Sample Questions PNLE
FUNDA PART I 1.
The parents of a 5-month old baby and a 3-year old child ask the nurse about the sequence and the timing of developmental milestones. Which of the following is the most appropriate response? A. “This infant should reach the milestones at the same time as your older child.” B. “The infant may reach the milestones in a different order than your older child.” C. “The sequence of reaching each milestone should follow the same pattern but may be at a different rate.” D. “There are no predictable patterns. Try to enjoy the uniqueness of every child. 2. A nurse decides that a review of which of the following theorists would be helpful before teaching a preschool class (4-5 years old) about how to brush their teeth? A. Fowler B. Erickson C. Gould D. Peck 3. Parents ask the nurse how they will know that their daughter has reached puberty. The best response includes which of the following? A. “The first noticeable sign of puberty is appearance of breasts bud.” B. “The growth spurt usually begins between ages 10-14.” C. “The apocrine glands, found over most of the body, begin to produce sweat.” D. “The adolescent will display significant mood swings.” 4. During the physical assessment of a 24-month old baby clings to the parent and cries everytime the nurse touch her. From the knowledge of Psychosocial Development, the nurse knows that this: A. Is normal in Toddler development B. Child needs further psychological evaluation C. Child is manipulative and should be taken from the parent to examined D. Is normal behavior for a 12-month old, but this child is too old for this action and is showing signs of regression 5. Because a 45-year old woman is still worried that she still has regular menstruation, she asks about menopause. Which of the following answers by the nurse is most appropriate? A. Regular menses in a 45-year old woman should be promptly evaluated by gynecologists. B. Although you continue to have menstrual periods, you are unlikely to become pregnant. C. It is common for women to experience menopause in their late 40’s D. Many women dread menopause because it is an unpleasant experience 6. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means: a. Pulse rate greater than 100 beats per minute b. Blood pressure of 140/90 c. Respiratory rate greater than 20 breaths per minute d. Frequent bowel sounds 7. The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse documents this as: a. Wheezes
b. Rhonchi c. Gurgles d. Vesicular 8. Which approach to problem solving tests any number of solutions until one is found that works for that particular problem? a. Intuition b. Routine c. Scientific method d. Trial and error 9. What is the order of the nursing process? a. Assessing, diagnosing, implementing, evaluating, planning b. Diagnosing, assessing, planning, implementing, evaluating c. Assessing, diagnosing, planning, implementing, evaluating d. Planning, evaluating, diagnosing, assessing, implementing 10. During the planning phase of the nursing process, which of the following is the outcome? a. Nursing history b. Nursing notes c. Nursing care plan d. Nursing diagnosis 11. What is an example of a subjective data? a. Heart rate of 68 beats per minute b. Yellowish sputum c. Client verbalized, “I feel pain when urinating.” d. Noisy breathing 12. Which expected outcome is correctly written? a. “The patient will feel less nauseated in 24 hours.” b. “The patient will eat the right amount of food daily.” c. “The patient will identify all the high-salt food from a prepared list by discharge.” d. “The patient will have enough sleep.” 13. The theorist who believes that adaptation and manipulation of stressors are related to foster change is: a. Dorothea Orem b. Sister Callista Roy c. Imogene King d. Virginia Henderson 14. Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response? a. Low blood pressure b. Warm, dry skin c. Decreased serum sodium levels d. Decreased urine output 15. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection? a. Use sterile gloves when obtaining urine. b. Open the drainage bag and pour out the urine. c. Disconnect the catheter from the tubing and get urine. d. Aspirate urine from the tubing port using a sterile syringe. 16. A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and swollen. Which of the following interventions would the nurse perform first? a. Stop the infusion b. Call the attending physician c. Slow that infusion to 20 ml/hr d. Place a clod towel on the site 17. The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do? a. Leave the medication at the bedside and leave the room. b. After few minutes, return to that patient’s room and do not leave until the patient takes the medication. c. Instruct the patient to take the medication and leave it at the bedside.
