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 1
Simulated Exam
1.
 
Which plan would be the highest priority for a client with a hemoglobin -10%; RBC
-4.5
million/mm
3
; and WBC -3.5 million/mm
3
?a.
 
Implement bleeding precautions.b.
 
Implement neutropenic precautions.c.
 
Provide periods of rest.d.
 
Recommend a diet high in iron.
Option #2 is correct. The WBCs are 5-10 million/mm
3
.With this report, there is an increased risk for infectionmandating the need to implement neutropenic precautions. Options #1, #3, and #4 are not a priority for this
client.2.
 
Which of these statements indicate the client understands how to safely take St. John's Wort?a.
 
"I will not drink milk while taking this herb."b.
 
"I will use sunscreen when going out in the sun."c.
 
"I will have my blood pressure monitored weekly."d.
 
"I will report a problem with a sore throat."
Option #2 is correct. St. John's Wort can cause problems with photosensitivity. It is also important to inform clientregarding the importance of sun protection when taking other medications that create a problem withphotosensitivity (i.e., tetracycline, sulfonamides, antipsychotics). Options #1 and #3 are not necessary for this herb.While it is always important to be aware of a sort throat (Option #4), this assessment would be more of a priority fora client who was taking a medication that caused agranulocytosis.
3.
 
A 3-year-old child presents with a T -102.3, P -180, R -58, with suprastemal retracting, drooling, and a croupycough. What would be the priority plan of care?a.
 
Begin the ordered antibiotic.b.
 
Start an IV in the left arm.c.
 
Evaluate the oral pharyngeal area for obstruction.d.
 
Place child in the Fowler's position.
Option #4 is correct. With this clinical presentation, an X-ray would show an enlarged epiglottis. While it would beimportant to start an antibiotic and IV (Options #1 and #2), it would not be the priority over the positioning because if child is in the supine position, airway obstruction can occur. It will take a few minutes to get the IV started. Option #3is never done due to the risk of a laryngeal spasm resulting in airway obstruction.
4.
 
After the nurse observes an absent patellar reflex, a decrease in the respirations, and a decrease in the urineoutput, what would be the priority nursing care for an obstetrical client who is receiving magnesium sulfate forpre-eclampsia?a.
 
Administer calcium gluconate.b.
 
Evaluate the magnesium level.c.
 
Implement respiratory resuscitation.d.
 
Administer Narcan.
Option #1 is correct. The client is experiencing magnesium sulfate toxicity. The antidote is calcium gluconate. Option#2 is incorrect because the assessments indicate a problem with the level. Option #3 is incorrect because therespirations have only decreased: they have not stopped. Option #4 is an incorrect antidote for magnesium sulfate
.5.
 
During the hospital delivery of a neonate, which intervention would be a priority?a.
 
Provide the mother with emotional support.b.
 
Maintain the mothers comfort.c.
 
Prepare the sterile field.d.
 
Monitor the fetal heart rate.
The physiological state of the neonate is the priority intervention to optimize neonatal safety. Options #1, #2, and #3are important to include in the plan. It is important to prioritize safety of care.
6.
 
A newborn is brought into the nursery for an initial assessment. What precautions are taken when weighingthe/infant?a.
 
Clean the scale with alcohol before and after the infant is weighed.b.
 
Weigh the infant with the diaper on; then calculate the weight of the diaper.c.
 
Place a cloth diaper or towel over the scale before placing the infant on the scale.d.
 
Place a waterproof barrier over the scale prior to weighing the infant.
 
 2
Since the infant has not been bathed, he is still covered with amniotic fluids and secretions. There needs to be sometype of water proof barrier on the scale. Options #1, #2, and #3, cleaning the scale with alcohol, or placing a towelover the scale, do not prevent fluids from coming in contact with the scale.
7.
 
While performing CPR, the initial assessment would be the:a.
 
cause of the arrest.b.
 
unresponsiveness of the client.c.
 
age of the client.d.
 
presence of the brachial pulse.
Based on the American Heart Associations criteria, the initial assessment is to establish unresponsiveness. Options #1and #3 are insignificant during the crisis. Option #4 is incorrect because the carotid pulse is most important, thoughnot the first assessment made
.8.
 
A nurse observes another nurse contaminate a Foley catheter. An appropriate nursing action would be to:a.
 
report the incident to the supervisor.b.
 
clean the catheter with Betadine and continue with procedure.c.
 
ignore the incident.d.
 
offer to assist and get another sterile catheter.
This is being a client advocate. The observed nurse may need some assistance, and this would be an excellentopportunity to provide education regarding this procedure. Options #1 and #3 do not address the problem. Option #2is unsafe practice and can lead to infection.
9.
 
While evaluating breath sounds of a client who is nasally intubated and on the ventilator, the nurse assessesdiminished and questionable asymmetrical sounds. Which nursing action has the highest priority?a.
 
Immediately notify physician regarding a pneumothorax.b.
 
Evaluate the nasal endotracheal tube placement with a chest X-ray.c.
 
Pull endotracheal tube back approximately 1/2 cm and retape.d.
 
