1. A five year old is in Bryant's traction for intervention for a fractured femur. Which finding
by the nurse would require intervention?
A. The parents are at the bedside reading a book with the child.
B. The child's hips are in 90-degree flexion.
C. The child's hips are gently resting on the bed.
D. The child is consuming 120 mL of grape juice.
Rationale:
The In Bryant's traction, the buttocks should be elevated off the bed not resting on the
mattress.
2. A client who is on the outpatient surgical unit is preparing for discharge after a
myringotomy with placement of ventilating tubes. Which response by the client indicates
that further teaching is necessary?
A. "I will avoid coughing, sneezing, and forceful nose blowing."
B. "Swimming can begin on the tenth postoperative day."
C. "Any mild discomfort can be managed with acetaminophen."
D. "Drainage from my ears is expected after the surgery."
Rationale:
The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and
drain fluid collection from the middle ear. The tube's patency allows air and water to enter
the middle ear, so the client should be reeducated if the client swims or allows water to
enter the external ear. Options A, C, and D reflect correct responses.
- MYRINGOTOMY: surgical incision into the eardrum, to relieve pressure or
drain fluid.
3. When the nurse-manager posts a schedule for volunteers to be on call, one staff
member immediately signs up for all available 7-to-3 day shifts. Other staff members
complain to the charge nurse that they were not permitted the opportunity to be on call for
the day shift. What action should the nurse-manager implement?
A. Speak privately with the nurse.
B. Hold a staff meeting to discuss this issue.
C. Review the nurse's current salary.
D. Nominate the nurse for employee of the month
Rationale:
The nurse-manager should speak privately with the nurse to assess the nurse's motives
and to discuss allowing other team members the opportunity to be on call for the day
shift.
Option B might become confrontational. Option C is irrelevant. Option D is not warranted.
4. What instruction(s) related to foot care is(are) appropriate for the client with type
1 diabetes mellitus? (Select all that apply.)
A. Use lanolin to moisturize the tops and bottoms of the feet. (LANOLIN This
medication is used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and
minor skin irritations)
B. Soak the feet in warm water for at least 1 hour daily.
C. Wash feet daily and dry well, particularly between the toes.
D. Use over-the-counter products to remove corns and calluses.
E. Wear leather shoes that fit properly.
Rationale: Options A, C, and E are therapeutic interventions for foot care in the diabetic
client. Options B and D are contraindicated and could cause foot infection or injury.
, 5. A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent
discharge. Which nursing intervention is most important in reducing the client's stress
associated with repeated hospitalization?
A. Allow the client to discuss the seriousness of the illness.
B. Ensure that the client is provided with information about medications.
C. Encourage as much independence in decision making as possible.
D. Include the client in planning the course of treatment.
Rationale:
Hospitalization compromises an individual's sense of control and independence, which
contributes to stress, so allowing the client as much independence in decisions as possible
helps reduce stress experienced with repeated hospitalization. Options A, B, and D are
important components in stress reduction, but the isolation and dependence associated with
hospitalization alter the client's sense of control and affect the client's cognitive ability to
understand and participate in the hospitalized plan of care.
6. A client with hepatic failure tells the nurse about recent use of acetaminophen. How
should the nurse respond to this client's statement?
A. Bleeding precautions should be implemented.
B. Tylenol is indicated for minor aches and pains.
C. Acetaminophen reduces inflammation.
D. The drug is hepatotoxic and contraindicated.
Rationale:
Acetaminophen is hepatotoxic and can cause further complications for a client with impaired
liver function, so its use is contraindicated. Although bleeding is a risk in clients with liver
disease caused by decreased production of clotting components, this drug significantly
increases this risk and is contraindicated. Although option B is an indicated use for this drug,
it remains contraindicated in clients with hepatic failure. Option C is inaccurate.
7. The nurse is teaching a client newly diagnosed with diabetes mellitus about the
subcutaneous administration of regular and NPH insulin. Which statement indicates that the
client needs further instruction?
A. "I should balance my daily exercise with my dietary intake and insulin dosages."
B. "When I give myself an injection, I should aspirate to make sure that I am not in
a blood vessel."
C. "I should inject my insulin into a different site to reduce the development of scar tissue."
D. "I should remove the dose of clear insulin first and then the dose of cloudy insulin from
the vials."
Rationale:
Aspiration is not necessary when giving insulin because it could increase tissue trauma and
affect the absorption rate. Option C helps minimize tissue atrophy, which can affect the
absorption of the insulin. Options A and D are correct procedures. The client should balance
an active physical lifestyle with diet, insulin, and blood glucose monitoring to ensure tight
serum glucose level control. When mixing insulins in the same syringe, the clear (Regular)
insulin is withdrawn first to avoid contamination of the clear vial with cloudy NPH insulin,
which will alter the absorption rate of the remaining Regular insulin.
8. Which assessment finding for a client with peritoneal dialysis requires immediate
intervention by the nurse?
A. The color of the dialysate outflow is opaque yellow.
B. The dialysate outflow is greater than the inflow.
C. The inflow dialysate feels warm to the touch.
by the nurse would require intervention?
