NCLEX practice #14

1. Which contraindication should the nurse assess for prior to giving a child immunizations?

A) Mild cold symptoms

B) Chronic asthma

C) Depressed immune system

D) Allergy to eggs

The correct answer is C: Depressed immune system

Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

2. Which of the following situations is most likely to produce sepsis in the neonate?

A) Maternal diabetes

B) Prolonged rupture of membranes

C) Cesarean delivery

D) Precipitous vaginal birth

The correct answer is B: Prolonged rupture of membranes

Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

3.A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the provider ordering

A) pulmonary embolectomy

B) vena caval interruption

C) increasing the Coumadin therapy to an INR of 3-4

D) thrombolytic therapy

The correct answer is B: vena caval interruption

Clients with contraindications to Heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

4. A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that such remedies

A) destroy organisms causing disease

B) maintain fluid balance

C) boost the immune system

D) increase bodily energy

The correct answer is C: boost the immune system

The practitioner treats with minute doses of plant, mineral or animal substances which provide a gentle stimulus to the body''s own defenses.

Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle River, New Jersey.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

5. The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?

A) bounding pulse

B) rapid respirations

C) oliguria

D) neck veins are distended

The correct answer is C: oliguria

Kidneys maintain fluid volume through adjustments in urine volume.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

6. The nurse is at the community center speaking with retired people about glaucoma. Which comment by one of the retirees would the nurse support to reinforce correct information?

A) "I usually avoid driving at night since lights sometimes seem to make things blur."

B) "I take half of the usual dose for my sinuses to maintain my blood pressure."

C) "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem."

D) "I take extra fiber and drink lots of water to avoid getting constipated."

The correct answer is D: "I take extra fiber and drink lots of water to avoid getting constipated."

Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase intraocular pressure.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

7. A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention?

A) Capillary refill of fingers on right hand is 3 seconds

B) Skin warm to touch and normally colored

C) Client reports prickling sensation in the right hand

D) Slight swelling of fingers of right hand

The correct answer is C: Client reports prickling sensation in the right hand

A prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

8. The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. What is the nurse’s best response to the parents?

A) "Your child must use a care seat until he weighs at least 40 pounds."

B) "The child must be 5 years of age to use a regular seat belt."

C) "Your child must reach a height of 50 inches to sit in a seat belt."

D) "The child can use a regular seat belt when he can sit still."

The correct answer is A: "Your child must use a care seat until he weighs at least 40 pounds."

Children should use car seats until they weigh 40 pounds.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

9. The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspects of this care is/are

A) sedation as needed to prevent exhaustion

B) antibiotic therapy for 10 to 14 days

C) humidified air and increased oral fluids

D) antihistamines to decrease allergic response

The correct answer is C: humidified air and increased oral fluids

The most important aspects of home care for a child with acute spasmodic croup are humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids is mucociliary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

10. A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially?

A) Conduct guided imagery or distraction

B) Ensure that the stump is elevated the first day post-op

C) Wrap the stump snugly in an elastic bandage

D) Administer opioid narcotics as ordered

The correct answer is B: Ensure that the stump is elevated the first day post-op

This priority intervention prevents pressure caused by pooling of blood, thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Opioid narcotics are given for severe pain.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

11. A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial temperature is 95 degrees Fahrenheit (35 degrees Celsius) axillary. The nurse recognizes that cold stress may lead to what complication?

A) Lowered BMR

B) Reduced PaO2

C) Lethargy

D) Metabolic alkalosis

The correct answer is B: Reduced PaO2

Cold stress causes increased risk for respiratory distress. The baby delivered in such circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97 degrees Fahrenheit (36 degrees Celsius).

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

12. A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?

A) Regulate the neonate’s temperature using a radiant heater

B) Withhold feedings while under the phototherapy

C) Provide water feedings at least every 2 hours

D) Protect the eyes of neonate from the phototherapy lights

The correct answer is C: Provide water feedings at least every 2 hours

Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It is recommended that the neonate remain under the lights for extended periods. The neonate’s skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

13. A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process?

A) Disruption of fetal glucose supply

B) Pancreatic insufficiency

C) Maternal insulin dependency

D) Reduced glycogen reserves

The correct answer is A: Disruption of fetal glucose supply

After delivery, the high glucose levels which crossed the placenta to the fetus are suddenly stopped. The newborn continues to secrete insulin in anticipation of glucose. When oral feedings begin, the newborn will adjust insulin production within a day or two.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

14. A client with a fractured femur has been in Russell’s traction for 24 hours. Which nursing action is associated with this therapy?

