Predictive exam XXIV RN

Question 1 of 50

When taking the blood pressure of a small child, the nurse notes that of the cuffs available, one is too large and one is too small. What would be the best nursing action?

Use the large cuff.
Use the small cuff.
Use the palpation method with either cuff.
Do not take the blood pressure until a proper cuff can be located.

Question 2 of 50

When examining the mouth and throat of a child, the nurse understands which of the following? Select all that apply.

Infants and toddlers usually resist keeping the mouth open.
Nurses should place the tongue blade on the center of the back area of the tongue.
Nurses should use a flavored tongue blade.
Nurses should place the tongue blade on the side of the tongue for examination.
Nurses should assess the mouth and throat at the beginning of the physical examination.
Nurses should position the child supine with arms held above the head for safety and to limit movement of the head.

Question 3 of 50

The nurse needs to palpate the abdomen of a preschooler. Light palpation of the abdomen is often perceived by the child as tickling. Which of the following nursing measures is most likely to minimize the sensation of tickling and promote cooperation and relaxation during the examination?

Explain to the child not to laugh or move if it tickles.
Encourage the child to "help" with palpation by placing his or her hand over the palpating hand.
Distract the child by palpating another area simultaneously.
Start with deeper palpation and then gradually progress to superficial palpation.

Question 4 of 50

A client with which of the following diagnoses should be given highest priority for obtaining a blood pressure measurement?

A client with diabetes mellitus has an elevated blood glucose.
A client complaining of a "pounding" headache.
A client complaining of nausea.
A previously immobilized client who feels dizzy when first standing up.

Question 5 of 50

The nurse understands which of the following accurate principles about applying heat and cold applications.

Vasoconstriction can lead to increased pain sensation.
Clients are better able to tolerate short exposure to temperature extremes than prolonged exposure.
Clients who have problems with sensing temperatures should be allowed to adjust their temperature settings on electric heat applications.
Hands and feet are the most sensitive areas on the body.

Question 6 of 50

At the change of shift report the nurse is told one of his assigned clients is experiencing Cheyne-Stokes respirations. What would the nurse expect to find on the assessment of this client?

Irregular respirations with periods of apnea and deep breathing
Wet, gurgling irregular respirations
Very slow, shallow, irregular respirations
Rapid, shallow respirations followed by periods of slow, irregular respirations

Question 7 of 50

A client is near death; his heart rate is 148 beats per minute and respirations are 38 breaths per minute. There is a decrease in function in all other body systems. What would the nurse explain to the family regarding the symptoms the client is exhibiting?

These symptoms may indicate the client is experiencing an improvement in the cardiac and respiratory status.
The cardiac and respiratory statuses are reflex responses secondary to a decrease in other functions.
It is not unusual for the heart and respirations to begin to increase as the other body systems began to fail.
The heart and the lungs are attempting to compensate and bring the acid–base balance back to normal.

Question 8 of 50

The nurse is admitting a 35-year-old woman who is in the advanced stages of breast cancer. The woman tells the nurse that she does not want any heroic measures taken to prolong her life. What is the best nursing action?

Ask the woman to provide a notarized advance directive or the physician cannot recognize her request.
Ask the woman if she has discussed her decision regarding no resuscitation with her admitting physician.
Document the request in the client's chart and the response of the woman's husband to her decision.
Request that if the client is unable to make this type of decision that she designate someone to assist her to make these choices and to carry out the choices if she is not competent.

Question 9 of 50

The nurse is working with a group of clients. Which client would be the most appropriate to refer for hospice care?

A 35-year-old man with advanced AIDS who is experiencing severe pain and respiratory difficulty
A 60-year-old woman who has pancreatic cancer and her daughter cannot care for her at home
A 15-year-old girl with acute myelogenous leukemia whose parents cannot discuss the latest poor prognosis
A 45-year-old woman who is diagnosed with advanced breast cancer and has elected not to have surgery or chemotherapy treatments

Question 10 of 50

The hospice nurse is planning an admission visit to the home of a client who has metastatic breast cancer. What will be important for the nurse to do on the home visit?

Discuss with the client the importance of chemotherapy and radiation.
Complete a detailed history regarding the diagnosis and progress of the cancer.
Discuss any concerns and determine preferences and needs for the client's care.
Complete a psychosocial assessment to validate any changes in transition of the grief process.

Question 11 of 50

The nurse is caring for a child who is in the end stages of cancer. The parents ask you how they will know when death is imminent. What sign is indicative of imminent death?

Difficulty swallowing
Anorexia
Increased sleeping
Muscle weakness

Question 12 of 50

What is the physiologic principle behind the effective use of epidural anesthesia during surgery?