d. Wait for the patient to return to bed and just leave the medication at the bedside. 18. Which of the following is inappropriate nursing action when administering NGT feeding? a. Place the feeding 20 inches above the pint if insertion of NGT. b. Introduce the feeding slowly. c. Instill 60ml of water into the NGT after feeding. d. Assist the patient in fowler’s position. 19. A female patient is being discharged after thyroidectomy. After providing the medication teaching. The nurse asks the patient to repeat the instructions. The nurse is performing which professional role? a. Manager b. Caregiver c. Patient advocate d. Educator 20. Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia? a. Oriented to date, time and place b. Clear breath sounds c. Capillary refill greater than 3 seconds and buccal cyanosis d. Hemoglobin of 13 g/dl 21. During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient? a. That the patient verbalized, “My headache is gone.” b. That the patient’s barium enema performed 3 days ago was negative c. Patient’s NGT was removed 2 hours ago d. Patient’s family came for a visit this morning. 22. Which statement is the most appropriate goal for a nursing diagnosis of diarrhea? a. “The patient will experience decreased frequency of bowel elimination.” b. “The patient will take anti-diarrheal medication.” c. “The patient will give a stool specimen for laboratory examinations.” d. “The patient will save urine for inspection by the nurse. 23. Which of the following is the most important purpose of planning care with this patient? a. Development of a standardized NCP. b. Expansion of the current taxonomy of nursing diagnosis c. Making of individualized patient care d. Incorporation of both nursing and medical diagnoses in patient care 24. Using Maslow’s hierarchy of basic human needs, which of the following nursing diagnoses has the highest priority? a. Ineffective breathing pattern related to pain, as evidenced by shortness of breath. b. Anxiety related to impending surgery, as evidenced by insomnia. c. Risk of injury related to autoimmune dysfunction d. Impaired verbal communication related to tracheostomy, as evidenced by inability to speak. 25. When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position? a. 30 degrees b. 90 degrees c. 45 degrees d. 0 degree
ANSWER KEY: 1. C. Toddlers typically demonstrate negative behavior and are hesitant around strangers, resisting close contact with people they do not know well. 2. B. Erickson’s late childhood stage focuses on Initiative Vs. Guilt 3. A. Although the appearance of the hair in the labia may precede this. 4. A. Although the toddlers like to explore the environment, they always need to have a significant person nearby. Parents need to know that the child experiences acute separation anxiety and that abandonment is their greatest fear. 5. C. The average age for the onset of menopause in American women is 47 years old. 6. (C) Respiratory rate greater than 20 breaths per minute A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds. 7. (A) Wheezes Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration. 8. (D) Trial and error The trial and error method of problem solving isn’t systematic (as in the scientific method of problem solving) routine, or based on inner prompting (as in the intuitive method of problem solving). 9. (C) Assessing, diagnosing, planning, implementing, evaluating The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating. 10. (C) Nursing care plan The outcome, or the product of the planning phase of the nursing process is a Nursing care plan. 11. (C) Client verbalized, “I feel pain when urinating.” Subjective data are those that can be described only by the person experiencing it. Therefore, only the patient can describe or verify whether he is experiencing pain or not. 12. (C) “The patient will identify all the high-salt food from a prepared list by discharge.” Expected outcomes are specific, measurable, realistic statements of goal attainment. The phrases “right amount”, “less nauseated” and “enough sleep” are vague and not measurable. 13. (B) Sister Callista Roy Sister Roy’s theory is called the adaptation theory and she viewed each person as a unified biophysical system in constant interaction with a changing environment. Orem’s theory is called self-care deficit theory and is based on the belief that individual has a need for self-care actions. King’s theory is the Goal attainment theory and described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. Henderson introduced the nature of nursing model and identified the 14 basic needs. 14. (D) Decreased urine output Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output. 15. (D) Aspirate urine from the tubing port using a sterile syringe. The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection. 16. (A) Stop the infusion The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site.
