75 - Nursing Exams QAs

 

Question 5071) 

A 5-year-old boy is admitted because he bled profusely when he lost his first baby tooth. After a workup, he is diagnosed as having classic hemophilia. His mother asks the nurse if his two younger sisters will also develop hemophilia. What is the best answer for the nurse to give? 

A. “They will not develop the disease.” 

B. “Statistically, one of them is likely to develop the disease.” 

C. “They are not likely to get the disease, but they may be carriers.” 

D. “If it doesn’t show up by the time they start school, they are unlikely to develop the condition.” 

Answer: C 

Explanation: Hemophilia is carried on the X chromosome and causes disease when it appears in combination with the Y chromosome in the male. Answer 1 is a true statement, but it is not complete and, therefore, not the best answer. 

Question 5072) 

The nurse has been teaching the parents of a child with hemophilia about the care he will need. Which statement by the parents indicates a need for more instruction? 

A. “If my child needs something for pain or a fever, I will give him acetaminophen instead of aspirin.” 

B. “I will take my child to the dentist for regular checkups.” 

C. “I will keep my child in the house most of the time.” 

D. “My son’s Medic Alert Bracelet arrived.” 

Answer: C 

Explanation: Parents of children with hemophilia tend to overprotect them. A goal is to have the child lead as normal a life as possible. Answer 1 is correct. He should not receive aspirin because it is an anticoagulant. Answer 2 indicates good knowledge. Prophylactic dental care is important so he will not need dental work or extractions. Answer 4 indicates good knowledge. He should always wear a Medic Alert Bracelet in case he is injured. 

Question 5073) 

A college student who is diagnosed as having infectious mononucleosis asks how the disease is spread. The nurse’s response is based on the knowledge that the usual mode of transmission is through 

A. skin. 

B. genital contact. 

C. contaminated water 

D. intimate oral contact 

Answer: D 

Explanation: The virus is spread through intimate oral contact. It is called the “kissing disease.” It can also be spread by sharing eating and drinking utensils and by coughing and sneezing. 

Question 5074) 

A young man who has infectious mononucleosis asks what the treatment is for his condition. What is the best response for the nurse to make? 

A. “You will receive large doses of antibiotics for the next 10 days.” 

B. “Rest and good nutrition are the best things you can do.” 

C. “You will be given an antiviral agent that will help to control the symptoms.” 

D. “You will probably be given steroid medications for several months.” 

Answer: B 

Explanation: Rest and good nutrition are the hallmarks of treatment for mononucleosis. Recovery may take several months. Because it is caused by a virus, antibiotics are not indicated. He would receive antibiotics only if he develops a secondary infection. There are no effective antiviral agents for this condition. Steroids are not indicated. 

Question 5075) 

An 8-year-old boy is admitted to the unit with a diagnosis of acute lymphocytic leukemia. During a routine physical exam, numerous ecchymotic areas were noted on his body. The parent reported that the child has been more tired than usual lately. The parent says that the child has had a cold for the last several weeks and asks if this is related to the leukemia. The nurse’s response is based on the knowledge that: 

A. leukemia causes a decrease in the number of normal white blood cells in the body. 

B. a chronic infection such as the child has had makes a child more likely to develop leukemia. 

C. the virus responsible for colds is thought to cause leukemia. 

D. having an infection prior to the onset of leukemia is merely a coincidence. 

Answer: A 

Explanation: Leukemia causes a decrease in normal white blood cells. White blood cells are the infection fighting cells. Infections occur because of the decrease in white blood cells due to leukemia. Infections do not cause leukemia. 

Question 5076) 

A child with leukemia bruises easily. This is most likely due to which of the following? 

A. Decreased fibrinogen levels 

B. Excessive clotting elsewhere in the body 

C. Decreased platelets 

D. Decreased erythrocytes 

Answer: C 

Explanation: leukemia, there is bone marrow failure. In addition to producing abnormal, immature white blood cells, the bone marrow fails and does not produce stem cells from which red blood cells and platelets develop. 

Question 5077) 

A child who is being treated for leukemia develops stomatitis. Which of the following nursing care measures is essential? 

A. Using dental floss to clean the teeth 

B. Frequent cleaning of the mouth with an astringent mouthwash 

C. Use of an overbed cradle 

D. Swabbing the mouth with moistened cotton swabs 

Answer: D 

Explanation: Stomatitis (mouth inflammation) is a frequent complication of chemotherapy for leukemia. He has a tendency to bleed because of his decreased platelets. Dental floss might cause bleeding. An astringent mouthwash is too strong for his tender mouth. An overbed cradle does not relate to stomatitis. Moistened cotton swabs are a gentle means of cleaning the mouth. 

Question 5078) 

When planning care for a client who is HIV positive, the nurse should do what? 

A. Teach persons coming in contact with the client to wear a gown and mask at all times 

B. Teach persons to wear gloves when handling any of the client’s body fluids 

C. Restrict visitors to immediate family 

D. Encourage the client to stay away from other persons as much as possible 

Answer: B 

Explanation: Standard precautions are indicated. Answer 1 is not correct. It is not necessary to wear a gown and mask unless there is a risk of exposure to body fluids. Answer 3 is not correct. There is no reason to limit visitors. Answer 4 is not correct. The client is HIV positive. There is no indication that the client is immunocompromised and at an increased risk of infection from others. The client will not transmit the disease unless there is contact with body fluids. 

Question 5079) 

Which action should the nurse expect to perform after a client has a bone marrow biopsy taken from the iliac crest? 

A. Apply pressure to the site for one minute 

B. Administer a narcotic analgesic 

C. Apply an adhesive bandage to the site 

D. Place the client in a recumbent position 

Answer: D 

Explanation: The client should lie in bed in a recumbent position on top of a pressure dressing that has been applied to the site. Hemorrhage poses a slight risk after this procedure. Pressure should be applied to the site for several minutes. A pressure dressing should then be applied for one hour to reduce the chances of bleeding or hemorrhage. An analgesic may be ordered and administered prior to the procedure. Use of deep breathing and relaxation techniques may also be helpful. There is seldom any pain after the biopsy, although the site may ache for a few days. 

Question 5080) 

Which of the following would be the most appropriate snack for a client who has iron deficiency anemia? 

A. Half of a grapefruit 

B. A carrot raisin salad 

C. A cup of yogurt 

D. Apple slices and cheese 

Answer: B 

Explanation: Carrots and raisins are both high in iron. Red meats and spinach are other good iron sources. Citrus fruits such as grapefruit are high in folic acid, vitamin C, and potassium, but not iron. Dairy products such as yogurt and cottage cheese provide calcium but no iron. Apples are not good sources of iron. 

