Category: Toddler

A child, age 3, is brought to the emergency department in respiratory

distress caused by acute epiglottiditis. Which clinical manifestations
should the nurse expect to assess?
CORRECT ANSWER a) Severe sore throat, drooling, and inspiratory stridor Reason:
A child with acute epiglottiditis appears acutely ill and clinical manifestations may
include drooling (because of difficulty swallowing), severe sore throat, hoarseness, a high
temperature, and severe inspiratory stridor. A low-grade fever, stridor, and barking
cough that worsens at night are suggestive of croup. Pulmonary congestion, productive
cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased
breath sounds, and crackles indicate pneumococcal pneumonia. A sore throat, fever, and
general malaise point to viral pharyngitis.

b) Low-grade fever, stridor, and a barking cough

c) Pulmonary congestion, a productive cough, and a fever

d) Sore throat, a fever, and general malaise

Category: Oncologic Disorders

The American Cancer Society recommends routine screening to

detect colorectal cancer. Which screening test for colorectal cancer
should a nurse recommend?
a) Carcinoembryonic antigen (CEA) test after age 50

b) Proctosigmoidoscopy after age 30

CORRECT ANSWER c) Annual digital examination after age 40 Reason: The

American Cancer Society recommends an annual digital examination after age 40 for the
purpose of detecting colorectal cancer. The CEA test is performed on clients who have
already been treated for colorectal cancer. It helps monitor a client's response to
treatment as well as detect metastasis or recurrence. Proctosigmoidoscopy is
recommended every 3 to 5 years for people older than age 50. Barium enema isn't a
screening test.

d) Barium enema after age 20

Category: Basic Physical Care A nurse is caring for a client who

required chest tube insertion for a pneumothorax. To assess for
 pneumothorax resolution, the nurse can anticipate that the client will
require:
a) monitoring of arterial oxygen saturation (SaO2).

b) arterial blood gas (ABG) studies.

c) chest auscultation.

CORRECT ANSWER d) a chest X-ray. Reason: Chest X-ray confirms diagnosis by

revealing air or fluid in the pleural space. SaO2 values may initially decrease with a
pneumothorax but typically return to normal within 24 hours. ABG studies may show
hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not
necessarily related to a pneumothorax. Chest auscultation will determine overall lung
status, but it's difficult to determine if the chest has re-expanded sufficiently.

Category: Medication and I.V. Administration

To prevent development of peripheral neuropathies associated with

isoniazid administration, the nurse should teach the client to:
a) Avoid excessive sun exposure.

b) Follow a low-cholesterol diet.

c) Obtain extra rest.

CORRECT ANSWER d) Supplement the diet with pyridoxine (vitamin B6). Reason:
Isoniazid competes for the available vitamin B6 in the body and leaves the client at risk
for developing neuropathies related to vitamin deficiency. Supplemental vitamin B6 is
routinely prescribed to address this issue. Avoiding sun exposure is a preventive measure
to lower the risk of skin cancer. Following a low-cholesterol diet lowers the individual's
risk of developing atherosclerotic plaque. Rest is important in maintaining homeostasis
but has no real impact on neuropathies.

Category: The Nursing Process

A nurse is documenting a variance that has occurred during the

shift, and this report will be used for quality improvement to identify
high-risk patterns and potentially initiate in-service programs. This is
an example of which type of report?
CORRECT ANSWER a) Incident report. Reason: An incident report, also termed a
variance report or occurrence report, is a tool healthcare agencies use to document
anything out of the ordinary that results in or has the potential to result in harm to a
client, employee, or visitor. These reports are used for quality improvement and not for
disciplinary action. They are a means of identifying risks and high-risk patterns and
 initiating in-service programs to prevent future problems. A nurse's shift report is given
by a primary nurse to the nurse replacing him or her or by the charge nurse to the nurse
who assumes responsibility for continuing client care. A transfer report is a summary of a
client's condition and care when transferring clients from one unit or institution to
another. A telemedicine report can link healthcare professionals immediately and enable
nurses to receive and give critical information about clients in a timely fashion.

Category: Infant A 10-month-old child has cold symptoms. The

mother asks how she can clear the infant's nose. Which of the
following would be the nurse's best recommendation?
a) Use a cool air vaporizer with plain water.

CORRECT ANSWER b) Use saline nose drops and then a bulb syringe. Reason:
Although a cool air vaporizer may be recommended to humidify the environment, using
saline nose drops and then a bulb syringe before meals and at nap and bed times will
allow the child to breathe more easily. Saline helps to loosen secretions and keep the
mucous membranes moist. The bulb syringe then gently aids in removing the loosened
secretions. Blowing into the child's mouth to clear the nose introduces more organisms
to the child. A nonprescription vasoconstrictive nasal spray is not recommended for
infants because if the spray is used for longer than 3 days a rebound effect with
increased inflammation occurs.

c) Blow into the child's mouth to clear the infant's nose.

d) Administer a nonprescription vasoconstrictive nose spray.

