Nursing Concepts 6 Practice Test

Front 1

The nurse is obtaining a sputum specimen for acid-fast bacillus. Which action will best protect the nurse during this procedure?

Back 1

Place the specimen container in a sealed plastic bag.

Front 2

Which nursing diagnosis should receive priority in the plan of care for a three-month-old infant who has a salmonella infection?

Back 2

fluid volume deficit

Front 3

The nurse is assessing a three-year-old patient with upper respiratory symptoms. Which clinical manifestation is indicative of rubeola (measles)?

Back 3

Koplik's spots on the buccal mucosa

Front 4

Which is the drug of choice for the treatment of streptococcal pharyngitis?

Back 4

penicillin V potassium (Pen-Vee K)

Front 5

A three-year-old patient is admitted with sepsis and possible Haemophilus influenzae meningitis. Which action should the nurse take prior to initiating the prescribed antibiotic therapy?

Back 5

Ensure that blood, urine, and cerebrospinal fluid (CSF) cultures are obtained.

Front 6

Why is it particularly important for the nurse interviewing a patient with gonorrhea to identify the patient's sexual contacts?

Back 6

Gonorrhea may be asymptomatic.

Front 7

Which health problem often precedes the occurrence of rheumatic fever?

Back 7

streptococcal pharyngitis

Front 8

The nurse reviews the nutritional history of a 10-year-old child who developed a salmonella infection. Which food is most likely to be the cause of the infection?

Back 8

cookie dough

Front 9

Which vaccine is contraindicated for a child who is HIV seropositive and severely immunocompromised?

Back 9

rubella

Front 10

A positive response to which diagnostic test is the best indicator that a patient who is HIV seropositive has tuberculosis?

Back 10

sputum specimen

Front 11

Which observation indicates a urinary tract infection (UTI) in a school-age child?

Back 11

enuresis

Front 12

Which infectious disease can be diagnosed through the use of blood studies

Back 12

syphilis

Front 13

A patient with chills uses accessory neck muscles to breathe. Chest movement is restricted and inspiratory crackles are heard on auscultation. Which acute condition should the nurse suspect?

Back 13

pneumonia

Front 14

A patient with a urinary tract infection is taking sulfisoxazole (Gantrisin). Why should the nurse increase this patient's fluid intake?

Back 14

to prevent crystalluria

Front 15

A patient with a urinary tract infection (UTI) is seen at a community health center and amoxicillin trihydrate (Amoxil) is prescribed. Three days later, the laboratory report on the patient's urine specimen reads, "Bacterial count 150,000 colonies per mL. Sensitive to Amoxil. Which statement provides the best interpretation of this report?

Back 15

The bacterial count is excessive and Amoxil should be continued.

Front 16

Which is a clinical manifestation of herpes zoster (shingles)?

Back 16

vesicles along one side of the thorax

Front 17

Which symptoms in a patient with AIDS are most characteristic of Pneumocystis carinii pneumonia infection?

Back 17

fever, dyspnea, and nonproductive cough

Front 18

The nurse is planning discharge instructions for a patient who has acquired immunodeficiency syndrome (AIDS). The nurse should stress that disinfection can be effectively achieved in the home by cleaning contaminated surfaces with which substance?

Back 18

a dilute solution of sodium hypochlorite

Front 19

What is natural immunity?

Back 19

protection induced by actually contracting the causative agent of the disease

Front 20

How does the herpes simplex virus, type 2 (HSV-2) survive in the body? The virus

Back 20

invades nerve ganglia when its replication diminishes.

Front 21

Which person is most likely to have a significant positive response (greater than 9 mm) to the Mantoux test?

Back 21

a person who has a history of tuberculosis

Front 22

Which information in a patient's health history indicates that the patient is at risk for infection from hepatitis B?

Back 22

employed as a dentist

Front 23

Which clinical manifestation is most indicative of Lyme disease in children?

Back 23

ring-shaped rash

Front 24

What are the initial clinical manifestations of shigella infection?

Back 24

fever and abdominal cramping

Front 25

Which measure should be included in the nursing management of a patient with pelvic inflammatory disease (PID)?

Back 25

Maintain semi-Fowler's position.

