Are you preparing for the RN NCLEX or an upcoming nursing exam? Assess your readiness with this free nurse test bank. This test bank includes 10 questions with detailed answers provided at the end of this test.
Question 1
When a mother brings her toddler to a clinic, she tells the nurse that she finds it hard to convince her to go to bed at night. Which action would be best to recommend to the mother by the nurse?
A. Allow the child to set bedtime limits.
B. Allow the child to have temper tantrums.
C. Avoid letting the child nap during the day.
D. Inform the child of bedtime a few minutes before it is time for bed.
Question 2
Which interventions are appropriate for the care of an infant?
Select all that apply.
A. Provide swaddling.
B. Talk in a loud voice.
C. Provide the infant with a bottle of juice at nap time.
D. Hang mobiles with black and white contrast designs.
E. Caress the infant while bathing or during diaper changes.
F. Allow the infant to cry for at least 10 minutes before responding.
Question 3
The client, who has a fractured rib, is being evaluated by the nurse for his or her inspiratory capacity. Which finding should the nurse anticipate noting?
A. Slow, deep respirations
B. Rapid, deep respirations
C. Paradoxical respirations
D. Pain, especially with inspiration
Question 4
The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise.
Using GTPAL, what should the nurse document in the client's chart?
A. G = 3, T = 2, P = 0, A = 0, L = 1
B. G = 2, T = 1, P = 0, A = 0, L = 1
C. G = 1, T = 1, P = 1, A = 0, L = 1
D. G = 2, T = 0, P = 0, A = 0, L = 1
Question 5
With a client who is multiparous, the nurse is going over actual and false labor signals. If the client makes the comment, the nurse can conclude that she is aware of the symptoms of actual labor.
A. "I won't be in labor until my baby drops."
B. "My contractions will be felt in my abdominal area."
C. "My contractions will not be as painful if I walk around."
D. "My contractions will increase in duration and intensity."
Question 6
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?
A. Folate deficiency
B. Malabsorption of fat
C. Intestinal obstruction
D. Fluid and electrolyte imbalance
Question 7
Which of the following is the responsibility of a nurse who is caring for a client receiving PCA?
A. instruct family to refrain from pushing the button for the client while she is asleep
B. inform the client that b/c she is on PCA, vital signs will be taken g8hr
C. teach the client to avoid pushing the button unless pain is above a 7 on a 0-10 scale
D. increase the basal rate and shorten the lock out interval time if the clients pain level is to high
Question 8
A nurse is evaluating a patient who claims to be in more discomfort after physical therapy. When determining the degree of the client's pain, which of the following questions should the nurse inquire about?
A. "Is your pain constant or intermittent?"
B. "What would you rate your pain on a scale of 0-10?"
C. "Does the pain radiate?"
D. "Is your pain sharp or dull?"
Question 9
A nurse is going over lab results for a patient who was involved in a car accident and has chest wall contusions. Out of all the values, which one should the nurse report?
A. Hct 40%
B. SaO2 86%
C. WBC 9,000 mm3
D. Serum Potassium 4.1 mEq/L
Question 10
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further instructions by the nurse?
A. "I will tape electrical cords to the baseboards in each room."
B. "I will hire someone to trim the tree that overhangs the front porch stairs."
C. "I will remove the table from the hall."
D. "I will replace the old throw rug in the kitchen with a new one."
Answer Key
Question 1 Answer - D
Rationale: Toddlers often resist going to bed. Bedtime protests may be reduced by establishing a consistent before-bedtime routine and enforcing consistent limits regarding the child's bedtime behavior. Informing the child of bedtime a few minutes before it is time for bed is the most appropriate option. Most toddlers take an afternoon nap and, until their second birthday, also may require a morning nap. Firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics.
Question 2 Answers - A, D, E
Rationale: Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to do so also. Additional interventions include playing a music box, radio, or television, or having a ticking clock or metronome nearby. Hanging a bright, shiny object in midline within 20 to 25 cm of the infant's face and hanging mobiles with complementary colors, such as black and white, provide visual stimulation. Crying is an infant's way of communicating; therefore, the nurse would respond to the infant's crying. The mother is taught to do so also. An infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, sweetened water, or another sweet liquid because of the risk of nursing (bottlemouth)
caries.
Question 3 Answer - D
Rationale: Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with a flail chest.
Question 4 Answer - B
Rationale: Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies; T is term births, the number born at term (longer than 37 weeks); P is preterm births, the number born before 37 weeks of gestation; A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks of gestation; included in parity [number of births] if past 20 weeks of gestation); and L is the number of current living children. A woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.
Question 5 Answer - D
Rationale: True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.
Question 6 Answer - D
Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.
Question 7 Answer - A
Rationale: the nurse should instruct the family members not to push the button while the client sleeps; toxic effects could still result if the client receives more medications than she needs to control her pain
Question 8 Answer - D
Rationale: asking if the pain is sharp or dull detemines quality of pain
Question 9 Answer - B
Rationale: this value may indicate hypoxia and therefore thenurse should
report this finding
Question 10 Answer - D
Rationale: The use of throw rugs increases the clients risk for falls, as it creates a tripping and slipping hazard
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