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مذكرة مراجعة

أغسطس 2026

478 سؤال مع الإجابات الصحيحة، مرتبة للقراءة والمراجعة استعدادا لاختبار التمريض SNLE.

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478 سؤال ظاهر

  1. 1

    A 10-year-old child presents with joint pain, low-grade fever, and a history of untreated strep throat 3 weeks ago. Which complication should the nurse prioritize monitoring for?

    A Pulmonary hypertension leading to increased peripheral resistance
    B Pancarditis leading to long-term valve damage, especially the mitral valve الإجابة الصحيحة
    C Acute kidney injury leading to bladder insufficiency
    D Coronary artery aneurysms arising from hypertension
  2. 2

    Several hours after delivery, a new mother expresses ambivalence regarding her infant. How will the nurse promote bonding between this mother and her newborn?

    A Having the mother feed the infant الإجابة الصحيحة
    B Removing the infant from the mother's arms if it cries
    C Positioning the infant so the head rests on the mother's shoulder
    D Encouraging the mother to sleep for 4 to 6 hours before interacting with the infant
  3. 3

    A nurse observes a mother on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. What action by the nurse is best?

    A Realize that this situation is perfectly acceptable
    B Offer to hand the baby to the woman
    C Hand the baby to the woman الإجابة الصحيحة
    D Explain the taking-in phase to the woman
  4. 4

    Which type of skull fracture is associated with raccoon eyes and Battle sign?

    A Linear Fracture
    B Open Fracture
    C Depressed Fracture
    D Basilar Fracture الإجابة الصحيحة
  5. 5

    When assessing a client suspected of having Cushing syndrome, the nurse is aware that the most prominent clinical manifestation is:

    A dehydration and hypotension
    B bulking of skeletal muscles
    C hypoglycemia and intense hunger
    D weight gain with truncal obesity الإجابة الصحيحة
  6. 6

    A preoperative client wears a hearing aid and is extremely hard of hearing without it. Which action should the nurse take to help reduce the client's anxiety?

    A Actively listen to the client
    B Allow the client to wear the hearing aid to surgery
    C Ask whether the client may wear the hearing aid until anesthesia is administered الإجابة الصحيحة
    D Explain the policy requiring removal of the hearing aid
  7. 7

    A nurse is reviewing laboratory results for a child with suspected acute rheumatic fever. Which diagnostic result provides the required evidence of a preceding streptococcal infection?

    A Elevated C-reactive protein
    B Elevated antistreptolysin O titer الإجابة الصحيحة
    C Prolonged PR interval
    D Leukocytosis with a left shift
  8. 8

    A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is:

    A Not yet engaged
    B Entering the pelvic inlet
    C Below the ischial spines الإجابة الصحيحة
    D Visible at the vaginal opening
  9. 9

    Which recommendation should the nurse make to a client with mastitis who is concerned about breastfeeding?

    A Continue breastfeeding because mastitis will not infect the neonate الإجابة الصحيحة
    B Do not take analgesics while breastfeeding
    C Stop breastfeeding until the antibiotic course is complete
    D Supplement all feedings with formula
  10. 10

    A two-year-old child is in the clinic for a well visit. The nurse notes that the patient's vaccinations are up to date. Which additional vaccination would the nurse suggest to the provider after noting a recent diagnosis of type one diabetes mellitus?

    A Hepatitis B (Hep B)
    B Meningococcal vaccine
    C Human papillomavirus (HPV)
    D Pneumococcal polysaccharide (PPSV23) الإجابة الصحيحة
  11. 11

    A nurse palpates a postpartum uterus that is boggy. What is the first nursing action?

    A Administer antibiotics
    B Perform fundal massage الإجابة الصحيحة
    C Insert urinary catheter
    D Administer magnesium sulfate
  12. 12

    A nurse assesses a client 2 hours postpartum and finds the fundus boggy and displaced to the right. Which action should the nurse take first?

    A Notify the health care provider
    B Massage the fundus
    C Encourage the client to void الإجابة الصحيحة
    D Document the finding
  13. 13

    A client at 11 weeks of gestation has had slight, occasional, painless vaginal bleeding for 2 weeks. The fetus has died and the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings?

    A Incomplete miscarriage
    B Complete abortion
    C Missed abortion الإجابة الصحيحة
    D Inevitable abortion
  14. 14

    A nurse is writing an article for his hospital's newspaper. Which action constitutes plagiarism?

    A Using quotation marks for a word-for-word quotation
    B Referencing a paraphrased idea
    C Reusing content from a previous article without acknowledging it الإجابة الصحيحة
    D Using common knowledge without a citation
  15. 15

    Which action should the nurse take first in response to an incorrect insulin dose given by a colleague?

    A Assess the patient الإجابة الصحيحة
    B Notify the nurse manager
    C Complete an incident report
    D Notify the health care provider
  16. 16

    A nurse is caring for a client diagnosed with paranoid personality disorder. Which behavior would the nurse expect to assess in this client?

    A Emotional attention-seeking behavior
    B Indifference to praise or criticism
    C Disregard for others with exploitation
    D Distrust and suspiciousness toward others الإجابة الصحيحة
  17. 17

    A client with suspected appendicitis asks for a laxative. Why should the nurse instruct the client not to take a laxative?

    A It decreases the spread of infection
    B It should not be taken before surgery
    C The client is not truly constipated
    D It may cause the appendix to rupture الإجابة الصحيحة
  18. 18

    Which manifestation should the nurse expect in a client with acute appendicitis?

    A High fever
    B Nausea and vomiting
    C Rebound tenderness الإجابة الصحيحة
    D Pain relieved by ambulation
  19. 19

    Calcium gluconate is the antidote for:

    A Magnesium sulfate toxicity الإجابة الصحيحة
    B Hyperkalemia
    C Digoxin toxicity
    D Heparin overdose
  20. 20

    Magnesium sulfate is administered to a patient with preeclampsia primarily to:

    A Lower blood pressure
    B Prevent seizures الإجابة الصحيحة
    C Increase urine output
    D Induce labor
  21. 21

    A client has stress urinary incontinence related to decreased pelvic muscle tone. Which therapeutic intervention should the nurse teach?

    A Use adult diapers
    B Perform intermittent catheterization
    C Take bethanechol
    D Perform Kegel exercises الإجابة الصحيحة
  22. 22

    A neonate is diagnosed with esophageal atresia and tracheoesophageal fistula (EA/TEF). The nurse prepares for emergency care. Which clinical sign would confirm this condition?

    A Absence of meconium within 48 hours of birth
    B Currant jelly stools and abdominal distension
    C Excessive frothy mucus, coughing, choking, and cyanosis with feeding الإجابة الصحيحة
    D Projectile vomiting and a palpable olive-shaped mass
  23. 23

    A nurse gave medication to the wrong patient after being interrupted. Which action should the nurse take first?

    A Document the error
    B Keep the error secret
    C Tell the immediate supervisor or charge nurse الإجابة الصحيحة
    D Keep the error secret and assess the patient hourly
  24. 24

    Which action by a newly licensed nurse should prompt intervention by the charge nurse?

    A Verifying the medication label
    B Scanning the client's identification barcode
    C Checking the prescription and a medication reference
    D Documenting the medication before administering it الإجابة الصحيحة
  25. 25

    A woman gave birth to a healthy term newborn about 2 hours ago. She asks the nurse about the appearance of her newborn's head. Assessment reveals swelling of the head that extends across the midline. Which response by the nurse would be appropriate?

    A Your newborn has a collection of blood that was caused by tearing of the veins and is pushing on the brain. This collection of blood will need to be drained.
    B You must have had some problems during labor with keeping your blood pressure under control. Your newborn will need to be handled gently.
    C The swelling in your newborn's head is due to the head pressing against your cervix during labor and birth. It will go away on its own in a few days. الإجابة الصحيحة
    D The tiny blood vessels under your newborn's skull broke during labor and caused the swelling. It will get better in about 2 to 3 weeks.
  26. 26

    A hospital wants to reduce patient falls. Which action should the nurse expect first?

    A Staff discipline
    B Root cause analysis of previous falls الإجابة الصحيحة
    C Immediate policy termination
    D Legal review
  27. 27

    The nurse is caring for a client with an acid-base imbalance secondary to prolonged vomiting. Which acid-base imbalance should the nurse monitor?

    A Respiratory alkalosis
    B Respiratory acidosis
    C Metabolic acidosis
    D Metabolic alkalosis الإجابة الصحيحة
  28. 28

    A mother reports that her 3-day-old infant looks slightly yellow. Which explanation should the nurse provide?

    A Physiologic jaundice is a normal finding that peaks at this age الإجابة الصحيحة
    B The infant's liver is not working
    C The infant's bowels are not excreting bilirubin
    D The infant has brain damage
  29. 29

    A school nurse wants to decrease childhood obesity. Which community action would be most effective?

    A Lobby for school lunch and snack legislation
    B Provide nutrition education programs
    C Involve the entire family in the intervention الإجابة الصحيحة
    D Offer after-school weight-loss camps
  30. 30

    A 25kg child needs fluids, what should the daily maintenance fluid requirement be?

    A 900mL/day
    B 1300mL/day
    C 6700mL/day
    D 1600mL/day الإجابة الصحيحة
  31. 31

    What percentage of pregnancies is affected by hyperemesis gravidarum?

    A 0.5% الإجابة الصحيحة
    B 1%
    C 2%
    D 5%
  32. 32

    Which clinical manifestation should the nurse expect when a child with sickle cell anemia experiences an acute vaso-occlusive crisis?

    A Circulatory collapse
    B Cardiomegaly, systolic murmurs
    C Hepatomegaly, intrahepatic cholestasis
    D Painful swelling of hands and feet; painful joints الإجابة الصحيحة
  33. 33

    Which one of the following nursing interventions should take priority for a child with ADHD?

    A Structured daily routine
    B Ensuring the child's safety and that of others الإجابة الصحيحة
    C Simplifying instructions and directions
    D Improved role performance
  34. 34

    The nurse is caring for a 154-pound patient with 50% total body surface area (TBSA) burns. If using the Parkland formula, the nurse will calculate which amount of intravenous solution to provide this patient in the first 24 hours of care?

    A 14,000 mL الإجابة الصحيحة
    B 42,000 mL
    C 3500 mL
    D 7000 mL
  35. 35

    A mother refuses the MMR vaccine because she believes having the diseases will help her child fight illness later. Which response should the nurse make?

    A Honor the decision without discussion
    B Explain that antibodies fight many diseases
    C Explain that not immunizing protects pregnant women
    D Explain that these diseases can cause serious permanent complications الإجابة الصحيحة
  36. 36

    Which type of immunity does an infant receive from the mother in utero and through breast milk?

    A Natural passive immunity الإجابة الصحيحة
    B Artificial active immunity
    C Artificial passive immunity
    D Natural active immunity
  37. 37

    Before enema administration, the nurse positions the client in a left lateral position. What is the rationale for using this position?

    A It is more comfortable.
    B It facilitates the passage of stool.
    C It prevents a vasovagal response from occurring.
    D It facilitates instillation of the enema solution into the colon. الإجابة الصحيحة
  38. 38

    Why is it important for a pregnant woman to avoid supine positioning?

    A Inferior vena cava pressure, hypotension الإجابة الصحيحة
    B Superior vena cava pressure, increased pulse
    C Liver compression, hypertension
    D Lung compression, hypotension
  39. 39

    A client has difficulty remembering daily pills, wants highly reliable contraception for at least 3 years, and prefers to avoid a method associated with reduced bone mineral density. Which contraceptive method is best?

    A Norethindrone tablets taken daily
    B Etonogestrel implant placed once and removed in 3 years الإجابة الصحيحة
    C Medroxyprogesterone intramuscularly every 3 months
    D Ethinyl estradiol and norelgestromin patch weekly
  40. 40

    A public health nurse is providing a smoking cessation program to a group of community members. This is an example of which level of prevention?

    A Primary prevention الإجابة الصحيحة
    B Secondary prevention
    C Tertiary prevention
    D Quaternary prevention
  41. 41

    What sign is commonly observed in a person with a basilar skull fracture?

    A nystagmus (jerky eyeball movements)
    B partial loss of visual fields
    C pinpoint pupils
    D periorbital bruising (raccoon eyes) الإجابة الصحيحة
  42. 42

    Which finding should the nurse expect in a patient with Cushing syndrome?

    A Protruding abdomen with increased facial fat الإجابة الصحيحة
    B Hypoglycemia with decreased blood pressure
    C Dehydration with hyponatremia
    D Anorexia with weight loss
  43. 43

    A patient going for surgery wants to give a hearing aid to the spouse. Which action should the nurse take?

    A Encourage the patient to wear the hearing aid until anesthesia is administered الإجابة الصحيحة
    B Tape the hearing aid to the patient's ear
    C Give the hearing aid to the spouse immediately
    D Tell the surgery nurse that the hearing aid was removed
  44. 44

    A charge nurse is preparing to admit a child with rubeola. Which factor should be of greatest concern?

    A Children on the unit are receiving chemotherapy
    B Parents of other children do not want the admission
    C The infection-control liaison is absent
    D No negative-airflow rooms are available الإجابة الصحيحة
  45. 45

    A 4 week old girl with projectile vomiting for 2 days is seen. She is jaundiced, and the physician is able to palpate an olive-shaped mass in the RUQ on physical examination. What is the most likely diagnosis?

    A Intussusception
    B Pyloric stenosis الإجابة الصحيحة
    C Reflux
    D Ulcer
  46. 46

    The parents of a 4-week-old infant phone the pediatric clinic to report that their infant eats well but vomits after each feeding. To differentiate between normal regurgitating and pyloric stenosis, which is most important for the nurse to obtain?

    A Degree of forcefulness of vomiting episodes. الإجابة الصحيحة
    B Level of infant's distress after vomiting.
    C Odor and texture associated with emesis.
    D Position of the infant when vomiting occurs.
  47. 47

    Which finding is the primary distinction between bulimia nervosa and anorexia nervosa?

    A Condition of the dentition
    B Body mass index الإجابة الصحيحة
    C Bingeing and purging behavior
    D Distorted perception of weight
  48. 48

    A patient becomes unresponsive and the nurse takes control and directs the resuscitation team. Which leadership style is the nurse using?

    A Autocratic الإجابة الصحيحة
    B Democratic
    C Laissez-faire
    D Bureaucratic
  49. 49

    A client reports abrupt, sharp, right-sided lower quadrant abdominal pain, bright red vaginal bleeding, and a missed menstrual cycle while using an intrauterine device. Which condition should the nurse suspect?

    A Missed abortion
    B Ectopic pregnancy الإجابة الصحيحة
    C Severe preeclampsia
    D Hydatidiform mole
  50. 50

    A 4-month-old infant has undergone repair of an isolated cleft lip. In which position should the nurse place the infant immediately after surgery?

