FYI numbers that are highlighted in yellow are confirmed

VERSION 2 - 2021

1. A nurse is planning care for a preschool-age child who isin the acute phase of Kawasaki disease. Which of the

following interventions should the nurse include in the plan of care?

a. Give acetaminophen to control the child’s fever

B. Monitor the client’s cardiac status (Peds p120)

c. Administer antibiotics via intermittent IV bolus for 24 hrs

d. Provide stimulation with children of the same age in the playroom

2. A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, “The

voices are telling me to jump.” Which of the following is an appropriate response by the nurse?

a. “Do you recognize the voices as belonging to anyone you know?”

B. “I understand the voices are frightening you, but I do not hear any voices.”

c. “That can’t be true. The only voicesin this room are yours and mine.”

d. “You shouldn’t be afraid when you think the voices are telling you to hurt yourself.”

Rationale: try to reorient the client back to reality.

3. A nurse is caring for a client who is preparing his advance directives. Which of the following statements by the

client indicates an understanding of advance directives? (Select all that apply.)

a. “I need an attorney to witness my signature on the advance directives.” *(nurse witnesses it)

b. “I have the right to refuse treatment.” (Leadership p38)

c. “My doctor will need to approve my advance directives.” (just needsto write a prescription)

d. “My health care proxy can make medical decisions for me.” (Leadership p38)

e. “I can’t change my advance directives once submitted.” (yes you can)

4. A client who is pregnant voices her concern that her 3-year-old son will feel left out once the newborn arrive.

Which of the following statements by the nurse is appropriate?

a. “Offer your son a gift when the baby receives one.” (Provide a gift from the infant to give the sibling)

b. “Teach your son to change the baby’s diapers.” (Allow older siblings to help in providing care for the

infant)

c. “Tell yourson to kissthe baby.” (Maternity p126: Let the sibling be one of the first to see the infant) Don’t force

interactions betch

d. “Move your son to a toddler bed when the baby arrives. (do this weeks prior to baby’s arrival)

5. A nurse is teaching a client who has nephrotic syndrome about dietary management. Which of the following

instructions should the nurse include in the teaching?

a. Limit total daily sodium intake to 4 to 5 grams

B. Obtain most calories from complex carbohydrates

c. Consume a high-protein diet (Sufficient amount of protein, high potassium, low sodium)

d. Avoid intake of soy products.

Rationale: Excess of protein should be avoided because a very high protein diet may cause tubular damage to the

kidneys asthe kidneys will have to filter more of the proteins. But moderate protein intake (about 1 gm/kg body

weight) is mandatory to compensate for the protein loss in the urine.

6. A nurse is interviewing an adolescent client who has a history of physical aggression due to anger management

issues. Which of the following is an appropriate question by the nurse?

a. “Did you think about removing yourself from the situation when you became angry?”

b. “Why do you get angry when things don’t go your way?”

c. “How do you think othersfeel when you express anger?”

D. “What are you thinking about when you express anger?” (assessing the underlying issue of aggression)

7. A nurse is planning care for a client who has a sealed radiation implant and isto remain in the hospital for 1

week. Which of the following should the nurse include in the plan of care?

a. Wear a dosimeter film badge while in the client’s room. (Med Surg p583)

b. Ensure family membersremain at least 3 feet from the client (should be at least 6ft)

c. Limit each of the client’s visitorsto 1 hr per day. (should be 30 minutes)

d. Remove dirty linens from the room after double bagging. Keep in the room

8. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should

the nurse plan to take? talaga

a. Sit at or below the client’s eye level during feedings (Funds p215: Observe for aspiration and pocketing of

food in the cheeks or other areas of the mouth)

b. Talk with the client during her feeding

c. Discourage the client from coughing during feedings (encourage pt to cough to prevent aspiration)

d. Instruct the client to lift her chin when swallowing (tuck chin)

9. A nurse is caring for a preschool child who is dehydrated. Which of the following assessment findings indicates

moderate dehydration?

a. Bradypnea

B. Oliguria (Funds p343)

c. Diaphoresis

d. Excessive tears

10. A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should

the nurse include in the teaching?

a. “Your child can return to school after a negative titer result.”

b. “Your child can return to school 24 hours after beginning antibiotics.”

c. “Your child can return to school once the lesions have crusted over.”

d. “Your child can return to school once the fever has subsided.”

11. A nurse is providing information for a client who has a new prescription for simvastatin. For which of the

following should the nurse instruct the client to monitor and report to the provider?

a. Muscle weakness - rhabdomyolysis

b. Edema

c. Weight loss

d. Fever

Rationale: Simvastatin

Although mild muscle pain is a relatively common side effect of statins, some people who take statin medications to

lower their cholesterol may have severe muscle pain. Thisintense pain may be a symptom of rhabdomyolysis, a rare

condition that causes muscle cells to break down. The most common signs and symptoms of rhabdomyolysis

include:

● Severe muscle aching throughout the entire body

● Muscle weakness

● Dark or cola-colored urine

The higher the dose of statins, the higher the risk of rhabdomyolysis becomes. The risk also increases if certain

drugs — including cyclosporine (Sandimmune) and gemfibrozil (Lopid) — are taken in combination with statins.

However, the risk of developing rhabdomyolysis from statin therapy is very low, around 1.5 for each 100,000 people

taking statins. Rhabdomyolysis or milder forms of muscle inflammation from statins can be diagnosed with a blood

test measuring levels of the enzyme creatinine kinase. If you notice moderate or severe muscle aches after starting to

take a statin, contact your doctor. If you have signs and symptoms of rhabdomyolysis, stop taking your statin

medication immediately and seek medical treatment right away. If necessary, your doctor may take steps to help

prevent kidney damage and other complications.

