Nursing Leadership and Management Practice

Question 1 Which scenario below complies with the HIPAA (Canadian Privacy Act and Personal Information Protection and Electronic Documents Act) regulations? You Selected: • A nurse talks with the spouse about a client's condition. Correct response: • The healthcare team is discussing a client's care during a formal care conference. Question 2 The nurse is to administer insulin to a client with diabetes mellitus. Which illustration indicates the appropriate syringe to use? You Selected: • Correct response: • Question 3 A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white blood cell (WBC) count, especially the neutrophil count, is low. What is the most important intervention the nurse should teach the parents? You Selected: • Protect your child from infections because his resistance to infection is decreased Correct response: • Protect your child from infections because his resistance to infection is decreased Question 4 A nurse is assessing a 10-year-old girl. The girl's parent informs the nurse that the parent is concerned about the daughter's breasts. The nurse assesses the breasts and notes the areola and nipple protrude slightly. Which statement by the nurse is an appropriate response? You Selected: • "The changes in your daughter's breasts are the first signs of puberty." Correct response: • "The changes in your daughter's breasts are the first signs of puberty." Question 5 An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures the right leg and right wrist. The nurse finding the client states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions? You Selected: • negligence Correct response: • negligence Question 6 The nurse is taking a nursing history from a client prior to surgery. Which information in the client’s history would have a significant impact on the client’s recovery postoperatively? The client: You Selected: • has smoked 1 pack of cigarettes a day for 12 years. Correct response: • has smoked 1 pack of cigarettes a day for 12 years. Question 7 The nurse on a mental health unit cares for a client who asks the nurse for a date. What action should the nurse take in this situation? You Selected: • Explain the limits of the nurse-client relationship. Correct response: • Explain the limits of the nurse-client relationship. Question 8 A nurse working on a critical care unit was informed by a client with multiple sclerosis that the client did not wish to be resuscitated in the event of cardiac arrest. The client is no longer able to express their wishes, and the family has informed the physician that they want the client to be resuscitated. Aware of the client's wishes, the nurse is involved in a situation that may cause You Selected: • ethical distress Correct response: • ethical distress Question 9 A multigravid client who stands for long periods while working in a factory visits the prenatal clinic at 35 weeks' gestation, stating, "The varicose veins in my legs have really been bothering me lately." Which instruction would be most helpful? You Selected: • Take frequent rest periods with the legs elevated above the hips. Correct response: • Take frequent rest periods with the legs elevated above the hips. Question 10 A nurse needs to give a pediatric client furosemide orally before one unit of packed red blood cells. How many mL should the nurse give? Record the answer using a whole number. Order: Furosemide 3 mg/kg/dose orally Dose on hand: Furosemide 40 mg/5 mL Client’s weight: 40 kg Your Response: • 15 Correct response: • 15 Question 11 A client who was recently hospitalized has constipation related to the medical regimen. Which medication may contribute to this problem? You Selected: • iron Correct response: • iron Question 12 A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? You Selected: • Serum potassium level of [2.6 mEq/L (2.6 mmol/L)} Correct response: • Serum potassium level of [2.6 mEq/L (2.6 mmol/L)} Question 13 A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client’s chart (shown above), into which position would the nurse assist the client? You Selected: • left lateral Correct response: • left lateral Question 14 Family members of a client with bipolar disorder tell a nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by: You Selected: • flight of ideas and inflated self-esteem. Correct response: • flight of ideas and inflated self-esteem. Question 15 The nurse makes initial rounds for the clients. Five medications are scheduled for administration at the same time to five different clients. Which medication should the nurse administer first after initial rounds? You Selected: • morphine sulfate to a client with a myocardial infarction reporting chest pain Correct response: • morphine sulfate to a client with a myocardial infarction reporting chest pain Question 16 A parent brings a 7-month-old infant to the well-baby clinic for a check-up. The parent feeds the infant formula whenever the infant is hungry but is concerned that the infant is overweight. What instructions should the nurse give the parents? You Selected: • Bring a 3-day record of the infant's intake back for further