Question 1

A 39-year-old male client, brought to the Emergency Department after sustaining a traumatic brain-stem injury during a football game, has died. You have met with the family about the possibility of organ and tissue donation, and they are considering the option. You are showing an awareness of his role in providing care for this family by (select all that apply):

Accepted Answer

Families need compassionate support when unexpected and sudden death occurs. Grieving families may respond positively to the opportunity of honoring their loved one by sharing the gift of life with others. Respectful, sensitivity and support is required.

Question 2

By returning to a client's room at the time promised, the nurse is demonstrating:

Accepted Answer

Keeping a promise is known as the ethical principal of fidelity. It is a secondary ethical principle. Secondary ethical principles are incorporated into the primary principles when making clinical decisions and determining ethical issues.

Question 3

You are caring for a 55-year-old client experiencing mid-sternal chest pain. What is the priority nursing action for this client?

Accepted Answer

A complete set of vitals is the priority nursing action for clients in any sort of distress. The first step in the nursing process is the assessment. A complete set of vitals will provide information on the client's status, give a baseline for further assessment, and help to form the plan for further care and treatment. Auscultation of heart and breath sounds and gathering history information are both important parts of the assessment process, but only after vital signs are measured. Starting an IV and administering analgesics are not part of the assessment process.

Question 4

A nurse is caring for a female client who complains of easy fatigability and weakness. Laboratory tests reveal that the client has an iron-deficiency anemia. History reveals that the client is a practicing vegetarian. Which of the following food items is correctly included in the client's daily diet to correct iron-deficiency anemia?

Accepted Answer

Among the choices, raisins have the most iron content. Iron from plants is less efficiently absorbed by the body when compared to the amount of iron obtained from meats. Other good sources of iron are whole grains and green leafy vegetables. Brewer's yeast is high in Vitamin B12. Soybean milk and tofu are high in calcium. Bananas are rich in potassium.

Question 5

A nurse gathered the assessment findings from a group of clients assigned to her during the shift. Among the details of information she noted, which of the following is most likely attributed to poor hygiene care?

Accepted Answer

Among the data gathered from the group of clients, reddish skin that doesn't blanch when touched is highly attributable to poor hygiene care. This condition indicates an early stage of pressure ulcer. Option A refers to seborrheic dermatitis which is a chronic inflammation of skin formed in oily areas. Option C refers to psoriasis, which is an auto-immune disease. Option D indicates allergic contact dermatitis due to nickel exposure.

Question 6

What is the most fundamental principle of professional behavior?

Accepted Answer

According to the American Nurses Association, respect of persons is the most fundamental principle of professional behavior. It emphasizes that all people are worthy individuals and should be treated as such. In nursing, this principle is simplified to respecting a client's autonomy.

Question 7

A 35-year old client says that both of her parents were diagnosed with hypertension and that she is afraid that she might get it as well. Although the client is not demonstrating any sign of the disease, what should the nurse include in her home care teaching to help the client prevent hypertension?

Accepted Answer

Maintaining a regular exercise program, about 30 minutes per day at least 5 times a week, can help reduce the risk of hypertension. Increasing foods high in sodium escalates the risk. Controlling stress levels is essential; however, getting rid of any form of stress is not realistic. Teaching how to obtain the blood pressure measurement may be necessary if the client is later diagnosed with hypertension.

Question 8

A nurse is caring for a client with genital herpes. The nurse uses which of the following measures to promote comfort?

Accepted Answer

Wearing of tight-fitting and nylon underwear can irritate the skin and slow down the process of healing. It is best to avoid hydrogen peroxide applications. Cool, wet compresses can soothe the itch.

Question 9

Which of the following is the number 1 modifiable risk factor for stroke?

Accepted Answer

Hypertension is the single most important modifiable risk factor for ischemic stroke.

Question 10

What kind of ulcers are usually formed as a result of the chronic usage of nonsteroidal anti-inflammatory drugs?

Accepted Answer

Nonsteroidal anti-inflammatory drugs primarily cause gastric ulcers.

