Question 1

As the nurse assesses a six-month-old female infant, the nurse notices that when the infant's feet are placed on a firm surface, she pushes down with her legs. Which of the following is the nurse's initial action?

Accepted Answer

A) Document the finding as normal. 
B) Instruct the parents to stretch the infant's legs when lying on her stomach. 
C) Inform the parents about possible treatment options for cerebral palsy. 
D) Notify the physician.

Question 2

A nurse is assigned to the in-hospital triage area, which utilizes a three-tier system: emergent, urgent, and non-urgent. Which of the following clients has an emergent condition and needs to receive treatment immediately or within 15 to 30 minutes of admission?

Accepted Answer

A) An 11-year-old boy with wheezing and difficulty breathing. 
B) A 12-year-old boy with a complex long bone fracture. 
C) A 5-year-old girl with a high fever with stable vital signs. 
D) A 3-year-old girl with minor laceration in the abdominal region.

Question 3

John Isles, a 10-year-old client with sickle cell disease, is admitted for sickle cell crisis. Initials assessment shows a temperature of 38.2°Cand swelling in the left leg. The client complains of severe pain in the affected extremity. The nurse recognizes this as what type of sickle cell crisis?

Accepted Answer

A) Vaso-occlusive 
B) Hypovolemic 
C) Aplastic 
D) Sequestration

Question 4

A client with schizophrenia refuses to leave his room to have dinner. The client tells the nurse that the Queen of England will be seeing him in his room. The nurse's best response is:

Accepted Answer

A) "Anyone in this unit who refuses to follow our schedule shall be placed in seclusion." 
B) "It is dinner time. Let's go to the dining hall so you can eat." 
C) "The Queen of England asked me to inform you that she's meeting you in the dining hall instead." 
D) "The Queen of England is not meeting you. You don't know her personally."

Question 5

A client with total parenteral nutrition complains of chest pain and difficulty breathing. The nurse suspects air embolism. Which of the following is the initial action of the nurse?

Accepted Answer

A) Notify the physician. 
B) Clamp the intravenous catheter. 
C) Place the client in left-side lying position. 
D) Administer oxygen.

Question 6

Joe Engel, a 15-year-old high school student, had a skating accident. A cast is applied to his left arm due to an ulnar fracture. The nurse teaches the client exercises that maintain the muscle strength of the affected arm. The most recommended group of exercises to regain or maintain muscle strength is:

Accepted Answer

A) Isotonic exercise 
B) Isokinetic exercise 
C) Isometric exercise 
D) Aerobic exercise

Question 7

A client complaining of joint pain is diagnosed with osteoarthritis, a progressive degeneration of a joint as a result of wear-and-tear. The nurse expects to note which of the following findings in the client's record?

Accepted Answer

A) Joint symptoms in symmetrical pattern 
B) Hand deformities 
C) Joint pain that intensifies after inactivity 
D) Joint pain that diminishes after rest

Question 8

A nurse is assessing a client who gave birth twelve hours ago. On assessment, the nurse notes that the client's fundus is above the umbilicus to the right. Which of the following is the nurse's initial action?

Accepted Answer

A) Place the client on her left side 
B) Massage the fundus 
C) Ask the client to void 
D) Notify the physician

Question 9

A client undergoes a radical mastectomy of the right breast. The nurse interprets that the client is beginning to adjust to the physical change if which of the following behaviors is noted?

Accepted Answer

A) The client refuses to look at her chest. 
B) The client is actively participating in caring for the surgical drain. 
C) The client is surfing on her laptop and reading about breast reconstruction surgery on the Internet. 
D) The client asks for pain medications.

Question 10

A nurse is caring for an eighty-year-old female client who is bedridden. The nurse would include the following nursing actions in the care plan, to prevent respiratory complications, except:

Accepted Answer

A) Instruct the client to bear down and hold her breath every two hours 
B) Monitor the client's vital signs every four hours 
C) Turn the client every two hours 
D) Teach the client deep breathing and coughing exercises

Question 11

A nurse is monitoring an 82-year-old male who had a transurethral resection of the prostate 12 hours ago. A three-way urinary catheter is inserted through the client's urethra and into the bladder for continuous irrigation. A total of 3,000 mL of bladder irrigant has been infused for the past 8 hours. After assessing the client, the nurse immediately contacts the physician for a possible complication of the procedure. Which of the following is most likely noted by the nurse during the assessment?

