Drill 9


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Drill 9

  1. 1. DRILL 9 1. A 10 year old who has sustained a head injury is brought to the emergency department by his mother. A diagnosis of a mild concussion is made. At the time of discharge, nurse Ron should instruct the mother to: A. Withhold food and fluids for 24 hours. B. Allow him to play outdoors with his friends. C. Arrange for a follow up visit with the child’s primary care provider in one week. C. Check for any change in responsiveness every two hours until the follow-up visit. Signs of epidural hematoma in children usually do not appear 24 hours or more hours a follow up visit usually is arranged for one to two days after injury. 2. A male client has suffered a motor accident and is now suffering from hypovolemic shock. Nurse Helen should frequency assess the client’s vital signs during the compensatory stage of shock, because: A. Arteriolar constriction occurs B. The cardiac workload decreases C. Decreased contractility of the heart occurs D. The parasympathetic nervous system is triggered 3. A paranoid male client with schizophrenia is losing weight, reluctant to eat, and voicing concerns about being poisoned. The best intervention by nurse Dina would be to: A. Allow the client to open canned or pre-packaged food B. Restrict the client to his room until 2 lbs are gained C. Have a staff member personally taste all of the client’s food D. Tell the client the food has been x-rayed by the staff and is safe 4. One day the mother of a young adult confides to nurse Frida that she is very troubled by he child’s emotional illness. The nurse’s most therapeutic initial response would be: A. “You may be able to lessen your feelings of guilt by seeking counseling” B. “It would be helpful if you become involved in volunteer work at this time” C. “I recognize it’s hard to deal with this, but try to remember that this too shall pass” D. “Joining a support group of parents who are coping with this problem can be quite helpful. 5. To check for wound hemorrhage after a client has had a surgery for the removal of a tumor in the neck, nurse grace should: A. Loosen an edge of the dressing and lift it to see the wound B. Observe the dressing at the back of the neck for the presence of blood C. Outline the blood as it appears on the dressing to observe any progression D. Press gently around the incision to express accumulated blood from the wound 6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she is labor. To verify that the client is in true labor nurse Trina should: A. Obtain sides for a fern test B. Time any uterine contractions C. Prepare her for a pelvic examination D. Apply nitrazine paper to moist vaginal tissue
  2. 2. 7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse Julius is aware that children with pulmonic stenosis have increased pressure: A. In the pulmonary vein B. In the pulmonary artery C. On the left side of the heart D. On the right side of the heart 8. An obese client asks nurse Julius how to lose weight. Before answering, the nurse should remember that long-term weight loss occurs best when: A. Eating patterns are altered B. Fats are limited in the diet C. Carbohydrates are regulated D. Exercise is a major component 9. As a very anxious female client is talking to the nurse May, she starts crying. She appears to be upset that she cannot control her crying. The most appropriate response by the nurse would be: A. “Is talking about your problem upsetting you?” B. “It is Ok to cry; I’ll just stay with you for now” C. “You look upset; lets talk about why you are crying.” D. “Sometimes it helps to get it out of your system.” 10. A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids is given first? A. Albumin B. D5W C. Lactated Ringer’s solution D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml 11. During the first 48 hours after a severe burn of 40% of the clients body surface, the nurse’s assessment should include observations for water intoxication. Associated adaptations include: A. Sooty-colored sputum B. Frothy pink-tinged sputum C. Twitching and disorientation D. Urine output below 30ml per hour 12. After a muscle biopsy, nurse Willy should teach the client to: A. Change the dressing as needed B. Resume the usual diet as soon as desired C. Bathe or shower according to preference D. Expect a rise in body temperature for 48 hours 13. Before a client whose left hand has been amputated can be fitted for a prosthesis, nurse Joy is aware that: A. Arm and shoulder muscles must be developed B. Shrinkage of the residual limb must be completed C. Dexterity in the other extremity must be achieved D. Full adjustment to the altered body image must have occurred
