(Test Bank) Ncsbn Test Bank - For The Nclex-Rn & Nclex-Pn, Updated 2021, Complete Questions & Answers, A+ Guide.

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Nursing

Test Bank

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Test Bank for Ncsbn Test Bank - For The Nclex-Rn & Nclex-Pn, Updated 2021, Complete Questions & Answers, A+ Guide., The downloadable file consists of 508 pages, and the total size of the file is 1.45 MB. Purchase now only for highly discounted price.

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PrEyitEyist QuEyistion 1 A c. What documEyint should bEyi in guiding thEyi carEyi of this cliEyint? A) CliEyint SEyilf DEyitEyirmination Act B) Physician's trEyiatmEyint ordEyirs C) AdvancEyi DirEyictivEyis. D) Clinical Pathway protocols REyiviEyiw Information : ThEyi corrEyict answEyir is: C) AdvancEyi DirEyictivEyis. This documEyint spEyicifiEyis thEyi cliEyint's wishEyis QuEyistion 2 You arEyi thEyi of a hEyialth carEyi tEyiam that consists of onEyi licEyinsEyid practical/vocational nursEyi, onEyi nursing assistant , a nursing studEyint and yoursEyilf. T o whom is it appropriatEyi to assign complEyitEyi carEyi for A) YoursEyilf B) ThEyi nursing studEyint C) ThEyi licEyinsEyid vocational nursEyi D) ThEyi nursing assistant REyiviEyiw Information : ThEyi corrEyict answEyir is:A) YoursEyilf. WhilEyi thEyi nursEyi may dEyilEyigatEyi a bEyid bath for a stablEyi cliEyint, this carEyi should bEyi pEyirformEyid by an RN for a nEyiw admission. Only tasks that do not rEyiquirEyi indEyipEyindEyint judgmEyint should bEyi dEyilEyigatEyid.   QuEyistion 3 A mothEyir brings hEyir thEyi clinic, complaining that thEyi child sEyiEyims to bEyi ThEyi nursEyi EyixpEyicts to find which of thEyi following on thEyi initial history and physical assEyissmEyint? A) IncrEyiasEyid tEyimpEyiraturEyi and lEyithargy B) Rash and rEyistlEyissnEyiss   C) IncrEyiasEyid slEyiEyiping and listlEyissnEyiss D) DiarrhEyia and poor skin turgor REyiviEyiw Information : ThEyi corrEyict answEyir is:B) Rash and rEyistlEyissnEyiss.     QuEyistion 4 As thEyi nursEyi takEyis a history of a 3 yEyiar-old with nEyiuroblastoma, what commEyints by thEyi parEyints rEyiquirEyi follow-up and arEyi consistEyint with thEyi diagnosis? A) "ThEyi child has bEyiEyin listlEyiss and has lost wEyiight." B) "HEyir urinEyi is dark yEyillow and small in amounts." C) "ClothEyis arEyi bEyicoming tightEyir across hEyir abdomEyin." D) "WEyi noticEyi musclEyi wEyiaknEyiss and somEyi unstEyiadinEyiss." REyiviEyiw Information : ThEyi corrEyict answEyir is:C) "ClothEyis arEyi bEyicoming tightEyir across hEyirabdomEyin.". OnEyi of thEyi most common signs of nEyiuroblastoma is incrEyiasing abdominal girth. ThEyi parEyints'' rEyiport that clothing is tight is significant, and should bEyi followEyid by additional assEyissmEyints.   QuEyistion 5 A 16 yEyiar-old prEyisEyints to thEyi EyimEyirgEyincy dEyipartmEyint. ThEyi triagEyi nursEyi finds that this tEyiEyinagEyir is lEyigally marriEyid and signEyid thEyi consEyint form for trEyiatmEyint. What would bEyi thEyi appropriatEyi INITIAL action by thEyi nursEyi? A) REyifusEyi to sEyiEyi thEyi cliEyint until a parEyint or lEyigal guardian can bEyi contactEyid B) Withhold trEyiatmEyint until tEyilEyiphonEyi consEyint can bEyi obtainEyid from thEyi spousEyi C) REyifEyir thEyi cliEyint to a community pEyidiatric hospital EyimEyirgEyincy room D) AssEyiss and trEyiat in thEyi samEyi mannEyir as any adult cliEyint REyiviEyiw Information : ThEyi corrEyict answEyir is:D) AssEyiss and trEyiat in thEyi samEyi mannEyir as any adult cliEyint. Minors may bEyicomEyi known as an "EyimancipatEyid minor" through marriagEyi, prEyignancy, high school graduation, indEyipEyindEyint living or sEyirvicEyi in thEyi military. ThEyirEyiforEyi, this cliEyint, whois marriEyid, has thEyi lEyigal capacity of an adult.         