AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM.

THIS IS A DRAFT BURNS (01-90-150-284) The nurse should expect which procedure to be performed within two hours after the burn injury involving the chest and neck? A. Tracheostomy. B. Esharotomy. C. Intubation. D. Chest tube insertion. " "(01-90-150-285) A burn client will probably be more comfortable in an environment in which the temperature is: A. Lower than skin surface temperature with a humidity of 25 percent or less. B. Lower than skin surface temperature with a humidity 40 to 50 percent. C. Slightly higher than skin surface temperature with a humidity of 25 percent or less. D. Slightly higher than skin surface temperature with a humidity of 40 to 50 percent. " "(01-90-150-287) A nursing care plan for a severely burned client should include observing for bleeding. Which is a sign of both Curlings ulcer and: A. Disseminated intravascular cougulopathy. B. Impending circulatory collapse. C. Increased intracranial pressure. D. Acute renal failure. " "(02-00-125-363) The nurse determines that the client has 2nd and 3rd degree burns. Which of the following would be characteristic of a fresh, 2nd degree burn? a.. Absence of pain and pressure sense b. White or dark, dry, leathery appearance c. Large thick blisters d. Visible, thrombosed small vessels " "(02-00-126-366) A major goal during the first 48 hours is to prevent hypovolemic shock. Which of the following would not be a useful guide to fluid restitution during this period? a. Elevated hematocrit b. Urine output of 30mL per hour c. Change in sensorium d. Estimate of fluid loss through the burn eschar. " "(02-00-126-367) Mafenide Acetate (Sulfamylon) is applied to the clients burn wound every 12 hours. The nurses assessment would include observation for which of the following side effects of this drug? a. Metabolic acidosis b. Discoloration of the skin c. Maceration of the skin d. Dehydration and electrolyte loss " "(02-00-126-368) Autograft are done for the burn wounds. Care of the donors site would not include: a. Changing the dressing every shift. b. Reporting any odor to the physician

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT c. Using a heat lamp to dry the wound d. Exposing the mesh covered wound to the air " "(02-00-126-369) Contractures are among the most serious of the long term complications of a burn. Because the burns involve the face, neck, anterior chest, and both arms and hands, which of the following nursing measures would most likely cause the patient to have contracture? a. Change the location of the bed or the TV set, or both daily. b. Encourage her to chew gum and blow up balloons. c. Avoid using a pillow or place the head a position of hyperextension d. Assist her to assume a position of comfort " "(02-00-126-370) What is the primary goal of all burn wound care? a. To debride the wound of dead tissues and eschar b. To limit fluid loss through the skin c. To prevent growth of microorganisms d. To decrease formation of disfiguring scars " "(03-93-303-258). When teaching first aid, the nurse should explain that the best first-aid treatment for acid burns on the skin is to flush them with water and then apply a solution of sodium: a. Hydroxide b. Chloride c. Bicarbonate d. Sulfate " "(03-93-303-259). A good first-aid treatment for an alkali burn is to flush it with water and then with: a. A weak acid c. A salt solution b. A dilute base d. An antibiotic solution " "(03-93-303-264). A skin graft that is taken from another portion of a clients own body is known as: a. A homograft b. An autograft c. A heterograft d. An alllograft " "(03-93-303-265). A pigskin graft is often applied to burned areas. This graft is known as: a. A homograft b. An allograft c. A heterograft d. An isograft " "(03-93-303-267). When evaluating fluid loss in a burned client, the nurse should recognize that the relationship between body surface area and fluid loss is: a. Directly proportional b. Inversely related c. Equal d. Unrelated

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT " "(06-0-683-14) Hyponatremia may develop in clients with burns due to: a. Displacement of sodium in edema fluids and loss through denuded areas of the skin b. Increased aldosterone secretion c. Inadequate fluid replacement d. Metabolic acidosis " "(07-05-508-56) A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. Using the rule of nines, the nurse would determine that about what percentage of the clients body surface has been burned? A. 18%. B.27%. C. 45%. D. 64%. " "(07-05-508-57) The nurse assesses the client for fluid shifting that occurs during the emergent phase of a burn injury are caused by fluid moving. A. From the vascular to the interstitial space. B. From the Extracellular to the intracellular space. C. From the intracellular to the Extracellular space. D. From the interstitial to the vascular space. " "(07-05-509-58) The nurse should recognizes that the fluid shift in a client with burn injury result from an increase in the: A. Permeability of capillary. B. Total volume of Intravascular plasma. C. Total volume of circulating whole blood. D. Permeability of the kidney tubules. " "(07-05-509-59) A priority nursing diagnosis category for a client with burns during the emergent period would be: A. Excess Fluid Volume. B. Imbalanced Nutrition: Less Than Body Requirements. C. Risk for injury (falling). D. Risk for infection. " "(07-05-509-60) Which of the following activities should the nurse include in the care plan of a client with burn injuries to be carried out about one-half hour before the daily whirlpool bath and dressing changes? A. Soak the dressing. B. Remove the dressing. C. Administer an analgesic. D. Slit the dressing with blunt scissors. " "(07-05-509-61) The client with a major burn injury receives total Parenteral nutrition (TPN). The primary reason for this therapy is to help: A. Correct water and electrolyte imbalances. B. Allow the gastrointestinal vitamins and minerals.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT C. Provide supplemental vitamins and minerals. D. Ensure adequate caloric and protein intake. " "(07-05-509-63) An advantage of using biologic burn grafts, such as porcine (pisgskin) grafts, is that they appear to help. A. Encourage formation of tough skin. B. Promote the growth of epithelial tissue. C. Provide for permanent wound closure. D. Facilitate development of subcutaneous tissue. " "(07-05-509-64) Which of the following factors would have the least influence on the survival and effectiveness of a burn victims porcine grafts? A. Absence of infection in the wounds. B. Adequate vascularization in the area being grafted area. C. Immobilization of the area being grafted. D. Use of analgesics as necessary for pain relief. " "(07-05-509-65) The nurse would plan to begin rehabilitation efforts for the burn client. A. Immediately after the burn has occurred. B. After the clients circulatory status has been stabilized. C. After grafting of the burns wounds has occurred. D. After the clients pain has been eliminated. " "(07-05-509-66) When an individual is burned there is massive cell destruction resulting in a disruption of the normal homeostasis of the body. The nurse anticipates that the client will be susceptible to which of the following in the early phase of burn care? A. Hypernatremia. B. Hyponatremia. C. Metabolic alkalosis. D.Hyperkalemia. " "(07-05-509-67) Endotracheal or tracheostomy tubes are placed in clients who have experienced. A. Electrical burns of the hands and arms causing dysrhythmais. B. Thermal burns to the head, face, and airway resulting in hypoxia. C. Chemical burns on the chest and abdomen. D. Secondhand smoke inhalation. " "(07-05-510-68) A newly burned client is admitted to the unit. The nurse measures the clients urine output on an hourly basis, anticipating fluid balance problems related to fluid balance problem related to fluid shift. Which of the following hourly urinary output rates will alert the nurse to potential problems? A. 20 mL/hour. B. 30 mL/hour. C. 50 mL/hour. D. 100mL/hour. "

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT "(07-05-510-69) After the initial phase of the burn injury, the clients plan of care will focus primarily on: A. Helping the client maintain a positive self-concept. B. Promoting hygiene. C. Preventing infection. D. Educating the client regarding care of the skin grafts. " "(07-05-510-70) The burned client needs fluid replacement because massive amount of fluid are lost. The rate at which intravenous fluids are infused is based on the burn clients. A. Lean muscle mass and body surface area burned. B. Total body weight and body surface area burned. C. Total body surface area and body surface area burned. D. Height and weight and body surface area burned. " "(07-05-510-71) The nurse is caring for a client with a burn injury and understands that stress reaction can result in hypersecretion of a gastric acids, Therefore, the nurse must assess the client for sign and symptoms of which of the following potential complications? A. Paralytic ileus. B. Gastric distention. C. Hiatal hernia. D. Curling ulcer. " "(14-83-13-70) Two-year-old Glenda Dawson is brought to the emergency room with burns on both legs and her entire abdomen. She pulled a kettle of boiling water off the stove. The nurse admitting Glenda should FIRST observe for signs of a. infection. b. shock. c. respiratory distress. d. dehydration. " "(14-83-16-102) Eight-year-old Felipe Reyes is admitted to the hospital with a diagnosis of osteomyelitis secondary to a bum of his upper thigh. A blood culture will probably reveal which of the following causative organisms? a. Staphlococcus aureus. b. Hemolytic Streptococcus. c. Escherichia coli. d. Salmonella. " "(7-05-221-3) The nurse is assessing a 3 year old child who has 3rd degree burns involving the entire right leg. Using the rule of 9s, the estimated total body area burned is: a. 9% b. 14% c. 18% d. 24% " "(7-05-221-8) when caring for the child with moderate burns from the waist down, which of the following would a nurse do in positioning the child?

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT a. Place the child in a position of comfort b. Allow the child to lie on the abdomen c. Ensure the application of the leg splint d. Have the child flex the hips and knees " "(03-93-303-266). To best evaluate fluid loss due to burns, the nurse should monitor the: a. Blood PH b. Sedimentation rate c. Hematocrit d. BUN " "A 13-year-old boy is brought to the ER because of second-degree burns of his right hand and forearm. Immediate care of the burn wound should include: (604-168) a. Immersing the hand and forearm in cool water. b. Applying ice packs to the injury. c. Pulling adherent charred clothing from the burn wounds. d. Covering the burn with cortisone cream. " "A 13-year-old boy was admitted with second-degree burns to 30% of his body. Tetanus prophylaxis for the child should also include: (604-169) a. Tetanus toxoid b. Tetanus immune globulin c. Tetanus toxoid and tetanus immune globulin d. No additional protection " "A burn client becomes confused and shouts whenever anyone enters the room. His CVP reading is 18 centimeters, and he has a 2.2 kilogram (5-pounds) weight gain and a urine output of 100 ml/hr. The nurse should recognize these as signs of: a. the diuretic stage. b. Hypovolemia. c. Circulatory overload. d. Septic shock. " "A burn patient has been instructed to turn and move the unaffected parts of his body, and he is given a series of exercises, with nursing assistance, for his affected parts. He tells the nurse that the rehabilitation therapist told him that activity would reduce the negative physiological and psychological effects of immobilization. How should the nurse respond to his queries on the basic psychological effect of mobility? a. Movement will help you to determine your own body space, which has been altered by your burns and immobility. b. Movement will increase you circulation so that the healing process will take place and give you a sense on well being. c. Through activity, you will have a feeling of control over your environment and yourself. d. As you become more active, you will also stimulate your sensoriperceptual area, and become more involved. "