Both sensory and motor fibers to the lower part of the body are completely inactivated.
Both sensory and motor fibers to the bladder arise from the first lumbar vertebra and are always blocked by epidural anesthesia.
Pain motor tracts from the lower part of the body are completely desensitized.
The anesthetic agent does not enter the cerebrospinal fluid, but binds to nerve roots as they enter and exit the spinal cord.

Question 13 of 50

The nurse is caring for a client who is 6 hours postoperative for an abdominal laparotomy. The client has an order for morphine, IV prn every 3 to 4 hours. With regard to effective pain management, what nursing actions will provide the most effective pain control?

Assess for pain every 3 hours.
Give the analgesic every 4 hours when the client is awake.
When repositioning fails to relieve the pain, administer the analgesic.
Administer the analgesic only when the client requests pain medication.

Question 14 of 50

The nurse is entering the room of a client admitted for back pain. He asks the nurse if she could give him something for pain. Which of the following should the nurse do first?

Ask the client what type of medication he normally takes.
Obtain more information about the client's back pain.
Administer oral acetaminophen.
Place a call to the physician for direction on which medications to give.

Question 15 of 50

A client with metastatic cancer has been taking oxycodone and amitriptyline for pain control at home. She is in constant severe pain and is at the pain clinic for evaluation. When developing a pain management control program for this client, the nurse should initially obtain which information related to the client’s pain?

The past pain medication schedule, including dosages of the drugs and when breakthrough pain occurred
Identification of trigger points of pain
The pattern, area, intensity, and nature of her pain
The pattern of pain relief achieved with oxycodone and amitriptyline during episodes of acute pain

Question 16 of 50

In encouraging the client to use pain medication after surgery, the nurse should explain that

side effects of the pain medication are minimal and will decrease over time.
very few clients become addicted to opioids when using them for pain control.
there are a variety of medications, and if one drug does not relieve the pain, other drugs may be tried.
unrelieved pain can be harmful because it alters respiratory and gastrointestinal function and can impair recovery from surgery.

Question 17 of 50

The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam hydrochloride during a colonoscopy. The nursing assessment reveals the client has nystagmus, slurred speech, and responds slowly to verbal commands. What is the best nursing action?

Assess the adequacy of the airway.
Administer naloxone to reverse sedation.
Continue to monitor the client.
Obtain an arterial blood gas to determine acid-base balance.

Question 18 of 50

The nurse is reviewing the healthcare provider’s orders for a postoperative client. The client has just returned from surgery for aortic aneurysm repair. He is NPO, he has a nasogastric tube, and vital signs indicate a pulse rate of 110, respirations 20, and BP 112/78; however, he is very drowsy and moans in his sleep. Which nursing intervention or assessment is a priority in caring for this client?

Determine adequacy of breath sounds bilaterally.
Position the client in a semi-Fowler's position and offer liquids.
Increase fluid intake to make coughing more effective.
Evaluate the client for the presence of pain.

Question 19 of 50

The nurse is assessing a group of clients who will be having surgery. Which client would be at the highest risk for postoperative complications?

Client taking birth control pills for the past 5 years
Client who has had difficulty with constipation for the past 6 months
Client who recently completed antibiotic therapy for a streptococcal throat infection
Client on a daily aspirin regimen for arthritis

Question 20 of 50

A postoperative client says it hurts too much to deep breathe and cough every 2 hours and refuses to carry out the activity. What is the best initial nursing action?

Respect the client's request and plan to ambulate as soon as possible.
Teach the client to splint the incision and then perform coughing and deep breathing exercises, and use incentive spirometry.
Advise the doctor about the problem and ask him to emphasize to the client the need to cough and deep breathe.
Document on the chart the client's refusal to participate in requested postoperative procedures.

Question 21 of 50

The nurse is completing a preoperative assessment. What data from the assessment should the nurse investigate more thoroughly?

Use of multiple herbal medications for the past year
Infection when he had surgery 2 years ago
History of problems with pain control postoperatively
Discontinued taking aspirin for his arthritis about 3 weeks ago

Question 22 of 50

The nurse is assessing a client’s incision on the second postoperative day. There is warmth and tenderness around the incision site. There is a 3 mm area of peri-incisional erythema. The wound is well approximated with no drainage. What is the best nursing action?

Irrigate the wound with cool normal saline.
Document the status of the wound.
Place warm packs on the incision to relieve the discomfort.
Notify the surgeon and anticipate an order for wound cultures.

Question 23 of 50

A client with diabetes is being admitted for abdominal surgery. What nursing actions would the nurse implement to promote wound healing for this client?

Maintain the client's blood glucose within a normal range.
Administer an acetaminophen suppository for any temperature above 101°F (38.3°C).
Monitor the client's calorie count to provide adequate carbohydrate intake for healing.
Maintain a wet-to-dry dressing to facilitate wound granulation.