74 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

 

Question 5161) 

A child with appendicitis is scheduled for surgery this evening. The nurse enters the room and sees the child’s mother starting to place hot, wet washcloths on her daughter’s abdomen so that “she will feel better.” The nurse explains that this action is contraindicated because heat: 

A. can cause the appendix to rupture and cause peritonitis. 

B. can mask symptoms of acute appendicitis 

C. will increase peristalsis throughout the abdomen. 

D. will arrest progression of the disease. 

Answer: A 

Explanation: Heat can cause drawing of the inflammation and rupture of the appendix, which will cause peritonitis. Heat is not likely to mask the symptoms of appendicitis, increase peristalsis, or arrest progression of the disease. 

Question 5162) 

A client returns from having had abdominal surgery. Her vital signs are stable. She says she is thirsty. What should the nurse give her initially? 

A. Orange juice 

B. Milk 

C. Ice chips 

D. Mouth wash 

Answer: C 

Explanation: Ice chips can be given to help relieve thirst. Only clear liquids will be given until peristalsis has returned; milk and orange juice are not clear liquids. Mouth wash is not consumed and, when used appropriately, does not relieve thirst. It may freshen the mouth but does not relieve thirst. 

Question 5163) 

The client who has had an appendectomy and has a Penrose drain in place has recovered from anesthesia. The nurse places her in a semi-sitting position. What is the primary reason for selecting this position? 

A. To promote optimal ventilation 

B. To promote drainage from the abdominal cavity 

C. To prevent pressure sores from developing 

D. To reduce tension on the suture line 

Answer: B 

Explanation: The client has a Penrose drain in place. The primary reason for the semi-sitting position is to promote drainage. This position may also help reduce tension on the suture line and promote ventilation. Turning will help prevent pressure sores. 

Question 5164) 

The client is admitted to the hospital complaining of malaise, abdominal discomfort, and severe diarrhea. The diagnosis is possible Crohn’s disease. The client says that he has lost 27 pounds in the last four months even though he has not been dieting. To plan nursing care, which assessment data are most essential for the nurse to obtain? 

A. Approximate number and characteristics of stools each day 

B. Amount of liquid consumed daily 

C. History of previous gastric surgery 

D. Bowel sounds in the right lower quadrant 

Answer: A 

Explanation: It is most important for the nurse to know how many stools he has been having each day. Frequent stools are characteristic of Crohn’s disease and may cause dehydration and skin breakdown. The nurse may want to know how much liquid he has been consuming, but that is not the most important information. Previous gastric surgery is not usually related to Crohn’s disease. Bowel sounds may be assessed but are not the most important assessment data. 

Question 5165) 

The nurse is preparing a client with Crohn’s disease for discharge. Which of the following statements indicates that he needs further teaching? 

A. “Stress can make it worse.” 

B. “Since I have Crohn’s disease, I don’t have to worry about colon cancer.” 

C. “I realize I shall always have to monitor my diet.” 

D. “I understand there is a high incidence of familial occurrence with this disease.” 

Answer: B 

Explanation: Persons with Crohn’s disease are at high risk for the development of colon cancer. The other answers are all correct and therefore do not indicate a need for more instruction. 

Question 5166) 

A low-residue diet is ordered for a client. Which food would be contraindicated for this person? 

A. Roast beef 

B. Fresh peas 

C. Mashed potatoes 

D. Baked chicken 

Answer: B 

Explanation: Fresh peas are high in residue. Roast beef, mashed potatoes, and baked chicken are not high in residue. High-residue foods are those that contain skins, seeds, and leaves. Milk products are also to be avoided on a low-residue diet. 

Question 5167) 

A client is to have a sigmoidoscopy in the morning. Which activity will be included in the care of this client? 

A. Give him an enema one hour before the examination 

B. Keep him NPO for eight hours before the examination. 

C. Order a low-fat, low-residue diet for breakfast. 

D. Administer enemas until the returns are clear this evening. 

Answer: A 

Explanation: An enema one hour before the exam will clear the sigmoid colon. A client having an upper GI series will be NPO. A low-fat diet is indicated prior to a gallbladder series. A low-residue diet is part of the preparation for a barium enema. Enemas until clear are sometimes ordered prior to a barium enema or colonoscopy. 

Question 5168) A client had a barium enema. Following the barium enema, the nurse should anticipate an order for which of the following?

A. An antacid 

B. A laxative 

C. A muscle relaxant 

D. A sedative 

Answer: B 

Explanation: Barium can be very constipating and may cause blockage of the bowel. Laxatives help to empty the bowel of barium. The other drugs are not appropriate following a barium enema 

Question 5169) 

A client is found to have colon cancer. An abdominoperineal resection and colostomy are scheduled. Neomycin is ordered. The nurse explains to the client that the primary purpose for administering this drug is to: 

A. decrease peristalsis in the intestines. 

B. decrease the bacterial content in the colon. 

C. reduce inflammation of the bowel. 

D. help prevent postoperative pneumonia. 

Answer: B 

Explanation: Neomycin is an antibiotic that is poorly absorbed from the GI tract and will therefore kill the bacteria in the bowel. This must be done before colon surgery to prevent peritonitis. Neomycin is an antibiotic and does not decrease peristalsis or reduce inflammation. Because it is not absorbed from the bowel, it does not kill bacteria outside the GI tract and therefore will not prevent pneumonia. 

Question 5170) 

The day after surgery in which a colostomy was performed, the client says, “I know the doctor did not really do a colostomy.” The nurse understands that the client is in an early stage of adjustment to the diagnosis and surgery. What nursing action is indicated at this time? 

A. Agree with the client until the client is ready to accept the colostomy 

B. Say, “It must be difficult to have this kind of surgery.” 

C. Force the client to look at his colostomy 

D. Ask the surgeon to explain the surgery to the client 

Answer: B 

Explanation: The first stage of major loss is usually denial. The client is denying the colostomy. This empathic response encourages the client to discuss feelings. The nurse should never agree with the client’s denial. The denial should not be confronted at this point in time. He needs time to adjust. Notice that the stem of the question focuses on the denial stage. 

73 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

 

Question 5151) 

The nurse is caring for a client who is very hard of hearing. How should the nurse communicate with this person? 

A. Speak loudly and talk in his better ear 

B. Stand in front of him and speak clearly and distinctly 

C. Yell at him using a high-pitched voice 

D. Write all communication on a note pad or magic slate 

Answer: B 

Explanation: Standing in front of him and speaking clearly and distinctly will allow him to read lips. Speaking loudly is usually not the best approach. Most persons with difficulty hearing hear lowpitched sounds better than highpitched ones; yelling and speaking loudly tend to raise the pitch of the voice. Written communication might become necessary for some persons; however, that would only be a last resort after all other methods of communication have failed. 

Question 5152) 

The day following a stapedectomy, the client tells the nurse that he cannot hear much in the operative ear and thinks the stapedectomy was a failure. What is the best response for the nurse to make? 