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT "A burn patient is to be discharged from the hospital, but must continue his therapy in the community. What specific goal should the health team plan for at this time? a. Encourage the client to verbally express his feelings of anger and helplessness. b. Facilitate client participation in activities of daily living. c. Help the client to identify what changes have to be made in his life style. d. Assess the clients positive adaptive mechanisms as used in previous stressful situations. " "A burn patient states that he does not feel that his body is his own. Pointing to the burned area, he says, This makes me want to disown my own body. How should the nurse respond initially? a. Facilitate his interaction with others b. Emphasize his areas of strength c. Encourage him to make physical movements d. Involve him in self care activities. " "A client with burns has excruciating pain in the area of his second degree burns. After the administration of an analgesic, what other measure will best help to alleviate his pain? a. explore the meaning of pain with him. b. Remain with him quietly, and communicate through touch. c. Give instructions on how he can control his pain. d. Reduce the noxious environmental stimuli. " "A nursing care plan for severely burned patient should include observing for bleeding, which is a sign of both Curlings ulcer and: a. disseminated intravascular coagulopathy b. impending circulatory collapse c. increased intracranial pressure d. acute renal failure. " "After cleansing and debridement of a second-degree burn, the physician decides to apply silver sulfadiazine (Silvadene) and cover the wound with a bulky gauze dressing. The primary advantage of the closed method used to treat the burn is that it (604-170) a. Protects the wound from further injury. b. Minimizes fluid loss from the burn surface c. Alleviates pain caused by exposure of the wound to air d. Prevents contractures of the hand and wrist. " "The physician has ordered reverse isolation for a burn patient. While performing reverse isolation techniques, the nurse should understand that: a. it is not necessary to use sterile linen if the linen has been properly washed. b. Only some persons who come in direct contact with the client need wear gloves and mask. c. Sterile gown and gloves must be worn while caring for the client. d. It is not necessary to wear a mask. " "To prevent contractures of the left leg following burn injury on it, the nurse prevent it by: (87-01-46661) a. Maintaining abduction of the left leg, extension of the left knee and flexion of the left ankle

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT b. Maintaining adduction of the left leg and extension of the left knee and ankle c. Maintaining abduction of the left leg and flexion of the left knee and ankle d. Maintaining adduction of the left leg, flexion of the left knee, and extension of the left ankle " "Visual inspection of a full thickness burn would reveal. a. a swollen reddened area that blanches when pressure is applied. b. Blisters of varying sizes with a cherry red base c. Moist skin surface with a mottled, redden are d. Dry skin surface with a pearly white or charred appearance. " "Which instructions should the nurse include in the teaching plan for the parents of a boy who had second degree burns? (604-171) a. The silver sulfadiazine cream will be painful when first applied to the burn. b. The child should return to the laboratory each day to have his blood pH monitored. c. Old cream should be removed by soaking the wound in warm, soapy water. d. The silver sulfadiazine cream may cause a change in color of adjacent healthy skin. " "Which of the following food is highly recommended to a child who had burns on 40% of her body. (605172) a. Meats, citrus fruits, and milk b. Vegetables, cheese, and yogurt c. Breads, cereals, and pastas d. Milkshakes, salads, and soups. " "While barbecuing at an outdoor pool party, the client sustains second and third degree burns of the anterior portion of both arms, the upper half of his anterior trunk, and the anterior and posterior portions of his left leg. Based on the rule of nines, which of the following percentages is the best estimate of the extent of the client's burns? a. 27 b. 36 c. 45 d. 54 ORTHO: "(01-90-286-607). With resolution of the fat embolism, a client with a hip fracture is scheduled for surgery. Skin care prior to surgery should include massaging which area of the affected extremity? a. Heel b. Calf c. Thigh d. Hip " "(14-83-13-71) Nineteen-month-old Russell Warren fell from his high chair and fractured his femur. He is admitted to the hospital and placed in Bryants traction. The PRIORITY nursing intervention while Russell is in traction is a. frequent assessment of the circulatory status in both lower extremities. b. providing frequent skin care` to Russell.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT c. encouraging Russell to cough and deep-breathe every 2 hours. d. providing small, frequent feedings of Russells favorite foods. " "(14-83-16-101) While playing football, 8-year-old Jonathon Ramsey fractured his humerus. Supracondylar fractures of the humerus are often treated with a. Russells traction. b. Bryants traction. c. Bucks traction. d. Dunlops traction. " "(14-83-16-103) Seven-year-old Michael Weiss has been complaining of a persistent pain in his right hip and has been limping. The physician believes that Michael may have Legg-Calv-Perthes disease. This is a. an infection of the hip joint. b. a dislocation of the femur from the acetabulum. c. a sprain of the hip adductors. d. an aseptic necrosis of the head of the femur. " "(14-83-16-40) Which of these interventions would demonstrate that the nurse understands the underlying principles of traction? a. Supplying countertraction. b. Maintaining the client in a prone position. c. Maintaining the spreader in contact with the bed. d. Maintaining the weights in a dependent position. " "(14-83-17-115) Health maintenance of adolescents should include yearly screening for a. venereal disease. b. diabetes mellitus. c. tuberculosis. d. scoliosis. " "(14-83-18-122) Monica Freeman. 13 years old has functional scoliosis. While teaching Monica about her condition the nurse a. demonstrates proper application of a Milwaukee brace. b. emphasizes principles of cast care. c. prepares Monica for the possibility of a spinal fusion. d. helps Monica plan an exercise program. " "(14-83-30-252) The nurse should explain to the patient experiencing an acute flare-up of rheumatoid arthritis that absolute bed rest is necessary to a. decrease the bodys caloric needs. b. prevent damage to the inflamed joints. c. allow the body to manufacture red blood cells and antibodies. d. reduce the metabolic activities of the muscles and nerves. " "(14-83-30-255) What measure in regard to mobility should a nurse take for a patient in continuous skeletal traction/balanced suspension?

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT a. Instruct the patient in the use of the trapeze bar. b. Remove the weights when pulling the patient up in bed. c. Adjust the level of the bed to provide sensory stimulation. d. Turn the patient from side to side every 2 hours. " "(14-83-30-256) The nurse must assess the patient with a long-leg cast for pressure on the a. dorsalis pedis. b. posterior tibalis. c. popliteal artery. d. peroneal nerve. " "(14-83-31-257) You can tell when a plaster cast is dry because it. a. has a dull sound to percussion. b. is white and shiny. . c. is warm to the touch. d. has a musky smell. " "(14-83-31-258) Immediately after the application of a long leg plaster cast, the nursing intervention aimed at reducing edema and stimulating circulation would be a. covering the cast with a blanket. b. handling the wet cast only with the fingers. c. assessing the toes for color and temperature once each 8 hours. d. placing the cast on a pillow. " "(14-83-31-260) X-rays show that the lower end of a patient`s femur has been splintered into fragments. This type of fracture is called a. greenstick. b. compound. c. oblique. d. comminuted. " "(19-00, 165-12) In the immediate postoperative period following a hip replacement, the patient should be assisted to perform which of the following exercises on the affected extremity? a. Leg raising b. Dorsiflexion and extension of the foot c. Flexion and extension of the knee d. Quadriceps setting " "(19-00, 57-08) A six-year-old child has a short arm cast placed on the right extremity. While assessing the fingers during the immediate period after casting, a nurse would report which of the following findings? a. Mild edema b. Pain on movement c. Slight coolness of the cast when touched d. Capillary refill greater than three seconds "

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT "(19-00, 89-69) A nurse teaches self-care management to a teenaged patient who is being treated for scoliosis using a Milwaukee brace. Which of the following statements, made by the patient, indicates a correct understanding of the instructions? a. ""I can swim for one hour without the brace."" b. ""I must wear the brace over my jacket."" c. ""I can remove the brace for sleeping."" d. ""I must give up driving my car."" " "(7-05-215-45) During the initial assessment of the child with osteomyelitis of the left tibia, the nurse would expect the area to exhibit: a. Diffused tenderness b. Decreased pain c. Increased warmth d. Localized edema " "The nurse's primary goal when caring for a child with juvenile rheumatoid arthritis is to: A) Prevent skin breakdown. B) Prevent joint deformity. C) Prevent physical discomfort. D) Prevent weight gain. " "A client develops fat embolism, a serious complication after sustaining a right hip fracture. 1. (01-90-286-605). Which finding is most indicative of a fat embolism? a. Decreased body temperature b. Muscle spasm c. Petechial rash d. Swelling at the site 2. (01-90-286-606). Immediate treatment of the fat embolism should include a. Trendelenburgs position b. High concentration of oxygen c. High molecular weight dextran d. Fluid restriction " "A client diagnosed with rheumatoid arthritis complains of joint stiffness and difficulty beginning the day's activities. The client is concerned about functioning at home. The nursing diagnosis is impaired physical mobility related to joint stiffness. An expected outcome to evaluate nursing care is: A) Client is able to sleep. B) Client's vital signs are stable. C) Client performs self-care activities. D) Client is pain free. " "Alda Bagnoy is a 75-year-old widow who fell while cleaning the yard. The nurse noticed that she is unable to move her left leg. The first priority is to: (583-20) a. Extend her leg into a normal position b. Try to reduce the fracture. c. Elevate the extremity.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT d. Treat her as if a fracture has occurred. " "An 11-month-old infant with a fractured right femur from a car accident is admitted to the hospital and placed in Bryant's traction. The nurse finds the mother crying in the hallway outside the room, and the mother says, Oh, my poor infant is so sick. The best action the nurse should take at this time would be to: A) Agree with the mother that the infant is very sick and say that he or she is sorry. B) Say nothing at this time, because the infant's accident might have been prevented. C) Ask the mother if she would like to see her clergyman. D) Check the mother's understanding of the infant's injury, treatment, and prognosis. " "An 11-year-old boy with a fractured femur treated with a Steinmann pin and 90-90 traction is admitted. A short while later, the nurse notes that he has suddenly developed pallor, tachycardia, and dyspnea. The first action the nurse should take would be to: A) Catheterize him and measure his urine output. B) Check his vital signs and page the MD stat. C) Place him in high-Fowler's position and give him oxygen. D) Turn him on his left side. " "CASE: Alice Long, a 23-yearold stockroom clerk, fell over a carton at work. Immediately after, she complains of pain in her left leg and is unable to bear weight on that leg. She is taken to the emergency room. 1. (14-83-16-38) Another symptom that Ms. Long may exhibit that indicates she has fractured her left leg is a. shortening of the leg. b. internal rotation. c. increased range of motion. d. flaccidity of the muscle. 2. (14-83-16-39) Ms. Long is admitted to the hospital, where Bucks extension traction is applied. What type of traction can Bucks extension be classified as? a. Skin traction. b. Skeletal traction. c. Intermittent traction. d. Suspension traction. 3. (14-83-16-41) Bucks traction has been discontinued, and a long leg plaster cast applied. The integrity of Ms. Longs newly applied, wet cast can BEST be maintained by which of these nursing interventions? a. Maintaining it in a prone position. b. Covering it with a blanket. c. Handling it with both hands. d. Elevating it on several pillows. 4. (14-83-16-42) Which of these nursing interventions would be of MOST benefit in the prevention of skin breakdown while Ms. Long is wearing a cast? a. Keeping the cast soil free. b. Maintaining the client in a prone position. c. Maintaining the cast in an elevated position. d. Applying lotion to the skin under the edge of the cast.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT 5. (14-83-417-43) Evaluation of Ms. Long for indication of nerve damage should include a. checking peripheral pulses. b. inspecting the toes for color change. c. noting changes in sensation in the toes. d. feeling the toes for temperature change. " "CASE: Daryl sustained a vehicular accident. An open reduction of the left femur is done and a Steinman pin is inserted for skeletal traction. A closed reduction of the left ulna is done with an application of a plaster cast. (01-90-302-777). After Daryl returns to his room, he complains of pain in his right arm. The initial action of the nurse should be to: a. administer analgesics as ordered b. check his fingers c. notify his physician immediately d. pad the edges of the cast (01-90-302-778). To maintain proper alignment and immobilization of the femur, the physician has ordered balanced skeletal traction with a Thomas splint. While caring for Daryl, the nurse should explain to him that he a. cannot turn or sit up b. cannot turn but can sit up c. can turn but cannot sit up d. can turn and sit up (01-90-303-779). In dealing with the weights that are applying the traction, the nurse should: a. allow them to hang freely in place b. hold them up if the client is shifting position in bed c. remove them if the client is being moved up in bed d. lighten them for shorts periods if the client complains of pain (01-90-303-780). If Daryl should show an increase in blood pressure and signs of confusion and increased restlessness, the nurse should suspect: a. a conclusion b. impending shock c. fat emboli d. anxiety (01-90-303-781). Daryl develops an acute localized osteomyelitis. He is placed on intravenous antibiotic therapy. The wound is incised and drained, and neomycin irrigations are ordered four times a day. It is important that these irrigations be performed a. with strict aseptic techniques b. with a warm solution c. for at least 5 minutes d. at equal time intervals " "CASE: Joan Harrison, a 36-year-old housewife, has recently been diagnosed as having rheumatoid arthritis. Her chief complaints are joint pain and morning stiffness of both hands. 69. (14-83-431-69) Mrs. Harrisons fingers are swollen. The swelling of her fingers is due to:

