Rest of Review Questions

Question 1

A client exposed to Mycobacterium tuberculosis starts on chemoprophylaxis. The nurse provides what instruction to the client?

1. “You will take a single drug such as isoniazid (INH) by mouth every day for 6 to 12 months.”
2. “You will be on at least two drugs effective against the tubercle bacillus for three months.”
3. “You will be on combination therapy in order to prevent development of drug resistance.”
4. “You will need to learn to give yourself subcutaneous injections.”

Answer 1

1. “You will take a single drug such as isoniazid (INH) by mouth every day for 6-12 months

To prevent active TB after exposure, the client is initiated on a single agent regimen, usually isoniazid.

[The critical word is “exposed” & “chemoprophylaxis”. Recall that if active infection requires multi-drug therapy, exposure can be managed with a single agent alone.]

Question 2

The nurse delegates an unlicensed assistive person (UAP) to assist a client with a clean urinary catheterization procedure. The client had formerly been able to do the procedure but because of arthritis, he has been unable to perform the catheterization. Although the UAP has done this procedure before, which of the following must the nurse emphasize to the UAP?

1. Let the client do most of the procedure and report the expected output.
2. Report immediately any unusual observations, such as bleeding.
3. Complete in proper order the steps of the procedure.
4. Perform health teaching while performing the procedure.

Answer 2

2. Report immediately any unusual observations, such as bleeding.

The nurse ensures that the UAP understands the importance of reporting immediately any difficulties during the procedure such as bleeding. This provides for safe and effective care.

[The core issue of the question is the appropriate procedure for the nurse to use when delegating care to a UAP. Eliminate option 4 first because it is the role of the nurse. Eliminate options 1 & 3 next, because they are not indicated or unnecessary, respectively.

Question 3

The client is in the operating room for a surgical procedure. The nurse in the operating room is monitoring the physiological integrity of the client. Which of the following activities is most appropriate?

1. Determine client satisfaction with care received.
2. Assess client’s emotional status.
3. Monitor asepsis in the environment.
4. Calculate fluid loss and its effects.

Answer 3

4. Calculate fluid loss and its effects.

Only option 4 relates to the client’s physiological integrity. Options 1 and 2 pertain to the psychological aspects of client care, while option 3 relates to the safety in the environment.

[The core issue of the question is knowledge of physiological assessment priorities in the perioperative client. Fluid los directly related to cardiovascular status, which is one of the ABCs. Use nursing knowledge and the process of elimination to make a selection.

Question 4

The clinic nurse is conducting health screenings. Which of the following client assessment findings indicates that client teaching is needed about the risk for stroke? Select all that apply.

1. Weight 205 lbs and height 5 feet 4 inches
2. Blood pressure 164/92 mmHg
3. Eats bran for breakfast daily
4. Smokes 1/2 pack cigarettes per day
5. Serum cholesterol level is 172 mg/dL

Answer 4

1. Weight 205 lbs and height 5 feet 4 inches
2. Blood pressure 164/92 mmHg
3. Smokes 1/2 pack cigarettes per day

Obesity, hypertension, and smoking are modifiable risk factors for stroke. Hypercholesterolemia (cholesterol level greater than 200 mg) would also be a risk factor, but this client’s level is less than 200 mg/dL. Eating a diet containing fiber helps keep cholesterol levels low and is not a risk factor for stroke.

[The core issue of the question is knowledge of risk factors for stroke. Recall that these are similar to the risk factors for cardiac disease to help make your selections]

Question 5

Which of the following actions would the nurse take to maintain medical asepsis when caring for a client with diabetes mellitus on the medical nursing unit who requires irrigation of a leg ulcer and insulin injections? Select all that apply.

1. Wash hands before and after client care.
2. Wear personal protective equipment during the dressing change.
3. Recap a needle after administering insulin.
4. Change the dressing for a diabetic ulcer using sterile gloves.
5. Wipe the rubber stopper on the insulin vial before withdrawing dose.

