PREBOARD APRIL 2021 - assessment should the nurse make to help determ...

PREBOARD APRIL 2021

• The parent of a 21-day old male infant reports that the infant is “throwing up a lot”. Which

assessment should the nurse make to help determine if pyloric stenosis is an issue? SELECT ALL

THAT APPLY.

• Assess the parent’s feeding technique.
• Check for family history of gluten enteropathy
• Check for history of physiological hyperbilirubinemia
• Check if the vomit is projectile
• Compare the current weight to birth weight

• Which client condition is concerning and requires further nursing assessment and intervention?

SELECT ALL THAT APPLY.

• Before liver biopsy, pulse is 80/min and blood pressure is 120/80 mm Hg; 1 hours afterward,

pulse is 112/min and BP is 90/60 mm Hg

• Before lumbar puncture, pulse is 100/min and BP is 140/86 mm Hg; 1 hour afterward, pulse is

80/min and BP is 126/82 mm Hg

• Client with coronary artery disease on metoprolol; pulse is 62/min
• Elderly client with black stools; pulse is 112/min
• Neonate crying inconsolably at feeding time; pulse is 160/min

• The nurse assists with a staff education conference about appropriate non pharmacological pain

management interventions for newborns and infants. Which of the following strategies should be included in the presentation? SELECT ALL THAT APPLY.

• Administer an oral sucrose solution to a newborn during circumcision procedure
• Apply a cold pack to a newborn’s heel 30 minutes before performing a heel stick
• Assist the parent to hold a newborn skin – to- skin during an immunization injection.
• Offer pacifier to an infant while performing venipuncture
• Swaddle an infant while leaving one arm unwrapped during an IV dressing change.

• The nurse is admitting a client at 41 weeks gestation for induction of labor due to oligohydramnios.

Considering the client’s indication for induction, what should the nurse anticipate?

• Additional neonatal personnel present for birth
• Intermittent fetal monitoring during labor
• Need for forceps-assisted vaginal birth
• Need for uterotonic drugs for postpartum hemorrhage

• The most recent laboratory results for a 12 – month old who is HIV – positive show a CD4

lymphocyte count of 500/mm3 and a CD4 lymphocyte percentage of 10%. The nurse anticipates administering which immunizations? SELECT ALL THAT APPLY.

• Haemophilus influenza type B (Hib)
• Hepatits A (Hep A)
• Measles, mumps, rubella (MMR)
• Pneumococcal conjugate vaccine (PCV)
• Varicella

• The clinic nurse supervises a graduate nurse who is teaching the parents of a 2-year old with acute

diarrhea about home management. The nurse would need to intervene when the graduate nurse provides which instruction

• “Do not administer antidiarrheal medications to your child.”
• “Follow the bananas, rice, applesauce and toast diet for the next few days.”
• “Record the number of wet diapers and return to the clinic if you notice a decrease”
• “Use a skin barrier cream such as zinc oxide in the diaper area until diarrhea subsides”

• The home health nurse is visiting an infant who recently had surgery to repair tetralogy of Fallot.

Which of the following sign of heart failure should the nurse teach the parents to report to the health care provider? SELECT ALL THAT APPLY.

• Cool extremities
• Increase in appetite
• Puffiness around the eyes
• Reduction in number of wet diapers
• Weight gain

• Which of the following drug administrations should be reported as a practice error? SELECT ALL

THAT APPLY.

• Cephalexin administered; client has history of anaphylaxis from penicillin
• Hydromorphone 2 mg administered; client reports pruritus
• Immunizations for a 3 month old administered in ventrogluteal site
• Oral niacin (nicotinic acid) administered; client has facial flushin
• Warfarin administered; client at 12 weeks gestation

• The parent of an 11 month old client child calls the pediatric outpatient clinic and tells the nurse that

the child is exposed to measles 2 days ago during a family trip to a theme park. What is the best response by the nurse?

• Bring the baby into the clinic for the measles, mumps, rubella (MMR) vaccine
• Check the baby’s temperature twice a day
• Do not allow the child to have contact with other children
• Does your child have a fever or rash?

• The nurse is planning education for clients in group prenatal care who are entering the second

trimester of pregnancy. Which of the following are appropriate for the nurse to include in second trimester teaching? SELECT ALL THAT APPLY.

• Anticipate light movements around 16-20 weeks gestation
• Expects to have an abdominal ultrasound for fetal anatomy evaluation
• Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal
• Increase consumption of iron – rich foods like meat and dried fruit
• Plan for gestational diabetes screening near the end of the second trimester

• A pregnant client at 30 weeks gestation comes to the prenatal clinic. Which vaccines may be

administered safely at this prenatal visit? SELECT ALL THAT APPLY.

