Fundamentals
Mental Health
Obstetrical
PEDS
Med Surg
100
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
1) "Information about a client can be disclosed to family members at any time."
2) "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form."
3) "A client's address would be an example of personally identifiable information."
4) "HIPAA is a federal law, not a state law."
1) "Information about a client can be disclosed to family members at any time."
Answer Rationale:
This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of his or her own personal health information.
100
A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?
1) Place the client in seclusion if visual hallucinations are present.
2) Limit the number of questions asked during assessments
3) Use frequent touch to provide client support.
4) Directly tell the client that delusions are not real.
2) Limit the number of questions asked during assessments
Answer Rationale:
Minimizing the number of questions is appropriate since a client who has acute schizophrenia has difficulty concentrating on information and answering assessment questions. The nurse should plan to use other sources of client information, such as medical records, family members, or reports from other interprofessional sources.
100
A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
1) Decrease the rate of infusion of the maintenance IV solution.
2) Discontinue the infusion of the IV oxytocin.
3) Increase the rate of infusion of the IV oxytocin.
4) Slow the client’s rate of breathing.
2) Discontinue the infusion of the IV oxytocin.
Answer Rationale:
Discontinue the oxytocin infusion immediately if a client is experiencing late decelerations due to uterine hyperstimulation.
100
A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis?
1) Absent bowel sounds
2) Increased sodium levels
3) Projectile vomiting after feedings
4) Golf ball-sized mass over the left quadrant
3) Projectile vomiting after feedings
Answer Rationale:
Pyloric stenosis is a narrowing and thickening of the pyloric canal between the stomach and the duodenum, resulting in projectile vomiting.
100
A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate?
1) Hypernatremia
2) Oliguria
3) Weight loss
4) Increased thirst
1) Hypernatremia
Answer Rationale:
The nurse should expect hyponatremia, due to the development SIADH.
200
A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
1) A client who has a lumbosacral spinal tumor
2) A client who has Guillain-Barre syndrome
3) A client who has amyotrophic lateral sclerosis (ALS)
4) A client who has systemic sclerosis
1) A client who has a lumbosacral spinal tumor
Answer Rationale:
The nurse should delegate a task to the AP that is safe for a specific client. The client who has a lumbosacral spinal tumor is not at risk for dysphagia; therefore, the nurse should delegate meal assistance to the AP for this client.
200
A nurse is observing a group therapy session. Which of the following client statements should the nurse identify as an indication of bulimia nervosa?
1)"I only use the laxatives when I am feeling constipated."
2)"I feel an emotional high during my binge-purge episodes."
3)"I have binged and purged for years without my family or friends knowing."
4)"I feel a sense of power by restricting my food intake."
3)"I have binged and purged for years without my family or friends knowing."
Clients who have bulimia nervosa typically hide bingeing and purging behaviors from others.
200
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
1) Document the findings and continue to monitor the client.
2) Notify the client’s provider.
3) Increase the frequency of fundal massage.
4) Encourage the client to empty her bladder.
1) Document the findings and continue to monitor the client.
Answer Rationale:
These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client.
200
A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include?
1) "Position the newborn at a 45-degree angle in the car seat."
2) "Place the retainer clip across the newborn's abdomen."
3) "Keep the car seat rear-facing until the newborn can sit unsupported."
4) "Place the shoulder harness straps below the level of the newborn's armpits."
1) "Position the newborn at a 45-degree angle in the car seat."
Answer Rationale:
The nurse should instruct the parent to place the newborn at a 45° angle to prevent the newborn's head from falling forward and obstructing the airway.
200
A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes mellitus?
1) HbA1c 5.5%
2) 2 hr blood glucose 170 mg/dL
3) Fasting blood glucose 155 mg/dL
4) Casual blood glucose 180 mg/dL
3) Fasting blood glucose 155 mg/dL
Answer Rationale:
A fasting blood glucose above 126 mg/dL meets the criteria for a diagnosis of diabetes mellitus.
300
A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?
1) Take an arterial blood gas (ABG) specimen to the laboratory.
2) Transport a client to the radiology department for an x-ray.
3) Pass fresh water to clients on the unit.
4) Obtain a routine urine sample from a newly-admitted client.
1) Take an arterial blood gas (ABG) specimen to the laboratory.
Answer Rationale:
When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority action is to take the ABG blood sample to the laboratory. ABG samples are placed on ice and must be transported to the laboratory immediately or the specimen will deteriorate, making any results inaccurate.
300
A nurse is caring for a client who has bipolar disorder. The client states, “I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator.” Which of the following findings is this client exhibiting?
1) Flight of ideas
2) Grandiosity
3) Reality testing
4) Derealization
2) Grandiosity
Answer Rationale:
Grandiosity refers to the client’s belief that he has special abilities or great powers.
300
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
1) Uteroplacental insufficiency
2) Maternal bradycardia
3) Umbilical cord compression
4) Fetal head compression
1) Uteroplacental insufficiency
Answer Rationale:
The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late decelerations are the result of uteroplacental insufficiency and the fetus becomes hypoxemic. They are an ominous sign if they cannot be corrected and place the fetus at risk for a low Apgar score.
300
A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant?