Manually ventilate client with ambu and auscultate breath sounds.
This is the priority. Always evaluate the client further because the ventilator may be malfunctioning. After thisevaluation, the nurse would proceed with the data. Options #1, #2, and #3 are not initial priorities.
10.
 
Which intervention would be a priority for the infant having apnea?a.
 
Call a code blue.b.
 
Physically stimulate the infant to breathe.c.
 
Immediately start CPR.d.
 
Administer naloxone (Narcan).
It is normal for infants to experience short periods of apnea (10 seconds or less). Stimulating the infant may besufficient to get the infant to breathe. Options #1, #3 and #4 may have to come later.
11.
 
The nurse observes a run of 6 premature ventricular beats on a clients ECG monitor. The nurse should:a.
 
cardiovert the client.b.
 
elevate the head of the bed.c.
 
administer IV Lidocaine as orderedd.
 
administer IV epinephrine as ordered.
Lidocaine hydrochloride is a sodium channel blocker. It suppresses the depolarization of the ventricles. Options #1, #2,and #4 are inappropriate.
12.
 
In evaluating the effectiveness of teaching a client with a permanent-demand pacemaker, the client should statethat feelings of fainting, dizziness, and a slow irregular pulse most likely indicate:a.
 
failure of the pacemaker battery.b.
 
competition between the heart and the pacemaker.c.
 
occurrence of pericardial tamponade.d.
 
a rejection of the foreign body.
Battery failure will cause the pacemaker to be inoperable. The client may experience a heart block, or the signspresented in this situation. Pacing spikes will not occur if the pacemaker is not firing. Options #2, #3, and #4 areincorrect.
13.
 
At birth a newborn delivered by C-section is depressed and at 1 minute has not begun spontaneous respirationsdue to copious secretions. The priority nursing intervention would be to:a.
 
intubate the newborn.b.
 
initiate CPR.
 
 3c.
 
administer naloxone (Narcan).d.
 
suction the airway.
This is the priority intervention for a newborn not breathing. Ventilation may be prevented by an obstructed airway.Options #1 and #2 are not a priority until Option #4 is implemented. Option #3 is incorrect because there was nodocumentation that the respirations were depressed due to medication.
14.
 
The nurse indicates she has an appropriate understanding of prioritizing her workload when she implementswhich clients plan of care first?a.
 
A 7-year-old in a sickle cell crisis.b.
 
An 8-year-old admitted for shunt revision.c.
 
A 17-year-old with a fractured femur.d.
 
A 20-year-old with pelvic inflammatory disease.
The sickle cell crisis would be a priority due to the need to start IV fluids for hydration purposes. The hypoxia must becorrected immediately with IV fluids and oxygen. Option #2 would only be a preparation prior to surgery. Options #3and #4 are important but not priorities to Option # 1.
15.
 
Before beginning oxygen on a client with COPD, it is important to confirm an oxygen flow rate of:a.
 
2 liters per minute.b.
 
5 liters per minute.c.
 
6 liters per minute.d.
 
9 liters per minute.
Oxygen must be administered in low concentrations to maintain the stimulus to breathe. Increased oxygen levelsdecrease the stimulation to breathe which will result in CO
2
narcosis. Options #2, #3, and #4 are settings that are toohigh.
16.
 
Which parameter most affects the accuracy of a measurement made on a pulse oximeter?a.
 
Hypothermia.b.
 
Irritability.c.
 
Oxygen intake.d.
 
Digit used.
Hypothermia may result in vasoconstriction which will not provide an accurate reading. It is important to keep thedigit and extremity warm. Though irritability will increase the oxygen demand. Option #2 is incorrect because thereading will remain accurate. Option #3 is incorrect because it is the parameter that is being evaluated. Option #4 isinsignificant as long as the digit and extremity are kept warm.
17.
 
Which statement indicates a client has an understanding of postoperative management of a hip repair?a.
 
"I will be sitting in a chair dangling my legs within 24 hours."b.
 
"I will maintain my affected leg in the adducted position."c.
 
"I will need to remain flat on my back for 2 days."d.
 
"I will not be able to flex my hip greater than 90 degrees."
Do not allow the hip to ilex greater than 90 degrees and avoid adduction and internal rotation of the extremity.Options #1, #2, and #3 could cause the hip prosthesis to be dislocated.
18.
 
After a spontaneous delivery of a newborn, the nurse assesses the client's fundus. Which assessment indicatesthe nursing intervention was effective?a.
 
Client is participating in her own care.b.
 
Fundus remains 2 to 3 cm below the umbilicus.c.
 
Client has no complaints of discomfort.d.
 
Client-experiences minimal Ioss of-vaginal blood.
Frequent evaluation of the fundus, along with massaging, facilitates contraction of the uterus which minimizes bloodloss through the vessels at the placental site. Options #1 and #3 are good but not as effective. Option #2 is incorrectbecause the fundus should recede daily.
19.
 
On the fourth postoperative day after GI surgery, the nurse assesses a client shaking, diaphoretic, with atemperature of 103.6°F. The physician is called for antibiotic orders. The most important assessment the nursewould want now is:a.
 
clients weightb.
 
vital signsc.
 
blood and urine culturesd.
 
neurological evaluation.
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