Reviewer for the Board Exam part 2

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1 Health Promotion and Maintenance Questions are numbered by the order in which they appeared in the test. * Represents the correct answer. Question 1 The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which evaluation data would best measure learning? A) Performance on written tests B) Responses to verbal questions C) Completion of a mailed survey 



D)

Reported behavioral changes

Review Information: Information: The correct answer is D: Reported behavioral changes If the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that learning has occurred. Additionally, physical assessments and lab data may confirm risk reduction.

Question 2 The nurse is assessing a client who states her  last menstrual period was March 16, and she has missed one period. She reports episodes of  nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)? A) April 8 B) January 15 C) February 11 D)

December 23

Review Information: Information: The correct answer is D: December 23 Naegele''s rule states: Add 7 days and subtract 3 months from the first day of the last regular  menstrual period to calculate the estimated date of  delivery.

Question 3

The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments? A) Focus on the child's needs and recovery B) Explain the cause of the child's illness Acknowledge that early care would have C) been better 

Accept their feelings without  judgment

D)

Review Information: Information: The correct answer is D: Accept their feelings without judgment Parents often blame themselves for their child''s illness. Feeling helpless and angry is normal and these feelings must be accepted.

Question 4 When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in? Competitive board games with older  A) children Playing with their own toys along side with B) other children Playing alone with hand held computer  C) games

Playing cooperatively with other   preschoolers

D)

Review Information: Information: The correct answer is D: Playing cooperatively with other preschoolers Cooperative play is typical of the late preschool period.

Question 5 A 64 year-old client scheduled for surgery with a

general anesthetic refuses to remove a set of  dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse? Explain to the client that the dentures must A) come out as they may get lost or broken in the operating room Ask the client if there are second thoughts B) about having the procedure Notify the anesthesia department and the C) surgeon of the client's refusal D)

Ask the client if the preference would be to remove the dentures in the operating room receiving area

Review Information: Information: The correct answer is D: Ask the client if the preference would be to remove the dentures in the operating room receiving area Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client''s sense of self-esteem and self-concept. Question 6 When teaching a 10 year-old child about their  impending heart surgery, which form of  explanation meets the developmental needs of  this age child? Provide a verbal explanation just prior to A) the surgery Provide the child with a booklet to read B) about the surgery Introduce the child to another child who C) had heart surgery 3 days ago D)

Explain the surgery using a model of the heart

Review Information: Information: The correct answer is D: Explain the surgery using a model of the heart According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using something concrete, like a model will help the child understand the explanation of the heart surgery.

2 Question 7 When screening children for scoliosis, at what time of development would the nurse expect early signs to appear? A) Prenatally on ultrasound B) In early infancy C) When the child begins to bear weight D)

During the preadolescent growth spurt

Review Information: The correct answer is D: During the preadolescent growth spurt Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of the preadolescent growth spurt. It is more common in females than in males.

Question 8 A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? "Good morning. Do you remember where A) you are?" "Hello. My name is Elaine Jones and I am B) your nurse for today." "How are you today? Remember, you're in C) the hospital." D)

Question 9 The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding? A) Hold a rattle B) Bang two blocks C) Drink from a cup D)

Wave "bye-bye"

Review Information: The correct answer is A: Hold a rattle The age at which a baby will develop the skill of  grasping a toy with help is 4 to 6 months.

Question 10 An appropriate treatment goal for a client with anxiety would be to A) ventilate anxious feelings to the nurse B) establish contact with reality C) learn self-help techniques D) become

desensitized to past trauma

Review Information: The correct answer is C: learn self-help techniques Exploring alternative coping mechanisms will decrease present anxiety to a manageable level. Assisting the client to learn self-help techniques will assist in learning to cope with anxiety.

Adequate blood supply to the bone growth delay after  fractures

D) prevents

Review Information: The correct answer is B: Epiphyseal fractures often interrupt a child''s normal growth pattern The epiphyseal plate in children is where active bone growth occurs. Damage to this area may cause growth arrest in either longitudinal growth of  the limb or in progressive deformity if the plate is involved. An epiphyseal fracture is serious because it can interrupt and alter growth.

