1. A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of
the following interventions should the nurse include in the plan?
a) Ask the client to tilt their head back when swallowing.
b) Have the client sit upright for 1 hr. following meals.
c) Administer liquids to the client using a syringe.
d) Allow the client to rest for 10 min prior to eating.
Answer: b) Have the client sit upright for 1 hr. following meals.
Rationale:
Having the client sit upright for 1 hour following meals helps prevent aspiration in clients with
dysphagia. It allows gravity to assist in moving food through the oesophagus and reduces the risk
of aspiration pneumonia.
2. A nurse is assessing the IV infusion site of a client who report pain at the site. The site is red
and there is warmth along the course of the vein. Which of the following actions should the
nurse take?
a) Initiate a new IV line below the original insertion site.
b) Discontinue the infusion
c) Raise the head of the bed
d) Obtain a culture from the area of the insertion site.
Answer: d) Obtain a culture from the area of the insertion site.
Rationale:
The client's symptoms indicate phlebitis, which is an inflammation of the vein. Obtaining a
culture will help identify the organism causing the infection and guide appropriate treatment.
3. A nurse is preparing to perform a routine abdominal assessment for a client. Which of the
following actions should the nurse take?
a) Document shiny, taut skin as an expected finding.
b) Perform palpitation after auscultation.
c) Listen for 1 min before documenting absent bowel sounds
d) Perform auscultation immediately after the client has consumed a meal.
Answer: b) Perform palpation after auscultation.
Rationale:
Auscultation should be performed before palpation during an abdominal assessment to prevent
altering bowel sounds. Palpation before auscultation can stimulate bowel sounds and give a false
interpretation of the assessment findings.
4. A nurse is discussing immunity with a client who has received an immunization. The nurse
should identify that an immunization functions as a part of the which of the following types of
immunity?
a) Passive immunity
b) Active immunity
c) Cellular immunity
d) Acquired immunity
Answer: b) Active immunity
Rationale:
Immunization triggers an active immune response in the body, leading to the production of
antibodies against a specific antigen. This is an example of active immunity.
5. A nurse is reviewing the medical records of a group of older adult clients. The nurse should
identify that which of the following is a risk factor that places older clients at an increased risk
for developing infections?
a) Overproduction of lymphocytes
b) Elevated albumin levels
c) Lowered immune system function
d) Increased body fat
Answer: c) Lowered immune system function
Rationale:
As people age, their immune system function tends to decrease, which increases their risk of
developing infections.
6. A nurse is teaching a client who has asthma the use of a metered dose inhaler. Which of the
following instructions should the nurse include in the teaching?
a) Hold your breath for 6 seconds after inhaling the medication.
b) Inhale the medication deeply for 5 seconds.
c) Do not shake the medication in the inhaler
d) Hold the inhaler 3 inches away from your mouth.
Answer: a) Hold your breath for 6 seconds after inhaling the medication.
Rationale:
Holding the breath for 5-10 seconds after inhaling the medication allows the medication to
deposit in the lungs effectively.
7. A nurse is performing a focused assessment on a client who has a history of COPD and is
experiencing dyspnea. Which of the following findings should the nurse expect?
a) Pulse oximetry reading of 95 %
b) Decreased depth of respirations
c) Flaring of the nostrils
d) Respiratory rate of 16/min
Answer: c) Flaring of the nostrils
Rationale:
Flaring of the nostrils is a compensatory mechanism the body uses to increase airway size and
improve airflow in clients with respiratory distress, such as those with COPD.
8. A nurse is teaching a client about the correct use of a cane. Which of the following instruction
should the nurse include in the teaching? (Selected all that apply)
a) Ensure the cane has a rubber cap.
b) Hold the cane on the weaker side.
c) Flex the elbow slightly when using the cane.
d) Move the cane and stronger leg forward simultaneously
e) Use a quad cane for increased support.
Answer: a) Ensure the cane has a rubber cap.
b) Hold the cane on the weaker side.
c) Flex the elbow slightly when using the cane.
Rationale:
a) A rubber cap helps provide traction and prevents slipping.
b) Holding the cane on the weaker side provides increased support and stability.
c) Flexing the elbow slightly when using the cane helps absorb shock and provides better
balance.
9. A nurse is teaching a group of assistive personnel about the expected integumentary changes
in older adult clients. Which of the following findings should the nurse include in the teaching?
a) Increase in subcutaneous tissue
b) Decrease in pigmentation
c) Increase in moisture levels
d) Decrease in elasticity
Answer: d) Decrease in elasticity
Rationale:
Elastic fibres in the skin decrease with age, leading to a decrease in skin elasticity, which
increases the risk of skin tears and injuries.
16. A nurse is providing teaching about measures to promote sleep with a client who has
insomnia. Which of the following client statements indicates an understanding of the teaching?
a) “I can exercise as late as 2 hours before bedtime.”
b) “I should reduce my fluid intake 2 hours before bedtime.”
c) “I should take a 1-hour nap each day”
d) “I can eat a large meal as late as 1 hour before bedtime”
Answer: b) “I should reduce my fluid intake 2 hours before bedtime.”
Rationale:
Consuming fluids close to bedtime can cause nocturia, disrupting sleep. By reducing fluid intake
two hours before bedtime, the client can minimize the need to urinate during the night,
promoting uninterrupted sleep.
17. A nurse is assessing the pain level of a client who has dementia and difficulty
communicating. Which of the following pain assessment techniques should the nurse use?
a) Numerical pain scale
b) Verbal description
c) Faces pain scale
d) Behavioral indicators
Answer: d) Behavioral indicators
Rationale:
Clients with dementia and communication difficulties may not be able to self-report pain.
Therefore, the nurse should rely on behavioral indicators such as facial expressions, body
movements, and vocalizations to assess pain.
18. A nurse in an emergency department is monitoring the hydration status of a client who is
receiving oral rehydration. Which of the following findings should the nurse identify as requiring
further interventions?
a) Heart rate 120/min
b) BP 121/74 mm Hg
c) Temperature 37.78°C (100°F)
d) Urine specific gravity 1.020
Answer: c) Temperature 37.78°C (100°F)
Rationale:
A temperature of 37.78°C (100°F) indicates a fever, which may increase fluid loss through
sweating and evaporation. The nurse should monitor the client closely for signs of dehydration
and consider additional interventions to manage the fever and prevent further fluid loss.
19. A nurse in a provider’s office is assessing the motor skill development of a 15-month-old
toddler during a well-child visit. Which of the following gross motor skills should the nurse
expect?
a) Takes several steps on tiptoes
b) Walks without assistance using a wide stance
c) Has an accentuated cervical curvature when standing
d) Stands with the feet turned slightly inward.
Answer: b) Walks without assistance using a wide stance
Rationale:
By 15 months, toddlers typically achieve the gross motor skill of walking without assistance,
using a wide stance for balance and stability.
