,In planning care for a 6 month-old infant, what must the nurse provide to assist in the
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development of trust?
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A) Food ii
B) Warmth ii
C) Securityii
D) Comfort - C) Security
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A nurse has just received a medication order which is not legible. Which statement best
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reflects assertive communication?
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A) "I cannot give this medication as it is written. I have no idea of what you mean."
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B) "Would you please clarify what you have written so I am sure I am reading it
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C) "I am having difficulty reading your handwriting. It would save me time if you would be
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more careful."
ii ii
D) "Please print in the future so I do not have to spend extra time attempting to read your
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writing." - B) "Would you please clarify what you have written so I am sure I am reading it
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What is the most important consideration when teaching parents how to reduce risks in the
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home?
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A) Age and knowledge level of the parents
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B) Proximity to emergency services
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C) Number of children in the home
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D) Age of children in the home - D) Age of children in the home
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A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse
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enters the room to request something for pain. The nurse should
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A) Administer a placebo
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B) Encourage increased fluid intake
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C) Administer the prescribed analgesia
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D) Recommend relaxation exercises for pain control - C) Administer the prescribed
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analgesia
ii
While caring for a toddler with croup, which initial sign of croup requires the nurse's
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immediate attention?
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A) Respiratory rate of 42
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B) Lethargy for the past hour
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C) Apical pulse of 54
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D) Coughing up copious secretions - A) Respiratory rate of 42
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,A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial
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assessment, the nurse would anticipate which of the following assessment findings?
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A) Lethargyii
B) Heat intolerance
ii ii
C) Diarrheaii
D) Skin eruptions - A) Lethargy
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The emergency room nurse admits a child who experienced a seizure at school. The
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father comments that this is the first occurrence, and denies any family history of epilepsy.
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What is the best response by the nurse?
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A) "Do not worry. Epilepsy can be treated with medications."
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B) "The seizure may or may not mean your child has epilepsy."
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C) "Since this was the first convulsion, it may not happen again."
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D) "Long term treatment will prevent future seizures." - B) "The seizure may or may not
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mean your child has epilepsy."
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Alcohol and drug abuse impairs judgment and increases risk taking behavior. What
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nursing diagnosis best applies?
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A) Risk for injury
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B) Risk for knowledge deficit
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C) Altered thought process
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D) Disturbance in self-esteem - A) Risk for injury
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Which these findings would the nurse more closely associate with anemia in a 10 month-
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old infant? ii
A) Hemoglobin level of 12 g/dI
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B) Pale mucosa of the eyelids and lips
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C) Hypoactivity
ii
D) A heart rate between 140 to 160 - B) Pale mucosa of the eyelids and lips
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The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority
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assessment in the first hour of care is
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A) Heart rate
ii ii
B) Pedal pulses
ii ii
C) Lung sounds
ii ii
D) Pupil responses - D) Pupil responses
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Which of these clients who are all in the terminal stage of cancer is least appropriate to
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suggest the use of patient controlled analgesia (PCA) with a pump?
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A) A young adult with a history of Down's syndrome
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B) A teenager who reads at a 4th grade level
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C) An elderly client with numerous arthritic nodules on the hands
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D) A preschooler with intermittent episodes of alertness - D) A preschooler with
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intermittent episodes of alertness
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, The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive
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(NOFTT). Upon entering the room, the nurse would expect the baby to be
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A) Irritable and "colicky" with no attempts to pull to standing
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B) Alert, laughing and playing with a rattle, sitting with support
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C) Skin color dusky with poor skin turgor over abdomen
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D) Pale, thin arms and legs, uninterested in surroundings - D) Pale, thin arms and legs,
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uninterested in surroundings
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As the nurse is speaking with a group of teens which of these side effects of chemotherapy
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for cancer would the nurse expect this group to be more interested in during the
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discussion?
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A) Mouth sores ii ii
B) Fatigue ii
C) Diarrhea ii
D) Hair loss - D) Hair loss
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While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the
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nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degreesCelsius). The
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appropriate nursing intervention is to
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A) Call the health care provider immediately
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B) Administer acetaminophen as ordered as this is normal at this time
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C) Send blood, urine and sputum for culture
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D) Increase the client's fluid intake - B) Administer acetaminophen as ordered as this is
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normal at this time
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A client is admitted for first and second degree burns on the face, neck, anterior chest and
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hands. The nurse's priority should be
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A) Cover the areas with dry sterile dressings
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B) Assess for dyspnea or stridor
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C) Initiate intravenous therapy
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D) Administer pain medication - B) Assess for dyspnea or stridor
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Which of these clients who call the community health clinic would the nurse ask to come in
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that day to be seen by the health care provider?
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A) I started my period and now my urine has turned bright red.
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B) I am an diabetic and today I have been going to the bathroom every hour.
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C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when
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I go to the bathroom.
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D) I went to the bathroom and my urine looked very red and it didn't hurt when I went. - D) I
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went to the bathroom and my urine looked very red and it didn't hurt when I went.
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Which of these parents' comment for a newborn would most likely reveal an initial finding
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of a suspected pyloric stenosis?
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A) I noticed a little lump a little above the belly button.
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B) The baby seems hungry all the time.
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C) Mild vomiting that progressed to vomiting shooting across the room.
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