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT a. distension of the joint capsule by an increased amount of synovial fluid. b. infiltration of plus into the muscle and fibrous tissue surrounding the joints. c. collection of blood into the subcutaneous surface. d. Formation of bony spurs on the articulating surfaces of the joints. 70. (14-83-431-70) Mrs. Harrison is being treated with aspirin and prednisone. During the early days of drug treatment, it is essential that she be carefully monitored for adverse effects. Common adverse effects that may be observed are a. gastrointestinal upset and bleeding. b. diarrhea and pruritus. c. vertigo and tachycardia. d. diaphoresis and blurred vision. 71. (14-83-431-71) To minimize or prevent adverse effects from aspirin and prednisone. when should the nurse administer these medications to Mrs. Harrison? a. At bedtime. b. With meals. c. An hour after meals. d. A half hour before meals. 72. (14-83-431-72) Mrs. Harrison is receiving aspirin and prednisone because the-effect of these drugs is a. anti-infective. b. antimetabolitic. c. antimicrobic. d. anti-inflammatory. " "CASE: Mr. Joseph Dunne has had a left total hip replacement for osteoarthritis. He has been recovering without complications and has started physical therapy. (01-90-297-728). The physical therapist orders exercises of Mr. Dunnes left hip, knee and foot to gradual increase range of motion to the left hip. The nurse can best assist Mr. Dunne by: a. administering an analgesic before the exercises b. stopping the exercises if Mr. Dunne experiences pain c. performing the exercises for Mr. Dunne d. observing Mr. Dunnes ability to perform the exrcises (01-90-297-729). Mr. Dunne should be instructed to avoid a. adduction of his left leg b. abduction of his left leg c. bearing any weight on his left leg d. the prone position in bed (01-90-297-730). When the rehabilitation therapist tells Mr. Dunne that the outcome of this therapy depends on the ability of the nursing staff as well as on his motivation, Mr. Dunne questions the nurse on the meaning of this phrase. The nurse should reply that the nurses role in rehabilitation is to: a. make the client as comfortable as possible b. follow the directions of the rehabilitations c. supervise the clients therapy appointments and exercise program d. assist the client in establishing therapy priorities and goals (01-90-298-731). Mr. Dunne asks the nurse if his new joint will function normal. The nurse can best answer this by saying that: a. the new joint will be stronger than the old one

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT b. the new joint wont function as well as a normal joint, but it will be better than the arthritic joint c. the new joint will function almost as well as a normal joint, particularly if you perform your exercises faithfully d. the doctor will be able to assess your limitations in 6 weeks and then explain them to you (01-90-298-732). On the initial visit to Mr. Dunne after his discharge from the hospital, the community health nurse notes that Mr. Dunne has understood his discharge instructions and is making progress when the client states: a. I am pleased that now I can tie my own shoelaces b. I have been able to lie face down for about 15-20 minutes each day c. I have been able to remove the high toilet seat d. I no longer need a pillow between my legs when I lay on my left side " "CASE: The school nurse held a scoliosis screening clinic at a local high school. She suspects that 11-yearold Pamela Silvestri and 13-year-old Meredith Astor have scoliosis. Both children were referred to their family physicians. 74. (14-83-408-74) The school nurse conducting the scoliosis screening clinic observed each child in which of the following positions? a. Bending forward at the waist, feet together, knees unbent, and arms hanging freely. b. Lying on the side, with arms extended above the head and legs unbent. c. Seated in a chair with arms extended above the head. d. Standing with legs apart and hands placed on hips. 75. (14-83-409-75) Pamela Silvestri visits her family physician. A diagnosis of functional scoliosis is made. In order to plan nursing care for Pamela, the nurse needs to consider that functional scoliosis a. is treated by a tumbuckle cast followed by spinal fusion. b. does not require medical or surgical treatment. c. is correctable by exercises and improvement in posture. d. is treated by. a diet high in protein and vitamin C. 76. (14-83-409-76) Meredith Astor visits her family physician. A diagnosis of structural scoliosis is made. Meredith is to be fitted with a Milwaukee brace. When she asks the nurse why she has to wear the brace, the nurse replies: a. ""The Milwaukee brace will decrease your back pain and improve your posture."" b. ""The Milwaukee brace will help to increase the strength of the muscles supporting the spinal column."" c. The Milwaukee brace is worn in the daytime to protect your spine from injury."" d. ""The Milwaukee brace is a pressure device that will prevent the degree of curvature from increasing. 77. (14-83-409-77) Meredith tells the nurse, ""I`m not going to wear the brace to school. Im only going to wear it at home."" The nurse interprets Merediths behavior as a. rebellion against adult authority. b. concern about her body image. c. anger at having scoliosis. d. fear of bodily harm. " "The nurse is responsible for ensuring the safety of the client. The nurse is providing care to a client with a full leg cast. The nurse is legally obligated to check blood circulation in the toes: A) On the basis of nursing judgment.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT B) Only with a physician order. C) If checking blood circulation is mentioned in the nursing care plan. D) If nurses on previous shifts have checked for circulation. " "What assessment finding would prompt the RN to suspect compartment syndrome in a client with a long leg cast? A) Presence of foot pallor. B) Severe, unrelieved pain. C) Spastic movement of the toes. D) Absence of pedal pulses. " "What nursing care must be given initially to an infant in a spica cast? A) Turn and position the infant every 2 hours. B) Teach the parents how to care for this infant. C) Apply baby lotion to the skin around the cast edges. D) Clean the cast with soap and water, especially in the perineal area. PEDIA " (06-06-18-127) A middle-school teacher questions the school nurse about why the girls in her class are more developed than the boys. The nurses best response would be: a. This is normal. Girls begin puberty before boys and as a result are taller, heavier, and more developed than the boys. b. This is abnormal. Boys begin puberty before girls and as a result should be taller, heavier, and more developed than the girls. I will pay a visit to your classroom and assess your students. c. I will consult with the school physician about your observations and get back to you."" d. What is the ethnic mix in your classroom?"" " " (06-06-21-175) Hirschsprungs disease is suspected in a newborn. When admitting the newborn to the pediatric unit, the nurses most important assessment will be the newborns: a. Weight. b. Hydration status. c. Abdominal circumference. d. Laboratory value. " " (06-06-22-186) The nurse observes a nursing student caring for an infant with hydrocephalus and a newly revised ventriculoperitoneal shunt. Which action on the part of the nursing student requires immediate intervention by the nurse? a. The nursing student places the infant on the nonoperative side. b. The nursing student maintains the infant flat in bed for the first 24 postoperative hours. c. The nursing student places the infant in a slightly head-down position. d. The nursing student gradually increases the angle of the head of the bed with each postoperative day. " " (06-06-26-249) The nurse performs a physical assessment on a newborn infant. Which finding requires that the pediatrician be notified? a. Small, peachcolored crystals in the diaper. b. Mongolian spots across the buttocks.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT c. Firm skull with overlapping sutures. d. Unequal leg creases. " " (06-06-27-259) While conducting a Denver Developmental Screening Test (DDST), the nurse would anticipate that a 1-year-old infant could be expected to: a. Jabber. b. Say da da"" and ma ma."" c. Point to at least one named body part. d. Combine 2 or 3 words. " " (06-06-28-282) The nurse in charge of a daycare center is assessing the children. Which infant/child is at high risk for developing meningitis? a. A 3-month-old infant who is bottlefed. b. A 5-month-old infant who is breastfed. c. A 2-year-old child with quadriplegia due to cerebral palsy. d. A 3-year-old child who lives with parents who smoke cigarettes. " " (14-83-10-36) The nurse assesses 8-month-old Jessica Stanleys motor development. Which of the following behaviors should she expect to observe? a. Jessica will pull herself to a sitting position. b. Jessica will pull herself to a standing position. c. Jessica will be able to walk holding on. d. Jessica will walk independently. " "(04-94-12-99). A four-month-old infant is admitted with a ventricular septal defect, and undergoes a cardiac catheterization. Post catheterization, which sign would alert the nurse to a potential complication? a. Pedal pulses palpable bilaterally. b. Apical pulse 140 beats/minute. c. Blood pressure 96/40. d. Groin dressing intact with small amount of blood noted. " "(04-94-43-19). In planning care for a newborn with a surgical repair of a myelomeningocele, the nurse should be aware that this child is prone to developing which of the following? a. Osteomyelitis b. Decubitus c. Otitis media d. Hydrocephalus " "(04-94-84-9). Upon assessing gestational age of a baby, the nurse determines that he is 40 weeks gestational age. Which of the following characteristics are most likely to be found in this baby? a. Lanugo abundant over shoulders and lower coccyx. b. Pinna of ear springs back slowly when folded. c. Vernix well distributed over entire body. d. Creases covering the entire bottom of both feet. "

