Sample Nursing Board Exam Questions

MEDICAL SURGICAL NURSING

2011-01-14T05:07:00.000-08:00

1. Following a prostatectomy, the client has a three-way, indwelling catheter for continuous bladder irrigation. During evening shift, 2400 ml of irrigant was instilled. At the end of the shift, the drainage bag was drained of 2900 ml of fluid. The nurse calculates the urine output to be

A. 5300 ml.

B. 2900 ml.

C. 240 ml.

D. 500 ml.

Answer Rationale

A. Urine output is calculated by subtracting the amount of irrigant instilled from the total fluid removed from the drainage bag.

B. Urine output is calculated by subtracting the amount of irrigant instilled from the total fluid removed from the drainage bag.

C. Urine output is calculated by subtracting the amount of irrigant instilled from the total fluid removed from the drainage bag.

D. Urine output is calculated by subtracting the amount of irrigant instilled from the total fluid removed from the drainage bag (2900 ml drainage - 2400 ml irrigant = 500 ml urine).

2. An adult has just been brought in by ambulance after a motor vehicle accident and has moderate anxiety. When assessing the client, the nurse would expect which of the following from sympathetic nervous system stimulation?

A. A rapid pulse and increased respiratory rate.

B. Decreased physiologic functioning.

C. Rigid posture and altered perceptual focus.

D. Increased awareness and attending.

Answer Rationale

A. The sympathetic nervous system during moderate anxiety will increase the pulse and respirations.

B. If there is any decreased physiologic functioning, it is from the parasympathetic nervous system and not the sympathetic.

C. Both a rigid posture and either fixed or scattered perceptual focus indicate severe anxiety or panic, not moderate stress.

D. The increased awareness and attending as well as the ability to focus on most of what is really happening is a sign of mild anxiety. Learning can take place during mild anxiety.

3. An adult is on a clear liquid diet. The nurse can offer him

A. milk.

B. Jello.

C. freshly squeezed orange juice.

D. ice cream.

Answer Rationale

A. Milk is not permitted on a clear liquid diet, but is allowed on a full liquid diet.

B. Plain gelatins can be given on a clear liquid diet, as well as tea, coffee, ginger ale, or 7-Up.

C. The only fruit juices allowed on a clear liquid diet are those that are strained and clear (able to be seen through).

D. Ice cream is allowed with a full liquid diet, not a clear liquid diet.

4. An adult is being taught about a healthy diet. The nurse explains that the food pyramid can guide him

A. by indicating exactly how many servings of each group to eat.

B. on how many calories he should have.

C. in making daily food choices.

D. to divide food into four basic groups.

Answer Rationale

A. Each person differs in nutritional needs according to age, activity level, size, and other factors. Therefore the pyramid serves as a guide.

B. The food pyramid does not indicate caloric count. It can serve to guide eating patterns.

C. The pyramid helps to guide the client in choosing a variety of foods to obtain the nutrients he needs. It also aids in eating more of some groups (bread, cereal, rice, and pasta) and less of others (fats, oils, and sweets).

D. The pyramid replaces the old basic four, by dividing food into six groups: bread, cereal, rice, and pasta; fruit; vegetables; milk, yogurt, and cheese; meat, poultry, fish, dry beans, eggs, and nuts; and fats, oils, and sweets. It also indicates to eat more of some foods and less of others.

5. Before administering a tube feeding the nurse knows to perform which of the following assessments?

A. gastrointestinal (GI) tract, including bowel sounds, last BM, and distention.

B. The client's neurologic status, especially gag reflex.

C. The amount of air in the stomach.

D. That the formula is used directly from the refrigerator.

Answer Rationale

A. The GI tract should be assessed before each feeding to ensure functioning and minimal problems.

B. An altered neurologic status can be the reason for tube feedings, the gag reflex need not be present as the tube provides the conduit although it can be a significant risk factor for aspiration.

C. The gastric residue can be checked to evaluate gastric emptying. If there is more than 100 ml, then the feeding is often held and the physician contacted.

D. The formula is administered at room temperature to avoid cramping, which can occur if the formula is cold.

6. An adult is on long-term aspirin therapy and is experiencing tinnitus. The nurse best interprets this to mean:

A. the aspirin is working correctly.

B. the client ingested more medicine than was recommended.

C. client has an upper GI bleed.

D. he is experiencing a mild overdosage.

Answer Rationale

A. Tinnitus or ringing in the ears is a sign of an overdosage and the aspirin should be stopped to allow the tinnitus to clear.

B. Although the client has an overdosage, it does not mean that he took too much medicine. A build-up can occur, especially among those with limited liver or kidney function.

C. Although aspirin can cause GI irritation and bleeding, tinnitus or ringing in the ears is a sign of aspirin overdosage.

D. Tinnitus is a classic sign of aspirin overdosages, either from too much ingestion or limited excretion.

7. An adult is to receive an intramuscular (IM) injection of morphine for post-op pain. Which of the following is necessary for the nurse to assess prior to giving a narcotic analgesic?

A. client's level of alertness and respiratory rate.

B. The last time the client ate or drank something.

C. The client's bowel habits and last bowel movement.

D. The client's history of addictions.

Answer Rationale

A. A decreasing level of alertness can signal early respiratory depression and a significant drop in the respiratory rate is a warning sign. Both should be taken prior to giving the medication for baseline purposes.

B. The last meal is important for surgery, but narcotic analgesics can be given after eating or drinking as long as care is given to avoid vomiting and aspiration.

C. Although constipation is a common side-effect of narcotics, it should not prohibit the administration of the drug.

D. A history of addictions does not preclude a client from receiving the analgesic.

8. An adult suffered second and third degree burns over 20% of his body two days ago. The nurse knows that the best way to assess fluid balance is to

A. maintain strict records of intake and output.

B. weigh the client daily.

C. monitor skin turgor.

D. check for edema.

Answer Rationale

A. Although inputs and outputs are important, they do not take into account other losses (especially through the wound) which can be significant.