A) Check the skin on the sacrum for breakdown

B) Inspect the pin site for signs of infection

C) Auscultate the lungs for atelectasis

D) Perform a neurovascular check for circulation

The correct answer is D: Perform a neurovascular check for circulation

While each of these is an important assessment, the neurovascular integrity check is most associated with this type of traction. Russell’s traction is Buck’s traction with a sling under the knee.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

15. A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct?

A) Days 7-10

B) Days 10-13

C) Days 14-16

D) Days 17-19

The correct answer is D: Days 17-19

Ovulation occurs 14 days prior to menses. Considering that the woman''s cycle is 32 days, subtracting 14 from 32 suggests ovulation is at about the 18th day.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New Jersey: Prentice Hall.

16. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?

A) Neurotoxicity

B) Hepatomegaly

C) Nephrotoxicity

D) Ototoxicity

The correct answer is C: Nephrotoxicity

Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th edition). Philadelphia: Saunders.

17.The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?

A) "I'm going to try feeding my baby some rice cereal."

B) "When he wakes at night for a bottle, I feed him."

C) "I dip his pacifier in honey so he'll take it."

D) "I keep formula in the refrigerator for 24 hours."

The correct answer is C: "I dip his pacifier in honey so he''ll take it."

Honey has been associated with infant botulism and should be avoided. Older children and adults have digestive enzymes that kill the botulism spores.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

18. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in an incubator. Which action is a nursing priority?

A) Protect the eyes of the neonate from the heat lamp

B) Monitor the neonate’s temperature

C) Warm all medications and liquids before giving

D) Avoid touching the neonate with cold hands

The correct answer is B: Monitor the neonate’s temperature

When using a warming device the neonate’s temperature should be continuously monitored for undesired elevations. The use of heat lamps is not safe as there is no way to regulate their temperature. Warming medications and fluids is not indicated. While touching with cold hands can startle the infant it does not pose a safety risk.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

19. A 16 year-old boy is admitted for Ewing's sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the initial treatment most often includes

A) amputation just above the tumor

B) surgical excision of the mass

C) bone marrow graft in the affected leg

D) radiation and chemotherapy

The correct answer is D: radiation and chemotherapy

The initial treatment of choice for Ewing''s sarcoma is a combination of radiation and chemotherapy.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

20. A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?

A) Place the child in the nearest bed

B) Administer IV medication to slow down the seizure

C) Place a padded tongue blade in the child's mouth

D) Remove the child's toys from the immediate area

The correct answer is D: Remove the child''s toys from the immediate area

Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child''s mouth and the child should not be moved. Of the choices given, the first priority would be to provide a safe environment.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

21. A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?

A) Call the health care provider

B) Access the site by cutting a window in the cast

C) Simply record the findings in the nurse's notes only

D) Outline the spot with a pencil and note the time and date on the cast

The correct answer is D: Outline the spot with a pencil and note the time and date on the cast

This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse’s notes.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby.

22.The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?

A) Irritability

B) Slight edema at site

C) Local tenderness

D) Seizure activity

The correct answer is D: Seizure activity

Other reactions that should be reported include crying for >3 hours, temperature over 104.8 degrees Fahrenheit following DPT immunization, and tender, swollen, reddened areas.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

23. When suctioning a client's tracheostomy, the nurse should instill saline in order to

A) decrease the client's discomfort

B) reduce viscosity of secretions

C) prevent client aspiration

D) remove a mucus plug

The correct answer is D: remove a mucus plug

While no longer recommended for routine suctioning, saline may thin and loosen viscous secretions that are very difficult to move, perhaps making them easier to suction.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

24. Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?