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT "(06-06-22-179) An 11-month-old infant with hydrocephalus is admitted to the pediatric unit for revision of a malfunctioning ventriculoperitoneal shunt. On physical assessment, the nurse would expect to find: a. An increasing head circumference. b. An increasing abdominal circumference. c. Difficulty in sucking and feeding. d. Hyperactivity. " "(06-06-28-278) A 3-day-old infant has been exclusively breastfed since birth. The infant now has developed lethargy and appears icteric. What is the probable cause of the infants current condition? a. Physiological jaundice b. Liver failure c. Neonatal sepsis d. Blood incompatibility " "(07-05-138-6) When determining the parents compliance with treatment for their toddler who has recurrent otitis media, which of the following measures would the nurse expect the parents to describe? a. Cleaning the ear canals with hydrogen peroxide b. Administering continuous, small dose antibiotic therapy c. Instilling eardrops regularly to prevent cerumen impaction d. Holding the child upright when feeding with a bottle " "(07-05-140-24) At a follow up appointment after being hospitalized, an adolescent with a history of cystic fibrosis describes his stools to the nurse. Which of the following descriptions would the nurse interpret as indicative of continued problem with malabsorption? a. Soft with little odor b. Large and foul smelling c. Loose with bits of food d. Hard with streaks of blood " "(07-05-140-26) Which of the following if described by the parents of a child with cystic fibrosis indicates that the parents understand the underlying problem of the disease? a. An abnormality in the bodys mucus secreting glands b. Formation of fibrous cysts in various body organs c. Failure of the pancreatic ducts to develop properly d. Reaction to the formation of antibodies against streptococcus " "(07-05-140-27) Which of the following outcome criteria would the nurse develop for a child with Cystic fibrosis who has a nursing diagnosis of ineffective airway clearance related to an increased pulmonary secretions and inability to expectorate? a. Respiratory rate and rhythm within expected range b. Absence of chills and fever c. Ability to engage in age-related activities d. Ability to tolerate usual diet without vomiting " "(07-05-141-28) A school age child with cystic fibrosis asks the nurse what sports she can involved in as she becomes older. Which of the following activities can the nurse suggest?

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT a. Swimming b. Track c. Baseball d. Javelin throwing " "(07-05-141-29) After the parents bring their infant to the emergency room, the nurse obtains a brief history of events occurring before and after the parents found the infant not breathing. Which of the following questions would be most appropriate to ask? a. Was the infant sleeping while wrapped in a blanket? b. Was the infant lying on his stomach? c. What did the infant look like when you found him? d. When had you last checked the infant? " "(07-05-150-10) which of the following will be included in the plan of care of child with tetralogy od fallot who has undergone corrective surgery? a. 2 to 3 grams of sodium in the diet each day b. Physical activity restrictions c. Visits limited to a selected few d. Assignment to an isolation room " "(07-05-151-21) Which of the following should be included when giving discharge instructions to the for the parents of a 12 month old child with Kawasaki Disease who is to be discharged home? a. Offer the child extra fluids every 2 hours for 2 weeks b. Take the childs temperature daily for several days c. Check the childs blood pressure daily until the follow up appointment d. Call the physician if the irritability lasts for 2 more weeks " "(07-05-158-4) The nurse is teaching how to use elbow restrains to a mother of an infant who has just undergone cleft lip and palate repair. Which of the following statements by the mother indicates effective teaching? a. We will keep the restraints on continuously except when checking the skin underneath for redness. b. We will keep the restraints on during the day while he is awake, but take them off when we put him to bed at night. c. After we got home, we wont have to use the restraints because our child does not suck on his hands or fingers. d. We will be sure to keep the restraints on all the time until we come to see the physician for a follow up visit. " "(07-05-158-5) The parent of a child with cleft lip and palate asks the nurse when the cleft palate will be repaired. The nurse responds most appropriately which of the following? a. Before the eruption of the teeth b. When the child weighs approximately 10kg (22lbs) c. Before the development of speech d. After the child learns drink from a cup. "

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT "(07-05-158-6) On the second post-operative day after repair of a cleft palate, which of the following would the nurse expect to be most appropriately used on a toddler? a. Cup b. Straw c. Rubber tipped syringe d. Large holed nipple " "(07-05-160-17) The nurse assess the urine of the newborn with imperforate anus for: a. Meconium b. Blood c. Bile d. acetone " "(07-05-161-32) When assessing a 4 month old infant diagnosed with possible intussusception, the nurse would expect the mother to relate which of the following about the infants crying and episodes of pain? a. Constant accompanied by leg extension b. Intermittent with the knees drawn to the chest c. Shrill during ingestion of solids d. Intermittent while being held in the mothers arms " "(07-05-161-33) When obtaining the nursing history from the mother of an infant with suspected intussusception, which of the following questions would be most helpful? a. What do the stools look like? b. When the last time your child urinated? c. Is your child eating normally? d. Has your child had any episodes of vomiting? " "(07-05-161-34) An NGT inserted during surgery to correct an infants intussusception is no longer freely draining gastric secretions. Which of the following would the nurse do next? a. Aspirate the tube with a syringe b. Irrigate the tube with distilled water c. Increase the level of suction d. Rotate the tube " "(07-05-162-45) The teaching to the parents of a child with Hirschsprungs Disease regarding the diagnosis is deemed effective if they state which of the following? a. There is no rectal opening for stool to pass. b. There is a tube between the trachea and esophagus c. The nerves at the end of the colon is missing d. The muscle below the stomach is too tight. " "(07-05-163-47) When developing the plan of care for a child with Hirschsprungs Disease, which of the following would the nurse include? a. Administering a tap water enema b. Inserting a gastrostomy tube

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT c. Restricting oral intake to clear liquids d. Using betadine to prepare the perineum " "(07-05-163-48) An infant with Hirschsprungs Disease undergone surgery for creation of colostomy. Which of the following statements about the colostomy if made by the mother requires further teaching? a. My child should be able to care for the colostomy by the time hes 8 years old. b. The colostomy will give the intestine time to shrink to its normal size. c. The colostomy may include 2 separate abdominal opening. d. Right after the procedure, the stoma will appear big and red. " "(07-05-163-52) An infant with Hirschsprungs Disease is to be discharged in 1 to 2 days after colostomy surgery. After teaching the parents about the overall effects of the surgery to the baby, which of the following statements by the parents indicate understanding? a. His abdomen will be large for a while. b. When he is ready, toilet training will be difficult. c. We need to limit his intake of daily products. d. We will give him vitamin supplements until he is an adolescent. " "(07-05-177-12) Which of the following statements by a mother would suggest to the nurse that her child has Celiac Disease? a. His urine is so dark in color. b. His stools are large and smelly. c. His belly is so small. d. He is too short. " "(07-05-177-13) During assessment of a child with Celiac Disease, the nurse would most likely note which of the following findings? a. Enlarged liver b. Protuberant belly c. Tender inguinal lymph nodes d. Periorbital edema " "(07-05-177-14) After teaching the mother of a child with Celiac Disease about dietary management, which of the following statements of the mother indicates successful teaching? a. I will feed my child foods that contain wheat products. b. I will be sure to give my child lots of milk. c. I will plan to feed my child foods that contain rice. d. I will be sure my child gets oatmeal everyday. " "(07-05-177-15) After teaching the parents about diet for a child with Celiac Disease, which of the following if stated by the parents as to be avoided indicates correct understanding? a. Chocolate candy b. hot dogs c. Bologna on rye sandwich d. White rice