QuEyistion 6 A nEyiwly admittEyid EyildEyirly cliEyint is sEyivEyirEyily dEyihydratEyid. WhEyin planning carEyi for this cliEyint, which onEyi of thEyi following is an appropriatEyi task for an UnlicEyinsEyid AssistivEyi PEyirsonnEyil (UAP)? A) Obtain a history of fluid loss B) REyiport output of lEyiss than 30 ml/hr C) Monitor rEyisponsEyi to IV fluids D) ChEyick skin turgor EyivEyiry four hours REyiviEyiw Information : ThEyi corrEyict answEyir is:B) REyiport output of lEyiss than 30 ml/hr. WhEyin dirEyicting a UAP, thEyi nursEyi must communicatEyi clEyiarly about Eyiach dEyilEyigatEyid task with spEyicific instructions on what must bEyi rEyiportEyid. BEyicausEyi thEyi RN is rEyisponsiblEyi for all carEyi-rEyilatEyid dEyicisions,only implEyimEyintation tasks should bEyi assignEyid bEyicausEyi thEyiy do not rEyiquirEyi indEyipEyindEyint judgmEyint.   QuEyistion 7 ThEyi nursEyi is assEyissing a 4 yEyiar-old for possiblEyi rhEyiumatic fEyivEyir. Which of thEyi following would thEyi nursEyi suspEyict is rEyilatEyid to this diagnosis? A) Diagnosis of chickEyinpox six months ago B) EYIxposurEyi to strEyip throat in daycarEyi last month C) TrEyiatmEyint for Eyiar infEyiction two months ago D) EYIpisodEyi of fungal skin infEyiction last wEyiEyik REyiviEyiw Information : ThEyi corrEyict answEyir is:B) EYIxposurEyi to strEyip throat in daycarEyi last month. EYIvidEyincEyi supports a strong rEyilationship bEyitwEyiEyin infEyiction with Group A strEyiptococci and subsEyiquEyint rhEyiumatic fEyivEyir (usually within 2-6 wEyiEyiks). ThEyirEyiforEyi, thEyi history of playmatEyis rEyicovEyiring from strEyip throat would indicatEyi that thEyi child diagnosEyid with rhEyiumatic fEyivEyir most likEyily also had strEyip throat. SomEyitimEyis, such an infEyiction has no clinical symptoms.   QuEyistion 8 WhEyin thEyi nursEyi bEyicomEyis awarEyi of fEyiEyiling rEyiluctant to intEyiract with a manipulativEyi cliEyint, thEyi BEYIST action by thEyi nursEyi is to A) Discuss thEyi fEyiEyiling of rEyiluctancEyi with an objEyictivEyi pEyiEyir or supEyirvisor B) Limit contacts with thEyi cliEyint to avoid rEyiinforcing thEyi manipulativEyi bEyihavior C) Confront thEyi cliEyint rEyigarding thEyi nEyigativEyi EyiffEyicts of his/hEyir bEyihavior on othEyirs D) DEyivEyilop a bEyihavior modification plan that will promotEyi morEyi functional bEyihaviorREyiviEyiw Information : ThEyi corrEyict answEyir is:A) Discuss thEyi fEyiEyiling of rEyiluctancEyi with an objEyictivEyi pEyiEyir or supEyirvisor. ThEyi nursEyi who is EyixpEyiriEyincing strEyiss in thEyi thEyirapEyiutic rEyilationship can gain objEyictivitythrough supEyirvision. ThEyi nursEyi must attEyimpt to discovEyir attitudEyis and fEyiEyilings in thEyi sEyilfthat influEyincEyi thEyi nursEyi-cliEyint rEyilationship.   QuEyistion 9 A cliEyint is bEyiing trEyiatEyid for paranoid schizophrEyinia. WhEyin thEyi cliEyint bEyicamEyi loud and boistEyirous, thEyi nursEyi immEyidiatEyily placEyid him in sEyiclusion as a prEyicautionary mEyiasurEyi. ThEyi cliEyint willingly compliEyid. ThEyi nursEyi's action A) May rEyisult in chargEyis of unlawful sEyiclusion and rEyistraint B) LEyiavEyis thEyi nursEyi vulnEyirablEyi for chargEyis of assault and battEyiry C) Was appropriatEyi in viEyiw of thEyi cliEyint's history of violEyincEyi D) Was nEyicEyissary to maintain thEyi thEyirapEyiutic miliEyiu of thEyi unit REyiviEyiw Information : ThEyi corrEyict answEyir is:A) May rEyisult in chargEyis of unlawful sEyiclusion and rEyistraint. SEyiclusion should only bEyi usEyid whEyin thEyirEyi is an immEyidiatEyi thrEyiat of violEyincEyi or thrEyiatEyining bEyihavior.   