Question 12 While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following assessments is appropriate for the nurse to perform? A) Measure the length of the mass B) Auscultate the mass C) Percuss the mass D)

Palpate the mass

Review Information: The correct answer is B: Auscultate the mass Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the provider. The mass should not be palpated because of the risk of rupture.

"Good morning. You’re in the hospital. I am your nurse Elaine Jones."

Review Information: The correct answer is D: "Good morning. You’re in the hospital. I am your  nurse Elaine Jones." As cognitive ability declines, the nurse pr ovides a calm, predictable environment for the client. This response establishes time, location and the caregiver’s name.

Epiphyseal fractures often interrupt a B) child's normal growth pattern Children usually heal very quickly, so C) growth problems are rare

Question 11 The family of a 6 year-old with a fractured femur  asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children? Growth problems will occur if the fracture A) involves the periosteum

Question 13 While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best? A) " That's OK, its all right to skip your 

3 medication now and then." "I will have to call your doctor and report B) this." "Is there a reason why you don't want to C) take your medicine?"

"I think you’re good. So you see, there’s B) one person who likes you." "I’m not sure what you mean. Tell me a bit C) more about that."

"Do you understand the D) consequences of refusing your   prescribed treatment?"

D)

Review Information: The correct answer is C: "Is there a reason why you don''t want to take your  medicine?" When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.

Question 14 The nurse is teaching the parents of a 3 monthold infant about nutrition. What is the main source of fluids for an infant until about 12 months of age? A) Formula or breast milk B) Dilute nonfat dry milk C) Warmed fruit juice D)

Fluoridated tap water 

"Let's discuss this to see the reasons you create this impression on people."

Review Information: The correct answer is C: "I’m not sure what you mean. Tell me a bit more about that." This therapeutic communication technique elicits more information, especially when delivered in an open, non-judgmental fashion.

Question 16 When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend? A) Biofeedback B) Deep breathing C) Distraction D)

Imagery

Review Information: The correct answer is B: Deep breathing Deep breathing is a reliable and valid method for  reducing stress, and can be taught and reinforced in a short period pre-operatively.

Review Information: The correct answer is A: Formula or breast milk Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.

Question 15 A client states, "People think I’m no good, you know what I mean?" Which of these responses would be most therapeutic? "Well people often take their own feelings A) of inadequacy out on others."

Question 17 The nurse is planning care for an 18 month-old child. Which action should be included in the child's care? A) Hold and cuddle the child frequent ly Encourage the child to feed himself finger  B) food

Allow the child to walk independently on C) the nursing unit D)

Engage the child in games with other children

Review Information: The correct answer is B: Encourage the child to feed himself finger food According to Erikson, the toddler is in the stage of  autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living that allow the toddler to assert his budding sense of control.

Question 18 A client being treated for hypertension returns to the community clinic for follow up. The client says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which of  these is the best nursing diagnosis? Noncompliance related to medication side A) effects Knowledge deficit related to B) misunderstanding of disease state C) Defensive coping related to chronic illness D)

Altered health maintenance related to occupation

Review Information: The correct answer is A: Noncompliance related to medication side effects The client kept his appointment, and stated he knew the pills were important. He is unable to comply with the regimen due to side effects, not because of a lack of knowledge about the disease process.

Question 19 A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most

4 appropriate nursing action? Discharge the client from home health care A) because of noncompliance Notify the provider of the client's failure to B) follow prescribed diet Discuss diet with the client to learn the C) reasons for not following the diet D)

Make a referral to Meals-onWheels

Review Information: The correct answer is C: Discuss diet with the client to learn the reasons for  not following the diet When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client''s behavior and feelings as a basis for future teaching and intervention. Question 20 A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that such fantasies can gratify unconscious A) wishes or prepare for anticipated future events detaching or dissociating in this way B) postpones painful feelings converting or transferring a mental conflict C) to a physical symptom can lead to conflict within the partnership D)

Questions are numbered by the order in which they appeared in the test. * Represents the correct answer. Question 1 Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to help a client ambulate for the first time after a colon resection? "Have the client sit on the side of the bed A) before helping the client to walk." "If the client is dizzy ask the client to take B) some slow, deep breaths." "Help the client to walk in the room as C) often as the client wishes." 