A) Venturi mask

B) Partial rebreather mask

C) Non-rebreather mask

D) Simple face mask

The correct answer is C: Non-rebreather mask

The non-rebreather mask has a one-way valve that prevents exhales air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of the oxygen is available.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

25. At a senior citizens meeting a nurse talks with a client who has Type 1 diabetes mellitus. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?

A) "I give my insulin to myself in my thighs."

B) "Sometimes when I put my shoes on I don't know where my toes are."

C) "Here are my up and down glucose readings that I wrote on my calendar."

D) "If I bathe more than once a week my skin feels too dry."

The correct answer is B: "Sometimes when I put my shoes on I don''t know where my toes are."

Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients who do not feel pressure and/or pain are at high risk for skin impairment.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

26 A 78 year-old client with pneumonia has a productive cough, but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration?

A) Suction the client frequently while restrained

B) Secure all 4 restraints to 1 side of bed

C) Obtain a sitter for the client while restrained

D) Request an order for a cough suppressant

The correct answer is C: Obtain a sitter for the client while restrained

The plan to use safety devices (restraints) should be rethought. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These are to be provided by the facility in the event the family cannot do so. This client needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

27. Which client is at highest risk for developing a pressure ulcer?

A) 23 year-old in traction for fractured femur

B) 72 year-old with peripheral vascular disease, who is unable to walk without assistance

C) 75 year-old with left sided paresthesia who is incontinent of urine and stool

D) 30 year-old who is comatose following a ruptured aneurysm

The correct answer is C: 75 year-old with left sided paresthesia who is incontinent of urine and stool

Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

28. The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When coming to a conclusion using the Ballard scale, which of these factors may affect the score?

A) Birth weight

B) Racial differences

C) Fetal distress in labor

D) Birth trauma

The correct answer is C: Fetal distress in labor

The effects of earlier distress may alter the findings of reflex responses as measured on the Ballard tool. Other physical characteristics that estimate gestational age, such as amount of lanugo, sole creases and ear cartilage are unaffected by the other factors.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

29. The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action?

A) Periorbital edema

B) Dizzy spells

C) Lethargy

D) Shortness of breath

The correct answer is B: Dizzy spells

Cardiac dysrhythmias may cause a transient drop in cardiac output and decreased blood flow to the brain. Near syncope refers to lightheartedness, dizziness, temporary confusion. Such "spells" may indicate runs of ventricular tachycardia or periods of asystole and should be reported immediately.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

30. A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach?

A) Vary the interview style for each candidate to learn different techniques

B) Use simple questions requiring "yes" and "no" answers to gain definitive information

C) Obtain an interview guide from human resources for consistency in interviewing each candidate

D) Ask personal information of each applicant to assure he/she can meet job demands

The correct answer is C: Obtain an interview guide from human resources for consistency in interviewing each candidate

An interview guide used for each candidate enables the nurse manager to be more objective in the decision making. The nurse should use resources available in the agency before attempts to develop one from scratch. Certain personal questions are prohibited, and HR can identify these for novice managers.

Marquis, B. & Huston, C. (2002). Leadership roles and Management Functions in Nursing. Philadelphia: Lippincott williams and Wilkins.

Yoder Wise, P. (2002). Leading and Managing in Nursing. St. Louis: Mosby.

31. Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that it:

A) considers client and staff needs

B) conserves time spent on planning

C) frees the nurse manager to handle other priorities

D) allows requests for special privileges

The correct answer is A: considers client and staff needs

Decentralized staffing takes into consideration specific client needs and staff interests and abilities.

Marriner-Tomey, A. (2000). Guide to Nursing Management and Leadership. . St. Louis: Mosby.

Zerwekh, J. and Claborn, J. (2003). Nursing Today. Transitions and Trends. St. Louis: Elsevier.

32. The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child?

A) Using a moist soft brush or cloth to clean teeth and gums

B) Swabbing teeth and gums with flavored mouthwash

C) Offering a bottle of water for the child to drink

D) Brushing with toothpaste and flossing each tooth

The correct answer is A: Using a moist soft brush or cloth to clean teeth and gums

The nurse should use a soft cloth or soft brush to do mouth care so that the child can adjust to the routine of cleaning the mouth and teeth.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

33. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?