B. This is the best way to assess fluid balance, especially acute changes in those with large losses or acutely ill.

C. Skin turgor can assist in assessing fluid balance, but daily weights can provide a better measure for the burn victim.

D. Edema informs the nurse about fluid in the interstitial spaces, but would not reflect the vascular component.

9. Ms. H. has gastroenteritis and is on digitalis. Her lab values are: K 3.2 mEq/L, Na 136 mEq/L, Ca 4.8 mEq/L, and Cl 98 mEq/L. The nurse puts which of the following on the client's plan of care?

A. Monitor for hyperkalemia.

B. Avoid foods rich in potassium.

C. Observe for digitalis toxicity.

D. Observe for Trousseau's and Chvostek's signs.

Answer Rationale

A. The client has hypokalemia, not hyperkalemia, and needs to be observed for problems related to too little potassium.

B. Ms. H.'s problem is hypokalemia, too little potassium. She needs to increase the amount in her diet, not limit it.

C. Hypokalemia enhances digitalis toxicity, and must be observed for carefully.

D. These signs indicate hypocalcemia or hypomagnesemia. This client has hypokalemia.

10. Mr. B. is anxious and hyperventilating. His blood gases are: pH 7.47, PaCO 2 33. What is the best initial action for the nurse to take?

A. Try to have the client breathe slower or into a paper bag.

B. Monitor the client's fluid balance.

C. Give O 2 via nasal cannula.

D. Administer sodium bicarbonate.

Answer Rationale

A. The client is in respiratory alkalosis, and needs to increase the carbon dioxide. The easiest way to do this is to try and calm the client and/or have him breathe in and out of a paper bag, thus inhaling the exhaled carbon dioxide.

B. Fluid loss, especially vomiting and diarrhea will often result in metabolic alkalosis. This client's problem is respiratory alkalosis and would not be corrected through fluid administration.

C. The problem is not too little oxygen as much as it is too much exhalation of carbon dioxide.

D. There is not too little bicarbonate (which occurs with metabolic acidosis), rather too little carbonic acid.

11. A nurse is teaching a class in a community center about lung cancer. Which statement best demonstrates the client's understanding of the risk factors for lung cancer?

A. "My husband smokes, but I don't! So, I really don't need to worry about getting lung cancer."

B. "I guess I will need to eat more green and yellow vegetables."

C. "Just because I have COPD doesn't mean that I have a higher risk."

D. "I've worked with asbestos all my life and have never had any problems."

Answer Rationale

A. Cigarette smoke may be inhaled actively by smoking or passively (second hand smoke). Both types of inhalation are positively correlated with development of lung cancer.

B. Research has shown that there may be a correlation between vitamin A deficiency in the diet and the development of lung cancer. Daily consumption of green and yellow vegetables is encouraged.

C. Clients with chronic respiratory diseases are at higher risk for development of lung cancer.

D. Lung cancer has a higher incidence in industrial areas. Coal tar, radioactive ore, asbestos, nickel, silver, arsenic and plastics have been found to be carcinogenic. Asbestos exposure is a definite risk factor for development of lung cancer.

12. A client presents with symptoms of increased intracranial pressure, papilledema, and headache. No history of trauma is found. Vital signs are: BP 110/60, HR 80, T 98.9 ° F, RR 24. Based on this assessment, the nurse suspects the client has a(n):

A. brain tumor.

B. meningitis.

C. skull fracture.

D. encephalitis.

Answer Rationale

A. These findings are consistent with a brain tumor.

B. Meningitis is accompanied by fever, headache, nuchal rigidity, and Kernig's and Brudzinski's signs.

C. There is no history of head trauma.

D. The symptoms of encephalitis include headache, fever, vomiting, and meningeal signs.

13. Mr. P., a 45-year-old, complains of excessive weight loss and anorexia. Laboratory studies show that Mr. P. is anemic. Hepatocellular carcinoma is suspected. A liver biopsy is performed at the bedside. The nurse can expect that after the procedure Mr. P. will be

A. encouraged to ambulate to prevent the formation of venous thrombosis.

B. 2. Incorrect asked to turn, cough, and deep breathe every two hours for the next eight hours.

C. placed in a high Fowler's position to maximize thoracic expansion.

D. positioned on his right side with a pillow under the costal margin, and immobile for several hours.

Answer Rationale

A. Clients are to remain immobile on bedrest for several hours post liver biopsy.

B. Turning the client side to side is contraindicated; bleeding from the puncture site is encouraged.

C. High Fowler's position does not provide pressure against the puncture site, which would discourage bleeding.

D. The client experiencing a liver biopsy is at risk for bleeding or hemorrhage related to penetration of the liver capsule. Positioning on the right side acts as a tamponade against the puncture site discouraging bleeding from the site.

14. A 36 - year - old female reports double vision, visual loss, weakness, numbness of the hands, fatigue, tremors, and incontinence. On assessment, the nurse notes nystagmus, scanning speech, ataxia, and muscular weakness. Based on these findings, the nurse suspects the client has

A. Parkinson's disease.

B. myasthenia gravis (MG).

C. amyotrophic lateral sclerosis (ALS).

D. multiple sclerosis (MS).

Answer Rationale

A. The symptoms of Parkinson's include masklike appearance to the face, drooling, slow speech, and shuffling gait.

B. The symptoms of MG include weakness, fatigue, drooling, and ptosis.

C. The symptoms of ALS include progressive muscle weakness, atrophy, fasciculations, dysphagia, and spasticity of the flexor muscles.

D. These are the symptoms of MS, which is more common in women ages 20 - 40.

15. A client is being assessed to rule out cardiovascular problems. The nurse understands that some of the common symptoms associated with cardiovascular disease are

A. shortness of breath, chest discomfort, palpitations.

B. dyspnea, chest discomfort, sputum production.

C. fatigue, weight changes, mood swings.

D. mood swings, headaches, fainting.

Answer Rationale

A. Some of the most common clinical manifestations of cardiovascular disease are shortness of breath, chest pain or discomfort, dyspnea, palpitations, fainting, and peripheral skin changes such as edema.