    A Right side-lying
    B Left side-lying
    C Supine الإجابة الصحيحة
    D Prone
  51. 51

    Which instruction would the nurse provide to a patient diagnosed with gastroesophageal reflux disease (GERD)?

    A Sleep only on your back.
    B Avoid eating 1 hour before going to sleep.
    C Elevate the head of your bed 6 to 12 inches. الإجابة الصحيحة
    D Avoid using continuous positive airway pressure (CPAP).
  52. 52

    Which description of a stool is characteristic of intussusception?

    A Ribbon-like stools
    B Hard stools positive for guaiac
    C Currant jelly stools الإجابة الصحيحة
    D Loose, foul-smelling stools
  53. 53

    A neonate has not passed meconium within 48 hours and has abdominal distention and bilious vomiting. Which diagnostic test confirms Hirschsprung disease?

    A Barium enema
    B Anorectal manometry
    C Rectal suction biopsy الإجابة الصحيحة
    D Abdominal ultrasound
  54. 54

    A nursing assistant uses a forceful conflict style. Which action by the charge nurse is best?

    A Confront the assistant in front of the registered nurses
    B Ask another nurse to handle the problem
    C Speak with the assistant privately and discuss other approaches الإجابة الصحيحة
    D Penalize the assistant immediately
  55. 55

    A newborn infant should have the first bath:

    A Immediately
    B Just prior to discharge
    C After the vitamin K injection
    D After temperature stabilization الإجابة الصحيحة
  56. 56

    A nurse is caring for a client who is breathing spontaneously. Which oxygen delivery device provides the highest concentration of oxygen?

    A Partial rebreather mask
    B Nonrebreather mask الإجابة الصحيحة
    C Simple mask
    D Venturi mask
  57. 57

    Which action prevents radiant heat loss in a newborn?

    A Dry the skin with a towel
    B Place the infant on a padded covered surface
    C Provide warmed humidified oxygen
    D Keep the bassinet away from windows الإجابة الصحيحة
  58. 58

    Which action is most effective in preventing evaporative heat loss in a newborn?

    A Warm the crib pad
    B Close the room doors
    C Dry the newborn with a warm blanket الإجابة الصحيحة
    D Place the newborn under an overhead warmer
  59. 59

    A nurse is reinforcing discharge teaching regarding self-administration of regular insulin. Which instruction should the nurse include?

    A Plan to eat a snack 6 hours after insulin administration
    B Store opened insulin vials at room temperature for up to 4 weeks الإجابة الصحيحة
    C Warm the insulin vial to dissolve any crystals
    D Keep unopened insulin vials in the freezer
  60. 60

    Which recommendation about an insulin injection site is most appropriate?

    A Use the abdomen for rapid, consistent absorption and avoid the area within 2 inches of the umbilicus الإجابة الصحيحة
    B Use the thigh because it provides the fastest absorption
    C Use the arm because it always provides the most consistent absorption
    D Use the buttocks because they provide rapid absorption
  61. 61

    What is a common side effect of captopril?

    A Hypokalemia
    B Lower extremity edema
    C Hypertension
    D Dry cough الإجابة الصحيحة
  62. 62

    A 10-month-old infant has been confirmed with HIV. Which statement is correct?

    A The infant should be immediately placed on antiretroviral therapy الإجابة الصحيحة
    B The infant should begin antiretroviral therapy after turning 12 months old
    C Antiretroviral therapy should begin only after a manifestation of AIDS
    D The mother must be mandatorily tested
  63. 63

    Which pain-relief measure is appropriate for a laboring client whose cervix is dilated less than 4 cm?

    A Administer naloxone intramuscularly
    B Administer meperidine intramuscularly الإجابة الصحيحة
    C Administer promethazine intramuscularly
    D Administer fentanyl by epidural
  64. 64

    Which antidote should be readily available before administering warfarin?

    A Potassium
    B Protamine sulfate
    C Vitamin K الإجابة الصحيحة
    D Naloxone
  65. 65

    Which instruction should the nurse give a client with COPD who has increased work of breathing?

    A Lie prone
    B Avoid side-lying
    C Sit with the arms supported on an overbed table الإجابة الصحيحة
    D Lie down with the hands on the abdomen
  66. 66

    Which position is appropriate for a child after tonsillectomy?

    A Supine
    B Trendelenburg
    C Side-lying الإجابة الصحيحة
    D High Fowler's
  67. 67

    Which position will increase comfort for a client with appendicitis?

    A Prone
    B Supine with the right knee flexed الإجابة الصحيحة
    C Upright in a chair
    D Left side-lying
  68. 68

    Which laboratory pattern should the nurse expect in a client with severe hyperthyroidism?

    A High TSH, high T3, and high T4
    B Low TSH, high T3, and high T4 الإجابة الصحيحة
    C Low TSH, high T3, and low T4
    D Low TSH, low T3, and low T4
  69. 69

    In which position should the nurse place a client with suspected hypovolemic shock?

    A Prone
    B High Fowler's
    C Left lateral
    D Supine with the legs elevated الإجابة الصحيحة
  70. 70

    A client's chest tube becomes dislodged. Which action is the priority?

    A Activate the emergency response system
    B Apply oxygen and transport the client
    C Assess breathing and oxygen saturation
    D Cover the insertion site with a clean gloved hand الإجابة الصحيحة
  71. 71

    An occupational health nurse holds a flu vaccine clinic. This is an example of which level of prevention?

    A Primary الإجابة الصحيحة
    B Policy development
    C Tertiary
    D Secondary
  72. 72

    A community offers annual tuberculosis screening and free treatment for people with positive results. Which level of prevention does this program represent?

    A Primary prevention
    B Tertiary prevention
    C Secondary prevention
    D Secondary and tertiary prevention الإجابة الصحيحة
  73. 73

    Which type of isolation is required for a client with suspected bacterial meningitis?

    A Contact precautions
    B Droplet precautions الإجابة الصحيحة
    C Airborne precautions
    D Protective isolation
  74. 74

    An infant of a diabetic mother is jittery 1 hour after birth. Which action should the nurse take first?

    A Administer oxygen
    B Assess the blood glucose level الإجابة الصحيحة
    C Place the infant under a radiant warmer
    D Continue routine monitoring
  75. 75

    Which statement best explains phantom limb pain after a below-knee amputation?

    A It has no physiological basis and is only in the client's mind
    B It originates in superficial subcutaneous tissue
    C It is pain experienced as if it arises from the amputated limb الإجابة الصحيحة
    D It arises only from deep internal receptors
  76. 76

    The nurse is teaching a breastfeeding mother about mastitis. Which statement by the client indicates a need for more teaching?

    A I will take antibiotics for 2 to 3 days until the soreness subsides الإجابة الصحيحة
    B I can continue breastfeeding while the mastitis resolves
    C I will take analgesics to relieve some of the discomfort
    D I need to wear a supportive bra
  77. 77

    Which food should a client taking a monoamine oxidase inhibitor avoid?

    A Salami الإجابة الصحيحة
    B Scallops
    C Pineapple
    D Mashed potatoes
  78. 78

    A nurse provides rehabilitation and medication education to a client recovering from a stroke. Which level of prevention is this?

    A Primary
    B Secondary
    C Tertiary الإجابة الصحيحة
    D Quaternary
  79. 79

    What is the proper order of removal of soiled personal protective equipment when the nurse leaves the patient's room?

    A Gown, goggles, mask, gloves, and exit the room
    B Gloves, wash hands, remove gown, mask, and wash hands
    C Gloves, goggles, gown, mask, and wash hands الإجابة الصحيحة
    D Goggles, mask, gloves, gown, and wash hands
  80. 80

    The correct progression of steps of the nursing process is:

    A assessment, diagnosis, planning, implementation, and evaluation. الإجابة الصحيحة
    B planning, assessment, diagnosis, evaluation, and implementation.
    C diagnosis, implementation, assessment, evaluation, and planning.
    D implementation, planning, evaluation, assessment, and diagnosis.
  81. 81

    A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. The patient's respiratory rate has decreased to 12 breaths per minute. The nurse would expect the patient to have which of the following arterial blood gas values?

    A pH 7.78, PaCO2 40 mm Hg, HCO3- 30 mEq/L
    B pH 7.52, PaCO2 48 mm Hg, HCO3- 28 mEq/L الإجابة الصحيحة
    C pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L
    D pH 7.25, PaCO2 47 mm Hg, HCO3- 29 mEq/L
  82. 82

    The clinical nurse leader needs to identify the staff who must go home due to low census. Which answer below describes a democratic style of decision making?

    A The clinical nurse leader identifies the staff person with the most vacation and asks them to go home.
    B The clinical nurse leader tells the last person to show up for their shift to go home.
    C The clinical nurse leader decides not to send anyone home because it is too difficult to decide who should lose hours.
    D The clinical nurse leader asks the group if any of them would like the opportunity to go home and selects staff who volunteer. الإجابة الصحيحة
  83. 83

    A client gives birth within an hour of arriving at the labor and delivery unit and delivers the placenta 5 minutes later. During assessment, the nurse notes that the uterus is midline and boggy. Which action should the nurse take first?

    A Check for pooled blood under buttocks
    B Increase IV oxytocin infusion rate
    C Monitor blood pressure and pulse
    D Perform firm fundal massage الإجابة الصحيحة
  84. 84

    A patient refuses a prescribed treatment. What is the nurse's best action?

    A Tell the patient they must receive the treatment.
    B Ask the family to force the patient to agree.
    C Respect the patient's decision and provide education about risks and benefits. الإجابة الصحيحة
    D Ignore the patient's concerns.
  85. 85

    A couple is considered infertile after how many months of trying to conceive?

    A 6 MONTHS
    B 12 MONTHS الإجابة الصحيحة
    C 18 MONTHS
    D 23 MONTHS
  86. 86

    A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?

    A Over-riding suture lines
    B Dilated scalp veins الإجابة الصحيحة
    C Hypertension
    D A backward sloping appearance of the forehead.
  87. 87

    The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency?

    A A Caucasian female who is 39 weeks gestation.
    B An African-American female who is breastfeeding. الإجابة الصحيحة
    C An Asian female diagnosed with hypoglycemia.
    D A Hispanic female who has a BMI of 24.1.
  88. 88

    A malnourished child is receiving several nutritional supplements. Which statement by the child indicates to the nurse that an adequate amount of Vitamin A is being provided?

    A The bruises on my arms are all gone.
    B My feet don't tingle like they used to.
    C I can see at night when I wake up now. الإجابة الصحيحة
    D My tummy seems so much smaller now.
  89. 89

    The nurse is teaching a patient about how to take a sublingual nitroglycerin tablet. Which statement by the patient best demonstrates understanding of the teaching?

    A I will take the tablet with plenty of water.
    B I will place the tablet inside my cheek.
    C I will put the tablet under my tongue. الإجابة الصحيحة
    D I will take the tablet while I am eating.
  90. 90

    A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication?

    A Every 3 hours
    B Every 4 hours
    C Daily
    D As needed الإجابة الصحيحة
  91. 91

    The nurse in the nursery is caring for a 24-hour-old infant. The nurse suspects the infant of having pyloric stenosis. Which of the following manifestations would support this finding?

    A Melena
    B Currant jelly stools
    C Projectile vomiting الإجابة الصحيحة
    D Steatorrhea
  92. 92

    Which newborn rash is BEST described as a benign, self-limited condition associated with retention of keratin in pilosebaceous follicles?

    A Milia الإجابة الصحيحة
    B Erythema toxicum neonatorum
    C Neonatal pustular melanosis
    D Cutis marmorata
  93. 93

    The communication tool SBAR is an acronym for which words?

    A Symptoms-Background-Alignment-Referral
    B Site-Benefits-Agreement-Resolution
    C Situation-Background-Assessment-Recommendation الإجابة الصحيحة
    D Situation-Background-Assignment-Reconciliation
  94. 94

    Lithium (Eskalith) is the drug of choice for which of the following disorders?

    A Psychotic episodes
    B Obsessive compulsive disorders (OCDs)
    C Bipolar disorders الإجابة الصحيحة
    D Depressive disorders
  95. 95

    A woman at 12 weeks gestation comes to the ER with vaginal bleeding and a closed cervix. Which type of abortion should the nurse suspect?

    A Incomplete
    B Inevitable
    C Threatened الإجابة الصحيحة
    D Missed
  96. 96

    An ultrasound on a woman who is 32 weeks pregnant reveals the placenta implanted over the entire cervical os. What does the nurse understand best describes this condition?

    A Low-lying placenta
    B Marginal placenta previa
    C Partial placenta previa
    D Total placenta previa الإجابة الصحيحة
  97. 97

    When should a premenopausal woman perform breast self-examination?

    A At the end of her menstrual cycle.
    B On the same day each month.
    C On the 1st day of the menstrual cycle.
    D Immediately after her menstrual period. الإجابة الصحيحة
  98. 98

    The nurse is performing an Apgar assessment on a newborn client at 1 minute of life. The newborn is completely blue, has a heart rate of 110/min, and is emitting a weak cry. Active movement and flexion of extremities are noted and the newborn grimaces when nares are suctioned. Which Apgar score should the nurse assign this newborn?

    A Apgar score of 4
    B Apgar score of 5
    C Apgar score of 6 الإجابة الصحيحة
    D Apgar score of 8
  99. 99

    A nurse performing an assessment of a newborn in the neonatal unit records these findings: heart rate 85 bpm, irregular respiratory rate, normal muscle tone, weak crying, and bluish tint to skin. Using the APGAR scoring chart what would be the score for this newborn?

    A 5 الإجابة الصحيحة
    B 7
    C 8
    D 10
  100. 100

    Which statement accurately represents a characteristic of the third or fourth heart sound?

    A S3 is considered normal in children and young adults and abnormal in middle-age and older adults. الإجابة الصحيحة
    B S3 is best heard with the stethoscope bell at the mitral area, with the client lying on the right side.
    C S4 is the fourth heart sound, represented by lub-dub-dee.
    D S4 is considered normal in children and adults, but abnormal in older adults.
  101. 101

    The nurse is caring for a child with intussusception. Which assessment finding is most characteristic of this condition?

    A Constant, high-pitched crying
    B Abdominal distension with decreased bowel sounds
    C Palpable sausage-shaped mass in the abdomen الإجابة الصحيحة
    D Frequent vomiting of formula
  102. 102

    A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is due to:

    A Reduced cardiac output الإجابة الصحيحة
    B Increased stroke volume
    C Reduced blood volume
    D Blood flow blocked in the pulmonary circulation
  103. 103

    The nurse admits an infant with vomiting and the diagnosis of hypertrophic pyloric stenosis. Which metabolic alteration should the nurse plan to assess for with this infant?

    A Metabolic alkalosis الإجابة الصحيحة
    B Metabolic acidosis
    C Respiratory acidosis
    D Respiratory alkalosis
  104. 104

    A nurse is caring for a client after a supratentorial craniotomy. The nurse places a sign above the client's bed stating that the client should be maintained in which of the following positions?