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT " "(07-05-177-17) The mother of a child with Celiac Disease asks, How long will he stay on this type of diet? The nurses response? a. Until the jejunal biopsy is normal. b. When his stools appears normal. c. For the next 6 months d. For the rest of his life. " "(07-05-177-18) When preparing to get a neonatal screening test for phenylketonuria (PKU), the child must have received which of the following to ensure accurate results? a. A feeding of an iron rich formula b. Nothing by mouth for 4 hours before the test c. Cows or breast milk for 24 hours before the test d. A loading dose of glucose water " "(07-05-178- 20) When taking a diet history from the mother of a 7 year old child with PKU, a report of an intake of which of the following would cause the nurse to become concerned? a. Cola b. Carrots c. Orange juice d. Bananas " "(07-05-178-22) When teaching the mother of a child diagnosed with PKU about its transmission, the nurse would use knowledge of which of the following as the basis for the discussion? a. Chromosome translocation b. Chromosome deletion c. Autosomal recessive gene d. X-linked recessive gene " "(07-05-179-34) After teaching a parent about lactose intolerance, the nurse determines the teaching as effective when the mother describes the disease by which of the following statements? a. The lack of an enzyme to breakdown lactose. b. An allergy to lactose found in cows milk. c. Inability to digest proteins completely. d. Inability to digest fats completely. " "(07-05-184-4) When assessing the child with undescended testes, the nurse needs to be alert also about which of the following? a. Abnormal lower extremity reflexes b. A history of frequent emesis c. A bulging in the inguinal area d. Poor weight gain " "(14-83-11-45) Eighteen-month-old Kareem Walters is admitted to the pediatric unit with a diagnosis of intussusception. Intussusception is a. a telescoping of one portion of the intestine into another.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT b. a hemiation of the abdominal viscera at the level of the umbilicus. c. a faulty development of the bile ducts linking the gall bladder to the duodenum. d. an absence of parasympathetic ganglion nerve cells in the descending colon. " "(14-83-11-46) The nurse is teaching the parents of a child with cystic fibrosis the procedure for postural drainage. When should the nurse instruct the parents to do postural drainage? a. Each morning as soon as the child gets out of bed. b. Before each meal and at bedtime. c. Once or twice a day when they have time. d. Each night just before the child`s bed time. " "(14-83-12-61) Mrs. Ralslon asks the nurse when she should begin taking her 2-year-old son to the dentist. The nurse replies: a. It is not necessary to visit a dentist until your child enters kindergarten."" b. ""Most dentists like to see children for the first time when they are 4 years old."" c. ""Dental care should begin when a child is 1 year old."" d. ""Your child should first visit the dentist when all 20 temporary teeth are present."" " "(14-83-15-92) Seven-year-old Tabitha Holt is having her annual physical examination. Since last year she has gained .5 pounds and has grown 2 inches. This pattern of growth is a. above average for both height and weight for her age group. b. above average for weight and below average for height for her age group. c. below average for both height and weight for her age group. d. within the normal range for both height and weight for her age group. " "(14-83-15-93) Assessment of motor development during the school-age years should indicate that hand-eye coordination is fully developed at a. 6 years of age. b. 8 years of age. c. 9 years of age. d. 11 years of age. " "(14-83-422-91) Two-year-old Charles Adelsky is admitted to the pediatric unit with a diagnosis of possible intussusception. The nurse assessing Charles would expect to observe a. loose, green stools. b. soft, brown stools. c. constipated, black stools. d. currant jelly stools. " "(14-83-423-94) Two-year-old Benjamin Peters has celiac disease. The nurse is counseling his parents about Benjamins diet. She concludes that Mr. and Mrs. Peters understand the diet when they state that a food group that MUST be eliminated is a. breads and cereals. b. lean meats and poultry. c. fresh green, leafy vegetables. d. citrus fruits.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT " "(14-83-7-1) The average initial weight loss for the normal newborn is what percentage of his/her body weight? a. 10-15%. c. 0-5%.4 b. 5-10%. d. 15-20%. " "(14-83-7-10) Which of the following findings related to a newborn`s umbilical cord is normal? a. Redness at the base of the cord. b. Drying of the cord. c. Discharge from the base of the cord. d. Foul odor from the cord. " "(14-83-7-13) The tonic neck reflex in the newborn is manifested by a. the fencing position. b. a coordinated sucking and swallowing reflex. c. the startle reflex. d. rigidity of the neck when held. " "(14-83-7-2) The startle reflex present in all newborns is known as a. the tonic neck reflex. c. the Babinski reflex. b. the Moro reflex. d. Hagers sign. " "(14-83-7-3) A clinical manifestation that a newborn is distressed is a. bluish discoloration of the hands and feet. b. rapid, irregular respirations. c. periods of loud crying. d. habitual extension of the arms and legs. " "(14-83-7-4) lf a newborn has swollen breast tissue at birth, the mother should be instructed to a. rub the breasts until the swelling disappears. c. leave the breasts alone. b. put ice on the breasts. d. squeeze the breasts to eliminate fluid. " "(14-83-7-5) The hemoglobin of a newborn is a. 17-20 gm. c. 12-14 gm. b. 10-12 gm. d. 9-10 gm. " "(14-83-7-7) Which of the following is abnormal in the newborn? a. Irregular respirations 40 per minute. b. Slight cyanosis of the extremities. c. Black, tarry stools. d. Persistent, high-pitched, whining cry. " "(14-83-8-14) Which of the following would require immediate notification of an infant's physiclan? a. A small green stool with yellow material mixed in it. b. Loose yellow-orange stool in a breastfed infant. c. Greenish yellow. watery stools forcefully expelled.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT d. Dark green, tarry-stools. " "(14-83-8-15) Milia is a condition of the infant`s skin in which there is (are) a. presence of a yeastlike infection. b. small red ""port wine"" areas on the nose and the face. c. dark areas on the back. d. white pinhead-sized papules on the face. " "(14-83-8-16) Cephalhematoma in an infant a. is an engorgement of the soft tissue at the hack of the head. b. is often due to trauma during delivery. c. occurs over a nonbony area. d. indicates a frontal presentation at delivery. " "(14-83-8-17) When the Ryans see their baby for the first time, they express concern because the babys head appears elongated. The nurses best reply would be that the apparent elongation is due to a. a collection of blood under the bones. b. a collection of fluid in the tissues. c. the overlapping of bones during birth. d. a genetically inherited trait. " "(14-83-8-19) Upon admission of a newborn, the nursery nurse notes the presence of protruding tongue and slanted eyes. These can be an indication of a. PKU. b. hypoglycemia. c. Down syndrome. d. drug addiction. " "(14-83-8-22) In inspecting the fontanels on a newborn infant, which of the following observations would suggest an abnormality? a. Posterior fontanel smaller than anterior fontanel. b. Diamond-shaped anterior fontanel. c. Bulging anterior fontanel. d. Posterior fontanel difficult to palpate. " "(14-83-8-25) Baby Marlo Levy has a meningomyelocele. The FIRST priority in providing nursing care for Marlo is to a. maintain fluid and electrolyte balance. b. prevent rupture of the external sac. c. begin passive range of motion exercises. d. prevent urinary tract infections. " "(14-83-9-27) Two-year-old Ricardo Colon has just had a cleft-palate repair. The BEST method of feeding Ricardo a clear liquid diet is with a. an Ascepto syringe. b. special cleft-palate nipple.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT c. a rubber-tipped syringe. d. a plastic cup. " "(14-83-9-29) The nursery nurse observes that a 1-day-old female infant has not passed a meconium stool. Further assessment is required as the nurse suspects that the newborn may have a. an imperforate anus. b. a congenital megacolon. c. biliary atresia. d. a rectovaginal fistula. " "(14-83-9-30) One-month-old Drew MacDonald has a patent ductus artcriosus. This anomaly occurs when. a. the opening between the left and the right atrium fails to close after birth. b. the structure that shunts blood from the pulmonary artery to the aorta remains open after birth. c. there is a narrowing of the aortic lumen near .the level of the ductus arteriosus. d. the aorta arises from the right ventricle and the pulmonary artery originates from the left ventricle. " "(14-83-9-33) Two-week old Tamara Johnson is admitted to the pediatric unit with a diagnosis of pyloric stenosis. She is placed on a regimen of thickened feedings. The BEST position to place Tamara in after feeding is a. on her right side, with her head elevated. b. on her back, in an infant seat. c. on her abdomen, with her head turned to the side. d. on her left side, supported by sandbags. " "(14-83-9-34) Mrs. Parker brought her 6-month-old son Anthony to the Child Health Conference. Anthonys birth weight was 7 pounds, 9 ounces. The nurse weighing Anthony would expect him to weigh approximately a. 10 pounds. b. 12 pounds. c. 15 pounds. d. 20 pounds. " "(19-00, 164-03) When assessing a six-month-old baby girl, the nurse should expect the infant to exhibit which of the following abilities indicative of normal development? a. Creeping on her hands and knees b. Pulling herself to a standing position c. Waving bye-bye d. Turning over completely " "(19-00, 58-15) A nurse evaluates a three-month-old, developmentally-delayed infant for manifestations of cerebral palsy. Which of the following findings would a nurse report? a. Exaggerated arching of the back b. Absence of the extrusion reflex when fed from a spoon c. Head circumference measurement less than the 50th percentile d. Slight head lag when pulled to a sitting position

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT " "(19-00, 68-85) A preterm newborn would receive surfactant (Exosurf) for which of the following purposes? a. To stimulate digestive enzymes b. To minimize the effects of jaundice c. To prevent intracranial hemorrhage d. To improve respiratory function " "(19-00, 76-135) A six-year-old child who has celiac disease is selecting food items from a hospital menu. Based on an understanding of celiac disease, a nurse would discourage the child from selecting which of the following foods? a. Fried sweet potatoes b. Corn meal muffin c. Puffed rice cereal d. Whole wheat toast " "(19-00, 76-136) Which of the following findings in a 12-hour-old infant boy would require the nurse to investigate further? a. The newborn has voided one time b. The foreskin on the newborns penis is not retractable c. The newborn has lost 12% of his birth weight d. The newborn is excreting milky-Iooking fluid from his breasts " "(19-00, 77-142) A six-month-old infant is suspected of having intussusception. A nurse should expect the child to undergo which of the following procedures? a. Colonoscopy b. Rectal biopsy c. Barium enema d. Cholangiography " "(7-05-196-1) When assessing a newborn admitted for an upper lumbar myelomeningocele, which of the following would the nurse expect to see? a. Minimal movement of the lower extremities b. Upper extremity paralysis c. Urinary bladder prolapse d. Respiratory problems " "(7-05-196-4) The parents of the baby with myelomeningocele asks about their childs future mental ability. Which of the following would be the nurses best response? a. About one-third are mentally retarded, but its too early to tell about your child. b. About two-thirds are mentally retarded, and youll know soon if this will occur. c. Your child probably will be of normal intelligence since he demonstrates some of it now. d. Youll need to talk to the doctor about that. But you can ask later. " "(7-05-196-6) When positioning the baby with unrepaired myelomeningocele, which of the following positions would be most appropriate?

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT a. Supine with the hips at 90 degrees flexion b. Right side lying position with the knees flexed c. Prone with the hips in abduction d. Semi-Fowlers position " "(7-05-197-13) A 4-year old child with hydrocephalus is scheduled for a ventro peritoneal shunt in the right side of the head. When developing the childs post operative plan of care, the nurse would anticipate to place the preschooler in what position immediately after surgery? a. On the right side, with the foot of the bed elevated. b. On the left side, with the head of the bed elevated. c. Prone, with the head of the bed elevated d. Supine, with the head of the bed flat. " "(7-05-197-8) Which of the following would alert the nurse initially to suspect hydrocephalus in an infant who has undergone surgical repair of myelomeningocele? a. Seizure and vomiting b. Frontal bossing and sunset eyes c. Increased head circumference and bulging fontanel d. Irritability and shrill cry " "(7-05-198-18) Which of the following would alert the nurse to suspect a physical problem commonly associated with Down Syndrome? a. Weight loss b. Irregular heart rate c. Rapid respirations d. Increased blood pressure " "(7-05-198-19) when developing a teaching plan for the parents of a child with Down Syndrome, the nurse focuses on activities to increase which of the following on the parents? a. Affection for their child b. Responsibility for their childs welfare c. Understanding of their childs disability d. Confidence in their ability to care for their child " "(7-05-199-30) When interviewing the parents of a 2 year old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? a. Bladder infection b. Middle ear infection c. Fractured clavicle d. Septic arthritis " "(7-05-210- 3) A characteristic abnormality in which of the following would lead the nurse to suspect that in infant has torticollis (wry neck)? a. Quadriceps b. Cervical vertebrae c. Trapezius muscle