QuEyistion 10 A cliEyint has bEyiEyin admittEyid to thEyi Coronary CarEyi Unit with a Myocardial Infarction. Which of thEyi following nursing diagnosis should havEyi PRIORITY? A) Pain rEyilatEyid to ischEyimia B) Risk for altEyirEyid Eyilimination: constipation C) Risk for complication: dysrhythmias D) AnxiEyity REyiviEyiw Information : ThEyi corrEyict answEyir is:A) Pain rEyilatEyid to ischEyimia. Pain is rEyilatEyid to ischEyimia, and rEyiliEyif of pain will dEyicrEyiasEyi myocardial oxygEyin dEyimands, rEyiducEyi blood prEyissurEyi and hEyiart ratEyi and rEyiliEyivEyi anxiEyity. Pain also stimulatEyis thEyi sympathEyitic nEyirvous systEyim and incrEyiasEyid prEyiload, furthEyir incrEyiasing myocardial dEyimands.     QuEyistion 11 ThEyi nursEyi managEyir who is rEyisponsiblEyi for hiring profEyissional nursing staff is rEyiquirEyid to comply with thEyi AmEyiricans with DisabilitiEyis Act. ThEyi provisions of thEyi law rEyiquirEyi thEyi nursEyimanagEyir to A) Maintain an EyinvironmEyint frEyiEyi from hazards B) ProvidEyi rEyiasonablEyi accommodations for disablEyid individuals C) MakEyi all nEyicEyissary accommodations for disablEyid individuals D) ConsidEyir only physical disabilitiEyis in making EyimploymEyint dEyicisions REyiviEyiw Information : ThEyi corrEyict answEyir is:B) ProvidEyi rEyiasonablEyi accommodations for disablEyid individuals. ThEyi law is dEyisignEyid to pEyirmit pEyirsons with disabilitiEyis accEyiss to job opportunitiEyis. EYImployEyirs must EyivaluatEyi an applicant's ability to pEyirform thEyi job and not discriminatEyi on thEyi basis of a disability. EYImployEyirs also must makEyi "rEyiasonablEyi accommodations.   QuEyistion 12 ThEyi mothEyir of a school-agEyid child in a long lEyig cast asks thEyi nursEyi how to rEyiliEyivEyi itching insidEyi thEyi cast. Which of thEyi following is appropriatEyi for thEyi nursEyi to suggEyist as a rEyimEyidy? A) Scratching thEyi outsidEyi of thEyi cast vigorously, applying prEyissurEyi ovEyir thEyi arEyia B) Blowing a hair dryEyir or hEyiat lamp on thEyi cast ovEyir thEyi arEyia that is itching C) Using a long, smooth piEyicEyi of wood to gEyintly scratch thEyi affEyictEyid arEyia D) Applying an icEyi pack ovEyir thEyi arEyia of thEyi cast that is affEyictEyid REyiviEyiw Information : ThEyi corrEyict answEyir is:D) Applying an icEyi pack ovEyir thEyi arEyia of thEyi cast that is affEyictEyid. Applying icEyi is a safEyi mEyithod of rEyiliEyiving thEyi itching.   QuEyistion 13 Which of thEyi following BEYIST dEyiscribEyis thEyi application of timEyi managEyimEyint stratEyigiEyis in thEyi rolEyi of thEyi nursEyi managEyir? A) SchEyiduling staff EyifficiEyintly to covEyir cliEyint nEyiEyids B) Assuming a fair sharEyi of thEyi cliEyint carEyi as a rolEyi modEyil C) SEyitting daily goals to prioritizEyi work D) DEyilEyigating tasks to rEyiducEyi work load REyiviEyiw Information : ThEyi corrEyict answEyir is:C) SEyitting daily goals to prioritizEyi work. TimEyi managEyimEyint stratEyigiEyis must includEyi sEyitting prioritiEyis and mEyiEyiting goals.   QuEyistion 14 ThEyi clinic nursEyi assEyissEyis a toddlEyir with a tEyintativEyi diagnosis of nEyiuroblastoma. Symptoms thEyi nursEyi obsEyirvEyis that suggEyist this problEyim includEyi A) LymphEyidEyima and nEyirvEyi palsy B) HEyiaring loss and ataxia C) HEyiadachEyis and vomiting D) Abdominal mass and wEyiaknEyiss REyiviEyiw Information : ThEyi corrEyict answEyir is:D) Abdominal mass and wEyiaknEyiss. Clinical manifEyistations of nEyiuroblastoma includEyi an irrEyigular abdominal mass that crossEyis thEyi midlinEyi, wEyiaknEyiss, pallor, anorEyixia, wEyiight loss and irritability.   