    A Prone
    B Supine
    C Semi-Fowlers الإجابة الصحيحة
    D Dorsal recumbent
  105. 105

    The nurse positions a neonate with an unrepaired myelomeningocele. Which position is most appropriate?

    A Supine with the hips at 90-degree flexion.
    B Right side lying position with the knees flexed.
    C Prone with the hips in abduction. الإجابة الصحيحة
    D Supine in semi-Fowler's position with the chest and abdomen elevated.
  106. 106

    The nurse determines that it is necessary to implement airborne precautions for children with which infection?

    A Measles الإجابة الصحيحة
    B Streptococcus group A
    C Rubella
    D Scarlet fever
  107. 107

    What is the client's pulse pressure when the nurse finds that his or her blood pressure is 148/86 mm Hg?

    A 48 mm Hg
    B 56 mm Hg
    C 62 mm Hg الإجابة الصحيحة
    D 86 mm Hg
  108. 108

    On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?

    A The client taking diuretics and has tenting of the skin
    B The client with an ileostomy from a recent abdominal surgery
    C The client who requires intermittent gastrointestinal suctioning
    D The client with kidney disease and a 12-year history of diabetes mellitus الإجابة الصحيحة
  109. 109

    Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which of the following conditions is suspected?

    A Placenta previa الإجابة الصحيحة
    B Abruptio placentae
    C Premature labor
    D Sexually transmitted disease
  110. 110

    The nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy?

    A Decreased absorption of digoxin
    B Increased risk for digoxin toxicity الإجابة الصحيحة
    C Decreased therapeutic effect of digoxin
    D Increased risk for side effects related to digoxin
  111. 111

    The nurse is preparing to perform a focused assessment of the patient's abdomen. Which of the following choices is the correct order in which the focused assessment is performed?

    A Palpation, Auscultation, Inspection, Percussion
    B Inspection, Palpation, Percussion, Auscultation
    C Percussion, Palpation, Inspection, Auscultation
    D Inspection, Auscultation, Percussion, Palpation الإجابة الصحيحة
  112. 112

    A mother who is breastfeeding puts ice packs on her breast 15 minutes before feeding in order to "relieve the pain." The nurse should teach the mother that:

    A this is an appropriate action.
    B cold packs should not be used on the breasts of breastfeeding mothers.
    C cold packs can be used after feeding to reduce pain. الإجابة الصحيحة
    D hot packs can be used before feeding to reduce pain.
  113. 113

    A nurse admits a patient who has chronic pain and has been taking morphine sulfate for 4 months. The nurse should anticipate which of the following long-term effects in the patient?

    A Tolerance الإجابة الصحيحة
    B Psychosomatic symptoms
    C Withdrawal
    D Respiratory depression
  114. 114

    In assessing a patient with a vitamin A deficiency, the nurse should determine if the patient has which manifestation?

    A Excessive sweating
    B Impaired night vision الإجابة الصحيحة
    C Tender, bleeding gums
    D Disturbed sleep patterns
  115. 115

    The nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse notes that the client's respiratory rate is 10 breaths per minute. The client is somnolent, with minimal response to physical stimulation. Which medication will the nurse administer immediately?

    A intravenous naloxone الإجابة الصحيحة
    B intravenous flumazenil
    C oral modafinil
    D nebulized albuterol
  116. 116

    The nurse is caring for a 6-year-old child with hypovolemic shock. The child is a Jehovah's Witness. The child needs an immediate blood transfusion, but the child's parents refuse to provide consent. Which action would be most appropriate?

    A Administer blood to the child. الإجابة الصحيحة
    B Administer intravenous fluids.
    C Provide oral hydration and nutrition.
    D Seek a court order for blood transfusion.
  117. 117

    A nurse is calculating maintenance fluids for a child who weighs 18 kg. According to the Holliday-Segar method, what would be the total maintenance fluid requirement for this child?

    A Total maintenance fluids = 1800 mL/day.
    B Total maintenance fluids = 1200 mL/day.
    C Total maintenance fluids = 1600 mL/day.
    D Total maintenance fluids = 1400 mL/day. الإجابة الصحيحة
  118. 118

    A 58-year-old male patient with a history of chronic anemia is scheduled to receive a red blood cell transfusion. The patient has been properly identified using two identifiers and the blood product has been verified by two nurses. During the transfusion, the patient begins to exhibit signs of distress including facial flushing, itching, and shortness of breath. What is the FIRST action the nurse should take?

    A Administer an antihistamine to the patient
    B Slow the rate of the transfusion
    C Stop the transfusion immediately الإجابة الصحيحة
    D Notify the healthcare provider
  119. 119

    Which root cause analysis tool is also known as the Ishikawa or fishbone diagram?

    A Five whys technique
    B Cause-and-effect diagram الإجابة الصحيحة
    C Pareto analysis
    D Brainstorming
  120. 120

    Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment?

    A I will limit my intake of fluids daily.
    B I will maintain normal salt intake. الإجابة الصحيحة
    C I will take Lithobid on an empty stomach.
    D I will increase my caloric intake to prevent weight loss.
  121. 121

    Which pain scale would the nurse use when assessing a 4-year-old child?

    A CRIES
    B FLACC
    C Numerical
    D Wong-Baker الإجابة الصحيحة
  122. 122

    One week after beginning therapy with thiothixene (Navane), the client demonstrates muscle rigidity, a temperature of 103°F, an elevated serum creatinine phosphokinase level, stupor, and incontinence. The nurse should notify the physician because these symptoms are indicative of:

    A acute dystonic reaction.
    B extrapyramidal side effects.
    C neuroleptic malignant syndrome. الإجابة الصحيحة
    D tardive dyskinesia.
  123. 123

    The nurse is admitting a child with rheumatic fever. Which therapeutic management should the nurse expect to implement?

    A Administering penicillin الإجابة الصحيحة
    B Avoiding salicylates (aspirin)
    C Imposing strict bed rest for 4 to 6 weeks
    D Administering corticosteroids if chorea develops
  124. 124

    Which of the following best describes marasmus?

    A A protein deficiency with edema and fatty liver
    B A type of overnutrition with excess fat stores
    C Protein-calorie malnutrition with severe fat and muscle wasting الإجابة الصحيحة
    D A vitamin A deficiency disorder
  125. 125

    The nurse is assessing a client immediately following a thoracentesis. The nurse understands that the most common complication following this procedure is a:

    A Pleural effusion
    B Pneumonia
    C Pulmonary embolism
    D Pneumothorax الإجابة الصحيحة
  126. 126

    A client presents to the emergency department in sickle cell disease crisis. What intervention by the nurse takes priority?

    A Administer oxygen. الإجابة الصحيحة
    B Initiate pulse oximetry.
    C Give pain medication.
    D Start an IV line.
  127. 127

    What should the nurse look for when reviewing a patient's chart to determine whether she has progressed from HIV disease to AIDS?

    A CD4+ count below 500, chronic fatigue, night sweats
    B HIV-positive test result, CD4+ count below 200, history of opportunistic disease الإجابة الصحيحة
    C Weight loss, persistent generalized lymphadenopathy, chronic diarrhea
    D Fever, chills, CD4+ count below 200
  128. 128

    An infant with bronchiolitis is hospitalized. The causative organism is RSV. The nurse knows that a child infected with this virus requires the following isolation:

    A Airborne precautions
    B Contact Precautions and droplet precautions
    C Standard Precautions and droplet precautions الإجابة الصحيحة
    D Positive pressure isolation and airborne isolation
  129. 129

    A woman in week 34 of gestation reports that she is very uncomfortable because of heartburn. The nurse suggests that the woman:

    A Substitute other calcium sources for milk in her diet
    B Lie down after each meal
    C Reduce the amount of fiber she consumes
    D Eat five small meals daily الإجابة الصحيحة
  130. 130

    A client undergoes a right below-the-knee amputation. After surgery, the client reports right foot pain. The healthcare provider tells the client they are suffering from "phantom pain" in the amputated extremity. The client asks the nurse to explain phantom pain. What is the appropriate response by the nurse?

    A Phantom pain occurs because nerves continue to send messages. الإجابة الصحيحة
    B Phantom pain only exists in your mind.
    C I can't answer that. You'll have to ask the provider.
    D Phantom pain occurs when you think about your loss. Keep your mind occupied.
  131. 131

    The 2 thumb-encircling hands technique for the infant:

    A generates less blood pressure than the 2-finger technique.
    B is the preferred chest compression technique for 1-rescuer CPR.
    C is the preferred chest compression technique for 2-rescuer CPR. الإجابة الصحيحة
    D produces less blood flow than the 2-finger technique.
  132. 132

    What is the correct order of the 5 stages of grief according to Kubler Ross?

    A Shock & Denial, bargaining, anger, depression, acceptance
    B Acceptance, anger, shock & denial, bargaining, depression
    C Anger, depression, acceptance, bargaining, shock & denial
    D Shock & Denial, anger, bargaining, depression, acceptance الإجابة الصحيحة
  133. 133

    Which EKG findings can occur in hypermagnesemia?

    A Shortened PR interval and ST elevation
    B Prolonged PR and QT intervals, wide QRS الإجابة الصحيحة
    C Pathologic Q waves and sinus tachycardia
    D Prominent U waves and QT shortening
  134. 134

    A client asks the nurse at the family planning clinic whether contraception is needed while she is breastfeeding. How should the nurse reply?

    A As long as you aren't having periods, you won't need a contraceptive.
    B It would be best to delay sexual relations until you have your first period.
    C You should use contraceptives, because ovulation may occur without a period. الإجابة الصحيحة
    D Breastfeeding suppresses ovulation, so you don't need to worry about pregnancy.
  135. 135

    A newly admitted client diagnosed with bipolar I disorder is experiencing a manic episode. Which nursing diagnosis is a priority at this time?

    A Risk for violence: other-directed R/T poor impulse control. الإجابة الصحيحة
    B Altered thought process R/T hallucinations.
    C Social isolation R/T manic excitement.
    D Low self-esteem R/T guilt about promiscuity.
  136. 136

    The nurse is preparing to discharge a client who has been treated for fecal impaction due to chronic constipation. Which of the following foods can the nurse recommend that will act as a laxative?

    A All whole wheat products
    B Substituting beans for meat
    C All dried fruit for snacks
    D Unprocessed wheat bran الإجابة الصحيحة
  137. 137

    A nurse is identifying tertiary prevention. Which example is correct?

    A Vaccinations
    B Blood pressure screening
    C Rehabilitation after stroke الإجابة الصحيحة
    D Health education
  138. 138

    A nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?

    A The client fell out of bed
    B The client climbed over the side rails
    C The client was found lying on the floor الإجابة الصحيحة
    D The client became restless and tried to get out of bed
  139. 139

    A breastfeeding patient asks, "What hormone actually makes the milk?" Which response is most accurate?

    A Oxytocin
    B Prolactin الإجابة الصحيحة
    C Estrogen
    D Cortisol
  140. 140

    An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?

    A Prone position
    B On the stomach
    C Left lateral position الإجابة الصحيحة
    D Right lateral position
  141. 141

    A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?

    A Side or prone
    B Back or prone
    C Stomach with the face turned
    D Back rather than on the stomach الإجابة الصحيحة
  142. 142

    Which finding indicates a Stage 2 pressure injury?

    A Intact skin with redness
    B Partial-thickness skin loss الإجابة الصحيحة
    C Exposed muscle
    D Black eschar
  143. 143

    While auscultating heart sounds on a 7-year-old child for a routine physical, the nurse hears an S3, a soft murmur at left midsternal border, and a venous hum when the child is standing. Which of these would be a correct interpretation of these findings?

    A S3 is indicative of heart disease in children.
    B These findings can all be normal in a child. الإجابة الصحيحة
    C These findings are indicative of congenital problems.
    D The venous hum most likely indicates an aneurysm.
  144. 144

    Which of the following definitions BEST describes a systematic literature review?

    A Secondary analysis of individual studies with similar characteristics الإجابة الصحيحة
    B Secondary analysis of individual studies with divergent characteristics
    C Aggregation of raw data from multiple studies to increase the sample size
    D Aggregation of raw data from multiple studies to generate new hypotheses
  145. 145

    A nurse is caring for a patient with an indwelling catheter. Which nursing action may increase the risk for a catheter-associated urinary tract infection?

    A Collecting specimens via a port in the tubing
    B Keeping the drainage bag above the level of the bladder الإجابة الصحيحة
    C Allowing the patient to wear a leg bag while ambulating
    D Monitoring the drainage system to prevent backflow of urine
  146. 146

    The nurse is preparing for a vaginal delivery by a multipara who has a history of shoulder dystocia. The nurse explains to the student nurse that one of the maneuvers used for shoulder dystocia involves having the patient flex her hips while pulling her thighs straight up to her abdomen to help rotate the symphysis pubis anteriorly and dislodge the fetus's anterior shoulder. What is the name of this maneuver?

    A Suprapubic pressure
    B Rubin's maneuver
    C Zavanelli maneuver
    D McRoberts maneuver الإجابة الصحيحة
  147. 147

    A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?

    A Inspect the clamp to insure that it is tightly closed and applied correctly. الإجابة الصحيحة
    B Clean the cord with soap and water, as oozing of blood is a common finding.
    C Remove the clamp and replace with another one just above the old one.
    D Notify the doctor to come suture the site of the bleeding.
  148. 148

    A mother expresses concern about breastfeeding her newborn, who is receiving phototherapy for jaundice. The nurse should teach the mother that:

    A Breastfeeding is discontinued during phototherapy, but she should pump her breasts.
    B Breastfeeding can continue after the newborn has been under the light for 12 hours.
    C Breastfeeding should continue and the newborn can be removed from the light to be fed. الإجابة الصحيحة
    D Breastfeeding can continue after the bilirubin level decreases.
  149. 149

    A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?

    A This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor. الإجابة الصحيحة
    B This is a cephalhematoma, which will resolve on its own in 3 to 5 days.
    C This is a Mongolian spot, which is found on many newborns.
    D This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin.
  150. 150

    The nurse is providing discharge teaching to parents about cord care. Which statement by the parent indicates correct understanding?

    A We will apply alcohol to the cord daily until it falls off.
    B We should keep the cord dry and open to air. الإجابة الصحيحة
    C We should pull on the cord gently once it's dry.
    D We should cover the cord stump with the diaper to protect it.
  151. 151

    A nurse is teaching a female patient how to prevent urinary tract infections (UTIs). Which instruction is most important?

    A Drink less fluid to reduce the frequency of urination.
    B Wipe from back to front after using the toilet.
    C Wipe from front to back after using the toilet. الإجابة الصحيحة
    D Take a bath rather than a shower every day.
  152. 152

    Which position would be best for the client in the early postoperative period after a hemorrhoidectomy?

    A High Fowler's.
    B Supine.
    C Side-lying. الإجابة الصحيحة
    D Trendelenburg's.
  153. 153

    A client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first?