17. (B) After few minutes, return to that patient’s room and do not leave until the patient takes the medication This is to verify or to make sure that the medication was taken by the patient as directed 18. (A) Place the feeding 20 inches above the pint if insertion of NGT. The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting. 19. (D) Educator When teaching a patient about medications before discharge, the nurse is acting as an educator. A caregiver provides direct care to the patient. The nurse acts as s patient advocate when making the patient’s wishes known to the doctor. 20. (C) Capillary refill greater than 3 seconds and buccal cyanosis Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13 g/dl are normal data. 21. (C) Patient’s NGT was removed 2 hours ago The change-of-shift report should indicate significant recent changes in the patient’s condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report. 22. (A) “The patient will experience decreased frequency of bowel elimination.” The goal is the opposite, healthy response of the problem statement of the nursing diagnosis. In this situation, the problem statement is diarrhea. 23. (C) Making of individualized patient care To be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient. 24. (A) Ineffective breathing pattern related to pain, as evidenced by shortness of breath. Physiologic needs (ex. Oxygen, fluids, nutrition) must be met before lower needs (such as safety and security, love and belongingness, self-esteem and self-actualization) can be met. Therefore, physiologic needs have the highest priority. 25. (D) 0 degree The patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings
FUNDA PART II 1. A patient is wearing a soft wrist-safety device. Which of the following nursing assessment is considered abnormal? a. Palpable radial pulse b. Palpable ulnar pulse c. Capillary refill within 3 seconds d. Bluish fingernails, cool and pale fingers 2. Pia’s serum sodium level is 150 mEq/L. Which of the following food items does the nurse instruct Pia to avoid? a. broccoli b. sardines c. cabbage d. tomatoes 3. Jason, 3 years old vomited. His mom stated, “He vomited 6 ounces of his formula this morning.” This statement is an example of: a. objective data from a secondary source b. objective data from a primary source c. subjective data from a primary source d. subjective data from a secondary source 4. Which of the following is a nursing diagnosis? a. Hypethermia b. Diabetes Mellitus c. Angina d. Chronic Renal Failure 5. What is the characteristic of the nursing process? a. stagnant b. inflexible c. asystematic d. goal-oriented 6. A skin lesion which is fluid-filled, less than 1 cm in size is called: a. papule b. vesicle c. bulla d. macule 7. During application of medication into the ear, which of the following is inappropriate nursing action? a. In an adult, pull the pinna upward. b. Instill the medication directly into the tympanic membrane. c. Warm the medication at room or body temperature. d. Press the tragus of the ear a few times to assist flow of medication into the ear canal. 8. Which of the following is appropriate nursing intervention for a client who is grieving over the death of her child? a. Tell her not to cry and it will be better. b. Provide opportunity to the client to tell their story. c. Encourage her to accept or to replace the lost person. d. Discourage the client in expressing her emotions. 9. It is the gradual decrease of the body’s temperature after death. a. livor mortis b. rigor mortis c. algor mortis d. none of the above 10. When performing an admission assessment on a newly admitted patient, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ? a. thigh b. liver c. intestine d. lung 11. The nurse is aware that Bell’s palsy affects which cranial nerve? a. 2nd CN (Optic) b. 3rd CN (Occulomotor)
c. 4th CN (Trochlear) d. 7th CN (Facial) 12. Prolonged deficiency of Vitamin B9 leads to: a. scurvy b. pellagra c. megaloblastic anemia d. pernicious anemia 13. Nurse Cherry is teaching a 72 year old patient about a newly prescribed medication. What could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medication? a. Absence of family support b. Decreased sensory functions c. Patient has no interest on learning d. Decreased plasma drug levels 14. When assessing a patient’s level of consciousness, which type of nursing intervention is the nurse performing? a. Independent b. Dependent c. Collaborative d. Professional 15. Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the patient has had pain for more than: a. 3 months b. 6 months c. 9 months d. 1 year 16. Which of the following statements regarding the nursing process is true? a. It is useful on outpatient settings. b. It progresses in separate, unrelated steps. c. It focuses on the patient, not the nurse. d. It provides the solution to all patient health problems. 17. Which of the following is considered significant enough to require immediate communication to another member of the health care team? a. Weight loss of 3 lbs in a 120 lb female patient. b. Diminished breath sounds in patient with previously normal breath sounds c. Patient stated, “I feel less nauseated.” d. Change of heart rate from 70 to 83 beats per minute 18. To assess the adequacy of food intake, which of the following assessment parameters is best used? a. food preferences b. regularity of meal times c. 3-day diet recall d. eating style and habits 19. Van Fajardo is a 55 year old who was admitted to the hospital with newly diagnosed hepatitis. The nurse is doing a patient teaching with Mr. Fajardo. What kind of role does the nurse assume? a. talker b. teacher c. thinker d. doer 20. When providing a continuous enteral feeding, which of the following action is essential for the nurse to do? a. Place the client on the left side of the bed. b. Attach the feeding bag to the current tubing. c. Elevate the head of the bed. d. Cold the formula before administering it. 21. Kussmaul’s breathing is; a. Shallow breaths interrupted by apnea. b. Prolonged gasping inspiration followed by a very short, usually inefficient expiration.
c. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea. d. Increased rate and depth of respiration. 22. Presty has terminal cancer and she refuses to believe that loss is happening ans she assumes artificial cheerfulness. What stage of grieving is she in? a. depression b. bargaining c. denial d. acceptance 23. Immunization for healthy babies and preschool children is an example of what level of preventive health care? a. Primary b. Secondary c. Tertiary d. Curative 24. Which is an example of a subjective data? a. Temperature of 38 0C b. Vomiting for 3 days c. Productive cough d. Patient stated, “My arms still hurt.” 25. The nurse is assessing the endocrine system. Which organ is part of the endocrine system? a. Heart b. Sinus c. Thyroid d. Thymus
ANSWER KEY: FUNDA PART II 1. (D) Bluish fingernails, cool and pale fingers A safety device on the wrist may impair blood circulation. Therefore, the nurse should assess the patient for signs of impaired circulation such as bluish fingernails, cool and pale fingers. Palpable radial and ulnar pulses, capillary refill within 3 seconds are all normal findings. 2. (B) sardines The normal serum sodium level is 135 to 145 mEq/L, the client is having hypernatremia. Pia should avoid food high in sodium like processed food. Broccoli, cabbage and tomatoes are good source of Vitamin C. 3. (A) objective data from a secondary source Jason is the primary source; his mother is a secondary source. The data is objective because it can be perceived by the senses, verified by another person observing the same patient, and tested against accepted standards or norms. 4. (A) Hypethermia Hyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are medical diagnoses. 5. (D) goal-oriented The nursing process is goal-oriented. It is also systematic, patientcentered, and dynamic. 6. (B) vesicle Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister, chicken pox). 7. (B) Instill the medication directly into the tympanic membrane. During the application of medication it is inappropriate to instill the medication directly into the tympanic membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal. 8. (B) Provide opportunity to the client to tell their story. Providing a grieving person an opportunity to tell their story allows the person to express feelings. This is therapeutic in assisting the client resolve grief. 9. (C) algor mortis Algor mortis is the decrease of the body’s temperature after death. Livor mortis is the discoloration of the skin after death. Rigor mortis is the stiffening of the body that occurs about 2-4 hours after death. 10. (D) lung Resonance is loud, low-pitched and long duration that’s heard most commonly over an air-filled tissue such as a normal lung. 11. (D) 7th CN (Facial) Bells’ palsy is the paralysis of the motor component of the 7th caranial nerve, resulting in facial sag, inability to close the eyelid or the mouth, drooling, flat nasolabial fold and loss of taste on the affected side of the face. 12. (C) megaloblastic anemia Prolonged Vitamin B9 deficiency will lead to megaloblastic anemia while pernicious anemia results in deficiency in Vitamin B12. Prolonged deficiency of Vitamin C leads to scurvy and Pellagra results in deficiency in Vitamin B3. 13. (B) Decreased sensory functions Decreased in sensory functions could cause a geriatric patient to have difficulty retaining knowledge about the newly prescribed medications. Absence of family support and no interest on learning may affect compliance, not knowledge retention. Decreased plasma levels do not alter patient’s knowledge about the drug. 14. (A) Independent Independent nursing interventions involve actions that nurses initiate based on their own knowledge and skills without the direction or supervision of another member of the health care team.
15. (B) 6 months Chronic pain s usually defined as pain lasting longer than 6 months. 16. (C) It focuses on the patient, not the nurse. The nursing process is patient-centered, not nurse-centered. It can be use in any setting, and the steps are related. The nursing process can’t solve all patient health problems. 17. (B) Diminished breath sounds in patient with previously normal breath sounds Diminished breath sound is a life threatening problem therefore it is highly priority because they pose the greatest threat to the patient’s well-being. 18. (C) 3-day diet recall 3-day diet recall is an example of dietary history. This is used to indicate the adequacy of food intake of the client 19. (B) teacher The nurse will assume the role of a teacher in this therapeutic relationship. The other roles are inappropriate in this situation. 20. (C) Elevate the head of the bed. Elevating the head of the bed during an enteral feeding prevents aspiration. The patient may be placed on the right side to prevent aspiration. Enteral feedings are given at room temperature to lessen GI distress. The enteral tubing should be changed every 24 hours to limit microbial growth. 21. (D) Increased rate and depth of respiration. Kussmaul breathing is also called as hyperventilation. Seen in metabolic acidosis and renal failure. Option A refers to Biot’s breathing. Option B is apneustic breathing and option C is the Cheyne-stokes breathing. 22. (C) denial The client is in denial stage because she is unready to face the reality that loss is happening and she assumes artificial cheerfulness. 23. (A) Primary The primary level focuses on health promotion. Secondary level focuses on health maintenance. Tertiary focuses on rehabilitation. There is n Curative level of preventive health care problems. 24. D) Patient stated, “My arms still hurt.” Subjective data are apparent only to the person affected and can or verified only by that person. 25. (C) Thyroid The thyroid is part of the endocrine system. Heart, sinus and thymus are not.