Front 26

A nurse has given home care instructions to the husband of a 78-year-old woman who is going home after an open reduction and internal fixation of a hip fracture. The nurse realizes that the patient's husband needs further instruction when the husband makes which comment?

Back 26

I have put a hospital bed in the dining room so that I do everything for her more easily

Front 27

Which condition has clinical manifestations similar to those of systemic lupus erythematosus (SLE)?

Back 27

rheumatoid arthritis

Front 28

The community health nurse arrives at a patient's home to find the patient lying on the floor. The patient is oriented to person, time, and place. The patient's right leg is shorter than the left and is adducted. The nurse suggests that the patient be transported by ambulance to the hospital. What is the rationale for the nursing action?

Back 28

The nurse suspects a fracture of the femoral neck.

Front 29

The nurse has provided pin site care for a patient in skeletal traction who has a Steinmann pin in place. Which observation should the nurse be certain to include in the nurse's report?

Back 29

heat and swelling at the pin site

Front 30

Which are primary goals for a patient scheduled for orthopedic surgery?

Back 30

pain relief, tissue perfusion, health maintenance, improved mobility, and improved self-concept

Front 31

Which is the best indicator of circulatory complications in a patient who underwent a right total hip replacement 3 days ago? The patient experiences pain upon

Back 31

dorsiflexion of the right ankle.

Front 32

The presence of a diseased bone would make a patient more prone to which type of fracture?

Back 32

pathologic

Front 33

Which laboratory blood test result supports a diagnosis of systemic lupus erythematosus (SLE)?

Back 33

positive for antinuclear antibodies

Front 34

After teaching a patient with osteoporosis about nutritional needs, the nurse determines the patient understands high-calcium foods when the patient selects which meal?

Back 34

tuna sandwich on whole wheat bread, one cup of fruit yogurt, and one cup of skim milk

Front 35

Which is an alternative means to reduce the perception of pain?

Back 35

back massage

Front 36

A nurse is caring for a 29-year-old patient who is admitted with a spiral fracture of the femur resulting from a motor vehicle accident. The patient's pain seemed to decrease during the night. In the morning, the patient is restless and irritable. What further assessment would be of high priority?

Back 36

Get an order to obtain blood gas values.

Front 37

What will cause a pressure bandage to become saturated with blood immediately following a below-the-knee amputation?

Back 37

bleeding from a loosened suture

Front 38

Which nursing intervention is appropriate to include in a plan of care for a patient in Buck's traction?

Back 38

Remove the foam boot and inspect the skin three times daily.

Front 39

Two days following multiple fractures, a patient reports shortness of breath and chest pain. Upon assessment, the nurse also finds the patient to be confused. The nurse should suspect which complication?

Back 39

fat embolism

Front 40

A patient complains of pain in the right great toe 24 hours after a right above-the-knee amputation. What is the nurse's first action?

Back 40

Administer the prescribed narcotic analgesic.

Front 41

A patient with rheumatoid arthritis of the hands asks the nurse why resting splints are necessary. The nurse explains that resting splints are used for which purpose? Resting splints

Back 41

stabilize and immobilize joints in desired position when use of the hand is not required.

Front 42

Which discharge instruction should the nurse provide to the parents of an 18-month-old child who is in a hip spica cast?

Back 42

"Tuck a disposable diaper beneath the entire perineal opening of the cast to keep it clean."

Front 43

Which injury of a child is most suggestive of physical abuse?

Back 43

spiral fracture of the humerus

Front 44

Which nursing action should receive priority for a patient who is recovering from a total hip replacement?

Back 44

Position the patient using an abductor pillow.

Front 45

Which instruction should the nurse give to a patient who is receiving prophylactic probenecid-colchicine (ColBENEMID) therapy?

Back 45

Drink eight glasses of water a day.

Front 46

A 60-year-old patient is admitted to the hospital with a fracture of the right femur. Which assessment should the nurse be most concerned about?

Back 46

The patient pulls at the bed covers and talks to the wall.

Front 47

The nurse teaches an adolescent client about management of scoliosis with a body brace. Which client statement indicates that the teaching was effective?

Back 47

"Wearing the brace 23 hours a day will be hard for me."

Front 48

Which action should the nurse take when caring for a patient with a newly applied cast?

Back 48

Keep the cast uncovered.

Front 49

What is the appearance of normal synovial fluid?