A. “There is packing in your ear. You will not hear well for a few days.” 

B. “The doctors have not yet turned on the stapes replacement.” 

C. “You may not have hearing, but you will now be free of pain.” 

D. “You seem upset that you aren’t hearing well.” 

Answer: A 

Explanation: Packing in the ear will reduce sound wave transmission. Hearing will be muffled until the packing is removed. The stapes replacement does not need to be turned on. The purpose of a stapedectomy is to restore some hearing. Otosclerosis, for which the stapedectomy was performed, is not a painful condition. It is more appropriate to give the client the information that he needs regarding hearing rather than to focus on the client’s feelings. 

Question 5153) 

A cataract extraction is performed on a client’s right eye. What is the priority nursing care immediately postoperative? 

A. Assist her to turn, cough, and deep breathe every two hours. 

B. Keep her NPO for four hours. 

C. Assist her in moving her arms and legs in ROM. 

D. Position client on her right side. 

Answer: C 

Explanation: Of these answers, moving arms and legs is the best answer because it will help to prevent thrombophlebitis. The client should not cough because this will increase intraocular pressure. There is no need to keep her NPO. She should not be positioned on the operative side because this will increase intraocular pressure. 

Question 5154) 

A client is admitted to the hospital with a gnawing pain in the mid-epigastric area and black stools for the past week. A diagnosis of chronic duodenal ulcer is made. During the initial nursing assessment, the client makes all of the following statements. Which is most likely related to his admitting diagnosis? 

A. “I am a vegetarian.” 

B. “My mother and grandmother have diabetes.” 

C. “I take aspirin several times a day for tension headaches.” 

D. “I take multivitamin and iron tablets every day.” 

Answer: C 

Explanation: Aspirin is very irritating to the gastric mucosa and is known to cause ulcers. Being a vegetarian does not cause ulcers. Ulcers are not known to be inherited. Multivitamins and iron do not cause ulcers. 

Question 5155) 

An upper GI series is ordered for a client. Which action is essential for the nurse before the test? 

A. Check to see if the client has an allergy to shellfish. 

B. Instruct the client to have nothing to eat after midnight the night before the test. 

C. Encourage the client to drink plenty of liquids before the test. 

D. Be sure the client does not eat fat-containing foods for 18 hours before the test. 

Answer: B 

Explanation: Preparation for an upper GI series is NPO for eight hours. In an upper GI series, the client swallows barium, a radiopaque substance. An iodine dye is not used, so it is not necessary to ask about iodine allergies (shellfish). Fats are restricted before gallbladder x-rays, not for an upper GI series. 

Question 5156) 

The client with a duodenal ulcer is ready for discharge. Which statement made by the client indicates a need for more teaching about his diet? 

A. “It’s a good thing I gave up drinking alcohol last year.” 

B. “I will have to drink lots of milk and cream every day.” 

C. “I will stay away from cola drinks after I am discharged.” 

D. “Eating three nutritious meals and snacks every day is okay.” 

Answer: B 

Explanation: Milk and cream are now known to cause rebound acidity and are not prescribed for ulcer clients. The other choices all indicate good knowledge. He should not drink alcohol or cola. Three meals and snacks will help keep the stomach from staying empty for long periods. 

Question 5157) 

The client, admitted with appendicitis, overhears the physician say that the pain has reached McBurney’s point. She becomes very frightened and asks the nurse to explain what this means. Which is the best response? 

A. “The next time the doctor comes in, we should ask him what he meant by that.” 

B. “I’ve felt that I don’t understand the doctor at times either.” 

C. “That is the term used to indicate that the pain has traveled to the right lower side.” 

D. “McBurney’s point refers to severe pain for which surgery is the only treatment.” 

Answer: C 

Explanation: McBurney’s point is the area in the right lower quadrant where the appendix is. The client asked for information that the nurse should be able to provide. Answer 4 is not correct. McBurney’s point refers to the location of the appendix, not the severity of the pain. 

Question 5158) 

Which blood test results would confirm a diagnosis of appendicitis? 

A. WBC of 13,000 

B. RBC of 4.5 million 

C. Platelet count of 300,000 

D. Positive heterophil antibody test 

Answer: A 

Explanation: An elevated WBC count indicates appendicitis. The RBC and platelet levels given are normal but are not specifically related to appendicitis. A positive heterophil antibody test indicates infectious mononucleosis. 

Question 5159) 

The nurse is admitting a client with the diagnosis of appendicitis to the surgical unit. Which question is it essential to ask? 

A. “When did you last eat?” 

B. “Have you had surgery before?” 

C. “Have you ever had this type of pain before?” 

D. “What do you usually take to relieve your pain?” 

Answer: A 

Explanation: When a person is admitted with possible appendicitis, the nurse should anticipate surgery. It will be important to know when she last ate when considering the type of anesthesia so that the chance of aspiration can be minimized. The other information is “nice to know” but not essential. 

Question 5160) 

The client with appendicitis asks the nurse for a laxative to help relieve her constipation. The nurse explains to her that laxatives are not given to persons with possible appendicitis. What is the primary reason for this? 

A. Laxatives will decrease the spread of infection. 

B. Laxatives are not given prior to any type of surgery. 

C. The client does not have true constipation. She only has pressure. 

D. Laxatives could cause a rupture of the appendix. 

Answer: D 

Explanation: Laxatives cause increased peristalsis, which may cause the appendix to rupture. Answer 2 is not a true statement. Laxatives may well be given prior to gynecological, rectal, and colon surgery. Answer 3 is true but is not the primary reason why laxatives are not given when a person has appendicitis. 

72 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

 

Question 5141) 

How should a nurse walk a client who is blind? 

A. Stand slightly behind the client and tell her when to turn 

B. Stand slightly behind and to the side of the client and guide her by holding her hand 

C. Walk slightly ahead with the client’s arm inside the nurse’s arm 

D. Walk beside the client and gently guide her by grasping her elbow 

Answer: C 

Explanation: Walking slightly ahead of the client allows the nurse to see what is in the way. The client feels more in control if her arm is through the nurse’s rather than the other way around. 

Question 5142) 

The client is a 60-year-old man who had a stapedectomy. He is to ambulate for the first time. Which nursing action should be taken? 

A. Encourage him to walk as far as he comfortably can 

B. Suggest that he practice bending and stretching exercises 

C. Walk with him, holding his arm 

D. Tell him to take deep breaths while he is ambulating 

Answer: C 

Explanation: The client is apt to be dizzy after ear surgery. For safety, the nurse should be with him. 

Question 5143) 

A client complains of tinnitus and dizziness and has a diagnosis of Ménière’s disease. She asks the nurse, “What is the cause of Ménière’s disease?” What is the nurse’s best response? 

