) Meperidine hydrochloride 
C) Codeine sulfate 
D) Neomycin

Question 14

A nurse is applying a compression bandage around the client's leg. Which of the following describes the appropriate application of a compression bandage?

Accepted Answer

A) Apply the bandage at the knee and work toward the calf. 
B) Stretch the bandage slightly with each turn. 
C) Apply heavy pressure with each turn. 
D) Apply the bandage around the knee, work toward the calf and apply the bandage down the calf again.

Question 15

A female client has just been admitted with a diagnosis of major depression. Which of the following is the most appropriate question for the nurse to ask at this time?

Accepted Answer

A) "What is bothering you?" 
B) "Why do feel this way?" 
C) "How do you feel about yourself?" 
D) "Do you need help?"

Question 16

Rachel, a G1P0 female at 30 weeks' gestation, was admitted to the facility due to persistent headaches. On physical assessment, a blood pressure of 180/130 mm Hg was noted. Laboratory tests were conducted, revealing proteinuria of more than 5 grams in a 24-hour collection. History reveals that Rachel was diagnosed with pre-eclampsia. Her physician orders the administration of magnesium sulfate IV to prevent convulsions. The nurse who is tasked with preparing and administering the drug ensures that which of the following medications is readily available as an antidote for magnesium sulfate toxicity?

Accepted Answer

A) Naloxone 
B) Calcium gluconate 
C) Protamine sulfate 
D) N-acetylcysteine

Question 17

A nurse is obtaining the vital signs of a client with increased intracranial pressure. The nurse determines that which of the following findings suggest an increase of ICP?

Accepted Answer

A) Increased temperature, increased pulse rate, and a fall in blood pressure with widening pulse pressure 
B) Increased temperature, slowing of pulse, and a rise in blood pressure with widening pulse pressure 
C) Decreased temperature, slowing of pulse, and a rise in blood pressure with narrowing pulse pressure 
D) Decreased temperature, increased pulse rate, and a fall in blood pressure with narrowing pulse pressure

Question 18

Celine, a 45-year-old client, complains of sense of a curtain being drawn in her vision. Flashes of light, floaters, and blurred vision are also reported. Based on these details of information, the client is most likely diagnosed with:

Accepted Answer

A) Hyphema 
B) Glaucoma 
C) Retinal detachment 
D) Cataract

Question 19

Which of these clients should the nurse assess first?

Accepted Answer

A) A 10-year-old boy who is scheduled for a tonsillectomy in an hour 
B) A 3-year-old boy who had an episode of tonic-clonic seizure a day ago 
C) A 5-year-old child on a gluten-restricted diet initiated 48 hours ago 
D) A 6-month-old child sleeping quietly with bulging and tense anterior fontanel

Question 20

A nurse is caring for Mrs. Thomas, an adult female who sustained second-to-third-degree burn injuries in the anterior and posterior thorax. A physician orders silver sulfadiazine during wound dressing. The nurse recognizes the client's susceptibility to infection. Which of the following is the best action to prevent wound infection during cleaning and dressing?

Accepted Answer

A) Clean the burned areas using an irrigation system. 
B) Clean the burned areas with povidine iodine before applying silver sulfadiazine. 
C) Initiate contact precautions, and inform the other health care professionals about it. 
D) Wear sterile gloves, mask, and gown during wound care.

Exam 1: Changes in Health