Q & A RANDOM – 16

Question Number 1 of 40
The nurse is caring for a client with a hemopneumothorax. The client has a chest tube. The nurse would expect which of
the following color of drainage

A) Red
B) Yellow
C) Clear
D) Brown
Your response was "A". The correct answer is A: Red
"Hemo" implies a bloody pneumothorax, therefore red drainage

Question Number 2 of 40
The nurse is caring for a client with a pneumothorax. The nurse expects the client to have a chest tube inserted because
".
A) It will drain the purulent drainage from the empyema that caused it
B) It is the appropriate post-operative treatment for a pneumothorax
C) It will increase the intrathoracic pressure, restoring it back to normal
D) It will drain air out of the thorax, restoring normal intrathoracic pressure
Your response was "A". The correct answer is D: It will drain air out of the thorax, restoring normal intrathoracic pressure

With a pneumothorax, which is not the result of a surgical procedure, normal intrathoracic pressure increases as a result
of the opening in the thorax which allows outside air to rush in and "collapse" the lung; therefore, draining the air out of the
thoracic cage reduces that increased intrathoracic pressure and restores it to normal - essentially re-inflating the collapsed
lung.

Question Number 3 of 40
A client with a terminal condition is admitted to the nursing unit. The initial action by the nurse would be to

A) Ensure the client is free from pain, nausea, or dyspena

B) refer the client's family to the chaplain
C) discuss the options for advance directions with the client and family
D) collaborate with the multidisciplinary team members
Your response was "A". The correct answer is A: Ensure the client is free from pain, nausea, or dyspena The client should
be kept as comfortable and free from pain, nausea, or dyspnea as possible. After the immediate needs of the client are
met, any of the other choices would be appropriate.

Question Number 4 of 40
A pregnant women is advised to increase her protein and Vitamin C to meet the needs of the growing fetus. Which diet
best meets the client’s needs?

A) Scrambled egg, hash browned potatoes, large nectarine

B) 3oz. chicken, 1/2 C. corn, lettuce salad, small banana
C) 1 C. macaroni, 3/4 C. peas, glass whole milk, medium pear
D) Beef, 1/2 C. lima beans, glass of skim milk, 3/4 C. strawberries
Your response was "A". The correct answer is D: Beef, ½ C. lima beans, glass of skim milk, ¾ C. strawberries
Beef and beans are an excellent source of protein as is skim milk. Strawberries are a good source of Vitamin C.

Question Number 5 of 40
The RN is planning the care of a 79-year-old client with skin abrasions from a fall in the home. What aspect of this client's
care is the primary responsibility of the nurse?

A) Identification of a change in skin color

B) Report the finding of any break in the skin
C) Assessment of the integumentary condition
D) Apply lotion to unaffected areas
Your response was "A". The correct answer is C: Assessment of the integumentary condition
The RN is ultimately responsible for thorough, ongoing assessment and evaluation of integument for this client. Because
the nurse is responsible for all care-related decisions, only implementation tasks that do not require independent judgment
can be delegated

Question Number 6 of 40
Which management style best demonstrates the end of the continuum of management behaviors referred to by Douglas
McGregor as theory Y? The manager
 A) is responsible for motivation of employees towars the organizational goals
B) assumes employees are self-motivated and want to work toward organizational and personal goals
C) takes a hands-off attitude and makes no decisions for employees
D) organizes teams of staff and gives compensation to the team rather than individual success
Your response was "A". The correct answer is B: assumes employees are self-motivated and want to work toward
organizational and personal goals McGregor''s theory placed management behaviors on a continuum, with Y being a set
of propositions that describes managers as supporting people who naturally work for organizational and personal goals

Question Number 7 of 40
The nurse, while assessing a 2 day-old newborn, notices that the breasts are enlarged bilaterally with a white, thin
discharge. What action should the nurse do next?

A) Notify the healthcare provider within that shift

B) Ask about medications taken during pregnancy
C) Record the findings while thinking that they are "normal"
D) Obtain fluid to check for glucose by dextrastix
Your response was "A". The correct answer is C: Record the findings as "normal" Newborn infants of both sexes may
have engorged breasts and may secrete milk during the first few days and weeks after birth

Question Number 8 of 40
The nurse is caring for a client with chronic renal failure on hemodialysis 3 times a week. The client becomes confused
and irritable 6 hours before his next treatment. Which of these items might explain the reason for the client’s behavior?