A) Drink small amounts of liquids frequently

B) Eat the evening meal just before retiring

C) Take sodium bicarbonate after each meal

D) Sleep with head propped on several pillows

The correct answer is D: Sleep with head propped on several pillows

Heartburn is a burning sensation caused by regurgitation of gastric contents. It is best relieved by sleeping position, eating small meals, and not eating before bedtime.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

34. Included in teaching the client with tuberculosis taking isoniazid (INH) about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?

A) Liver function

B) Kidney function

C) Blood sugar

D) Cardiac enzymes

The correct answer is A: Liver function

INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

35. In addition to standard precautions, a nurse should implement contact precautions for which client?

A) 60 year-old with herpes simplex

B) 6 year-old with mononucleosis

C) 45 year-old with pneumonia

D) 3 year-old with scarlet fever

The correct answer is A: 60 year-old with herpes simplex

Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

36. What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention?

A) Set good examples themselves

B) Protect their child from outside influences

C) Make sure their child understands all the safety rules

D) Discuss the consequences of not wearing protective devices

The correct answer is A: Set good examples themselves

The preschool years are the time for parents to begin emphasizing safety principles as well as providing protection. Setting a good example themselves is crucial because of the imitative behaviors of pre-schoolers; they are quick to notice discrepancies between what they see and what they are told.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

37. A client who is 12 hour post-op becomes confused and says: “Giant sharks are swimming across the ceiling.” Which assessment is necessary to adequately identify the source of this client's behavior?

A) Cardiac rhythm strip

B) Pupillary response

C) Pulse oximetry

D) Peripheral glucose stick

The correct answer is C: Pulse oximetry

A sudden change in mental status in any post-op client should trigger a nursing intervention directed toward respiratory evaluation. Pulse oximetry would be the initial assessment. If available, arterial blood gases would be better. Acute respiratory failure is the sudden inability of the respiratory system to maintain adequate gas exchange which may result in hypercapnia and/or hypoxemia. Clinical findings of hypoxemia include these finding which are listed in order of initial to later findings: restlessness, irritability, agitation, dyspnea, disorientation, confusion, delirium, hallucinations, and loss of consciousness. While there may be other factors influencing the client''s behavior, the first nursing action should be directed toward maintaining oxygenation. Once respiratory or oxygenation issues are ruled out then significant changes in glucose would be evaluated.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

38. A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client’s greatest risk factors for osteoporosis?

A) History of menopause at age 50

B) Taking high doses of steroids for arthritis for many years

C) Maintaining an inactive lifestyle for the past 10 years

D) Drinking 2 glasses of red wine each day for the past 30 years

The correct answer is B: Taking high doses of steroids for arthritis for many years

The use of steroids, especially at high doses over time, increases the risk for osteoporosis. The other options also predispose to osteoporosis, as do low bone mass, poor calcium absorption and moderate to high alcohol ingestion. Long-term steroid treatment is the most significant risk factor, however.

Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness Perspectives. (7th Edition). Mosby: St. Louis, Missouri.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

39. The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to

A) restrict visitors to immediate family

B) avoid arousal of the client except for family visits

C) keep client's hips flexed at no less than 90 degrees

D) apply a warming blanket for temperatures of 98 degrees Fahrenheit or less

The correct answer is A: restrict visitors to immediate family

Maintaining a quiet environment will assist in minimizing cerebral rebleeding. When family visit, the client should not be disturbed. If the client is awake, topics of a general nature are better choices for discussion than topics that result in emotional or physiological stimulation.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

40. A nurse is performing the routine daily cleaning of a tracheostomy. During the procedure, the client coughs and displaces the tracheostomy tube. This negative outcome could have avoided by

A) placing an obturator at the client’s bedside

B) having another nurse assist with the procedure

C) fastening clean tracheostomy ties before removing old ties

D) placing the client in a flat, supine position

The correct answer is C: fastening clean tracheostomy ties before removing old ties

Fastening clean tracheostomy ties before removing old ones will ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the airway open only after the tracheostomy outer tube is coughed out. A second nurse is not needed. Changing the position may not prevent a dislodged tracheostomy.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition). Philadelphia, PA. Lippincott Williams & Wilkins.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.