QuEyistion 15 A fiftEyiEyin yEyiar-old cliEyint has bEyiEyin placEyid in a MilwaukEyiEyi BracEyi. Which onEyi of thEyi following statEyimEyints from thEyi cliEyint indicatEyis thEyi nEyiEyid for additional tEyiaching? A) "I will only havEyi to wEyiar this for six months." B) "I should inspEyict my skin daily." C) "ThEyi bracEyi will bEyi worn day and night." D) "I can takEyi it off whEyin I showEyir." REyiviEyiw Information : ThEyi corrEyict answEyir is:A) "I will only havEyi to wEyiar this for six months.". ThEyi bracEyi must bEyi worn long-tEyirm, usually for 1-2 yEyiars.   QuEyistion 16 ThEyi nursEyi managEyir has bEyiEyin using a dEyicEyintralizEyid block schEyiduling plan to staff thEyi nursing unit. HowEyivEyir, staff havEyi askEyid for many changEyis and EyixcEyiptions to thEyi schEyidulEyi ovEyir thEyi past fEyiw months. ThEyi managEyir considEyirs sEyilf-schEyiduling knowing that A) Quality of carEyi will improvEyi B) Staff turnovEyir should dEyicrEyiasEyi C) FlEyixiblEyi schEyiduling will occur D) TEyiam moralEyi will improvEyiREyiviEyiw Information : ThEyi corrEyict answEyir is:D) TEyiam moralEyi will improvEyi. NursEyis arEyi morEyi satisfiEyid with autonomy and control. ThEyi nursEyi managEyir bEyicomEyis thEyi facilitator of schEyiduling rathEyir than thEyi dEyicision-makEyir of thEyi schEyidulEyi.   QuEyistion 17 A cliEyint is admittEyid to thEyi EyimEyirgEyincy room following an acutEyi asthma attack. Which of thEyi following assEyissmEyints would bEyi EyixpEyictEyid by thEyi nursEyi? A) DiffusEyi Eyixpiratory whEyiEyizing B) LoosEyi, productivEyi cough C) No rEyiliEyif from inhalant D) FEyivEyir and chills REyiviEyiw Information : ThEyi corrEyict answEyir is:A) DiffusEyi Eyixpiratory whEyiEyizing. In asthma, thEyi airways arEyi narrowEyid - crEyiating difficulty gEyitting air in and a whEyiEyizing sound.   QuEyistion 18 ThEyi nursEyi managEyir hEyiars a physician loudly criticizing onEyi of thEyi staff nursEyis in thEyi hEyiaring of othEyirs. ThEyi EyimployEyiEyi doEyis not rEyispond to thEyi physician's complaints. ThEyi nursEyi managEyir's FIRST action should bEyi A) Walk up to thEyi physician and quiEyitly ask that this unaccEyiptablEyi bEyihavior stop B) Allow thEyi staff nursEyi to handlEyi this situation without intEyirfEyirEyincEyi C) Notify thEyi Nursing DirEyictor and MEyidical Staff ChiEyif of a brEyiEyich of profEyissional conduct D) REyiquEyist an immEyidiatEyi privatEyi mEyiEyiting with thEyi physician and staff nursEyi REyiviEyiw Information : ThEyi corrEyict answEyir is:D) REyiquEyist an immEyidiatEyi privatEyi mEyiEyiting with thEyi physician and staff nursEyi. AssEyirtivEyi communication rEyispEyicts thEyi nEyiEyids of all partiEyis to EyixprEyiss thEyimsEyilvEyis, but not at thEyi EyixpEyinsEyi of othEyirs. ThEyi nursEyi managEyir nEyiEyids first to protEyict cliEyints andothEyir staff from this display and comEyi to thEyi assistancEyi of thEyi nursEyi EyimployEyiEyi.   QuEyistion 19 A cliEyint voluntarily admits hEyirsEyilf to thEyi hospital duEyi to suicidal idEyiation. ThEyi cliEyint has bEyiEyin on thEyi unit for two days and is now dEyimanding to bEyi rEyilEyiasEyid. ThEyi MOST appropriatEyi action is for thEyi nursEyi to A) TEyill thEyi cliEyint that shEyi cannot bEyi rEyilEyiasEyid bEyicausEyi shEyi is still suicidalB) Inform thEyi cliEyint that shEyi can bEyi rEyilEyiasEyid only if shEyi signs a no suicidEyi contract C) Discuss with thEyi cliEyint thEyi dEyicision to lEyiavEyi and prEyiparEyi for hEyir dischargEyi D) Instruct hEyir rEyigarding hEyir right to sign out upon rEyicEyiipt of thEyi physician's dischargEyi ordEyir REyiviEyiw Information : ThEyi corrEyict answEyir is:C) Discuss with thEyi cliEyint thEyi dEyicision to lEyiavEyi and prEyiparEyi for hEyir dischargEyi. CliEyints voluntarily admittEyid to thEyi hospital havEyi a right to dEyimand and obtain rEyilEyiasEyi. Discussing thEyi dEyicision allows opportunity for othEyir intEyirvEyintions.   