Question 11

A client was rushed in due to severe abdominal pain unrelieved by repositioning. Assessment shows a high fever and yellowish hue of the skin. The client's friends reported that they had been drinking hard liquor the whole night. The client was diagnosed with pancreatitis. The nurse understands that pancreatitis is caused by:

Accepted Answer

Pancreatitis is an inflammatory disease of the pancreatic gland which results in auto-digestion by its own enzyme. Manifestations of pancreatitis are abdominal pain, nausea and vomiting. A common cause of acute pancreatitis is a heavy meal or drinking too much alcohol.

Question 12

Each of the following is a cause of vitamin B-12 deficiency EXCEPT

Accepted Answer

Duodenal resection does not cause vitamin B-12 deficiency.

Question 13

According to the International Council of Nurses, Code of Ethics for Nurses, which one or more of the following statements reflect(s) the fundamental responsibility of a nurse?

Accepted Answer

The International Council of Nurses' Code of Ethics for Nurses states the fundamental responsibilities of a nurse are to promote health, alleviate suffering, prevent illness, and restore health. The ICN Code of Ethics for Nurses serves as the standard of practice for nurses worldwide.

Question 14

A nurse is giving instructions to a client who just had an arthroscopy of the right knee. Which of the following instructions is the least appropriate?

Accepted Answer

After the sensation returns, the client can carefully walk on the affected leg. Crutches can be used for a few days to aid the client during walking. The other options are appropriate.

Question 15

A nurse prepares a nursing care plan for a newly-admitted client with myasthenia gravis. Understanding the risks of myasthenia gravis, it is a must that the nurse prepares which of the following near the client's bedside?

Accepted Answer

A client with myasthenia gravis is at risk for respiratory distress caused by considerable muscle weakness or fatigue, including the diaphragm. Suction equipment, Ambubag, and intubation tray are kept near the client's bedside.

Question 16

A nurse is caring for a client admitted due to bowel obstruction and a nasogastric tube is about to be inserted, as ordered. The nurse knows that nasogastric tube is inserted to:

Accepted Answer

The nasogastric tube empties the stomach of fluids and gas. Intestinal tubes remove contents in the small and large bowels

Question 17

A nurse is providing discharge instructions to a 75-year-old client who had surgery to remove a cataract from her left eye. The nurse should include which of the following instructions?

Accepted Answer

Increasing fluid and fiber intake prevents constipation, which should be avoided during the postoperative period. An eye shield is used at bedtime. Drainage is wiped from the inner to the outer canthus. Rapid movements, sneezing, coughing, and lifting objects weighing more than 5 pounds must be avoided to prevent straining.

Question 18

A nurse is assessing a client with peripheral arterial disease. The client's pulses are not palpable in the left foot or leg. The nurse's most immediate action is which of the following?

Accepted Answer

On assessment, if the foot and leg pulses are not palpable, verify the findings with the Doppler ultrasonography. If the Doppler cannot detect the pulse, notify the physician immediately.

Question 19

A client is diagnosed with trichomoniasis. On assessment, the nurse notes which of the following signs and symptoms?

Accepted Answer

Trichomoniasis is manifested by frothy green or gray vaginal discharge. Mucoid purulent discharge is associated with chlamydia; whereas, thin and grayish vaginal discharge with a fishy odor is associated with Gardnerella. Candidiasis is characterized by a thick and cottage cheese-like discharge.

Question 20

A nurse is delegating nursing activities to the nursing assistant. The female client being cared for has been diagnosed with fluid volume deficit due to massive bleeding. The client was accidentally shot. Which of the following activities can be safely delegated to the nursing assistant?

Accepted Answer

The nursing assistant can report decreased urine output. He or she is not responsible for regulating IV fluids, assessing intake and output, or performing health teaching to clients. These activities require the additional knowledge and skills of a registered nurse.

Quiz 1: American Association of Colleges of Nursing (AACN) Clinical Nurse Specialist