    A Obtain cultures of the lesions.
    B Place the client on Airborne Precautions. الإجابة الصحيحة
    C Prepare to administer antibiotics.
    D Provide comfort measures for the rash.
  154. 154

    The gold standard for definitive diagnosis of sickle cell anemia is:

    A Reticulocyte count
    B Sickle cell test
    C Hemoglobin electrophoresis الإجابة الصحيحة
    D Peripheral smear
  155. 155

    A patient with anemia receives a new prescription for oral iron supplements. What should the nurse include in the medication education related to improving the absorption of the supplement?

    A Take the supplement with meals.
    B Take the supplement one hour after eating.
    C Take the supplement one hour before breakfast with orange juice. الإجابة الصحيحة
    D Take the supplement on an empty stomach with a full glass of water.
  156. 156

    The nurse cares for a client with bacterial meningitis. Which isolation precaution will the nurse apply?

    A Standard precautions
    B Contact precautions
    C Droplet precautions الإجابة الصحيحة
    D Airborne precautions
  157. 157

    A client in the prenatal clinic complains of nausea and vomiting. Which intervention should the nurse suggest?

    A Eat dry crackers or toast before arising. الإجابة الصحيحة
    B Consume liquids with meals.
    C Eat foods high in fiber.
    D Brush the teeth immediately after eating.
  158. 158

    To prevent pressure injuries in a patient who spends most of the day in bed, which intervention should the nurse include?

    A Allow the patient to determine the repositioning schedule.
    B Reposition the patient every hour. الإجابة الصحيحة
    C Do not reposition the patient when a thick foam mattress is used.
    D Use a doughnut-shaped ring under pressure areas.
  159. 159

    In girls, what is the initial indication of puberty?

    A Menarche
    B Growth spurt
    C Growth of pubic hair
    D Breast development الإجابة الصحيحة
  160. 160

    A client under lithium medication suffered from diarrhea and vomiting. Which nursing intervention should be implemented first?

    A Recognize a drug interaction.
    B Give benztropine.
    C Reassure the client that these are common effects.
    D Hold the next dose and obtain a stat lithium level. الإجابة الصحيحة
  161. 161

    Which statement by the parent indicates understanding of a newborn's feeding capacity during the first few days of life?

    A My newborn can take up to 60 mL on the first day.
    B On day 3, my baby's stomach can hold about 22-27 mL. الإجابة الصحيحة
    C By day 1, I should expect my baby to finish a 4-ounce bottle.
    D If my baby vomits, I should double the next feeding to make up for it.
  162. 162

    Which food should a client with gout avoid?

    A Low-fat milk
    B Whole-grain bread
    C Fresh fruit
    D Chicken liver الإجابة الصحيحة
  163. 163

    A nurse is providing discharge instructions to a client after TURP surgery. The client asks, "When can I resume normal activities like heavy lifting and strenuous exercises?" What is the nurse's best response?

    A You can resume heavy lifting and strenuous exercises immediately after discharge.
    B You should avoid heavy lifting and strenuous exercises for at least one week after surgery.
    C You can resume heavy lifting and strenuous exercises two days after surgery.
    D You should avoid heavy lifting and strenuous exercises for six to eight weeks after surgery. الإجابة الصحيحة
  164. 164

    A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client?

    A Keep visitors 3 feet from the client.
    B Wear gloves whenever entering the client's room. الإجابة الصحيحة
    C Place the client in a private negative-pressure room.
    D Use respiratory protection when entering the room.
  165. 165

    Which student statement indicates that learning has occurred regarding electroconvulsive therapy (ECT)?

    A During ECT, a state of euphoria is induced.
    B ECT induces a grand mal seizure. الإجابة الصحيحة
    C During ECT, a state of catatonia is induced.
    D ECT induces a petit mal seizure.
  166. 166

    A post-MI patient develops ventricular fibrillation (VF). The nurse should first:

    A Check for carotid pulse
    B Start CPR immediately الإجابة الصحيحة
    C Administer lidocaine
    D Prepare for synchronized cardioversion
  167. 167

    The nurse is giving instructions to parents of a 4-month-old infant with tetralogy of Fallot. Which teaching point should the nurse include?

    A If the infant becomes blue and is breathing deeply, put the infant in the knee-chest position. الإجابة الصحيحة
    B If the infant becomes blue and is breathing deeply, put the infant in the Trendelenburg position.
    C Feed the infant every 2 hours around the clock.
    D Add rice cereal to the infant's formula to increase calories.
  168. 168

    The nurse is preparing to insert a nasogastric tube. Which measurement determines the correct insertion length?

    A Nose to xiphoid plus 20 cm
    B Chin to ear to xiphoid
    C Nose to ear to xiphoid الإجابة الصحيحة
    D Earlobe to nose to umbilicus
  169. 169

    What is the AMDR for carbohydrates for adults, as a percentage of total daily calories?

    A 10-35%
    B 20-35%
    C 45-65% الإجابة الصحيحة
    D 50-70%
  170. 170

    A child with acute glomerulonephritis has peripheral edema and urine output of 35 mL/hr. Which diet should the nurse expect?

    A Low sodium with fluid restriction الإجابة الصحيحة
    B Regular diet with no added salt
    C Low carbohydrate and low protein
    D Low protein and low potassium
  171. 171

    A client with type 1 diabetes has rapid deep respirations and fruity-smelling breath. Which condition should the nurse suspect?

    A Hypoglycemia
    B Diabetic ketoacidosis الإجابة الصحيحة
    C Hyperosmolar hyperglycemic state
    D Hyperglycemia without ketosis
  172. 172

    At 39 weeks of gestation, which finding indicates true labor?

    A Contractions fluctuate in length.
    B Contractions are continuous with no relaxation.
    C Contractions are related to rupture of membranes.
    D Progressive cervical dilation occurs. الإجابة الصحيحة
  173. 173

    Which finding should the nurse expect in a client with placenta previa?

    A Severe occipital headache
    B History of thyroid cancer
    C Previous premature delivery
    D Painless vaginal bleeding الإجابة الصحيحة
  174. 174

    An infant has swelling and redness at the DTaP injection site. Which intervention should the nurse recommend?

    A Monitor the infant for fever.
    B Bring the infant to the clinic immediately.
    C Apply a hot pack to the site.
    D Apply a cold pack to the site. الإجابة الصحيحة
  175. 175

    A client with schizophrenia speaks using unrelated words and phrases. How should the nurse document this finding?

    A Pressure of speech
    B Word salad الإجابة الصحيحة
    C Neologism
    D Clang association
  176. 176

    When assessing a patient's telemetry monitor, the nurse notes a sawtooth pattern of flutter waves at a rate of 300/min. What rhythm is this most likely indicative of?

    A Sinus bradycardia
    B Atrial fibrillation
    C Atrial flutter الإجابة الصحيحة
    D Ventricular tachycardia
  177. 177

    A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?

    A Impaired gas exchange related to increased blood flow
    B Ineffective peripheral tissue perfusion related to venous congestion الإجابة الصحيحة
    C Risk for injury related to edema
    D Excess fluid volume related to peripheral vascular disease
  178. 178

    During the interview process, the nurse obtains which type of data from the client?

    A Secondary data
    B Oral data
    C Primary data الإجابة الصحيحة
    D Objective data
  179. 179

    The nurse reviews ABG results showing pH 7.30, PaCO2 58 mm Hg, PaO2 80 mm Hg, and HCO3 27 mEq/L. Which acid-base disturbance is present?

    A Metabolic acidosis
    B Metabolic alkalosis
    C Respiratory acidosis الإجابة الصحيحة
    D Respiratory alkalosis
  180. 180

    The nurse is providing nutrition counseling for a patient planning pregnancy. Which nutrient should be emphasized to prevent neural tube defects?

    A Folic acid الإجابة الصحيحة
    B Calcium
    C Protein
    D Vitamin D
  181. 181

    The prenatal clinic nurse assesses a woman at 15 weeks gestation. Her blood pressure is 146/96 mm Hg on two measurements one hour apart. Which condition does the nurse suspect?

    A Chronic hypertension الإجابة الصحيحة
    B Gestational hypertension
    C Preeclampsia
    D Transient hypertension
  182. 182

    An infant with esophageal atresia and tracheoesophageal fistula is awaiting surgery. Which preoperative nursing diagnosis is the priority?

    A Ineffective tissue perfusion: gastrointestinal
    B Ineffective feeding pattern
    C Acute pain
    D Risk for aspiration الإجابة الصحيحة
  183. 183

    A pregnant client after 20 weeks has painless bright-red vaginal bleeding and normal vital signs. Which condition should the nurse suspect?

    A Eclampsia
    B Preeclampsia
    C Pyelonephritis
    D Placenta previa الإجابة الصحيحة
  184. 184

    A hypertensive pregnant client receiving magnesium sulfate develops drowsiness, slurred speech, and depressed respirations. Which medication should the nurse anticipate administering?

    A Intravenous diazepam
    B Nifedipine
    C Hydralazine
    D Calcium gluconate الإجابة الصحيحة
  185. 185

    Tuberculosis is transmitted by which mode?

    A Airborne transmission الإجابة الصحيحة
    B Droplet transmission
    C Direct contact
    D Indirect contact
  186. 186

    A client in the second trimester reports low back pain and ankle edema. Which measure can relieve both symptoms?

    A Lie on the left side with the feet dorsiflexed.
    B Soak in a hot bath and perform pelvic tilts.
    C Lie on the right side with the feet elevated and apply heat.
    D Lie on the floor with the legs elevated on a couch and hips and knees at right angles. الإجابة الصحيحة
  187. 187

    A nurse is preparing to insert an oropharyngeal airway in an emergency. Which patient is the most appropriate candidate?

    A An alert patient with mild dyspnea
    B An unconscious patient with tongue obstruction الإجابة الصحيحة
    C A conscious patient who is drowsy
    D A patient who can follow commands
  188. 188

    The provider orders 1500 mL of lactated Ringer's solution to infuse over 12 hours. What rate should the nurse set on the IV pump?

    A 100 mL/hr
    B 125 mL/hr الإجابة الصحيحة
    C 150 mL/hr
    D 175 mL/hr
  189. 189

    The nurse assesses a laboring client who is dilated 6 cm and is becoming more intense and more tired. Which phase of labor represents this response?

    A Transition phase
    B Latent phase
    C Second stage
    D Active phase الإجابة الصحيحة
  190. 190

    Postoperatively, a client who had a thyroidectomy complains of tingling and numbness of the fingers and toes, and the nurse observes muscle twitching. Which complication does the nurse suspect?

    A Hypokalemia
    B Hypocalcemia الإجابة الصحيحة
    C Thyrotoxic crisis
    D Hypovolemic shock
  191. 191

    A nurse at an outpatient surgery center is caring for a patient who had a hemorrhoidectomy. What discharge education topic should the nurse address?

    A The appropriate use of antibiotics to prevent postoperative infection
    B The correct procedure for taking a sitz bath الإجابة الصحيحة
    C The need to eat a low-residue, low-fat diet for the next 2 weeks
    D The correct technique for keeping the perianal region clean without water
  192. 192

    A nurse is reinforcing teaching with a client who asks which diagnostic test is the preferred method for detecting cervical cancer. Which response is appropriate?

    A An endometrial biopsy
    B CA 125
    C Papanicolaou test الإجابة الصحيحة
    D Transvaginal ultrasound
  193. 193

    A client with a closed head injury is unconscious and has an intracranial pressure monitor. Which position is most appropriate after nursing care activities?

    A High-Fowler's position
    B Semi-Fowler's position الإجابة الصحيحة
    C Right lateral recumbent position
    D Supine position
  194. 194

    A client in labor is receiving oxytocin. The nurse observes fetal heart rate decelerations that are not associated with contractions. Which action should the nurse take?

    A Discontinue the oxytocin
    B Start oxygen by tight face mask
    C Increase the IV fluid rate
    D Change the client's position الإجابة الصحيحة
  195. 195

    A patient is receiving magnesium sulfate for severe preeclampsia. Which finding should the nurse report immediately?

    A Patellar and biceps reflexes of +4
    B Urinary output of 50 mL/hr
    C Respiratory rate of 10 breaths/min الإجابة الصحيحة
    D Serum magnesium level of 5 mg/dL
  196. 196

    The nurse is caring for a newborn with hypospadias. His parents ask if circumcision is an option. Which is the nurse's best response?

    A Circumcision can never be performed in a child with hypospadias.
    B Circumcision is an option, but it cannot be done at this time. الإجابة الصحيحة
    C Circumcision is a fading practice and is now contraindicated in most children.
    D Circumcision in children with hypospadias is recommended because it prevents urinary tract infections.
  197. 197

    Which of the following would be essential to implement to prevent late postpartum hemorrhage?

    A Inspecting the placenta after delivery for intactness. الإجابة الصحيحة
    B Manually removing the placenta at delivery.
    C Administering broad-spectrum antibiotics prophylactically.
    D Applying traction on the umbilical cord to speed up separation of the placenta.
  198. 198

    Which of the following interventions are used to treat congenital diaphragmatic hernia?

    A I and III only
    B II and IV only
    C I, II, and IV only الإجابة الصحيحة
    D II, III, and IV only
  199. 199

    The nurse should make which statement to a pregnant client found to have a gynecoid pelvis?

    A Your type of pelvis has a narrow pubic arch.
    B Your type of pelvis is the most favorable for labor and birth. الإجابة الصحيحة
    C Your type of pelvis has a wide pelvis with a short diameter.
    D You will need a cesarean birth because this type of pelvis is not favorable for a vaginal delivery.
  200. 200

    A patient is admitted with anemia, hypotension, malnutrition, and confusion. Which intervention should be used to prevent the patient from developing pressure ulcers?

    A Ensure all meals are protein-rich.
    B Administer 2 units of packed red blood cells.
    C Infuse medication to increase blood pressure.
    D Reposition every 1–2 hours. الإجابة الصحيحة
  201. 201

    The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the defect is scheduled the next day. What is the most appropriate way to position and feed this neonate?

    A Prone with the head turned to the side الإجابة الصحيحة
    B On the side
    C Supine in an infant carrier
    D Supine, with defect supported with rolled blankets
  202. 202

    A nurse is caring for a child after a tonsillectomy. In which position should the nurse place the child?

    A Supine
    B Side-lying الإجابة الصحيحة
    C High-Fowler
    D Trendelenburg
  203. 203

    Which instruction should the nurse give to a pregnant client with genital herpes?

    A Abstain from intercourse throughout pregnancy.
    B Use sitz baths daily throughout pregnancy.
    C Take acyclovir every day throughout pregnancy.
    D A cesarean birth will be needed if lesions are present at the onset of labor. الإجابة الصحيحة
  204. 204

    The process of EBP begins with a specific and answerable question typically in a PICO-format. What does PICO stand for?