B. Some of the most common clinical manifestations of respiratory disease are cough, sputum production, dyspnea, hemopytosis, wheezing, and chest pain.

C. Some of the most common clinical manifestations of endocrine disorders are fatigue, depression, decreased energy, sleep pattern disorders, weight changes, altered mood, changes in the condition of the skin and hair, sexual dysfunction.

D. Some of the most common clinical manifestations of neurologic disorders are behavior changes, mood swings, loss of consciousness, seizures, memory deficits, motor and sensory function problems.

16. A 52 - year - old patient is admitted to the nursing unit from the recovery room following a left pneumonectomy. When planning his care, the nurse can expect this patient to:

A. have a chest tube to water seal.

B. have a chest tube to suction.

C. be monitored closely for respiratory and cardiac complications.

D. have his left arm maintained in a sling to prevent pain and discomfort.

Answer Rationale

A. In an pneumonectomy, the entire lung is removed and the pleural space is left empty. Closed chest drainage is generally not used because it is helpful for serous fluid to accumulate in the empty space to prevent an extensive mediastinal shift.

B. In an pneumonectomy, the entire lung is removed and the pleural space is left empty. Closed chest drainage is generally not used because it is helpful for serous fluid to accumulate in the empty space to prevent an extensive mediastinal shift.

C. Post-op respiratory insufficiency may result from an altered level of consciousness related to anesthesia, pain medications, decreased respiratory effort secondary to pain, or inadequate airway clearance. So, the client must be monitored very closely with frequent vital sign checks and respiratory assessments.

D. It is very important that the client move the arm on the affected side. Generally the pain is due to muscle dissection and restricted positioning while the patient is in the OR. Encouraging use of analgesics and arm exercises will help decrease discomfort.

17. To prevent possible complication, which of the following questions should a nurse ask a client prior to a cardiac catheterization?

A. "Have you ever had a cardiac catheterization before?"

B. "Can you eat shellfish?"

C. "Do you understand the procedure?"

D. "Have you ever had a heart attack?"

Answer Rationale

A. Client teaching can enforce new material but does not reduce complications.

B. Shellfish contains iodine, which is also in the contrast media used during a catheterization. It is imperative to obtain information regarding iodine allergies.

C. Anxiety can be reduced by client education, but this does not reduce complications.

D. Past history is important; however, this information will not prevent life-threatening complications.

18. The nurse caring for a patient who has had a removal of the larynx and a permanent opening made into the trachea will plan care for a patient who has undergone a

A. total laryngectomy.

B. tracheostomy.

C. radical neck dissection.

D. partial laryngectomy.

Answer Rationale

A. A total laryngectomy is the removal of the larynx and formation of the tracheostomy. The esophagus remains attached to the pharynx. No air will enter through the nose. The patient will breathe through the tracheostomy. The procedure is indicated for large glottic tumors with fixation of vocal cords.

B. A tracheostomy is a surgical opening made into the trachea for airway management with a creation of a stoma. This procedure can be indicated for (but not limited to) long-term airway management, upper airway obstruction, altered level of consciousness, sleep apnea, airway burns.

C. Radical neck dissection is the removal of the lymphatic drainage channels and nodes, sternicleodomastoid muscle, spinal accessory nerve, jugular vein, and submandibular area. This procedure is indicated when metastasis occurs to the cervical lymph nodes from tumors in the upper aerodigestive tract.

D. A partial laryngectomy is removal of half or more of the larynx. This procedure is performed for cancer of the vocal cords.

19. Mr. W., a 55-year-old, is scheduled for a resection of the lower thoracic esophagus to remove a malignant tumor. In planning for Mr. W.'s postoperative care, the nurse would expect to

A. keep Mr. W. in a supine position to encourage thoracic expansion.

B. carefully advance the nasogastric tube past the anastomosis site.

C. frequently assess Mr. W.'s breath sounds.

D. provide a regular diet high in protein.

Answer Rationale

A. Post-op clients experiencing esophageal resections are positioned in a semi-Fowler's position to help prevent reflux of gastric contents.

B. Nasogastric tubes of clients with an esophageal resection should not be manipulated.

C. Surgical resection of the esophagus has a relatively high mortality rate related to pulmonary complications.

D. Clients with an esophageal resection when beginning to take food orally would have a liquid or soft diet.

20. Mr. J., a 35 - year - old stockbroker, has recently been diagnosed with peptic ulcer disease. Diagnostic studies confirm the presence of the gram - negative bacteria Helicobacter pylori in his gastrointestinal tract. If Mr. J. has a duodenal ulceration, the nurse would expect Mr. J. to describe the "ulcer pain" as:

A. located in the upper right epigastric area radiating to his right shoulder or back.

B. relieved by vomiting.

C. occurring two to three hours after a meal, often awakening him between 1:00 and 2:00 a.m.

D. worsening with the ingestion of food.

Answer Rationale

A. This pain is typical of the pain associated with cholecystitis.

B. Vomiting is more frequently associated with a gastric ulcer.

C. Duodenal ulcer pain characteristically occurs two to three hours after a meal, often awakening the client in the very early morning hours.

D. Pain that worsens with the ingestion of food is more often associated with gastric ulcers.

OBSTETRIC & GYNECOLOGIC NURSING

2011-01-14T04:36:00.000-08:00

1. When caring for a patient with cardiac disease who has just entered the second stage of labor, the nurse understands that the management of the patient will likely include:

A. doubling the rate of the pitocin infusion to shorten the length of the second stage of labor.

B. monitoring the IV infusion rate so that intake does not exceed output during labor.

C. evaluating the rate of fetal descent by frequent cervical examinations.

D. decreasing the length of the second stage of labor by performing a forceps or vacuum-assisted delivery.

ANSWER RATIONALE

A. The rate of infusion of pitocin would never be doubled at this point in labor.

B. During the second stage of labor, there is very little measurable output, while the IV infusion rate will continue as ordered.

