Gab-Nic Excelsior Nursing Tutoring Center
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Frequently Asked Questions
Readiness Evaluation Test
1. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?
A postoperative client preparing for discharge with a new medication
A client requiring daily dressing changes of a recent surgical incision
A client scheduled for a chest x-ray after insertion of a nasogastric tube
A client with asthma who requested a breathing treatment during the previous shift
2. The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pa co 2 of 30 mm Hg (30 mm Hg), and HCO 3 – of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?
Metabolic acidosis, compensated
Respiratory alkalosis, compensated
Metabolic alkalosis, uncompensated
Respiratory acidosis, uncompensated
3. A prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Record your answer to the nearest whole number.
4. The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
Urinary output of 20 mL/hr
Temperature of 37.6° C (99.6° F)
Blood pressure of 100/70 mm Hg
Serous drainage on the surgical dressing
5. The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg’s theory of moral development. What information should the nurse include in the session? Select all that apply.
Individuals move through all 6 stages in a sequential fashion.
Moral development progresses in relationship to cognitive development.
A person’s ability to make moral judgments develops over a period of time.
The theory provides a framework for understanding how individuals determine a moral code to guide their behavior.
In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society.
In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.
6. The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate ?
Increase oral fluids.
Document the finding.
Notify the pediatrician.
Elevate the head of the bed to 90 degrees.
7. A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?
“Come to the clinic immediately.”
“The vaginal discharge may be bothersome, but is a normal occurrence.”
“Report to the emergency department at the maternity center immediately.”
“Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours.”
8. The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply.
The contractions are regular.
The membranes have ruptured.
The cervix is dilated completely.
The client begins to expel clear vaginal fluid.
The Ferguson reflex is initiated from perineal pressure.
9. The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?
Elevate the client’s legs.
Massage the fundus until it is firm.
Ask the client to turn on her left side.
Push on the uterus to assist in expressing clots.
10. The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?
Protects the newborn’s eyes from possible infections acquired while hospitalized.
Prevents cataracts in the newborn born to a woman who is susceptible to rubella.
Minimizes the spread of microorganisms to the newborn from invasive procedures during labor.
Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.
11. The nurse is providing home care instructions to the parents of a 10-year-old child with hemophilia. Which sport activity should the nurse suggest for this child?
12. The mother of a 4-year-old child tells the pediatric nurse that the child’s abdomen seems to be swollen. During further assessment, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms’ tumor, should avoid which during the physical
13. The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?
Bile-stained fecal emesis
The passage of currant jelly–like stools
Failure to pass meconium stool in the first 24 hours after birth
Sausage-shaped mass palpated in the upper right abdominal quadrant
14. The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply.
Place the infant in a private room.
Ensure that the infant’s head is in a flexed position.
Wear a mask, gown, and gloves when in contact with the infant.
Place the infant in a tent that delivers warm humidified air.
Position the infant on the side, with the head lower than the chest.
Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
15. On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?
Desquamation of the skin
16. A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action?
Administer an antiemetic.
Increase the intravenous fluids.
Place the child in a Sims’ position.
Notify the primary health care provider (PHCP).
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