20. A nurse is teaching a group of parents and guardians about safety risks for adolescents.
Which of the following statements should the nurse include in the teaching?
a) “Exploring the environment commonly leads to injuries for this age group.”
b) “Most injuries sustained during this time of life are caused by developing motor skills.”
c) “At this age, peer influence to participate in high-risk behaviors can lead to injury”
d) The risk for injuries sustained during this age are often a result of changes in cognitive
function”
Answer: c) “At this age, peer influence to participate in high-risk behaviors can lead to injury”
Rationale:
Adolescents are particularly vulnerable to peer pressure, which can lead to engagement in highrisk behaviors such as substance abuse, reckless driving, and unsafe sexual practices, increasing
the risk of injury.
21. A nurse is caring for a client who expresses anxiety about an upcoming surgery. Which of the
following actions should the nurse take?
a) Ask the client to describe their feelings
b) Discuss the competency of the surgeon with the client
c) Inform the client that others have had the procedure without problems.
d) Ask the client why they are experiencing anxiety.
Answer: a) Ask the client to describe their feelings
Rationale:
Encouraging the client to describe their feelings helps the nurse to understand the source of
anxiety and provides an opportunity for the client to express their concerns, fears, and
expectations regarding the surgery.
22. A nurse is reviewing information about advance directives with a newly admitted client.
Which of the following statements by the client indicates an understanding of the teaching?
a) “I need to have an attorney sign my advance directives”
b) “I have a living will that outlines my wishes if I am unable to make decisions”
c) “I must have a family member appointed to make my health care decisions”
d) “I will need to sign a document stating that I want to be resuscitated if I require CPR.”
Answer: b) “I have a living will that outlines my wishes if I am unable to make decisions”
Rationale:
A living will be a type of advance directive that outlines a person's wishes regarding medical
treatment if they are unable to communicate their decisions. This statement indicates an
understanding of advance directives.
23. A nurse is planning a community education program about colorectal cancer. Which of the
following risk factors should the nurse identify as modifiable? (Select all that apply)
a) Smoking
b) Alcohol consumption
c) Inflammatory bowel disease
d) High-fat diet
e) Colorectal polyps
Answer: a) Smoking, b) Alcohol consumption, d) High-fat diet
Rationale:
Smoking, alcohol consumption, and a high-fat diet are modifiable risk factors for colorectal
cancer. Encouraging lifestyle changes such as smoking cessation, reducing alcohol intake, and
adopting a low-fat diet can help reduce the risk of developing colorectal cancer.
24. A nurse is reviewing the laboratory report of a client who has been experiencing a fever for
the last 3 days. Which of the following laboratory results indicates the client is experiencing
fluid volume deficit?
a) Decreased blood urea nitrogen (BUN)
b) Increased hematocrit
c) Decreased urine specific gravity
d) Increased calcium level
Answer: b) Increased hematocrit
Rationale:
An increased hematocrit indicates haemoconcentration, which is a sign of fluid volume deficit.
When the body experiences fluid loss, the concentration of red blood cells in the blood increases,
leading to an elevated haematocrit level.
25. A charge nurse discovered that a nurse did not notify the provider that a client’s condition
had changed. The charge nurse should identify that the nurse is accountable for which of the
following torts?
a) Negligence
b) Slander
c) Invasion of privacy
d) Libel
Answer: a) Negligence
Rationale:
Negligence is the failure to act as a reasonably prudent person would have acted in the same
circumstances. In this case, the nurse's failure to notify the provider of the client's changing
condition constitutes negligence as it breaches the standard of care expected in the situation.
26. A nurse is performing a cultural assessment of a group of clients to maintain respect for their
value systems and beliefs. Which of the following should the nurse identify as examples of
cultural variables? (Select all that apply).
a) Eye contact
b) Personal space
c) Level of education
d) Touch
e) Blood Type
Answer: b) Personal space, c) Level of education, d) Touch
Rationale:
Cultural variables are aspects of culture that influence an individual's behavior, beliefs, and
values. Personal space, level of education, and touch are examples of cultural variables that can
vary among different cultural groups.
27. A nurse is admitting a client who has recently developed fever, confusion, and a decreased
level of consciousness. Which of the following actions should the nurse take first after obtaining
the client’s history and assessment?
a) Insert an intravenous catheter to begin fluid therapy
b) Develop actions to address the client’s manifestations
c) Identify the client’s needs
d) Determine the effectiveness of treatment.
Answer: c) Identify the client’s needs
Rationale:
After obtaining the client's history and assessment, the nurse's priority is to identify the client's
immediate needs. This allows the nurse to prioritize care and address any urgent issues, such as
airway, breathing, or circulation problems, in a timely manner.
28. A nurse is planning to administer several medications to a client through a nasogastric (NG)
tube. Which of the following actions should the nurse take?
a) Mix the medications together and administer through the NG tube .
b) Crush the sublingual medication into powder form
c) Dissolve crushed tablet medications in sterile water.
d) Flush the tube with 5 ml saline between each medication.
Answer: d) Flush the tube with 5 ml saline between each medication.
Rationale:
Flushing the NG tube with 5 ml of saline between each medication prevents drug interactions
and ensures that each medication is completely delivered to the client.
29. A nurse is preparing to perform a sterile dressing change for a client who has a surgical
wound. Which of the following actions should the nurse take to prevent contamination during the
dressing change?
a) Remove a piece of the new dressing that falls 5cm(2in) from the edge of the sterile field
during the dressing change.
b) Begin the dressing change by applying sterile gloves and removing the existing dressing
c) Restart the procedure if the sterile solution splashes onto the sterile field when pouring the
solution into the dressing tray
d) Place the existing dressing on the outermost portion of the sterile field and discard it when the
dressing change is finished.
Answer: c) Restart the procedure if the sterile solution splashes onto the sterile field when
pouring the solution into the dressing tray
Rationale:
If the sterile solution splashes onto the sterile field during the dressing change, it can
contaminate the field. The nurse should restart the procedure to ensure a sterile environment is
maintained.
31. A nurse is reviewing the health history of an older adult client who has a hip fracture. The
nurse should identify that which of the following findings places the client at risk for developing
a pressure injury?
a) Osteoporosis
b) Urinary incontinence
c) Macular degeneration
d) Psoriasis
Answer: b) Urinary incontinence
Rationale:
Urinary incontinence can lead to prolonged exposure of the skin to moisture, increasing the risk
of developing pressure injuries, especially in older adults with limited mobility.
32. A nurse is performing a focused assessment for a client who has dysrhythmia. Which of the
following indicates ineffective cardiac contractions?
a) Carotid bruit
b) Heart murmur
c) Pulse deficit
d) Bounding radial pulse
Answer: c) Pulse deficit
Rationale:
Pulse deficit is the difference between the apical and radial pulse rates. A pulse deficit indicates
ineffective cardiac contractions, where some contractions are not strong enough to produce a
peripheral pulse.
33. A nurse is preparing to transfer a client from a chair to the client’s bed. The client can bear
partial weight and has upper body strength. Which of the following devices should the nurse use
to transfer the client?
a) A stand-assist lift
b) A footboard
c) A slide board
d) A mechanical lift with a full-body sling
Answer: c) A slide board
Rationale:
A slide board is appropriate for transferring a client who can bear partial weight and has upper
body strength. It provides a smooth surface for the client to slide from one surface to another.