  3. 3. 14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart rate below the baseline lasting 15 seconds. Nurse Cathy should: A. Change the maternal position B. Prepare for an immediate birth C. Call the physician immediately D. Obtain the client’s blood pressure 15. A male client receiving prolonged steroid therapy complains of always being thirsty and urinating frequently. The best initial action by the nurse would be to: A. Perform a finger stick to test the client’s blood glucose level B. Have the physician assess the client for an enlarged prostate C. Obtain a urine specimen from the client for screening purposes D. Assess the client’s lower extremities for the presence of pitting edema 16. Nurse Bea recognizes that a pacemaker is indicated when a client is experiencing: A. Angina B. Chest pain C. Heart block D. Tachycardia 17. When administering pancrelipase (Pancreases capsules) to child with cystic fibrosis, nurse Faith knows they should be given: A. With meals and snacks B. Every three hours while awake C. On awakening, following meals, and at bedtime C. After each bowel movement and after postural draianage 18. A preterm neonate is receiving oxygen by an overhead hood. During the time the infant is under the hood, it would be appropriate for nurse Gian to: A. Hydrate the infant q15 min B. Put a hat on the infant’s head C. Keep the oxygen concentration consistent D. Remove the infant q15 min for stimulation 19. A client’s sputum smears for acid fast bacilli (AFB) are positive, and transmission-based airborne precautions are ordered. Nurse Kyle should instruct visitors to: A.Limit contact with non-exposed family members B. Avoid contact with any objects present in the client’s room C. Wear an Ultra-Filter mask when they are in the client’s room D. Put on a gown and gloves before going into the client’s room 20. A client with a head injury has a fixed, dilated right pupil; responds only to painful stimuli; and exhibits decorticate posturing. Nurse Kate should recognize that these are signs of: A. Meningeal irritation B. Subdural hemorrhage C. Medullary compression D. Cerebral cortex compression
  4. 4. 21. After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s chest demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should carefully observe for would be: A. Mediastinal shift B. Tracheal laceration C. Open pneumothorax D. Pericardial tamponade 22. When planning care for a client at 30-weeks gestation, admitted to the hospital after vaginal bleeding secondary to placenta previa, the nurse’s primary objective would be: A. Provide a calm, quiet environment B. Prepare the client for an immediate cesarean birth C. Prevent situations that may stimulate the cervix or uterus D. Ensure that the client has regular cervical examinations assess for labor 23. When planning discharge teaching for a young female client who has had a pneumothorax, it is important that the nurse include the signs and symptoms of a pneumothorax and teach the client to seek medical assistance if she experiences: A. Substernal chest pain B. Episodes of palpitation C. Severe shortness of breath D. Dizziness when standing up 24. After a laryngectomy, the most important equipment to place at the client’s bedside would be: A. Suction equipment B. Humidified oxygen C. A nonelectric call bell D. A cold-stream vaporizer 25. Nurse Oliver interviews a young female client with anorexia nervosa to obtain information for the nursing history. The client’s history is likely to reveal a: A. Strong desire to improve her body image B. Close, supportive mother-daughter relationship C. Satisfaction with and desire to maintain her present weight D. Low level of achievement in school, with little concerns for grades 26. Nurse Bea should plan to assist a client with an obsessive-compulsive disorder to control the use of ritualistic behavior by: A. Providing repetitive activities that require little thought B. Attempting to reduce or limit situations that increase anxiety C. Getting the client involved with activities that will provide distraction D. Suggesting that the client perform menial tasks to expiate feelings of guilt 27. A 2 ½ year old child undergoes a ventriculoperitoneal shunt revision. Before discharge, nurse John, knowing the expected developmental behaviors for this age group, should tell the parents to call the physician if the child:
  5. 5. A. Tries to copy all the father’s mannerisms B. Talks incessantly regardless of the presence of others C. Becomes fussy when frustrated and displays a shortened attention span D. Frequently starts arguments with playmates by claiming all toys are “mine” 28. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina can best plan to avoid this complication by: A. Assessing urine specific gravity B. Maintaining the ordered hydration C. Collecting a weekly urine specimen D. Emptying the drainage bag frequently 29. A client has sustained a fractured right femur in a fall on stairs. Nurse Troy with the emergency response team assess for signs of circulatory impairment by: A. Turning the client to side lying position B. Asking the client to cough and deep breathe C. Taking the client’s pedal pulse in the affected limb D. Instructing the client to wiggle the toes of the right foot 30. To assess orientation to place in a client suspected of having dementia of the alzheimers type, nurse Chris should ask: A. “Where are you?” B. “Who brought you here?” C. “Do you know where you are?” D. “How long have you been there?” 31. Nurse Mary assesses a postpartum client who had an abruption placentae and suspects that disseminated intravascular coagulation (DIC) is occurring when assessments demonstrate: A. A boggy uterus B. Multiple vaginal clots C. Hypotension and tachycardia D. Bleeding from the venipuncture site 32. When a client on labor experiences the urge to push a 9cm dilation, the breathing pattern that nurse Rhea should instruct the client to use is the: A. Expulsion pattern B. Slow paced pattern C. Shallow chest pattern D. blowing pattern 33. Nurse Ronald should explain that the most beneficial between-meal snack for a client who is recovering from the full-thickness burns would be a: A. Cheeseburger and a malted B. Piece of blueberry pie and milk C. Bacon and tomato sandwich and tea D. Chicken salad sandwich and soft drink