A. “Ménière’s disease is caused by a virus.” 

B. “The cause of Ménière’s disease is unknown.” 

C. “Ménière’s disease frequently follows a streptococcal infection 

D. It is hereditary - both parents are having affected genes. Answer: B Explanation: The cause of Ménière’s disease is unknown. Glomerulonephritis and rheumatic fever follow a streptococcal infection. As far as is known, Ménière’s disease is not hereditary and is not caused by a virus. 

Question 5144) 

An adult man fell off a ladder and hit his head. His wife rushed to help him and found him unconscious. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. When the nurse enters the room, he is sleeping. While caring for the client, the nurse finds that his systolic blood pressure has increased, his pulse has decreased, and his tem perature is slightly elevated. What does this suggest? 

A. Increased cerebral blood flow 

B. Respiratory depression 

C. Increased intracranial pressure 

D. Hyperoxygenation of the cerebrum 

Answer: C 

Explanation: These are classic manifestations of increased intracranial pressure. 

Question 5145) 

The physician has ordered mannitol IV for a client with a head injury. What should the nurse closely monitor because the client is receiving mannitol? 

A. Deep tendon reflexes 

B. Urine output 

C. Level of orientation 

D. Pulse rate 

Answer: B 

Explanation: Mannitol is an osmotic diuretic. Urine output should increase. He must be on intake and output. 

Question 5146) 

A 17-year-old client had one generalized convulsion several hours prior to admission to the medical unit for a neurological workup. Physician’s orders include Dilantin (phenytoin) 100 mg orally (PO) tid and phenobarbital 100 mg PO daily. He tells the nurse, “I can’t believe I really had a seizure. My mom says she was in the room when it happened, but I don’t even remember it.” What is the best interpretation of his comments? 

A. They indicate an initial denial mechanism, but he will begin to remember the seizure later. 

B. Anoxia suffered during the seizure has damaged part of his cerebral cortex. 

C. Inability to remember the seizure is a normal response of a person who has had a seizure. 

D. They are an indication that he would rather not talk about his seizure at this time. 

Answer: C 

Explanation: People seldom remember a seizure; this is a normal response. 

Question 5147) 

What should the nurse include when teaching the client with Parkinson’s disease? 

A. He should try to continue working as long as he can remain sitting most of the day. 

B. Drooling may be reduced somewhat if he remembers to swallow frequently 

C. He should return monthly for lab tests, which will predict the progression of the disease. 

D. Emotional stress has no effect on voluntary muscle control in clients with Parkinson’s disease. 

Answer: B 

Explanation: Swallowing may reduce drooling. Sitting most of the day causes stiffness. There is no lab test to determine disease progression. Emotional stress can aggravate the symptoms. 

Question 5148) 

A 68-year-old woman is brought to the emergency room by ambulance. She was found by her husband slumped in her chair and unresponsive. Tentative diagnosis is cerebrovascular accident (CVA). The physician orders a 15% solution of mannitol IV. The nurse knows that this drug is given for what purpose? 

A. To increase urine output 

B. To dissolve clots 

C. To reduce blood pressure 

D. To decrease muscle spasms 

Answer: A 

Explanation: Mannitol is an osmotic diuretic that increases urine output and will decrease intracranial pressure. Streptokinase and tPA dissolve clots and might be ordered for this client. Antihypertensive medications may also be ordered for this client. 

Question 5149) 

An older woman has had a CVA. The nurse notes that she seems to be unaware of objects on her right side (right homonymous hemianopia). Which nursing action is most important in planning to assist her to compensate for this loss? 

A. Place frequently used items on the affected side 

B. Position her so that her affected side is toward the activity in the room 

C. Encourage her to turn her head from side to side to scan the environment on the affected side 

D. Stand on the affected side while assisting her in ambulating 

Answer: C 

Explanation: Encouraging her to turn her head from side to side will do the most to help her learn a skill that will compensate for loss of the visual field. With homonymous hemianopia, the client does not see on the affected or paralyzed side. Choices 1 and 2 will make life more difficult for her. If the nurse stands on the affected side, the client will be unaware of the nurse. 

Question 5150) 

A client asks the nurse what causes Parkinson’s disease. The nurse’s correct reply would be that Parkinson’s disease is thought to be due to: 

A. a deficiency of dopamine in the brain. 

B. a demyelinating process affecting the central nervous system. 

C. atrophy of the basal ganglia 

D. insufficient uptake of acetylcholine in the body. 

Answer: A 

Explanation: A deficiency of dopamine is thought to be the cause of Parkinson’s disease. Multiple sclerosis is caused by demyelination of the central nervous system. Alzheimer’s disease involves atrophy of the basal ganglia. Myasthenia gravis is caused by insufficient uptake of acetylcholine in the body. 

71 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

 

Question 5131) 

A 27-year-old woman is admitted to the hospital complaining of numbness in both legs, difficulty walking, and double vision of one week in duration. Multiple sclerosis is suspected. Orders include bed rest with bathroom privileges, brain scan, EEG, lumbar puncture, adrenocorticotropic hormone (ACTH) 40 units intramuscularly (IM) bid × 3 days, then 30 units IM bid × 3 days, then 20 units IM bid × 3 days; and passive range of motion (ROM) progressing to active ROM as tolerated. In planning care for this client, which activity is most important to include? 

A. Encouraging her to perform all care activities for herself 

B. Frequent ambulation to retain joint mobility 

C. Scheduling frequent rest periods between physical activity 

D. Feeding the client to reduce energy needs 

Answer: C 

Explanation: She will need rest periods between activities. She may be too weak to perform all self activities. Her orders include bed rest, not ambulating ad lib. Feeding her is not necessary and is likely to cause her to be upset. 

Question 5132) 

The doctor orders a Tensilon test for a woman suspected of having myasthenia gravis. Which statement is true about this test? 

A. A positive result will be evident within one minute of injection of Tensilon if she has myasthenia gravis. 

B. This is of diagnostic value in only 25% of patients with myasthenia gravis. 

C. Administration of Tensilon causes an immediate decrease in muscle strength for about an hour in persons with myasthenia gravis. 

D. Tensilon works by blocking the action of acetylcholine at the myoneural junction. 

Answer: A 

Explanation: Tensilon works almost immediately to cause an increase in muscle strength by increasing the amount of acetylcholine at the myoneural junction. The test is of value in almost all clients suspected of having myasthenia gravis. 

Question 5133) 

When planning care for a woman with myasthenia gravis, the nurse asks her what time of day she feels strongest. The nurse would expect which of the following replies? 

A. “I can wash up and comb my hair before breakfast because I feel best in the morning.” 

B. “I only feel good for about an hour after I take my medication.” 

C. “I feel strongest in the evening, so I would prefer to take a shower before bedtime.” 

D. “I feel best after lunch after I’ve been moving around a little 

Answer: A 

Explanation: Muscle strength is best early in the day. Weakness usually progresses during the day and is at its worst in the evening. 