34. A charge nurse is making assignments for the upcoming shift. Which of the following client
assignments should the charge nurse assign to a licensed practical nurse (LPN)
a) A client who is to receive moderate (conscious) sedation.
b) A client who was just admitted with multiple rib fractures
c) A client who is scheduled for a bone marrow transplant
d) A client who has dehydration and inflammatory bowel disease.
Answer: d) A client who has dehydration and inflammatory bowel disease.
Rationale:
Licensed practical nurses (LPNs) are qualified to provide care for stable clients with predictable
outcomes, such as a client who has dehydration and inflammatory bowel disease. This
assignment allows the LPN to use their skills effectively while ensuring that registered nurses are
available for clients with more complex needs.
35. A nurse is caring for a client who has a prescription for a narcotic medication. After the
medication is administered, the nurse is left with an unused portion. Which of the following
actions should the nurse take?
a) Discard the medication with another nurse as a witness
b) Send the remaining medication back to the pharmacy
c) Place the unused portion of the medication in the sharps container
d) Dispose of the unused portion of the medication in the trash
Answer: a) Discard the medication with another nurse as a witness
Rationale:
Unused portions of narcotic medications should be properly disposed of to prevent diversion or
misuse. The nurse should discard the medication in a medication waste container, with another
nurse as a witness, following facility policy and procedures for medication disposal.
37. A nurse is caring for an older adult client who has a nonpalpable skin lesion that is less than
0.5cm (0.2 in) in diameter. Which of the following terms should the nurse use to document this
finding?
a) Papule
b) Vesicle
c) Nodule
d) Macule
Answer: d) Macule
Rationale:
A macule is a nonpalpable skin lesion that is characterized by a change in the color of the skin,
such as a freckle or a flat mole. Macules are typically less than 1 cm in diameter. Therefore, the
nurse should use the term "macule" to document a nonpalpable skin lesion that is less than 0.5
cm in diameter.
Capstone Med Surg
1. A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device
to treat obstructive sleep apnea. Which of the following information should the nurse include in
the teaching?
a) It delivers a preset amount of inspiratory pressure at the beginning of each breath
b) It has a continuous adjustment feature that changes the airway pressure throughout the cycle.
c) It delivers a preset amount of airway pressure throughout the breathing cycle
d) It delivers positive pressure at the end of each breath
Answer: c) It delivers a preset amount of airway pressure throughout the breathing cycle
Rationale:
A CPAP device delivers a continuous, fixed-pressure airway pressure throughout the breathing
cycle, which helps keep the airway open during sleep and prevents episodes of obstructive sleep
apnea.
2. A nurse is providing discharge teaching to a client following a heart transplant. Which of the
following information should the nurse include in the teaching?
a) Immunosuppressant medications need to be taken for up to 1 year.
b) Shortness of breath might be an indication of transplant rejection
c) The surgical site will heal in 3 to 4 weeks after surgery
Answer: b) Shortness of breath might be an indication of transplant rejection
Rationale:
Shortness of breath can be an early sign of transplant rejection, and the client should be
instructed to report any such symptoms to the healthcare provider immediately.
3. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone
(SIADH) and is receiving 3% sodium chloride via continuous IV. Which of the following
laboratory findings should the nurse identify as an indication that the SIADH is resolving?
a) Urine specific gravity 1.020
b) Sodium 119 mEq/L
Answer: a) Urine specific gravity 1.020
Rationale:
A urine specific gravity within the normal range (1.005 to 1.030) indicates that the kidneys are
beginning to excrete excess water, resolving the SIADH.
4. A nurse is teaching a client about fecal occult blood testing (FOBT) for the screening of
colorectal cancer. Which of the following statements should the nurse include in the teaching?
a) Your provider will use stool from your digital rectal examination to perform the test
b) Your provider will prescribe a stimulant laxative prior to the procedure
c) You should begin annual fecal occult blood testing for colorectal cancer screening at 40 years
old
Answer: c) You should begin annual fecal occult blood testing for colorectal cancer screening at
40 years old
Rationale:
Annual fecal occult blood testing for colorectal cancer screening should begin at 50 years old,
not 40. It is recommended for adults aged 50 to 75 years.
5. A nurse is preparing a client for a colonoscopy. Which of the following medications should the
nurse anticipate the provider to prescribe as an anaesthetic for the procedure?
a) Propofol
b) Pancuronium
Answer: a) Propofol
Rationale:
Propofol is commonly used as an anesthetic for colonoscopy procedures due to its rapid onset
and short duration of action, allowing for quick recovery.
7. A nurse is reviewing the medical record of a client who has unstable angina. Which of the
findings should the nurse report to the provider?
Answer: Temperature
Rationale:
Unstable angina is a medical emergency. Any elevation in temperature could indicate an
infectious process, which could worsen the client's condition and needs immediate attention.
9. A nurse is developing a plan of care for a client who will be placed in halo traction following
surgical repair of the cervical spine. Which of the following interventions should the nurse
include in the plan?
a) Inspect the pin site every 48 hr
b) Monitor the client's skin under the halo vest
c) Ensure two personnel hold the halo device when repositioning the client
Answer: a) Inspect the pin site every 48 hr
Rationale:
Regular inspection of the pin site helps prevent complications such as infection and ensures early
detection and treatment of any potential issues.
10. A nurse is caring for a client who has a traumatic brain injury. Which of the following
findings should indicate to the nurse the need for immediate intervention?
a) Axillary temperature 37.2°C (99°F)
b) Apical pulse 100/min
c) Respiratory rate 30/min
Answer: c) Respiratory rate 30/min
Rationale:
An increased respiratory rate can indicate increased intracranial pressure (ICP), which is a lifethreatening complication of traumatic brain injury and requires immediate intervention.
11. A nurse is assessing a client who has meningitis. The nurse should identify which of the
following findings as a positive Kernig's sign?
a) After stroking the lateral area of the foot, the client's toes contract and draw together.
b) After hip flexion, the client is unable to extend their leg completely without pain.
Answer: b) After hip flexion, the client is unable to extend their leg completely without pain.
Rationale:
Kernig's sign is a physical examination finding indicative of meningeal irritation. It is assessed
by flexing the client's hip and knee to 90 degrees, then attempting to extend the knee. A positive
Kernig's sign is present if the client experiences pain and resistance to knee extension.
12. A nurse is providing discharge teaching to a client who has heart failure and a prescription for
furosemide 20 mg PO twice daily. Which of the following instructions should the nurse include
in the teaching?
a) Monitor for increased blood pressure
b) Increase intake of high-potassium foods
c) Expect an increase in swelling in the hands and feet
Answer: c) Expect an increase in swelling in the hands and feet.
Rationale:
Furosemide is a loop diuretic used to reduce fluid volume in clients with heart failure. An
expected side effect of furosemide is increased urine output, which can lead to dehydration and
electrolyte imbalances. Therefore, the nurse should instruct the client to expect an increase in
swelling in the hands and feet.