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT d. Sternocleidomastoid muscle " "(7-05-211-11) When assessing the development of a 15 month old child with cerebral palsy, which of the following milestones would the nurse expect a toddler of this age to have achieved. a. Walking up steps b. Using a spoon c. Copying a circle d. Putting a block in cup " "(7-05-214-42) The child with hip spica cast seems to be adjusting to the cast, except that after each meal, the child complains of the cast is too tight. Which of the following would the nurse plan to do? a. Give the enema that was ordered as needed b. Offer smaller more frequent meals c. Give the child mechanical soft diet d. Offer the child more fruits and grains " "(7-05-230-19) The nurse visits a day care center and assesses several 18 month-old toddlers. Which of the following would the nurse expect a child in this age group to be able to accomplish? a. Build a tower of four cubes b. Say three words c. Use spoon with little spilling d. Throw a ball overhand " "22. At the time of discharge from the hospital, the nurse notes that a newborn, born 36 hours previously, has yet to pass meconium. The nurse should: A) Inform the newborn's parents about what to look for in the stool for the first few days at home. B) Notify the pediatrician stat before discharging the newborn. C) Obtain an order for a glycerine suppository before discharging the newborn. D) Know that this is a normal finding in some newborns. " "48. (14-83-406-48) A reflex that may indicate an abnormality in a newborn is a a. positive grasp reflex. b. positive Babinski reflex. c. one-sided Moro reflex. d. positive rooting reflex. " "65. The nurse is teaching an infant growth and development class to a group of new mothers. The nurse should explain that by 4 months of age, the infant should be able to: A) Show palmar grasp. B) Bang two cubes together. C) Put a block in a cup. D) Demonstrate pincer grasp. " "A 3-day-old infant who is breastfed is observed to have facial jaundice; the bilirubin level is 8 mg/dL. The appropriate nursing action is to: A) Obtain orders to start phototherapy.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT B) Assess serum bilirubin level. C) Continue observation of baby. D) Start supplementation of formula feeding. " "A child with cystic fibrosis is scheduled to start school in the upcoming fall and may participate in most activities. What fluid replacement would be most therapeutic for this child after exercise? A) Mineral water. B) Gatorade. C) Fruit punch. D) Diet soda. " "An infant is born with trisomy 13 (Patau syndrome) and severe congenital anomalies. The health-care team and the family decide to withhold extraordinary measures. The nurse tells a nursing student that: A) The team's decision is unethical and illegal. B) This newborn will be allowed to die. C) The team presumed the newborn has no rights. D) The newborn will be euthanized. " "Baby Barbara Gordon, one day old infant is admitted to the nursery at 5:00 p.m. The next morning the nurse observes that her skin and the sclera of her eyes have become yellow. The nurse should first. (8702, 117-5) a. Notify the physician. b. Prepare for phototherapy. c. Observe for clay colored meconium. d. Record the observation. " "Baby Edmund has been diagnosed as having celiac disease. When teaching the family, the nurse explains that celiac disease is characterized by malabsorption resulting from a sensitivity to: (91-01; 22890) a. Fat b. Iron c. Lactose d. Gluten " "Failure to implement which nursing intervention would most closely correlate to the nursing diagnosis of high risk for injury in an infant who has just had a surgical repair for a cleft lip? A) Application of elbow restraints. B) Cleansing of the surgical site after every feeding. C) Allowing the parents to hold the infant. D) Placing the infant in an upright position. " "If meconium is present in the amniotic fluid, an infant's mouth and pharynx should be suctioned after the head is born, but before the rest of the body. The primary reason for this action is to: A) Limit transfer of infectious substances to the lower airways. B) Reduce the likelihood that secondary apnea will occur.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT C) Prevent persistence of abnormal cardiac shunts. D) Avoid drawing meconium into the lower airways with the first breath. " "Of the following findings in a full-term newborn, which is not an expected outcome of maternal hormone influence, and therefore should be reported? a. Witch milk b. Slight vaginal bleeding c. Undesended testicles d. Linea nigra " "The nurse in the well-baby clinic is caring for several infants, aged 1 to 6 months. Jean is 1 month old. Her mother tells the nurse that jean is an exceptionally good baby who sleeps well and rarely cries. The nurse should carefully observes for signs of cretinism when Jeans mother adds that her baby a. feeds well, quickly finishing all the formula in her bottle b. is very active when awake, making crawling movements in her crib c. seems constipated and has one firm yellow stool every other day d. is usually warm, flushing readily " "The parents of an infant who died of SIDS will most likely want to know the cause of SIDS. The most appropriate response by the nurse would be for her to tell them that its most likely caused by: (91-01, 643-1) a. Hypercalcemia b. History of gastrointestinal disease c. Meningitis d. Unknown etiology " "Which of the following congenital metabolic disorders detected in newborn screening may cause brain damage and development of cataract in the baby? a. Galactosemia c. Congenital hypothyroidism b. Phenylketoturia d. Congenital adrenal hyperplasia EMERGENCY " (06-06-39-446) A hospital is preparing for emergency admission of clients who were in a bus accident. Which client can be discharged to make room for the new admissions? a. A client with a fractured femur and suspected fat embolus. b. A client with bronchial asthma with 95% oxygen saturation on room air. c. An elderly client with dementia who was admitted the day before with congestive heart failure. d. A client admitted 3 days ago with small bowel obstruction who has a nasogastric tube in place. " "(06-06-32-337) The nurse triages clients in the emergency department. Which client should the nurse treat first? a. A 27-year-old man with right-side chest pain, shortness of breath, and unequal chest excursion who was in a motor vehicle accident. b. A 7-year-old child who sustained a scalp laceration in a soccer game. The child is awake and crying. c. An 82-year-old man with chest pain who is pale and diaphoretic. d. A 35-year-old woman with a compound tibial fracture.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT " "(07-05-141-32) On finding a child is not breathing, which of the following would the nurse do first? a. Clear the airway b. Begin mouth to mouth resuscitation c. Initiate oxygen therapy d. Start chest compression " "(07-05-141-33) Which of the following rates would the nurse use when performing rescue breathing during cardio-pulmonary resuscitation (CPR) for a 5 year old? a. 10 breathes/ minute b. 12 breathes/ minute c. 15 breathes/ minute d. 20 breathes/ minute " "(07-05-141-34) At which of the following rates will the nurse deliver the external chest compressions in a 5 year old child? a. 60 compression per minute b. 80 compression per minute c. 100 compression per minute d. 120 compression per minute " "(07-05-141-35) As part of the health education program, the nurse teaches a group of parents of preschoolers how to perform chest compressions during CPR. Which of the following would be the correct depth of compression? a. 1 to 1.5 inches b. 1.5 to 2 inches c. 2 to 2.5 inches d. 2.5 to 3 inches " "(07-05-141-36) When performing CPR, which of the following assessments would indicate that external chest compressions are effective? a. Mottling of the skin b. Pupillary dilation c. Palpable pulse d. Cool, dry skin " "(07-05-141-37) A nurse walks into the room just as a 10 month old infant places an object in his mouth and starts to choke. After opening the infants mouth, which of the following will the nurse do next to clear the airway? a. Use blind finger sweeps b. Deliver back blows and chest thrusts c. Apply 4 subdiaphragmatic abdominal thrusts d. Attempt to visualize the object " "(07-05-142-38) When preparing to deliver back blows to an infant who is choking on a foreign object, in which of the following positions would the nurse position the infant?

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT a. Head down and lower than the trunk b. Head up and raised above the trunk c. Head to one side and even with the trunk lower than the head d. Head parallel to the nurse and supported at the buttocks " "(07-05-142-39) When teaching the parents of an infant how to perform back blows to dislodge a foreign body, which of the following will the nurse tell the parents to use to deliver the blows? a. Palm of the hand b. Heel of the hand c. Fingertips d. Entire hand " "(07-05-142-40) While the nurse delivers abdominal thrusts to a 6 year old choking on a foreign body, the child begins to cry. Which of the following would the nurse do next? a. Tap or gently shake the shoulders b. Deliver back blows c. Perform a blind finger sweep of the mouth d. Observe the child closely " "(07-05-176-1) While conducting a medication inventory, the emergency room nurse checks to ensure that syrup of ipecac is readily available because this drug is used to: a. Induce vomiting b. Promote diuresis c. Control seizure d. Stimulate the heart " "(07-05-176-2) A toddler was brought to the emergency room for ingestion of undetermined amount of drain cleaner. The nurse is expected to prepares and assist with which of the following? a. Administering an emetic b. Performing a tracheostomy c. Performing gastric lavage d. Inserting an indwelling urinary catheter " "(07-05-176-3) After the acute stage following ingestion of drain cleaner by a child, the nurse would be alert for which of the following possible complication? a. Tracheal stenosis b. Tracheal varices c. Esophageal strictures d. Esophageal diverticula " "(07-05-176-4) A child presents to the emergency room with history of ingestion of large amounts of acetaminophen. For which of the following would the nurse assess? a. Hypertension b. Frequent urination c. Right upper quadrant pain d. headache

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT " "(07-05-176-5) When developing the plan of care for a toddler who ingested large amount of acetaminophen, which of the following would the nurse expect to be included in the initial treatment? a. Frequent blood level determination b. Gastric lavage c. Tracheostomy d. ECG " "(07-05-176-6) While assessing a preschooler for ingestion of kerosene, the nurse would be alert for which of the following? a. Uremia b. Hepatitis c. Carditis d. Pneumonitis " "(07-05-177-9) When teaching the mother of a toddler diagnosed with lead poisoning, which of the following would the nurse include as the most serious complication if the condition goes untreated? a. Cirrhosis of the liver b. Stunted growth rate c. Neurologic deficits d. Heart failure " "(14-83-13-67) A nurse is speaking to a group of mothers about safety during the toddler period. One of the mothers asks what she should do if her child ingests a poisonous substance. The BEST reply by the nurse is: a. ""Induce vomiting by stimulating the back of the childs throat."" b. ""Identify what was ingested, and call the local poison control center."" c. ""Have the child drink large quantities of milk."" d. ""Administer syrup of ipecac immediately."" " "(14-83-13-68) Twenty-month-old Juan Lopez is brought to the emergency room by his parents after he ingested half a bottle of aspirin. The nurse assessing Juan immediately takes his vital signs. She would expect to observe a. hyperventilation. b. elevated blood pressure. c. hypopyrexia. d. a slow, thready pulse. " "(14-83-13-69) Fifteen-month-old Tyrone Harris is being treated for lead poisoning with EDTA and BAL intravenously; these medications act to a. promote excretion of lead via the gastrointestinal tract. b. aid in depositing lead in the soft tissues. c. aid in depositing lead at the ends of the long bones. d. promote urinary excretion of lead. " "(14-83-30-249) Which of the following applies to an epidural hematoma?