1. The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP). Which of the following task could the registered nurse safely assigned to a UAP? A) Monitor the I&O of a comatose toddler client with salicylate poisoning B) Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall C) Check the IV of a preschooler with Kawasaki disease D) Give an outmeal bath to an infant with eczema 2. A nurse manager assigned a registered nurse from telemetry unit to the pediatrics unit. There were three patients assigned to the RN. Which of the following patients should not be assigned to the floated nurse? A) A 9-year-old child diagnosed with rheumatic fever B) A young infant after pyloromyotomy C) A 4-year-old with VSD following cardiac catheterization D) A 5-month-old with Kawasaki disease 3. A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager safely assign to the float nurse? A) A child who had multiple injuries from a serious vehicle accident B) A child diagnosed with Kawasaki disease and with cardiac complications C) A child who has had a nephrectomy for Wilm’s tumor D) A child receiving an IV chelating therapy for lead poisoning 4. The registered nurse is planning to delegate task to a certified nursing assistant. Which of the following clients should not be assigned to a CAN? A) A client diagnosed with diabetes and who has an infected toe B) A client who had a CVA in the past two months C) A client with Chronic renal failure D) A client with chronic venous insufficiency 5. The nurse in the medication unit passes the medications for all the clients on the nursing unit. The head nurse is making rounds with the physician and coordinates clients’ activities with other departments. The nurse assistant changes the bed lines and answers call lights. A second nurse is assigned for changing wound dressings; a licensed practitioner nurse takes vital signs and bathes theclients. This illustrates of what method of nursing care? A) Case management method B) Primary nursing method C) Team method D) Functional method 6. A registered nurse has been assigned to six clients on the 12hour shift. The RN is responsible for every aspect of care such as formulating the care of plan, intervention and evaluating the care during her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. This nursing care illustrates of what kind of method? A) primary nursing method B) case method C) team method D) functional method 7. A newly hired nurse on an adult medicine unit with 3 months experience was asked to float to pediatrics. The nurse hesitates to perform pediatric skills and receive an interesting assignment that feels overwhelming. The nurse should: A) resign on the spot from the nursing position and apply for a position that does not require floating B) Inform the nursing supervisor and the charge nurse on the pediatric floor about the nurse’s lack of skill and feelings of hesitations and request assistance C) Ask several other nurses how they feel about pediatrics and find someone else who is willing to accept the assignment
D) Refuse the assignment and leave the unit requesting a vacation a day 8. An experienced nurse who voluntarily trained a less experienced nurse with the intention of enhancing the skills and knowledge and promoting professional advancement to the nurse is called a: A) mentor B) team leader C) case manager D) change agent 9. The pediatrics unit is understaffed and the nurse manager informs the nurses in the obstetrics unit that she is going to assign one nurse to float in the pediatric units. Which statement by the designated float nurse may put her job at risk? A) “I do not get along with one of the nurses on the pediatrics unit” B) “I have a vacation day coming and would like to take that now” C) “I do not feel competent to go and work on that area” D) “ I am afraid I will get the most serious clients in the unit” 10. The newly hired staff nurse has been working on a medical unit for 3 weeks. The nurse manager has posted the team leader assignments for the following week. The new staff knows that a major responsibility of the team leader is to: A) Provide care to the most acutely ill client on the team B) Know the condition and needs of all the patients on the team C) Document the assessments completed by the team members D) Supervise direct care by nursing assistants 11. A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. The nurse prepared the consent form and it should be signed by: A) The Physician B) The Registered Nurse caring for the client C) The 15-year-old mother of the baby boy D) The mother of the girl 12. A nurse caring to a client with Alzheimer’s disease overheard a family member say to the client, “if you pee one more time, I won’t give you any more food and drinks”. What initial action is best for the nurse to take? A) Take no action because it is the family member saying that to the client B) Talk to the family member and explain that what she/he has said is not appropriate for the client C) Give the family member the number for an Elder Abuse Hot line D) Document what the family member has said 13. Which is true about informed consent? A) A nurse may accept responsibility signing a consent form if the client is unable B) Obtaining consent is not the responsibility of the physician C) A physician will not subject himself to liability if he withholds any facts that are necessary to form the basis of an intelligent consent D) If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the signature is that of the purported person and that the person’s condition is as indicated at the time of signing 14. A mother in labor told the nurse that she was expecting that her baby has no chance to survive and expects that the baby will be born dead. The mother accepts the fate of the baby and informs the nurse that when the baby is born and requires resuscitation, the mother refuses any treatment to her baby and expresses hostility toward the nurse while the pediatric team is taking care of the baby. The nurse is legally obligated to:
A) Notify the pediatric team that the mother has refused resuscitation and any treatment for the baby and take the baby to the mother B) Get a court order making the baby a ward of the court C) Record the statement of the mother, notify the pediatric team, and observe carefully for signs of impaired bonding and neglect as a reasonable suspicion of child abuse D) Do nothing except record the mother’s statement in the medical record 15. The hospitalized client with a chronic cough is scheduled for bronchoscopy. The nurse is tasks to bring the informed consent document into the client’s room for a signature. The client asks the nurse for details of the procedure and demands an explanation why the process of informed consent is necessary. The nurse responds that informed consent means: A) The patient releases the physician from all responsibility for the procedure. B) The immediate family may make decision against the patient’s will. C) The physician must give the client or surrogates enough information to make health care judgments consistent with their values and goals. D) The patient agrees to a procedure ordered by the physician even if the client does not understand what the outcome will be. 16. A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an amputation. The client tells the nurse that he will not sign the consent form and he does not want any surgery or treatment because of religious beliefs about reincarnation. What is the role of the RN? A) call a family meeting B) discuss the religious beliefs with the physician C) encourage the client to have the surgery D) inform the client of other options 17. While in the hospital lobby, the RN overhears the three staff discussing the health condition of her client. What would be the appropriate nursing action for the RN to take? A) Tell them it is not appropriate to discuss the condition of the client B) Ignore them, because it is their right to discuss anything they want to C) Join in the conversation, giving them supportive input about the case of the client D) Report this incident to the nursing supervisor 18. A staff nurse has had a serious issue with her colleague. In this situation, it is best to: A) Discuss this with the supervisor B) Not discuss the issue with anyone. It will probably resolve itself C) Try to discuss with the colleague about the issue and resolve it when both are calmer D) Tell other members of the network what the team member did 19. The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose confidential information when: A) The nurse discusses the condition of the client in a clinical conference with other nurses B) The client asks the nurse to discuss the her condition with the family C) The father of a woman who just delivered a baby is on the phone to find out the sex of the baby D) A researcher from an institutionally approved research study reviews the medical record of a patient 20. A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes that consent has not been signed after preoperative medications were given. What should the nurse do?