D)

"When you help the client to walk, ask if any pain occurs."

Review Information: The correct answer is A: "Have the client sit on the side of the bed before helping the client to walk." This statement gives clear directions to the UAP about the task and is most closely associated with the information provided in the stem that this is the client''s first time out of bed after surgery.

Q&A-Delegation

D)

Check the documentation of the aide for appropriateness and comprehensiveness

Review Information: The correct answer is B: Determine if the home health aide''s care is consistent with the plan of care Although the nurse must complete all of the above responsibilities, evaluation of an adherence to the plan of care is the first priority. The plan of care is based on the reason for referral, provider''s orders, the initial nursing assessment, the client’s responses to the planned interventions, and the client''s and family''s feedback or inquires. The other possible answers represent aspects of  accomplishing “B”.

Question 3 Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)? Assess and document skin turgor and A) color changes Test stool for occult blood and urine for  B) glucose and report results Suggest foods high in iron and those easily C) consumed

isolating the feelings in this way reduces conflict within the client and with others

Review Information: The correct answer is A: such fantasies can gratify unconscious wishes or  prepare for anticipated future events Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes.

Determine if the home health aide's care is B) consistent with the plan of care Investigate if the home health aide is C) prompt and stays an appropriate length of  time for care

D)

Question 2 The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? Ask the client and family if they are

Report mental status changes and the degree of mental clarity

Review Information: The correct answer is B: Test stool for occult blood and urine for glucose and report results The UAP can do standard, unchanging procedures that require no decision making.

Question 4

5 The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)? A client with peripheral vascular disease A) and an ulceration of the lower leg. A pre-operative client awaiting B) adrenalectomy with a history of asthma An elderly client with hypertension and C) self-reported non-compliance D)

A new admission with a history of  transient ischemic attacks and dizziness

Review Information: The correct answer is A: A client with peripheral vascular disease and an ulceration of the lower leg. This client is stable with no risk of instability as compared to the other clients. And this client has a chronic condition, needs supportive care.

Question 6 The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client’s blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client’s left arm. Which of  these statements is most immediately accurate? The RN has no accountability for this A) situation B) The RN did not delegate appropriately C) The UAP is covered by the RN’s license D)

The UAP is responsible for  following instructions

Review Information: The correct answer is D: The UAP is responsible for following instructions The UAP is responsible for carrying out the activity correctly once directions have been clearly communicated especially if given verbally and in writing.

Question 5 A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate? A client admitted with multiple trauma with A) a history of a newly implanted pacemaker  A new admission with left-sided weakness B) from a stroke and mild confusion A 53 year-old client diagnosed with cardiac C) arrest from a suspected myocardial infarction D)

A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident

Review Information: The correct answer is D: A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident This client is the most stable with a predictable outcome.

Question 7 As the RN responsible for a client in isolation, which can be delegated to the practical nurse (PN)? A) Reinforcement of isolation precautions Assessment of the client's attitude about B) infection control Evaluation of staffs' compliance with C) control measures

D)

Observation of the client's total environment for risks

Review Information: The correct answer is A: Reinforcement of isolation precautions PNs and UAPs can reinforce information that was originally given by the RN.

Question 8 A 25 year-old client, unresponsive after a motor  vehicle accident, is being transferred from the hospital to a long term care facility. To which staff member should the charge nurse assign the client? A) Unlicensed assistive personnel (UAP) B) Senior nursing student C) PN D)

RN

Review Information: The correct answer is D: RN The RN is responsible for teaching and assessment associated with discharge and these activities cannot be delegated to the others listed.