Question 5134) 

Which of the following would not be included in the nursing care plan for a client with Parkinson’s disease? 

A. Restricting his intake of oral fluids 

B. Range of motion exercises 

C. Allowing him to carry out activities of daily living by himself even though he is very slow 

D. Providing him with diversionary tasks that require motor coordination of hands 

Answer: A 

Explanation: Fluids should be encouraged because he has a tendency to drool and lose fluid. Encouraging the client to perform activities of daily living is desirable. He should be encouraged to move frequently to prevent joint contractures. Activities requiring hand coordination will help him to retain function. 

Question 5135) 

The nurse is caring for a client admitted with Guillain-Barré syndrome. On day three of hospitalization, his muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in his nursing care plan should be to prevent which of the following? 

A. Aspiration pneumonia 

B. Decubitus ulcers 

C. Bladder distention 

D. Hypertensive crisis 

Answer: A 

Explanation: Because he is having difficulty swallowing and talking, he is at high risk for aspiration pneumonia. He is also at risk for decubitus ulcers, but this is of lesser priority than the airway. Bladder distention is a possibility but not as high a priority as the risk of aspiration pneumonia. There is no evidence that he is at risk for hypertensive crisis. 

Question 5136) 

An adult client is admitted for removal of a cataract from her right eye. Which of the following would the client likely have experienced as a result of the cataracts? 

A. Acute eye pain 

B. Redness and constant itching of the right eye 

C. Gradual blurring of vision 

D. Severe headaches and dizziness 

Answer: C 

Explanation: Cataracts are characterized by a gradual blurring of vision. Acute eye pain is characteristic of acute glaucoma or foreign objects in the eye. Redness and itching is more characteristic of an eye infection. Severe headaches and dizziness are not characteristic of cataracts. 

Question 5137) 

A client has had a cataract extraction performed. Which statement would indicate that the client needs more teaching? 

A. “I will take a stool softener daily.” 

B. “I’m going to start doing calisthenic exercises as soon as I get home.” 

C. “I’m going to my daughter’s for a few weeks until I am recovered.” 

D. “I am looking forward to watching television during my recovery period.” 

Answer: B 

Explanation: Bending, stooping, and lifting should be avoided for several weeks following eye surgery. A stool softener is recommended so that the client will not strain at stool. Television and reading are not restricted following cataract extraction. Eye movement is restricted following surgery for detached retina. 

Question 5138) 

A 50-year-old client is admitted with the diagnosis of open-angle glaucoma. Which of the following symptoms would the nurse expect the client to have? 

A. Severe eye pain 

B. Constant blurred vision 

C. Severe headaches, nausea, and vomiting 

D. Severe headaches, nausea, and vomiting 

Answer: D 

Explanation: Chronic glaucoma is characterized by halos around objects. Severe eye pain and severe headaches, nausea, and vomiting are more characteristic of acute glaucoma. Constant blurred vision is characteristic of cataracts. 

Question 5139) 

The nurse is administering eye drops to a client. Which action is correct? 

A. Ask the client to report any blurring of vision and difficulty focusing that occurs after the administration of eye drops. 

B. Apply gentle pressure to the nasolacrimal canal for one to two minutes after instillation to prevent systemic absorption. 

C. Have the client lie down with eyes closed for 45 minutes after giving drops. 

D. Gently pull the lower lid down and place medicine in the center of the eye. 

Answer: B 

Explanation: This action will prevent systemic absorption of eye medication and prevent the nose from running. Blurred vision and difficulty focusing are normal immediately after administering eye drops. There is no need to lie down after eye drops are given. Eye drops should be placed in the conjunctival sac, not the center of the eye. 

Question 5140) 

A 10-year-old boy comes to the school clinic holding his broken pair of glasses. He says that he got hit in the face playing ball and his eye hurts and feels like there’s something in it. What should the nurse do before taking him to the emergency room? 

A. Thoroughly examine his eyes 

B. Put a pressure dressing on his right eye. 

C. Cover both eyes lightly with gauze 

D. Flush his right eye with water for 20 minutes 

Answer: C 

Explanation: Covering both eyes lightly with gauze prevents tracking by the affected eye, which would occur if the unaffected eye was not covered. Examining the eyes should be done only in the emergency room by a physician. A pressure dressing would further damage the eye if broken glass is in the eye. Flushing is appropriate for chemical spills in the eye.

70 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

 

Question 5121) 

A client who had a laryngectomy is nearly ready for discharge. Which instruction is most appropriate for the nurse to give? 

A. “Always be sure you have a buddy with you when you go swimming or boating.” 

B. “You may take a tub bath, but you should not take a shower.”

C. “Be sure to have only liquids for another three weeks.” 

D. “Never cover your stoma with anything.” 

Answer: B 

Explanation: Showering is not usually allowed because water will go into the stoma. The client will never be able to swim. The client does not need a liquid diet for three weeks. The stoma should be covered with a special absorbent scarf to filter and warm the air. 

Question 5122) 

A client asks the nurse why inspiration through the nose is preferable to inspiring through the mouth. What is the best response? 

A. It produces greater blood oxygen levels 

B. It is easier to breathe through the nose. 

C. The nares humidify, warm, and filter the air. 

D. Mouth breathing dilutes the air and reduces the amount of air entering the lungs. 

Answer: C 

Explanation: The purpose of the nares is to humidify, warm, and filter the air before it enters the lungs. Breathing through the nose does not produce greater blood oxygen levels. It is not easier to breathe through the nose. Mouth breathing does not dilute the air 

Question 5123) 

While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take? 

A. Suction deeper to pick up secretions 

B. Gently withdraw suction tubing to allow suction or coughing out of mucus 

C. Remove the suction as quickly as possible 

D. Put the suction tube in and out several times to pick up secretions 

Answer: B 

Explanation: Allow the client to cough. The client will frequently cough out the mucus. If he does not, then the nurse can suction to pick up secretions. The client’s cough is more powerful than the suction catheter. 

Question 5124) 

An adult man fell off a ladder and hit his head and lost consciousness. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. The nursing care plan will most likely include which of the following? 

A. Elevate head of bed 15 to 30 degrees 

B. Encourage fluids to 1000 mL every eight hours 

C. Assist the client to cough and deep breathe every two hours 

D. Perform chest physical therapy every four hours while awake 

Answer: A 

Explanation: The head of the bed should be slightly elevated to allow gravity drainage of fluid and reduce cerebral edema. Coughing and forcing fluids are contraindicated because they may raise intracranial pressure. Chest physical therapy would be apt to raise intracranial pressure. 

Question 5125) 

A teenager is admitted following a seizure. The next day, the nurse goes into his room and finds him lying on the floor starting to have a seizure. What action should the nurse take at this time? 

