WITH 100% CORRECT ANSWERS
Question 1
A child and his family were exposed to Mycobacterium tuberculosis
about 2 months ago. To confirm the presence or absence of an
infection, it is most important for all family members to have a:
A) Chest x-ray
B) Blood culture
C) Sputum culture
D) PPD intradermal test
Correct Answer: D) PPD intradermal test
Explanation: The PPD (Purified Protein Derivative) intradermal test
determines the presence of infection with the Mycobacterium
tuberculosis organism. It is effective at 3 to 6 weeks after the initial
infection. A chest x-ray would show active disease but not infection, and
sputum cultures are for diagnosing active TB, not screening.
Question 2
A 4-month-old child taking digoxin (Lanoxin) has a blood pressure of
92/78; resting pulse of 78; respirations 28 and a potassium level of 4.8
mEq/L. The client is irritable and has vomited twice since the morning
dose of digoxin. Which finding is most indicative of digoxin toxicity?
A) Bradycardia
,B) Lethargy
C) Irritability
D) Vomiting
Correct Answer: A) Bradycardia
Explanation: The most common sign of digoxin toxicity in children is
bradycardia (heart rate below 100 in an infant). While irritability and
vomiting are also signs of toxicity, a decreased heart rate is the most
critical and specific indicator of digoxin's effect on the heart.
Question 3
Which finding would be the most characteristic of an acute episode of
reactive airway disease?
A) Auditory gurgling
B) Inspiratory laryngeal stridor
C) Auditory expiratory wheezing
D) Frequent dry coughing
Correct Answer: C) Auditory expiratory wheezing
Explanation: In an acute episode of reactive airway disease (asthma),
breathing is characterized by wheezing on expiration. This sound is
made as air is forced through narrowed passages and often can be
heard without a stethoscope. Stridor is associated with upper airway
obstruction, not reactive airway disease.
Question 4
A client has been admitted for meningitis. In reviewing the laboratory
analysis of cerebrospinal fluid (CSF), the nurse would expect to note:
A) High protein
B) Clear color
,C) Elevated sed rate
D) Increased glucose
Correct Answer: A) High protein
Explanation: A positive CSF for meningitis includes the presence of
protein, decreased glucose, cloudy color with an increased opening
pressure, and an elevated white blood cell count. The sed rate (ESR) is a
blood test, not a CSF finding.
Question 5
At a routine health assessment, a client tells the nurse that she is
planning a pregnancy in the near future and asks about preconception
diet changes. Which of the statements made by the nurse is best?
A) Include fibers in your daily diet.
B) Increase green leafy vegetable intake.
C) Drink a glass of milk with each meal.
D) Eat at least 1 serving of fish weekly.
Correct Answer: B) Increase green leafy vegetable intake.
Explanation: Folic acid sources should be included in the diet and are
critical in the preconceptual and early gestational periods to foster
neural tube development and prevent birth defects such as spina bifida.
Green leafy vegetables are excellent sources of folic acid.
Question 6
A Hispanic client confides in the nurse that she is concerned that staff
may give her newborn the "evil eye." The nurse should communicate to
other personnel that the appropriate approach is to:
A) Touch the baby after looking at him
B) Talk very slowly while speaking to him
, C) Avoid touching the child
D) Look only at the parents
Correct Answer: A) Touch the baby after looking at him
Explanation: In many cultures, an "evil eye" is cast when looking at a
person without touching them. Thus, the spell is broken by touching
while looking or assessing. This is a culturally sensitive approach that
respects the family's beliefs while still allowing for necessary
assessment.
Question 7
During the care of a client with Legionnaire's disease, which finding
would require the nurse's immediate attention?
A) Pleuritic pain on inspiration
B) Dry mucus membranes in the mouth
C) A decrease in respiratory rate from 34 to 24
D) Decrease in chest wall expansion
Correct Answer: D) Decrease in chest wall expansion
Explanation: The respiratory status of a client with this acute bacterial
pneumonia is critical. Chest wall expansion reflects a possible decrease
in the depth and effort of respirations. Decreased chest expansion can
indicate worsening respiratory status and potential need for mechanical
ventilation.
Question 8
A newly appointed nurse manager is having difficulties with time
management. Which advice from an experienced manager should the
new manager do initially?
A) Set daily goals and establish priorities for each hour and each day.