Question 9 The charge nurse on a cardiac step-down unit makes assignments for the team consisting of a registered nurse (RN), a practical nurse (PN), and an unlicensed assistive personnel (UAP). Which client should be assigned to the PN? A 49 year-old with new onset atrial A) fibrillation with a rapid ventricular response A 58 year-old hypertensive with possible B) angina A 35 year-old scheduled for cardiac C) catheterization

6 D)

A 65 year-old for discharge after  angioplasty and stent placement

Review Information: The correct answer is B: A 58 year-old hypertensive with possible angina This is the most stable client. The clients in options C and D require initial teaching. The client in option A is considered unstable since the dysrhythmia is a new onset.

Question 10 The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? A) Practical nurse (PN) B) Registered Nurse (RN) C) Unlicensed assistive personnel (UAP) D)

Volunteer 

Review Information: The correct answer is C: Unlicensed assistive personnel (UAP) The measurement and recording of vital signs may be delegated to UAP. This falls under the umbrella of routine task with stable clients. Other  considerations for delegation of care to UAP would be: Who is capable and is the least expensive worker to do each task?

Question 11 Which of these clients would be appropriate to assign to a practical nurse (PN)? A trauma victim with multiple lacerations A) and requires complex dressings An elderly client with cystitis and an B) indwelling urethral catheter  A confused client whose family complains C) about the nursing care 2 days after surgery D)

A client admitted for possible transient ischemic attack with unstable neurological signs

Review Information: The correct answer is B: An elderly client with cystitis and an indwelling urethral catheter  This is a stable client, with predictable outcome and care and minimal risk for complications.

Question 12 Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of  these activities should the nurse assign to the UAP? A) Assist with plans for any clients discharged Provide basic hygiene care to all clients on B) the unit Assess a client after an acute myocardial C) infarction D)

matter" "I would like for you to approach the UAP C) about the problem the next time it occurs" D)

I will add this concern to the agenda for the next unit meeting

Review Information: The correct answer is C: "I would like for you to approach the UAP about the problem the next time it occurs" Helping staff manage conflict is part of the manager''s role. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager''s intervention when possible.

Gather the vital signs of all clients on the unit

Review Information: The correct answer is B: Provide basic hygiene care to all clients on the unit Basic client care, which is routine, should be delegated to a UAP since the unit is short on help. The vital signs can be done by the RN and PN as they make rounds since this data is more critical to making decisions about the care of the clients.

Question 13 A staff nurse complains to the nurse manager  that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of  these statements? "I will arrange for a conference with you A) and the UAP within the next week" B) "I can assure you that I will look into the

Question 14 A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)? Teach the client how to cough up A) secretions B) Changes the tracheostomy trach ties C) Monitor if client has shortness of breath D)

Perform routine tracheostomy dressing care

Review Information: The correct answer is D: Perform routine tracheostomy dressing care Unlicensed assistive personnel should be able to perform routine tracheostomy care.

18 "Omit the next doses until you talk with the B) doctor." "There were problems, but the C) recommended dose is changed." D)

"Your health care provider knows the best drug for your condition."

Review Information: The correct answer is C: "There were problems, but the recommended dose is changed." Wellbutrin was introduced in the U.S. in 1985 and then withdrawn because of the occurrence of  seizures in some patients taking the drug. The drug was reintroduced in 1989 with specific recommendations regarding dose ranges to limit the occurrence of seizures. The risk of seizure appears to be strongly associated with dose.

Question 32 A child presents to the Emergency Department with documented acetaminophen poisoning. In order to provide counseling and education for  the parents, which principle must the nurse understand? The problem occurs in stages with A) recovery within 12-24 hours Hepatic problems may occur and may be B) life-threatening Full and rapid recovery can be expected in C) most children D)

This poisoning is usually fatal, as no antidote is available

Review Information: The correct answer is B: Hepatic problems may occur and may be lifethreatening Clinical manifestations associated with acetaminophen poisoning occurs in 4 stages. The third stage is hepatic involvement which ma y last up to 7 days and be permanent. Clients who do not die in the hepatic stage gradually recover.