A. Carefully observe the seizure and gently restrain him 

B. Attempt to put an airway in his mouth so he does not swallow his tongue, and observe the type and duration of the seizure 

C. Place something soft under his head, carefully observe the seizure, and protect him from injury 

D. Shout for help so that someone can help you move him away from the furniture 

Answer: C 

Explanation: Protect his head from injury, and observe the seizure. Never try to restrain a seizing person. Current thinking indicates to not put an airway in the mouth. Placing something soft under his head will help to protect his head from injury. The question does not indicate that the client is in danger from the furniture. 

Question 5126) An adult is being treated with phenytoin (Dilantin) for a seizure disorder. Five days after starting the medication, he tells the nurse that his urine is reddish-brown in color. What action should the nurse take? 

A. Inform him that this is a common side effect of phenytoin (Dilantin) therapy 

B. Test the urine for occult blood 

C. Report it to the physician because it could indicate a clotting deficiency 

D. Send a urine specimen to the lab 

Answer: A 

Explanation: He is receiving phenytoin (Dilantin), which frequently causes the urine to turn reddish-brown in color. There is no indication for testing the urine or notifying the physician. The finding should be recorded on the client’s chart. 

Question 5127) 

The nurse is caring for a client who has recently had a cerebrovascular accident (CVA). When positioning the client and supporting her extremities, the nurse must remember that when voluntary control of muscles is lost: 

A. the feet will maintain a position of eversion. 

B. the upper extremities will rotate externally 

C. the hip joint will rotate internally 

D. flexor muscles will become stronger than extensors. 

Answer: D 

Explanation: Flexor muscles are stronger than extensors, causing flexion contractures. The hip joint tends to rotate externally. 

Question 5128) 

A stroke victim regains consciousness three days after admission. She has rightsided hemiparesis and hemiplegia and also has expressive aphasia. She becomes upset when she is unable to say simple words. The best approach for the nurse is to do which of the following? 

A. Stay with her and give her time and encouragement in attempting to speak. 

B. Say, “I’m sure you want a glass of water. I’ll get it for you.” 

C. Say, “Don’t get upset. You rest now and I’ll come back later and try to talk to you then.” 

D. Encourage her attempts and say, “Don’t worry, it will get easier every day.” 

Answer: A 

Explanation: Offering help is always therapeutic. This approach will help her to express herself. The nurse should not routinely anticipate her needs because this does not encourage attempts at speech. Telling her not to get upset is not therapeutic. Encouraging her attempts to speak is therapeutic, but telling her not to worry is not therapeutic 

Question 5129) 

A young man was swimming at the beach when an exceptionally large wave caused him to be drawn under the water. His family members found him in the water and pulled him ashore. He states that he heard something snap in his neck. When a nurse arrives, he is conscious and lying on his back. He states that he has no pain. He is unable to move his legs. How should he be transported? 

A. Position him in a prone position and place on a backboard. 

B. Apply a neck collar and position supine on a backboard. 

C. Log roll him to a rigid backboard 

D. Position in an upright position with a firm neck collar. 

Answer: B 

Explanation: He may have a neck or spinal cord injury. The neck and back should be supported and maintained in a rigid position. He should be transported in the position in which he was found. He should not be turned. 

Question 5130) 

A client who is recovering from a spinal cord injury complains of blurred vision and a severe headache. His blood pressure is 210/140. The most appropriate initial action for the nurse to take is to: 

A. check for bladder distention 

B. place him in the Trendelenburg position 

C. administer PRN pain medication 

D. position him on his left side. 

Answer: A 

Explanation: The symptoms suggest autonomic hyperreflexia, which is usually caused by bladder distention. The patient will need to be catheterized and the physician notified. Autonomic hyperreflexia is a medical emergency. The head is usually elevated to reduce blood pressure. 

69 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

Question 5111) 

An adult is being treated with isoniazid (INH) and streptomycin for active tuberculosis. He is also receiving pyridoxine (vitamin B6). Why is this medication prescribed for him? 

A. Pyridoxine is bacteriostatic against Mycobacterium tuberculosis. 

B. To enhance his general nutritional status 

C. To prevent side effects of INH 

D. Pyridoxine acts to increase the effects of streptomycin. 

Answer: C 

Explanation: Pyridoxine (vitamin B6) prevents the development of peripheral neuritis toxicity of INH. 

Question 5112) 

The wife of a client with active tuberculosis has a positive skin test for tuberculosis. She is to be started on prophylactic drug therapy. What drug is the drug of choice for prophylaxis of tuberculosis? 

A. Streptomycin 

B. Para-aminosalicylic (PAS) acid 

C. Isoniazid (INH) 

D. Ethambutol (Myambutol) 

Answer: C 

Explanation: INH is the drug of choice for chemoprophylaxis. All of the other drugs listed can be used in the treatment of tuberculosis. 

Question 5113) A farmer who has had a cough for several months has noticed a lack of energy lately. He is being tested for histoplasmosis. Which factor reported by the client would be most related to the diagnosis of histoplasmosis? 

A. He drinks raw milk. 

B. He cleans chicken houses 

C. He handles fertilizer frequently. 

D. He stepped on a rusty nail recently 

Answer: B 

Explanation: Histoplasma capsulatum is a fungus that grows in chicken and pigeon manure. Drinking raw milk might cause “milk fever.” Handling fertilizer could cause “white lung,” a COPD illness. Stepping on a nail might cause tetanus 

Question 5114) 

The nurse is caring for a client who is admitted with histoplasmosis. What drug is most likely to be prescribed for this client? 

A. Penicillin 

B. Chloromycetin 

C. Streptomycin 

D. Amphotericin B 

Answer: D 

Explanation: Amphotericin B is the drug of choice to treat histoplasmosis. 

Question 5115) An adult is to have a thoracentesis performed. What should the nurse do while preparing the client for this procedure? 

A. Keep him NPO for eight hours 

B. Prepare him to go to the operating room 

C. Explain the procedure to him 

D. Administer anticholinergic and analgesic as ordered 

Answer: C 

Explanation: The nurse should explain the procedure to the client and obtain a permit if one has not already been signed. Thoracentesis is usually done at the bedside. NPO is not necessary. Anticholinergics and analgesics are not ordered. 

Question 5116) The nurse is planning care for a client who has COPD. Which statement is the client most likely to say about activity tolerance? 

A. “The most difficult time of the day for me is the first hour after waking up in the morning.” 

B. “I feel best in the morning after a good night’s sleep. 

C. “I seem to have more energy after eating a big meal.” 

D. “I don’t know why, but I get my ‘second wind’ at night and don’t want to go to bed.” 

Answer: A 

Explanation: Morning is a difficult time for persons with COPD because secretions have accumulated during the night. They have to do a great deal of hacking and coughing to clear their air passages in the morning. The client with COPD is apt to be short of breath after a big meal because he is an abdominal breather. Most clients with COPD do not get a “second wind” at night. They need a lot of rest. 

