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Perinatal
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100
A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: A. Warming the crib pad B. Turning on the overhead radiant warmer C. Closing the doors to the room D. Drying the infant in a warm blanket
D. Drying the infant in a warm blanket. Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation.
100
The nurse is caring for a 59-year-old woman who had surgery 1 day ago for removal of a suspected malignant abdominal mass. The patient is awaiting the pathology report. She is tearful and says that she is scared to die. The most effective nursing intervention at this point is to use this opportunity to a. motivate change in an unhealthy lifestyle. b. teach her about the seven warning signs of cancer. c. instruct her about healthy stress relief and coping practices. d. allow her to communicate about the meaning of this experience
Correct answer: d Rationale: While the patient is waiting for diagnostic study results, you should be available to actively listen to the patient’s concerns, and you should be skilled in techniques that can engage the patient and the family members or significant others in a discussion about their cancer-related fears
100
A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when a. the patient is unable to tolerate prolonged immobilization. b. the patient cannot tolerate the surgery of a closed reduction. c. a temporary cast would be too unstable to provide normal mobility. d. adequate alignment cannot be obtained by other nonsurgical methods.
Correct answer: d Rationale: A comminuted fracture has more than two bone fragments. Open reduction with internal fixation (ORIF) is indicated for a comminuted fracture and is used to realign and maintain bony fragments. Other nonsurgical methods can result in a failure to obtain satisfactory reduction. Internal fixation reduces the hospital stay and the complications associated with prolonged bed rest.
100
This GI complication is the most common following surgery. A. Small Bowel Obstruction B. Fecal Impaction C. Paralytic Ileus D. Large Bowel Obstruction
C. Paralytic Ileus Paralytic Ileus is an obstruction of the intestine due to paralysis of the intestinal muscle and may be complete or partial.
100
A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following is the highest priority action by the nurse? A. Placing the client on one-to-one observation B. Assisting the client to perform ADLs C. Encouraging the client to participate in counseling D. Teaching the client about medication adverse effects
A. CORRECT: The greatest risk for a client who has MDD and comorbid anxiety is injury due to self‑harm. Therefore, the highest priority intervention is placing the client on one-to-one observation. B. INCORRECT: The client who has MDD may require assistance with ADLs; however, this does not address the greatest risk to the client and is therefore not the priority intervention. C. INCORRECT: The nurse should encourage the client who has MDD to participate in counseling; however, this does not address the greatest risk to the client and is therefore not the priority intervention. D. INCORRECT: The nurse should teach the client who has MDD about medication adverse effects; however, this does not address the greatest risk to the client and is therefore not the priority intervention.
200
While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? A. Activate the code blue or emergency system B. Do nothing because acrocyanosis is normal in the neonate C. Immediately take the newborn’s temperature according to hospital policy D. Notify the physician of the need for a cardiac consult
B. Do nothing because acrocyanosis is normal in the neonate. Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn’t last more than 24 hours after birth.
200
A patient on chemotherapy for 10 weeks started at a weight of 121 lb. She now weighs 118 lb and has no sense of taste. Which nursing intervention would be a priority? a. Advise the patient to eat foods that are fatty, fried, or high in calories. b. Discuss with the physician the need for parenteral or enteral feedings. c. Advise the patient to drink a nutritional supplement beverage at least three times a day. d. Advise the patient to experiment with spices and seasonings to enhance the flavor of food
Correct answer: d Rationale: Instruct the patient to experiment with spices and other seasoning agents in an attempt to mask taste alterations. Lemon juice, onion, mint, basil, and fruit juice marinades may improve the taste of certain meats and fish. Bacon bits, onion, and pieces of ham may enhance the taste of vegetables.
200
A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects compartment syndrome and notifies the physician when the patient experiences a. increasing edema of the limb. b. muscle spasms of the lower arm. c. rebounding pulse at the fracture site. d. pain when passively extending the fingers
Correct answer: d Rationale: One or more of the following are characteristic of compartment syndrome: (1) paresthesia (i.e., numbness and tingling sensation); (2) pain distal to the injury that is not relieved by opioid analgesics and, on passive stretch of muscle, pain that travels through the compartment; (3) increased pressure in the compartment; (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness, or diminished or absent peripheral pulses. The examination also includes assessment of peripheral edema, especially pitting edema, which may occur with severe injury.
