,A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment
identifies a current febrile illness with a cough. The nurse should:
a. Give the vaccine
b. Administer aspirin with the vaccine
c. Hold the vaccine and notify the health care provider
d. Reschedule administration of the vaccine for the next month - CORRECT
ANSWERS-D!
The appropriate response is to delay the administration of the vaccine until the client is
healthy. Vaccines should not be administered during a febrile illness. Administering an
aspirin is a dependent function of the nurse and requires a health care provider's
prescription. Although holding the vaccine and administering it after the fever and cough
are resolved is appropriate, notifying the health care provider is not necessary.
A daughter of a Chinese speaking client approaches a nurse and asks multiple
questions while maintaining direct eye contact. What culturally related concept does the
daughter's behavior reflect?
a. Prejudice
b. Stereotyping
c. Assimilation
d. Ethnocentrism - CORRECT ANSWERS-C!
Assimilation involves incorporating the behaviors of the dominant culture. Maintaining
eye contact is characteristic of the American culture and not Asian cultures. Prejudice is
a negative belief about another person or group and does not characterize this
behavior. Stereotyping is the perception that all members of a group are alike.
Ethnocentrism is the perception that one's beliefs are better than those of others.
A client has a hiatal hernia. The client is 5 feet 3 inches tall and weighs 160 pounds.
When the nurse discusses prevention of esophageal reflux, what should be included?
a. "Increase your intake of fat with each meal."
b. "Lie down after eating to help your digestion."
c. "Reduce your caloric intake to foster weight reduction."
,d. "Drink several glasses of fluid during each of your meals." - CORRECT ANSWERS-
C!
Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency
to reflux into the esophagus. Fats decrease emptying of the stomach, extending the
period that reflux can occur; fats should be decreased. Lying down after eating
increases the pressure against the diaphragmatic hernia, increasing symptoms.
Drinking several glasses of fluid during each meal will increase the pressure; fluid
should be discouraged with meals.
During an interview, the nurse discovers that the spouse of a debilitated, chronically
constipated client digitally removes stool from the client's rectum. What response to
disimpaction is the nurse attempting to prevent by presenting other strategies to
regulate the client's bowel movements?
a. Increased pulse rate
b. Slowing of the heart
c. Dilation of the bronchioles
d. Coronary Artery Vasodilation - CORRECT ANSWERS-B!
Disimpaction can cause vagal stimulation, which slows the heart. The vagus is the
principal nerve of the parasympathetic portion of the autonomic nervous system, and its
axon terminals release acetylcholine. The response of the viscera to acetylcholine
varies, but in general the organ is in a relaxed state. Increased pulse rate is an action of
the sympathetic nervous system (accelerator nerve) caused by the release of
norepinephrine. Stimulation of the sympathetic nervous system dilates bronchioles in
the lungs; the vagus nerve constricts them. There are parasympathetic fibers to the
coronary blood vessels; sympathetic impulses dilate these vessels.
Test-Taking Tip: You have at least a 25% chance of selecting the correct response in
multiple-choice items. If you are uncertain about a question, eliminate the choices that
you believe are wrong and then call on your knowledge, skills, and abilities to choose
from the remaining responses.
A nurse has just administered an immunization injection to a 2-month-old infant. What
instructions should the nurse give the parent if the infant has a reaction?
a. Give aspirin for pain; if swelling at the injection site develops, call the health care
provider.
b. Apply heat to the injection site for the first day after the injection; apply ice if the arm
is inflamed.
, c. Give acetaminophen for fever; call the health care provider if the child exhibits
marked drowsiness or seizures.
d. Apply ice to the injection site if soreness develops; call the health care provider if the
child comes down with a fever - CORRECT ANSWERS-C!
Fever is a common reaction to immunizations, and acetaminophen may be given to
minimize discomfort. A central nervous system reaction is rare and requires notification
of the health care provider. Aspirin should not be given to infants and children because
it is linked to Reye syndrome. Infants do not tolerate the application of ice, which will
increase discomfort. Fever is a common reaction to the immunizations; it is not
necessary to notify the health care provider.
A nurse inserts a nasogastric tube before an infant is to receive a tube feeding. What
action should the nurse take when the infant begins to cough and gag?
a. Auscultating for breath sounds
b. Removing the tube, then reinserting it
c. Administering the tube feeding slowly
d. Observing the infant for circumoral cyanosis - CORRECT ANSWERS-B!
The infant's response indicates that the tube may be in the trachea rather than the
stomach. The tube should be removed, reinserted, and verified for its placement before
the feeding is started. Auscultating for breath sounds does not provide information
about the placement of the tube. The tube should be removed immediately; it is unsafe
to assess the infant for additional signs of respiratory distress. It is unsafe to administer
the feeding until placement in the stomach has been confirmed.
A 26-year-old homosexual client is diagnosed with acquired immune deficiency
syndrome (AIDS). The primary nurse reports to the nursing team that the client cried
when told of the diagnosis. One of the nursing assistants responds, "I don't feel sorry for
him. He made his bed, and now he can lie in it." To best help the nursing assistant, the
nurse manager must first identify that this comment most likely is a result of the nursing
assistant's:
a. Values and beliefs about sexual lifestyles.
b. Anger and mistrust of homosexual males in general.
c. Discomfort with men who are unable to control their emotions.
d. Hostility over having to care for someone with a sexually transmitted infection -
CORRECT ANSWERS-A!
identifies a current febrile illness with a cough. The nurse should:
a. Give the vaccine
b. Administer aspirin with the vaccine
c. Hold the vaccine and notify the health care provider
d. Reschedule administration of the vaccine for the next month - CORRECT
ANSWERS-D!