Question 5117) 

The nurse is caring for a woman who is admitted with pneumonia. On admission, the client is anxious and short of breath but able to respond to questions. One hour later, the client becomes more dyspneic and less responsive, answering only yes and no questions. What is the best action for the nurse to take at this time? 

A. Stimulate the client until client responds 

B. Increase the oxygen from the ordered 6 L to 10 L. 

C. Assess the client again in 15 minutes 

D. Notify the charge nurse of the change in the client’s mental status. 

Answer: A 

Explanation: The change in the client’s status is significant and indicates hypoxia. The charge nurse or physician must be notified quickly. Stimulating a severely hypoxic client is not appropriate. Increasing the oxygen from 6 L to 10 L is not likely to change the client’s status. The licensed practical nurse (LPN) should notify the charge nurse now, not in 15 minutes. 

Question 5118) 

A client’s PPD test is positive, and a chest x-ray is negative. What is the best interpretation of these data? 

A. The client’s resistance to tuberculosis is low. 

B. The client has been exposed to the organism but has not developed the disease. 

C. The client has tuberculosis, but it is not serious. 

D. The client has active tuberculosis 

Answer: B 

Explanation: A positive PPD test indicates antibodies against tuberculosis. A positive PPD test and a negative x-ray indicate that the client has been exposed to tuberculosis but has not developed the disease. These findings do not give information regarding the client’s resistance. The negative x-ray indicates that the client does not have active tuberculosis. 

Question 5119) 

An adult with tuberculosis has started taking rifampin (Rimactane). Which side effect is the client most likely to experience when taking this drug?

A. Reddish-orange color of urine, sputum, and saliva 

B. Erythema and urticaria 

C. Tinnitus and deafness 

D. Peripheral neuritis 

Answer: A 

Explanation: Rimactane (rifampin) causes body secretions to turn reddish-orange. Erythema and urticaria are not likely to be seen. Tinnitus and deafness are side effects of streptomycin. Peripheral neuritis is a side effect of isoniazid (INH). 

Question 5120) 

Which laboratory tests should the client receive before prophylactic drug therapy for tuberculosis is started? 

A. Serum creatinine and blood urea nitrogen (BUN) 

B. Aspartate aminotransferase (AST; SGOT) and alanine aminotransferase (ALT; SGPT) 

C. Complete blood count (CBC) and hematocrit 

D. White blood cell (WBC) count and urinalysis 

Answer: B 

Explanation: AST (SGOT) and ALT (SGPT) are liver function tests. INH can cause liver toxicity. Serum creatinine and BUN are renal function tests and would test for toxicity to streptomycin or kanamycin. CBC and hematocrit might be indicated if bleeding or bone marrow depression were major expected toxicities. WBC and urinalysis might be indicted for urinary tract infections. 

68 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

 

Question 5101) 

During the preoperative period, which nursing action will be of greatest priority for a person who is to have a laryngectomy? 

A. Establish a means of communication. 

B. Prepare the bowel by administering enemas until clear. 

C. Teach the client to use an artificial larynx 

D. Demonstrate the technique for suctioning a laryngectomy tube. 

Answer: A 

Explanation: Establishing a means of communication is the highest priority. Teaching the client to use an artificial larynx is a postoperative task. Because the laryngectomy tube will be temporary, the client will not need to learn to suction. That is a nursing function. 

Question 5102) 

A 62-year-old man is admitted with emphysema and acute upper respiratory infection. Oxygen is ordered at 2 L/min. The reason for low-flow oxygen is to: 

A. prevent excessive drying of secretions 

B. facilitate oxygen diffusion of the blood 

C. prevent depression of the respiratory drive. 

D. compensate for increased airway resistance 

Answer: C 

Explanation: The stimulus to breathe in a person with COPD is a low oxygen level rather than a carbon dioxide level, as in normal persons. If high-flow oxygen were given, the oxygen level would increase, and the respiratory drive would cease. 

Question 5103) 

An adult is admitted with chronic obstructive pulmonary disease (COPD). The nurse notes that he has neck vein distention and slight peripheral edema. The practical nurse notifies the registered nurse and continues frequent assessments because the nurse knows that these signs signal the onset of which of the following? 

A. Pneumothorax 

B. Cor pulmonale 

C. Cardiogenic shock 

D. Left-sided heart failure 

Answer: B 

Explanation: Distended neck veins and peripheral edema are signs of right-sided heart failure or cor pulmonale— heart failure due to pulmonary causes. 

Question 5104) 

A 79-year-old client is admitted to the hospital with a diagnosis of pneumococcal pneumonia. The client has dyspnea. The client’s temperature is 102°F., respirations are 36, and pulse is 92. Bed rest is ordered for this client primarily to: 

A. promote thoracic expansion. 

B. prevent the development of atelectasis 

C. decrease metabolic needs. 

D. prevent infection of others. 

Answer: C 

Explanation: Bed rest will reduce metabolic needs in this client who has pneumonia and is having difficulty meeting oxygenation needs. Semiupright position, not bed rest, will promote thoracic expansion. Isolation prevents infection of others. Deep breathing will help to prevent the development of atelectasis. 

Question 5105) 

An adult is to have a tracheostomy performed. What is the nursing priority? 

A. Shave the neck 

B. Establish a means of communication 

C. Insert a Foley catheter 

D. Start an IV 

Answer: B 

Explanation: The nursing priority is to establish a means of communication because she will not be able to speak after the tracheostomy is performed. 

Question 5106) 

Which nursing action is essential during tracheal suctioning? 

A. Using a lubricant such as petroleum jelly 

B. Administering 100% oxygen before and after suctioning 

C. Making sure the suction catheter is open or on during insertion 

D. Assisting the client to assume a supine position during suctioning 

Answer: B 

Explanation: One hundred percent oxygen is given before and after suctioning to help prevent hypoxia. Petroleumbased lubricants are not water-soluble and should never be used near an airway. Saline is used as a lubricant. The suction catheter is off during insertion to avoid traumatizing the tissues. The client should be in a semi-sitting position during suctioning. Supine predisposes to aspiration. 

Question 5107) 

An adult has a chest drainage system. Several hours after the chest tube was inserted, the nurse observes that there is no bubbling in the water seal chamber. What is the most likely reason for the absence of bubbling? 

A. The client’s lungs have re-expanded. 

B. There is an obstruction in the tubing coming from the client. 

C. There is a mechanical problem in the pump 

D. Air is leaking into the drainage apparatus. 

Answer: B 

Explanation: Cessation of bubbling in the water seal bottle means either an obstruction in the tubing or reexpansion of the lung. This is the night of insertion of the tube. It takes at least 24 hours and often two to three days for the lung to reexpand. 

