NursGuru

    Exam Review

    1. The nurse is providing discharge instructions to the caregiver of an infant with recurrent otitis media. Which statement made by the caregiver should the nurse recognize as needing additional education about minimizing subsequent infections?
      A)
      Schedule visit for pneumococcal vaccine.
      B)
      Avoid any smoking inside the house.
      C)
      Instill benzocaine otic drops regularly.
      D)
      Give infant the full course of antibiotics.
    2. A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?
      A)
      Talk to the mother and gradually focus on the child's toy.
      B)
      Request extra staff to help with the nursing assessments.
      C)
      Explain to the child the reasons an examination is needed.
      D)
      Complete the assessment while allowing the child to cry.
    3. Exhibits The nurse reviews the client's history and physical, the nurses' notes, and the flow sheet. Select the findings that will help the nurse determine what is causing the client's symptoms.
      (SATA)
      A)
      Rupture of membranes for 16 hours
      B)
      Normal spontaneous vaginal birth
      C)
      Breastfeeding 7 to 8 times a day for 10 minutes
      D)
      Discharge hemoglobin of 9.2 g/dL (92 g/L)
      E)
      Current vital signs
      F)
      Shopping yesterday for 5 hours
      G)
      Foul-smelling lochia rubra
    4. Exhibits The nurse reviews the client's history and physical, the nurses notes, and the flow sheet to determine the cause of the client's symptoms. For each assessment finding, click to indicate whether findings from this client's assessment are generally associated with mastitis, endometritis, or could be a sign of both conditions. Each row must have only one response option selected.
      MastitisEndometritisBoth mastitis and endometritis
      Temperature of 101.2° F (38.4°C)✓
      Feeling chilled, achy, and fatigued✓
      Pulse of 105 beats/minute✓
      Foul-smelling lochia rubra at 2 weeks postpartum✓
      Baby fed pumped breast milk✓
      Pain rating of 4 on a 0 to 10 scale✓

    Exam Review

    1. Exhibits The nurse determines the need to perform more of an assessment based on the client's symptoms. Based on the new assessment findings, choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the assessment findings, the priority diagnosis suspected is▾ Mastitis, diagnosis places the client at risk of▾ plugged duct
      Dropdown 1:
      Option 1: Mastitis
      Option 2: endometritis
      Option 3: urinary tract infection
      Dropdown 2:
      Option 1: plugged duct
      Option 2: Fever
      Option 3: Pain rated 4 on a scale of 0 to 10
    2. Exhibits Choose the most likely options for the information missing from the statement by selecting from the list of options provided. The nurse knows that the mastitis in this scenario is most likely caused by ▾ a plugged ductas evidenced by▾ the firm red area at the 9 o'clock position
      Dropdown 1:
      Option 1: a nipple fissure
      Option 2: a plugged duct
      Option 3: thrush
      Dropdown 2:
      Option 1: the nipple being round with mature milk post feeding
      Option 2: the client being 2 weeks postpartum
      Option 3: the firm red area at the 9 o'clock position
    3. Exhibits Which education by the nurse will help resolve the issue for the client? Select all that apply.
      (SATA)
      A)
      Pump breasts if feeding will be missed, due to absence from the infant.
      B)
      Vary breastfeeding positions at each feeding.
      C)
      Start infant on the unaffected side, so there is less pain when infant is the hungriest.
      D)
      Apply warm compresses to affected area before feeding.
      E)
      Wear an underwire bra around the clock.
      F)
      Maintain activity due to the risk of blood clots with extra rest.
      G)
      Wash hands before handling the breast.
      H)
      Finish antibiotics even if symptoms improve.
      I)
      Pump breastmilk and feed it to infant instead of nursing.
    4. Exhibits Which description(s) by the client should help confirm that the mastitis has been resolved and breastfeeding/breast health is well maintained? Select all that apply.
      (SATA)
      A)
      The infant continues to want to nurse all the time.
      B)
      After a feeding, the nipple is creased.
      C)
      Pain during feeding lasts for 10 of the 20 minutes of the feed.
      D)
      The red area on her right breast has resolved.
      E)
      The feelings of fatigue continue, but there are no chills, achiness, or dizziness.
      F)
      The infant is breastfeeding every 2 to 3 hours for 20 minutes in a variety of positions.
      G)
      Pumping continues on the right side instead of breastfeeding on that side.
      H)
      The temperature taken at home is 99.0° F (37.2° C).

    Exam Review

    1. An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LHRH) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?
      A)
      "Sexual maturity differences between my daughter and her peers will disappear within a few years."
      B)
      "We should be sure to start our daughter on birth control pills."
      C)
      "We should encourage her to dress in clothing that suits her sexual maturity level."
      D)
      "Our daughter will be on this hormone treatment the rest of her life."
    2. The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?
      A)
      Arched back.
      B)
      Projectile vomiting.
      C)
      Frequent pauses.
      D)
      Coffee-ground emesis.
    3. A client who is 38 weeks pregnant is concerned her baby might get a communicable disease before any immunizations are given. Which physiological mechanism should the nurse use when responding to the mother's concerns?
      A)
      Neutrophils may be immature in protecting neonates from the risk for infection.
      B)
      Infants can receive antiinfectants that have not developed resistance to microbes.
      C)
      Active immunity in newborns is developed fully in the first month of life.
      D)
      Passive immunity in the first months of life provides protection in newborns.
    4. The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. Which priority issue should the nurse address to ensure the newborn's survival?
      A)
      Fluid balance.
      B)
      Bleeding tendencies.
      C)
      Heat loss.
      D)
      Hypoglycemia.