A) Elevated blood urea nitrogen (BUN)

B) Potassium loss
C) Calcium depletion
D) Metabolic alkalosis
Your response was "B". The correct answer is A: Elevated blood urea nitrogen (BUN) Confusion and irritability are signs of
renal encephalopathy secondary to elevated levels of BUN and creatinine in the blood. Other options do not explain the
client’s behavior. Potassium levels are generally high in renal failure. Side effects of calcium depletion manifest as
abdominal and muscle cramping and hyperactive reflexes. Metabolic acidosis not alkalosis is seen in renal failure.

Question Number 9 of 40
The client’s self-esteem is most damaged by the nurse’s

A) Anger
B) Indifference
C) Disapproval
D) Fear
Your response was "A". The correct answer is B: Indifference Positive connectedness/caring objectivity characterizes
therapeutic relationships and is incongruent with indifference

Question Number 10 of 40
A nurse consistently ignores the call lights clients who practice alternative lifestyles. The nurse's behavior is an example of

A) Discrimination
B) Prejudice
C) Stereotyping
D) Cultural insensitivity
Your response was "B". The correct answer is A: Discrimination The differential treatment of individuals because they
belong to a minority group. Generally refers to the limiting of opportunities, choices, or life experiences because of
prejudices about individuals, cultures, or social groups.

Question Number 11 of 40
The nurse is performing a cardiac assessment on a client. The nurse knows that the correct order of blood flow through
the valves of the heart is

A) Tricuspid, pulmonary, mitral, aortic

B) Aortic, mitral, tricuspic, pulmonary
C) Pulmonary, aortic, mitral, tricuspid
D) Mitral, pulmonary, tricuspic, aortic
Your response was "A". The correct answer is A: Tricuspid, pulmonary, mitral, aortic
The correct pathway of blood flow through the valves of the heart is: tricuspid, pulmonary, mitral, aortic.

Question Number 12 of 40
A client has just joined a health care maintenance organization (HMO) and asks for information about the payment
obligations with this plan. The most accurate description of health care costs is that the client will be charged

A) Only for services provided by specialists

B) A flat rate for each service rendered
C) A pre-determined fee for all services
D) The usual and customary fee for services
Your response was "B". The correct answer is C: A pre-determined fee for all services An HMO plan is a plan that provides
for all services based on a flat rate. During the specified period of enrollment, all health care services are provided with no
additional fees.

Question Number 13 of 40
The nurse is caring for a mother who has just delivered a stillborn baby. What would be the most therapeutic comment by
the nurse to this grieving mother?

A) "You are young and will have other children."

B) "Nature has a way of getting rid of the imperfect."
C) "Tell me about your pregnancy experience."
D) "You have an angel in heaven watching over you now."
Your response was "B". The correct answer is C: "Tell me about your pregnancy experience." The nurse must help the
mother actualize the loss by encouraging her to talk about it. Advice and cliches are not comforting
Question Number 14 of 40
Two hours after the normal spontaneous vaginal delivery of a woman, who is gravida 4 para 4, the nurse notes that the
fundus is boggy and displaced slightly above and to the left of the umbilicus. What is the initial nursing action?

A) Assess lochia for color and amount

B) Monitor pulse and blood pressure
C) Call the health care provider immediately
D) Ask the woman to empty her bladder
Your response was "A". The correct answer is D: Ask the woman to empty her bladder A full bladder can displace the
uterus and prevent contraction. After the woman empties the bladder, the fundus should be assessed again.

Question Number 15 of 40
A client is admitted for placement of a suprapubic catheter. Which statement by the client indicates a misunderstanding of
care?

A) "I will change the urine bag as needed."

B) "I will be sure to sit up or move around as much as I can."
C) "I will take the medication to prevent infection only when the urine gets to be cloudy."
D) "I plan to get lots of bottled water since it is easier to have nearby."
Your response was "A". The correct answer is C: "I will take the medication to prevent infection only when the urine gets to
be cloudy."

Prophylactic antibiotics are given continuously. Sitting up enhances the drainage of urine to prevent stasis in the kidney
and bladder. Adequate fluid intake will prevent crystallization of the urine and stone formation. Routine changing of the
urine bag, as needed is appropriate.

Question Number 16 of 40
The best action to establish correct placement of a gastric tube is for the nurse to

A) aspirate for the color and pH test

B) inject air while listening for the gastric gurgle
C) check the results of the X-ray of tube placement
D) measure the residual volume then reinsert the aspirate
Your response was "A". The correct answer is A: aspirate for the color and pH test All of the options are safe actions.
However checking the color and pH are the best actions for verification of tube placement

Question Number 17 of 40
If the nurse notes cloudy drainage 2 days post insertion of a Tenckhoff catheter for peritoneal dialysis, what other data
does the nurse need to collect before reporting this finding?
The correct response is "C".
A) bowel sounds
B) breath sounds
C) temperature
D) urine output
Your response was "A".