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT a. It is the most common of all brain injuries. b. It is a surgical emergency. c. The patient remains unconscious. d. A clot develops below the dura mater. " "(14-83-38-337) Susan Zimmerman is premedicated before surgery with Demerol 50 mg IM and atropine 0.6 mg IM. Understanding the effects of the narcotic, the nurse would observe her closely for which of the following untoward reactions? a. Bradycardia. b. Shortness of breath. c. Hypotension. d. Dryness of the mouth " "(14-83-409-78) Six months after a scoliosis diagnosis was made, the 11 year old client is admitted to the hospital for a spinal fusion. The nurse positioning the client the day after her surgery a. places her in a prone position with the head of the bed elevated 45 degree b. utilizes a log-rolling technique to move the client from one side to the other. c. raises the head of the bed slightly and elevates the clients knees 30. d. encourages the client to move as much as possible by herself. " "(14-83-409-80) After a spinal fusion to correct scoliosis, the client is placed in a body cast, which she will wear for several months. During a discharge planning conference with the client and her mother the nurse emphasizes the need for a. weekly visits to the physician to have the integrity of the cast assessed. b. coughing and deep breathing exercises to prevent respiratory infections. c. increasing fluids and roughage in the diet to promote elimination. d. keeping the skin surrounding the cast clean and dry and preventing sore areas at pressure points. " "(19-00, 165-13) Diazepam (Valium) is prescribed for a patient with low back pain. The desired therapeutic action of Valium in this situation is to: a. reduce anxiety levels. b. eliminate pain sensation. c. suppress the inflammatory process. d. lessen muscle spasticity. " "(19-00, 73-112) Which of the following menus would best meet the nutritional requirements of a patient who has major burns? a. Cottage cheese, fruit salad, a roll and tea b. Spaghetti with meatless sauce, green salad, garlic bread and coffee c. Roast beef, mashed potatoes with gravy, green beans, fruit salad and milk d. Pork chops, French fries, applesauce and iced tea " "(19-00, 77-139) A 14-year-old is admitted to the hospital after being hit by a car while riding her bicycle. She has a closed head injury and was unconscious for several minutes after the accident. While assessing the child, the nurse obtains all of the following data. Which finding definitely requires further investigation?

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT a. The child does not remember the accident b. The child asks what day it is c. The child has clear drainage from the left ear d. The childs pupils constrict in response to light " "(19-00, 82-24) To which of the following nursing diagnoses would a nurse give priority when caring for a patient who has septic shock? a. Initiating a bowel program b. Encouraging deep breathing c. Increasing sensory stimulation d. Promoting fluid intake " "(19-00, 83-30) Which of the following findings would a nurse identify as indicative of impending septic shock in a patient? a. Bradycardia b. Flushed appearance c. Cool, clammy skin d. S3 gallop " "(19-00, 87-57) A nurse observes a colleague taking all of the following actions when caring for a patient who has leakage of cerebrospinal fluid from the nose. Which action would require further discussion? a. Placing the patient in low-FowIer's position b. Assisting the patient to void on a bedpan c. Inserting gauze packing into the patients nose d. Shining a penlight into the patients eyes " "(7-05-198-21) After teaching a group of teachers about seizures, the teachers role-play a scenario involving a child with tonic-clonic seizure. Which of the following actions if performed first indicates learning? a. Asking the other children what happened before the seizure. b. Moving the child to the nurses office for privacy c. Removing any nearby object that could harm the child d. Placing a padded tongue blade between the childs teeth " "(7-05-199-34) The nurse caring for a toddler just admitted with a diagnosis of near drowning is most concerned with which of the following? a. Hypothermia b. Hypoxia c. Fluid aspiration d. Cutaneous capillary paralysis " "(7-05-199-37) Which of the following assessments would be most important for the nurse to make initially in a school aged child being seen in the clinic for complaints of sore throat, muscle tenderness, arms feeling weak, and generally not feeling well? a. Difficulty swallowing b. Diet intake for the last 24 hours

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT c. Exposure to illness d. Difficulty urinating " "(7-05-200-46) The nurse is caring for a child with head injury. Rank the following assessment in order according to priority: 1. Vital signs 2. Decreased urine output 3. Level of consciousness 4. Motor strength 5. Vomiting episodes a. 34152 b. 35124 c. 54312 d. 21534" "(7-05-201-47) When caring for an unconscious child after a serious head injury, in which of the following positions would the nurse place the child? a. Prone with hips and knees slightly elevated b. Lying on the side with the head of the bed elevated c. Lying on the back, in the Trendelenburg position d. In the semi-Fowlers position with the arms at the side. " "(7-05-201-53) A child who was intubated after craniotomy now shows signs of decreased LOC. The physicain orders manual ventilation to keep the CO2 between 25 and 29mmHg and the PAO2 between 80 and 100mmHg. The nurse understands the purpose of this order is to: a. Vasoconstrict cerebral capillaries b. Prevent atelectasis c. Lower the arousal level d. Produce hyperoxygenation of the brain " "(7-05-202-57) A nurse witnessed an adolescent riding a motorcycle, hitting a tree and being thrown 30 feet away, stops to help. The victim reports he is now unable to move his legs. While waiting for the emergency service, what would the nurse do? a. Flex the victims knees to relieve stress on his back. b. Leave the victim as he is, staying close by. c. Remove the victims helmet as soon as possible. d. Assess the victim for abdominal trauma. " "(7-05-202-60) Which of the following observations would lead the nurse to think that the spinal shock is now resolving in a victim with spinal cord injury? a. Atonic urinary bladder b. Flaccid paralysis c. Hyperactive reflexes d. Widened pulse pressure " "(7-05-214-34) A child is admitted with a fracture of the femur and placed in skeletal traction. Which of the following will the nurse assess first? a. The pull of the traction on the pin b. The Ace bandage c. The pin sites for signs of infection

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT d. The dressings for tightness " "(7-05-214-35) A preschooler with a fractured femur of the left leg in traction is complaining that his leg hurts. It is too early for pain medication. It is best to do which of the following? a. Place a pillow under the childs buttocks to provide support b. Remove the weight from the left leg. c. Assess the leg for signs of neuromuscular impairment d. Reposition the pulley so the traction is looser " "(7-05-214-36) The nurse in the emergency room is caring for a 3 year old child with a fractured humerus. The child is crying and screaming, I hate you. Which of the following would be most appropriate? a. Tell the parents they will need to wait out in the lobby. b. Ask the charge nurse to assign this client to another nurse. c. Reassure the parents that this is a normal behavior under this circumstances d. Ask the parents to discipline the child so that the physician can treat her. " "(7-05-214-37) After a plaster cast has been applied to the arm of a child with fractured right humerus, the nurse completes discharge teaching. The teaching is effective if the mother agrees to seek medical help if which of the following is experienced? a. Inability to extend the fingers of the right hand. b. Vomiting after the cast is applied c. Coolness and dampness of the cast after 5 hours. d. Fussiness with complaints that the cast is heavy " "(7-05-214-39) While assessing a three year old child who has had an injury to the leg, complains of pain, and refuses to walk, the nurse notes that the childs left thigh is swollen. Which of the following would the nurse do next? a. Assess the neurologic status of the toes b. Determine the circulatory status of the upper thigh c. Obtain the childs vital signs d. Notify the physician immediately " "(7-05-247-89) A rescuer is called after a 56 yr old man collapses. After quick assessment, the rescuer determines that the victim is unresponsive. To determine unresponsiveness, the rescuer can: a. Call the victims name and gently shake the victim b. Perform the chin-tilt maneuver to open the airway c. Feel for any air movement from the victims nose and mouth d. Watch the victims chest for respirations " "(7-05-247-90) Proper hand placement for chest compressions during CPR is essential to reduce the risk of what complication? a. Gastrointestinal bleeding b. Myocardial infarction c. Emesis d. Rib fracture

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT " "(7-05-247-94) Effectiveness of the CPR can be determined by noting which of the following? a. Pulse rate is normal b. Pupils are reacting to light c. Mucous membranes are pink d. Systolic pressure is at least 80mmHg " "(7-05-247-95) The client receives epinephrine during resuscitation in the emergency room. The drug is given because of its ability to: a. Dilate b. Constrict arterioles c. Free glycogen from the liver d. Enhance myocardial contractility " "(7-05-248-100) If the victims chest wall fails to rise with each inflation when rescue breathing is administered during CPR, the most likely reason is that the: a. Airway is not clear b. Victim is beyond resuscitation c. Inflation are being given at too rapid a rate d. Rescuer is using inadequate force for cardiac massage " "(7-05-248-101) During rescue in CPR, the victim will exhale by: a. Normal relaxation of the chest b. Gentle pressure of the rescuers hand on the upper chest c. The pressure of cardiac compression d. Turning the head to the side " "(7-05-248-102) The nurse understands that the estimated maximum time that a person can be without cardiopulmonary function and still not experience permanent brain damage is: a. 1 to 2 minutes b. 4 to 6 minutes c. 8 to 10 minutes d. 12 to 15 minutes " "(7-05-248-103) The nurse knows to perform the Heimlich Maneuver on a suspected choking victim, when the victim: a. Starts to become cyanotic b. Cannot speak due to airway obstruction c. Can make only minimal vocal noises d. Is coughing vigorously " "(7-05-248-104) When performing the Heimlich Maneuver on a conscious adult victim, the rescuer delivers inward and upward thrusts specifically a. Above the umbilicus b. At the level of the xiphoid process c. Over the victims midabdominal area

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT d. Below the xiphoid process and above the umbilicus " "(7-05-248-96) The rescuer understands that the compression-to ventilation ratio for one-rescuer adult CPR is: a. 5:1 b. 15:1 c. 5:2 d. 15:2 " "(7-05-248-97) During CPR, the xiphoid process at the lower end of the sternum should not be compressed when performing cardiac compressions. Which of the following organs would be most likely at risk for laceration by forceful compression over the xiphoid process? a. Lung b. Liver c. Stomach d. diaphragm " "(7-05-248-98) when performing external compressions in a baby, the rescuer should depress the sternum: a. 0.5 to 1 inch b. 1 to 1.5 inches c. 1.5 to 2 inches d. 2 to 2.5 inches " "(7-05-248-99) After determining unresponsiveness, the rescuer should: a. Perform CPR for 2 minutes on the adult victim b. Place a call for emergency assistance STAT c. Begin rescue breathing for the victim d. Begin CPR on the adult victim and wait until help comes on the scene " "(7-05-258-1) Peripheral blood flow is dependent on which of the following variables? a. Blood viscosity and diameter of the vessels b. Diameter and resistance of vessels c. Force of contraction of the heart and resistance of the vessels d. Pressure differences in the arterial and venous systems and resistance " "(7-05-276-18) The nurse administers packed RBC to a client. Which of the following nursing actions is appropriate? a. Discontinue the intravenous catheter if a blood transfusion reaction occurs. b. Administer the PRBC through percutaneously inserted central catheter line with a 20gauge needle c. Flush PRBC with 5% dextrose and 0.45% normal saline d. Stay with the client during the first 15minutes of infusion " "(7-05-283-93) Which of the following is the most important goal of nursing care for the client who is in shock? a. Manage fluid overload.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT b. Manage increased cardiac output. c. Manage inadequate tissue perfusion. d. Manage vasoconstriction of vascular beds. " "(7-05-283-94) Which of the following nursing assessment findings indicates hypovolemic shock in a client who has had 15% blood loss? a. Pulse rate less than 60bpm b. Respiratory rate of 4 breaths per minute c. Pupils unequally dilated d. Systolic blood pressure less than 90 mmHg " "(7-05-284-102) When assessing a client for early septic shock, the nurse observes for which of the following? a. Cool, clammy skin b. Warm, flushed skin c. Decreased systolic blood pressure d. Hemorrhage " "(7-05-284-103) A client with toxic shock has been receiving ceftriaxone sodium (Rocephin, 1 g every 12 hours). In addition to culture and sensitivity test, what other laboratory findings does the nurse monitor? a. Serum creatinine b. Spinal fluid analysis c. Arterial blood gases d. Serum osmolality " "(7-05-284-104) What nursing intervention is most important in preventing septic shock? a. Administering intravenous fluids as ordered b. Obtaining vital signs every 4 hours for all clients c. Monitoring RBC counts for elevation d. Maintaining asepsis of indwelling urinary catheters. " "(7-05-284-105) Which of the following is an indication of a complication of septic shock? a. Anaphylaxis b. ARDS c. COPD d. Mitral valve prolapse " "(7-05-284-95) Which of the following findings is the best indicator that the fluid replacement for a client in hyovolemic shock is adequate? a. Urine output greater than 30mL/hr b. Systolic blood pressure greater than 110mmHg c. Diastolic blood pressure greater than 90mmHg d. Respiratory rate 20breaths per minute " "(7-05-284-96) Which of the following is a risk factor for hypovolemic shock?