1) Oral electrolyte solution
2) Half-strength infant formula
3) Half-strength orange juice
4) Sterile water
1) Oral electrolyte solution
Answer Rationale:
After gastrointestinal surgery, infants should receive clear liquids that contain glucose and electrolytes, such as an oral electrolyte or rehydration solution. They should then advance to formula or breast milk as they demonstrate tolerance.
300
Name that rhythm:
Atrial Fibrillation, 4:1 conduction
"Sawtooth"
400
A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?
1) Instruct the client to look up and down without moving his head.
2) Observe the client's ability to smile and frown.
3) Have the client stand with eyes his closed and touch his nose.
4) Ask the client to shrug his shoulders against passive resistance.
1) Instruct the client to look up and down without moving his head.
Answer Rationale:
The nurse should observe the client's extraocular eye movements by instructing him to look at the cardinal fields of gaze as part of an evaluation of the function of cranial nerve III (Oculomotor).
400
A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching?
1) "Decrease your fluid intake to 1 liter per day."
2) "You might produce extra saliva while taking this medication."
3) "Notify your provider if you experience vomiting or diarrhea."
4) "Take the medication on an empty stomach."
3) "Notify your provider if you experience vomiting or diarrhea."
Answer Rationale:
Vomiting and diarrhea are both manifestations of lithium toxicity and should be reported to the provider. Vomiting and diarrhea can also cause dehydration, which can result in lithium toxicity.
400
A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?
1) 8
Correct Answer Rationale:
Apgar scoring is an assessment of five areas of newborn well-being: respiratory effort, heart rate, muscle tone, reflex irritability, and color. This newborn scores 2 each for heart rate, muscle tone, and reflex irritability. The weak cry and acrocyanosis of the hands and feet score 1 each, for a total of 8.
400
A nurse is educating new parents about risk factors for sudden infant death syndrome (SIDS). Which of the following statements should indicate to the nurse the need for additional teaching?
1) "Our baby will sleep in our bed because I am breastfeeding."
2) "We will give my baby a pacifier during naps and at bedtime."
3) "We will place my baby on her back when sleeping."
4) "We will remove blankets and toys from the crib."
1) "Our baby will sleep in our bed because I am breastfeeding."
Answer Rationale:
Allowing an infant to sleep in the same bed as an adult can lead to suffocation and falls. The parent should place the infant back in her crib or bassinet after breastfeeding.
400
A nurse is caring for a client who has developed agranulocytosis as a result of taking propylthiouracil to treat hyperthyroidism. The nurse should understand that this client is at increased risk for which of the following conditions?
1) Excessive bleeding
2) Ecchymosis
3) Infection
4) Hyperglycemia
3) Infection
Answer Rationale:
Agranulocytosis is a failure of the bone marrow to make enough white blood cells, causing neutropenia and lowering the body defenses against infection.
500
A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?
1) Droplet
2) Contact
3) Airborne
4) Standard
4) Standard
Answer Rationale:
Hepatitis C is a blood-borne pathogen that is commonly spread by needle stick injury, sharing of IV drug paraphernalia and sexual contact. The nurse should implement standard precautions when in contact with blood, body fluids (except sweat), broken skin, and mucous membranes. The nurse should wear additional personal protective equipment if there is possible blood contact or a risk for splashes or sprays of blood or body fluids.
500
1)"Why do you become so frightened about gaining weight?"
2)"Everyone feels better after they have completed the program."
3)"You will need to accept that increasing weight is a natural part of the program."
4) "What are your feelings about the restoration process?"
4)"What are your feelings about the restoration process?"
This question is therapeutic because it avoids referring to weight gain in a manner that might be distressing to a client who has anorexia nervosa. The use of the phrase "restoration process" is more sensitive to the client's feelings of fear about gaining weight.
500
A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of lactated Ringer’s with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?
1) Methylergonovine 0.2 mg IM now.
2) Insert an indwelling urinary catheter.
3) Administer oxygen by nonrebreather mask at 5 L/min.
4) Obtain laboratory study of prothrombin and partial thromboplastin time.
1) Methylergonovine 0.2 mg IM now.
Answer Rationale:
Methylergonovine is contraindicated in the client with a blood pressure greater than 140/90 mm Hg. This prescription requires clarification.
500
A nurse is assessing a child in an area struck by an earthquake. The child, who is crying, walks well, can state their first name, and repeatedly says "All done" and "Go bye-bye now" during the assessment. The child has 20 deciduous teeth and their anterior fontanel is closed. Based on these observations, the nurse should estimate that the child is how many months old?
1) 12
2) 18
3) 24
4) 30
4) 30
Answer Rationale:
The nurse should estimate that the child is at least 30 months old because the child has completed their primary dentition (20 deciduous teeth), which occurs by 30 months of age. In addition, the nurse should recognize that the child is at least 18 months old because the anterior fontanel is closed and should recognize that the child is at least 24 months old because the child speaks in two- and three-word phrases.
500
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
1) Urine specific gravity 1.002
2) Bounding peripheral pulses
3) Bradycardia
4) Moist mucous membranes
1) Urine specific gravity 1.002
Answer Rationale:
The nurse should expect a client who has diabetes insipidus to have diluted urine with a specific gravity less than 1.005.