1. A nurse is providing care to a client with negative pressure wound therapy to the left lower extremity. The nurse

PREBOARD 14

• A nurse is providing care to a client with negative pressure wound therapy to the left lower extremity. The nurse

notes an alarm on the device indicating a leak has been detected. Which action will the nurse perform next?

• Change the wound dressing on the incision
• Reposition the client’s lower extremity
• Replace the negative pressure wound therapy device
• Ensure the dressing is completely sealed

• A nurse is assessing a client with a traumatic brain injury who is unconscious. The nurse notes pinpoint,

nonreactive pupils and flaccid extremities. Which action does the nurse perform next?

• Administers a prescribed hypotonic solution
• Elevates the head of the bed
• Prepares the client for surgery
• Places the client on seizure precautions

• A nurse is providing care to a client admitted with an infected abdominal wound. Which clinical finding will the

nurse immediately report to the healthcare provider?

• Lactate level of 4 mmol/L
• White blood cell count of 11,000/mm³
• Temperature of 101°F (38.3°C)
• Heart rate of 110 beats/min

• A nurse is caring for a client after a spinal fusion to treat scoliosis. Which nursing intervention is appropriate in the

immediate postoperative period? Select all that apply.

• Encourage passive leg and ankle exercises
• Perform neurovascular checks every 8 hours
• Encourage use of patient-controlled analgesia
• Maintain bedrest with the head of the bed elevated at least 30 degrees
• Assist the client to stand and walk to the bathroom as needed
• Position the client flat in bed and logroll every 2 to 4 hours

• 24 hours after a dilation and curettage (D&C), an adult female client has a hemoglobin level of 14 g/dL and a

hematocrit of 42%. Which finding should the nurse expect when assessing the client?

• Respiration rate of 36 breaths per minute
• Pale mucous membranes
• Complaints of fatigue with ambulation
• Capillary refill of less than three seconds

• The nurse is caring for a child diagnosed with nephrotic syndrome. Which clinical manifestation should the nurse

expect to find?

• Periorbital edema
• Bradycardia
• Weight loss
• Hyperactivity

• The nurse is assessing a client who sustained multiple fractures, contusions, and lacerations in a motor vehicle

accident three days ago. The client suddenly becomes confused. Which findings would support the nurse's concern that the client has developed a fat embolism? Select all that apply.

• Elevated temperature
• Low oxygen saturation
• Petechiae on the upper anterior chest
• Dyspnea
• Hypertension

• A client with a history of asthma and kidney stones is admitted with a diagnosis of recurrent renal calculi. The

client experiences shortness of breath following a lithotripsy. The nurse auscultates the client's lungs and finds decreased air movement with no wheezing. The arterial blood gas (ABG) results are pH 7.31, PaO2 53 mm Hg, PaCO2 50 mm Hg, and O2 sat 82%. Which of the following actions are appropriate for the nurse to take? Select all that apply.

• Call respiratory therapy
• Start oxygen via nasal cannula
• Prepare for possible intubation
• Administer a short-acting bronchodilator via nebulizer
• Contact the health care provider
• Increase IV fluids
• Start high flow oxygen via face mask

• A nurse arrives at a child daycare center that was the site of an explosion. Which child should be tagged "green,"

or needing minimal treatment?

• An infant with bulging of the anterior fontanel while crying
• A preschooler with a lower leg fracture on one side and an upper leg fracture on the other
• A toddler with severe and deep abrasions over 98% of the body
• A school-age child with singed eyebrows and hair

• The nurse is developing a plan of care for a client who underwent total hip arthroplasty 24 hours ago. Which

interventions should the nurse include? Select all that apply.

• Assist the client with a clear liquid diet
• Encourage the use of an abduction pillow or splint between the legs
• Encourage the client to use the incentive spirometer every 2 hours
• Encourage the client to perform leg exercises while in bed
• Remind the client to not bend the knee of the affected leg while seated
• Provide a seat riser for the toilet or commode

• A client with late-stage lung cancer was started on chemotherapy two days ago and might be experiencing

tumor lysis syndrome. Which findings support this diagnosis? Select all that apply.

• A serum creatinine level of 2.4 mg/dL
• A serum calcium level of 13.8 mg/dL
• A serum phosphorus level of 1.8 mg/dL
• A serum uric acid level of 22 mg/dL
• Weakness and muscle cramps
• A serum potassium level of 3.0 mg/dL

• The nurse is caring for a 14-year old child who has been tentatively diagnosed with hyperthyroidism. Which of

these findings noted on the initial nursing assessment require intervention by the nurse?