evaluation. Correct response: • Bring a 3-day record of the infant's intake back for further evaluation. Question 17 A day-shift nurse gives a client an injection of pain medication. The nurse forgets to document the injection on the medication administration record (MAR). The dayshift nurse tells the evening-shift nurse that she gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening-shift nurse puts the day-shift nurse's initials and the date and time the dose was administered in the appropriate area of the MAR. The evening-shift nurse's action is considered to be which type of documentation error? You Selected: • unauthorized entry Correct response: • unauthorized entry Question 18 A client with an I.V. of normal saline at 150 mL/hour reports dyspnea and restlessness. What is the priority nursing action? You Selected: • assess lung sounds Correct response: • assess lung sounds Question 19 A nurse is developing a care plan for a client who is a single parent. The client is experiencing anxiety after the loss of a job and is verbalizing concerns regarding the ability to meet role expectations and financial obligations. Which is most important for the nurse to include in the plan of care? You Selected: • Determine the client’s ability to cope with the job loss and family obligations. Correct response: • Determine the client’s ability to cope with the job loss and family obligations. Question 20 The client with major depression and suicidal ideation has been taking bupropion 100 mg PO 3 times daily for 5 days. Assessment reveals the client to be somewhat less withdrawn, able to perform activities of daily living with minimal assistance, and eating 50% of each meal. At this time, the nurse should monitor the client specifically for which behavior? You Selected: • suicide attempt Correct response: • suicide attempt Question 21 One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse is most therapeutic? You Selected: • "Your behavior is disturbing to other clients. I'll walk with you to help you release some energy." Correct response: • "Your behavior is disturbing to other clients. I'll walk with you to help you release some energy." Question 22 A nurse is discharging a client diagnosed with a urinary tract infection. Which information should the nurse include in the discharge teaching? Select all that apply. You Selected: • • Take all antibiotics as prescribed. Avoid coffee, tea, and alcohol. Correct response: • • Take all antibiotics as prescribed. Avoid coffee, tea, and alcohol. Question 23 A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? You Selected: • urine pH of 3.0 Correct response: • urine pH of 3.0 Question 24 A client is receiving aspirin. Which statement made by the client needs follow-up? You Selected: • “I can take Ginkgo biloba with aspirin.” Correct response: • “I can take Ginkgo biloba with aspirin.” Question 25 A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should You Selected: • assist the client to a sitting position on the edge of the bed, leaning over the bedside table. Correct response: • assist the client to a sitting position on the edge of the bed, leaning over the bedside table. Question 26 The nurse is meeting with a community group to discuss the changes that need to be made to meet their health needs after a community assessment has been done. One cultural group is insisting their views need to be implemented because they are in the majority in that community. What is the best action by the nurse? You Selected: • Make decisions based on findings from the community assessment. Correct response: • Seek input from all groups and strive for consensus on what would benefit most or all of these people. Question 27 A primigravida in active labor is about 10 days postterm. The client desires a pudendal block anesthetic before childbirth. After the nurse explains this type of anesthesia to the client, which location if identified by the client as the area of relief would indicate to the nurse that the teaching was effective? You Selected: • perineum Correct response: • perineum Question 28 Which instruction is most important for the nurse to include in the teaching plan for a client who is taking phenelzine? You Selected: • Avoid foods high in tyramine. Correct response: • Avoid foods high in tyramine. Question 29 A nurse is caring for a child with pheochromocytoma. What is the most important intervention by the nurse? You Selected: • promoting an environment free from emotional distress Correct response: • promoting an environment free from emotional distress Question 30 An adolescent sustains a head injury and develops diabetes insipidus. The healthcare provider orders desmopressin, 10 mcg subcutaneously. When does the nurse assess the client to determine the need for an additional dose? You Selected: • 4 to 7 hours Correct response: • 4 to 7 hours Question 31 What is the priority nursing intervention in the postictal phase of a seizure? You Selected: • Assess the client's breathing pattern. Correct response: • Assess the client's breathing pattern. Question 32 The nurse is caring for a client who has a new prescription for amitriptyline for depression