Answer 5

1. Wash hands before and after client care.
2. Wear personal protective equipment during the dressing change.
3. Wipe the rubber stopper on the insulin vial before withdrawing dose.

1,2,5 are core principles of medical asepsis. 3 violates principles of medical asepsis. 4 uses principles of surgical asepsis.

[Use knowledge of medical vs surgical asepsis as essential core concepts. Eliminate options that utilize surgical asepsis or are unrelated to the needs of the client]

Question 6

Laboratory test results indicate a client is in the nadir period that follows administration of a chemotherapy drug. Which drug should the nurse avoid administering to this client at this time?

1. Acetaminophen (Tylenol)
2. Ibuprofen (Motrin)
3. Diphenhydramine (Benadryl)
4. Guanefesin (Robitussin)

Answer 6

2. Ibuprofen (Motrin)

RBC, WBC, and platelet counts may be decreased during the nadir period following administration of chemotherapy that has hematological toxicity. Medications that inhibit platelet aggregation should be avoided during the nadir period following antineoplastic therapy such as Aspirin, ibuprofen, and indomethacin.

[The core issue of the questions is the ability to determine which drugs could increase the risk of bleeding when a client’s blood counts may be low. Use the process of elimination and knowledge of drug actions and adverse effects to make a selection]

Question 7

The newborn nursery has recently formed a unit policy and procedure committee. The nurse, while attending and participating in the meetings, determines that which nurse exemplifies a situational leader?

1. The nurse who offers suggestions, asks questions, and guides the group toward achieving group goals.
2. The nurse who recognizes the group’s need for autonomy and abdicates responsibility.
3. The nurse who relies on the organization’s rules, policies, and procedures to direct the group’s work.
4. The nurse who recognizes that leadership style depends on the readiness and willingness of the group or the individuals to perform the assigned tasks.

Answer 7

4. The nurse who recognizes that leadership style depends on the readiness and willingness of the group or the individuals to perform the assigned tasks.

A situational leader recognizes that leadership style depends on the readiness and willingness of the group or the individuals to perform the assigned tasks. The democratic or participative leader offers suggestions, asks questions, and guides the group toward achieving the group goals. The laissez-faire leader recognizes the group’s need for autonomy and abdicates responsibility. A bureaucratic leader relies on the organization’s rules, policies, and procedures to direct the group’s work.

[The core issue of the question is knowledge of various leadership styles. Use this knowledge and the process of elimination to make a selection]

Question 8

The nurse places highest priority on taking which of the following actions to reduce the spread of microorganisms when caring for a client at risk for infection?

1. Wash hands before and after client care.
2. Use clean gloves when implementing client care.
3. Institute transmission-based precautions.
4. Place the client in a private room.

Answer 8

1. Wash hands before and after client care.

Question 9

The nurse would report to the physician which of the following abnormal laboratory values for a 58-year-old client newly admitted to the nursing unit with fever and diarrhea? Select all that apply.

1. White blood cell count 12,260/mm3
2. Sodium 142 mEq/L
3. Potassium 3.9 mEq/L
4. Blood urea nitrogen 38 mg/dL
5. Serum creatinine 0.9 mg/dL

Answer 9

1. White blood cell count 12,260/mm3
2. Blood urea nitrogen 38 mg/dL

WBC (5,000 - 10,000) & BUN (0.8-22) are elevated. These changes would be expected with infection and possibly accompanying dehydration from diarrhea.

Question 10

The mental health nurse working with children anticipates that unrealistic expectations or a sense of failure to meet standards would cause a 10-year-old child to develop a sense of which of the following?

1. Shame
2. Guilt
3. Inferiority
4. Role confusion

Answer 10

3. Inferiority

According to Erikson’s stages of development, a 10 yr old child is experiencing industry vs inferiority.