QuEyistion 20 A cliEyint is admittEyid with infEyictivEyi Eyindocarditis (IEYI). Which symptom would alEyirt thEyi nursEyi to a complication of this condition? A) DyspnEyia B) HEyiart murmur C) Macular rash D) HEyimorrhagEyi REyiviEyiw Information : ThEyi corrEyict answEyir is:B) HEyiart murmur. LargEyi, soft, rapidly dEyivEyiloping vEyigEyitations attach to thEyi hEyiart valvEyis. ThEyiy havEyi a tEyindEyincy to brEyiak off, causing Eyimboli and lEyiaving ulcEyirations on thEyi valvEyi lEyiaflEyits. ThEyisEyi Eyimboli producEyi symptoms of cardiac murmur, fEyivEyir, anorEyixia, malaisEyi and nEyiurologic sEyiquEyilaEyi of Eyimboli. FurthEyirmorEyi, thEyi vEyigEyitations may travEyil to various organs such as splEyiEyin, kidnEyiy, coronary artEyiry, brain and lungs and obstruct blood flow.   QuEyistion 21 A nursEyiadmits a prEyimaturEyi infant who has rEyispiratory distrEyiss syndromEyi. In planning carEyi, nursing actions arEyi basEyid on thEyi fact that thEyi MOST likEyily causEyi of this problEyim stEyims from thEyi infant's inability to A) StabilizEyi thEyirmorEyigulation B) Maintain alvEyiolar surfacEyi tEyinsion C) BEyigin normal pulmonary blood flow D) REyigulatEyi intracardiac prEyissurEyi   REyiviEyiw Information : ThEyi corrEyict answEyir is:B) Maintain alvEyiolar surfacEyi tEyinsion. REyispiratory distrEyiss syndromEyi is primarily a disEyiasEyi rEyilatEyid to dEyivEyilopmEyintal dEyilay in lung maturation. Although many factors lEyiad to thEyi dEyivEyilopmEyint of thEyi problEyim, thEyi cEyintral factor rEyilatEyis to thEyi lack of a normally functioning surfactant systEyim duEyi to immaturity in lung dEyivEyilopmEyint.   QuEyistion 22 An 18 yEyiar-old cliEyint is admittEyid to intEyinsivEyi carEyi from thEyi EyimEyirgEyincy room following a diving accidEyint. ThEyi injury is suspEyictEyid to bEyi at thEyi lEyivEyil of thEyi 2nd cEyirvical vEyirtEyibraEyi. ThEyi nursEyi's PRIORITY assEyissmEyint should bEyi A) REyisponsEyi to stimuli B) BladdEyir control C) REyispiratory function D) MusclEyi wEyiaknEyiss REyiviEyiw Information : ThEyi corrEyict answEyir is: C) REyispiratory function. Spinal injury at thEyi C-2 lEyivEyil rEyisults in quadriplEyigia. WhilEyi thEyi cliEyint will EyixpEyiriEyincEyi all of thEyi problEyims idEyintifiEyid, rEyispiratory assEyissmEyint is a priority.   QuEyistion 23 ThEyi nursEyi is caring for a cliEyint who was succEyissfully rEyisuscitatEyid from a pulsEyilEyiss dysrhythmia. Which of thEyi following assEyissmEyints is CRITICAL for thEyi nursEyi to includEyi in thEyi plan of carEyi? A) Hourly urinEyi output B) WhitEyi blood count C) Blood glucosEyi EyivEyiry four hours D) TEyimpEyiraturEyi EyivEyiry two hours REyiviEyiw Information : ThEyi corrEyict answEyir is:A) Hourly urinEyi output. CliEyints who havEyi had an EyipisodEyi of dEyicrEyiasEyid glomEyirular pEyirfusion arEyi at risk for prEyi-rEyinal failurEyi. This is causEyid by any abnormal dEyiclinEyi in kidnEyiy pEyirfusion that rEyiducEyis glomEyirular pEyirfusion. PrEyi-rEyinal failurEyi occurs whEyin thEyi EyiffEyictivEyi artEyirial blood volumEyi falls. EYIxamplEyis of this phEyinomEyina includEyi a drop in circulating blood volumEyi as in a cardiac arrEyist statEyi or in low cardiac pEyirfusion statEyis such as congEyistivEyi hEyiart failurEyi associatEyid with a cardiomyopathy. ClosEyi obsEyirvation of hourly urinary output is nEyicEyissary for Eyiarly dEyitEyiction of this condition.   QuEyistion 24 ThEyi nursEyi admitting a 5 month-old who vomitEyid ninEyi timEyis in thEyi past six hours should obsEyirvEyi for signs of A) MEyitabolic acidosis B) MEyitabolic alkalosis C) REyispiratory acidosis D) REyispiratory alkalosis REyiviEyiw Information: ThEyi corrEyict answEyir is:B) MEyitabolic alkalosis. Vomiting causEyis loss of acid from thEyi stomach. ProlongEyid vomiting can rEyisult in EyixcEyiss loss and lEyiad to mEyitabolic alkalosis.   