Question 24 of 50

A 3-year-old child is admitted into day surgery for repair of an inguinal hernia. The child begins to cry when the nurse takes her favorite blanket from her before transferring her from her room to the operating room. What is the best nursing action?

Explain to the child the blanket will be waiting for her after surgery.
Have the mother hold the child and tell her she cannot take her blanket to surgery.
Allow the child to take the blanket until she receives the medication for anesthesia.
Explain to the mother why the child cannot take the blanket into surgery.

Question 25 of 50

An older adult female immigrant tells the nurse that where she grew up women had no voice in the family, because the men made all the decisions. Over the past 20 years since becoming a US citizen, I have the same voice and control in the family that my husband has. What is this an example of?

Ethnicity
Acculturation
Ethnocentrism
Cultural assimilation

Question 26 of 50

A nurse wants to improve cultural competence. What action shows progress toward this goal?

Uses an evidence-based cultural assessment tool
Tries to treat all clients the same
Prioritizes care based on cultural needs
Wants to learn more about other ethnic groups

Question 27 of 50

The nurse is caring for a client who is unconscious and is dying. The family has requested a priest to come. Which of the following sacraments would the family of a Catholic client request at this time?

Reconciliation
Communion
Baptism
Anointing of the sick

Question 28 of 50

The clinic nurse answers a phone call from an Asian American client who is experiencing a fever. The client wants to self-treat first before taking an antipyretic medication. What would the nurse suggest to the client?

Ingest yin foods.
Meditate and pray.
Have a massage.
Ingest yang foods.

Question 29 of 50

What is ethnocentrism?

The process by which a person from one culture adapts to another culture.
A preconceived notion or fixed general idea or image about a group of people.
The process when members of a minority group are absorbed by a dominant culture by taking on the characteristics of that dominant culture.
The belief that one ethnic or cultural group is superior to that of another group.

Question 30 of 50

What is the most effective approach to obtaining a cultural assessment on a client?

Asking the client about their culture.
Conferring with another nurse about the client's cultural preferences.
Using a cultural assessment guide or tool.
Observing the client's particular cultural preferences.

Question 31 of 50

A client is experiencing spiritual distress related to loneliness and social alienation. What would be included in spiritual nursing interventions?

Assist with activities of daily living.
Participate in active listening.
Determine level of independent activities of living.
Evaluate ability to understand events.

Question 32 of 50

When the nurse asks the client, “How has being sick affected your spiritual practices?” the nurse is trying to determine the need in what spiritual dimension?

Spirit-enhancing practices or rituals.
Religious sources of hope, strength, and compassion.
Involvement with a religious or spiritual community.
Experience of God or a higher power.

Question 33 of 50

A nurse manager has been notified to obtain a bed for a client. Of the following clients, which one would the nurse anticipate being able to discharge?

A client who had a myocardial infarction (MI) 2 days ago, who has the following vital signs: blood pressure (BP) of 150/94 mm Hg, irregular pulse of 84 beats/min, respiration of 28 breaths/min, and minimal chest pain.
A client who underwent an abdominal aortic aneurysm resection 3 days ago, who has the following vital signs: BP of 130/88 mm Hg, pulse of 88 beats/min, respiration of 22 breaths/min, and oral temperature of 101°F (38.3°C). He is beginning oral intake without problems.
A client who has a subdural hematoma, who is lethargic; his pulse is 60 beats/min, BP is 150/90 mm Hg, respiration is 28 breaths/min, and temperature is 99°F (37.2°C).
A client who had abdominal exploratory surgery for a bowel obstruction 4 days ago, who has bowel sounds, is taking fluids orally, has an abdominal Penrose drain, and is continuing to experience abdominal pain.

Question 34 of 50

Which of the following clients would the emergency room (ER) nurse see first?

A client with a fractured left femur
A client with closed head injury
A client with third-degree burns to the fac
A client with severe diarrhea and vomiting

Question 35 of 50

After morning report, the nurse prioritizes care of the following assigned clients. Which client would the nurse see first?

A client with a leaky colostomy bag
A client who will be undergoing lumbar puncture at noon
A client receiving packed red blood cells, and the bag is half empty
A client in sickle cell crisis with an infiltrated intravenous (IV) line

Question 36 of 50

During morning report, a staff nurse organizes her client load based on the clients’ levels of acuity. Which of the following clients would the nurse see first?

A 40-year-old man with a bowel resection and nasogastric (NG) tube in place
A woman scheduled for a cholecystectomy complaining of chills
A young woman refusing her morning dose of sucralfate
A young man with right-side weakness requesting a bedside commode

Question 37 of 50

A staff nurse is beginning the evening shift. The day nurse has advised her that the suction equipment in the room of a client who has had surgery is not working properly. What is a priority nursing action?

Troubleshoot and fix the machine.
Continue to use the machine.
Evaluate the function of the suction equipment.
Replace the equipment.