A) Call the surgeon B) Ask the spouse to sign the consent C) Obtain a consent from the client as soon as possible D) Get a verbal consent from the parents of the client 21. A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be most correct in mixing it with: A) Normal Saline B) Heparinized normal saline C) 5% dextrose in water D) Lactated Ringer’s solution 22. The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should the nurse position the client? A) Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow B) Low Fowler’s with knees gatched at 30 degrees C) Supine with the head turned to the left D) Bed sloped at a 45 degree angle with the head lowest and the legs highest 23. The client is brought to the emergency department after a serious accident. What would be the initial nursing action of the nurse to the client? A) assess the level of consciousness and circulation B) check respirations, circulation, neurological response C) align the spine, check pupils, check for hemorrhage D) check respiration, stabilize spine, check circulation 24. A nurse is assigned to care to a client with Parkinson’s disease. What interventions are important if the nurse wants to improve nutrition and promote effective swallowing of the client? A) Eat solid food B) Give liquids with meals C) Feed the client D) Sit in an upright position to eat 25. During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements? A) limit suction pressure to 150-180 mmHg B) suction for 15-20 seconds C) wear eye goggles D) remove the inner cannula 26. The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of hypoglycemia should be taught to a client? A) warm, flushed skin B) hunger and thirst C) increase urinary output D) palpitation and weakness 27. A client admitted to the hospital and diagnosed with Addison’s disease. What would be the appropriate nursing action to the client? A) administering insulin-replacement therapy B) providing a low-sodium diet C) restricting fluids to 1500 ml/day D) reducing physical and emotional stress 28. The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is essential to prevent hypoxemia? A) aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning B) removing oral and nasal secretions C) encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions D) administering 100% oxygen to reduce the effects of airway obstruction during suctioning.
29. An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the swollen face resembling a handprint. The nurse does further assessment to the client. How would the nurse document the finding? A) Facial edema with ecchymosis and handprint mark: crackles and wheezes B) Facial edema, with red marks; crackles in the lung C) Facial edema with ecchymosis that looks like a handprint D) Red bruise mark and ecchymosis on face 30. On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which in the following clients should receive highest priority? A) an elderly woman complaining of a loss of appetite and fatigue for the past week B) A football player limping and complaining of pain and swelling in the right ankle C) A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw D) A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon 31. A 80-year-old female client is brought to the emergency department by her caregiver, on the nurse’s assessment; the following are the manifestations of the client: anorexia, cachexia and multiple bruises. What would be the best nursing intervention? A) check the laboratory data for serum albumin, hematocrit, and hemoglobin B) talk to the client about the caregiver and support system C) complete a police report on elder abuse D) complete a gastrointestinal and neurological assessment 32. The night shift nurse is making rounds. When the nurse enters a client’s room, the client is on the floor next to the bed. What would be the initial action of the nurse? A) chart that the patient fell B) call the physician C) chart that the client was found on the floor next to the bed D) fill out an incident report 33. The nurse on the night shift is about to administer medication to a preschooler client and notes that the child has no ID bracelet. The best way for the nurse to identify the client is to ask: A) The adult visiting, “The child’s name is ____________________?” B) The child, “Is your name____________?” C) Another staff nurse to identify this child D) The other children in the room what the child’s name is 34. The nurse caring to a client has completed the assessment. Which of the following will be considered to be the most accurate charting of a lump felt in the right breast? A) “abnormally felt area in the right breast, drainage noted” B) “hard nodular mass in right breast nipple” C) “firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’ D) “mass in the right breast 4cmx1cm 35. The physician instructed the nurse that intravenous pyelogram will be done to the client. The client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to: A) outline the kidney vasculature B) determine the size, shape, and placement of the kidneys C) test renal tubular function and the patency of the urinary tract D) measure renal blood flow 36. A client visits the clinic for screening of scoliosis. The nurse should ask the client to: A) bend all the way over and touch the toes B) stand up as straight and tall as possible C) bend over at a 90-degree angle from the waist D) bend over at a 45-degree angle from the waist