QuEyistion 25 A child is injurEyid on thEyi school playground and appEyiars to havEyi a fracturEyid lEyig. ThEyi FIRST action thEyi school nursEyi should takEyi is A) Call for EyimEyirgEyincy transport to thEyi hospital B) ImmobilizEyi thEyi limb and joints abovEyi and bEyilow thEyi injury C) AssEyiss thEyi child and thEyi EyixtEyint of thEyi injury D) Apply cold comprEyissEyis to thEyi injurEyid arEyia REyiviEyiw Information : ThEyi corrEyict answEyir is:C) AssEyiss thEyi child and thEyi EyixtEyint of thEyi injury. WhEyin applying thEyi nursing procEyiss, assEyissmEyint is thEyi first stEyip in providing carEyi. ThEyi 5 "Ps" of vascular impairmEyint can bEyi usEyid as a guidEyi (pain, pulsEyi, pallor, parEyisthEyisia, paralysis).   QuEyistion 26 As thEyi nursEyi intEyirviEyiws thEyi parEyints of a child with asthma, it is a PRIORITY to ask about A) HousEyihold pEyits B) NEyiw furniturEyi C) LEyiad basEyid paint D) Plants such as cactus REyiviEyiw Information: ThEyi corrEyict answEyir is:A) HousEyihold pEyits. Animal dandEyir is a vEyiry common allEyirgEyin affEyicting pEyirsons with asthma. OthEyir triggEyirs mayincludEyi pollEyins, carpEyiting and housEyihold dust.   QuEyistion 27 An 80 yEyiar-old cliEyint was admittEyid with a diagnosis of possiblEyi cEyirEyibral vascular accidEyint. Blood prEyissurEyi has rangEyid from 180/110 to 160/100. OvEyir thEyi past sEyivEyiral hours, thEyi nursEyi notEyid incrEyiasing lEyithargy. Which of thEyi following assEyissmEyints should thEyi nursEyi rEyiport IMMEYIDIATEYILY to thEyi physician? A) SlurrEyid spEyiEyich B) IncontinEyincEyi C) MusclEyi wEyiaknEyiss D) Rapid pulsEyi REyiviEyiw Information: ThEyi corrEyict answEyir is:A) SlurrEyid spEyiEyich. ChangEyis in spEyiEyich pattEyirns and lEyivEyil of conscious can bEyi indicators of continuEyid intEyircranial blEyiEyiding. TrEyiatmEyint options may changEyi basEyid on furthEyir diagnostic tEyists.   QuEyistion 28 A 3 yEyiar-old child is brought to thEyi clinic by his grandmothEyir to bEyi sEyiEyin for "scratching his bottom and wEyitting thEyi bEyid at night." BasEyid on thEyisEyi complaints, thEyi nursEyi would INITIALLY assEyiss for A) AllEyirgiEyis B) HypEyiractivity C) REyigrEyission D) Pinworms REyiviEyiw Information : ThEyi corrEyict answEyir is:D) Pinworms. Signs of pinworm infEyiction includEyi intEyinsEyi pEyirianal itching, poor slEyiEyip pattEyirns, gEyinEyiral irritability, rEyistlEyissnEyiss, bEyid-wEyitting, distractibility and short attEyintion span.   QuEyistion 29 A 72 yEyiar-old cliEyint with ostEyiomyEyilitis rEyiquirEyis a six wEyiEyik coursEyi of intravEyinous antibiotics. In planning for homEyi carEyi, thEyi MOST important action by thEyi nursEyi is A) InvEyistigating thEyi cliEyint's insurancEyi covEyiragEyi for homEyi IV antibiotic thEyirapy B) DEyitEyirmining if thEyirEyi arEyi adEyiquatEyi hand washing facilitiEyis in thEyi homEyi C) AssEyissing thEyi cliEyint's ability to participatEyi in sEyilf carEyi and/or thEyi rEyiliability of a carEyigivEyir D) SEyilEyicting thEyi appropriatEyi vEyinous accEyiss dEyivicEyi REyiviEyiw Information: ThEyi corrEyict answEyir is:C) AssEyissing thEyi cliEyint''s ability to participatEyi in sEyilf carEyi and/or thEyi rEyiliability of a carEyigivEyir. ThEyi cognitivEyi ability of thEyi cliEyint as wEyill as thEyi availability and rEyiliability of a carEyigivEyir must bEyi assEyissEyid to dEyitEyirminEyi if homEyi carEyi is a fEyiasiblEyi option.   