    A Population of interest, Intervention, Carryover, Other problems identified
    B Population of interest, Intervention, Comparison, Outcomes الإجابة الصحيحة
    C Population of interest, Internal Validity, Carryover, Outcomes
    D Population of interest, Intervention, Comparison, Other problems identified
  205. 205

    The nurse is monitoring a 10-year-old client post-op following a tonsillectomy. Which assessment finding should the nurse immediately report to the healthcare provider?

    A Drooling
    B Frequent swallowing الإجابة الصحيحة
    C Sneezing
    D Moaning
  206. 206

    Evidence based practice questions are typically formatted as PICO questions. What does PICO stand for?

    A Patient, Intervention, Comparison, Outcome الإجابة الصحيحة
    B Patient, Investigation, Comparison, Outlier
    C Population, Intervention, Counter intervention, Outlier
    D Problem, Investigation, Counter intervention, Outcome
  207. 207

    The nurse notes a bluish discoloration of the skin across the infant's sacral area. Which should the nurse do in response to this finding?

    A Assess the infant for cold stress.
    B Refer the parent to the care of a pediatric specialist.
    C Document this finding in the record. الإجابة الصحيحة
    D Evaluate the infant's neurological status.
  208. 208

    The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to consider the need for restraint?

    A The patient refuses to call for help to go to the bathroom.
    B The patient continues to remove the nasogastric tube. الإجابة الصحيحة
    C The patient gets confused regarding the time at night.
    D The patient does not sleep and continues to ask for items.
  209. 209

    What would the nurse do to determine the correct distance to insert a nasogastric tube?

    A Measure from the center of the forehead to the umbilicus.
    B Measure from the tip of the nose to the earlobe to the xiphoid process. الإجابة الصحيحة
    C Measure from the lips to the ear to the umbilicus.
    D Measure from the ear to midway between the sternum and umbilicus.
  210. 210

    A client in end-stage renal disease is prescribed epoetin alfa and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse?

    A Assesses the hemoglobin level الإجابة الصحيحة
    B Questions the administration of both medications
    C Ensures the client has completed dialysis treatment
    D Holds the epoetin alfa if the BUN is elevated
  211. 211

    The father of a child with acute glomerulonephritis asks why the nurse measures the child's blood pressure so often. Which response by the nurse is best?

    A The antibiotic used to treat the infection can increase blood pressure.
    B Hypotension may develop at any time during the illness.
    C Sudden increases in blood pressure can occur without warning. الإجابة الصحيحة
    D Frequent blood pressure checks help keep the kidneys working.
  212. 212

    The nurse is caring for a patient who had an indwelling urinary catheter removed during the previous shift. The patient has not voided in the last 9 hours. Which action should the nurse take first?

    A Call the health-care provider to obtain an order for a straight catheterization.
    B Review the fluid intake the patient had during the previous shift.
    C Ask the patient if they have attempted to void without the catheter.
    D Perform a bladder scan to identify retained urine. الإجابة الصحيحة
  213. 213

    What is the most common cause of painless scrotal swelling?

    A Spermatocele
    B Hydrocele الإجابة الصحيحة
    C Varicocele
    D Epididymitis
  214. 214

    A patient has been diagnosed with hepatitis B. Which action should the nurse take to avoid invasion of the patient's privacy?

    A Tell the patient's spouse about the diagnosis.
    B Do not inform anyone about the diagnosis.
    C Obtain permission from the patient to inform the spouse. الإجابة الصحيحة
    D Obtain consent from the spouse to reveal the diagnosis to the patient.
  215. 215

    Democratic leadership style involves:

    A Leader making all decisions independently
    B No structure or guidance
    C Shared decision-making with team input الإجابة الصحيحة
    D Delegation without oversight
  216. 216

    Which cranial nerve is in charge of hearing?

    A Olfactory nerve I
    B Auditory nerve VIII الإجابة الصحيحة
    C Vagus nerve X
    D Abducens nerve VI
  217. 217

    An infant with tetralogy of Fallot is crying and develops worsening cyanosis and dyspnea. In which position should the nurse place the infant?

    A Knee-chest position الإجابة الصحيحة
    B Orthopneic position
    C Lateral Sims position
    D Semi-Fowler position
  218. 218

    Preparation for an appendectomy includes:

    A Starting an intravenous infusion
    B Administering a prophylactic antibiotic
    C Administering salicylates to lower temperature
    D All of the above الإجابة الصحيحة
  219. 219

    Joseph is 55 years old and has diabetes with decreased sensation in both feet. Which instruction should the nurse include?

    A Walk barefoot at home to improve circulation.
    B Soak the feet in hot water each evening.
    C Have vision checked only every two years.
    D Inspect both feet every day for cuts, blisters, or redness. الإجابة الصحيحة
  220. 220

    A 12-year-old client is scheduled for surgery and is accompanied by the parents and a sibling. Which level of involvement applies to the child's permission for treatment?

    A Emancipated consent
    B Mature minor consent
    C Assent الإجابة الصحيحة
    D No involvement
  221. 221

    A nurse organizes a flu vaccination clinic in the community. This represents:

    A Primary prevention الإجابة الصحيحة
    B Secondary prevention
    C Tertiary prevention
    D Palliative care
  222. 222

    An occupational health nurse at a group of health care clinics is planning activities to prevent and control the spread of communicable disease. Which activity is a secondary level of prevention?

    A Influenza immunizations
    B Tuberculosis screenings الإجابة الصحيحة
    C Presentations about safer sex practices
    D Evaluations of bloodborne pathogen policies
  223. 223

    Which nursing action is most culturally competent for a client whose food choices are influenced by a belief in hot and cold foods?

    A Explain that cultural food beliefs are not medically relevant.
    B Ask the family to stop bringing food from home.
    C Provide a standard cardiac diet without modification.
    D Educate staff to help the client select culturally congruent foods within the prescribed diet. الإجابة الصحيحة
  224. 224

    A client with schizophrenia refuses to eat because the client believes the food is poisoned. Which nursing intervention is most appropriate?

    A Ask the family to bring food from home.
    B Insert a tube for feeding.
    C Taste the food in front of the client.
    D Offer food in unopened packages. الإجابة الصحيحة
  225. 225

    A laboring patient with a known diagnosis of preeclampsia suddenly experiences a tonic-clonic seizure. Which hypertensive disorder is now present?

    A Eclampsia الإجابة الصحيحة
    B Preeclampsia with severe features
    C Gestational hypertension
    D Chronic hypertension
  226. 226

    A 17-year-old college-bound student receives a vaccine against an organism that causes meningitis. This is an example of:

    A Tertiary prevention.
    B Primary prevention. الإجابة الصحيحة
    C Disease treatment.
    D Secondary prevention.
  227. 227

    A nurse is discussing communicable diseases with a newly licensed nurse. Which of the following statements should the nurse include?

    A Initiate contact precautions for a child who has measles.
    B Varicella is contagious until all lesions have crusted over. الإجابة الصحيحة
    C Pertussis is most contagious during the paroxysmal stage.
    D Wear an N95 respirator mask when caring for a child who has scarlet fever.
  228. 228

    A nurse understands that it is a priority to place a child in which position post-operative tonsillectomy?

    A Sitting upright
    B Prone position
    C Prone or side-lying position الإجابة الصحيحة
    D Lying flat on their back
  229. 229

    A nurse steps into an outdoor dining area and overhears two staff members talking about a client. Which action should the nurse take?

    A Tell the staff members that she will report the situation to their supervisor immediately.
    B Ask the staff members to lower the volume of their voices.
    C Remind the staff members that discussing a client where others can overhear them is a HIPAA violation. الإجابة الصحيحة
    D Avoid taking action unless she observes others listening to the conversation.
  230. 230

    A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach?

    A Milieu therapy الإجابة الصحيحة
    B Interpersonal therapy
    C Behavior modification
    D Support group therapy
  231. 231

    A 7-month-old infant has intermittent abdominal pain, distention, bilious vomiting, red currant jelly stool, and a sausage-shaped mass in the right upper quadrant. What is the most likely diagnosis?

    A Appendicitis
    B Intussusception الإجابة الصحيحة
    C Gastric volvulus
    D Gastroenteritis
  232. 232

    The nurse is assessing a client with a potential deep vein thrombosis (DVT). What sign does the nurse use by dorsiflexing the toes?

    A Homan's sign الإجابة الصحيحة
    B Pratt's sign
    C Kernig's sign
    D Brudzinski's sign
  233. 233

    Which action is most effective for preventing healthcare-associated infections?

    A Wear gloves for every client interaction.
    B Clean all equipment once daily.
    C Perform hand hygiene. الإجابة الصحيحة
    D Use sterile technique for all procedures.
  234. 234

    A client who is 8 weeks pregnant wants to try an herbal remedy for nausea. Which herb should the nurse suggest?

    A Ginger الإجابة الصحيحة
    B Milk thistle
    C Black cohosh
    D Echinacea
  235. 235

    Which action should the nurse take to address dyspnea in a client with COPD?

    A Elevate the head of the bed to high-Fowler position. الإجابة الصحيحة
    B Administer oxygen at 1 to 2 L/min without assessing the client.
    C Administer oxygen at 1 to 4 L/min without a prescription.
    D Instruct the client to deep breathe and cough continuously.
  236. 236

    A client recently diagnosed with Graves' disease has rapidly increasing temperature, blood pressure, heart rate, and respiratory rate. Which condition may the client be experiencing?

    A Hypertensive crisis
    B Malignant hyperthermia
    C Serotonin syndrome
    D Thyroid storm الإجابة الصحيحة
  237. 237

    The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse?

    A Administer 100% humidified oxygen. الإجابة الصحيحة
    B Teach the patient deep breathing exercises.
    C Encourage the patient to express feelings.
    D Assist the patient to a high Fowler's position.
  238. 238

    A patient with acute left-sided heart failure suddenly develops pink frothy sputum. What should the nurse suspect?

    A Pulmonary embolism
    B Pulmonary edema الإجابة الصحيحة
    C Right-sided heart failure
    D Stable angina
  239. 239

    A nurse is working with a patient who has limited English proficiency. What action by the nurse is best?

    A Use a qualified interpreter. الإجابة الصحيحة
    B Ask family members to translate.
    C Use drawings and pictures.
    D Speak in simple sentences.
  240. 240

    What are the early signs and symptoms of neurogenic shock?

    A Hypotension, bradycardia, and warm, dry skin الإجابة الصحيحة
    B Hypertension, bradycardia, and warm, dry skin
    C Hypotension, tachycardia, and cool, clammy skin
    D Hypertension, tachycardia, and cool, clammy skin
  241. 241

    The nurse is caring for a client who is a strict vegetarian; the client is at greatest risk for the development of:

    A Folic acid deficiency anemia
    B Blood loss anemia
    C Microcytic anemia
    D Vitamin B12 deficiency anemia الإجابة الصحيحة
  242. 242

    An older person is experiencing muscle weakness and a change in balance when walking. Which vitamin should the nurse ensure the person is taking in an adequate amount?

    A Vitamin E
    B Vitamin B12
    C Vitamin D الإجابة الصحيحة
    D Vitamin B6
  243. 243

    Which advice would the nurse provide about taking oral iron supplements?

    A Take them with milk
    B Take them before eating
    C Take them with fibrous food
    D Take them with orange juice الإجابة الصحيحة
  244. 244

    In a scenario where a patient is experiencing severe respiratory distress and requires immediate oxygen support, which device would be most appropriate to use and why?

    A A partial rebreather mask because it provides 60–90% oxygen.
    B A nasal cannula because it is less invasive.
    C A simple face mask because it provides moderate oxygen delivery.
    D A non-rebreather mask because it delivers the highest oxygen concentration available. الإجابة الصحيحة
  245. 245

    The nurse checks the apical pulse before giving digoxin and notes a heart rate of 56 beats/min. What is the best nursing action?

    A Give the medication as prescribed
    B Hold the dose and notify the provider الإجابة الصحيحة
    C Recheck the pulse after 5 minutes and give the drug
    D Administer the drug with food
  246. 246

    You have an adult patient with diabetes whose blood pressure is 145/95 mm Hg. Which stage of hypertension does this indicate?

    A Normal
    B Pre-hypertension
    C Stage I الإجابة الصحيحة
    D Stage II
  247. 247

    A community health nurse is providing teaching to clients at an assisted living facility. Which statement is an example of primary prevention?

    A I use a salt substitute instead of salt to keep my heart failure under control.
    B I got my pneumonia vaccine 2 years ago and get my annual flu shot every fall. الإجابة الصحيحة
    C I use my prescribed eye drops twice a day so my glaucoma doesn't get any worse.
    D I log my blood pressure weekly and take the list to each appointment with my doctor.
  248. 248

    Which of the following is an appropriate toy for a toddler?

    A Wooden building blocks الإجابة الصحيحة
    B Nerf guns
    C Legos
    D A Nintendo Switch
  249. 249

    A nurse wants to use democratic leadership with a group that is working on conflict resolution. Which action should the nurse take?

    A Observe the group's techniques without interfering.
    B Discuss a technique and then direct the group to practice it.
    C Ask the group for suggestions and support the discussion. الإجابة الصحيحة
    D Suggest techniques and ask members to reflect on them.
  250. 250

    Which action will the nurse take first for a patient with a suspected inhalation injury?

    A Obtain arterial blood gases.
    B Initiate cervical stabilization.
    C Assess for tachypnea.
    D Apply 100% oxygen. الإجابة الصحيحة
  251. 251

    The nurse notes that a peripheral IV site is cool, pale, and swollen and that the IV has stopped running. Which complication has probably occurred?

    A Phlebitis
    B Infection
    C Infiltration الإجابة الصحيحة
    D Thrombosis
  252. 252

    A nurse ensures that no obstacles are present between the bed and bathroom for a client with limited vision. Which ethical principle is demonstrated?

    A Veracity
    B Confidentiality
    C Fidelity
    D Beneficence الإجابة الصحيحة
  253. 253

    An older adult agrees to colon surgery after discussing all risks and benefits. Which ethical principle is demonstrated?

    A Beneficence
    B Nonmaleficence
    C Fidelity
    D Autonomy الإجابة الصحيحة
  254. 254

    After assessing a newborn, the nurse determines the newborn is small for gestational age based on which weight?

    A 2400 g الإجابة الصحيحة
    B 2600 g
    C 2800 g
    D 3000 g
  255. 255

    A nurse is teaching a pregnant woman about gestational diabetes screening. Which statement indicates understanding?

    A I will have an oral glucose tolerance test between 24 and 28 weeks of pregnancy. الإجابة الصحيحة
    B I should eat a high-carbohydrate meal immediately before the test.
    C Screening is unnecessary because I have no family history of diabetes.
    D The screening can be performed at any time during pregnancy.
  256. 256

    The nurse is teaching a new mother proper breastfeeding techniques. Which guideline should the nurse include?