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT a. Hemorrhage b. Antigen-antibody reaction c. Gram negative bacteria d. Vasodilation " "56. Which telephone call should the charge nurse respond to first? A) The laboratory reporting that a child scheduled for a tonsillectomy has an abnormal bleeding time. B) A pediatrician stating that a child will be admitted for a circumcision. C) A staff nurse reporting that a child is in respiratory difficulty and the pediatrician cannot be located. D) The pharmacy requesting clarification of an IV order. " "A 3-year-old boy arrives in the emergency department via an ambulance. The child is anxious, drooling, and refusing to lie down. The child's mother informs the nurse that the child became ill very suddenly. The nurse's first action should be to: A) Alert the emergency department physician and obtain an endotracheal tube tray. B) Visualize the back of the child's throat. C) Notify the respiratory therapy department. D) Prepare an IV setup. " "A 78-year-old client has arrived with a caregiver in the emergency department, with manifestations of anorexia, cachexia, and multiple bruises. What interventions would the RN implement? A) Complete a police report on elder abuse. B) Talk to the client about the caregiver and support system. C) Complete a GI and neurological assessment. D) Check the lab data for serum albumin, Hct, and Hgb. " "A client arrives in the emergency department after a motor vehicle accident. What assessment finding would suggest internal bleeding? A) Abdominal pain. B) Thirst and restlessness. C) Confusion and altered level of consciousness. D) Frank blood on the clothing. " "A client is admitted to the emergency department after ingesting 20 acetaminophen (Tylenol) tablets. What emergency action should the RN be prepared to implement? A) Administer acetylcysteine (Mucomyst). B) Give Narcan IV. C) Instill activated charcoal through a nasogastric tube. D) Give 8 ounces of milk. " "A client is admitted with carbon monoxide poisoning as a result of being in a car in an enclosed garage with the motor running. The RN would expect to see: A) A cherry-red color to the skin and mucous membranes. B) Black carbon deposits around the nares. C) Presence of a dry, raspy voice. D) Gross hemoptysis.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT " "A client is admitted with multiple chest and abdominal injuries from a motor vehicle accident. Blood pressure is 70/40, pulse is 128, respirations are 26. The client is unresponsive. The type of shock the client is at high risk for is: A) Hypovolemic. B) Cardiogenic. C) Neurogenic. D) Anaphylactic. " "A nurse is performing CPR on an 8-year-old child. What is the proper placement for the nurse's hand? A) At midsternum. B) On the lower half of the sternum. C) In the center of an imaginary line drawn between the child's nipples. D) On the lower half of the xiphoid process. " "A nurse stops at the sight of a motor vehicle accident to find a young woman slumped over the wheel. She is breathing with a regular rhythm at a rate of 22; ventilation efforts normal. Her pulse rate is 110. The nurses next action would be: a. Check the level of consciousness b. Immobilize the spine. c. Call the rescue squad. d. Check for bleeding. " "A patient was brought to the ER who has experienced chronic recurrent seizures. As a nurse, you know that the best diagnostic procedure in determining that the patient has seizures is: a. ECG b. EEG c. Myelogram d. Cerebral Angiography " "A three year old girl ingested approximately 100 tablets acetaminophen. The nurses first action should be what? (589-91) a. Have the child drink an 8 oz glass of milk b. Give the child 30 ml of syrup of ipecac followed by a glass of water c. Insert a nasogastric tube and administer activated charcoal d. Obtain a brief history of events leading up to the ingestion from the mother. " "After adequate respiratory and circulatory status has been established in a client admitted to the emergency department with burns, which nursing action has priority? A) Remove jewelry and smoldered clothing. B) Provide information on prognosis and burn care. C) Apply sterile dressings to the wounds. D) Assess the wounds for local signs of infection. " "An expected outcome for a client in cardiogenic shock who is being treated with a dopamine drip is that the client will maintain:

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT A) A urinary output of 30 to 50 cc/hr. B) Systolic BP less than 120 mm Hg. C) Oxygen saturation greater than 90 percent. D) Pulmonary capillary wedge pressure greater than 20 mm Hg. " "Carol Perez, 21 years old, is in acute renal failure following a large loss of blood from injuries she received in a car accident. Which of the following indicators would you expect to see in Mrs. Perez as the renal failure becomes more severe? (614-189) a. Anemia b. Hypokalemia c. Diaphoresis d. Hypotension " "During cardiac compression, manual pressure is applied to: a. the area under the left nipple b. the area halfway between the sternum and the left nipple c. the lower half of the sternum d. the midsternal area. " "During the diuretic stage of burns, there is resorption of fluid into the intravascular compartment and increased urinary output. Which electrolyte imbalance is most frequently associated with this stage? a. Hypernatremia, hyperkalemia, carbonic acid deficit. b. Hyponatremia, hyperkalemia, bicarbonate excess c. Hyponatremia, hypokalemia, bicarbonate deficit d. Hypernatremia, hypokalemia, carbonic acid excess. " "During the first 24 hours postburn, there is a shift of fluid from the intravascular compartment to the burn site. The nurse should expect a decreased a. specific gravity of urine. b. Hematocrit c. Serum potassium d. Urinary output " "If a client has an unmonitored cardiac arrest, the initial action by the rescuer before starting cardiopulmonary resuscitation (CPR) is to: a. check for dilated pupils b. establish unresponsiveness c. palpate the carotid artery d. listen for breathing. " "If a person experiencing anaphylaxis becomes unresponsive, which of the following actions should the nurse take first? a. elevate the feet higher than the head b. loosen all constricting clothing c. lift the chin and tilt the head back d. cover the individual with a blanket

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT " "If a victim had oral injuries, the nurse would deliver mouth-to-nose resuscitation. Which of the following would be correct for mouth-to-nose resuscitation but not correct for mouth-to-mask? (94-04, 61-02) a. More force is required. b. The victims mouth is closed during inspiration. c. The victim mouth is open during expiration. d. The victims neck is extended. " "Immediately after a storm has passed, the rescue team with which the nurse is working is searching for injured people. A victim lying next to a broken natural gas main is not breathing and is bleeding heavily from a wound on the foot. The nurses first step would be to: (99-01, 206-49) a. Treat the victim for shock b. Start rescue breathing immediately c. Apply surface pressure to the foot wound d. Remove the victim from the immediate vicinity " "In caring for a child following accidental ingestion of acetaminophen, which laboratory values should the nurse monitor most closely for changes in the childs health status? (590-92) a. Hemoglobin and hematocrit b. White-blood-cell count and differential c. Blood gases (PO2, PCO2, and pH) d. Serum transiminase levels (ALT and AST) " "Pain management, both acute and chronic, is a major responsibility of the nurse. A nursing intervention that will promote comfort for the client with severe arthritis during positioning is: A) Use of a bed cradle to minimize discomfort. B) Placing a pillow under a painful joint while moving. C) Encouraging the use of relaxation tapes. D) Keeping conversation to a minimum. " "Pneumothorax can be simply defined as: a. presence of air in the thoracic cavity Leading to loss of negative pressure b. Presence of blood in the thoracic cavity leading mediastinal shift c. Presence of blood and air in the thoracic cavity due to trauma d. All of the above. " "The direction of the of mediastinal shift in a patient with pneumothorax will be: a. from the affected to the nonaffected side b. from the non- affected to the affected side c. from the affected side to the diaphragm d. from the non affected side to the diaphragm " "The nurse should know that the client who is at high risk for developmental problems is: A) A 5-year-old with asthma on cromolyn sodium. B) An 18-month-old with cystic fibrosis.

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT C) A 3-year-old with acute glomerulonephritis on antihypertensives and antibiotics. D) A 4-year-old with tonsillitis. " "The rate of CPR when there are two rescuers is a. 1 lung inflation to 5 cardiac compressions b. 1 lung inflation to 10 cardiac compressions c. 4 lung inflations to 15 cardiac compressions d. 2 lung inflations to 30 cardiac compressions. " "The team leader starts an infusion of whole blood. She asks the practical nurse to continue monitoring the client during the blood transfusion. The nurse observes all of the following. Which one is the best indication that a blood reaction is occurring? (94-02; 144-13) a. The clients urine is very dark yellow. b. Client becomes dyspneic suddenly. c. Clients skin is pale and cool. d. Client says he is extremely thirsty. " "Upon a client's admission for extracapsular fracture of the left femur, the nurse notes that the affected extremity appears: A) Shorter than the other leg. B) Internally rotated. C) Blanched over the fracture site. D) To have foot-drop. " "Upon Murray, a 17-year-old senior in high school, has sustained a simple fracture of the mandible after falling from his motorbike. Upon admission to the emergency room, which observation should the nurse expect? a. Bleeding in the external auditory canal b. Dropped prominence of the cheek on the affected side c. Edema of the eyes and cheeks d. Teeth unevenly lined up. " "What is the best parameter for adequate fluid replacement in a client who is in shock? (94-04, 61-10) a. Systolic blood pressure above 100 mm Hg. b. Systolic blood pressure above 90 mm Hg. c. Urine output of 30 ml/hr. d. Urine output of 20 ml/hr. " "Which of the following nursing actions is least appropriate in caring for a patient who is seizing? a. lift side rails up b. note time & characteristic c. turn head to side d. apply tongue depressors " "Which prescribed drug will the nurse most likely give to treat respiratory stridor, wheezing, and hypotension following a bee sting?

AMBASSADORS NURSING REVIEW AURORA BLVD, CUBAO MM. THIS IS A DRAFT A) Epinephrine. B) Diphenhydramine (Benadryl). C) Furosemide (Lasix). D) Aminophylline. " "