[Need the ability to anticipate levels of growth & development in a 10 yr old child. Use knowledge of Erikson’s theory to make a selection]

Question 11

A postoperative client who has an order for 5,000 units of heparin SubQ for three doses wants to know why this drug is being ordered. What information would the nurse provide to the client to best answer the question?

1. “Heparin is used as a common medication in many clients who have surgery.”
2. “Heparin is essential during the postoperative period to maintain adequate blood clotting levels.”
3. “The injections will be given in the abdomen and are not usually associated with discomfort.”
4. “Heparin is being used to prevent blood clots from forming as a result of surgery or decreased mobility.”

Answer 11

4. “Heparin is being used to prevent blood clots from forming as a result of surgery or decreased mobility.”

Question 12

The Emergency Department has recently experienced a significant increase in client visits. The year-to-date census reveals a 20% increase in admission from the same period last year. In an effort to reduce staff stress and burnout by empowering the staff, the nurse manager uses which of the following approaches to demonstrate shared leadership?

1. Encourages the formation of self-directed work teams.
2. Encourages the group to try out nursing approaches that are evidence-based.
3. Suggests that staff who have demonstrated charting excellence be given opportunities for professional development activities.
4. Provides constructive criticism and facilitates the group to meet their goals.

Answer 12

1. Encourages the formation of self-directed work teams.

Shared leadership recognizes that there are many leaders within a group so the leader encourages the formation of self-directed work teams. In transformational leadership, the leader encourages risk taking such as trying out nursing approaches that are evidence based or research based. A transactional leader uses incentives to promote productivity such as giving rewards for excellent performance. A democratic leader provides constructive criticism and facilitates the group to meet their goals.

Question 13

A 56-year-old client reports to the nurse that his sleep patterns are different than when he was younger. The nurse anticipates that this client is likely to be experiencing which normal developmental pattern?

1. 6 to 8 hours of sleep per night with about 20 to 25% of rapid eye movement (REM) sleep and a marked decrease in Stage IV non-REM (NREM) sleep.
2. 6 to 8 hours of sleep per night with about 20% REM sleep and a decrease in Stage IV NREM sleep.
3. Erratic sleep because of work schedule with about 30% of REM sleep and no marked decrease in Stage IV NREM sleep.
4. Light sleep with equal amounts of REM sleep and NREM sleep.

Answer 13

2. 6 to 8 hours of sleep per night with about 20% REM sleep and a decrease in Stage IV NREM sleep.

Middle-aged adults have a decrease in deep sleep, stage IV NREM. 1 is an expected pattern in older adults. 3 is expected in young adults & 4 is expected in neonates.

[Knowledge of age-related changes in sleep pattern]

Question 14

The nurse concludes that teaching has been effective when the laboring client’s partner shouts, “She’s crowning!” as:

1. The nurse first starts to see a little of the baby’s head.
2. The baby’s head recedes upward between pushing contractions.
3. The perineum is thin and stretching around the occiput.
4. The mouth and nose are being suctioned.

Answer 14

3. The perineum is thin and stretching around the occiput.

Question 15

A client questions the surgical nurse about the personnel in the operating room. Which of the following initial responses by a nurse to the client’s concern is most therapeutic?

1. “The nurses are well-qualified for the job they do.”
2. “Have you had a bad experience in the OR?”
3. “You’re concerned about the personnel, but you have no need to worry.”
4. “Can you tell me about why you are interested in the personnel?”

Answer 15

4. “Can you tell me about why you are interested in the personnel?”

Option 4 gives the client an opportunity to explain to the nurse the reason for asking the question. This helps the nurse understand the client’s frame of reference and allows the nurse to best address the client’s concern. Options 1 and 3 offer false reassurance and can give the impression that the nurse did not listen to or address the client’s concerns. Option 2 is a close-ended question and may not help the nurse explore the client’s concerns.

[The core issue of the question is knowledge of communication techniques that are effective when working with a client who will undergo surgery. Use knowledge of communication theory and the process of elimination to make a selection.]