Back 49

clear and straw-colored

Front 50

Which nursing goal should receive priority for a patient in a full leg cast who is on prolonged bed rest?

Back 50

Maintain skin integrity.

Front 51

Which area of the brain is responsible for vision?

Back 51

occipital

Front 52

A patient with a newly diagnosed seizure disorder is started on phenytoin sodium (Dilantin). Which statement made by the patient indicates a need for further teaching related to the medication?

Back 52

"I'll need to eat potassium-rich foods."

Front 53

The nurse is assessing a patient who has a score of 6 on the Glasgow Coma Scale. Which level of response should the nurse expect to observe?

Back 53

The patient withdraws the arms to painful stimuli.

Front 54

How is the diagnosis of myasthenia gravis confirmed?

Back 54

IV administration of edrophonium chloride (Tensilon test)

Front 55

A patient with a head injury is scheduled for a magnetic resonance imaging (MRI) examination. To reduce the patient's anxiety, which health teaching would be most important to include?

Back 55

The use of relaxation procedures will promote reduction of the claustrophobia associated with placement in the narrow tube.

Front 56

What is the expected result of eliciting the biceps reflex in a patient?

Back 56

elbow flexion

Front 57

The nurse is taking care of a patient with breast cancer and chronic trigeminal neuralgia. The patient is complaining that the trigeminal neuralgia is bothering her and she would like treatment for it. What is the initial nursing intervention?

Back 57

Assess corneal reflex.

Front 58

A patient had a supratentorial craniotomy 24 hours ago. What is the rationale for maintaining this patient in semi-Fowler's position?

Back 58

to promote drainage of venous and cerebrospinal fluids

Front 59

A patient with a C5 spinal cord injury is entering the acute rehabilitative phase. Which is an appropriate long-term goal for this patient? The patient will

Back 59

feed self with adaptive equipment and assistance in setup.

Front 60

Which information should be included in the discharge teaching plan for a patient with epilepsy who experiences generalized tonic-clonic seizures?

Back 60

Precipitating factors for seizure activity include increased stress, insomnia, and alcohol use

Front 61

Which finding should the nurse expect when assessing a patient who exhibits agnosia after having a cerebrovascular accident? The patient will be unable to

Back 61

recognize or interpret objects.

Front 62

Which capability is impaired in a patient with myasthenia gravis?

Back 62

motor function

Front 63

Which nursing action should receive priority in the plan of care for a patient in the acute phase of a cerebrovascular accident?

Back 63

Place the patient in a lateral position with the head of the bed elevated.

Front 64

Which medication is used to decrease intracranial pressure (ICP) in a patient with a brain injury?

Back 64

mannitol (Osmitrol)

Front 65

Which sign is most characteristic of Parkinson's disease?

Back 65

pill-rolling tremors

Front 66

A patient who has sustained a complete spinal cord transection at level C4 will most likely have which condition?

Back 66

quadriplegia

Front 67

Which medication would a nurse anticipate immediately administering to a patient with a progressive brain attack (cerebrovascular accident [CVA]; stroke) who has a history of hypertension?

Back 67

heparin IV

Front 68

A 28-year-old patient with multiple sclerosis smiles and laughs almost constantly while awake. What is the pathophysiological basis for this clinical manifestation?

Back 68

demyelination of the nervous system

Front 69

Which information should the nurse provide to a school-age child prior to a noncontrast computerized axial tomography (CAT) scan?

Back 69

"You will need to lie perfectly still while a big machine takes pictures."

Front 70

A patient who has bacterial meningitis complains of severe headache and has a temperature of 39.2̊ C (102.6̊ F). What is the nurse's intervention?

Back 70

Perform a neurological assessment on the patient.

Front 71

Which long-term outcome is appropriate for a patient with early Parkinson's disease? The patient will

Back 71

continue to participate in usual activities.

Front 72

Which nursing measure is used to minimize pain in the affected arm of a patient who has had a cerebrovascular accident (CVA; brain attack; stroke)?

Back 72

applying a sling

Front 73

What can result from an injury to the frontal lobe of the cerebrum? A deficit in

Back 73

sense of humor

Front 74

A 10-year-old child with a neurogenic bladder has been taught to perform intermittent self-catheterization. Which data indicates that the child is achieving the goal of continence?

