Question: A nurse is assessing a client who is taking oxacillin to treat an infection. The nurse should recognize which of the following findings is a manifestation of an allergic reaction?
Answer Options:
Diarrhea
Dark urine
Fever
Urticaria
Answer: Urticaria
Question: A nurse in an emergency department is preparing to administer theophylline by continuous intravenous (IV) infusion to a client who is experiencing an asthma attack. Which of the following actions should the nurse take?
Answer Options:
Cover the IV container with dark paper.
Administer a test dose first.
Infuse the medication with an IV pump.
Infuse the medication at 35 mg/min.
Answer: Infuse the medication with an IV pump.
Question: A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include?
Answer Options:
“Place the retainer clip across the newborn’s abdomen.”
“Keep the car seat rear-facing until the newborn can sit unsupported.”
“Position the newborn at a 45-degree angle in the car seat.”
“Place the shoulder harness straps below the level of the newborn’s armpits.”
Answer: “Position the newborn at a 45-degree angle in the car seat.”
Question: A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client?
Answer Options:
A semi-private room across from the day room.
A private room in a quiet location on the unit.
A semi-private room across from the snack area.
A private room across from the exercise room.
Answer: A private room in a quiet location on the unit.
Question: A home health care nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurse’s job description. Which of the following is an appropriate nursing response?
Answer Options:
“Let’s look at some other resources to solve this problem.”
“I won’t be able to shop for you today because I have to get home to my family.”
“I would be happy to do whatever I can to help you.”
“What I think you should do is wait for the days when you feel better and do your grocery shopping then.”
Answer: “Let’s look at some other resources to solve this problem.”
Question: A nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?
Answer Options:
SaO₂ 94%
Respiratory rate 8/min
Pain level of 6 on a scale from 0 to 10
Sleepy, but arousing when her name is called
Answer: Respiratory rate 8/min
Question: A nurse is preparing a community presentation about repetitive motion injuries. Which of the following occupations should the nurse identify as increasing a client’s risk for carpal tunnel syndrome?
Answer Options:
Assembly line worker
Truck driver
Nursing assistant
Elementary school teacher
Answer: Assembly line worker
Question: A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?
Answer Options:
Reinforce discharge teaching to clients.
Focus on providing care that prevents life-threatening emergencies.
Stock additional unit supplies.
Instruct the assistive personnel (AP) to focus on clients’ ADLs.
Answer: Focus on providing care that prevents life-threatening emergencies.
Question: A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)
Answer Options:
Spinning a toy repetitively
Delayed language development
Speaking with direct eye contact
Long attention span
Ritualistic behavior
Answer: Spinning a toy repetitively
Delayed language development
Ritualistic behavior
Question: A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?
Answer Options:
Aplastic anemia results in an inability to absorb vitamin B12.
Aplastic anemia results in an increased rate of RBC destruction.
Aplastic anemia results from decreased bone marrow production of RBCs.
Aplastic anemia is associated with a decreased intake of iron.
Answer: Aplastic anemia results from decreased bone marrow production of RBCs.
Question: A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
Answer Options:
A staff member does not show up to work her assigned shift.
The nurse has a disagreement with the nursing supervisor about inadequate staffing.
A client discovers that his dentures are missing.
The nurse identifies a broken piece of equipment.
Answer: A client discovers that his dentures are missing.
Question: A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?
Answer Options:
Increasing age
Diagnosis of diabetes mellitus
Family history of cardiac disease
Cigarette smoking
Answer: Cigarette smoking
Question: A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client’s lung has re-expanded?
Answer Options:
Occasional bubbling in the water-seal chamber
No reports of pleuritic chest pain
No fluctuations in the water seal chamber
Oxygen saturation of 95%
Answer: No fluctuations in the water seal chamber
Question: A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child’s cooperation?
Answer Options:
Tell the child it is candy.
Offer the child a choice of taking the medication with juice or water.
Tell the child he will have to have a shot instead.
Hide the medication in a large dish of ice cream.
Answer: Offer the child a choice of taking the medication with juice or water.
Question: A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?
Answer Options:
Brainstorm solutions.
Evaluate the results.
Implement a resolution.
Identify the problem.
Answer: Identify the problem.
Question: A community health nurse is reviewing the levels of disease prevention. Which of the following activities is an example of tertiary prevention?
Answer Options:
Performing screening for sexually transmitted infections
Administering influenza immunizations at a local health fair
Testing new nurses for exposure to tuberculosis
Providing treatment for clients who have chronic obstructive pulmonary disease
Answer: Providing treatment for clients who have chronic obstructive pulmonary disease
Question: A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work. Which of the following is the appropriate action for the nurse to take?
Answer Options:
Administer antibiotic therapy.
Treat clients with an antitoxin.
Place the clients in isolation.
Initiate client decontamination.
Answer: Administer antibiotic therapy.