C. Cervical exams would be done as indicated by the progress of the patient.

D. The goal of management with this patient is to shorten the second stage of labor. Appropriate management could include: 1) spinal anesthesia, 2) episiotomy, and 3), forceps delivery.

2. The most effective breathing pattern during the transition phase of labor is:

A. deep abdominal breathing.

B. slow, rhythmic chest breathing.

C. "pant-pant-pant blow" breathing.

D. a light, rapid pant.

ANSWER RATIONALE

A. This type of breathing is not usually used during this phase.

B. This type of breathing may be used prior to the transition phase when the labor is less intense.

C. This pattern-paced breathing is used to enhance the concentration of the laboring women during a time when the contractions are most intense.

D. This method may be used to stop the urge to push during a contraction.

3. Rosemary, 36 weeks pregnant, is admitted to the hospital with 3+ proteinuria, a blood pressure of 160/90, and marked edema. Rosemary is started on IV magnesium sulfate. The purpose of this medication is to:

A. prevent seizures and inhibit peripheral neuromuscular transmission.

B. induce uterine muscle contractions to control the progress of labor.

C. act as a predominant betaminic agent on the smooth muscle of the uterus.

D. act as an antihypertensive sole agent.

ANSWER RATIONALE

A. Magnesium sulfate, an anticonvulsant and smooth muscle relaxant, is given to prevent convulsions.

B. An effect of magnesium sulfate is to inhibit smooth muscle contractions.

C. The predominant action of magnesium sulfate is to depress neuromuscular transmission.

D. The hypotensive effect of magnesium sulfate is a side effect of the drug.

4. Barbara's blood pressure reading at 34 weeks of pregnancy is elevated. When discussing pregnancy-induced hypertension with her, the nurse instructs her to report back immediately if she notes symptoms or signs of:

A. weight gain of 1 pound a week.

B. intractable headache or visual disturbances.

C. development of a backache with fatigue.

D. episodes of heartburn with indigestion.

ANSWER RATIONALE

A. Weight gain of one pound a week is the expected rate of gainin later pregnancy.

B. Severe headache and visual disturbances are considered two of several warning signs of preeclampsia.

C. Development of a backache with fatigue is not an abnormal occurrence.

D. Heartburn with indigestion is an expected discomfort of later pregnancy.

5. Rose has been having persistent late decelerations with moderate bradycardia while in labor. A fetal scalp pH was performed. The nurse explained to the patient that no intervention was needed at this time following a pH result of:

A. 7.0 to 7.05

B. 7.1 to 7.15

C. 7.2 to 7.25

D. 7.3 to 7.35

ANSWER RATIONALE

A. This is in the acidotic range.

B. This is in the acidotic range.

C. This is in the suspected acidotic range for fetal scalp pH.

D. The normal fetal scalp pH is 7.26 and above; borderline acidosis is 7.20 to 7.25; and for pH levels less than 7.15, an acidosis exists.

6. When developing a plan for the pregnant woman, the instructions include that lying on her left side will:

A. help alleviate backache.

B. help her breathe better.

C. prevent pelvic congestion.

D. prevent supine hypotension.

ANSWER RATIONALE

A. This not directly related to this problem.

B. This not directly related to this problem.

C. This not directly related to this problem.

D. The growing uterus may press on the inferior vena cava when the pregnant woman is supine. This reduces blood flow to the right atrium and a ower blood pressure, causing dizziness.

7. Betamethasone is ordered and given to a patient diagnosed with preterm labor at 34 weeks. In evaluating the effects of this medication, the nurse would note that it is given to:

A. decrease the intensity of the contractions.

B. delay the progress of preterm labor.

C. suppress the maternal immune response.

D. facilitate maturation of the fetal lung.

ANSWER RATIONALE

A. Betamethasone does not impact on the progress of labor.

B. Betamethasone does not impact on the progress of labor.

C. Betamethasone does not affect the maternal immune response.

D. The incidence and severity of respiratory distress syndrome has been found to be reduced if glucocorticoids (eg, betamethasone) are administered to the mother at least 24 to 48 hours before birth.

8. When developing a plan for the patient receiving a riodrine hydrochloride for premature labor, the nurse would include having which of the following available as an antidote?

A. propranolol (Inderal)

B. magnesium sulfate

C. Phenobarbital

D. calcium gluconate

ANSWER RATIONALE

A. Ritodrine hydrochloride stimulates Beta-adrenergic receptors, causing relaxation of smooth muscles. Propranolol is an adrenergic blocking agent and could be used to stop the effects of ritodrine hydrochloride.

B. This would not be used as an antidote because it is not an adrenergic blocking agent.

C. This would not be used as an antidote because it is not an adrenergic blocking agent.

D. This would not be used as an antidote because it is not an adrenergic blocking agent.

9. Diane and Ned Rampart have decided to practice natural family planning. They ask the nurse about the Billings method. The nurse explains that the Billings method is performed by:

A. taking the BBT (basal body temperature) daily to determine ovulation

B. checking for spinnbarkheit and the BBT.

C. evaluating the amount and consistency of cervical mucus.

D. monitoring for mittelschmerz signs to determine ovulation.

ANSWER RATIONALE

A. This is a technique which might be used by couples practicing natural family planning, but it does not represent the Billings method.

B. This is a technique which might be used by couples practicing natural family planning, but it does not represent the Billings method.

C. The Billings method, also called the cervical mucus method or the ovulation method, depends on the characteristic changes in the cervical mucus at the time of ovulation.

D. This is a technique which might be used by couples practicing natural family planning, but it does not represent the Billings method.

10. When teaching a family about the side effects of diuretics for their child, the nurse encourages giving tomato juice and meats. Which of the following electrolytes would the parents describe as needing replacement?

