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General Exams (Nursing Community) – Page 2

#21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which priority action?
A Call the radiology department for X-ray.
B Takes a set of vital signs.
C Immobilize the leg before moving the client.
D Reassure the client that everything will be alright.
Answer: Immobilize the leg before moving the client.
#22. A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge would take which priority action in the care of this client?
A Encourage family and friends to visit.
B Encourage the client to take frequent rest periods.
C Admit the client into a private room.
D Place client on reverse isolation.
Answer: Admit the client into a private room.
#23. A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis?
A Constipation
B Risk for infection
C Diarrhea
D Deficient knowledge
Answer: Risk for infection
#24. A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by the nurse?
A Stop the total parenteral nutrition.
B Place the client in high-Fowlers position.
C Notify the physician.
D Place the client on the left side in the Trendelenburg position.
Answer: Place the client on the left side in the Trendelenburg position.
#25. Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and directive. The nurse determines that the leadership style used at the trauma center is:
A Situational
B Democratic.
C Laissez-faire.
D Autocratic.
Answer: Autocratic.
#26. The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution?
A 1.5 cc
B 0.5 cc
C 5 cc
D 2.5 cc
Answer: 2.5 cc
#27. A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver this amount is:
A 66 cc/ hour
B 50 cc/ hour
C 55 cc/ hour
D 24 cc/ hour
Answer: 50 cc/ hour
#28. The nurse is aware that the most important nursing action when a client returns from surgery is:
A Assess the IV for type of fluid and rate of flow.
B Assess the dressing for drainage.
C Assess the Foley catheter for patency and urine output
D Assess the client for presence of pain.
Answer: Assess the client for presence of pain.
#29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction?
A BP – 180/100, Pulse – 90 irregular
B BP – 130/80, Pulse – 100 regular
C BP – 90/50, Pulse – 50 regular
D BP – 80/60, Pulse – 110 irregular
Answer: BP – 80/60, Pulse – 110 irregular
#30. Which is the most appropriate nursing action in obtaining a blood pressure measurement?
A Document the measurement, which extremity was used, and the position that the client was in during the measurement.
B Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart.
C Have the client recline or sit comfortably in a chair with the forearm at the level of the heart.
D Measure the client’s arm, if you are not sure of the size of cuff to use.
Answer: Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart.
#31. Asking the questions to determine if the person understands the health teaching provided by the nurse would be included during which step of the nursing process?
A Assessment
B Planning and goals
C Implementation
D Evaluation
Answer: Evaluation
#32. Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs?
A Diagnostic test results
B History of present illness
C Biographical date
D Physical examination
Answer: History of present illness
#33. In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use:
A Hip-abductor pillow
B Footboard
C Trochanter roll extending from the crest of the ileum to the midthigh.
D Pillows under the lower legs.
Answer: Trochanter roll extending from the crest of the ileum to the midthigh.
#34. Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?
A Stage I
B Stage II
C Stage III
D Stage IV
Answer: Stage III
#35. When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed ________________.
A Second intention healing
B Primary intention healing
C First intention healing
D Third intention healing
Answer: Second intention healing
#36. An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives alone and hasn’t been eating or drinking. When assessing him for dehydration, nurse Oliver would expect to find ___________________.
A Hypothermia
B Hypertension
C Tachycardia
D Distended neck veins
Answer: Tachycardia
#37. The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a client’s postoperative pain. The package insert is “Meperidine, 100 mg/ml.” How many milliliters of meperidine should the client receive?
A 0.5
B 0.25
C 0.6
D 0.75
Answer: 0.75
#38. A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit?
A It’s a common measurement in the metric system.
B It’s the basis for solids in the avoirdupois system.
C It’s a measure of effect, not a standard measure of weight or quantity.
D ’s the smallest measurement in the apothecary system.
Answer: It’s a measure of effect, not a standard measure of weight or quantity.
#39. Nurse Oliver measures a client’s temperature at 102oF. What is the equivalent Centigrade temperature?
A 40.1 oC
B 38.9 oC
C 48 oC
D 37 oC
Answer: 38.9 oC
#40. The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual physical exam. One of the first physical signs of aging is ________________.
A Having more frequent aches and pains.
B Failing eyesight, especially close vision.
C Accepting limitations while developing assets.
D Increasing loss of muscle tone.
Answer: Failing eyesight, especially close vision.
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