Version 6(V6) Actual Authentic Exam
With Multiple Choices
1. A mother runs into the emergency department with a toddler in
her arms and tells the nurse that her child got into some cleaning
products. the child smells
of chemicals on the hands, face, and on the front of the child's
clothes. after ensuring the airway is patent, what action should the
nurse implement first?
a. Assess the child for altered sensorium
b. Determine type of chemical exposure
c. Obtain equipment for gastric lavage
d. Call poison control emergency number
- ANS- b. Determine type of chemical exposure
2. Which conditions are most likely to respond to
treatment with antihistamines? Select all that apply.
a. Bronchitis
b. Allergic rhinitis
c. Otitis media
d. Contact dermatitis
e. Myocarditis
- ANS- b. Allergic rhinitis
d. Contact dermatitis
3. An older client's daughter calls the home health nurse and
reports that her mother has become forgetful and is very
confused at night. The daughter states that her mother's
behavior changed suddenly a few days ago and is now getting
worse. Which action should the nurse take? Select all that
apply.
a. Ask if the mother is experiencing any pain with urination
b. Encourage increased intake of high protein foods
c. Instruct the daughter to check her mother's temperature
,d. Review the client's current food and medication allergies
e. Determine if the mother has recently experienced a fall
- ANS- a. Ask if the mother is experiencing any pain with urination
,c. Instruct the daughter to check her mother's temperature
e. Determine if the mother has recently experienced a fall
4. The nurse is assessing a male with a history of Addison's
disease. The client has flu-like symptoms and nausea with
vomiting over the past week. The client's spouse reports that he
acted confused and was extremely weak when he awoke this
morning. The client is febrile and has tachycardia. The health
care provider diagnoses acute adrenal insufficiency. Which
medication will most likely be prescribed?
a. Hypertonic saline solution at 100 ml/hr until all edema disappears
b. Hydrocortisone 100 mg IV every six hours until systolic BP
reaches 110 mmHg
c. Potassium chloride 20 mEq IV to infuse over 2 hours until
confusion resolves
d. Regular insulin drip to keep blood glucose around 100
mg/dl (5.55 mmol/L)
- ANS- b. Hydrocortisone 100 mg IV every six hours until systolic
BP reaches 110 mmHg
5. A client with a history of mitral valve prolapse is admitted
because of fever and dyspnea on exertion, and is diagnosed
with acute infective endocarditis. During the admission
assessment, the nurse observes multiple areas of petechiae on
the client's skin. Which intervention should the nurse include in
the client's plan of care? Select all that apply.
a. Monitor cardiac rhythm via telemetry
b. Report changes in pre-existing murmurs
c. Schedule rest periods between activities
d. Maintain record of fluid intake and output
e. Initiate contact transmission precautions
- ANS- a. Monitor cardiac rhythm via telemetry
b. Report changes in pre-existing murmurs
6. The nurse is planning an educational session for new parents
on ways to prevent sudden infant death syndrome (SIDS).
Which information is most important to provide parents of
newborns and infants?
a. Remove pillows and soft toys from the crib at bedtime
b. Keep a bulb syringe accessible for use for an infant
c. Position the infant in a supine position while sleeping
d. Do not prop bottles for an infant during naps and bedtime
- ANS- c. Position the infant in a supine position while sleeping
, 7. The healthcare provider prescribes methylergonovine maleate
for a postpartum client with uterine atony. What findings
should indicate to the nurse to withhold the next dose of
medication?
a. Hypertension
b. Difficulty locating the uterine fundus
c. Saturation of more than one pad per hour
d. Excessive lochia
- ANS- a. Hypertension
8. The nurse notes that an older adult client has a moist cough that
increases in severity during and after meals. Based on this
finding, which action should the nurse take?
a. Collect a sputum specimen immediately
b. Request a consultation to confirm dysphasia
c. Offer the client additional clear liquids frequently
d. Encourage the client to do deep breathing exercises daily
- ANS- b. Request a consultation to confirm dysphasia
9. A multiparous client who delivered her infant 3 hours ago
asks the nurse if she can take a warm sitz bath because it
helped reduce perennial pain after her last delivery. What
action should the nurse implement?
a. Using analgesic spray to the perennial area to reduce pain
b. Apply an ice pack to the perineum for the first 24 hours
c. Teach the client how to practice Kegel exercises
d. Review the use of sitz bath equipment with the client
- ANS- d. Review the use of sitz bath equipment with the client
10. When the parents of a 6-year-old boy with a brain tumor are
told that his condition is terminal, the mother shouts at the
father, "This is your fault! It never would have happened if we
sought treatment sooner!" Which intervention is best for the
nurse to implement?
a. Refer the parents to the chaplain to provide grief counseling
b. Assure the parents that a terminal diagnosis was inevitable
c. Tell the parents that blame each other will not change the situation
d. Explain to the parents that anger is a common response to grief
- ANS- d. Explain to the parents that anger is a common response to
grief