A. Sodium

B. Potassium

C. Chlorides

D. vitamins

ANSWER RATIONALE

A. The excretion of this substance is not increased like that of potassium.

B. Diuretics increase the excretion of potassium; it will have to be replaced.

C. The excretion of this substance is not increased like that of potassium.

D. The excretion of this substance is not increased like that of potassium.

11. The nurse midwife performs a procedure in the last trimester to determine fetal position, lie, and presentation. The nurse would describe this procedure as:

A. an ultrasound test.

B. a pelvic exam.

C. Leopold's maneuvers.

D. a fundal sizing.

ANSWER RATIONALE

A. The nurse midwife would not perform this procedure.

B. This would not determine the fetal position or lie.

C. Fetal lie, presentation, position, and engagement can be determined by abdominal palpation of the mother.

D. This would not determine the fetal position or lie.

12. Elizabeth's first prenatal visit, 8 weeks after her last menstrual period, revealed a soft cervix, Chadwick's sign, and an enlarged uterus. When analyzing these findings, the nurse understands that they are considered:

A. presumptive signs of pregnancy.

B. probable signs of pregnancy.

C. possible signs of pregnancy.

D. positive signs of pregnancy.

ANSWER RATIONALE

A. This is not an accurate description.

B. The described findings are characteristic of the first trimester of pregnancy and are labeled the presumptive signs of pregnancy.

C. This is not an accurate description.

D. This is not an accurate description.

13. Rita, a 30-year-old gravida 3, para 2, is admitted to labor and delivery in active labor. She has a hypertonic uterus with severe pain. It is most important for the nurse to:

A. monitor contractions and the fetal heart rate.

B. prepare for an immediate cesarean section.

C. perform a vaginal exam to evaluate her progress.

D. provide psychological support to the mother.

ANSWER RATIONALE

A. The priority of care is monitoring fetal well-being and maintaining the cardiovascular status of the mother.

B. With a hypertonic uterus, the placenta is not well perfused between contractions and the fetus is subjected to increasing periods of hypoxia. The usual option is a C/S.

C. The priority of care is monitoring fetal well-being and maintaining the cardiovascular status of the mother.

D. The priority of care is monitoring fetal well-being and maintaining the cardiovascular status of the mother.

14. When working with the pregnant patient, the nurse bases psychosocial support on the patient's ability to adapt to the maternal role. One of the first psychosocial maternal role tasks is to:

A. establish realistic goals for herself as a mother.

B. incorporate the idea of a child into her body image.

C. prepare for the physical separation at the time of birth.

D. accept the growing fetus as distinct from herself.

ANSWER RATIONALE

A. This is a later achievement for the pregnant woman.

B. One of the earliest maternal role tasks is to "accept the biologic fact of pregnancy" and to "incorporate the idea of a child into her body image."

C. This is a developmental task of the third trimester.

D. This is a developmental task of the second trimester.

15. Maureen Limberti, aged 24, and 39 weeks gestation, is having contractions every 15 minutes. The characteristic that will help her distinguish the difference between early and false labor is when she:

A. falls asleep and contractions stop.

B. notes that the contractions start in the back.

C. realizes walking will intensify the contractions.

D. experiences gas-like abdominal pains.

ANSWER RATIONALE

A. Braxton-Hicks contractions, or false labor, are mild, intermittent, painless contractions which occur throughout the second half of pregnancy. Women often obtain relief from them by walking or lying down.

B. This is a characteristic of early labor and is often accompanied by "bloody show," which is not seen in false labor.

C. This is a characteristic of early labor and is often accompanied by "bloody show," which is not seen in false labor.

D. This is a characteristic of early labor and is often accompanied by "bloody show," which is not seen in false labor.

16. The purpose of Kegel’s exercise is:

A. improve the tone of the rectus abdominus.

B. enhance the mother's uterine contractions.

C. increase strength in the lower back and abdomen.

D. strengthen the muscles around the perineal area.

ANSWER RATIONALE

A. This is not the best reason for performing these exercises.

B. This is not the best reason for performing these exercises.

C. This is not the best reason for performing these exercises.

D. The purpose of Kegel's exercises is to strengthen the muscles around the perineal area.

17. Stephanie Curtain, age 25, is having strong contractions occurring every 2 minutes and lasting 60 to 90 seconds. She feels frustrated, starts to tremble, and is afraid she is losing control. The nurse identifies that she is moving into the:

A. latent phase of labor.

B. active phase of labor.

C. transition phase of labor.

D. second phase of labor.

ANSWER RATIONALE

A. The latent phase of labor is characterized by mild, irregular contractions, with the mother excited and alert.

B. The active phase of labor is characterized by contractions every 3 to 5 minutes, moderately strong, with women becoming more focused inward.

C. These are characteristic findings of the final or transition phase of the first stage of labor.

D. There is no second "phase" of labor. It is the second stage of labor.

18. Your patient is being maintained on lithium therapy for bipolar disorder. Her serum lithium level is 0.9 mEq/L. You assess this level as:

A. too low to be effective.

B. within the therapeutic range.

C. acceptable for acute episodes only.

D. a toxic indicator.

ANSWER RATIONALE

A. This is a suggestion which would not be appropriate given the level of the blood.

B. The therapeutic range for effective ongoing management of the patient on lithium carbonate can be as low as 0.6 mEq/L or as high as 1.5 mEq/L.