  6. 6. 34. Nurse Wilma recognizes that failure of a newborn to make the appropriate adaptation to extrauterine life would be indicated by: A. flexed extremities B. Cyanotic lips and face C. A heart rate of 130 beats per minute D. A respiratory rate of 40 breath per minute 35. The laboratory calls to state that a client’s lithium level is 1.9 mEq/L after 10 days of lithium therapy. Nurse Reese should: A. Notify the physician of the findings because the level is dangerously high B. Monitor the client closely because the level of lithium in the blood is slightly elevated C. Continue to administer the medication as ordered because the level is within the therapeutic range D. Report the findings to the physician so the dosage can be increased because the level is below therapeutic range 36. A client has a regular 30-day menstrual cycles. When teaching about the rhythm method, Which the client and her husband have chosen to use for family planning, nurse Dianne should emphasize that the client’s most fertile days are: A. Days 9 to 11 B. Days 12 to 14 C. Days 15 to 17 D. Days 18 to 20 37. Before an amniocentesis, nurse Alexandra should: A. Initiate the intravenous therapy as ordered by the physiscian B. Inform the client that the procedure could precipitate an infection C. Assure that informed consent has been obtained from the client D. Perform a vaginal examination on the client to assess cervical dilation 38. While a client is on intravenous magnesium sulfate therapy for preeclampsia, it is essential for nurse Amy to monitor the client’s deep tendon reflexes to: A. Determine her level of consciousness B. Evaluate the mobility of the extremities C. Determine her response to painful stimuli D. Prevent development of respiratory distress 39. A preschooler is admitted to the hospital with a diagnosis of acute glomerulonephritis. The child’s history reveals a 5-pound weight gain in one week and peritoneal edema. For the most accurate information on the status of the child’s edema, nursing intervention should include: A. Obtaining the child’s daily weight B. Doing a visual inspection of the child C. Measuring the child’s intake and output D. Monitoring the child’s electrolyte values 40. Nurse Mickey is administering dexamethasome (Decadron) for the early management of a client’s cerebral edema. This treatment is effective because: A. Acts as hyperosmotic diuretic B. Increases tissue resistance to infection
  7. 7. C. Reduces the inflammatory response of tissues D. Decreases the information of cerebrospinal fluid 41. During newborn nursing assessment, a positive Ortolani’s sign would be indicated by: A. A unilateral droop of hip B. A broadening of the perineum C. An apparent shortening of one leg D. An audible click on hip manipulation 42. When caring for a dying client who is in the denial stage of grief, the best nursing approach would be to: A. Agree and encourage the client’s denial B. Allow the denial but be available to discuss death C. Reassure the client that everything will be OK D. Leave the client alone to confront the feelings of impending loss 43. To decrease the symptoms of gastroesophageal reflux disease (GERD), the physician orders dietary and medication management. Nurse Helen should teach the client that the meal alteration that would be most appropriate would be: A. Ingest foods while they are hot B. Divide food into four to six meals a day C.Eat the last of three meals daily by 8pm D. Suck a peppermint candy after each meal 44. After a mastectomy or hysterectomy, clients may feel incomplete as women. The statement that should alert nurse Gina to this feeling would be: A. “I can’t wait to see all my friends again” B. “I feel washed out; there isn’t much left” C. “I can’t wait to get home to see my grandchild” D. “My husband plans for me to recuperate at our daughter’s home” 45. A client with obstruction of the common bile duct may show a prolonged bleeding and clotting time because: A. Vitamin K is not absorbed B. The ionized calcium levels falls C. The extrinsic factor is not absorbed D. Bilirubin accumulates in the plasma 46. Realizing that the hypokalemia is a side effect of steroid therapy, nurse Monette should monitor a client taking steroid medication for: A. Hyperactive reflexes B. An increased pulse rate C. Nausea, vomiting, and diarrhea D. Leg weakness with muscle cramps 47. When assessing a newborn suspected of having Down syndrome, nurse Rey would expect to observe:
  8. 8. A. long thin fingers B. Large, protruding ears C. Hypertonic neck muscles D. Simian lines on the hands 48. A 10 year old girl is admitted to the pediatric unit for recurrent pain and swelling of her joints, particularly her knees and ankles. Her diagnosis is juvenile rheumatoid arthritis. Nurse Janah recognizes that besides joint inflammation, a unique manifestation of the rheumatoid process involves the: A. Ears B. Eyes C. Liver D. Brain 49. A disturbed client is scheduled to begin group therapy. The client refuses to attend. Nurse Lolit should: A. Accept the client’s decision without discussion B. Have another client to ask the client to consider C. Tell the client that attendance at the meeting is required D. Insist that the client join the group to help the socialization process 50. Because a severely depressed client has not responded to any of the antidepressant medications, the psychiatrist decides to try electroconvulsive therapy (ECT). Before the treatment the nurse should: A. Have the client speak with other clients receiving ECT B. Give the client a detailed explanation of the entire procedure C. Limit the