13. A nurse is providing discharge instructions to a client who has GERD. Which of the
following statements by the client demonstrates an understanding of the teaching?
a) "I should take my medicine with orange juice."
b) "A bedtime snack will prevent heartburn."
Answer: b) "A bedtime snack will prevent heartburn."
Rationale:
A bedtime snack can help prevent heartburn by keeping the stomach partially full, reducing the
likelihood of gastric reflux during sleep. Taking medication with orange juice is not
recommended as citrus juices can exacerbate GERD symptoms.
14. A nurse at a provider's office is interviewing a client who has multiple sclerosis and has been
taking dantrolene for several months. Which of the following client statements should the nurse
identify as an indication that the medication is effective?
a) "I don't have muscle spasms as frequently."
b) "I haven't gotten any colds, even though it is flu season."
Answer: a) "I don't have muscle spasms as frequently."
Rationale:
Dantrolene is a muscle relaxant used to treat muscle spasticity associated with multiple sclerosis.
A decrease in the frequency of muscle spasms indicates that the medication is effective in
managing the client's symptoms.
15. A nurse is assessing a client who reports a possible exposure to HIV. Which of the following
findings should the nurse identify as an early manifestation of HIV infection?
a) Stomatitis
b) Fatigue
c) Wasting Syndrome
Answer: b) Fatigue
Rationale:
Fatigue is an early manifestation of HIV infection and can occur during the acute retroviral
syndrome phase, which develops within the first few weeks after exposure to the virus.
16. A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia. Which of
the following statements by the client indicates an understanding of the teaching?
a) "Exercise reduces the risk for hypoglycemia."
b) "I can skip my insulin when I don't eat."
c) "I can drink 4 ounces of soda if my blood sugar is low."
Answer: c) "I can drink 4 ounces of soda if my blood sugar is low."
Rationale:
Drinking 4 ounces of soda or fruit juice containing glucose is an appropriate treatment for
hypoglycemia in clients with diabetes, as it quickly raises blood sugar levels.
17. A nurse is teaching a client who has hypertension about dietary modifications to help control
blood pressure. Which of the following food choices should the nurse recommend the client to
include in their diet?
a) 1 packet of reconstituted dry onion soup
b) 3 oz of lean cured ham
c) 3 oz of chicken breast
Answer: c) 3 oz of chicken breast
Rationale:
Lean meats like chicken breast are lower in sodium compared to cured meats like ham and
processed foods like reconstituted dry onion soup, making them a better choice for clients with
hypertension.
18. A nurse is planning care for a client who has acute pancreatitis. Which of the following
interventions should the nurse include in the client's plan?
a) Initiate insulin drip
b) Monitor blood glucose levels
c) Continue regular diet as tolerated
d) Maintain NPO status until pain-free
e) Manage acute pain
Answer: b) Monitor blood glucose levels, d) Maintain NPO status until pain-free, e) Manage
acute pain
Rationale:
Monitoring blood glucose levels is important because acute pancreatitis can cause
hyperglycemia.
Maintaining NPO status until pain-free reduces pancreatic stimulation and helps promote rest
and healing of the pancreas.
Managing acute pain is a priority to ensure client comfort and promote rest, which aids in the
healing process.
Capstone Mental health
1. A nurse is creating a plan of care for a client who has panic disorder. Which of the following
interventions should the nurse include.
Answer: Use simple words to describe procedures to the client
2. A nurse is caring for a client is experiencing visual hallucinations followed by impaired
consciousness as a result of alcohol withdrawal. Which of the following conditions should the
nurse identify as causing these manifestations?
Answer: Delirium
3. A nurse is teaching male client who has a depressive disorder about sertraline. Which of the
following information should the nurse include in the teaching?
Answer: "This medication may cause an inability to orgasm."
4. A nurse is conducting a child maltreatment screening of a family who has a toddler. Which of
the following finding indicator of possible child neglect?
Answer: The child has had no immunizations since birth.
5. A nurse is preparing to teach a client who has major depressive disorder and is scheduled to
undergo electroconvulsive therapy (ECT). Which of the following statements should the nurse
include in the teaching?
Answer: ECT is delivered through electrodes attached to the head
6. A charge nurse is planning an in-service for newly licensed nurses on tort law in mental health
care. Which of the following scenarios should charge nurse provide as an example of an
unintentional tort?
Answer: A nurse did not clarify a client prescription that was difficult to read resulting in a
medication error.
7. A nurse is reviewing the medical records of a group of clients. For which of the following
clients should the nurse recommend a referral for assertive community treatment (ACT)?
Answer: A client who has repeated acute care admissions due to schizophrenia
8. A nurse is assessing a client who has delirium as a result of sepsis. Which of the following is
apply.
Answer: Rapid mood changes
hallucinations
Restlessness
9. Nurse is admitting a client to an alcohol abuse program. The client states, I’m here because of
my boss. It was part of my job to go to parties id drink with clients. The client's statement is an
example of which of the following defense mechanisms?
Answer: Rationalization
10. A charge nurse in a community mental health clinic is discussing ethical concepts of client
care with a newly licensed nurse. The charge nurse should use which of the following situations
as an Example of fidelity?
Answer: Attending an educational conference on identifying client at risk suicide
11. A nurse on an inpatient mental health unit is caring for a client who has major depressive
disorder and malnutrition. Which of the following actions should the nurse take to improve the
client nutritional status.
Answer: Weigh the client at the same time every morning.
12. A nurse is caring for a client who is receiving haloperidol 2 mg IM every 6 hr. Available is
haloperidol 5 mg/ml. how many ml should the nurse administer? (Round the answer to the
nearest tenth. Use a leading zero if it applies.
Answer: Respuesta 0.4 ml
13. A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa
and has a body mass index of 17.2. Which of the following actions should the nurse take? Select
all that apply.
Answer: Provide the client with small meals frequently
Monitor the client weight daily
Allow the client to choose the meals she Wilf eat
Stay with the client during meals and for 1 hr afterward
Offer specific privileges for sustained weight gain.
14. A nurse is caring for a client who has bipolar disorder. The client says to the nurse. Give me
your pen to should identify that the client is at risk for which of the following.
Answer: Self- mutilation
15. A nurse is caring for a client who has dementia and insists a doll is her infant child. Which
should the nurse use when interacting with the client?
Answer: Validation therapy
16. A nurse is discharging a client who was admitted for the treatment of alcohol withdrawal.
Which of the following resources recommend to the client.
Answer: Reach to recovery
A 12 step program
Al-Anon
Light therapy
17. A nurse is conducting an admission assessment for a client is experiencing a manic episode
of bipolar disorder. Which of the following behavior should the nurse expect. Select all that
apply .
Answer: Grandiosity
Flight of ideas
Hyperactivity
1. A nurse is assessing a client who started taking furosemide 2 days ago and has a potassium
level 3.1. Which of the following findings should the nurse expected?
Answer: Depressed deep tendon reflexes.