Back 74

The child experiences no dribbling between catheterizations.

Front 75

Which nursing action is appropriate when caring for a patient who is experiencing a generalized (grand mal) seizure?

Back 75

Place the patient in a lateral position.

Front 76

A patient who experienced a circumferential full-thickness (third-degree) burn of the left lower leg complains of numbness and tingling in the left foot. The nurse notes that the foot is cool to the touch and no pulse is palpable. What is the explanation for these clinical manifestations?

Back 76

Edema formation under the eschar has occluded the blood supply to the foot.

Front 77

Following major abdominal surgery, a patient's central venous pressure (CVP) decreases to 3 cm H2O. Based on this data, the nurse should continue to assess for which complication?

Back 77

hypovolemic shock

Front 78

Why is an injured person immobilized before being removed from the scene of a motor vehicle accident

Back 78

to prevent further damage and loss of neurological function

Front 79

A patient with malnutrition develops wound dehiscence following abdominal surgery. What is the most likely explanation for this problem?

Back 79

Collagen production is diminished.

Front 80

Which menu selection by a 10-year-old child with severe burns indicates that the nurse's nutritional instruction has been effective?

Back 80

milk shake and peanut butter sandwich

Front 81

Which patient should the nurse plan to monitor closely for postoperative complications of hypoventilation?

Back 81

a 78-year-old patient who had an open cholecystectomy

Front 82

The skin is most susceptible to excoriation from drainage following which surgical procedure?

Back 82

ileostomy

Front 83

Which measure should the nurse include in the plan of care for a patient with major burns to alleviate the patient's negative nitrogen balance?

Back 83

Increase protein intake

Front 84

Which side effect is associated with the combined use of skeletal muscle relaxants and general anesthesia?

Back 84

respiratory arrest

Front 85

Which ultrasound test result confirms cholelithiasis.

Back 85

calculi in the gall bladder

Front 86

Which assessment data are indicative of intraperitoneal injury in a patient who has sustained multiple injuries in an automobile accident?

Back 86

Which assessment data are indicative of intraperitoneal injury in a patient who has sustained multiple injuries in an automobile accident?

Front 87

How should the nurse position a postoperative patient in order to prevent aspiration?

Back 87

sidelying

Front 88

Which postoperative physiological process affects a patient's fluid and electrolyte balance?

Back 88

a stimulation of antidiuretic hormone

Front 89

Which instruction to parents is most effective in reducing the incidence of electrical burn injuries in toddlers? Eliminate a child's access to electrical sockets by

Back 89

inserting child-proof covers in all electrical sockets.

Front 90

Which outcome indicates adequate fluid resuscitation in a patient with a burn injury?

Back 90

urinary output greater than 30 mL per hour

Front 91

Which statement best describes the pain associated with a duodenal ulcer? It is localized in the

Back 91

epigastrium and occurs 1 - 3 hours after meals.

Front 92

Which manifestations occur following the ingestion of a corrosive chemical?

Back 92

pain, inability to swallow, and drooling

Front 93

What is the rationale for applying an elastic pressure garment to a patient who has sustained severe burn injuries?

Back 93

to minimize hypertrophic scarring

Front 94

The nurse is caring for a patient following an open cholecystectomy. The patient has a Penrose drain in place. Which action by the nurse should be included in the plan of care?

Back 94

Place dressings around and over the drain

Front 95

A patient who was severely burned two weeks ago eliminates a black stool. What does this finding indicate?

Back 95

the development of a Curling's ulcer

Front 96

Which is a common and early manifestation of diverticulitis?

Back 96

crampy pain in the lower left quadrant

Front 97

On the first day following a left below-the-knee amputation, a patient complains of pain in the left foot. Which nursing action is most appropriate initially?

Back 97

Administer the ordered analgesic

Front 98

Which laboratory finding would the nurse expect in a school-age child who has taken an overdose of acetaminophen (Tylenol)?

Back 98

increased liver enzymes

Front 99

Which food is permitted in the diet of a patient who has ulcerative colitis?

Back 99

cottage cheese

Front 100

The nurse should include which instruction in the discharge plan for a patient who has developed dumping syndrome following a gastrectomy?

Back 100

"Eat small, frequent meals that are low in simple sugars."