Category: Respiratory Disorders

The physician ordered I.V. naloxone (Narcan) to reverse the respiratory

depression from morphine administration. After administration of the
naloxone the nurse should:
a) Check respirations in 5 minutes because naloxone is immediately effective in
relieving respiratory depression.
b) Check respirations in 30 minutes because the effects of morphine will have worn off
by then.

CORRECT ANSWER c) Monitor respirations frequently for 4 to 6 hours because the

client may need repeated doses of naloxone.

Reason: The nurse should monitor the client's respirations closely for 4 to 6 hours
because naloxone has a shorter duration of action than opioids. The client may need
repeated doses of naloxone to prevent or treat a recurrence of the respiratory
depression. Naloxone is usually effective in a few minutes; however, its effects last only 1
to 2 hours and ongoing monitoring of the client's respiratory rate will be necessary. The
client's dosage of morphine will be decreased or a new drug will be ordered to prevent
another instance of respiratory depression.
 d) Monitor respirations each time the client receives morphine sulfate 10 mg I.M.

Category: Neurosensory Disorders

The client with a hearing aid does not seem to be able to hear the
nurse. The nurse should do which of the following?
a) Contact the client's audiologist.

b) Cleanse the hearing aid ear mold in normal saline.

c) Irrigate the ear canal.

CORRECT ANSWER d) Check the hearing aid's placement.

Reason: Inadequate amplification can occur when a hearing aid is not placed
properly. The certified audiologist is licensed to dispense hearing aids. The ear mold is
the only part of the hearing aid that may be washed frequently; it should be washed
daily with soap and water. Irrigation of the ear canal is done to remove impacted
cerumen or a foreign body.

Category: Musculoskeletal Disorders

A client has a herniated disk in the region of the third and fourth
lumbar vertebrae. Which nursing assessment finding most supports
this diagnosis?
a) Hypoactive bowel sounds

CORRECT ANSWER b) Severe lower back pain

Reason: The most common finding in a client with a herniated lumbar disk is
severe lower back pain, which radiates to the buttocks, legs, and feet usually
unilaterally. A herniated disk also may cause sensory and motor loss (such as foot drop)
in the area innervated by the compressed spinal nerve root. During later stages, it may
cause weakness and atrophy of leg muscles. The condition doesn't affect bowel sounds
or the arms.

c) Sensory deficits in one arm

d) Weakness and atrophy of the arm muscles

Category: Endocrine and Metabolic Disorders

 The best indicator that the client has learned how to give an insulin
self-injection correctly is when the client can:
CORRECT ANSWER a) Perform the procedure safely and correctly.

Reason: The nurse should judge that learning has occurred from evidence of a
change in the client's behavior. A client who performs a procedure safely and correctly
demonstrates that he has acquired a skill. Evaluation of this skill acquisition requires
performance of that skill by the client with observation by the nurse. The client must also
demonstrate cognitive understanding, as shown by the ability to critique the nurse's
performance. Explaining the steps demonstrates acquisition of knowledge at the
cognitive level only. A posttest does not indicate the degree to which the client has
learned a psychomotor skill.

b) Critique the nurse's performance of the procedure.

c) Explain all steps of the procedure correctly.

d) Correctly answer a posttest about the procedure.

Category: Gastrointestinal Disorders

A client has a nasogastric tube inserted at the time of abdominal

perineal resection with permanent colostomy. This tube will most likely
be removed when the client demonstrates:
a) Absence of nausea and vomiting.
b) Passage of mucus from the rectum.

CORRECT ANSWER c) Passage of flatus and feces from the colostomy.

Reason: A sign indicating that a client's colostomy is open and ready to function is
passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued,
and the client is allowed to start taking fluids and food orally. Absence of bowel sounds
would indicate that the tube should remain in place because peristalsis has not yet
returned. Absence of nausea and vomiting is not a criterion for judging whether or not
gastric suction should be continued. Passage of mucus from the rectum will not occur in
this client because the rectum is removed in this surgery.

d) Absence of stomach drainage for 24 hours.

Category: Oncologic Disorders

 The American Cancer Society recommends routine screening to
detect colorectal cancer. Which screening test for colorectal cancer
should a nurse recommend?
a) Carcinoembryonic antigen (CEA) test after age 50

b) Proctosigmoidoscopy after age 30

d) Barium enema after age 20

CORRECT ANSWER c) Annual digital examination after age 40

Reason: The American Cancer Society recommends an annual digital examination

after age 40 for the purpose of detecting colorectal cancer. The CEA test is performed on
clients who have already been treated for colorectal cancer. It helps monitor a client's
response to treatment as well as detect metastasis or recurrence. Proctosigmoidoscopy
is recommended every 3 to 5 years for people older than age 50. Barium enema isn't a
screening test.