client’s intake to a light breakfast on the days of the treatment D. Provide a simple explanation of the procedure and continue to reassure the client 51. Nurse Vicky is aware that teaching about colostomy care is understood when the client states, “I will contact my physician and report ____”: A. If I notice a loss of sensation to touch in the stoma tissue” B. When mucus is passed from the stoma between irrigations” C. The expulsion of flatus while the irrigating fluid is running out” D. If I have difficulty in inserting the irrigating tube into the stoma” 52. The client’s history that alerts nurse Henry to assess closely for signs of postpartum infection would be: A. Three spontaneous abortions B. negative maternal blood type C. Blood loss of 850 ml after a vaginal birth D. Maternal temperature of 99.9° F 12 hours after delivery 53. A client is experiencing stomatitis as a result of chemotherapy. An appropriate nursing intervention related to this condition would be to: A. Provide frequent saline mouthwashes B. Use karaya powder to decrease irritation C. Increase fluid intake to compensate for the diarrhea D. Provide meticulous skin care of the abdomen with Betadine
  9. 9. 54. During a group therapy session, one of the clients ask a male client with the diagnosis of antisocial personality disorder why he is in the hospital. Considering this client’s type of personality disorder, the nurse might expect him to respond: A. “I need a lot of help with my troubles” B. “Society makes people react in old ways” C. “I decided that it’s time I own up to my problems” D. “My life needs straightening out and this might help” 55. A child visits the clinic for a 6-week checkup after a tonsillectomy and adenoidectomy. In addition to assessing hearing, the nurse should include an assessment of the child’s: A. Taste and smell B. Taste and speech C. Swallowing and smell D. Swallowing and speech 56. A client is diagnosed with cancer of the jaw. A course of radiation therapy is to be followed by surgery. The client is concerned about the side effects related to the radiation treaments. Nurse Ria should explain that the major side effects that will experienced is: A. Fatigue B. Alopecia C. Vomiting D. Leucopenia 57. Nurse Katrina prepares an older-adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. Targeting the most frequent cause of falls, the nurse should: A. Offer the client assistance to the bathroom B. Move the bedside table closer to the client’s bed C. Encourage the client to take an available sedative D. Assist the client to telephone the spouse to say “goodnight” 58. When evaluating a growth and development of a 6 month old infant, nurse Patty would expect the infant to be able to: A. Sit alone, display pincer grasp, wave bye bye B. Pull self to a standing position, release a toy by choice, play peek-a-boo C. Crawl, transfer toy from one hand to the other, display of fear of strangers D. Turn completely over, sit momentarily without support, reach to be picked up 59. A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. Nurse Tina should instruct the client to: A. Manually express milk and feed it to the baby in a bottle B. Stop breastfeeding for two days to allow the nipple to heal C. Use a breast shield to keep the baby from direct contact with the nipple D. Feed the baby on the unaffected breast first until the affected breast heals 60. Nurse Sandy observes that there is blood coming from the client’s ear after head injury. Nurse Sandy should: A. Turn the client to the unaffected side B. Cleanse the client’s ear with sterile gauze
  10. 10. C. Test the drainage from the client’s ear with Dextrostix D. Place sterile cotton loosely in the external ear of the client 61. Nurse Gio plans a long term care for parents of children with sickle-cell anemia, which includes periodic group conferences. Some of the discussions should be directed towards: A. Finding special school facilities for the child B. Making plans for moving to a more therapeutic climate C. Choosing a means of birth control to avoid future pregnancies D. Airing their feelings regarding the transmission of the disease to the child 62. The central problem the nurse might face with a disturbed schizophrenic client is the client’s: A. Suspicious feelings B. Continuous pacing C. Relationship with the family D. Concern about working with others 63. When planning care with a client during the postoperative recovery period following an abdominal hysterectomy and bilateral salpingo-oophorectomy, nurse Frida should include the explanation that: A. Surgical menopause will occur B. Urinary retention is a common problem C. Weight gain is expected, and dietary plan are needed D. Depression is normal and should be expected 64. An adolescent client with anorexia nervosa refuses to eat, stating, “I’ll get too fat.” Nurse Andrea can best respond to this behavior initially by: A. Not talking about the fact that the client is not eating B. Stopping all of the client’s privileges until food is eaten C. Telling the client that tube feeding will eventually be necessary D. Pointing out to the client that death can occur with malnutrition. 65. A pain scale is used to assess the degree of pain. The client rates the pain as an 8 on a scale of 10 before medication and a 7 on a scale of 10 after being medicated. Nurse Glenda determines that the: A. Client has a low pain tolerance B. Medication is not adequately effective C. Medication has sufficiently decreased the pain level D. Client needs more education about the use of the pain scale