C. This is a suggestion which would not be appropriate given the level of the blood.

D. This is a suggestion which would not be appropriate given the level of the blood.

19. Karen, a gravida 2, para 1, is admitted for generalized edema, Proteinuria of +2, and an elevated blood pressure. She is placed on magnesium sulfate and is receiving 2 grams/hour IV. Preparing to mix the next liter of medication, the nurse assesses her, finding absent reflexes and a respiratory rate less than 10 breaths per minute. The first nursing action is to:

A. slow down the magnesium sulfate infusion.

B. stop the medication and monitor progress.

C. stop the magnesium and give calcium gluconate.

D. call the physician and have calcium gluconate in the room.

ANSWER RATIONALE

A. The patient has magnesium toxicity and should not receive more of the medication.

B. The medication should be stopped but the physician should be notified.

C. The medication should be stopped but the physician should be notified.

D. Absent reflexes and a respiratory rate of 10 per minute or less indicate magnesium toxicity and the antidote (calcium gluconate) should be in the patient's room. The physician should also be notified at once.

PEDIATRIC NURSING

2011-01-14T04:10:00.000-08:00

1. The nurse is testing reflexes in a four-month-old infant as part of the neurologic assessment. Which of the following findings would indicate an abnormal reflex pattern and an area of concern in a four-month-old infant?

		A		Closes hand tightly when palm is touched.
		B		Begins strong sucking movements when mouth area is stimulated.
		C		Hyperextends toes in response to stroking sole of foot upward.
		D		Does not extend and abduct extremities in response to loud noise.

Answer Rationale

A.	The palmar grasp is present at birth. The palmar grasp lessens by age three months and is no longer reflexive. The infant is able to close hand voluntarily.
B.	The sucking reflex is present at birth and persists throughout infancy, even with and without stimulation, such as seen during sleep.
C.	The Babinski reflex is present at birth. The Babinski reflex disappears after one year of age.
D.	The startle or Moro reflex is present at birth. This reflex is strongest during the first two months of life and disappears after three to four months of age.

2. The mother of a three-month-old infant asks the nurse when she can start feeding her baby solid food. Which of the following should the nurse include in teaching this mother about the nutritional needs of infants?

		A		Infant cereal can be introduced by spoon when the extrusion reflex fades.
		B		Solid foods should be given as soon as the infant's first tooth erupts.
		C		Pureed food can be offered when the infant has tripled his birth weight.
		D		Infant formula or breast milk provides adequate nutrients for the first year.

Answer Rationale

A.	Infant cereal is generally introduced first because of its high iron content. The infant is able to accept spoon feeding at around four to five months when the tongue thrust or extrusion reflex fades.
B.	Solid food can be offered even if the baby does not have any teeth. The first primary teeth usually erupt at approximately six to eight months.
C.	The infant usually triples his birth weight by the age of one year. The infant is capable of eating solid foods before this time. Doubling of birth weight is one of the readiness indicators to begin solid foods.
D.	Breast milk or commercial iron-fortified formula is recommended for the first year of life. Whole milk should not be introduced to infants until after one year of age. Solid foods should be offered to assist the infant in coordination and motor development and as well as essential nutrients.

3. The nurse is assessing a six-month-old infant during a well child visit. The nurse makes all of the following observations. Which of the following assessments made by the nurse is an area of concern indicating a need for further evaluation?

		A		Absence of Moro reflex.
		B		Closed posterior fontanel.
		C		Three pound weight gain in two months.
		D		Moderate head lag when pulled to sitting position.

Answer Rationale

A.	The Moro reflex is present at birth. The Moro reflex is strongest during the first two months of life and disappears after three to four months.
B.	The posterior fontanel is closed by two months of age.
C.	The infant gains 1½-2 pounds per month for the first five months of life. A three pound weight gain in the last two months is a normal weight gain.
D.	By four to six months, head control is well established. There should be no head lag when infant is pulled to a sitting position by the age of six months.

4. The nurse is giving anticipatory guidance regarding safety and injury prevention to the parents of an 18-month-old toddler. Which of the following actions by the parents indicates understanding of the safety needs of a toddler?

			A	Supervise the child in outdoor, fenced play areas.
			B	Teach the child swimming and water safety.
			C	Use automobile booster seat with lap belt.
			D	Allow child to cross the street with four-year-old sibling.

Answer Rationale

A.	The child has great curiosity and has the mobility to explore. Toddlers need to be supervised in play areas. Play areas with soft ground cover and safe equipment need to be selected.
B.	Swimming and water safety lessons are possible at this age; however, they are not a substitute for protection. The toddler is helpless in water and unaware of danger.
C.	Boosters are not restraint systems like the convertible devices because they depend on the vehicle belts to hold the child and booster in place. The rule of four serves as a guide: if the child weighs 40 pounds or is 40 inches or is four years old, then the child restraint can be replaced by the car's regular restraint system.
D.	The four-year-old child does not have the cognitive ability to keep himself safe or to protect the 18-month-old child. These children are often unable to recognize danger.

5. The parents of an eight-year-old child bring the child into the clinic for a school physical. The nurse makes all of the following assessments. Which assessment finding is an area of concern and needs further investigation?

A	Complains of a stomach ache on test days at school.
B		Has many evening rituals and resists going to bed at night.
C		Refers to self as being too dumb and too small during the exam.
D		Has lost three deciduous teeth and has the central and lateral incisors.

Answer Rationale

A.	The school-age child often experiences stress related to school in physical complaints. The school-age child is afraid of getting poor grades and afraid of failing.
B.	Bedtime resistance is a common characteristic during the middle school-age years. For some children it is related to normal fears of their age. These children use delay tactics to avoid going to bed.
C.	The school-age years are very important in the development of a healthy self-esteem. These statements by the eight-year-old child indicate a risk for development of a sense of inferiority and need further assessment.
D.	This is a normal pattern of permanent teeth eruption. Eruption of permanent teeth begins at approximately six years of age. The eruption of the secondary teeth follow the same order as the primary teeth and follow shedding of the deciduous teeth.

6. The nurse is performing a neurologic assessment on an eight-year-old child. As part of this neurologic assessment the nurse is assessing how the child thinks. Which of the following abilities best illustrates that the child is developing concrete operational thought?

		A		Able to make change from a dollar bill.
		B		Describes a ball as both red and round.
		C		Tells time in terms of after breakfast and before lunch.
		D		Able to substitute letters for numbers in simple problems.

