Question 1

A nurse is assessing a client who gave birth twelve hours ago. On assessment, the nurse notes that the client's fundus is above the umbilicus to the right. Which of the following is the nurse's initial action?
A)Place the client on her left side
B)Massage the fundus
C)Ask the client to void
D)Notify the physician

Accepted Answer

A fundus above the umbilicus and to the right suggests a full bladder. The nurse should ask the client to void and be re-checked. The other options are not appropriate.

Question 2

A client at 32 weeks gestation chokes on her food and becomes unconscious. The nurse's immediate action is to:
A)Perform backward chest thrusts
B)Place the client on her back with a pillow under the right abdominal flank and hip
C)Place the client on her left side
D)Place the paddles one rib interspace lower than usual during defibrillation

Accepted Answer

If a client becomes unconscious, chest thrusts are discontinued, and the client is placed on her back. A pillow or rolled blanket is placed under the right abdominal flank and hip to displace the uterus to the left side. If defibrillation is needed, the paddles are placed one rib interspace higher because the heart is slightly displaced by the uterus.

Question 3

A nurse is caring for an eighty-year-old client who is visually impaired. The nurse would take which of the following actions to reduce sensory deprivation?
A)Use of night light
B)Close the curtains on the windows
C)Open the curtains during daytime
D)Keep the overhead light on 24 hours a day, 7 days a week

Accepted Answer

Closing the curtains or blinds on windows can improve vision for the elderly and reduce glare. Controlled lighting can help the client see better in the hospital. The other options are not appropriate for this client.

Question 4

A nurse is caring for a postpartum client. Which of the following would be the earliest sign of excessive blood loss?
A)A blood pressure change from 130/83 to 126/80
B)A respiratory rate from 16 to 20 breaths per minute
C)An increase of pulse rate from 80 to 102 per minute
D)A temperature of 100.8°F

Accepted Answer

A rising pulse is the earliest sign of blood loss because the heart has to pump faster to compensate for reduced blood volume. The blood pressure decreases with reduced blood volume, but it is not the earliest indicator of hemorrhage. A slight increase in temperature and respiratory rate are expected.

Question 5

An adult client is diagnosed with chronic renal failure. Which of the following nursing interventions is most appropriate?
A)Instruct the client to drink at least 1500 ml per day
B)Weigh daily before breakfast
C)Advise client to increase his intake of foods rich in calcium and phosphorus and decrease his intake of potassium
D)Encourage the client to eat 3 large meals a day, avoiding between-meal snacks.

Accepted Answer

Weighing daily before breakfast is the most accurate method of monitoring fluid retention. A gain of two pounds over a 24-hour period indicates fluid retention. Fluid intake should be restricted. Consumption of phosphorus and potassium should be controlled. Smaller meals and between-meal snacks are recommended.

Question 6

A nurse is assessing a six-month-old child. On assessment, noting of which of the following findings should alert the nurse to a possible problem?
A)The posterior fontanel is not completely ossified.
B)The anterior fontanel is not completely ossified.
C)The tonic neck reflex is not demonstrated.
D)The infant's birth weight doubled.

Accepted Answer

The posterior fontanel closes between two and three months of age. The anterior fontanel closes between twelve and eighteen months of age. The tonic reflex disappears on the fourth month and the infant's weight should double by the sixth month.

Question 7

At 9:00 a.m. a nurse finds a client, being infused with 5% dextrose in 0.9% sodium chloride, is having difficulty breathing. On assessment, the nurse notes increased blood pressure, distended jugular veins, and crackles on auscultation. A 1,000-ml infusion bag of solution was hung at 8:00 a.m. The remaining solution is measured at 600 ml. The nurse's most immediate action is to:
A)Notify the physician
B)Place the client on semi-Fowler's
C)Slow down the rate of infusion
D)Stop the infusion and remove the IV catheter

Accepted Answer

The client is experiencing circulatory overload; therefore, slowing down the rate of infusion is the most immediate action. Positioning the client in semi-Fowler's and calling the physician are appropriate, but they are not the nurse's priority. Stopping the infusion is not necessary.

Question 8

A nurse notes that the site of the client's intravenous catheter is slightly edematous and cool. Blood return is not observed upon lowering the IV fluid below the IV site. Which of the following nursing actions is not appropriate for this client?
A)Removing the intravenous device immediately
B)Rubbing or massaging the infiltrated area
C)Elevating the affected extremity
D)Application of warm or cool compresses over the site

Accepted Answer

An infiltrated site is not rubbed or massaged, as it can cause the development of hematoma. The other options are appropriate.

