Question Number 1 of 20
Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours?
A) An infant with a positive culture of stool for Shigella
B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
D) A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin
The correct answer is B: An elderly factory worker with a lab report that is positive for acid-fast bacillus smear Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time. Options A and D may need contact isolation precautions. Option C -- findings may indicate the initial stage of autoimmune deficiency syndrome (AIDS).
Question Number 2 of 20
The parents of a toddler who is being treated for pesticide poisoning ask: “Why is activated charcoal used? What does it do?” What is the nurse's best response?
A) "Activated charcoal decreases the body’s absorption of the poison from the stomach."
B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child."
C) "This substance helps to get the poison out of the body through the gastrointestinal system." D) "The action may bind or inactivate the toxins or irritants that are ingested by children and adults."
The correct answer is B: "The charcoal absorbs the poison and forms a compound that doesn''t hurt your child."
All of the options are correct responses. However, option B is most accurate information to answer the parents’ questions about the use and action of activated charcoal. The language is appropriate for a parent''s understanding.
Question Number 3 of 20
Which of these nursing diagnoses, appropriate for elderly clients, would indicate the client is at greatest risk for falls?
A) Sensory perceptual alterations related to decreased vision
B) Alteration in mobility related to fatigue
C) Impaired gas exchange related to retained secretions
D) Altered patterns of urinary elimination related to nocturia
The correct answer is D: Altered patterns of urinary elimination related to nocturia
Nocturia is especially problematic because many elders fall when they rush to reach the bathroom at night. They may be confused or not fully alert. Inadequate lighting can increase their chances of stumbling, and then they may fall over furniture or carpets.
Question Number 4 of 20
A nurse who is assigned to the emergency department needs to understand that gastric lavage is a priority in which situation?
A) An infant who has been identified as suffering from botulism
B) A toddler who has eaten a number of ibuprofen tablets
C) A preschooler who has swallowed powdered plant food
D) A school aged child who has taken a handful of vitamins
The correct answer is A: An infant who has been identified as suffering from botulism
C. botulinum forms a toxin in improperly processed foods in anaerobic conditions. It is a neurotoxin that impairs autonomic and voluntary neurotransmission and causes muscular paralysis. Findings appear within 36 hours of ingestion. The nurse should be aware that all of these clients may be candidates for gastric lavage or for activated charcoal administration.
Question Number 5 of 20
The nurse is to administer a new medication to a client. Which of these actions best demonstrate awareness of safe, proficient nursing practice?
A) Verify the order for the medication. Prior to giving the medication the nurse should say, "Please state your name."
B) Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band.
C) As the room is entered say "What is your name?" then check the client's name band.
D) Verify the client's allergies on the admission sheet and order. Verify the client's name on the name plate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?"
The correct answer is B: Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" and then check the client''s name band and allergy band.
A dual check is always done for a client''s name. This would involve verbal and visual checks. Since this is a new medication an allergy check is appropriate.
Question Number 6 of 20
A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client?
C) Standard precautions
The correct answer is D: Contact
Contact precautions or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continue to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient''s sputum is expected. A private room and contact precautions , along with good hand washing techniques, are the best defenses against the spread of MRSA pneumonia.
Question Number 7 of 20
A school nurse has a 10 year-old child with a history of epilepsy with tonic-clonic seizures attending classes regularly. The school nurse should inform the teacher that if the child experiences a seizure in the classroom, the most important action to take during the seizure would be to
A) move any chairs or desks at least 3 feet away from the child
B) note the sequence of movements with the time lapse of the event
C) provide privacy as much as possible to minimize frightening the other children
D) place the hands or a folded blanket under the head of the child
The correct answer is D: place the hands or a folded blanket under the head of the child
The priority during seizure activity is to protect the person from physical injury. Place a pillow, folded blanket or your hands under the child''s head to prevent concussion or other head trauma. The other body parts are at less risk for injury, consequently the prioritized sequence of the actions above would be options D, A, B, and C.