    A Wash the hands and breasts before each feeding.
    B Bring the infant's wide-open mouth around the nipple and areola. الإجابة الصحيحة
    C Pull the infant away from the breast when ending the feeding.
    D Stroke the nipple against the infant's chin to stimulate rooting.
  257. 257

    Which action should a pregnant woman take to reduce the risk of neural tube defects?

    A Eat iron-rich foods.
    B Take folic acid daily. الإجابة الصحيحة
    C Avoid dairy products.
    D Limit fluid intake.
  258. 258

    Which communication strategy should the nurse use with a mechanically ventilated patient?

    A Use professional terminology and provide extensive detail.
    B Use simple language and explain the information another way if the patient does not understand. الإجابة الصحيحة
    C Provide minimal information to avoid overwhelming the patient.
    D Communicate primarily through the patient's family.
  259. 259

    A nurse administered lacosamide to the wrong patient. Which action should the nurse take first?

    A Assess vital signs and level of consciousness. الإجابة الصحيحة
    B Notify the health care provider.
    C Complete an incident report.
    D Call respiratory therapy to apply oxygen.
  260. 260

    Conflict develops between two staff nurses on the same unit. Which strategy is most important for the nurse manager?

    A Address the conflict in the break room.
    B Make a timely decision about if and when to intervene. الإجابة الصحيحة
    C Accept full responsibility for solving the conflict.
    D Redirect the disagreement to another issue.
  261. 261

    The nurse provides care for a client diagnosed with tuberculosis. Which transmission-based precautions will the nurse implement?

    A Standard
    B Airborne الإجابة الصحيحة
    C Droplet
    D Contact
  262. 262

    What is the best technique for removing secretions from the mouth and nose of a newborn during resuscitation?

    A Suction the nose before the mouth.
    B Use vigorous and deep suctioning.
    C Suction the mouth before the nose. الإجابة الصحيحة
    D The mouth or nose can be suctioned first.
  263. 263

    A 4-month-old infant is 6 hours postoperative following placement of a ventriculoperitoneal shunt. Which action is the priority?

    A Position in semi-Fowler's at 30 to 45 degrees.
    B Position the infant on the operative side.
    C Keep the infant supine and flat, turning every 2 hours to the nonoperative side. الإجابة الصحيحة
    D Measure head circumference once at discharge.
  264. 264

    A child with rubeola (measles) is being admitted to the hospital. Which precaution should the nurse plan?

    A Enteric
    B Airborne الإجابة الصحيحة
    C Protective
    D Neutropenic
  265. 265

    Which consideration is most important when a school nurse teaches bicycle safety to school-age children?

    A Collisions with automobiles are the most common bicycle injury.
    B Head injuries are a major cause of bicycle-related fatalities. الإجابة الصحيحة
    C A helmet is needed only when riding on paved roads.
    D Riding double is safe when the bicycle has an extra-large seat.
  266. 266

    A client with schizophrenia is starting clozapine. Which potentially fatal adverse effect should the nurse monitor for?

    A Agranulocytosis الإجابة الصحيحة
    B Akathisia
    C Pseudoparkinsonism
    D Akinesia
  267. 267

    Which physiological change contributes to heartburn in pregnancy?

    A Increased lower esophageal sphincter tone
    B Decreased intra-abdominal pressure
    C Relaxation of the lower esophageal sphincter الإجابة الصحيحة
    D Accelerated gastric emptying
  268. 268

    A patient has just undergone a renal biopsy. Which laboratory value should the nurse prioritize to identify complications?

    A Arterial blood gases
    B Calcium and phosphate levels
    C Complete blood count, renal function, and coagulation studies الإجابة الصحيحة
    D Liver enzymes and lipid profile
  269. 269

    Which position is appropriate early after an appendectomy for a ruptured appendix in an adolescent?

    A Semi-Fowler's الإجابة الصحيحة
    B Supine
    C Lithotomy
    D Prone
  270. 270

    What is the maximum height for the solution container when administering a high cleansing enema?

    A 30 cm
    B 46 cm الإجابة الصحيحة
    C 51 cm
    D 66 cm
  271. 271

    Which laboratory result should the nurse expect in a client who has Addison's disease?

    A Calcium 8.2 mg/dL
    B Potassium 6.2 mEq/L الإجابة الصحيحة
    C Glucose 320 mg/dL
    D Sodium 148 mEq/L
  272. 272

    Which position is appropriate for a newborn with a tracheoesophageal fistula?

    A Prone
    B Trendelenburg
    C Semi-Fowler's الإجابة الصحيحة
    D Supine
  273. 273

    A nurse is observing a client in four-point restraints for violent and self-destructive behavior. Which action should the nurse take?

    A Assess the client every hour for circulation, injury, and readiness for discontinuation.
    B Attach the restraint straps to the bed rails using a quick-release buckle.
    C Assist with passive range-of-motion exercises every 3 hours.
    D Check peripheral pulses and skin integrity every 15 minutes. الإجابة الصحيحة
  274. 274

    The nurse plans care for an infant with pyloric stenosis and deficient fluid volume. Which parameter best evaluates the outcome?

    A Abdominal distention
    B Weight loss الإجابة الصحيحة
    C Vomiting
    D Respiratory effort
  275. 275

    The principle of scalar chain refers to which concept?

    A Flexible organizational arrangements
    B Sharing responsibility equally
    C Equal treatment of all workers
    D A clear line of authority from top to bottom الإجابة الصحيحة
  276. 276

    Where should the nurse place the stethoscope to assess an adult client's apical pulse?

    A Third left intercostal space at the midclavicular line
    B Fourth left intercostal space at the midclavicular line
    C Fifth left intercostal space at the midclavicular line الإجابة الصحيحة
    D Second left intercostal space at the midclavicular line
  277. 277

    A nurse is caring for a client at 33 weeks of gestation in preterm labor who reports a sudden gush of fluid. Which action should the nurse take first?

    A Assess fetal heart rate and activity. الإجابة الصحيحة
    B Perform a nitrazine test.
    C Administer oxytocin.
    D Place the client in Trendelenburg position.
  278. 278

    A pregnant client at 25 weeks reports bright red vaginal bleeding after intercourse without pain or cramping. Which condition is most likely?

    A Placental abruption
    B Friable cervix
    C Placenta previa الإجابة الصحيحة
    D Sexually transmitted infection
  279. 279

    A client is 28 weeks pregnant, had an elective abortion at 9 weeks, twins at 36 weeks, and a miscarriage at 15 weeks. Which GTPAL is correct?

    A 4-0-0-2-2
    B 4-2-0-2-2
    C 4-0-2-2-2
    D 4-0-1-2-2 الإجابة الصحيحة
  280. 280

    A nurse is providing postoperative care for a child who had a cleft palate repair. In which position should the nurse place the child?

    A Infant seat
    B Supine
    C Prone الإجابة الصحيحة
    D Side-lying
  281. 281

    A client is 8 hours postoperative following a subtotal thyroidectomy. Which position should the nurse use?

    A High-Fowler's with the neck extended
    B High-Fowler's with the neck neutral
    C Semi-Fowler's with the neck extended
    D Semi-Fowler's with the neck neutral الإجابة الصحيحة
  282. 282

    Which isolation precaution should the nurse implement for a client with meningitis?

    A Droplet الإجابة الصحيحة
    B Contact
    C Standard
    D Reverse
  283. 283

    When using a full set of personal protective equipment, which sequence correctly describes donning the equipment?

    A Gown, gloves, mask, goggles
    B Gown, mask, goggles, gloves الإجابة الصحيحة
    C Gloves, gown, goggles, mask
    D Mask, gloves, gown, goggles
  284. 284

    Which personal protective equipment is required when caring for a client with tuberculosis?

    A N95 respirator الإجابة الصحيحة
    B Surgical mask
    C Full-face respirator
    D Gas-mask respirator
  285. 285

    A family member gives subcutaneous injections at home. How should used needles and syringes be discarded?

    A Break the needle, wrap it in newspaper, and place it in the trash.
    B Recap the needle and place it in the household garbage.
    C Save the needles for the visiting nurse to remove.
    D Place the unrecapped needle and syringe in a large plastic container with a secure lid. الإجابة الصحيحة
  286. 286

    After giving birth to a stillborn infant, the woman turns to the nurse and says, "I just finished painting the baby's room. Do you think that caused my baby to die?" The nurse's best response is:

    A That's an old wives' tale; lots of women are around paint during pregnancy and have healthy babies.
    B It is not likely. Paint was used in your house, and the fumes must have been strong.
    C Remain silent and sit with the client.
    D I can understand your need to find an answer to what caused this. What else are you thinking about? الإجابة الصحيحة
  287. 287

    A nurse assesses a newborn's umbilical cord and notes warmth, swelling, tenderness, and a foul odor. Which action should the nurse take first?

    A Document this as an expected finding.
    B Apply petroleum jelly to the cord.
    C Notify the provider immediately. الإجابة الصحيحة
    D Recommend a tub bath.
  288. 288

    Preventive measures such as immunizations and water fluoridation are examples of which type of prevention?

    A Quaternary prevention
    B Tertiary prevention
    C Secondary prevention
    D Primary prevention الإجابة الصحيحة
  289. 289

    If a patient has measles, which of the following is a required additional precaution?

    A Hand hygiene
    B N95 respirator الإجابة الصحيحة
    C Gloves
    D Eye protection
  290. 290

    Which of the following organisms is responsible for the development of rheumatic fever?

    A Group A beta-hemolytic streptococcus الإجابة الصحيحة
    B Staphylococcus aureus
    C Streptococcus pneumoniae
    D Haemophilus influenzae
  291. 291

    In which position should a nurse place a child postoperative tonsil and adenoidectomy (T&A)?

    A Semi-Fowler with the head turned to the side
    B High Fowler, head slightly forward and to the side
    C Side-lying الإجابة الصحيحة
    D Supine
  292. 292

    An infant with tetralogy of Fallot suddenly becomes cyanotic during a hypercyanotic spell. Which position should the nurse place the infant in?

    A Prone
    B Knee-chest الإجابة الصحيحة
    C High-Fowler's
    D Reverse Trendelenburg
  293. 293

    When caring for a hospitalized child who has varicella, which of the following actions should a nurse take?

    A Place the child on airborne and contact isolation until lesions have crusted over. الإجابة الصحيحة
    B Request a provider prescription for antibiotics.
    C Request a corticosteroid for pruritus.
    D Apply a hot, moist compress.
  294. 294

    A public health nurse is participating in the care of several populations within the community. Which action by the nurse is an example of primary prevention?

    A Creating a free exercise program for adults who have cardiovascular disease.
    B Implementing immunization clinics for students at elementary schools. الإجابة الصحيحة
    C Providing tuberculosis screenings for health care workers.
    D Administering immunoglobulin to members of the community after exposure to hepatitis A.
  295. 295

    Which combination of foods will the nurse recommend to a vegan patient for a healthy protein balance?

    A Eggs and fish
    B Dairy and eggs
    C Fish and poultry
    D Grains and legumes الإجابة الصحيحة
  296. 296

    A pregnant teenage client has iron-deficiency anemia. Which nutrient should she increase to enhance iron absorption?

    A Vitamin A
    B Vitamin C الإجابة الصحيحة
    C Vitamin D
    D Vitamin E
  297. 297

    A nurse is caring for a client recently diagnosed with active tuberculosis. Which infection-control measure is the priority when entering the client's room?

    A Wear a surgical mask.
    B Use a standard face shield.
    C Wear an N95 or HEPA respirator. الإجابة الصحيحة
    D Apply a gown only.
  298. 298

    Which is a common complication of acute renal failure during the oliguric phase?

    A Hyponatremia
    B Pulmonary edema الإجابة الصحيحة
    C Metabolic acidosis
    D Hypokalemia with arrhythmias
  299. 299

    The nurse is caring for a group of patients. Which patient is at greatest risk for increased extracellular fluid accumulation?

    A A patient with osmotic diuresis
    B A patient with renal impairment الإجابة الصحيحة
    C A patient with an intestinal obstruction
    D A patient with drainage from a rectal fistula
  300. 300

    A 29-year-old man is in the surgical ward on his first postoperative day after thyroidectomy. He appears drowsy but responds by nodding his head and is developing mild restlessness. What is the initial recommended goal of care?

    A Monitor vital signs for thyroid storm. الإجابة الصحيحة
    B Assess for bilateral vocal fold mobility.
    C Monitor for swelling of the neck.
    D Monitor for vocal cord paralysis.
  301. 301

    Which complication will the nurse monitor for when caring for a client with an infection caused by group A beta-hemolytic streptococci?

    A Hepatitis A
    B Rheumatic fever الإجابة الصحيحة
    C Spinal meningitis
    D Rheumatoid arthritis
  302. 302

    Which blood component is primarily responsible for oxygen transport?

    A White blood cells
    B Platelets
    C Red blood cells الإجابة الصحيحة
    D Plasma
  303. 303

    Patients with mental health issues are having difficulty resolving conflicts about their opinions. The nurse determines that the group is in which phase?

    A Forming
    B Storming الإجابة الصحيحة
    C Performing
    D Adjourning
  304. 304

    A nurse manager meets with staff about cost containment and asks for their input. Which leadership style is the manager using?

    A Autocratic
    B Democratic الإجابة الصحيحة
    C Laissez-faire
    D Moral
  305. 305

    In which stage of labor is the placenta expelled?

    A First stage
    B Second stage
    C Third stage الإجابة الصحيحة
    D Fourth stage
  306. 306

    What is the correct order patients go through the Kubler-Ross stages of dying?

    A Denial, anger, bargaining, depression, acceptance
    B Depression, denial, bargaining, anger, acceptance
    C Patients may move back and forth through the stages
    D Answers 1 and 3 الإجابة الصحيحة
  307. 307

    A nurse is planning care for a client who has a deep vein thrombosis in the right leg. Which action should the nurse include?

    A Maintain bed rest.
    B Elevate the affected extremity. الإجابة الصحيحة
    C Apply cold compresses.
    D Massage the muscle.
  308. 308

    Which action is an example of primary prevention?

    A Avoiding unnecessary imaging
    B Receiving a flu vaccination الإجابة الصحيحة
    C Attending cardiac rehabilitation after a heart attack
    D Undergoing breast cancer screening
  309. 309

    The nurse who is counseling a client with dissociative identity disorder should understand that which assessment is the highest priority?

    A Risk for self-harm الإجابة الصحيحة
    B Memory fragmentation
    C Cognitive function
    D Self-esteem
  310. 310

    A nurse manager is coordinating care after a plane crash brings multiple victims to the emergency department. Which leadership style is most appropriate?

    A Autocratic الإجابة الصحيحة
    B Democratic
    C Laissez-faire
    D Eclectic
  311. 311

    A nurse manager asks staff for suggestions to improve collaboration. Which leadership style is being used?

    A Laissez-faire
    B Democratic الإجابة الصحيحة
    C Autocratic
    D Transactional
  312. 312

    A client with angina asks, "Why am I taking nitroglycerin?" Which response should the nurse make?