The correct answer is C: temperature

This finding indicates potential infection so temperature is essential to evaluate before notification of the care provider.

Question Number 18 of 40
The nurse is caring for a client with a T-tube following a cholecystectomy, one-day postoperatively. The nurse would
expect which the following color of drainage from the client's T-tube

The correct response is "C".

A) Brown
B) Yellow
C) Green
D) Orange
Your response was "A". The correct answer is C: Green

Bile, which is green, is the expected drainage from a T-tube.

Question Number 19 of 40
Parents of a 4 year-old boy have just been informed that their son has a congenital neurologic demyelinating disorder that
is terminal. The nurse evaluates their reaction to be in which phase of the crisis process?

A) Pre-crisis phase
B) Impact phase
C) Crisis phase
D) Resolution phase
Your response was "A". The correct answer is B: Impact phase The impact of crisis is indicative of high levels of stress,
sense of helplessness, confusion, disorganization, and the inability to apply problem solving behavior.

Question Number 20 of 40
The nurse admits a 50 year-old client with a 3 day history of fever, flank pain, and elevated blood pressure. Which of the
following data obtained in the admission interview alerts the nurse that this may be acute glomerulonephritis?

A) Travel to a foreign country

B) Sore throat 3 weeks ago
C) Type 1 diabetes since age 15
D) History of mild hypertension
Your response was "A". The correct answer is B: Sore throat 3 weeks ago In the majority of cases of acute
glomerulonephritis there is a history of a group beta streptococcal infection of the throat preceding the onset by 2-3
weeks. The other options do not suggest acute glomerulonephritis

Question Number 21 of 40
The nurse is assigned to an adolescent unit. Which of these groups of needs would the nurse expect to have to deal with
that day?

A) Independence, confidence, narcissism

B) Interest in sports, competition, being right
C) Privacy, autonomy, peer interactions
D) School performance, reading, journal writing
Your response was "A". The correct answer is C: Privacy, autonomy, peer interactions Adolescents display the need for
privacy, autonomy and peer interaction concurrent with an evolving sense of identity

Question Number 22 of 40
A client states: "I do not want to be interrupted for breakfast because it interferes with my meditation time." What is the
next action for the nurse to take?

A) Contact the client's health care provider

 B) Contact the nutritionist or dietitian
C) Consult with the nurse manager to get suggestions
D) Talk with the client to workout a mutual plan
Your response was "B". The correct answer is D: Talk with the client to workout a mutual plan

The nurse should talk with the client to determine how the practice of meditation can be incorporated into the breakfast
schedule. Respect for differences must be incorporated into a client''s plan of care

Question Number 23 of 40
The RN is caring for a client immediately after a cholecystectomy. Which of these tasks can the RN safely ask an
unlicensed assistive personnel (UAP) to document?

A) Amount of output into the drainage collection device

B) Changes in abdominal distention
C) Amount of drainage on the surgical dressing
D) The check for the return of bowel sounds or passing flatus
Your response was "A". The correct answer is A: Amount of output into the drainage collection device The emptying,
measuring and recording of drainage from a postoperative drain may be delegated to unlicensed assistive personnel who
have demonstrated competence in performing this task. While the RN is responsible for all care-related decisions,
delegation of tasks not requiring independent judgment is appropriate.

Question Number 24 of 40
While performing a dialysate exchange for a client on peritoneal dialysis, which finding would alert the nurse that the client
has developed an acute complication?

A) Pulse 86 and blood pressure 112/74

B) Respiration rate of 30 with rales (use bibasilar)
C) Client sleeps throughout fluid exchange
D) Catheter dressing saturated with clear fluid
Your response was "A". The correct answer is B: Respiration rate of 30 with rales (use bibasilar) The development of an
increased respiratory rate with rales indicates fluid overload, which is an acute complication of peritoneal dialysis. In
option 1 the vital signs are normal. Sleeping throughout the fluid exchange is normal and indicates the client is
comfortable. Clear fluid on the dressing around the catheter indicates leakage of the dialysate fluid and can be controlled
instilling less fluid with each exchange

Question Number 25 of 40
An 8 year-old child is admitted to the child mental health unit for evaluation. After the mother’s departure, the client cries
and refuses to eat dinner. The best approach by the nurse is to

A) Offer to play with the child

B) Remind the child of the expectation to eat some or all of the dinner
C) Tell the child that privileges will be denied for uncooperative behavior
D) Discuss with the child that the parents will be upset if cooperation is not given
Your response was "A". The correct answer is A: Offer to play with him Play is both distracting and an avenue for a child’s
communication. Play facilitates mastery of feelings.