and is preparing to be discharged. What assessment is the nurse's priority? You Selected: • suicidal ideation Correct response: • suicidal ideation Question 33 Which statement indicates that the client with diabetes insipidus understands how to manage care? The client will: You Selected: • exhibit serum glucose level within normal range. Correct response: • maintain normal fluid and electrolyte balance. Question 34 What is the most important information for the nurse to include when teaching a client about metronidazole? You Selected: • Mixing this drug with alcohol causes severe nausea and vomiting. Correct response: • Mixing this drug with alcohol causes severe nausea and vomiting. Question 35 A primigravid client at about 36 weeks’ gestation in active labor has had no prenatal care and admits to cocaine use during the pregnancy. Which person must the nurse notify? You Selected: • primary care provider who will attend the birth of the infant Correct response: • primary care provider who will attend the birth of the infant Question 36 The nurse should inform a client with Ménière’s disease that before an attack of the disease, the client may experience: You Selected: • a feeling of inner ear fullness. Correct response: • a feeling of inner ear fullness. Question 37 A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should: You Selected: • increase the client’s fluid intake to 3,000 mL/day. Correct response: • increase the client’s fluid intake to 3,000 mL/day. Question 38 After abdominal surgery 3 days ago the client continues to have pain every 4 to 6 hours ranging from 3 to 7 on a 10-point scale. The client has prescriptions for morphine 10 mg IM every 3 to 4 hours and acetaminophen with codeine 30 mg every 3 to 4 hours as needed for pain. The client has been taking the morphine every 4 hours for the past 3 days but tells the nurse that the morphine is no longer lasting 4 hours and wants to receive pain medication every 3 hours. The nurse reviews the progress notes that indicate the client has obtained pain relief for 5 to 6 hours after receiving the morphine. What should the nurse do to help the client manage the pain? You Selected: • Encourage the client to ambulate more frequently. Correct response: • Suggest that the client take the acetaminophen with codeine every 3 hours. Question 39 The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated? You Selected: • droplet precautions Correct response: • droplet precautions Question 40 Which intervention is the highest priority for the therapeutic management of a child with congestive heart failure (CHF) resulting from pulmonary stenosis? You Selected: • administering furosemide to decrease systemic venous congestion Correct response: • administering furosemide to decrease systemic venous congestion Question 41 The nurse is caring for an older adult who has hip pain related to rheumatoid arthritis. The client is practicing appropriate self-care activities when the client chooses to sit in which type of chair? You Selected: • straight-back chair with elevated seat Correct response: • straight-back chair with elevated seat Question 42 The school nurse learns that at least one of the children in the school has a new diagnosis of erythema infectiosum (human parvovirus) after developing a bright red facial rash. What interventions should be implemented to prevent a possible spread of the infection to other students in the school? You Selected: • Require the client to remain at home until the rash fades. Correct response: • Teach everyone to implement hand hygiene. Question 43 A client is diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of ineffective coping? You Selected: • inability to make choices and decisions without advice Correct response: • inability to make choices and decisions without advice Question 44 A neonate, admitted to the neonatal intensive care nursery for probable meconium aspiration syndrome (MAS), weighs 10 lb, 4 oz (4,650 g), and is at 42 weeks’ gestation. The neonate has a heart rate of 110 bpm and a respiratory rate of 40 breaths/min with periods of apnea. The nurse should further assess the neonate for which condition? You Selected: • hypoglycemia Correct response: • hypoglycemia Question 45 A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction? You Selected: • "Keep the stoma moist." Correct response: • "Keep the stoma moist." Question 46 A mother brings her 18-month-old child to the clinic because the child eats ashes, crayons, and paper. Which information would be most important to obtain about this toddler? You Selected: • whether the toddler is experiencing changes in the home environment Correct response: • whether the toddler is experiencing changes in the home environment Question 47 The parents of a child with occasional generalized seizures want to send the child to summer camp. The parents contact the nurse for advice on planning for the camping experience. Which type of activity should the nurse and family decide the child should most avoid? You Selected: • rock climbing Correct response: • rock climbing Question 48 A postpartum clinic nurse is assessing a client 4 weeks postpartum