2. A nurse is caring for a client who has an infection and is starting to take gentamicin. Which of
the following client laboratory test should the nurse monitor to detect an adverse effect of the
medication?
Answer: Creatinine
3. A nurse is administering bumetanide to a client who has ascites. The nurse should recognize
that which of the following findings is an expected therapeutic effect this medication?
Answer: Increase urinary output
4. A nurse is providing teaching to a client who has fibromyalgia and a new prescription for
pregabalin. Which of the following instruction should the nurse include in the teaching?
Answer: You should notify your provider if you experience facial swelling.
5. A nurse is assessing a client who is in preterm labor and is receiving magnesium via
continuous IV infusion. Which of the following findings should the nurse identify as the
priority?
Answer: Deep tendon reflexes 1+
6. A nurse is caring for a client who has a systemic fungal infection and is receiving IV
amphotericin B deoxycholate. During previous infusion?
Answer: Admi diphenhydramine prior to administration.
7. A nurse is providing teaching to a client who has rheumatoid arthritis and is starting to take
hydroxychloroquine. Which of the following client statement indicates an understanding of the
teaching?
Answer: I will need to have regular eye exams while taking this medication
8. a nurse is monitoring a client who is receiving a continuous IV infusion of dopamine. Which
of the following findings requires immediate intervention by the nurse?
Answer: Infiltration of peripheral IV
9. A nurse is providing discharge instruction to a client who has a new prescription for
omeprazole for the treatment of GERD. Which of the following statements by the client indicates
an understanding of the teaching?
Answer: This medication reduces stomach acid
10. A nurse is providing teaching to a client who has prostate cancer and a new prescription for
leuprolide. The nurse should explain to the client that leuprolide treats prostate cancer by which
of the following actions?
Answer: Leuprolide decrease the production of testosterone
11. A nurse is reviewing laboratory data for a client who is taking niacin to correct plasm lipid
levels. Which of the following’s findings should the nurse identify as an adverse effect of this
therapy?
Answer: Elevated Alanine Aminotransferase (ALT)
12. A nurse is caring for a client who requires a transfusion of one unit of packed RBC. The
nurse received the following prescription diphenhydramine 50mg by mouth once, one hour to
transfusion. The nurse should identify this as which of the following types of prescription?
Answer: Single prescription
13. A nurse is caring for a client who has hyperlipidemia and a new prescription for colesevelam.
The nurse should monitor the client foe which of the following manifestations s an adverse of
COLESEVELAM
Answer: Constipation.
14. A nurse is caring for older adult client who is confirmed positive for HIV and will begin
medication therapy. Which of the following instructions should the nurse give the client? SATA
Answer: You will be prescribed more than one medication to fight the virus.
Your medication plan can also include an antibiotic medication.
You will need to take medication for the rest of your life
15. A nurse is completing an admission assessment for a client who has been taking ST John’s
worst. The nurse should identify that which of the following medications can interact with St
John worst?
Answer: Citalopram
16. The first action the nurse should take is to assess the client for injury due to medication error.
Answer: Assess the client
17. A nurse is providing teaching to a client who has angina and a new prescription for
sublingual nitroglycerine tablets. Which of the following instructions should the nurse include in
the teaching?
Answer: Store used tablet a room temperature
18. A nurse is teaching a client who has a new prescription for benzonatate. Which of the
following statements by the client indication understanding of the teaching?
Answer: I should not drive while taking this medication
19. A nurse is assessing a client who has diabetes insipidus and is starting intranasal
desmopressin. Which of the following findings should indicates to nurse that medication in
effective?
Answer: The client’s 24 hr urine is 1256ml
20. A nurse is transcribing a telephone prescription for acetaminophen 650mg by mouth daily at
bedtime. The nurse should identify that which of the following abbreviations are acceptable to
use when transcribing the prescription
Answer: Abbreviate by mouth as PO
21. A nurse is reviewing the medical record of a client who takes lithium. Which of the following
findings is the priority to report to use the provider?
Answer: Sodium 130
22. adverse effect of iron preparation
Answer: Monitor your child for constipation (increase fluid)
23. A nurse is teaching a client who has a seizure disorder and has a new prescription for
phenytoin. Which of the following client statements indicates an understanding of the teaching?
Answer: I will have my blood checked to monitor the medication levels
25. A nurse is reviewing the medical record of a client who has asthma and takes albuterol.
Which of the following findings should the nurse identify as an adverse effect of albuterol?
Answer: Heart rate 110bpm
26. A nurse is assessing a client who has a prescription for haloperidol 0.5mg PO three times
daily. The medication administration record shows that the client received 5 mg per dose on the
previous day. Which of the following manifestations is the nurse’s priority to assess?
Answer: Muscle stiffness
27. A nurse is teaching a client who has a new prescription for isoniazid to treat tuberculosis.
Which of the following information should the nurse include in the teaching
Answer: You will have frequent sputum test to monitor the effectiveness of this medication
28. A nurse is assessing a client who received ondansetron 1 hr ago, Which of the following
finding should the nurse identify as a therapeutic effect
Answer: Suppressed emesis
29. A nurse is caring for a client who is at risk for alcohol withdrawal delirium. Which of the
following medications should the nurse expect the provider to prescribe?
Answer: Chlordiazepoxide
30. A nurse is providing teaching to a client who has erectile dysfunction and has a new
prescription for tadalafil. Which of the following client statement indicates an understanding of
the teaching?
Answer: This medication can decrease BP
31. A nurse is assessing a group of clients. Which of the following findings is the priority to
reports to the provider?
Answer: A client who is receiving continuous IV lidocaine and has a respiratory rate of 10min
Maternal Newborn Assessment
1. A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which
of the following findings should the nurse report to the provider?
a) WBC count 11,000/mm³
b) Hgb 11.2 g/dL
c) Hct 34%
d) Platelets 140,000/mm³
Answer: b) Hgb 11.2 g/dL
Rationale:
Haemoglobin (Hgb) level below 11 g/dL in the third trimester of pregnancy may indicate iron
deficiency anaemia, which requires further evaluation and treatment to prevent complications for
both the mother and the fetus.
2. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe
features. Which of the following actions should the nurse take?
a) Restrict protein intake to less than 40 g/day.
b) Initiate seizure precautions for the client.
c) Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
d) Encourage the client to ambulate twice per day.
Answer: b) Initiate seizure precautions for the client.
Rationale:
Preeclampsia with severe features puts the client at risk for seizures (eclampsia). Therefore, the
nurse should initiate seizure precautions, including padding the side rails, ensuring suction
equipment is available, and providing a quiet environment to prevent stimulation.
3. A nurse is caring for a client who is in the transition phase of labor. Which of the following
actions should the nurse take?
a) Assist the client to void every 3 hr.
b) Monitor contractions every 30 min.
c) Place the client into a lithotomy position.
d) Encourage the client to use a pant-blow breathing pattern.
Answer: b) Monitor contractions every 30 min.
Rationale:
During the transition phase of labor, contractions are strong, frequent, and often come close
together. Monitoring contractions every 30 minutes allows the nurse to assess the progress of
labor and the effectiveness of contractions.