Question Number 26 of 40
A client is admitted with the diagnosis of testicular cancer. Which factor in the client’s history would be associated with the
disease?

A) Seminal vesiculitis
B) Undescended testis
C) Epididymitis
D) Sexual relations at an early age
Your response was "A". The correct answer is B: Undescended testis

A history of undescended testis or cryptorchidism is a known risk factor

Question Number 27 of 40
While obtaining the history of a 2 week-old infant during the well-baby exam, the nurse finds that the neonatal screening
for phenylketonuria (PKU) was done when the infant was less than 24 hours-old. What is the priority nursing action?

A) Schedule the infant for a repeat test in 2 weeks

B) Obtain a repeat blood test at this point
C) Contact the hospital of birth for the results
 D) Document that the test results are pending
Your response was "A". The correct answer is B: Obtain a repeat blood test at this point Testing for PKU is most reliable
when protein has been ingested. A repeat blood specimen must be obtained by the third week of life if the initial specimen
was taken from an infant less than 24 hours-old

Question Number 28 of 40
The nurse assists in the insertion of a chest tube. The nurse must apply which type of dressing after the application of
sterile vaseline gauze around the tube and sterile gauze over the vaseline gauze?

A) Transparent tape over the top and bottom horizontal edges of the gauze
B) Adhesive tape over the entire gauze with all edges covered with the tape
C) Elastic adhesive tape over the vertical edges of the gauze
D) Any kind of tape over the gauze in a criss-cross or "X" manner
Your response was "A". The correct answer is B: Adhesive tape over the entire gauze with all edges covered with the tape
An occlusive dressing which means all of the gauze as well as all of the edges being covered, is necessary to prevent air
from entering the thorax. Regular adhesive tape is preferred since it is more dense and resistent to air flow.

Question Number 29 of 40
The RN is doing initial discharge teaching to a 65 year-old female client with renal calculi. Which of the following should
be included as dietary recommendations to prevent recurrence?

A) Consume foods high in vitamin E

B) Reduce dietary calcium
C) Increase sources of vitamin C
D) Increase protein levels
Your response was "A". The correct answer is B: Reduce dietary calcium

Dietary restrictions of calcium and purines aid in the prevention of recurrence of renal calculi. Dietary recommendations
for prevention of kidney stones include restricting protein to 60 g/day to decrease urinary excretion of calcium and uric
acid. There is no evidence that increasing vitamins E or C affects or prevents the formation of urinary stones.

Question Number 30 of 40
In a client with mitral regurgitation the nurse would expect to see which of the following signs and symptoms?

A) Low red blood cell count

B) Exertional dyspnea
C) Crushing chest pain
D) Elevated white blood cell count
Your response was "A". The correct answer is B: Exertional dyspnea Fluid retention and diminished heart function cause
exterional dyspnea in clients with mitral regurgitation as heart failure worsens. This is due to a rise in left atrial pressure
and subsequent pulmonary and venous congestion

Question Number 31 of 40
Which entry on a client's progress notes is the most complete?

A) Demerol 75mg administered for severe abdominal pain

B) Client expresses anxiety about a low salt diet
C) Dark green drainage 100 ml from nasogastric tube this shift
D) Client's urinary output adequate for the past shift
Your response was "A". The correct answer is C: Dark green drainage 100ml from nasogastric tube this shift Entries in
client records need to be complete, accurate and factual. Reimbursement from third party payers is facilitated when
records are accurate, reliable and valid.

Question Number 32 of 40
Nurse colleagues are discussing their practice during lunch. Which statement is correct?

A) The employing agency is ultimately responsible to provide practice guidelines for licensed nurses.
B) Each state has specific regulations to license RNs and PNs
C) The federal government ensures the safety of clients by defining the scope of nursing practice.
D) "The national nurses’ associations work collaboratively to update the social policy statement for nursing.”
Your response was "A". The correct answer is B: State governmental agency This is the only correct statement. State
governmental agencies license nurses in each state.

Question Number 33 of 40
Which of these statements, made by a client who had a mastectomy 2 months ago, indicates a need for additional
assessment associated with the impact of an alteration in body-image?
 A) "It really isn't much of a problem for me, I never had large breasts anyway."
B) "I plan to volunteer to work with others who have had mastectomies in Reach for Recovery."
C) "I guess it's time for me to quit wearing a bikini at my age anyway."
D) "I only look at myself in the mirror after I am fully dressed."
Your response was "A". The correct answer is D: "I only look at myself in the mirror after I am fully dressed." An inability to
look at the incision or surgical site is associated with possible denial or anger during the process of coping with a loss.
This indicates that a problem area for this client is body image. The other statements reflect movement towards
acceptance of the loss of a “normal” figure

Question Number 34 of 40
The RN is responsible for the care of a client who is 2 days post-reconstructive nasal surgery. Which task can be safely
delegated to an unlicensed assistive personnel (UAP)?