after a vaginal birth. What finding would indicate to the nurse that the client is experiencing normal hemodynamic changes occurring in the postpartum period? You Selected: • The hematocrit rises from 34% to 40%. Correct response: • The hematocrit rises from 34% to 40%. Question 49 A 44-lb (20-kg) preschooler is being treated for inflammation. The physician orders 0.2 mg/kg/day of dexamethasone by mouth to be administered every 6 hours. The elixir comes in a strength of 0.5 mg/5 ml. How many teaspoons of dexamethasone should the nurse give this client per dose? Record your answer using a whole number. Your Response: • 2 Correct response: • 2 Question 50 When evaluating a client for complications of acute pancreatitis, the nurse should observe for You Selected: • decreased urine output. Correct response: • decreased urine output. Question 51 Which assessment finding should a nurse interpret as abnormal for a 38-week gestation neonate who is 1 hour old? You Selected: • slight yellowish hue to the skin Correct response: • slight yellowish hue to the skin Question 52 Which moral principle is a nurse applying when the nurse decides what is best for a client and acting without consulting the individual? You Selected: • paternalism Correct response: • paternalism Question 53 The nurse is to administer IV fluids to an infant. Which safeguard would be most important for the nurse to use? You Selected: • Use of an infusion pump to regulate the flow rate Correct response: • Use of an infusion pump to regulate the flow rate Question 54 A nurse is caring for a client who presents to the emergency department following a motor vehicle accident that caused chest trauma, as a result of hitting the steering wheel. Which assessment should most concern the nurse? You Selected: • lung movement outward during expiration and inward during inspiration Correct response: • lung movement outward during expiration and inward during inspiration Question 55 A nurse is conducting a physical examination on a neonate. Which pulse point should the nurse check if a possible coarctation of the aorta is suspected? You Selected: • femoral Correct response: • femoral Question 56 Which nursing intervention would most likely promote self-care behaviors in the client with a hiatal hernia? You Selected: • Ask the client to identify other situations in which the client changed health care habits. Correct response: • Ask the client to identify other situations in which the client changed health care habits. Question 57 Before the neonate’s discharge, the mother tells the nurse that she is worried that her 5-year-old daughter will be jealous of the new baby when they get home. After explaining ways to deal with sibling rivalry, the nurse determines that the mother understands the instructions when she says she will do which action? You Selected: • Allow the 5-year-old undivided attention several times a day. Correct response: • Allow the 5-year-old undivided attention several times a day. Question 58 Following the acute stage of diverticulosis, which foods should the nurse encourage a client to incorporate into the diet? Select all that apply. You Selected: • • • broccoli navy beans bran cereal Correct response: • • • bran cereal broccoli navy beans Question 59 The nurse is caring for a client in an inpatient setting. Assessment data include fruity-smelling breath, weakness, nausea, vomiting, and shortness of breath. The nurse paged the healthcare provider caring for the client but has not received a return call. What is the next action by the nurse? You Selected: • Ask the charge nurse to attempt to contact the healthcare provider. Correct response: • Consult another healthcare provider who is available on the unit. Question 60 The nurse is reviewing assessment data and admission orders of a client. The provider has ordered the I.V. administration of phenytoin. The nurse determines that further intervention is required when the admission assessment includes which findings? Select all that apply. You Selected: • • history of Stokes-Adams syndrome history of bone marrow depression Correct response: • • • episodic nosebleeds history of Stokes-Adams syndrome history of bone marrow depression Question 61 The nurse is administering digoxin .125mg IVP to the client via healthcare provider's order. Which interventions should the nurse implement? Select all that apply. You Selected: • • Call the healthcare provider and clarify the order. Hold the order. Correct response: • • Call the healthcare provider and clarify the order. Hold the order. Question 62 A primigravida client in labor is now fully dilated and effaced after 8 hours in labor. The client asks the nurse, "When is this going to be over? It hurts so bad!" What is the best response by the nurse? You Selected: • "Since it is your first baby, your second stage of labor can last up to 4 hours." Correct response: • "You are progressing well and the second stage of labor should be complete within an hour." Question 63 The nurse completes discharge teaching with the family of an 8-week-old infant with congenital heart disease. What is the most important information for the nurse