    A It dissolves clots in your coronary arteries.
    B It dilates cardiac blood vessels to deliver more oxygen. الإجابة الصحيحة
    C It relieves nausea caused by angina.
    D It acts as a bronchodilator.
  313. 313

    At a routine prenatal visit, the nurse notes that a patient at 37 weeks of gestation has a fetal heart rate of 120 beats/min, decreased from 160 beats/min earlier in pregnancy. What should the nurse do first?

    A Ask whether the patient took a sedative.
    B Record the finding as normal. الإجابة الصحيحة
    C Notify the physician.
    D Turn the patient onto her right side.
  314. 314

    A nurse is caring for a client with postpartum hemorrhage. Which surgical management should be expected if she has uterine atony?

    A Manual removal of retained fragments
    B Repair of lacerations or hematomas
    C Uterine tamponade with a balloon catheter or gauze packing الإجابة الصحيحة
    D Uterine artery embolization
  315. 315

    Which technique should the nurse implement when performing a Weber test?

    A Tap the patellar tendon using a reflex hammer.
    B Shine the light of an ophthalmoscope into the pupil.
    C Visualize the tympanic membrane using an otoscope.
    D Place a vibrating tuning fork midline on top of the head. الإجابة الصحيحة
  316. 316

    A client is receiving quinine for drug-resistant malaria. The nurse should monitor for cinchonism, which presents with which findings?

    A Diarrhea, nausea, and fever
    B Yellow sclera and skin
    C Tremors and ataxia
    D Vomiting, tinnitus, and vertigo الإجابة الصحيحة
  317. 317

    After a client receives newly prescribed captopril, which priority intervention decreases complications?

    A Provide food with the medication.
    B Ask the client to request assistance when rising from bed. الإجابة الصحيحة
    C Have assistive personnel give the client a bath.
    D Monitor the client for hypokalemia.
  318. 318

    Which statement best describes the most critical aspect of the client's pressure injury and treatment?

    A The client was admitted three days ago.
    B The pressure injury is stage 4. الإجابة الصحيحة
    C The client rates pain as 2 out of 10.
    D The dressing was reapplied and sealed.
  319. 319

    When caring for a patient with acute respiratory distress syndrome, which finding is most characteristic?

    A Progressive hypercapnia
    B Refractory hypoxemia الإجابة الصحيحة
    C Increased pulmonary artery wedge pressure
    D Bronchial breath sounds
  320. 320

    Where should the nurse collect a urine specimen from a patient with an indwelling catheter on day two?

    A The specimen port on the catheter الإجابة الصحيحة
    B The drainage valve on the bag
    C The tip of the catheter
    D The balloon port
  321. 321

    Which group of diseases is prevented by the MMR vaccine?

    A Measles, mumps, and rubella الإجابة الصحيحة
    B Measles, malaria, and rabies
    C Measles, mumps, and rotavirus
    D Malaria, mumps, and rubella
  322. 322

    A nurse is administering an injection to a patient at a 15-degree angle. Which type of injection is the nurse administering?

    A Subcutaneous
    B Z-track
    C Intramuscular
    D Intradermal الإجابة الصحيحة
  323. 323

    A nurse is applying an oxygen mask for a client with bronchial pneumonia. What should the nurse do to prevent skin breakdown?

    A Place cotton balls under the entire mask.
    B Place gauze pads under the elastic strap at pressure points. الإجابة الصحيحة
    C Apply powder around the edges of the mask.
    D Adjust the straps loosely.
  324. 324

    When a patient turns on the call bell every few minutes, what is the appropriate response?

    A Ask the patient not to call so often.
    B Stop by the patient's room more often. الإجابة الصحيحة
    C Put the call bell out of reach.
    D Tell the patient how busy the staff are.
  325. 325

    During a telephone follow-up conversation 5 days postpartum, a woman says, "I don't know what's wrong with me. I love my baby, but I seem to be crying all the time!" The woman is most likely experiencing:

    A Taking-in
    B Letting go
    C Postpartum blues الإجابة الصحيحة
    D Attachment
  326. 326

    Which statement by a client after transurethral resection of the prostate demonstrates understanding of discharge teaching?

    A I will use a daily enema.
    B I will avoid heavy lifting, climbing, and driving until my follow-up visit. الإجابة الصحيحة
    C I no longer have any risk for prostate cancer.
    D I will drink coffee, tea, and soft drinks frequently.
  327. 327

    A client has a closed ankle injury. The right foot is pale and cool, pain is 8 out of 10, and no pulse is palpable. Which action should the nurse take first?

    A Administer pain medication.
    B Prepare the client for reduction.
    C Obtain a Doppler assessment of the right foot pulse. الإجابة الصحيحة
    D Notify the physician that there is no pulse.
  328. 328

    A nurse is caring for an infant who just had a circumcision. Which action should the nurse take?

    A Avoid oral sucrose.
    B Administer intravenous morphine.
    C Swaddle the infant. الإجابة الصحيحة
    D Apply petroleum once daily.
  329. 329

    The ultimate goal of therapy for a client with dissociative identity disorder is most likely achieved through which treatment?

    A Crisis intervention and directed association
    B Psychotherapy and hypnosis الإجابة الصحيحة
    C Psychoanalysis and free association
    D Insight psychotherapy and dextroamphetamines
  330. 330

    A nurse is caring for a client who has pharyngeal diphtheria. Which of the following transmission-based precautions should the nurse initiate?

    A Contact precautions
    B Droplet precautions الإجابة الصحيحة
    C Airborne precautions
    D Protective environment
  331. 331

    A nurse is inserting an NG tube for a client. Which of the following actions should the nurse take?

    A Place the client on the right side
    B Place the client in Low Fowler's position
    C Place the client in High Fowler's position الإجابة الصحيحة
    D Place the client supine with the head flat
  332. 332

    A nurse is preparing to administer a DTaP immunization booster to a 4-year-old child. Which level of prevention does this action represent?

    A Primary prevention الإجابة الصحيحة
    B Tertiary prevention
    C Secondary prevention
    D Primary nursing care
  333. 333

    What is the proper order for putting on personal protective equipment (PPE)?

    A Gown, mask, goggles, gloves الإجابة الصحيحة
    B Gloves, goggles, gown, mask
    C Mask, gloves, goggles, gown
    D Gown, gloves, mask, goggles
  334. 334

    Which clinical finding would the nurse associate with hypokalemia?

    A Peripheral edema
    B Muscle spasms
    C Kussmaul respirations
    D Muscle weakness الإجابة الصحيحة
  335. 335

    Which finding should the nurse expect in a client who has a tension pneumothorax?

    A Tracheal deviation toward the unaffected side الإجابة الصحيحة
    B Bilateral equal chest movement
    C Decreased respiratory effort
    D Decreasing central venous pressure
  336. 336

    A nurse realizes that a medication error has occurred and the client appears unharmed. Which action should the nurse take first?

    A Document the error in the medical record
    B Notify the provider
    C Complete an incident report
    D Assess the client الإجابة الصحيحة
  337. 337

    Which intervention is the priority when uterine tachysystole occurs while a client is receiving oxytocin?

    A Increase the IV fluid rate
    B Stop the oxytocin infusion الإجابة الصحيحة
    C Administer oxygen
    D Place the client supine
  338. 338

    A client taking lithium has a serum lithium level of 1.8 mEq/L. Which action should the nurse take?

    A Administer the scheduled dose
    B Hold the dose الإجابة الصحيحة
    C Encourage the client to restrict water
    D Give the medication after supper
  339. 339

    Which source provides the highest level of evidence?

    A A single cohort study
    B A controlled study without randomization
    C A systematic review of qualitative studies
    D A meta-analysis of randomized controlled trials الإجابة الصحيحة
  340. 340

    Which blood pressure finding should the nurse expect in a client who has Cushing syndrome?

    A Hypotension
    B Normal blood pressure
    C Hypertension الإجابة الصحيحة
    D Orthostatic hypotension
  341. 341

    Treatment for group A beta-hemolytic streptococcal infection prevents which serious sequela?

    A Otitis media
    B Diabetes insipidus
    C Nephrotic syndrome
    D Acute rheumatic fever الإجابة الصحيحة
  342. 342

    A nurse is preparing a child for the postoperative period following a tonsillectomy. Which position should the nurse plan to use?

    A Supine
    B Side-lying الإجابة الصحيحة
    C High-Fowler's
    D Trendelenburg
  343. 343

    A 2-month-old infant with tetralogy of Fallot becomes cyanotic and tachypneic during a painful procedure. Which action should the nurse take initially?

    A Calm the infant and reduce stimuli
    B Administer 100% oxygen
    C Place the infant in the knee-chest position الإجابة الصحيحة
    D Administer IV fluids
  344. 344

    Which person would be an appropriate candidate for the BCG vaccine?

    A An infant born in the United States
    B A foreign-born person entering the United States
    C A home health nurse working in a rural area
    D A physician caring for clients with tuberculosis in an endemic region الإجابة الصحيحة
  345. 345

    A preschool child with varicella has fluid-filled skin lesions. How should the nurse classify these lesions?

    A Vesicles الإجابة الصحيحة
    B Wheals
    C Papules
    D Pustules
  346. 346

    A women's health club asks a community nurse to speak about primary prevention. Which activity should the nurse include?

    A Immunizations الإجابة الصحيحة
    B Routine physician visits
    C Antibiotic treatment
    D Cervical cancer screening
  347. 347

    Which food should the nurse offer a client who follows a vegan diet?

    A Bagel with cream cheese
    B Fried egg
    C Fruit yogurt
    D Wheat toast with peanut butter الإجابة الصحيحة
  348. 348

    Which vitamin enhances iron absorption?

    A Vitamin A
    B Vitamin B2
    C Vitamin C الإجابة الصحيحة
    D Vitamin D
  349. 349

    A nurse caring for a neonate notices excessive frothy mucus coming from the nose and mouth. Which condition should the nurse suspect?

    A Cleft lip
    B Cleft palate
    C Biliary atresia
    D Tracheoesophageal fistula الإجابة الصحيحة
  350. 350

    A nurse is caring for a client with active tuberculosis in a private room. What should the nurse do before entering the room?

    A Wear a surgical mask
    B Put on a gown and gloves
    C Wear a HEPA-filtered N95 respirator الإجابة الصحيحة
    D Use standard precautions only
  351. 351

    Which finding supports the nursing diagnosis of excess fluid volume in a client with acute renal failure?

    A Pitting edema of the lower extremities الإجابة الصحيحة
    B Normal bowel sounds
    C Wheezing without edema
    D Generalized weakness
  352. 352

    Which position is appropriate for a client following thyroidectomy?

    A Flat supine
    B Semi-Fowler's with the head and neck supported and avoiding extension الإجابة الصحيحة
    C High-Fowler's with the neck hyperextended
    D Side-lying without neck support
  353. 353

    Which measure is most effective for preventing and controlling pulmonary tuberculosis?

    A Screening only
    B Monthly medical missions
    C BCG vaccination الإجابة الصحيحة
    D Standard precautions alone
  354. 354

    An influenza vaccination clinic is an example of which level of prevention?

    A Primary prevention الإجابة الصحيحة
    B Secondary prevention
    C Tertiary prevention
    D Restorative prevention
  355. 355

    Which group of manifestations is characteristic of nephrotic syndrome?

    A Hematuria, bacteriuria, and weight gain
    B Gross hematuria, albuminuria, and fever
    C Hypertension, weight loss, and proteinuria
    D Massive proteinuria, hypoalbuminemia, and edema الإجابة الصحيحة
  356. 356

    Which nursing diagnosis is most directly related to the major manifestation of nephrotic syndrome?

    A Constipation
    B Risk for injury
    C Hyperthermia
    D Excess fluid volume related to generalized edema الإجابة الصحيحة
  357. 357

    Which position should the nurse use for a client immediately after thyroidectomy?

    A Side-lying with one pillow
    B Head of bed 30 degrees without pillows
    C Semi-Fowler's with the head supported by two pillows الإجابة الصحيحة
    D Supine with a neck roll
  358. 358

    A community health nurse is planning a primary prevention strategy. Which action should the nurse include?

    A Provide nutritional counseling to clients with diabetes
    B Report suspected child neglect
    C Conduct vision and hearing screening
    D Teach community members about handwashing الإجابة الصحيحة
  359. 359

    What is the first step in evidence-based practice?

    A Acquire the evidence
    B Appraise the evidence
    C Ask a focused clinical question الإجابة الصحيحة
    D Apply the evidence
  360. 360

    Which action should a nurse take when receiving a telephone order from a provider?

    A Print a copy of the order
    B Read the order back to the provider الإجابة الصحيحة
    C Ask another nurse to listen on an extension
    D Require the provider to write it within 24 hours before acting
  361. 361

    Which vaccine is given to prevent chickenpox?

    A DPT
    B IPV
    C HBV
    D Varicella الإجابة الصحيحة
  362. 362

    A postpartum client has heavy vaginal bleeding while the uterine fundus is firm. Which cause should the nurse suspect?

    A Uterine atony
    B Genital tract laceration الإجابة الصحيحة
    C Retained placenta
    D Endometritis
  363. 363

    A client is 48 hours postpartum. Where should the nurse expect to palpate the fundus?

    A 1 cm above the umbilicus
    B 2 cm above the umbilicus
    C 1 cm below the umbilicus
    D 2 cm below the umbilicus الإجابة الصحيحة
  364. 364

    A community health nurse is planning a public service campaign to decrease influenza transmission. Which intervention is primary prevention?

    A Provide influenza immunizations الإجابة الصحيحة
    B Screen clients for influenza
    C Refer ill clients for treatment
    D Provide rehabilitation after complications
  365. 365

    An infection is spread by direct and indirect contact. Which transmission-based precaution should the nurse implement?

    A Airborne precautions
    B Droplet precautions
    C Contact precautions الإجابة الصحيحة
    D Protective environment
  366. 366

    An adolescent has made repeated suicide attempts. Which nursing action is the priority?

    A Check the client every hour
    B Ask the client why the attempts occurred
    C Place the client in seclusion
    D Have a staff member remain with the client الإجابة الصحيحة
  367. 367

    A highly agitated client paces and says, 'I could buy and sell this place.' The mood fluctuates from laughter to anger. Which documentation is most accurate?

    A Mood 8/10, looseness of association, euphoric
    B Mood euthymic, magical thinking, restless
    C Mood labile, delusions of reference, hyperactive
    D Agitated and pacing, grandiosity, mood labile الإجابة الصحيحة
  368. 368

    A child's FLACC pain score is 9. How should the nurse interpret this score?

    A Little or no pain
    B Mild pain
    C Moderate pain
    D Severe pain الإجابة الصحيحة
  369. 369

    What is the correct sequence for assessing the abdomen?