Question Number 8 of 20
A parent calls the hospital hot line and is connected to the triage nurse. The caller proclaims: “I found my child with odd stuff coming from the mouth and an unmarked bottle nearby.” Which of these comments would be the best tool for the nurse to determine if the child has swallowed a corrosive substance?
A) "Ask the child if the mouth is burning or throat pain is present."
B) "Take the child’s pulse at the wrist and see if the child is has trouble breathing lying flat."
C) "What color is the child’s lips and nails and has the child voided today?"
D) "Has the child had vomiting, diarrhea or stomach cramps?"
Your response was "A".
The correct answer is A: "Ask the child if the mouth is burning or throat pain is present."
Local irritation of tissues indicates a corrosive poisoning. The other comments may be helpful in determining the child’s overall condition, however the question concerns evaluation for ingesting a caustic substance.
Which of these actions is the primary nursing intervention designed to limit transmission of a client’s Salmonella infection?
A) Wash hands thoroughly before and after client contact
B) Wear gloves when in contact with body secretions
C) Double glove when in contact with feces or vomitus
D) Wear gloves when disposing of contaminated linens
The correct answer is A: Wash hands thoroughly before and after client contact
Gram-negative bacilli cause Salmonella infection, and lack of sanitation is the primary means of contamination. Two million new cases appear each year. Thorough handwashing can prevent the spread of salmonella. Note that all of the options are appropriate activities, but handwashing is primary.
Question Number 10 of 20
After an explosion at a factory one of the employees approaches the nurse and says “I am an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks should the nurse assign first to this worker who wants to help care for the wounded workers?
A) Get temperatures
B) Take blood pressure
C) Palpate pulses
D) Check alertness
The correct answer is C: Palpate pulses
The heart rates would indicate if the client is in shock or has potential for shock. If the pulses could not be palpated, those clients would need to be seen first.
Question Number 11 of 20
A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to handwashing, is which of these?
A) Place appropriate signs outside and inside the room
B) Use a mask with a shield if there is a risk of fluid splash
C) Wear a gown to change soiled linens from incontinence
D) Have gloves on while handling bedpans with feces
The correct answer is D: Have gloves on while handling bedpans with feces
The specific measure to prevent the spread of hepatitis A is careful handling and protection while working with fecal material. All of the other actions are correct but not the most significant specific approach used with hepatitis A.
Question Number 12 of 20
A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. Which lunch selection suggests the client has learned about necessary dietary changes?
A) grilled chicken sandwich and skim milk
B) roast beef, mashed potatoes, and green beans
C) peanut butter sandwich, banana, and iced tea
D) barbeque beef, baked beans, and cole slaw
The correct answer is B: roast beef, mashed potatoes, and green beans
The client has correctly selected an appropriate lunch and appears to know the dietary restrictions. Low granulocyte counts and susceptibility to infection are expected. Compromised host precautions require that foods are either cooked or canned. Options A, C and D do not demonstrate learning, as raw fruits, vegetables, and milk are to be avoided.
Question Number 13 of 20
A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include in client teaching is which of these statements?
A) "In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation."
B) "Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice."
C) "Your family can use the same bathroom that you use without any special precautions."
D) "Drink plenty of water and empty your bladder often during the initial 3 days of therapy."
The correct answer is A: "In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation."
The client''s urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6 to 8 hours. The client should drink 3 to 4 liters of fluid a day for the initial 48 hours to help remove the (131I) from the body. Staff should limit contact with hospitalized clients to 30 minutes per day per person
Question Number 14 of 20
Which approach is the best way to prevent infections when providing care to clients in the home setting?
A) Handwashing before and after examination of clients
B) Wearing nonpowdered latex-free gloves to examine the client
C) Using a barrier between the client's furniture and the nurse's bag
D) Wearing a mask with a shield during any eye/mouth/nose examination
The correct answer is A: Handwashing before and after examination of clients
Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag. All of the options are correct, and the sequence of priorities would be options A, C, B, and D.
Question Number 15 of 20
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first?