to convey regarding feeding? You Selected: • Provide a higher calorie formula or fortified breast milk. Correct response: • Provide a higher calorie formula or fortified breast milk. Question 64 One minute after birth, a neonate has an Apgar score of 6. Based on this score, what is the best intervention the nurse could implement? You Selected: • Stimulate breathing by rubbing the neonate's back. Correct response: • Stimulate breathing by rubbing the neonate's back. Question 65 The nurse assesses a toddler in the emergency department for burns on both feet, both lower legs, and the buttocks. The only area not burned from the waist down is the inside of the back of the knee. The parents inform the nurse that the child stepped into the bathtub and then sat down in the water when the water was too hot. What should the nurse do in order of priority from first to last? All options must be used. You Selected: • • • • Assess burn depth in the different areas. Provide fluid resuscitation and pain medications. Document parent-child interactions. Report incident to the authorities. Correct response: • • • • Assess burn depth in the different areas. Provide fluid resuscitation and pain medications. Document parent-child interactions. Report incident to the authorities. Explanation: Question 66 The nurse is serving on the Quality Improvement Committee for the maternity unit. Quality improvement projects for this unit impacting safety and quality of care include which projects? Select all that apply. You Selected: • • • sibling and family visitation policies postpartum discharge instructions infant identification system Correct response: • • • • infant identification system sibling and family visitation policies postpartum discharge instructions rooming in guidelines Question 67 A child is diagnosed with right chronic otitis media. After the child returns from the myringotomy and placement of ear tubes, which intervention is appropriate? You Selected: • position the child on the right side Correct response: • position the child on the right side Question 68 A client with a serum glucose level of 618 mg/dl (34.33 mmol/L) is admitted to the facility. The client is awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6° F (38.1° C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes highest priority? You Selected: • Deficient fluid volume related to osmotic diuresis Correct response: • Deficient fluid volume related to osmotic diuresis Question 69 A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect child abuse? You Selected: • The child doesn't cry when the shoulder is examined. Correct response: • The child doesn't cry when the shoulder is examined. Question 70 A true crisis state, involving a period of severe disorganization, is difficult to endure emotionally and physically. The nurse recognizes that a client will only be able to tolerate being in crisis for how long? You Selected: • 4 to 6 weeks Correct response: • 4 to 6 weeks Question 71 A 24-year-old client, diagnosed with acute osteomyelitis in the left leg, has acute pain in the leg that intensifies on movement. The client has a temperature of 101° F (38.3° C) and a reddened, warm area in the midcalf region over the shaft of the tibia. Based on this information, what should the nurse do? You Selected: • Develop a plan for pain management. Correct response: • Develop a plan for pain management. Question 72 A client asks the nurse if she is at risk for developing postpartum depression. Which of the following assessment data would further assist the nurse to identify a postpartum depression risk? Select all that apply. You Selected: • • • The client states she has a history of postpartum depression. The client has had multiple pregnancies. The client states she has a history of depression. Correct response: • • • • The client states she has a history of postpartum depression. The client states she has a history of depression. The client’s partner has stated the couple has financial problems. The client’s pregnancy has had multiple complications. Question 73 The nurse is caring for a client in labor. Which assessment findings would prompt the nurse to notify the healthcare provider? Select all that apply. You Selected: • Late decelerations are noted on the external fetal monitor strip. • The client’s membranes rupture and the amniotic fluid is green. Correct response: • • The client’s membranes rupture and the amniotic fluid is green. Late decelerations are noted on the external fetal monitor strip. Question 74 The charge nurse for the pediatric unit is making client care assignments for the staff, which includes licensed practical nurses/licensed vocational nurses (LPNs/LVNs) and unlicensed assistive personnel. Which client would be most appropriate to assign to the LPN/LVN? You Selected: • a 9-year-old child with a week-old femur fracture who is in traction Correct response: • a 9-year-old child with a week-old femur fracture who is in traction Question 75 Which of the following may be the first sign of respiratory acidosis in an anesthetized client? You Selected: • ventricular fibrillation Correct response: • ventricular fibrillation