Question 5108) 

An adult has a chest drainage system. The client’s wife reports to the nurse that her husband is restless. The nurse enters the room just in time to see him pull out his chest tube. The most appropriate initial action for the nurse to take is to: 

A. go get petrolatum gauze and apply over the wound. 

B. place her/his hand firmly over the wound. 

C. apply a sterile 4 × 4 dressing. 

D. reinsert the chest tube. 

Answer: B 

Explanation: The nurse’s primary goal has to be to stop air from entering the thoracic cavity and causing the lung to collapse again. Placing a hand firmly over the wound will accomplish this. Answer 1 is wrong, because the nurse should not leave the client. Petrolatum gauze would be ideal, but the nurse should not leave the client. Answer 3 is wrong because a sterile 4 × 4 dressing allows air to enter the thoracic cavity. The nurse should not reinsert the chest tube 

Question 5109) 

An adult had a negative purified protein derivative (PPD) test when he was first employed two years ago. A year later, the client had a positive PPD test and a negative chest xray. This indicated that at that time the client: 

A. was less susceptible to a tuberculosis infection than the year before. 

B. had acquired some degree of passive immunity to tuberculosis. 

C. had fought the Mycobacterium tuberculosis but had not developed active tuberculosis. 

D. was harboring a mild tuberculosis infection in an organ other than the lung. 

Answer: C 

Explanation: A positive PPD test indicates that the client has come in contact with the organism and fought it. A negative chest x-ray indicates that the client won the fight and does not at that time have active tuberculosis. 

Question 5110) 

An adult is being treated with isoniazid (INH) and streptomycin for active tuberculosis. Which of the following symptoms would suggest a toxic effect of INH? 

A. Paroxysmal tachycardia 

B. Erythema multiforme 

C. Peripheral neuritis 

D. Tinnitus and deafness 

Answer: C 

Explanation: Peripheral neuritis is a toxic effect of INH. Tinnitus and deafness are side effects of streptomycin.

67 - Nursing Competitive Exams QAs - NORCET, ESIC, GUJARAT NURSING EXAM

 

Question 5091) 

The nurse knows that infectious mononucleosis is caused by which of the following? 

A. Cytomegalovirus 

B. Beta-hemolytic Streptococcus 

C. Epstein-Barr virus 

D. Herpes simplex virus I 

Answer: C 

Explanation: The Epstein-Barr virus is the causative organism for infectious mononucleosis. 

Question 5092) 

A child who has leukemia is to have a bone marrow biopsy performed. How will the child be positioned for this procedure? 

A. On his side with the top knee flexed 

B. Prone 

C. Modified Trendelenburg position 

D. On his back with his head elevated 30 degrees 

Answer: A 

Explanation: The iliac crest is the site usually used for a bone marrow biopsy. 

Question 5093) 

A child is being evaluated for possible leukemia. Which assessment finding is most likely to be present? 

A. Numerous bruises on the child’s body 

B. Ruddy complexion 

C. Diarrhea and vomiting

D. Chest pain 

Answer: A 

Explanation: The child with leukemia has a large number of immature white blood cells and not enough red blood cells and platelets. He is likely to have numerous bruises because of the low platelet count. He is likely to have a pale, not ruddy, complexion because he is deficient in red blood cells. Diarrhea and vomiting are possible if he had an intestinal virus, but bruises are much more common. Chest pain is unlikely. 

Question 5094) 

An adult client is to have a sputum for culture. When is the best time for the nurse to collect the specimen? 

A. In the morning right after he awakens 

B. Immediately after breakfast 

C. Two hours after eating 

D. Shortly before he retires for the evening 

Answer: A 

Explanation: The sputum has collected during the night. It is most concentrated early in the morning. 

Question 5095) 

A thoracentesis was performed on an adult client. After the procedure, the client has hemoptysis and a pulse of 80, respirations of 28, and temperature of 99°F. Which of these is of greatest concern to the nurse? A. Hemoptysis B. Respirations of 28 C. Pulse of 80 D. Temperature of 99°F Answer: A Explanation: Hemoptysis is the only abnormal finding. All of the others are within normal range for someone who has undergone an invasive procedure. Question 5096) An adult client is to have postural drainage four times a day. In developing the care plan, the nurse should schedule this for: 

A. 7 A.M.; 11 A.M.; 4 P.M.; 10 P.M. 

B. 10 A.M.; 2 P.M.; 6 P.M.; 10 P.M. 

C. 6 A.M.; 12 noon; 6 P.M.; 12 midnight 

D. 6 A.M.; 10 A.M.; 2 P.M.; 6 P.M. 

Answer: A 

Explanation: Postural drainage should be scheduled before or between meals and close to bedtime. 

Question 5097) 

An adult man has a tracheostomy tube in place. Which of the following actions is most appropriate for the nurse to take when suctioning the tracheostomy?

A. Use a sterile tube each time and suction for 30 seconds 

B. Use sterile technique and turn the suction off as the catheter is introduced 

C. Use clean technique and suction for 10 seconds 

D. Discard the catheter at the end of every shift 

Answer: B 

Explanation: Suctioning should be done under sterile technique for no more than 10 seconds. The suction should be off as the tube is inserted and applied intermittently as it is withdrawn. 

Question 5098) 

During suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal wall and creates a pulling sensation. What is the best action for the nurse to take? 

A. Release the suction by opening the vent 

B. Continue suctioning to remove the obstruction 

C. Increase the pressure 

D. Suction deeper 

Answer: A 

Explanation: Suction should not be applied as the suction tube is inserted, because this will cause the suction tube to appear to attach to the tracheal wall and create a pulling sensation. 

Question 5099) 

A client comes to the clinic with a bloody nose. Which instruction is most appropriate? 

A. “Sit up with your head tilted forward. Grasp the soft part of your nose firmly between your thumb and forefinger.” 

B. “Lay down and tilt your head backward. Grasp the end of your nose between your fingers.” 

C. “Sit up and lean backwards. Put pressure on the side of your nose with your hand.” 

D. “Lie down with your head lower than your feet. Grasp as much of your nose as possible between your fingers.” 

Answer: A 

Explanation: This position will help to stop bleeding without causing aspiration of any blood dripping down the back of the throat. 

Question 5100) 

A client is admitted with a diagnosis of cancer of the larynx. Which statement made by the client is most likely related to the cause of his illness? 

A. “I have always enjoyed hot Mexican-style food.” 

B. “I have smoked three packs of cigarettes a day for the last 40 years.” 

C. “I used to work in a factory that burned coal.” 

D. “I sang in the church choir every Sunday until my voice got hoarse last year.” 

Answer: B 

Explanation: Cigarette smoking is the greatest risk factor for development of laryngeal cancer.