The appropriate response is to delay the administration of the vaccine until the client is
healthy. Vaccines should not be administered during a febrile illness. Administering an
aspirin is a dependent function of the nurse and requires a health care provider's
prescription. Although holding the vaccine and administering it after the fever and cough
are resolved is appropriate, notifying the health care provider is not necessary.
A daughter of a Chinese speaking client approaches a nurse and asks multiple
questions while maintaining direct eye contact. What culturally related concept does the
daughter's behavior reflect?
a. Prejudice
b. Stereotyping
c. Assimilation
d. Ethnocentrism - CORRECT ANSWERS-C!
Assimilation involves incorporating the behaviors of the dominant culture. Maintaining
eye contact is characteristic of the American culture and not Asian cultures. Prejudice is
a negative belief about another person or group and does not characterize this
behavior. Stereotyping is the perception that all members of a group are alike.
Ethnocentrism is the perception that one's beliefs are better than those of others.
A client has a hiatal hernia. The client is 5 feet 3 inches tall and weighs 160 pounds.
When the nurse discusses prevention of esophageal reflux, what should be included?
a. "Increase your intake of fat with each meal."
b. "Lie down after eating to help your digestion."
c. "Reduce your caloric intake to foster weight reduction."
,d. "Drink several glasses of fluid during each of your meals." - CORRECT ANSWERS-
C!
Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency
to reflux into the esophagus. Fats decrease emptying of the stomach, extending the
period that reflux can occur; fats should be decreased. Lying down after eating
increases the pressure against the diaphragmatic hernia, increasing symptoms.
Drinking several glasses of fluid during each meal will increase the pressure; fluid
should be discouraged with meals.
During an interview, the nurse discovers that the spouse of a debilitated, chronically
constipated client digitally removes stool from the client's rectum. What response to
disimpaction is the nurse attempting to prevent by presenting other strategies to
regulate the client's bowel movements?
a. Increased pulse rate
b. Slowing of the heart
c. Dilation of the bronchioles
d. Coronary Artery Vasodilation - CORRECT ANSWERS-B!
Disimpaction can cause vagal stimulation, which slows the heart. The vagus is the
principal nerve of the parasympathetic portion of the autonomic nervous system, and its
axon terminals release acetylcholine. The response of the viscera to acetylcholine
varies, but in general the organ is in a relaxed state. Increased pulse rate is an action of
the sympathetic nervous system (accelerator nerve) caused by the release of
norepinephrine. Stimulation of the sympathetic nervous system dilates bronchioles in
the lungs; the vagus nerve constricts them. There are parasympathetic fibers to the
coronary blood vessels; sympathetic impulses dilate these vessels.
Test-Taking Tip: You have at least a 25% chance of selecting the correct response in
multiple-choice items. If you are uncertain about a question, eliminate the choices that
you believe are wrong and then call on your knowledge, skills, and abilities to choose
from the remaining responses.
A nurse has just administered an immunization injection to a 2-month-old infant. What
instructions should the nurse give the parent if the infant has a reaction?
a. Give aspirin for pain; if swelling at the injection site develops, call the health care
provider.
b. Apply heat to the injection site for the first day after the injection; apply ice if the arm
is inflamed.
, c. Give acetaminophen for fever; call the health care provider if the child exhibits
marked drowsiness or seizures.
d. Apply ice to the injection site if soreness develops; call the health care provider if the
child comes down with a fever - CORRECT ANSWERS-C!
Fever is a common reaction to immunizations, and acetaminophen may be given to
minimize discomfort. A central nervous system reaction is rare and requires notification
of the health care provider. Aspirin should not be given to infants and children because
it is linked to Reye syndrome. Infants do not tolerate the application of ice, which will
increase discomfort. Fever is a common reaction to the immunizations; it is not
necessary to notify the health care provider.
A nurse inserts a nasogastric tube before an infant is to receive a tube feeding. What
action should the nurse take when the infant begins to cough and gag?
a. Auscultating for breath sounds
b. Removing the tube, then reinserting it
c. Administering the tube feeding slowly
d. Observing the infant for circumoral cyanosis - CORRECT ANSWERS-B!
The infant's response indicates that the tube may be in the trachea rather than the
stomach. The tube should be removed, reinserted, and verified for its placement before
the feeding is started. Auscultating for breath sounds does not provide information
about the placement of the tube. The tube should be removed immediately; it is unsafe
to assess the infant for additional signs of respiratory distress. It is unsafe to administer
the feeding until placement in the stomach has been confirmed.
A 26-year-old homosexual client is diagnosed with acquired immune deficiency
syndrome (AIDS). The primary nurse reports to the nursing team that the client cried
when told of the diagnosis. One of the nursing assistants responds, "I don't feel sorry for
him. He made his bed, and now he can lie in it." To best help the nursing assistant, the
nurse manager must first identify that this comment most likely is a result of the nursing
assistant's:
a. Values and beliefs about sexual lifestyles.
b. Anger and mistrust of homosexual males in general.
c. Discomfort with men who are unable to control their emotions.
d. Hostility over having to care for someone with a sexually transmitted infection -
CORRECT ANSWERS-A!