4. A nurse is teaching the parents of a newborn how to care for their child’s uncircumcised penis.
Which of the following instructions should the nurse include?
a) Retract the foreskin until you feel resistance.
b) Use a cotton swab to clean under the foreskin.
c) Apply petroleum jelly to the foreskin.
d) Wash the penis once per day with soap and water.
Answer: d) Wash the penis once per day with soap and water.
Rationale:
The foreskin should not be retracted in infants or young boys, as it may cause injury or
adhesions. Instead, the parents should be instructed to wash the penis with soap and water once
per day during bathing.
5. A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings
show potential prenatal complication?
a) Periodic tingling of fingers
b) Absence of clonus
c) Leg cramps
d) Blurred vision
Answer: d) Blurred vision
Rationale:
Blurred vision can be a sign of gestational hypertension or preeclampsia, which are potential
prenatal complications.
6. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the
umbilical cord protruding through the cervix. Which of the following actions should the nurse
take?
a) Administer oxytocin to the client via intravenous infusion.
b) Apply oxygen at 2 L/min via nasal cannula.
c) Prepare for insertion of an intrauterine pressure catheter.
d) Assist the client into the knee-chest position.
Answer: d) Assist the client into the knee-chest position.
Rationale:
If the umbilical cord is protruding through the cervix, the nurse should immediately relieve
pressure on the cord by placing the client in the knee-chest or Trendelenburg position to facilitate
blood flow to the fetus.
7. A nurse is providing dietary teaching for a client who is at 29 weeks of gestation and has
phenylketonuria. Which of the following suggested foods should the nurse include in the
teaching?
a) A peanut butter sandwich on wheat bread.
b) A sliced apple and red grapes.
c) A chocolate chip cookie with a glass of skim milk.
d) A scrambled egg with cheddar cheese.
Answer: d) A scrambled egg with cheddar cheese.
Rationale:
A scrambled egg with cheddar cheese is a low-phenylalanine food option suitable for a client
with phenylketonuria.
8. A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the
following clients should the nurse assess first?
a) A client who gave birth 1 day ago and needs Rh (D) immune globulin.
b) A client who gave birth 3 days ago and reports breath fullness.
c) A client who gave birth 12 hours ago and reports an increase in urinary output.
d) A client who gave birth 8 hours ago and is saturating a perineal pad every hour.
Answer: d) A client who gave birth 8 hours ago and is saturating a perineal pad every hour.
Rationale:
Excessive perineal bleeding could indicate postpartum hemorrhage, a potentially life-threatening
complication, and requires immediate assessment and intervention.
9. A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone
use during pregnancy. Which of the following manifestations should the nurse identify as an
indication of neonatal abstinence syndrome?
a) Hyporeactivity
b) Excessive high-pitched cry
c) Acrocyanosis
d) Respiratory rate of 50/min
Answer: b) Excessive high-pitched cry
Rationale:
Excessive high-pitched cry is a common manifestation of neonatal abstinence syndrome, along
with other signs such as irritability, tremors, poor feeding, vomiting, diarrhoea, and hyperactive
Moro reflex.
10. A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes
recurrent variable decelerations on the fetal heart rate monitor. Which of the following actions
should the nurse take first?
a) Prepare the equipment necessary to initiate an amnioinfusion.
b) Administer oxygen at 10 L/min via nonrebreather face mask.
c) Discontinue the infusion of oxytocin.
d) Place the client in a left lateral position.
Answer: d) Place the client in a left lateral position.
Rationale:
Variable decelerations are often caused by umbilical cord compression. Placing the client in a left
lateral position can help relieve pressure on the umbilical cord and improve fetal oxygenation.
11. A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal
bleeding due to placenta previa. Which of the following actions should the nurse plan to take?
a) Initiate continuous monitoring of the FHR.
b) Administer a dose of betamethasone.
c) Check the cervix for dilation every 8 hr.
d) Request that the provider prescribe misoprostol PRN.
Answer: a) Initiate continuous monitoring of the FHR.
Rationale:
Placenta previa can cause painless vaginal bleeding due to the abnormal placement of the
placenta over or near the cervical os. Continuous monitoring of the fetal heart rate (FHR) is
essential to assess fetal well-being and detect signs of fetal distress.
12. A nurse is reviewing a laboratory result for a client who is at 33 weeks of gestation and has
preeclampsia. Which of the following laboratory results should the nurse report to the provider?
a) BUN 35 mg/dL
b) Hgb 15 mg/dL
c) Bilirubin 0.6 mg/dL
d) Hct 37%
Answer: a) BUN 35 mg/dL
Rationale:
An elevated blood urea nitrogen (BUN) level is indicative of renal impairment, which is a
common complication of preeclampsia. Therefore, the nurse should report this finding to the
provider for further evaluation and management.
13. A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance and
notes the presence of edematous swelling on the newborn's head that crosses the suture line. The
nurse should identify the swellings as which of the following?
a) Caput succedaneum
b) Cephalohematoma
c) Erythema toxicum
d) Nevus flammeus
Answer: b) Cephalohematoma
Rationale:
A cephalohematoma is a collection of blood between the skull and the periosteum. It is typically
caused by trauma during delivery and does not cross the suture lines. Caput succedaneum is
localized edema of the scalp that crosses the suture lines.
14. A nurse is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals.
Which of the following findings should the nurse expect?
a) Hypotonicity
b) Moderate tremors of the extremities
c) Axillary temperature 36.1°C (96.9°F)
d) Excessive sleeping
Answer: b) Moderate tremors of the extremities
Rationale:
Newborns experiencing opioid withdrawal often display signs such as irritability, tremors, highpitched cry, poor feeding, vomiting, diarrhea, sweating, and fever.
15. A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an
intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the
following is an indication that the nurse should discontinue the infusion?
a) Contraction frequency every 3 min
b) Contraction duration of 100 seconds
c) Fetal heart rate with moderate variability
d) Fetal heart rate of 118/min
Answer: b) Contraction duration of 100 seconds
Rationale:
A contraction duration of 100 seconds is prolonged and can lead to decreased oxygenation of the
fetus. Therefore, the nurse should discontinue the oxytocin infusion to prevent fetal hypoxia.
16. A nurse is providing teaching to a group of women about risk factors for ovarian cancer.
Which of the following should the nurse include? (Select all that apply.)
a) Nulliparity
b) History of breastfeeding
c) Previous use of oral contraceptives
d) History of breast cancer
e) Hormone replacement therapy
Answer: a) Nulliparity
c) Previous use of oral contraceptives
d) History of breast cancer
e) Hormone replacement therapy
Rationale:
Risk factors for ovarian cancer include nulliparity, a history of breast cancer, previous use of oral
contraceptives, and hormone replacement therapy.
17. A nurse is caring for a client who is in active labor and notes late decelerations in the FHR on
the external fetal monitor. Which of the following actions should the nurse take first?
a) Change the client’s position.
b) Palpate the uterus to assess for tachysystole.
c) Increase the client’s IV infusion rate.
d) Administer oxygen at 10 L/min via nonrebreather mask.
