Select All That Apply Practice Exam Flashcards

An unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which of the following is the best action?

Answer: Transport the client to the operating department immediately, as required by the health care provider without obtaining an informed consent.

In emergency situations where a client is unconscious and immediate medical intervention is necessary to save their life, the principle of implied consent applies. It is presumed that the client would consent to life-saving treatment if they were able to. Delaying surgery to obtain formal consent would jeopardize the client's survival, making immediate transport to the operating room the best action.

When caring for a 3-year-old child, the nurse should provide which toy for this child?

Answer: A wagon

A 3-year-old child is a toddler who is actively developing gross motor skills and engaging in parallel play. A wagon is an excellent toy for this age group as it encourages walking, pulling, and imaginative play, supporting their physical development and exploration. Other options like a golf set or farm set are typically more suited for older children with more refined motor skills or specific interests.

When caring for a 3-year-old child, the nurse should provide which toy for this child?

Answer: A wagon

A 3-year-old child is a toddler who is actively developing gross motor skills and engaging in parallel play. A wagon is an excellent toy for this age group as it encourages walking, pulling, and imaginative play, supporting their physical development and exploration. Other options like a golf set or farm set are typically more suited for older children with more refined motor skills or specific interests.

A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty:

Answer: Expressing anger toward others

Suicidal clients often struggle with expressing anger outwardly, instead internalizing these intense emotions. This internalized anger can manifest as self-blame, guilt, and feelings of worthlessness, contributing to their suicidal ideation. The inability to verbalize anger towards others can prevent healthy emotional processing and coping mechanisms.

A client receiving hydrochlorothiazide is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:

Answer: Banana

Hydrochlorothiazide is a thiazide diuretic that can lead to potassium depletion in the body. Therefore, clients taking this medication are often advised to increase their dietary potassium intake. Bananas are an excellent source of potassium, making them the best snack choice among the options to help maintain adequate potassium levels.

The nurse is caring for a client following removal of the thyroid. Immediately post-op, the nurse should:

Answer: Maintain the client in a semi-Fowler’s position with the head and neck supported by pillows

Immediately following a thyroidectomy, maintaining the client in a semi-Fowler's position with the head and neck supported by pillows is crucial. This position helps to reduce tension on the surgical incision, minimize swelling, and promote venous and lymphatic drainage from the surgical site. It also facilitates easier breathing and prevents hyperextension or hyperflexion of the neck, which could compromise the airway or incision integrity.

A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer?

Answer: Luncheon meats

Luncheon meats and other processed meats are often preserved using nitrates and nitrites, which can form N-nitroso compounds in the body. These compounds are recognized carcinogens and have been consistently linked to an increased risk of gastric cancer. A diet high in such processed foods is considered a significant risk factor for this type of malignancy.

A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client’s record, the nurse could expect to find:

Answer: A history of cruelty to animals

Antisocial personality disorder is characterized by a pervasive pattern of disregard for and violation of the rights of others, often beginning in childhood. A history of cruelty to animals or people during childhood is a common diagnostic criterion and an early indicator of this disorder. This behavior reflects a profound lack of empathy, a core feature of antisocial personality disorder.

The licensed vocational nurse may not assume the primary care for a client:

Answer: With a venous access device

The management of venous access devices, especially central lines, typically falls outside the scope of practice for a Licensed Vocational Nurse (LVN) in many jurisdictions. These devices require advanced assessment skills, specialized knowledge of potential complications, and complex interventions that are generally reserved for Registered Nurses. Therefore, an LVN would not assume primary care for a client with a venous access device.

The physician has ordered dressings with Sulfamylon cream for a client with full-thickness burns of the hands and arms. Before dressing changes, the nurse should give priority to:

Answer: Administering pain medication

Dressing changes for full-thickness burns, especially when applying topical agents like Sulfamylon cream, are intensely painful procedures. Administering pain medication prior to the dressing change is the highest priority to ensure the client's comfort and minimize their suffering. Effective pain management also helps reduce anxiety and promotes client cooperation during this critical care activity.

The nurse is teaching a group of parents about gross motor development of the toddler. Which behavior is an example of the normal gross motor skill of a toddler?

Answer: She can pull a toy behind her.

A toddler's gross motor development involves gaining better balance and coordination, often seen in activities like walking, running, and pulling objects. The ability to pull a toy behind her is a characteristic gross motor skill typically achieved by a toddler, demonstrating improved coordination and purposeful movement. Other options like copying lines or broad-jumping are usually developed later in the preschool years.

A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?

Answer: Wire cutters

For a client with a fractured mandible treated with maxillomandibular fixation (jaw wired shut), wire cutters are essential equipment that must be kept at the bedside. In an emergency, such as vomiting or airway obstruction, the wires may need to be cut immediately to prevent aspiration and maintain a patent airway. This ensures client safety and allows for rapid intervention if complications arise.

Which finding is the best indication that a client with ineffective airway clearance needs suctioning?

Answer: Breathe sounds

Adventitious breath sounds, such as rhonchi, crackles, or diminished sounds heard upon auscultation, are the most direct and immediate indication that a client has secretions in their airway requiring suctioning. These sounds signify an obstruction to airflow caused by mucus or other fluids. While oxygen saturation and respiratory rate are important, breath sounds specifically pinpoint the need for secretion removal.

A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:

Answer: Changes in color vision

Ethambutol (Myambutol) is an antitubercular medication known to have a significant ocular side effect: optic neuritis. This condition can manifest as changes in color vision, particularly red-green discrimination, and decreased visual acuity. Clients must be instructed to report any visual changes immediately, as early detection can prevent irreversible vision loss.

The primary cause of anemia in a client with chronic renal failure is:

Answer: Insufficient erythropoietin

The primary cause of anemia in clients with chronic renal failure is the kidneys' inability to produce sufficient erythropoietin. Erythropoietin is a hormone vital for stimulating red blood cell production in the bone marrow. As kidney function declines, erythropoietin levels drop, leading to a decreased red blood cell count and subsequent anemia.

Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?

Answer: Asking if the client has allergies to shellfish

An intravenous pyelogram (IVP) involves the injection of an iodine-based contrast dye, which carries a risk of allergic reaction. Asking about allergies to shellfish is the highest priority intervention because a shellfish allergy often indicates a potential sensitivity to iodine, increasing the risk of an adverse reaction to the contrast medium. This assessment is crucial for client safety before the procedure.