• Influenza injection
• Influenza nasal spray
• Measles, mumps and rubella
• Tetanus, diphtheria and pertussis
• Varicella

• The nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus

and end – stage renal disease who is scheduled for dialysis today. Which medication should the nurse hold for clarification prior to administration?

• Atenolol
• Calcium acetate
• Insulin lispro
• Vitamin E

• The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct

techniques? SELECT ALL THAT APPLY.

• Apply the suction for no longer than 5-10 seconds
• Insert catheter with low, intermittent suction applied
• Set suction higher than 130 mm Hg for thick copious secretions
• Wait at least 1 minute between suction passes
• Withdraw the catheter immediately if the client begins coughing

• A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action

would be appropriate to reduce the client’s risk aspiration pneumonia?

• Fully inflate the cuff before feeding
• Have the client sit in an upright position with the neck hyperextended
• Partially or fully deflate the cuff
• Provide a modified diet of pureed foods

• The initial prenatal laboratory screening results of a client 12 weeks gestation indicated a rubella

titer status of non immune. What will the nurse anticipate as the plan of care for this client?

• Administer measles, mumps, rubella (MMR) vaccine now
• Administer MMR vaccine immediately postpartum
• Administer MMR vaccine in the 3

rd trimester

• An MMR vaccine is not indicated for this client

• The family practice nurse is conducting client intake histories. Which client findings or histories

indicate a need for heightened concern that the client may have cancer. SELECT ALL THAT APPLY.

• The 60 yr old client was just diagnosed with benign prostatic hyperplasia (BPH)
• The client reports a mobile, golf ball – sized lesion under the skin over the right thigh that feels

doughy

• The client reports a nagging cough with hoarseness for the past 3 months
• The female client who weighed 150 lb (68 kg) has lost 15 lb (6.8 kg) in 3 months without dieting
• The male client reports a skin change on the breast that looks like an orange peel

• The nurse in the outpatient procedure unit is caring for a client immediately post bronchoscopy.

Which assessment data indicate that the nurse needs to contact the health care pro vider immediately?

• Absence of gag reflex
• Bright red blood mixed with sputum
• Headache
• Respirations 10/min and saturation of 92%

• An elderly client with end – stage renal disease who has refused dialysis is admitted to a long – term

care facility for rehabilitation following hospitalization. The next days, the client becomes agitated and says to the nurse, “I’ve got to get back home to my things. Have so much to do.”Which is the most likely interpretation of this client’s behavior?

• The client has been admitted to the facility without the client’s consent
• The client is becoming delirious and should be assessed for infection
• The clients is concerned that someone might steal possessions
• The client wants to take care of business before imminent death

• The nurse is reviewing the medication administration record of a client with atrial fibrillation. Which

of the following should the nurse monitor before giving these medications? SELECT ALL THAT

APPLY.

• Digoxin level
• Glucose

3. INR

• Platelet count
• Serum potassium

• The home health nurse visits a client with atrial fibrillation who is prescribed digoxin 0.25 mg orally

on even – numbered days. Which of the following client statement show that teaching has been effective? SELECT ALL THAT APPLY.

• “I need to call my health care provider if I have trouble reading”
• “I need to check my blood pressure before taking my medicine”
• “I should call the HCP if I develop nausea and vomiting”
• “I should check my heart rate prior to taking this medication”
• “I will call the HCP if I feel dizzy and lightheaded”

• The nurse is caring for a client with a chest tube that was placed 2 hours ago for pneumothorax.

Where would the nurse expect gentle, continuous, bubbling?

• Air leak monitor
• Collection chamber
• Suction control chamber
• Water seal chamber

• The nurse takes the admission history of a 70 year old client diagnosed with chronic obstructive

pulmonary disease (COPD). Which of the following statements by the client does th e nurse recognize as contributing to the development of COPD? SELECT ALL THAT APPLY.

• “I have been drinking alcohol almost daily since age 20”
• “I have been overweight for as long as I can remember”
• “I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year”
• “I know I eat too much food”
• “I was a car mechanic for about 40 years and had my own garage”

• The nurse teaches safety precautions of home oxygen use to a client with em physema being

discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching? SELECT ALL THAT APPLY.

• “I can apply Vaseline to my nose when my nostrils feel dry from the oxygen”
• “I can cook on my gas stove as long as I have a fire extinguisher in the kitchen”