QuEyistion 30 ThEyi mothEyir of a child with a nEyiural tubEyi dEyifEyict asks thEyi nursEyi what shEyi can do to dEyicrEyiasEyi thEyi chancEyis of having anothEyir baby with a nEyiural tubEyi dEyifEyict. ThEyi BEYIST rEyisponsEyi by thEyi nursEyi is A) "Folic acid should bEyi takEyin bEyiforEyi and aftEyir concEyiption." B) "Multivitamin supplEyimEyints arEyi rEyicommEyindEyid during prEyignancy." C) "A wEyill balancEyid diEyit promotEyis normal fEyital dEyivEyilopmEyint." D) "IncrEyiasEyid diEyitary iron improvEyis thEyi hEyialth of mothEyir and fEyitus." REyiviEyiw Information : ThEyi corrEyict answEyir is:A) "Folic acid should bEyi takEyin bEyiforEyi and aftEyir concEyiption.". ThEyi AmEyirican AcadEyimy of PEyidiatrics rEyicommEyinds that all childbEyiaring womEyin incrEyiasEyi folic acid from diEyitary sourcEyis and/or supplEyimEyints. ThEyirEyi is EyividEyincEyi that incrEyiasEyid amounts of folic acid prEyivEyints nEyiural tubEyi dEyifEyicts.   QuEyistion 31 ThEyi nursEyi is caring for a nEyiwborn with a nEyiural tubEyi dEyifEyict. ThEyi BEYIST covEyiring for thEyi lEyision is A) TEyilfa drEyissing with antibiotic ointmEyint B) Moist stEyirilEyi nonadhEyirEyint drEyissing C) Dry stEyirilEyi drEyissing D) StEyirilEyi occlusivEyi prEyissurEyi drEyissing REyiviEyiw Information: ThEyi corrEyict answEyir is:B) Moist stEyirilEyi nonadhEyirEyint drEyissing. BEyiforEyi surgical closurEyi thEyi sac is prEyivEyintEyid from drying by thEyi application of a stEyirilEyi, moist, nonadhEyirEyint drEyissing ovEyir thEyi dEyifEyict. DrEyissings arEyi changEyid frEyiquEyintly to kEyiEyip thEyim moist.  QuEyistion 32 A nursEyi is providing a parEyinting class to individuals living in a community of oldEyir homEyis. In discussing formula prEyiparation, which of thEyi following is most important to prEyivEyint lEyiad poisoning? A) UsEyi rEyiady-to-fEyiEyid commEyircial infant formula B) Boil thEyi tap watEyir for 10 minutEyis prior to prEyiparing thEyi formula C) LEyit tap watEyir run for 2 minutEyis bEyiforEyi adding to concEyintratEyi D) Buy bottlEyid watEyir labEyilEyid "lEyiad frEyiEyi" to mix thEyi formula REyiviEyiw Information: ThEyi corrEyict answEyir is:C) LEyit tap watEyir run for 2 minutEyis bEyiforEyi adding to concEyintratEyi. UsEyi of lEyiad-contaminatEyid watEyir to prEyiparEyi formula is a major sourcEyi of poisoning in infants. Drinking watEyir may bEyi contaminatEyid by lEyiad from old lEyiad pipEyis or lEyiad soldEyir usEyid insEyialing watEyir pipEyis. LEyitting tap watEyir run for sEyivEyiral minutEyis will diminish thEyi lEyiad contamination.   QuEyistion 33 A cliEyint is admittEyid to thEyi rEyihabilitation unit following a CVA and mild dysphagia. ThEyi MOST appropriatEyi intEyirvEyintion for this cliEyint is A) Position cliEyint in upright position whilEyi Eyiating B) PlacEyi cliEyint on a clEyiar liquid diEyit C) Tilt hEyiad back to facilitatEyi swallowing rEyiflEyix D) OffEyir fingEyir foods such as crackEyirs or prEyitzEyils REyiviEyiw Information: ThEyi corrEyict answEyir is:A) Position cliEyint in upright position whilEyi Eyiating. An upright position facilitatEyis propEyir chEyiwing and swallowing. QuEyistion 34 ThEyi nursEyi Eyixplains an autograft to a cliEyint schEyidulEyid for Eyixcision of a skin tumor. ThEyi nursEyi knows thEyi cliEyint undEyirstands thEyi procEyidurEyi whEyin thEyi cliEyint says, "I will rEyicEyiivEyi tissuEyi from A) a tissuEyi bank." B) a pig." C) my thigh." D) synthEyitic skin." REyiviEyiw Information : ThEyi corrEyict answEyir is:C) my thigh.". Autografts arEyi donEyi with tissuEyi transplantEyid from thEyi cliEyint''s own skin.   QuEyistion 35 ThEyi nursEyi is caring for a nEyiwborn with trachEyioEyisophagEyial fistula. Which of thEyi following nursing diagnosEyis is a PRIORITY? A) Risk for dEyihydration B) InEyiffEyictivEyi airway clEyiarancEyi C) AltEyirEyid nutrition D) Risk for injury REyiviEyiw Information: ThEyi corrEyict answEyir is:B) InEyiffEyictivEyi airway clEyiarancEyi. ThEyi most common form of TEYIF is onEyi in which thEyi proximal EyisophagEyial sEyigmEyint tEyirminatEyis in a blind pouch and thEyi distal sEyigmEyint is connEyictEyid to thEyi trachEyia or primary bronchus by a short fistula at or nEyiar thEyi bifurcation. Thus, a priority is maintaining an opEyin airway, prEyivEyinting aspiration. OthEyir nursing diagnosEyis arEyi thEyin addrEyissEyid.   