Question: A school nurse is using the Weber’s test to check a child’s hearing acuity. Which of the following actions should the nurse take?
Answer Options:
Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child’s ears
Measure the amount of time the child can hear the sound
Obtain a tympanogram reading prior to initiating the test
Place a vibrating tuning fork on the top of the child’s head
Answer: Place a vibrating tuning fork on the top of the child’s head
Question: A nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest?
Answer Options:
“Plan for your son to meet his sister for the first time at home.”
“Give your son a little gift from his new sister.”
“Give your son plenty of ‘alone time’ with his sister.”
“Hold your daughter when your son first meets her.”
Answer: “Give your son a little gift from his new sister.”
Question: A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter. Which of the following actions should the nurse take to help minimize the client’s risk for acquiring a UTI?
Answer Options:
Loop the tubing so that it is lower than the collection bag
Obtain urinary samples by disconnecting the tubing connections
Keep the urinary bag at bladder level when ambulating
Secure the catheter to the client’s thigh
Answer: Secure the catheter to the client’s thigh
Question: A nurse is assessing a client who has Alzheimer’s disease and has been taking donepezil. Which of the following information is the priority for the nurse to report to the provider?
Answer Options:
Loss of weight since previous visit
Heart rate 54/min
BP 120/78 mm Hg
New onset of incontinence
Answer: Heart rate 54/min
Question: A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take?
Answer Options:
Withdraw the NPH insulin before the regular insulin
Administer the mixture within 5 min of preparing it
Shake both insulin vials for 2 min before withdrawing the doses
Inject air into the regular insulin vial before injecting air into the NPH vial
Answer: Administer the mixture within 5 min of preparing it
Question: A nurse is assessing a client who has a sliding hiatal hernia. Which of the following findings should the nurse expect?
Answer Options:
Abdominal cramping
Breathlessness
Heartburn
Constipation
Answer: Heartburn
Question: A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?
Answer Options:
Instruct the client to use an overbed trapeze to move around in bed
Place the client on an air mattress
Turn the client every 4 hr while in bed
Rewrap the bandage every 8 hr in a circular pattern
Answer: Instruct the client to use an overbed trapeze to move around in bed
Question: A nurse is assessing a client who has Alzheimer’s disease and has been taking donepezil. Which of the following information is the priority for the nurse to report to the provider?
Answer Options:
Loss of weight since previous visit
Heart rate 54/min
BP 120/78 mm Hg
New onset of incontinence
Answer: Heart rate 54/min
Question: A nurse is assessing a client who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?
Answer Options:
Dark brown emesis
Sore throat
Blood-tinged mucus
Frequent swallowing
Answer: Frequent swallowing
Question: A nurse is admitting a school-age child who has bacterial meningitis. Which of the following types of isolation precautions should the nurse initiate?
Answer Options:
Airborne
Droplet
Protective environment
Contact
Answer: Droplet
Question: A nurse is receiving change-of-shift report for four clients. For which of the following clients should the nurse initiate seizure precautions?
Answer Options:
A child who has Kawasaki disease
An infant who has hypertrophic pyloric stenosis
An infant who has respiratory syncytial virus
A child who has bacterial meningitis
Answer: A child who has bacterial meningitis
Question: A nurse is teaching the guardian of a newborn about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?
Answer Options:
“I will position the shoulder harness straps 3 inches above my baby’s shoulders.”
“I will turn the car seat forward facing when my baby is 1 year old.”
“I will position my baby at a 45-degree angle in the car seat.”
“I will place the retainer clip on my baby’s upper abdomen.”
Answer: “I will position my baby at a 45-degree angle in the car seat.”
Question: A community health nurse is assisting a client with developing a safety plan following repeated incidents of partner violence. Which of the following information should the nurse include?
Answer Options:
Plan to evacuate to a friend or family member’s home if you decide to leave your partner.
I will provide you with a list of phone numbers of local community health nurses to call for immediate assistance.
Obtain an order of protection which states your partner can only contact you by phone.
Prepare a bag that remains packed containing resources such as keys and a phone.
Answer: Prepare a bag that remains packed containing resources such as keys and a phone.
Question: A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following adverse effects of the medication is the priority finding for the nurse to report to the provider?
Answer Options:
Dry mouth
Visual disturbances
Constipation
Irregular pulse
Answer: Irregular pulse
Question: A nurse observes two assistive personnel (AP) discussing a client’s information in the facility cafeteria. Which of the following actions should the nurse take?
Answer Options:
File an incident report with the risk management department.
Notify the client of the breach of confidentiality.
Notify the ethics committee of the breach of confidentiality.
Remind the AP about maintaining client confidentiality.
Answer: Remind the AP about maintaining client confidentiality.
Question: A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?
Answer Options:
A client who had a right hemisphere stroke
A client who has a right peripherally inserted central catheter
A client who had dialysis and is using an arteriovenous shunt in the left lower forearm
A client who had blood drawn from the right antecubital area 1 hr ago
Answer: A client who has a right peripherally inserted central catheter
Question: A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse include?
Answer Options:
Monitor the client’s temperature every 4 hr.
Use clean technique for invasive procedures.
Make sure the client’s room is cleaned every 2 days.
Allow healthy children to visit.
Answer: Monitor the client’s temperature every 4 hr.