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1. The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:
- Mongolian spots
- Scrotal rugae
- Head lag
- Polyhydramnios
2. Barbara, 72 years old patient is being treated with antibiotics for her UTI. After three days of taking them, she developed diarrhoea with blood stains. What is the most possible reason for this?
- Antibiotics causes chronic inflammation of the intestine
- An anaphylactic reaction
- Antibiotic alters her Gl flora which made Clostridium-difficile to multiply
- she is not taking the antibiotics with food
3. A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
- Alteration in coping related to pain
- Potential for injury related to precipitate delivery
- Alteration in elimination related to anesthesia
- Potential for fluid volume deficit related to NPO status
4. Define standard precaution:
- The precautions that are taken with all blood and ‘high-risk’ body fluids.
- The actions that should be taken in every care situation to protect patients and others from infection, regardless of what is known of the patient’s status with respect to infection.
- It is meant to reduce the risk of transmission of blood bourne and other pathogens from both recognized and unrecognized sources.
- The practice of avoiding contact with bodily fluids, by means of wearing of nonporous articles such as gloves, goggles, and face shields.
5. Patient with Clostridium deficile has stools with blood and mucus, due to which condition?
- Ulcerative colitis
- Chrons disease
- Inflammatory bowel disease
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1. Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?
2. What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?
3. The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?
4. Your patient has Diverticulitis for about a decade now. You have assessed her to be having soft stools of Type 4/5. Which of the following will need urgent intervention?
5. A client is admitted to the unit two hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
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1. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
- Call security for assistance and prepare to sedate the client.
- Tell the client to calm down and ask him if he would like to play cards.
- Tell the client that if he continues his behavior he will be punished.
- Leave the client alone until he calms down.
2. After two weeks of receiving lithium therapy, a patient in the psychiatric unit becomes depressed. Which of the following evaluations of the patient’s behavior by the nurse would be MOST accurate?
- The treatment plan is not effective; the patient requires a larger dose of lithium.
- This is a normal response to lithium therapy; the patient should continue with the current treatment plan.
- This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior.
- The treatment plan is not effective; the patient requires an antidepressant
3. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
- Chronic fatigue syndrome
- Normal aging
- Sundowning
- Delusions
4. A client is brought to the emergency room by the police. He is combative and yells, “I have to get out of here. They are trying to kill me.” Which assessment is most likely correct in relation to this statement?
- The client is experiencing an auditory hallucination.
- The client is having a delusion of grandeur.
- The client is experiencing paranoid delusions.
- The client is intoxicated.
5. To provide effective feedback to a client, the nurse will focus on:
- The present and not the past.
- Making inferences of the behaviors observed.
- Providing solutions to the client.
- The client.
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1. A patient with a Bipolar Disorder makes a sexually inappropriate comment to the nurse. One should take which of the following actions?
- Ignore the comment because the client has a mental health disorder and cannot help it.
- Report the comment to the nurse manager.
- Ignore the comment, but tell the incoming nurse to be aware of the client’s propensity to make inappropriate comments.
- Tell the client that is it inappropriate for clients to speak to any nurse that way.
2. A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is:
- Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels.
- Total Parenteral Nutrition cannot be managed with oral hypoglycemics.
- Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.
- Total Parenteral Nutrition leads to further pancreatic disease.
3. A carer has reported that she has seen a resident fall off his bed. What initial assessment should be done?
- Check the patient’s Early Warning Score along with the Glasgow Coma Scale immediately.
- Ask the patient if he is in pain; if so, administer painkillers immediately.
- Dial 999 and request for an ambulance to take your patient to the hospital.
- Contact the out-of-hours GP and request for a home visit.
4. You were on the phone with a family member, and one of the carers has reported that one of your residents has stopped breathing and turned blue. What should you do first?
- End your conversation with the family member, attend to your patient and do the CPR.
- End your conversation with the family member, go to your patient’s bedroom and assess for airway, breathing and circulation.
- End your conversation with the family member, and dial 999 to request for an ambulance.
- Dial 111, and request for an urgent visit from the General Practitioner.
5. Karen, one of the residents in the nursing home, has not yet had her mental capacity assessment done. She has been making decisions that you personally think are not beneficial for her. Which of the following should not be implemented?
- Force her to change her mind every time she makes a decision
- Explain the benefits of making the right decision
- Allow her to make her own decision, as she still has mental capacity
- All of the above
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- Category: CBT Test
1. A two-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?
- The infant no longer complains of pain.
- The buttocks are 15° off the bed.
- The legs are suspended in the traction.
- The pins are secured within the pulley.
2. The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:
- Administer the medications together in one syringe
- Administer the medication separately
- Administer the Valium, wait five minutes, and then inject the Phenergan
- Question the order because they cannot be given at the same time
3. The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:
- Phlebostatic axis
- PMI
- Erb’s point
- Tail of Spence
4. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
- Likes to play football
- Drinks carbonated drinks
- Has two sisters
- Is taking acetaminophen for pain
5. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
- Question the order.
- Administer the medications.
- Administer separately.
- Contact the pharmacy.
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