200
A nurse is reviewing the clinical manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? (Select all that apply.) A. Dry skin B. Heat intolerance C. Constipation D. Palpitations E. Weight loss F. Bradycardia
A. INCORRECT: Moist skin is an expected finding for the client who has hyperthyroidism. B. CORRECT: Hyperthyroidism increases the client’s metabolism. Therefore, heat intolerance is an expected finding. C. INCORRECT: Diarrhea is an expected finding for the client who has hyperthyroidism. D. CORRECT: Hyperthyroidism increases the client’s metabolism. Therefore, palpitations are an expected finding for the client who has hyperthyroidism. E. CORRECT: Hyperthyroidism increases the client’s metabolism. Therefore, weight loss is an expected finding for the client who has hyperthyroidism. F. INCORRECT: Hyperthyroidism increases the client’s metabolism. Therefore, tachycardia is an expected finding for the client who has hyperthyroidism.
200
A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following is appropriate for the nurse to include in the plan of care? (Select all that apply.) A. Provide flexible client behavior expectations B. Offer concise explanations C. Establish consistent limits D. Disregard client complaints E. Use a firm approach with communication
A. Incorrect: The nurse should establish consistent client behavior expectations to decrease the risk for client manipulation. B. Correct: Offering concise explanations improves the client’s ability to focus and comprehend the information. C. Correct: Establishing consistent limits decreases the risk for client manipulation. D. Incorrect: The nurse should respond to valid client complaints to foster a trusting nurse-client relationship. E. Correct: Using a firm approach with client communication promotes structure and minimizes inappropriate client behaviors.
300
A nursing is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? A. Nifedipine (Adalat) B. Pyridoxine (vitamin B6) C. Ferrous sulfate D. Calcium gluconate
D. Calcium gluconate is the antidote for magnesium sulfate. Nifedipine is an antihypertensive medication that may be administered to women who have gestational hypertension, Pyridoxine (vitamin B6) is a vitamin supplement prescribed for clients who have hyperemesis gravidarum, Ferrous sulfate is a medication used in the treatment of iron deficiency anemia.
300
A 70-year-old male patient has multiple myeloma. His wife calls to report that he sleeps most of the day, is confused when awake, and complains of nausea and constipation. Which complication of cancer is this most likely caused by? a. Hypercalcemia b. Tumor lysis syndrome c. Spinal cord compression d. Superior vena cava syndrome
Correct answer: a Rationale: Hypercalcemia can occur with multiple myeloma. Immobility and dehydration can contribute to or exacerbate hypercalcemia. The primary manifestations of hypercalcemia include apathy, depression, fatigue, muscle weakness, electrocardiographic changes, polyuria and nocturia, anorexia, nausea, and vomiting
300
The most common early symptom of a spinal cord tumor is A. Urinary incontinence B. Back pain that worsens with activity C. Paralysis below the level of involvement D. Impaired sensation of pain, temperature, and light touch
Correct answer: B Rationale: The most common early symptom of a spinal cord tumor outside the cord is pain in the back, with radicular pain simulating intercostal neuralgia, angina, or herpes zoster. The location of the pain depends on the level of compression. The pain worsens with activity, coughing, straining, and lying down.
300
A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following is an appropriate nursing action? A. Decrease the client’s fluid intake. B. Apply pressure to the puncture site. C. Place the client’s head of bed flat. D. Instruct the client to lie prone.
C. CORRECT: Placing the client’s head of bed flat will decrease the intensity of the headache and decrease cerebral spinal fluid leakage. A. INCORRECT: Increase fluid intake to keep the client well-hydrated and to help replace the cerebral spinal fluid. B. INCORRECT: Applying pressure to the puncture site is not an appropriate nursing action and will not relieve the headache from cerebral spinal fluid leakage. D. INCORRECT: Instructing the client to lie prone is not an appropriate action by the nurse in the treatment of a headache caused from cerebral spinal fluid leakage.
300
Which of the following are clinical manifestations of anaphylaxis? (Select all that apply) A. High Blood Pressure B. Diarrhea C. Hives D. Shortness of breath E. Dry Nose
B, C, & D - Diarrhea, hives and shortness of breath are all clinical manifestations of anaphylaxis. In anaphylaxis the blood pressure would be low and the patient will experience a runny nose.