12. A nurse on a medical-surgical unit isreceiving report on four clients. Which of the following clients should the

nurse assess first?

a. A client who isreceiving warfarin and has an INR of 3.3

b. A client who had an NG tube inserted 6 hrs ago and has abdominal distention

c. A client who is 4 hrs postoperative following a thyroidectomy and reports fullness in the back of the

throat (edema can lead to resp distress)

d. A client who has acute kidney injury, a creatinine of 4 mg/dL, and a BUN of 52 mg/dL

13. A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to

attend to first?

a. A client who reports changing her perineal pad every 2 hrs

b. A client who reports abdominal pain during breastfeeding

c. A client who has a urine output of 250 mL in 6 hrs

D. A client who has hyporeflexia while receiving magnesium sulfate

14. A nurse is providing nutritional teaching regarding appropriate food choicesto a client who has a new diagnosis

of uric acid calculi. Which of the following should the nurse include in the teaching?

a. Roast beef

b. Chicken breast

c. Low-fat yogurt (avoid purine foods: organ meats & shellfish & poultry)

d. Tuna fish

15. A nurse in the emergency department is caring for a client who has a full-thickness burn of the thorax and

upper torso. After securing the client’s airway, which of the following isthe nurse’s priority intervention?

a. Preventing infection

b. Offering emotional support

c. Providing pain management

D. Initiating IV fluid resuscitation repeat

16. A nurse is caring for a client who will undergo a procedure. The client states she does not want the provider to

discussthe results with her partner. Which of the following is an appropriate response for the nurse to make?

a. “The provider will be tactful when talking to your partner.”

B. “You have the right to decide who receives information.”

c. “Isthere a reason you don’t want your partner to know about your procedure?”

d. “Your partner can be a great source of support for you at thistime.”

17. A nurse is providing teaching about dietary recommendationsto the parents of a school-age child who has acute

kidney injury. Which of the following recommendations should the nurse include in the teaching?

a. Provide low-calcium foods

b. Provide high-phosphorus foods

C. Provide low-potassium foods

d. Provide high-sodium foods

Rationale: P. 380 MS PHOSPHATE , POTASSIUM, SODIUM AND MAGNESIUM NEED TO BE

RESTRICTED

18. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis.

Which of the following actions should the nurse include in the plan of care?

a. Apply a warm compressto the operative site every 4 hr

b. Offer small amounts of clear liquids 6 hrsfollowing surgery

c. Give cromolyn nebulized solution every 8 hr

D. Administer analgesics on a scheduled basis for the first 24 hrs

19. A nurse is assessing a client who is 8 hr postpartum and has been unable to void. Which of the following actions

should the nurse take first?

a. Pour warm water over the client’s perineum

b. Offer the client a sitz-bath

c. Insert a sterile catheter

d. Administer an analgesic

20. A nurse is providing nutritional teaching for an older adult client who has seizure disorder and a new

prescription for phenytoin. Which of the following statements by the nurse is appropriate?

a. “Limit foodsthat contain folic acid while taking this medication.”

b. “You should expect a change in the color of your stool while taking this medication.”

c. “Increase your intake of vitamin D while taking this medication.” - phenytoin complication (bone

pain and weakness)

d. “Plan to take this medication with antacids.”

21. A nurse is assessing a client who sustained fracturesto both legsin a motor-vehicle crash. Which of the

following findings indicates the client is experiencing a fat embolism?

a. Pete$h&ae )* the $he+t a*d a-d)me* / 01a$t&$e te+t 2345 6

b. Decreased pedal pulses

c. Pain unrelieved by opioid analgesics

d. Crepitus at the knee joint

22. A nurse is teaching a client who is at 41 weeks of gestation about a nonstress test. Which of the following

information should the nurse include in the teaching?

a. “You will have a Doppler transducer applied to your abdomen during the test.”

b. “You should massage one of your nipplesto stimulate contractions of your uterus.”

c. “You will need blood work before and after the test.”

d. “You should avoid eating or drinking for 4 hrs before the test.”

23. A home health nurse is assessing a client who has amyotrophic lateral sclerosis(ALS) and has had recent weight

loss. Which of the following isthe priority admission data for the nurse to obtain? TALAGA

a. Changesin appetite

b. Daily fluid intake

c. Swallowing ability - aspirations precautions

d. Prescribed medications

24. A nurse is providing discharge teaching for a client who has myelosuppression following chemotherapy

treatment. Which of the following statements should the nurse include in the teaching?

a. “Eat a diet rich in fresh fruits and vegetables.”

B. “Wear disposable gloves under gardening gloves while working with house plants.”

c. “Children may visit aslong asthey’ve recently received a live influenza vaccination.”

d. “Check your temperature weekly.”

BONE MARROW SUPPRESSION- IMMUNOCOMPROMISED. AVOID

25. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction

drain. Which of the following actions should the nurse take?

a. Maintain the client in supine position for the first 24 hrs

b. Secure the drain to the bedding

c. Reset the vacuum by compressing the container

d. Position the affected extremity below the level of the client’s heart

26. A nurse is providing discharge instructionsto a client who is 1-day postoperative vertical banded gastroplasty

for morbid obesity. Which of the following statements demonstrates an understanding for the dietary teaching?

a. “It should take me 30 to 60 minutes to eat a meal”

b. “I will be limited to pureed foodsfor the next 6 months.” (weeks)

c. “I should eat three meals per day.”

d. “Vomiting is common and I will have to learn to live with it.”

SERVE TO RESTRICT AND DECREASE FOOD INTAKE HELPS TO PROMOTE WT. LOSS