Answer Rationale

A.	This ability illustrates the concept of conservation, which is one of the major cognitive tasks of school-age children.
B.	The ability to understand two characteristics of an object is attained during the preschool period and is an example of preoperational thought.
D.	This is an example of egocentric thought. The child understands time in terms of how it relates to himself. Egocentrism is a characteristic of the preschool child.
E.	This is an example of formal operations or abstract thinking in using letters to represent numbers as used in the math concepts of algebra. School-age children can serialize and use combinational skills to manipulate numbers and to learn the skills of addition, subtraction, multiplication, and division.

7. A two-month-old infant is in the clinic for a well baby visit. Which of the following immunizations can the nurse expect to administer?

	A			TD, Varicella, IPV.
	B			DTaP, Pneumovax.
	C			DTaP, MMR, Menomune.
	D			DTaP, Hib, OPV, HBV.

Answer Rationale

A.	The tetanus, diphtheria is given between the ages of 14-16 years, the varicella or chickenpox has no current recommendation by CDC, and inactivated poliovirus vaccine (IPV) is given for immunocompromised children.
B.	The DTP is given; however, the pneumovax is given to children two years and older who have sickle cell disease, asplenia, nephrotic syndrome, HIV infection, and Hodgkin's disease before beginning cytoreduction therapy.
C.	The diphtheria, tetanus, and acellular pertussis is given as the third dose of the DTP. The MMR is given after the infant's first birthday. The Menomune is recommended for children two years and older with terminal complement deficiencies and anatomic or functional asplenia.
D.	Helthy infants at two months of age receive diphtheria, tetanus and pertussis (DTP); hemophilus influenza (Hib); oral polio vaccine (OPV); and hepatitis B virus (HBV).

8. The nurse is discussing the risk of sudden infant death syndrome (SIDS) in infants with the parents whose second baby died of SIDS six months ago. The parents express fear that other children will die from SIDS since they have already had one baby die. Which of the following statements made by the parents indicate their understanding of the relationship of future children and the risk of SIDS?

	A			"Any new baby will be on home monitoring for one year to prevent SIDS.''
	B			"There is a 99% chance that we will not have another baby die of SIDS.''
	C			"Genetic testing is available to determine the likelihood of another baby dying from SIDS.''
	D			"There is medicine that can be used to stimulate the heart rate while the baby is sleeping.''

Answer Rationale

A.	Home monitoring is not recommended for subsequent siblings. Home infant monitoring does not prevent SIDS.
B.	Whether subsequent siblings of the SIDS infant are at risk is unclear. Even if the increased risk is correct, families have a 99% chance that their subsequent child will not die of SIDS.
C.	No genetic link has been identified as a causative risk factor in SIDS.
D.	Theophylline is used in neonatal apnea as a cardiac stimulant to reduce bradycardiac events. There is no medication to prevent or reduce the risk of SIDS.

9. A ten-day-old baby is admitted with 5% dehydration. The nurse notes which of the following signs?

		A		Tachycardia.
		B		Bradycardia.
		C		Hypothermia.
		D		Hyperthermia.

Answer Rationale

A.	Tachycardia is associated with dehydration.
B.	Bradycardia is not noted until the patient is greater than 25% dehydrated.
C.	Hypothermia is not associated with dehydration.
D.	Hyperthermia is not always associated with dehydration.

1O. The nurse is asked why infants are more prone to fluid imbalances than adults. The response is

		A		adults have a greater body surface area.
		B		adults have a greater metabolic rate.
		C		infants have functionally immature kidneys.
		D		infants ingest a lesser amount of fluid per kilogram.

Answer Rationale

A.	Infants have a greater BSA that allows larger quantities of fluid to be lost through the skin.
B.	Infants have a greater metabolic rate related to their larger BSA.
C.	Infant kidneys are unable to concentrate or dilute urine, to conserve or secrete sodium, or to acidify urine.
D.	Infants excrete a greater amount of fluid per kilogram of body weight than do older children or adults.

11. The community health nurse is making a newborn follow-up home visit. During the visit the two-year-old sibling has a temper tantrum. The parent asks the nurse for guidance in dealing with the toddler's temper tantrums. Which of the following is the most appropriate nursing action?

	A			Help the child understand the rules.
	B			Leave the child alone in his bedroom.
	C			Suggest that the parent ignore the child's behavior.
	D			Explain that the toddler is jealous of the new baby.

Answer Rationale

A.	Reasoning is an ineffective discipline technique to use for toddlers related to their limited cognitive ability.
B.	Using the bedroom as a punishment should be avoided. The bedroom is often a stimulating environment. The bedroom should be a safe and secure place.
C.	The best approach toward extinguishing attention-seeking behavior is to ignore it as long as the behavior is not inflicting injury.
D.	The toddler may be jealous of the new baby; however, the parent is asking for guidance in dealing with the temper tantrum at this time.

12. The parent of a three-year-old child brings the child to the clinic for a well child checkup. The history and assessment reveals the following findings. Which of these assessment findings made by the nurse is an area of concern and requires further investigation?

	A			Unable to ride a tricycle.
	B			Has ability to hop on one foot.
	C			Uses gestures to indicate wants.
	D			Weight gain of four pounds in last year.

Answer Rationale

A.	While a child of three years of age is expected to have the gross motor ability to ride a tricycle, this finding would not be an area of concern and need for referral or further investigation.
B.	The child is expected to have the gross motor ability to hop on one foot by the age of four years. This ability is still considered normal.
C.	This behavior indicates a delay in language and speech development. The child may not be able to hear. The child should have a vocabulary of about 900 words and use complete sentences of three to four words.
D.	Usual weight gain at the age of three years is four to six pounds per year. A four pound weight gain in one year is normal.

13. The parents of a four-year-old child tell the nurse that the child has an invisible friend named "Felix.'' The child blames "Felix'' for any misbehavior and is often heard scolding "Felix,'' calling him a "bad boy.'' The nurse understands that the best interpretation of this behavior is which of the following?