Question 38 of 50

To optimally use the level of preparation of the LPN/LVN, which task should the RN delegate to the LPN/LVN?

Transporting a client to the laboratory
Assisting with a thoracentesis
Restocking and counting the sterile supplies
Passing afternoon nutrition supplements and waters

Question 39 of 50

The charge nurse has observed the following: one nurse’s aide is usually pleasant and helpful; the other is often abrasive and angry. What is the most important guideline to be observed by the charge nurse, who must resolve the conflict between the two nurse’s aides?

Require the aides to reach a compromise.
Weigh the consequences of every possible solution.
Encourage ventilation of anger and use humor to minimize the conflict.
Address the conflict between the nurse's aides, not their personalities.

Question 40 of 50

When planning nursing activities to improve time management, the nurse should schedule which activity?

Performing tracheotomy suctioning
Assessing the client's knowledge of wound care
Administering medications
Assisting with clients' personal hygiene

Question 41 of 50

A female client in the medical-surgical unit is diagnosed with anemia and complains of weakness. Which of the following assignments could be designated to the nursing assistant?

Organize the client's meal tray for dinner.
Talk with the client about managing her rest and activities.
Get a diet history and list of the client's favorite foods.
Take an apical pulse and listen to the lungs for fluid.

Question 42 of 50

A nursing assistant is bathing an incontinent, comatose client under the supervision of the RN. The nurse would know to redirect the nursing assistant if he did which of the following?

Performed back care on the client after logrolling him to his side
Picked up a writing pad and pen and moved it to the nightstand while wearing gloves
Rolled the client from side to side to place an incontinent pad under the client
Before finishing, placed the client on the right side in a low-Fowler's position

Question 43 of 50

The nurse is in charge of nursing care on the afternoon shift in an ambulatory care center. Which client would the charge nurse evaluate first?

A client who had a laparoscopic cholecystectomy, has been in the unit for 4 hours, and is complaining of left shoulder pain
A client who had a prostate biopsy about 6 hours ago and is beginning to complain of perineal discomfort, chills, and feeling flushed
A young adult who refuses to take his oral postoperative antibiotic
An older adult who required placement of an NG tube

Question 44 of 50

Which of the following tasks should the charge nurse delegate to an experienced LPN working on the adult medical unit?

Teaching a client about the pre procedure preparation for a gastric endoscopy
Inserting an NG tube for gastric acid analysis
Administering IV midazolam hydrochloride during endoscopy
Administering IV midazolam hydrochloride during endoscopy

Question 45 of 50

The charge nurse on an acute care unit has been directed to determine who can be transferred to a residential and/or a rehabilitation facility. For which client would the nurse contact the physician regarding a transfer? A client

who had a left-hemisphere stroke 5 days ago and has a stage III sacral pressure ulcer.
who is diabetic and has a foot ulcer that is gangrenous on the first two toes.
with a urinary tract infection, a temperature of 102°F (38.9°C) and positive blood cultures.
with diagnosis of bilateral pneumonia and a sputum culture positive for Pseudomonas bacteria.

Question 46 of 50

What is an important consideration for the nurse when delegating an assignment?

Making sure the person accepting that task does so willingly
Delegating to a nursing staff member the supervision of the delegated tasks
Making sure there are clear, concise directions regarding the tasks
Assigning the task of delegation to a qualified nurse

Question 47 of 50

An RN from a postpartum unit has been reassigned to a cardiac unit because of staffing issues. The nurse is very uncomfortable and does not feel competent to deliver care on this unit. What is the best nursing action she can take?

Ask to "buddy" with an experienced cardiac nurse.
Decline the transfer because of lack of competence.
Notify the state board of nursing.
Notify the local branch of the American Nurses Association.

Question 48 of 50

A nursing supervisor would be most concerned about which statement made by a staff nurse after the completion of an incident report?

"I know this information will go to the risk management team for review."
"I only included the facts as best I could remember them."
"I will make sure a copy of the report is placed on the client's chart."
"I don't like incident reports, but I understand they are necessary to prevent future problems."

Question 49 of 50

The Joint Commission’s (TJC) National Patient Safety Goals clearly state that healthcare facilities must implement safe approaches and procedures for client safety. Which practice has been instituted as a result of these goals established by TJC?

Use of hand hygiene dispensers at the bedside
Use of two client identifiers when providing nursing care or treatments
Providing a standard shift report form
Instituting a "no-lift" policy

Question 50 of 50

Which client should the nurse see first after receiving the shift report?

Client complaining of fever, severe headache, and neck stiffness
Client with three episodes of diarrhea in the past 24 hours
Client who has just been told that she has colon cancer
Client who is going to be transferred to a step-down unit after hip replacement surgery 4 days ago

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