Accepted Answer

A) Urinary output of 3,500 mL for the past 8 hours 
B) Pain and sense of urgency to urinate are reported by the client 
C) Blood pressure of 110/50 mm Hg; 120 bpm 
D) Blood in urine with small clots

Question 12

A female client complains of vaginal burning and itching. Vaginal discharge with a cottage-cheese-like appearance is reported. History reveals that the client is on antibiotic therapy. The nurse suspects that the client is experiencing which of the following vaginal infections?

Accepted Answer

A) Gonorrhea 
B) Bacterial vaginosis 
C) Trichomoniasis 
D) Candidiasis

Question 13

A twelve-year-old girl just had surgery, and an incision was made in the abdominal area. The nurse would expect which of the following questions from the client?

Accepted Answer

A) "When can I go back to school?" 
B) "Are there any complications?" 
C) "When is my mother coming back?" 
D) "Will I have a large scar?"

Question 14

A client tells the nurse that her officemates are trying to sabotage her work because they do not want her to get a promotion. As the nurse assesses the situation, the client becomes aggressive. This behavior of the client shows personality traits associated with which of the following personality disorders?

Accepted Answer

A) Schizoid 
B) Paranoid 
C) Borderline 
D) Antisocial

Question 15

A nurse notes that the site of the client's intravenous catheter is slightly edematous and cool. Blood return is not observed upon lowering the IV fluid below the IV site. Which of the following nursing actions is not appropriate for this client?

Accepted Answer

A) Removing the intravenous device immediately 
B) Rubbing or massaging the infiltrated area 
C) Elevating the affected extremity 
D) Application of warm or cool compresses over the site

Question 16

A nurse just received the report from the previous shift. Which of the following clients would the nurse see first?

Accepted Answer

A) A client who has been vomiting for the past 24 hours 
B) A client who is scheduled for a cholecystectomy in an hour 
C) A client who had tumor lysis syndrome 3 hours ago 
D) A client who has been having recurring pain for short periods of time for the past 24 hours

Question 17

A physician ordered Anthony, a male client who was admitted due to aspiration of gastric contents, to undergo decompression of the stomach. A nurse is tasked withinserting a nasogastric tube. As the nurse inserts the tube, resistance is met. Which of the following is the next action of the nurse?

Accepted Answer

A) Ask the client to drink swallow by sipping on small amounts of water. 
B) Remove the tube and insert it into the other nostril. 
C) Pull back the tube a little and then try to continue pushing the tube into the nostril. 
D) Check patency by placing the open end of the tube in a cup of water.

Question 18

Melissa is a 46-year-old office clerk with multiple sclerosis. Her symptoms have been progressing over the years. Melissa is complaining of difficulty of swallowing with occasional episodes of choking every time food particles get caught up in her throat. Which of the following would not be an appropriate strategy to prevent discomfort in swallowing for Melissa?

Accepted Answer

A) Allowing ample time eating. 
B) Offering water during meals. 
C) Encouraging her to avoid speaking while eating. 
D) Encouraging her to maintain an upright position during meals.

Question 19

Cooper is a 7-year-old male diagnosed with bronchial asthma. The boy and his mother consult a physician after he experiences increasingly frequent episodes of Cooper's acute asthma over a period of several months. The child has a case of hypersensitivity. The physician describes a medication taken routinely to prevent acute asthma episodes. Which of the following medications is taken prophylactically?

Accepted Answer

A) Albuterol 
B) Ipratropium 
C) Cromolyn sodium 
D) Methylprednisolone

Question 20

The nurse attending Inna, a female client who had a recent surgery with spinal anesthesia, notes restlessness, cool clammy skin, and hypotension. Hypovolemic shock is suspected. Which of the following is NOT a safe nursing intervention for the client?

Accepted Answer

A) Elevate the legs above the level of the heart. 
B) Administer oxygen. 
C) Administer colloid solutions, as prescribed. 
D) Monitor level of consciousness.

Exam 1: Changes in Health