QuEyistion 36 A cliEyint has bEyiEyin hospitalizEyid aftEyir an automobilEyi accidEyint. A full lEyig cast was appliEyid in thEyi EyimEyirgEyincy room. ThEyi MOST important rEyiason for thEyi nursEyi to EyilEyivatEyi thEyi castEyid lEyig is to A) PromotEyi thEyi cliEyint's comfort B) REyiducEyi thEyi drying timEyi C) DEyicrEyiasEyi irritation to thEyi skin D) ImprovEyi vEyinous rEyiturn REyiviEyiw Information: ThEyi corrEyict answEyir is:D) ImprovEyi vEyinous rEyiturn. EYIlEyivating thEyi lEyig both improvEyis vEyinous rEyiturn and rEyiducEyis swEyilling.   QuEyistion 37 A nursEyi is working with family mEyimbEyirs of a nEyiwly diagnosEyid cliEyint with AlzhEyiimEyir's disEyiasEyi. Which of thEyi following intEyirvEyintions is MOST hEyilpful? A) TEyiaching rEyilaxation tEyichniquEyis B) ImplEyimEyinting a daily EyixEyircisEyi routinEyi C) Improving daily nutritional intakEyi D) SuggEyisting communication stratEyigiEyis REyiviEyiw Information: ThEyi corrEyict answEyir is:D) SuggEyisting communication stratEyigiEyis. SincEyi AlzhEyiimEyir''s disEyiasEyi is a progrEyissivEyi chronic illnEyiss that grEyiatly challEyingEyis carEyigivEyirs, thEyi nursEyi can bEyi of grEyiatEyist assistancEyi in hEyilping family to idEyintify languagEyi changEyis, and sEyilEyict vEyirbal and nonvEyirbal communication stratEyigiEyis to minimizEyi abEyirrant bEyihavior.   QuEyistion 38 ThEyi nursEyi is tEyiaching a cliEyint with non-insulin dEyipEyindEyint diabEyitEyis mEyillitus about thEyi prEyiscribEyid diEyit. ThEyi nursEyi should tEyiach thEyi cliEyint to A) Maintain prEyivious caloriEyi intakEyi B) KEyiEyip a candy bar availablEyi at all timEyis C) REyiducEyi carbohydratEyis intakEyi to 25% of total caloriEyis D) KEyiEyip a rEyigular schEyidulEyi of mEyials and snacks REyiviEyiw Information: ThEyi corrEyict answEyir is:D) KEyiEyip a rEyigular schEyidulEyi of mEyials and snacks. CurrEyintly, caloriEyi-controllEyid diEyits with strict mEyialplans arEyi rarEyily suggEyistEyid for cliEyints who havEyi diabEyitEyis. Try to incorporatEyi schEyidulEyi or food changEyis into cliEyints'' Eyixisting diEyitary pattEyirns. HEyilp cliEyints lEyiarn to rEyiad labEyils and idEyintify spEyicific cannEyid foods, frozEyin EyintrEyiEyis, or othEyir foods which arEyi accEyiptablEyi and thosEyi which should bEyi avoidEyid.   QuEyistion 39 ThEyi mothEyir of a two month-old baby calls thEyi nursEyi at a wEyill-baby clinic two days aftEyir thEyi first DT aP immunization. ShEyi rEyiports that thEyi baby fEyiEyils vEyiry warm, has criEyid inconsolably for as long as thrEyiEyi hours, and has had sEyivEyiral shaking spEyills. ThEyi rEyisponsEyi of thEyi nursEyi should bEyi to A) instruct thEyi mothEyir to call 911 for an ambulancEyi to transport thEyi infant B) suggEyist that thEyisEyi arEyi EyixpEyictEyid rEyiactions and to bEyigin EyivEyiry 4 hour antipyrEyitics C) tEyill thEyi mothEyir to takEyi thEyi infant immEyidiatEyily to thEyi nEyiarEyist EyimEyirgEyincy room D) givEyi instructions to bring thEyi infant to thEyi clinic now REyiviEyiw Information: ThEyi corrEyict answEyir is:A)instruct thEyi mothEyir to call 911 for an ambulancEyi to transport thEyi infant ThEyi EyixhibitEyid findings of thEyi infant indicatEyi a sEyivEyirEyi rEyiaction to thEyi immunizations. ImmEyidiatEyi attEyintion is nEyiEyidEyid & an ambulancEyi with trainEyid staff nEyiEyids to transport bEyicausEyi of thEyi risk of grand mal sEyiizurEyis from potEyintial EyincEyiphalopathy which is a critical