ACTUAL EXAM ALL 150 QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+.
A nurse is assessing a client who has a new diagnosis of celiac disease. Which
of the following clinical manifestations should the nurse expect?
A- Steatorrhea
B- projectile vomiting
C- sunken abdomen
D- weight gain - ANSWER - A- Steatorrhea; The nurse should realize that clients who have
celiac disease are unable to digest
gluten. This will cause damage to the cells in the bowel, leading to
malabsorption, steatorrhea, and diarrhea.
A nurse is assessing a school-age child immediately post-operative following a
perforated appendix repair. Which of the following findings should the nurse
expect?
A- Purulent nasogastric drainage
B- absence of peristalsis
C- passage of dark red stool with mucus
D- WBC of 6000 - ANSWER - B- absence of peristalsis; The nurse should expect absence of
peristalsis in the immediate postoperative
period, until the bowel resumes functioning.
A nurse is assessing a three-year-old toddler at a well-child visit. Which of the
following manifestations should the nurse report to the provider?
A- Blood pressure 90/ 50
B- respiratory rate 45/min
,C- weight 14.5 kg or 32 lb.
D- heart rate 110/min - ANSWER - B- respiratory rate 45/min; A respiratory rate of 45/min is
above the expected reference range for a 3-year-old
toddler and can indicate respiratory dysfunction and acute respiratory distress.
Therefore, the nurse should report this finding to the provider immediately.
A nurse is assessing an adolescent who received a sodium polystyrene
sulfonate enema. Which of the following findings indicates effectiveness
of the medication?
A- The Adolescents reports in absence of nausea and vomiting
B- the client experiences onset of loose stools within 15 minutes of administration
C- The Adolescents serum potassium level is 4.1
D- the Adolescent has a blood pressure of 86/ 52 - ANSWER - C- The Adolescents serum
potassium level is 4.1; The nurse should monitor the adolescent's serum potassium level
following the
administration of sodium polystyrene sulfonate. This medication is used to
treat hyperkalemia by exchanging sodium ions for potassium ions in the
intestine.
A nurse is assessing an infant who has pneumonia. Which of the following
findings are the priority for the nurse to report to the provider?
A- Nasal flaring
B- WBC 11,300
C- diarrhea
D- abdominal distension - ANSWER - A- Nasal flaring; When using the airway, breathing,
circulation approach to client care, the nurse
should place the priority on nasal flaring. Nasal flaring indicates that the
,infant is experiencing acute respiratory distress.
A nurse is assessing the pain level of a three-year-old toddler. Which of the
following pain assessment scales should the nurse use?
A- FACES Pain rating scale
B- numeric pain rating scale
C- CRIES pain assessment scale
D- non communicating children's pain checklist - ANSWER - A- FACES Pain rating scale;
The nurse should use the FACES pain rating scale for pediatric clients who are 3
years old and older. This scale allows the toddler to point to the face that depicts the
current level of pain. The nurse can then determine the need for pain management.
A nurse is assessing the vital signs of a 10-year-old child following a burn
injury. Which of the following clinical manifestations indicate early septic
shock?
A- Blood pressure 130/ 90
B- heart rate 60/ Minute
C- temperature 39.1 degrees Celsius or 102.4 degrees Fahrenheit
D- urinary output 100 mL/hr. - ANSWER - C- temperature 39.1 degrees Celsius or 102.4
degrees Fahrenheit; The nurse should expect a child who has early septic shock to have a
fever and
chills.
A nurse is auscultating the lungs of an adolescent who has asthma. The nurse
should identify the sound as which of the following? Click the audio button
to listen.
A- Boit's respiration
, B- Chaney Stokes respiration
C- tachypnea
D - Bradypnea - ANSWER - C- tachypnea; The nurse should identify the sound heard during
auscultation as tachypnea, which
is a rapid, regular breathing pattern. This breathing pattern often occurs with
anxiety, fever, metabolic acidosis, or severe anemia.
A nurse is caring for a 10-year-old child following a head injury. Which
of the following findings should the nurse identify as an indication that
the child is developing diabetes insipidus?
A- Urine specific gravity of 1.045
B- sodium 155
C- blood glucose 45
D- urine output 35 ml per hour - ANSWER - B- sodium 155; A child who has a head injury
can develop diabetes insipidus because of
pituitary hypo function leading to a deficiency of antidiuretic hormone.
Under excretion of antidiuretic hormone leads to polyuria and polydipsia and
possibly dehydration. With the excessive loss of free water, sodium levels rise
above the expected reference range.
A nurse is caring for a hospitalized preschooler. The child's mother is going
home for a few hours while another relative stay with the child. Which of the
following statements should the nurse make to explain to the child when her
mother will return?
A- Your mommy will be back at 7 p.m.
B- your mommy will be back after she takes care of your brother