    Exam Review

    1. Exhibits Review H and P, laboratory results, flow sheet, and orders. The nurse notifies the health care provider of the lab values, blood pressure and pulse, and current intake and output. Which prescriptions does the nurse expect the healthcare provider to write based on the information? Select all that apply.
      A)
      Add potassium to the intravenous fluids
      B)
      Bolus calcium
      C)
      Flush the central line with 3% sodium chloride
      D)
      Increase the intravenous fluid rate
      E)
      Decrease the percentage of sodium in the intravenous fluids
      F)
      Turn off the suction on the nasogastric tube
      G)
      Administer a diuretic
    2. A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day by mouth once a day. The bottle is labelled "Isoniazid Oral Solution, USP 50 mg per 5 mL." How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
    3. The nurse is caring for a primigravida client who delivered vaginally 48-hours ago. The client's laboratory results are: haemoglobin 12.5 g/dL (125 g/L), hematocrit 34% (0.34 volume fraction), hepatitis B surface antigen negative, rubella non-immune, group B Streptococcus positive. Which prescription should the nurse prepare to administer? Reference Range Hemoglobin [Pregnant female: greater than 11 g/dL (greater than 110 g/L)] Hematocrit [Pregnant female: greater than 33% (greater than 0.33 volume fraction)] Hepatitis B surface antigen [Negative] Rubella [Immune] Group B Streptococcus [Negative]
      A)
      Blood transfusion.
      B)
      Hepatitis B immunoglobulin.
      C)
      Penicillin G potassium.
      D)
      Rubella vaccination.
    4. The nurse who is working on a pediatric unit receives shift report for 4 neonates with congenital heart defects. The neonate with which report requires the most immediate intervention?
      A)
      Tetralogy of Fallot (TOF) with hypercyanotic (TET) spells is crying.
      B)
      Coarctation of aorta has an elevated blood pressure in upper extremity.
      C)
      Patent ductus arteriosus is fatigued after feedings.
      D)
      Ventricular septal defect (VSD) has audible murmurs.

    Exam Review

    1. The nurse is giving instructions to the mother of a 10-year-old boy who is newly diagnosed with type 1 diabetes mellitus (DM). When attempting to teach the mother how to administer subcutaneous insulin injections to the child, the mother tells the nurse that she is afraid of needles and cannot perform the procedure. Which intervention should the nurse implement?
      A)
      Determine if the child can administer the insulin.
      B)
      Ask if the father can help with the injections.
      C)
      Encourage the mother to handle the needles.
      D)
      Assess the mother's parenting skills.
    2. An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?
      A)
      Monitor strict urinary output.
      B)
      Gather supplies for an IV infusion.
      C)
      Measure abdominal circumference.
      D)
      Prepare for anorectal manometry.
    3. A one-month-old infant admitted to the hospital with dehydration and failure to thrive receives a prescription for enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?
      A)
      Use sterile technique during feedings.
      B)
      Offer a pacifier for non nutritive sucking.
      C)
      Speak to the healthcare provider about instituting physical therapy.
      D)
      Ensure placement of the nasogastric tube with an abdominal x-ray.
    4. During the admission procedure of a school age child, the child states, "I'm going to have an operation." Which response is best for the nurse to provide to this child?
      A)
      "Are you scared?"
      B)
      "Tell me what an operation is."
      C)
      "I'm glad your mother told you why you were coming to the hospital."
      D)
      "We're going to do everything we can to take very good care of you.

    Exam Review

    1. A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure. Which action should the nurse implement next?
      A)
      Collect a urine sample to screen for protein.
      B)
      Ask about a history of delivering large babies.
      C)
      Establish the frequency of headaches.
      D)
      Examine the client for pedal edema.
    2. A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?
      A)
      Sore throat.
      B)
      Chickenpox.
      C)
      Influenza.
      D)
      Mumps.
    3. Exhibits The nurse is reviewing the assessment data. Which are the 3 most likely reasons that the infant is crying?
      A)
      Separation anxiety
      B)
      Hypoxia
      C)
      Hemorrhage
      D)
      Hypovolemia
      E)
      Opioid withdrawal
      F)
      Hunger
      G)
      Pain
    4. Exhibits The nurse determines the client is in pain. Which pain scales would be appropriate for this client? Select all that apply.
      A)
      Riley Infant Pain Scale
      B)
      Numeric
      C)
      Poker Chip Tool
      D)
      Visual Analog Scale
      E)
      FLACC Postoperative Pain Scale
      F)
      FACES