A) Ask the client if the medication for pain worked

B) Observe for restlessness or a change in breathing
C) Remind the client to report increased discomfort
D) Suggest that the client ask for medication every few hours
Your response was "A". The correct answer is C: Remind the client to report increased discomfort The person to whom
the activity is delegated must be capable of performing it. It is within the role of the UAP to reinforce the nurse’s teaching
about pain management.
Question Number 35 of 40
A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). What would be the nurse's
best response?

A) "It tells us how far along your pregnancy is."

B) "The results help determine if the baby is growing normally."
C) "Placental well-being is being evaluated."
D) "Possible neurological defects may be identified."
Your response was "A". The correct answer is D: "Possible neurological defects may be identified." A fetus with neural
tube defects loses alfa-fetoprotein (AFP) to the amniotic fluid and hence the maternal blood. High levels in the blood
indicate the possibility of defects such as spina bifida and meningocele. Further evaluative tests are indicated if a test is
positive.

Question Number 36 of 40
An external disaster has occurred in the town. The triage nurse from the emergency department is transported to the site
and assigned to triage the injuryed. Which of these clients would the nurse tag as a “to be seen last” by the health care
providers at the seen?

A) An infant with bilateral fractured lower legs

B) A middle-aged person with deep abrasions that are over 90% of the body
C) A teenager with small amount of bright red blood dripping out of the nose
D) An elderly person with a open fracture of the left arm
Your response was "A". The correct answer is B: A middle-aged person with deep abrasions that are over 90% of the body
The clients that are least likely to survive are to be tagged as the “last to be seen.” Deep abrasions are usually treated as
second or third degree burns since the fluid loss is great.

Question Number 37 of 40
During urinary catheterization in the male client it is important to lubricate the tip of the catheter prior to insertion to

A) Reduce friction within the urethra

B) Prevent bladder distention
C) Prevent infection
D) Reduce leakage of urine around the catheter
Your response was "A". The correct answer is A: Reduce friction within the urethra Lubrication reduces friction and eases
insertion. Due to the tortuous nature of the male urethra lubrication also reduces potential trauma

Question Number 38 of 40
When planning the therapeutic milieu, what is the most important factor in selecting group activities?

A) Match them to the clients' preferences

B) Consistentcy with clients’ skills
C) Achieving clients’ therapeutic goals
D) Build the skills of group participation
Your response was "A". The correct answer is C: Achieving clients’ therapeutic goals Activity groups are used to enhance
the therapeutic milieu and to meet the clinical and social needs of clients, e.g., to minimize withdrawal and regression, to
develop self care skills, etc.

Question Number 39 of 40
An internal disaster is declared in the hospital at 9:00 PM. The charge nurse on this evening shift is asked to determine
which client is a candidate for discharge. Which of these clients should the nurse select as a potential candidate for
discharge

A) A middle-aged man with a history of type 2 diabetes mellitus and 1 day post diabetic ketoacidosis
A young adult with a history of asthma since age 5 who was admitted at the beginning of the shift with an
B)
exacerbation of asthma
An elderly female who is expected to die within the next day or so , is a “do not resuscitate” and has a son at the
C)
bedside
A adolescent who is a new admission of the prior shift, has been diagnosed with rule out acute pancreatitis, and
D)
reported stopped drinking alcohol 2 days ago
Your response was "A". The correct answer is A: A middle-aged man with a history of type 2 diabetes mellitus and 1 day
post diabetic ketoacidosis The client to be discharged would be one that is most stable with minimal risk of complications
or instability. Client with chronic disease may be better to function at home than those of acute or a new onset of disease

Question Number 40 of 40
A nurse documents “effective use of guided imagery to change pain from a 4 to a 1.” Which definition best describes this
technique?

A) closure of the eyes to focus on the back of the eyelids or blank screen
B) the repetition of a word to self
C) inhalation to a count of 4 and exhalation to a count of four
D) focus on a pleasant, relaxed mental pictures
Your response was "A". The correct answer is D: focus on a pleasant, relaxed mental pictures

Guided imagery is a technique that uses pleasant mental visuals that can be recalled by the client to reduce stress,
anxiety, or pain. Option 2 describes meditation. Option 3 is slow deep breathing.