A. The parents are at the bedside reading a book with the child.
B. The child's hips are in 90-degree flexion.
C. The child's hips are gently resting on the bed.
D. The child is consuming 120 mL of grape juice.
Rationale:
The In Bryant's traction, the buttocks should be elevated off the bed not resting on the
mattress.
2. A client who is on the outpatient surgical unit is preparing for discharge after a
myringotomy with placement of ventilating tubes. Which response by the client indicates
that further teaching is necessary?
A. "I will avoid coughing, sneezing, and forceful nose blowing."
B. "Swimming can begin on the tenth postoperative day."
C. "Any mild discomfort can be managed with acetaminophen."
D. "Drainage from my ears is expected after the surgery."
Rationale:
The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and
drain fluid collection from the middle ear. The tube's patency allows air and water to enter
the middle ear, so the client should be reeducated if the client swims or allows water to
enter the external ear. Options A, C, and D reflect correct responses.
- MYRINGOTOMY: surgical incision into the eardrum, to relieve pressure or
drain fluid.
3. When the nurse-manager posts a schedule for volunteers to be on call, one staff
member immediately signs up for all available 7-to-3 day shifts. Other staff members
complain to the charge nurse that they were not permitted the opportunity to be on call for
the day shift. What action should the nurse-manager implement?
A. Speak privately with the nurse.
B. Hold a staff meeting to discuss this issue.
C. Review the nurse's current salary.
D. Nominate the nurse for employee of the month
Rationale:
The nurse-manager should speak privately with the nurse to assess the nurse's motives
and to discuss allowing other team members the opportunity to be on call for the day
shift.
Option B might become confrontational. Option C is irrelevant. Option D is not warranted.
4. What instruction(s) related to foot care is(are) appropriate for the client with type
1 diabetes mellitus? (Select all that apply.)
A. Use lanolin to moisturize the tops and bottoms of the feet. (LANOLIN This
medication is used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and
minor skin irritations)
B. Soak the feet in warm water for at least 1 hour daily.
C. Wash feet daily and dry well, particularly between the toes.
D. Use over-the-counter products to remove corns and calluses.
E. Wear leather shoes that fit properly.
Rationale: Options A, C, and E are therapeutic interventions for foot care in the diabetic
client. Options B and D are contraindicated and could cause foot infection or injury.
, 5. A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent
discharge. Which nursing intervention is most important in reducing the client's stress
associated with repeated hospitalization?
A. Allow the client to discuss the seriousness of the illness.
B. Ensure that the client is provided with information about medications.
C. Encourage as much independence in decision making as possible.
D. Include the client in planning the course of treatment.
Rationale:
Hospitalization compromises an individual's sense of control and independence, which
contributes to stress, so allowing the client as much independence in decisions as possible
helps reduce stress experienced with repeated hospitalization. Options A, B, and D are
important components in stress reduction, but the isolation and dependence associated with
hospitalization alter the client's sense of control and affect the client's cognitive ability to
understand and participate in the hospitalized plan of care.
6. A client with hepatic failure tells the nurse about recent use of acetaminophen. How
should the nurse respond to this client's statement?
A. Bleeding precautions should be implemented.
B. Tylenol is indicated for minor aches and pains.
C. Acetaminophen reduces inflammation.
D. The drug is hepatotoxic and contraindicated.
Rationale:
Acetaminophen is hepatotoxic and can cause further complications for a client with impaired
liver function, so its use is contraindicated. Although bleeding is a risk in clients with liver
disease caused by decreased production of clotting components, this drug significantly
increases this risk and is contraindicated. Although option B is an indicated use for this drug,
it remains contraindicated in clients with hepatic failure. Option C is inaccurate.
7. The nurse is teaching a client newly diagnosed with diabetes mellitus about the
subcutaneous administration of regular and NPH insulin. Which statement indicates that the
client needs further instruction?
A. "I should balance my daily exercise with my dietary intake and insulin dosages."
B. "When I give myself an injection, I should aspirate to make sure that I am not in
a blood vessel."
C. "I should inject my insulin into a different site to reduce the development of scar tissue."
D. "I should remove the dose of clear insulin first and then the dose of cloudy insulin from
the vials."
Rationale:
Aspiration is not necessary when giving insulin because it could increase tissue trauma and
affect the absorption rate. Option C helps minimize tissue atrophy, which can affect the
absorption of the insulin. Options A and D are correct procedures. The client should balance
an active physical lifestyle with diet, insulin, and blood glucose monitoring to ensure tight
serum glucose level control. When mixing insulins in the same syringe, the clear (Regular)
insulin is withdrawn first to avoid contamination of the clear vial with cloudy NPH insulin,
which will alter the absorption rate of the remaining Regular insulin.
8. Which assessment finding for a client with peritoneal dialysis requires immediate
intervention by the nurse?
A. The color of the dialysate outflow is opaque yellow.
B. The dialysate outflow is greater than the inflow.
C. The inflow dialysate feels warm to the touch.