Answer: a) Change the client’s position.
Rationale:
Late decelerations are indicative of uteroplacental insufficiency. The priority action is to improve
uteroplacental perfusion by changing the client's position, typically to a left lateral position, to
relieve pressure on the vena cava and improve blood flow to the placenta.
18. A nurse is caring for a client who is in labor and has an epidural for pain control. Which of
the following clinical manifestations should the nurse expect as an adverse effect of epidural
anesthesia?
a) Polyuria
b) Hypertension
c) Pruritus
d) Dry mouth
Answer: c) Pruritus
Rationale:
Pruritus is a common adverse effect of epidural anesthesia due to the release of histamine. Other
adverse effects include hypotension, urinary retention, and decreased mobility.
19. A nurse is caring for a client who is in labor and has a diagnosis of group B Streptococcus
(GBS) infection. Which of the following medications should the nurse plan to administer?
a) Ampicillin
b) Azithromycin
c) Ceftriaxone
d) Acyclovir
Answer: a) Ampicillin
Rationale:
Ampicillin is the antibiotic of choice for intrapartum prophylaxis in clients with GBS infection to
reduce the risk of neonatal GBS disease. It is typically administered intravenously during labor.
CAPSTONE PEDIATRY
1. A nurse on a paediatric unit is receiving change-of-shift report on a group of clients. Which of
the following clients should the nurse assess first?
a) A child who had a cardiac catheterization using the femoral artery and has blanching of the
toes.
b) A child with asthma who has audible wheezing and is using accessory muscles to breathe.
c) A child with type 1 diabetes who has a blood glucose level of 60 mg/dL (3.3 mmol/L).
d) A child with a fractured arm who is requesting pain medication.
Answer: a) A child who had a cardiac catheterization using the femoral artery and has blanching
of the toes.
Rationale:
Blanching of the toes following a cardiac catheterization using the femoral artery indicates a
potential complication like impaired circulation or thrombosis. This requires immediate
assessment and intervention to prevent further complications such as tissue damage or loss.
2. A nurse is providing teaching to an adolescent who has a new prescription for cefazolin. For
which of the following should the nurse instruct the adolescent to monitor and report to the
provider?
a) Dry mouth
b) Constipation
c) Back Pain
d) Urticaria
Answer: d) Urticaria
Rationale:
Urticaria (hives) can be a sign of an allergic reaction to cefazolin and should be reported to the
provider immediately.
3. A nurse in the emergency department is caring for a preschooler who has epiglottitis. Which of
the following actions should the nurse take?
a) Place the child in a left lateral position.
b) Obtain a specimen from the child’s throat for culture.
c) Inspect the child’s throat with a padded tongue depressor.
d) Initiate droplet precaution for the child.
Answer: d) Initiate droplet precaution for the child.
Rationale:
Epiglottitis is highly contagious and requires droplet precautions to prevent the spread of
infection.
4. A nurse is caring for an infant who has gastroesophageal reflux (GER). Which of the
following actions should the nurse take to prevent regurgitation? Select all that apply.
a) Thicken the infant’s formula with cereal.
b) Avoid giving the infant citrus juices.
c) Position the child with their head elevated after meals.
Answer: a) Thicken the infant’s formula with cereal.
c) Position the child with their head elevated after meals.
Rationale:
Thickening the formula helps to reduce regurgitation by making it harder for stomach contents to
flow back up the esophagus. Positioning the child with the head elevated after meals also helps
to reduce reflux.
5. A nurse is providing teaching to the parent of a child about home care following a cardiac
catheterization. Which of the following statements should the nurse include?
a) You should give your child aspirin if they report pain at the site.
b) You can remove the pressure dressing 8 hours after the procedure.
c) Your child can soak in the bathtub 24 hours after the procedure.
d) Your child should avoid strenuous physical activities for several days.
Answer: d) Your child should avoid strenuous physical activities for several days.
Rationale:
Strenuous physical activities should be avoided after a cardiac catheterization to prevent
bleeding or disruption of the insertion site.
6. A nurse is assessing a toddler who is toilet trained and has temporally _______ recognized as
an indication of urinary tract infection (UTI)?
a) Steatorrhea
b) Jaundice
c) Incontinence
d) Rebound tenderness
Answer: c) Incontinence
Rationale:
Incontinence in a toilet-trained toddler can be a sign of a urinary tract infection (UTI) due to
irritation of the bladder.
7. A nurse on a paediatric unit is reviewing the laboratory results for a group of clients. Which of
the following results should the nurse prioritize?
a) An adolescent who has iron-deficiency anaemia and Hgb level of 11 mg/dl.
b) A school-age child who has diabetes mellitus and an HbA1c of 8%.
c) A toddler who has moderate dehydration and an RBC count of 5.6/mm.
d) A preschooler who has cystic fibrosis-related diabetes and WBC count of 15,000/mm.
Answer: c) A toddler who has moderate dehydration and an RBC count of 5.6/mm.
Rationale:
A toddler with moderate dehydration and an elevated RBC count indicates haemoconcentration,
which may require immediate intervention to prevent complications such as hypovolemic shock.
8. A nurse in a paediatric clinic is discussing the pathophysiology of Reye syndrome with a
newly licensed nurse. Which of the following statements by the newly licensed nurse indicates
an understanding of the disorder?
a) Reye syndrome causes fatty changes in the liver.
b) Reye syndrome leads to venous thrombus formation.
c) Reye syndrome is associated with misuse of acetaminophen.
d) Reye syndrome is linked to decreased serum ammonia level.
Answer: c) Reye syndrome is associated with misuse of acetaminophen.
Rationale:
Reye syndrome is a rare but serious condition that primarily affects children and teenagers
recovering from viral infections, particularly the flu or chickenpox. It is associated with the use
of aspirin during these viral illnesses, not acetaminophen. The exact cause is unknown, but it is
characterized by acute encephalopathy and fatty changes in the liver.
9. A nurse in a paediatric clinic is performing a history and physical for a toddler who is
scheduled to receive immunization. Which of the following findings indicate that the
immunization should be withheld?
a) Temperature of 38°C (100.4°F).
b) Family history of sudden infant death syndrome (SIDS).
c) Taking an antihistamine for seasonal allergies.
d) Receiving prednisone for nephrotic syndrome.
Answer: a) Temperature of 38°C (100.4°F).
Rationale:
A temperature of 38°C (100.4°F) or higher is considered a contraindication for routine
immunizations due to the risk of exacerbating the fever. Immunizations should be postponed
until the fever resolves to avoid potential adverse effects and to ensure accurate interpretation of
adverse reactions.
10. A nurse is teaching the parents of a toddler about strategies to manage temper tantrums.
Which of the following instructions should the nurse include in the teaching?
a) Honor the child’s request if she holds her breath.
b) Establish a structured daily routine for the child.
c) Place the child in her room alone until the temper tantrum ends.
Answer: b) Establish a structured daily routine for the child.