Question 33 A client is receiving digitalis. The nurse should instruct the client to report which of the following side effects? A) Nausea, vomiting, fatigue B) Rash, dyspnea, edema C) Polyuria, thirst, dry skin D)

Increase uterine blood flow

Review Information: The correct answer is B: Prevent convulsive seizures Magnesium sulfate is a central nervous system depressant. While it has many systemic effects, it is used in the client with pregnancy induced hypertension (PIH) to prevent seizures.

Hunger, dizziness, diaphoresis

Review Information: The correct answer is A: Nausea, vomiting, fatigue Side effects of digitalis toxicity include fatigue, nausea, vomiting, anorexia, and bradycardia. Digitalis inhibits the sodium potassium ATPase, which makes more calcium available for  contractile proteins, resulting in increased cardiac output.

Question 34 The provider has ordered transdermal nitroglycerin patches for a client. Which of these instructions should be included when teaching a client about how to use the patches? Remove the patch when swimming or  A) bathing Apply the patch to any non-hairy area of  B) the body C) Apply a second patch with chest pain D)

D)

Remove the patch if ankle edema occurs

Review Information: The correct answer is B: Apply the patch to any non-hairy area of the body The patch application sites should be rotated. Question 35 A pregnant woman is hospitalized for treatment of pregnancy induced hypertension (PIH) in the third trimester. She is receiving magnesium sulfate intravenously. The nurse understands that this medication is used mainly for what purpose? A) Maintain normal blood pressure B) Prevent convulsive seizures C) Decrease the respiratory rate

Question 36 A client with anemia has a new prescription for  ferrous sulfate. In teaching the client about diet and iron supplements, the nurse should emphasize that absorption of iron is enhanced if  taken with which substance? A) Acetaminophen B) Orange juice C) Low fat milk D)

An antacid

Review Information: The correct answer is B: Orange juice Ascorbic acid enhances the absorption of iron. Question 37 The health care provider has written "Morphine sulfate 2 mgs IV every 3-4 hours prn for pain" on the chart of a child weighing 22 lb. (10 kg). What is the nurse's initial action? A) Check with the pharmacist Hold the medication and contact the B) provider  C) Administer the prescribed dose as ordered D)

Give the dose every 6-8 hours

Review Information: The correct answer is B: Hold the medication and contact the provider  The usual pediatric dose of morphine is 0.1 mg/kg every 3 to 4 hours. At 10 kg, this child typically should receive 1.0 mg every 3 to 4 hours.

Question 38 The nurse is monitoring a client receiving a thrombolytic agent, alteplase (Activase tissue

19 plasminogen activator), for treatment of a myocardial infarction. What outcome indicates the client is receiving adequate therapy within the first hours of treatment? A) Absence of a dysrhythmia (or arrhythmia) B) Blood pressure reduction C) Cardiac enzymes are within normal limits D)

Return of ST segment to baseline on ECG

Review Information: The correct answer is D: Return of ST segment to baseline on ECG Improved perfusion should result from this medication, along with the reduction of ST segment elevation. Question 39 A nurse is assigned to perform well-child assessments at a day care center. A staff  member interrupts the examinations to ask for  assistance. They find a crying 3 year- old child on the floor with mouth wide open and gums bleeding. Two unlabeled open bottles lie nearby. The nurse's first action should be A) call the poison control center, th en 911 administer syrup of Ipecac to induce B) vomiting C) give the child milk to coat her stomach D)

ask the staff about the contents of  the bottles

Review Information: The correct answer is D: ask the staff about the contents of the bottles The nurse needs to assess what the child ingested before determining the next action. Once the substance is identified, the poison control center and emergency response team should be called.

Question 40 A client is receiving erythromycin 500mg IV every 6 hours to treat a pneumonia. Which of  the following is the most common side effect of  the medication? A) Blurred vision B) Nausea and vomiting

C) Severe headache D)

Insomnia

Review Information: The correct answer is B: Nausea and vomiting Nausea is a common side-effect of erythromycin in both oral and intravenous forms.

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