• A 10% weight loss in the last month despite an excellent appetite
• An apical heart rate of 190 bpm
• A comment by the client, "I just can't sit still."
• A report of irritability worsening in the past two weeks

• Upon entering a client's room, the client is found to be unresponsive and is not breathing. After immediately

calling for help, what is the next action the nurse should take?

• Maintain an open airway
• Check for a carotid pulse
• Deliver 30 chest compressions
• Give two rescue breaths

• In which situation would a child be treated by the use of enemas followed by an antitoxin?

• A child who is diagnosed with botulism
• A child who has swallowed a handful of iron-fortified vitamins
• A child who bit into a laundry detergent packet
• A child who has eaten an undetermined number of ibuprofen tablets

• A client is transported to the emergency department following a boating accident and submersion in cold water.

The client is conscious, shivering and confused. What interventions should the nurse implement? Select all that apply.

• Provide warmed blankets
• Massage extremities
• Remove wet clothing
• Administer warmed IV fluids as ordered

• The school nurse is educating teachers that the number of children diagnosed with fifth disease has increased.

Which clinical manifestation of fifth disease should the nurse emphasize to the teachers?

• Koplik spots appear first followed by a rash that appears first on the face and spreads downward
• Macule that rapidly progresses to papule and then vesicles
• Bright red cheeks, with a "slapped face" appearance
• Discrete rose pink macules will appear first on the trunk and fade when pressure is applied

• A 3-year-old child presents with exam findings that may suggest a neuroblastoma. The nurse is collecting

information from the child's parents. Which statement by the parent is suggestive of neuroblastoma and requires follow-up by the health care provider?

• "He seems to be getting weaker and weaker and is sometimes unsteady on his feet."
• "We keep having to buy him larger size pants because he's growing so big around the waist
• "Our child has been quieter than normal lately and has lost weight."
• "He doesn't seem to be going to the bathroom as much and his urine is dark yellow in color."

• A child is injured on the school playground and appears to have a fractured leg. What is the first action that the

school nurse should take?

• Immobilize the limb and joints above and below the injury
• Call for emergency transport to the hospital
• Assess the child and the extent of the injury
• Apply cold compresses to the injured area

• A school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth

of a 9-year-old child has been avulsed ("knocked out"). After recovering the tooth, which action should the nurse take?

• Ask the child to replace the tooth even if the bleeding continues
• Rinse the tooth in water before placing it into its socket
• Place the tooth in a clean plastic bag for transport to the dentist
• Hold the tooth by the roots until reaching the emergency room

• The nurse is performing a respiratory assessment on a newborn. Which assessment finding would require

intervention by the nurse?

• Rapid, shallow respirations
• Short periods of apnea (<10 seconds)
• Nasal flaring
• Symmetric chest movement

• Several hours after a total gastrectomy, the client's nasogastric tube (NGT) stops draining. After referring to the

postoperative orders, which order will the nurse implement first?

• Notify the surgeon
• Irrigate the nasogastric tube
• Reposition the tube until it begins to drain
• Increase the amount of suction by 5 mmHg

• The nurse in a primary care office is examining a 15-month-old child with suspected otitis media. Which group of

findings should the nurse anticipate?

• Periorbital edema, absent light reflex and translucent tympanic membrane
• Irritability, rhinorrhea, and bulging tympanic membrane
• Vomiting, pulling at ears and pearly white tympanic membrane
• Diarrhea, retracted tympanic membrane and enlarged parotid gland

• The nurse and a student nurse are discussing the health issues related to a laboring HBsAg-positive client. Which

of these comments by the student is incorrect and indicates a need for further instruction?

• "The infant will receive the hepatitis B immune globulin within 12 hours after birth."
• "The HBsAg-positive mother should not breastfeed her baby."
• "The HBsAg-positive mother should be reported to the state or local health department."
• "The infant will receive the hepatitis B vaccine within 12 hours after birth."

• The nurse on a critical care unit is admitting a client who is experiencing a hypertensive urgency or crisis. Which

assessment is the priority?

• Heart rate
• Orientation
• Pedal pulses
• Lung sounds

• The nurse is caring for a child diagnosed with Kawasaki disease. The nurse should monitor the child for which

potential complication?

• Pulmonary embolism
• Occlusions at the vessel bifurcations
• Coronary artery aneurysm
• Chronic vessel plaque formation