Rationale:
Establishing a structured daily routine can help prevent temper tantrums by providing the child
with a sense of security and predictability. Consistency in daily activities, such as mealtimes, nap
times, and playtimes, can help reduce the occurrence of tantrums.
11. A nurse is assessing a child who has received the first 50 ml of a blood transfusion. Which of
the following findings would indicate that the child may be experiencing an air embolism?
Answer: Sharp pain in the middle of the chest.
Rationale:
Sharp pain in the middle of the chest can indicate an air embolism, a potentially life-threatening
complication of blood transfusion. Other signs and symptoms of an air embolism include
cyanosis, dyspnea, tachypnea, tachycardia, hypotension, and loss of consciousness.
12. A nurse is instilling otic drops into an 18-month-old. Which of the following actions should
the nurse take?
Answer: Pull the pinna back and down.
Rationale:
When instilling otic drops in a child older than 3 years or in an adult, the nurse should pull the
pinna up and back. However, in a child younger than 3 years, the nurse should pull the pinna
down and back to straighten the ear canal.
13. A charge nurse is assisting a newly licensed nurse with the preoperative assessment of a 2year-old child. Which of the following actions by the newly licensed nurse indicates an
understanding of the needed care?
Answer: Measuring the child’s abdominal circumference.
Rationale:
Measuring the child's abdominal circumference is important preoperatively to monitor for
potential complications such as abdominal distension or changes in abdominal girth. This can
indicate fluid retention, bowel obstruction, or other conditions that could affect the surgical
outcome.
14. A nurse working on an outpatient surgical unit is providing discharge teaching to the parent
of a preschooler following placement of tympanoplasty tubes. The parent asks the nurse, “What
should I do if the tubes fall out?” Which of the following responses should the nurse make?
a) Gently put the tubes back into the child’s ears.
b) Bring the child to the emergency department immediately.
c) Notify the provider that the tubes have fallen out.
d) The tubes are sutured in place and must be surgically removed.
Answer: c) Notify the provider that the tubes have fallen out.
Rationale:
If tympanoplasty tubes fall out, the parent should notify the provider. The provider will assess
whether replacement is necessary. In many cases, the tubes will need to be replaced, but this
decision should be made by the provider based on the child's individual circumstances.
15. A nurse is caring for a 4-month-old infant who is immediately postoperative following cleft
repair. Which of the following actions should the nurse take?
a) Give the infant liquids using a small spoon with a long handle.
b) Apply elbow restraints to the infant.
c) Gently check the infant’s suture line using a padded tongue depressor.
d) Place the infant in a supine position.
Answer: c) Gently check the infant’s suture line using a padded tongue depressor.
Rationale:
After cleft repair surgery, it is important to assess the infant's surgical site for signs of bleeding,
infection, or dehiscence. Using a padded tongue depressor to gently lift the lip allows for
inspection of the suture line without disrupting the surgical repair.
16. A nurse is caring for a child who is experiencing status asthmaticus. Which of the following
actions should the nurse take?
a) Initiate an infusion of IV fluids.
b) Obtain a blood specimen for ABG analysis.
c) Administer a dose of IV corticosteroids.
d) Apply humidified oxygen.
Answer: d) Apply humidified oxygen.
Rationale:
Humidified oxygen helps to soothe inflamed airways, loosen secretions, and improve
oxygenation in a child experiencing status asthmaticus. It is an essential component of managing
an acute asthma exacerbation. Once the child is stabilized, further interventions such as IV
fluids, corticosteroids, and blood gas analysis may be appropriate.
17. A nurse is caring for a school-age child who has metastatic osteosarcoma. The child asks the
nurse, “Am I going to die?” Which of the following responses should the nurse make?
a) "What is your pain level right now?"
b) "Your doctor will be able to answer your questions tomorrow."
c) "It sounds like you are worried. Tell me what you have been told."
d) "It’s natural to worry about death, but you should focus your energy on getting better.”
Answer: c) "It sounds like you are worried. Tell me what you have been told."
Rationale:
Acknowledging the child's concerns and inviting them to share their feelings can help establish
trust and open communication. It also provides an opportunity for the nurse to assess the child's
understanding of their condition and provide age-appropriate information and support.
18. A nurse is caring for an infant following a cleft lip and palate repair. Which of the following
interventions should the nurse include in the plan of care during the immediate postoperative
period?
a) Encourage the use of a pacifier.
b) Provide hard toys.
c) Administer analgesics.
Answer: c) Administer analgesics.
Rationale:
Following cleft lip and palate repair, it is important to manage pain effectively to promote
comfort and facilitate feeding. The nurse should administer analgesics as prescribed to ensure the
infant's comfort.
19. A nurse is providing dietary education to the mother of an infant. What recommendations
regarding the introduction of solid foods should the nurse make? Select all that apply.
a) Solids can be introduced between 4 and 6 months of age.
b) Iron-fortified rice cereal should be offered first.
c) New foods should be introduced one at a time over a 5 to 7 day period to observe for allergic
reactions.
d) Vegetables or fruit are first started between 6 and 8 months of age.
e) Milk, eggs, wheat, citrus, peanut butter, and honey can be given after 6 months of age.
Answer: a) Solids can be introduced between 4 and 6 months of age.
b) Iron-fortified rice cereal should be offered first.
c) New foods should be introduced one at a time over a 5 to 7 day period to observe for allergic
reactions.
d) Vegetables or fruit are first started between 6 and 8 months of age.
Rationale:
Solids can be introduced between 4 and 6 months of age, according to the infant's readiness cues.
Iron-fortified rice cereal is often recommended as the first solid food due to its low allergenic
potential and high iron content.
New foods should be introduced one at a time over a 5 to 7 day period to monitor for any signs
of allergic reactions.
Vegetables or fruit are typically introduced between 6 and 8 months of age to provide a variety of
nutrients and flavors.
20. A nurse is caring for an infant who has a congenital heart defect. Which of the following
defects results in increased pulmonary blood flow?
a) Coarctation of the aorta.
b) Patent ductus arteriosus.
c) Tetralogy of Fallot.
d) Tricuspid atresia.
Answer: b) Patent ductus arteriosus.
Rationale:
Patent ductus arteriosus (PDA) is a congenital heart defect characterized by a persistent opening
between the aorta and the pulmonary artery, which allows for increased pulmonary blood flow.
In PDA, oxygen-rich blood from the aorta is shunted back into the pulmonary artery, leading to
increased pulmonary blood flow.
21. A nurse is caring for a 6-month-old infant following surgery. Which of the following pain
assessment tools should the nurse use?
a) FLACC pain scale.
b) Oucher numeric scale.
c) Wong-Baker faces pain rating scale.
Answer: a) FLACC pain scale.
Rationale:
The FLACC (Face, Legs, Activity, Cry, Consolability) pain scale is appropriate for infants and
young children who are unable to verbalize their pain. It assesses pain based on five categories:
facial expression, leg movement, activity level, cry, and consolability. It is commonly used for
infants and young children from birth to 7 years old.