400
A mother presents to the labor and delivery department with the following signs. Which of these are signs of FALSE labor? (Select all that apply) A. Presenting part of the fetus is not engaged in the pelvis. B. Contractions are felt in lower back or abdomen above umbilicus C. Cervix has a bloody show D. Contractions often stop with sleep or comfort measures such as oral hydration or emptying of the bladder E. Contractions are felt in lower back, radiating to abdomen
A, B, D - The presenting part of the fetus is not engaged in the pelvis, contractions are felt in the lower back or abdomen above umbilicus and contractions that stop with sleep or comfort measure like oral hydration and emptying the bladder are signs of FALSE labor. C & E - The cervix having a bloody show and contractions are felt in lower back, radiating to abdomen are signs of TRUE labor.
400
A cancer that originates in the blood stem cells, is environmental and progressive is likely to be in an adult patient, true or false? A. True B. False
B - False Cancers that originate in the blood stem cells, are environmental and progressive are more likely to be in a pediatric patient.
400
Goals of rehabilitation for the patient with an injury at the C6 level include (select all that apply) A. Stand erect with leg brace B. Feed self with hand devices C. Assist with transfer activities D. Drive adapted van from wheelchair. E. Push a wheelchair on a flat surface
Correct answers: B, C, D, E Rationale: Rehabilitation goals for a patient with a spinal cord injury at the C6 level include the ability to assist with transfer and perform some self-care; feed self with hand devices; push a wheelchair on smooth, flat surfaces; drive an adapted van from a wheelchair; independent computer use with adaptive equipment; and need for attendant care for only 6 hours per day
400
A nurse is providing information to a group of surgical nurses for the treatment of malignant hyperthermia. Which of the following should the nurse include in the information? A. Infuse iced IV fluids. B. Provide 100% oxygen. C. Place on a cooling blanket. D. Treat the condition while continuing surgery. E. Administer IV dantrolene (Dantrium).
A. CORRECT: Infusing iced IV fluids should help lower the client’s rapidly rising temperature. B. CORRECT: Providing 100% oxygen will help to prevent hypoxia due to muscle tremors and rigidity from increased lactic acid. C. CORRECT: Placing the client on a cooling blanket will help lower the rapidly rising temperature. D. INCORRECT: Terminating surgery should occur as soon as malignant hyperthermia is suspected. E. CORRECT: Dantrolene IV is a muscle relaxant used to treat malignant hyperthermia.
400
Which of the following is not a criteria for SIRS? A. Fever > 38 C or < 36 C B. Heart rate > 130/min C. Respiratory rate > 20/min or PaC02 < 32 mmHg D. WBCs > 12,000 or < 4,000 or > 10% immature forms
B - Heart rate > 130/min The heart rate criteria for SIRS is > 90/min. All other criteria are correct.
500
Which of the following are signs of sepsis in a newborn? (Select all that apply) A. High blood pressure B. Decreased oxygen saturation C. Irritability and seizure activity D. Stable temperature E. Tachypnea
B, C & E - Decreased oxygen saturation, Irritability and seizure activity and Tachypnea are signs of sepsis in a newborn. A septic newborn would have low blood pressure and an unstable temperature.
500
This type of cancer occurs in the connective tissue. A. Carcinoma B. Sarcomas C. Myelomas D. Leukemia E. Lymphomas
B - Sarcomas: Connective tissue Carcinoma: Epithelial lining, Myelomas: Plasma cells (bone marrow), Leukemia: Blood components (bone marrow), Lymphomas: Immune system cells
500
A nurse instructs a nursing assistant on the proper method to support the extremities during repositioning of the client with bone cancer. Which most common complication is the nurse indenting to prevent? a. Delayed bone healing b. Fat emboli c. Pathological fracture d. Pressure ulcers
c. Bone tumors weaken the bone such that bone fractures can occur with normal activity or position changes. Delayed bone healing, fat emboli, and pressure ulcers are complications that can occur with bone cancer but only option C is the complication that occurs most frequently during repositioning.
500
A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to “throw up.” A priority nursing intervention would be to a. increase the rate of the IV fluids. b. obtain vital signs, including O2 saturation. c. position patient in lateral recovery position. d. administer antiemetic medication as ordered
Correct answer: c Rationale: If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs.
500
What is the correct order for the stages of shock? A. Initial, Compensatory, Irreversible, Progressive B. Progressive, Initial, Compensatory, Irreversible C. Initial, Compensatory, Progressive, Irreversible D. Initial, Progressive, Compensatory, Irreversible
C. According to MedSurg the four stages of shock are Initial, Compensatory, Progressive, Irreversible.