37. A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s family members come to visit, they would be adhering to respiratory isolation precautions when they: A) wash their hands when leaving B) put on gowns, gloves and masks C) avoid contact with the client’s roommate D) keep the client’s room door open 38. An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following would be the best nursing response of the nurse? A) “Your baby eats too rapidly and overfills the stomach, which causes vomiting B) “Your baby can’t empty the formula that is in the stomach into the bowel” C) “The vomiting is due to the nausea that accompanies pyloric stenosis” D) “Your baby needs to be burped more thoroughly after feeding” 39. A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of the test. Which of the following would be the best rationale for this? A) reactivation of an old tuberculosis infection B) increased incidence of new cases of tuberculosis in persons over 65 years old C) greater exposure to diverse health care workers D) respiratory problems are characteristic in this population 40. The nurse is making a health teaching to the parents of the client. In teaching parents how to measure the area of induration in response to a PPD test, the nurse would be most accurate in advising the parents to measure: A) both the areas that look red and feel raised B) The entire area that feels itchy to the child C) Only the area that looks reddened D) Only the area that feels raised 41. A community health nurse is schedule to do home visit. She visits to an elderly person living alone. Which of the following observation would be a concern? A) Picture windows B) Unwashed dishes in the sink C) Clear and shiny floors D) Brightly lit rooms 42. After a birth, the physician cut the cord of the baby, and before the baby is given to the mother, what would be the initial nursing action of the nurse? A) examine the infant for any observable abnormalities B) confirm identification of the infant and apply bracelet to mother and infant C) instill prophylactic medication in the infant’s eyes D) wrap the infant in a prewarmed blanket and cover the head 43. A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck and arms. The client is scratching the affected areas. What would be the best nursing intervention to prevent the client from scratching the affected areas? A) elbow restraints to the arms B) Mittens to the hands C) Clove-hitch restraints to the hands D) A posey jacket to the torso 44. The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric stenosis. The appropriate nursing response would be A) There is no way to determine this preoperatively B) Their baby was born with this condition
C) Their baby developed this condition during the first few weeks of life D) Their baby acquired it due to a formula allergy 45. A male client comes to the clinic for check-up. In doing a physical assessment, the nurse should report to the physician the most common symptom of gonorrhea, which is: A) pruritus B) pus in the urine C) WBC in the urine D) Dysuria 46. Which of the following would be the most important goal in the nursing care of an infant client with eczema? A) preventing infection B) maintaining the comfort level C) providing for adequate nutrition D) decreasing the itching 47. The nurse is making a discharge instruction to a client receiving chemotherapy. The client is at risk for bone marrow depression. The nurse gives instructions to the client about how to prevent infection at home. Which of the following health teaching would be included? A) “Get a weekly WBC count” B) “Do not share a bathroom with children or pregnant woman” C) “Avoid contact with others while receiving chemotherapy” D) “Do frequent hand washing and maintain good hygiene” 48. The nurse is assigned to care the client with infectious disease. The best antimicrobial agent for the nurse to use in handwashing is: A) Isopropyl alcohol B) Hexachlorophene (Phisohex) C) Soap and water D) Chlorhexidine gluconate (CHG) (Hibiclens) 49. The mother of the client tells the nurse, “ I’m not going to have my baby get any immunization”. What would be the best nursing response to the mother? A) “You and I need to review your rationale for this decision” B) “Your baby will not be able to attend day care without immunizations” C) “Your decision can be viewed as a form of child abuse and neglect” D) “You are needlessly placing other people at risk for communicable diseases” 50. The nurse is teaching the client about breast self-examination. Which observation should the client be taught to recognize when doing the examination for detection of breast cancer?