	A			A delay in moral development.
	B			Impaired parent-child relationship.
	C			A way for the child to assume control.
	D			Inconsistent parental discipline strategies.

Answer Rationale

A.	This is expected moral development for this age group. In the punishment and obedience orientation (ages two to four), children judge an action as good or bad depending on rewards or punishment.
B.	There are no data to support that there is an alteration in the parent-child relationship. The active imagination of the preschool child support the appearance of imaginary friends.
C.	Imaginary friends are a normal part of development for many preschool children. These imaginary friends often have many faults. The child plays the role of the parent with the imaginary friend. This becomes a way of assuming control and authority in a safe situation.
D.	There are no data to support that the parents are inconsistent in discipline strategies or have unrealistic behavioral expectations of this four-year-old child.

14. The nurse is caring for a five-year-old child who is in the terminal stages of acute leukemia. The child refuses to go to sleep and is afraid that his parents will leave. The nurse recognizes that the child suspects he is dying and is afraid. Which of the following questions about death is most likely to be made by a five-year-old child?

	A			"What does it feel like when you die?''
	B			"Who will take care of me when I die?''
	C			"What will my friends do when I die?''
	D			"Why do children die if they're not old?''

Answer Rationale

A.	This is an expected response of a school-age child who wants to know concretely what it feels like to experience death. School-age children often ask if it hurts when you die.
B.	The greatest fear of preschool children is being left alone and abandoned. Preschool children still think as though they are alive and need to be taken care of.
C.	This is an expected response of a school-age child who is interested in peer relationships and has lost some of their egocentric thinking. School-age children can think of how something will affect others.
D.	This is an expected response of a school-age child. School-age children know that everyone dies; however, they think death happens to old people and not people they know or love.

15. The nurse is caring for a 10-year-old child during the acute phase of rheumatic fever. Bedrest is part of the child's plan of care. Which of the following diversional activities is developmentally appropriate and meets the health needs of this child in the acute phase of rheumatic fever?

	A			Using hand-held computer video games.
	B			Sorting and organizing baseball cards in a notebook.
	C			Playing basketball with a hoop suspended from the bed.
	D			Using art supplies to make drawings about the hospital experience.

Answer Rationale

A.	The disease process of rheumatic fever may prevent the child from having the fine motor skill to utilize the hand-held computer game and increase the child's frustration.
B.	The middle childhood years are times for collections. The collections of middle to late school-age children become orderly, selective, and neatly organized in scrapbooks. This quiet activity supports the development of industry and concrete operational thought as well as the physical restrictions related to the rheumatic fever.
C.	The basketball hoop demands high level of physical energy for the child and although it provides an important physical outlet for the school-age child, the activity increases the workload of the heart during the acute phase of rheumatic fever.
D.	The disease process of rheumatic fever including the effects on the central nervous system interferes with the child's fine motor ability. Drawing with art supplies may be too difficult for the child during the acute stage.

16. A 10-month-old weighs 10 kg and has voided 100 ml in the past four hours. The nurse determines normal urine output based on the fact that normal urine output is

	A			1-2 ml/kg/hour.
	B			3-5 ml/kg/hour.
	C			7-9 ml/kg/hour.
	D			10 ml/kg/hour.

Answer Rationale

A.	Normal urine output is 1-2 ml/kg/hour.
B.	Normal urine output is 1-2 ml/kg/hour.
C.	Normal urine output is 1-2 mg/kg/hour.
D.	Normal urine output is 1-2 ml/kg/hour.

17. A three-month-old is NPO for surgery. The nurse attempts to comfort him by

	A			administering acetaminophen.
	B			encouraging parents to leave so the child can rest.
	C			offering pacifier.
	D			giving 10 cc Pedialyte.

Answer Rationale

A.	There is no basis to administer any meds.
B.	The nurse should encourage family to stay.
C.	Non-nutritive sucking will help console and pacify him.
D.	Patient is NPO.

18. An 11-year-old is admitted for treatment of lead poisoning. The nurse includes which of the following in the plan of care?

	A			Oxygen.
	B			Strict intake and output.
	C			Heme-occult stool testing.
	D			Calorie counts.

Answer Rationale

A.	Oxygen is not indicated for treatment of lead poisoning.
B.	CaNaEDTA (treatment for lead poisoning) is nephrotoxic andPlPh/10Apstrict intake and output records need to be kept.
C.	This is not indicated for treatment of lead poisoning.
D.	This is not indicated for treatment of lead poisoning.

19. A two-month-old is admitted with diarrhea. What is the best room assignment for the nurse to make?

	A			Semi-private room with no roommate.
	B			Private room with no bathroom.
	C			Semi-private room with 10-year-old who has acute lymphocytic leukemia.
	D			Open ward.

Answer Rationale

A.	Diarrhea is considered infectious until proven otherwise. There is a potential for infection of a roommate.
B.	A bathroom is irrelevant with an infant in diapers. A private room is necessary.
C.	Immunocompromised patients should also be in a private room.
D.	Infant diarrhea is considered infectious until proven otherwise so this is an inappropriate assignment.

20. The nurse is discussing safety measures to prevent poisoning with the mother of a one-year-old. The nurse knows the mother understands safety precautions when she states,

	A			"I have child protection locks on my cabinet under the sink.''
	B			"My child is not potty-trained, so the bathroom is safe.''
	C			"I keep all poisons and cleaners above the fridge.''
	D			"I don't think I have any poisons in my house.''

Answer Rationale

A.	Child protection locks are not child-proof and all cleaners/poisons should be kept in high cabinets.
B.	Developmentally, this child will explore all surroundings, including the bathroom cabinets.
C.	All cleaners and poisons should be kept in high locked cabinets .
D.	Poisons are prevalent in many household products including cleaners, pool chemicals, cosmetics, and over-the-counter medications.