Question 9

A client is found unresponsive on the floor. On assessment, the nurse notes that the client is not breathing and is pulseless. After activating the medical resuscitation team, what is the next nursing action?
A)Administer oxygen
B)Initiate ventilation
C)Begin chest compressions
D)Open the airway

Accepted Answer

New standards in CPR emphasize chest compressions over airway, so the next step after calling for help is to check the pulse and begin chest compressions. Chest compressions should be given immediately (30 for an adult patient), and then followed by opening the airway and beginning respirations. Ventilation is only initiated when the airway is open or patent, as oxygen is not needed until the patient is breathing.

Question 10

A client with pregnancy-induced hypertension is given magnesium sulfate. Which finding, during assessment, should alert the nurse?
A)Fetal heart rate of 155 beats per minute
B)Urinary output of 30 ml per hour
C)A grading of 2+ deep tendon reflexes
D)Respiratory rate of 10 breaths/ minute

Accepted Answer

Magnesium sulfate can cause respiratory depression. Therefore, a respiratory rate less than 12 breaths/ minute should be reported to the physician. The fetal heart rate and the client's urinary output and deep tendon reflexes are within the normal range.

Question 11

A client comes to the emergency department complaining of dyspnea and has a respiratory rate of 30 breaths per minute. The client receives a diagnosis of pneumonia. Which of the following is the initial action of the nurse?
A)Initiate antibiotics, as ordered
B)Instruct bed rest with bathroom privileges
C)Administration of oxygen
D)Encourage consumption of foods high in calories

Accepted Answer

Administration of oxygen is the initial priority of the nurse. Oxygen administration addresses the immediate problems of the client. The other options are appropriate, but they are not a priority at this time.

Question 12

A client with persistent cough is complaining of severe pain when coughing. The nurse would instruct the client to do which of the following comfort measures?
A)Elevate the head of bed to 15 to 30-degrees
B)Restrict fluid consumption
C)Hold in coughing
D)Splint the chest wall with a pillow

Accepted Answer

Splinting the chest wall with a pillow decreases discomfort. The head of the bed must be elevated to at least 45-degrees to allow lung expansion. Restricting fluid consumption can thicken and immobilize the secretions, and holding in the cough can cause more pain; therefore, these instructions are inappropriate.

Question 13

A client who had open heart surgery 24 hours ago has had a urine output of about 20 ml/hr for the past 12 hours. The laboratory findings reveal a BUN level of 38 mg/dl and a serum creatinine level of 2.0 mg/dl. A nurse reviewing these results determines that the client is at risk for which of the following?
A)Acute renal failure
B)Glomerulonephritis
C)Pyelonephritis
D)Uremic syndrome

Accepted Answer

Based on the laboratory findings, the client is at increased risk for acute renal failure. Cardiac surgery can result in poor kidney perfusion, breakdown of red blood cells, and low cardiac output, consequently increasing the risk for renal failure.

Quiz 1: Changes in Health

A nurse is assessing a client who gave birth twelve hours ago. On assessment, the nurse notes that the client's fundus is above the umbilicus to the right. Which of the following is the nurse's initial action?

A client at 32 weeks gestation chokes on her food and becomes unconscious. The nurse's immediate action is to:

A nurse is caring for an eighty-year-old client who is visually impaired. The nurse would take which of the following actions to reduce sensory deprivation?

A nurse is caring for a postpartum client. Which of the following would be the earliest sign of excessive blood loss?

An adult client is diagnosed with chronic renal failure. Which of the following nursing interventions is most appropriate?

A nurse is assessing a six-month-old child. On assessment, noting of which of the following findings should alert the nurse to a possible problem?

A nurse notes that the site of the client's intravenous catheter is slightly edematous and cool. Blood return is not observed upon lowering the IV fluid below the IV site. Which of the following nursing actions is not appropriate for this client?

A client is found unresponsive on the floor. On assessment, the nurse notes that the client is not breathing and is pulseless. After activating the medical resuscitation team, what is the next nursing action?

A client with pregnancy-induced hypertension is given magnesium sulfate. Which finding, during assessment, should alert the nurse?

A client comes to the emergency department complaining of dyspnea and has a respiratory rate of 30 breaths per minute. The client receives a diagnosis of pneumonia. Which of the following is the initial action of the nurse?

A client with persistent cough is complaining of severe pain when coughing. The nurse would instruct the client to do which of the following comfort measures?