ANSWER KEY 1. D. Bathing an infant with eczema can be safely delegated to an aide; this task is basic and can competently performed by an aid. 2. B. The RN floated from the telemetry unit would be least prepared to care for a young infant who has just had GI surgery and requires a specific feeding regimen 3. C. RN floated from the obstetrics unit should be able to care for a client with major abdominal surgery, because this nurse has experienced caring for clients with cesarean births. 4. A. The patient is experiencing a potentially serious complication related to diabetes and needs ongoing assessment by an RN 5. D. It describes functional nursing. Staff is assigned to specific task rather than specific clients. 6. B. Case management. The nurse assumes total responsibility for meeting the needs of the client during her entire duty. 7. B. The nurse is ethically obligated to inform the person responsible for the assignment and the person responsible for the unit about the nurse’s skill level. The nurse therefore avoids a situation of abandoningclients and exposing them to greater risks 8. A. This describes a mentor 9. B. This action demonstrates a lack of responsibility and the nurse should attempt negotiation with the nurse manager. 10. B. The team leader is responsible for the overall management of all clients and staff on the team, and this information is essential in order to accomplish this 11. C. Even though the mother is a minor, she is legally able to sign consent for her own child. 12. B. This response is the most direct and immediate. This is a case of potential need for advocacy and patient’s rights. 13. D. The nurse who witness a consent for treatment or surgery is witnessing only that the client signed the form and that the client’s condition is as indicated at the time of signing. The nurse is not witnessing that the client is “informed”. 14. C. Although the statements by the mother may not create a suspicion of neglect, when they are coupled with observations about impaired bonding and maternal attachment, they may impose the obligation to report child neglect. The nurse is further obligated to notify caregivers of refusal to consent to treatment 15. C. It best explains what informed consent is and provides for legal rights of the patient 16. B. The physician may not be aware of the role that religious beliefs play in making a decision about surgery. 17. A. The behavior should be stopped. The first step is to remind the staff that confidentiality may be violate 18. C. Waiting for emotions to dissipate and sitting down with the colleague is the first rule of conflict resolution. 19. C. The nurse has no idea who the person is on the phone and therefore may not share the information even if the patient gives permission 20. A. The priority is to let the surgeon know, who in turn may ask the husband to sign the consent. 21. A. Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it should be mixed with normal saline. 22. A. This position increases venous return, improves cardiac volume, and promotes adequate ventilation and cerebral perfusion 23. D. Checking the airway would be a priority, and a neck injury should be suspected 24. D. Client with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing. 25. C. It is important to protect the RN’s eyes from the possible contamination of coughed-up secretions 26. D. There has been too little food or too much insulin. Glucose levels can be markedly decreased (less than 50 mg/dl). Severe hypoglycemia may be fatal if not detected
27. D. Because the client’s ability to react to stress is decreased, maintaining a quiet environment becomes a nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial. 28. D. Presuctioning and postsuctioning ventilation with 100% oxygen is important in reducing hypoxemia which occurs when the flow of gases in the airway is obstructed by the suctioning catheter. 29. B. This is an example of objective data of both pulmonary status and direct observation on the skin by the nurse. 30. C. These are likely signs of an acute myocardial infarction (MI). An acute MI is a cardiovascular emergency requiring immediate attention. Acute MI is potentially fatal if not treated immediately. 31. D. Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, and the bruises may be attributed to ataxia, frequent falls, vertigo or medication. 32. B. This is closest to suggesting action-assessment, rather than paperwork- and is therefore the best of the four. 33. C. The only acceptable way to identify a preschooler client is to have a parent or another staff member identify the client. 34. C. It describes the mass in the greatest detail. 35. C. Intravenous pyelogram tests both the function and patency of the kidneys. After the intravenous injection of a radiopaque contrast medium, the size, location, and patency of the kidneys can be observed by roentgenogram, as well as the patency of the urethra and bladder as the kidneys function to excrete the contrast medium. 36. C. This is the recommended position for screening for scoliosis. It allows the nurse to inspect the alignment of the spine, as well as to compare both shoulders and both hips. 37. A. Handwashing is the best method for reducing crosscontamination. Gowns and gloves are not always required when entering a client’s room. 38. B. Pyloric stenosis is an anomaly of the upper gastrointestinal tract. The condition involves a thickening, or hypertrophy, of the pyloric sphincter located at the distal end of the stomach. This causes a mechanical intestinal obstruction, which leads to vomiting after feeding the infant. The vomiting associated with pyloric stenosis is described as being projectile in nature. This is due to the increasing amounts of formula the infant begins to consume coupled with the increasing thickening of the pyloric sphincter. 39. B. Increased incidence of TB has been seen in the general population with a high incidence reported in hospitalized elderly clients. Immunosuppression and lack of classic manifestations because of the aging process are just two of the contributing factors of tuberculosis in the elderly. 40. D. Parents should be taught to feel the area that is raised and measure only that. 41. C. It is a safety hazard to have shiny floors because they can cause falls. 42. D. The first priority, beside maintaining a newborn’s patent airway, is body temperature. 43. B. The purpose of restraints for this child is to keep the child from scratching the affected areas. Mittens restraint would prevent scratching, while allowing the most movement permissible. 44. C. Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown. It develops during the first few weeks of life. 45. B. Pus is usually the first symptom, because the bacteria reproduce in the bladder.
46. A. Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection. 47. D. Frequent hand washing and good hygiene are the best means of preventing infection. 48. D. CHG is a highly effective antimicrobial ingredient, especially when it is used consistently over time. 49. A. The mother may have many reasons for such a decision. It is the nurse’s responsibility to review this decision with the mother and clarify any misconceptions regarding immunizations that may exist. 50. D. The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a dimpling appearance. A) tender, movable lump B) pain on breast self-examination C) round, well-defined lump D) dimpling of the breast tissue