Question

420. A 42 year old patient is admitted to the emergency department (ED. following being mugged. The patient received blunt trauma to the face and has clear fluid draining from the right nostril. What does the ED nurse know to assess this fluid for? A. Sodium B. Protein C. Calcium D. Glucose

421. As an asthma educator, you are teaching a patient newly diagnosed with asthma and her family about the use of a peak flow meter. What does a peak flow meter measure? A. Highest airflow during a fo rced inspiration B. Highest airflow during a forced expiration C. Highest airflow during a normal inspiration D. Highest airflow during a normal expiration

422. You are caring for a post operative patient on the medical - surgical unit. During each patient asses sment, you evaluate your patient for infection. Which sign or symptom would be most indicative of infection? A. Presence of an indwelling urinary catheter B. Rectal temperature of 100 F. (37.8 C C. Red, warm, tender incision D. White blood cell (WBC. Count of 8,000/mL

423. You admit a patient to the postanesthesia care unit with a blood pressure of 130/90 and pulse of 68 beats per minute. After 30 minutes, the patient’s blood pressure is 120/65, and the pulse is 100. You document the patient’s skin as cold, moist and pale. What is the patient showing sign of? A. Hypothermia B. Hypovolemic shock C. Neurogenic shock D. Malignant hypothermia

424. You are the nurse caring for 82 year old women in the PACU. The woman begins to awaken and responds to her name but is con fused, restless and agitated. What are you aware of? A. Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery. B. Confusion, restlessness, and agitation are normal postoperative findings and will diminish in time C. Post operative confusion is common in the elderly, but it could also indicate a significant blood loss D. Confusion, restlessness, and agitation indicate inadequate pain management, and analgesics will help/

425. You admit a patient to the postanesthesia care unit with a blood pressure of 130/90 and a pulse of 68 per minute. After 30 minutes, the patient’s blood pressure is 120/65, and pulse is 100. You document the patient’s skin as cold and pale. What patient showing signs of? A. Hypothermia B. Hypovolemic shock C. Neur ogenic shock D. Malignant hypothermia

426. You are caring for a postoperative patient on the medical - surgical unit. During each patient assessment, you evaluate for patient for infection. Which signor symptom would be most indicative of infection? A. Presence of an indwelling urinary catheter B. Rectal temperature of 100 degree F ( 37.8 degree C C. Red, warm, tender incision D. White blood cell (WBC. count of 8,000 mL 427. You admit a patient to the PACU who has undergone a surgical procedure that required the use of general anesthesia. What is the patient most at risk for following general anesthesia? A. Atlectasis B. Anemia C. Dehydration D. Peripheral edema

428. The registered nurse had just admitted a client with severe depression. What domain should be the priority foc us as the nurse identifies the nursing diagnoses? A. Nutrition B. Elimination C. Activity D. Safety

430. The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first? A. Perform defibrillation B. Administer epinephrine as ordered C. Assess for presence of pulse D. Institute CPR

431. Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)? A. Neuro malignant syndrome B. Acute extrapyramidal syndrome C. Glaucoma, prostatic hypertrophy D. Parkinson’s disease, atypical tremors

432. The nurse is caring for a post - op colostomy client. The client begins to cry, saying “I’ll never be attractive again with this ugly red thing. “What shoul d the first action taken by the nurse? A. Arrange a consultation with a sex therapist experienced in working with colostomy clients B. Suggest sexual positions that hide the colostomy C. Invite the partner to participate in colostomy care after viewing an instructional video D. Encourage the client to discuss her feelings about the colostomy

433. A schizophrenic client talks animatedly but the staff are unable to understand what the client is communicating. The client is observed mumbling to herself and speaki ng to the radio. A desirable outcome for this client’s care will be A. Expresses feelings appropriate through interactions B. Accurately interprets events and behaviors of others C. Demonstrates improved social relationships D. Engages in meaningful and understandab le verbal communications

434. The caring for a client with benign prostatic hypertrophy ( BPH). Which of the following assessments would the nurse anticipate finding? A. Large volume of urinary output with each voiding B. Involuntary voiding with coughing and sneezing C. Frequent urination D. Urine is dark and concentrated

435. A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client’s color changes to gray and she expect orates large amounts of pink frothy sputum. The first action of the nurse would be which of the following? A. Call the health care provider B. Check vital signs C. Position in high Fowler’s D. Administer oxygen

436. Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication? A. Involuntary rhythmic stereotypic movements and tongue protrusion ‘ B. Cheek puffing, involuntary movements of extremities and trunk C. Agitation, constant state of motion D. Hyperpyrexia, severe muscle rigidity, malignant hypertension

437. A 3 year old is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first? A. Provide the ordered humidified oxygen via ma sk B. Suction the mouth and the nose C. Check the mouth and radial pulse D. Start the ordered intravenous fluids

438. Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about rea diness for toilet training? A. The child learns voluntary sphincter control through repetition B. Myelination of the spinal cord is completed by this age C. Neuronal impulses are interrupted at the base of the ganglia D. The toddler can understand cause and effect 439 . The nurse is caring for a 14 month old just diagnosed with cystic fibrosis. The parents state this is the first child in wither family with this disease, and ask about the risk to future children. What is the best response by the nurse? A. 1 in 4 chance for each child to carry that trait B. 1 in 4 risk for each child to have the disease C. 1 in 2 chance of avoiding the trait and disease D. 1 in 2 chance that each child will have the disease

440. During seizure activity which observation is the priority to enhance further direction of treatment? A. Observe the sequence or types of movement B. Note the tim e from beginning to end C. Identify the pattern of breathing D. Determine if loss of bowel or bladder control occurs. 441. The nurse is preparing to perform a physical examination on an 8 - month old who is sitting contently on his mother’s lap. Which

of the fol lowing should the nurse do first? A. Elicit reflexes B. Measure height and weight C. Ausculate heart and lungs D. Examine the ears

442. A client is unconscious following a tonic - clonic seizure. What should the nurse do first? A. Check the pulse B. Administer valium C. Place the client in a side - lying position D. Place a tongue blade in the mouth

443. When counseling parents of a child who has recently been diagnosed with hemophilia, what must the nurse know about the offspring father and a carrier moth er? A. It is likely that all sons are affected B. There is a 50% probability that s ons will have the disease C. Every daughter is likely to be a carrier D. There is a 25% chance a daughter will be a carrier

444. The nurses on a unit are planning for stoma care for c lients who have a stoma for fecal diversion. Which stomal diverionposes the highest for skin breakdown A. Illeostomy B. Transverse colostomy C. Illeal conduit D. Sigmoid colostomy

445. The nurse is assessing a client with delayed wound healing. Which of the follo wing risk factors is most important in this situation? A. Glucose level of 120 B. History of myocardial infarction C. Long term steroid usage D. Diet high in carbohydrates 446. In assessing the healing of a client 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

447. The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to asses s for findings of her heart conduction disturbance? A. Aterial septal defect B. Patent ductusarterious C. Aortic stenosis D. Ventricular septal defect

448. 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 ca n’t have anymore food until you use the spoon.”

449. 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 450. 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 t ake 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

451. Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called A. Craving B. Crashing C. Outward bound D. Nodding out

452. Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy (ECT)? A. Permission to videotape B. Salivary pH C. Mini - mental status exam D. Pre - anesthesia work - up

453 . The nurse detects blood - tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate is nursing action? A. Pack the nose and ears with sterile gauze B. Apply pressure to the injury site C. Ap ply bulky, loose dressing to nose a nd ears D. Apply an ice to the back of the neck

454. The nurse is caring for a client with increased intracranial pressure ( ICP) understands that which condition(s) can cause problem? Select all that apply. A. Edema B. Trauma C. Tumors D. Migraines E. Hemorrhages F. Hydrocephalus 456. The nurse understands that which are risk factor(s) for the development of breast cancer? Select all that apply. A. Age B. Obesity C. Multiparity D. Family history E. Early menarche F. Early menopause 457. The nurse is instructing a cl ient with diabetes mellitus in measures to prevent the chronic complication of diabetic nephropathy. Which statement by the client indicates a need for further instruction? A. “I should increase my dietary protein, sodium, and potassium.” B. “I need to be sure t o avoid any medications that may harm my kidneys.” C. “I will have to have routine laboratory work done to monitor kidney function.” D. “If the condition develops, it may be necessary to undergo dialysis or transplant.”

458. The nurse is caring for a client who has diagnosed with suspected acute pancreatitis. When reviewing the client’s laboratory results, the nurse determines that which finding will support the diagnosis? A. Elevated cholesterol B. Elevated serum amylase C. Decreased serum amylase D. Decreased serum bili rubin

459. The nurse working in the community health center is conducting a teaching session on the risk factors for colorectal cancer. The nurse includes which item(s) in the teaching session? Select all that apply. A. History of breast cancer B. Age older than 50 years C. History of ovarian cancer D. History of bladder cancer E. History of chronic inflammatory bowel dis

Answer 1

420:Clear drainage from one side of the nostril post trauma is a sign of CSF leakage.It can be confirmed by a diagnostic test which determines the presence of Beta 2 transferrin, it is a protein found in the cerebrospinal fluid only

Ans:B.Protein

421:Peak flow meter is a portable devices to measure the extent of asthmatic symptoms.It is a very simple procedure to assess the lung function in asthmatic patient .The patient is asked to expire forcefully after a complete full inspiration. It has three zones Green zone:80_100%,yellow zone:50_80% and red zone:<50%

Ans:BHighest airflow during a forced expiration

422:Presence of indwelling catheter means the patient is at rusk of getting infection if not cared properly

A rectal temperature of 100°F is normal because ,the temperature taken here is usually 1°F higher than the core body temperature

The signs and symptoms of infection are redness,warmth,swelling,pain or tenderness, oozing at the site of incision or a wound

The normal WBC count is 4000 to 11000/ml

Ans:C.Red,warm tender incision

423:One of the post operative complication is hypovolemic shock on which the patient develops an increased heart rate with decrease in blood pressure ,The skin turns cold and clammy to touch .

Ans:B.Hypovolemic shock