A) Institute seizure precautions
B) Monitor neurologic status every hour
C) Place in respiratory/secretion precautions
D) Cefotaxime IV 50 mg/kg/day divided q6h
The correct answer is C: Place in respiratory/secretion precautions
Meningococcal meningitis is a bacterial infection that can be communicated to others. The initial therapeutic management of acute bacterial meningitis includes respiratory/secretions precautions, initiation of antimicrobial therapy, monitoring neurological status along with vital signs, instituting seizure precautions and lastly maintaining optimum hydration. The first action for nurses to take is initiate any necessary precautions to protect themselves and others from possible infection. Viral meningitis usually does not require protective measures of isolation.
Question Number 16 of 20
The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these interventions would be a priority for the nurse to implement?
A) Have the client cough into a tissue and dispose in a separate bag
B) Instruct the client to cover the mouth with a tissue when coughing
C) Reinforce that everyone should wash their hands before and after entering the room
D) Place client in a negative pressure private room and have all who enter the room use masks with shields
The correct answer is D: Place client in a negative pressure private room and have all who enter the room use masks with shields
A client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. Tuberculosis (TB) is caused by spore-forming mycobacteria, more often Mycobacterium tuberculosis. In developed countries the infection is airborne and is spread by inhalation of infected droplets. In underdeveloped countries, transmission also occurs by ingestion or by skin invasion, particularly when bovine TB is poorly controlled.
Question Number 17 of 20
When an infant car seat is properly installed, the infant should face
A) forward, so child may look out window
B) backward, so child faces the seat
C) the side window, to increase sensory stimulation
D) upward, as child lies on back with seat installed sideways
The correct answer is B: backward, so child faces the seat
Nurses are now responsible for promoting the continued safety of infants and children outside of the hospital. Emergency Department and Women’s Services staff are trained in child seat placement. Growth and development data indicate that infants still require support of the head. Therefore, they should be positioned reclining and facing the rear until their leg muscles are strong enough to kick away from the backseat (about 10-12 months-old) for the greatest protection.
Question Number 18 of 20
Several clients are admitted to an adult medical unit. For which client condition(s) would the nurse institute airborne precautions?
A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV)
B) A positive purified protein derivative (PPD) test with an abnormal chest x-ray
C) A tentative diagnosis of viral pneumonia with productive brown sputum
D) Advanced carcinoma of the lung with hemoptysis
The correct answer is B: A positive purified protein derivative (PPD) test with an abnormal chest x-ray
The client who must be placed in airborne precautions is the client with these findings that suggest a suspicious tuberculin lesion. A sputum smear for acid fast bacillus would be done next. CMV usually causes no signs or symptoms in children and adults with healthy immune systems. Good handwashing is recommended for CMV. When signs and symptoms do occur, they are often similar to those of mononucleosis, including sore throat, fever, muscle aches and fatigue.
Question Number 19 of 20
The school nurse is teaching the faculty the most effective methods to prevent the spread of lice (Pediculus Humanus Capitis) in the school. The information that would be most important to include is reflected in which of these statements?
A) "The treatment medication requires reapplication in 8 to 10 days."
B) "Bedding and clothing can be boiled or steamed to kill lice."
C) "Children should not share hats, scarves and combs."
D) "Nit combs are necessary to comb lice eggs (nits) out of children's hair."
The correct answer is C: "Children should not share hats, scarves and combs."
Head lice live only on human beings and can be spread easily by sharing hats, combs, scarves, coats and other items of clothing that touch the hair. All of the options are correct statements, however they do not best answer the question of how to prevent the spread of lice in a school setting.
Question Number 20 of 20
Which of these clients would the nurse recommend keeping in the hospital during an internal disaster at that facility?
A) An adolescent diagnosed with sepsis 7 days ago and whose vital signs are maintained within low normal limits.
B) A middle-aged woman known to have had an uncomplicated myocardial infarction 4 days ago
C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis
D) A young adult in the second day of treatment for an overdose of acetometaphen
The correct answer is D: A young adult in the second day of treatment for an overdose of acetometaphen
An overdose of Tylenol requires close observation for 3 to 4 days as well as Mucomyst PO during that time . A strong risk of liver failure exists immediately following Tylenol overdose.