    A Inspect, palpate, auscultate, percuss
    B Inspect, auscultate, percuss, palpate الإجابة الصحيحة
    C Auscultate, inspect, palpate, percuss
    D Palpate, inspect, auscultate, percuss
  370. 370

    A 3-day-old infant has abdominal distention, vomiting, and has not passed meconium. Which disorder should the nurse suspect?

    A Pyloric stenosis
    B Intussusception
    C Hirschsprung disease الإجابة الصحيحة
    D Celiac disease
  371. 371

    Which finding distinguishes preeclampsia from gestational hypertension?

    A Blood pressure above 140/90 mm Hg
    B Abnormal proteinuria الإجابة الصحيحة
    C Generalized edema
    D Epigastric pain
  372. 372

    Which intervention is appropriate for a child experiencing a sickle cell vaso-occlusive crisis?

    A Correct acidosis only
    B Provide hydration and pain management الإجابة الصحيحة
    C Administer heparin with analgesics
    D Give oxygen and factor VIII
  373. 373

    Which vitamin helps the body absorb calcium?

    A Vitamin A
    B Vitamin B
    C Vitamin C
    D Vitamin D الإجابة الصحيحة
  374. 374

    Which food should a client take with an oral iron supplement to enhance absorption?

    A Milk
    B Yogurt
    C Antacid
    D Orange juice الإجابة الصحيحة
  375. 375

    Which community health activity is an example of primary prevention?

    A Screen adults for hypertension
    B Provide rehabilitation after stroke
    C Treat active tuberculosis
    D Administer recommended immunizations الإجابة الصحيحة
  376. 376

    A pregnant client reports leg cramps. Which action should the nurse recommend?

    A Bend the foot toward the body while flexing the knee
    B Bend the foot toward the body while extending the knee الإجابة الصحيحة
    C Point the foot away while flexing the knee
    D Point the foot away while extending the knee
  377. 377

    A client is taking furosemide. Which electrolyte imbalance should the nurse monitor for?

    A Hypernatremia
    B Hypokalemia الإجابة الصحيحة
    C Hyperkalemia
    D Hypocalcemia
  378. 378

    Which laboratory test is most specific for acute coronary syndrome or myocardial infarction?

    A Troponin markers الإجابة الصحيحة
    B Serum lactate dehydrogenase
    C Serum myoglobin
    D Creatine kinase-MB
  379. 379

    A child is admitted with respiratory syncytial virus infection. Which precautions should the nurse initiate?

    A Protective precautions
    B Contact precautions الإجابة الصحيحة
    C Standard precautions only
    D Airborne precautions
  380. 380

    Which injection site should the nurse use to administer vitamin K to a newborn?

    A Lower rectus femoris
    B Lateral middle third of the vastus lateralis الإجابة الصحيحة
    C Medial deltoid
    D Gluteus maximus
  381. 381

    What do the Rinne and Weber tests assess?

    A Air and bone conduction الإجابة الصحيحة
    B Tympanic membrane movement
    C Mastoid tenderness
    D Ear canal nodules
  382. 382

    A nurse stops a blood transfusion after identifying a transfusion reaction. Which action should the nurse take next?

    A Check the tubing and blood bag
    B Obtain vital signs
    C Keep the IV line open with normal saline الإجابة الصحيحة
    D Notify the health care provider
  383. 383

    Which finding should the nurse expect in a newborn who has Hirschsprung disease?

    A Acute diarrhea and poor skin turgor
    B Currant-jelly stools and episodic pain
    C Projectile vomiting and hypochloremia
    D Failure to pass meconium and abdominal distention الإجابة الصحيحة
  384. 384

    Which statement should a nurse include when teaching a community group about the primary reason vaccinations are recommended?

    A They eliminate the need for antihypertensive medicines
    B They improve skin tone
    C They protect against serious disease and help prevent spread to others الإجابة الصحيحة
    D They mainly treat illness after it occurs
  385. 385

    Which beverage should a client increase to help reduce the risk of urinary tract infections?

    A Nut-based drinks
    B Caffeinated beverages
    C Citrus drinks
    D Cranberry juice الإجابة الصحيحة
  386. 386

    Several households in a community lack access to clean water. What is the most effective long-term intervention?

    A Provide water-purification tablets
    B Install a deep well or community water-filtration system الإجابة الصحيحة
    C Advise residents to boil water
    D Distribute bottled water
  387. 387

    Which finding in a client with malnutrition should the nurse report?

    A BMI of 18.5 kg/m2
    B Potassium 3.7 mEq/L
    C Phosphorus 3.5 mg/dL
    D Albumin 2.5 g/dL الإجابة الصحيحة
  388. 388

    Which blood pressure reading is classified as stage 2 hypertension?

    A 118/76 mm Hg
    B 126/78 mm Hg
    C 134/86 mm Hg
    D 146/92 mm Hg الإجابة الصحيحة
  389. 389

    A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action would be most appropriate?

    A Document the findings الإجابة الصحيحة
    B Contact the physician
    C Circle the drainage and reassess in 30 minutes
    D Reinforce the dressing
  390. 390

    The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention?

    A Blood pressure 116/80 mm Hg
    B Respirations 18 breaths/min
    C Pulse rate 70 beats/min
    D Temporal temperature 100.8°F (38.2°C) الإجابة الصحيحة
  391. 391

    Which postoperative nursing care would the nurse provide to a 3-week-old infant after cleft lip repair?

    A Provide spoon feeding
    B Cleanse the suture line الإجابة الصحيحة
    C Provide a pacifier
    D Apply wrist restraints
  392. 392

    What should the nurse stress when teaching a woman how to deal with premenstrual syndrome?

    A Decrease caffeine intake الإجابة الصحيحة
    B Drink wine with meals
    C Decrease fluid intake
    D Eat three large meals daily
  393. 393

    A client is attempting a vaginal delivery after a previous cesarean birth. She suddenly has intense abdominal pain and the fetal monitor stops recording contractions. What has occurred?

    A Placenta previa
    B Uterine rupture الإجابة الصحيحة
    C Prolapsed cord
    D Abruptio placentae
  394. 394

    During a staff meeting, nurses discuss problems accessing research studies for evidence-based clinical decisions. Which suggestion by the nurse manager would best help?

    A Form a committee to conduct research studies
    B Post published studies on the unit bulletin boards
    C Encourage nurses to visit the library
    D Teach nurses how to conduct electronic searches for research studies الإجابة الصحيحة
  395. 395

    What is the most important nursing action to reduce transmission of microorganisms before beginning a physical assessment?

    A Clean the bell and diaphragm of the stethoscope
    B Perform hand hygiene الإجابة الصحيحة
    C Wear gloves when anticipating exposure to body fluids
    D Wear eye protection when anticipating splatter
  396. 396

    A nurse is obtaining vital signs for a client who has AIDS. Before entering the room, which action should the nurse take?

    A Wear gloves and a gown
    B Perform hand hygiene الإجابة الصحيحة
    C Review the client's viral load
    D Obtain a disposable stethoscope
  397. 397

    A nurse is teaching a patient how to manage chronic obstructive pulmonary disease. This intervention is an example of which level of health promotion?

    A Primary prevention
    B Secondary prevention
    C Tertiary prevention الإجابة الصحيحة
    D Risk factor prevention
  398. 398

    Which nursing intervention is an example of tertiary preventive care?

    A Administering immunizations
    B Teaching stress-reduction classes
    C Performing blood-pressure screening
    D Assisting with speech therapy after traumatic brain injury الإجابة الصحيحة
  399. 399

    Which statement best describes evidence-based practice?

    A The conscientious integration of the best research evidence with clinical expertise and patient needs and values الإجابة الصحيحة
    B Standards of behavior that professional nurses are expected to perform
    C Using one study to determine the best evidence
    D Determining the factors that control patient responses to nursing care
  400. 400

    What is the first step in the evidence-based practice process?

    A Apply
    B Assess
    C Appraise
    D Ask الإجابة الصحيحة
  401. 401

    Which barrier do nurses rank as the chief obstacle to conducting evidence-based practice inquiries?

    A Difficulty understanding research articles and data
    B Lack of computer skills
    C Not having enough time الإجابة الصحيحة
    D Not understanding the organization
  402. 402

    Which is considered the highest level of evidence?

    A A systematic review of descriptive studies
    B A controlled study without randomization
    C A systematic review or meta-analysis of randomized controlled trials الإجابة الصحيحة
    D An expert panel opinion
  403. 403

    Which database is best for locating synthesized evidence such as systematic reviews and meta-analyses?

    A Cochrane Database الإجابة الصحيحة
    B PubMed
    C National Guideline Clearinghouse
    D CINAHL
  404. 404

    What is the main function of a meta-analysis?

    A Collect qualitative data
    B Combine statistical results from multiple studies الإجابة الصحيحة
    C Develop clinical guidelines
    D Conduct interviews
  405. 405

    A client reports persistent headaches. Which finding is an example of subjective data?

    A Temperature is 104.1°F (40.1°C)
    B The client is slow to respond to questions
    C The client is oriented to person, place, and time
    D Pain is 4 out of 10 on a pain scale الإجابة الصحيحة
  406. 406

    A child has elbow restraints after cleft palate repair. What should the nurse do when the mother asks to remove them?

    A Remove one restraint at a time الإجابة الصحيحة
    B Remove both restraints
    C Loosen both restraints
    D Explain that the restraints cannot be removed
  407. 407

    A young child with tetralogy of Fallot may assume a posturing position as a compensatory mechanism. Which position should the nurse expect?

    A Low Fowler's
    B Prone
    C Supine
    D Knee-chest الإجابة الصحيحة
  408. 408

    A nurse realizes that a medication due 4 hours ago was not administered. Which action should the nurse take first?

    A File an incident report
    B Determine factors that led to the omission
    C Assess the client for adverse reactions الإجابة الصحيحة
    D Report the missed dose to the provider
  409. 409

    A nurse checks a client's perineal pad 3 days postpartum and finds 2 cm of red lochia. How should this finding be documented?

    A Heavy lochia alba
    B Heavy lochia rubra
    C Moderate lochia serosa
    D Scant lochia rubra الإجابة الصحيحة
  410. 410

    A mother refuses the MMR vaccine because she believes childhood diseases help the immune system. What is the nurse's most appropriate response?

    A Honor the mother's decision without further discussion
    B Explain that antibodies protect against many illnesses
    C Explain that not vaccinating protects pregnant women
    D Explain that these diseases can cause serious permanent complications الإجابة الصحيحة
  411. 411

    A client at 36 weeks of pregnancy is admitted with eclampsia. Which medication should the nurse anticipate to prevent seizures?

    A Hydralazine
    B Nifedipine
    C Magnesium sulfate الإجابة الصحيحة
    D Diazepam
  412. 412

    Which situation is an example of democratic leadership?

    A A manager explains the rules and then asks staff to vote الإجابة الصحيحة
    B A manager directs all actions during an emergency
    C A manager asks only close nurse friends
    D A manager ignores policy and allows staff to decide
  413. 413

    Which laboratory finding should the nurse expect in a client who has diabetic ketoacidosis?

    A Blood glucose 30 mg/dL
    B Negative serum ketones
    C Arterial pH 7.38
    D Serum bicarbonate 12 mEq/L الإجابة الصحيحة
  414. 414

    A home health nurse is teaching parents about endotracheal suctioning of their child. Which instruction should the nurse include?

    A Apply suction when inserting the catheter
    B Apply suction for less than 10 seconds الإجابة الصحيحة
    C Set suction pressure to 110 mm Hg
    D Allow 10 to 15 seconds of rest after each attempt
  415. 415

    Which preoperative action is appropriate for a child who has Wilms tumor?

    A Limit fluids
    B Do not palpate the abdomen الإجابة الصحيحة
    C Force oral fluids
    D Palpate the abdomen every 4 hours
  416. 416

    A nurse overhears two staff members discussing a client's diagnosis in a public hallway. Which action should the nurse take?

    A Ask them to speak more quietly
    B Tell them to stop discussing confidential information الإجابة الصحيحة
    C Alert the facility attorney
    D Ignore the situation because no one is nearby
  417. 417

    Which finding indicates a healthy stoma?

    A Dark pink and moist الإجابة الصحيحة
    B Red and dry
    C Off-white and pale
    D Dark purple
  418. 418

    A nurse manager has a reputation as an autocratic leader. Which statement supports that reputation?

    A I would like to hear your ideas for improving morale
    B I am placing a suggestion box in the break room
    C The new work schedule is posted for the next six weeks الإجابة الصحيحة
    D Please add comments to the blank sheet on the new procedure manual
  419. 419

    A client receives an antipsychotic medication. Which finding indicates pseudoparkinsonism?

    A Drooling
    B Blurred vision
    C Muscle tremors الإجابة الصحيحة
    D Photosensitivity
  420. 420

    What is a neural tube defect that is not visible externally in the lumbosacral area called?

    A Meningocele
    B Myelomeningocele
    C Spina bifida cystica
    D Spina bifida occulta الإجابة الصحيحة
  421. 421

    During two clinic visits, a patient's blood pressure readings are 162/91 mm Hg and 165/94 mm Hg. Which classification should the nurse anticipate?

    A Normotensive
    B Hypotensive
    C Hypertensive crisis
    D Stage 2 hypertension الإجابة الصحيحة
  422. 422

    A nurse administers a vaccine to children in an immunization program. Which level of prevention does this represent?

    A Primary prevention الإجابة الصحيحة
    B Tertiary prevention
    C Secondary prevention
    D Early diagnosis
  423. 423

    A client is scheduled for MRI of the cervical vertebrae. Which history finding is a contraindication?

    A A new tattoo
    B Unable to sit upright
    C Peripheral vascular disease
    D A pacemaker الإجابة الصحيحة
  424. 424

    What is the antidote for Heparin?

    A Protamine sulfate الإجابة الصحيحة
    B Vitamin K
    C Flumazenil
    D Narcan
  425. 425

    Your patient is post-op from surgery. The patient is receiving Morphine. The patient is experiencing severe respiratory depression. What medication below do you anticipate the physician to order for this patient?

    A Hydroxocobalamin
    B Succimer
    C Atropine
    D Naloxone الإجابة الصحيحة
  426. 426

    A nurse prepares to administer a vitamin K injection to a newborn. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be:

    A Your newborn needs vitamin K to develop immunity.
    B Newborns have sterile bowels and vitamin K promotes the growth of bacteria in the bowel.
    C The vitamin K will protect your infant from being jaundiced.
    D Newborns are deficient in vitamin K, and this injection prevents your baby from abnormal bleeding. الإجابة الصحيحة
  427. 427

    A client refuses a medication. What should the nurse do first?

    A Document the refusal and discard the medication
    B Explain that refusing medications is harmful
    C Ask the client why they do not want to take it الإجابة الصحيحة
    D Call the provider immediately
  428. 428

    When performing a physical assessment, the first technique the nurse will always use is:

    A Palpation
    B Inspection الإجابة الصحيحة
    C Percussion
    D Auscultation
  429. 429

    A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make?

    A Apply cold compresses between feedings. الإجابة الصحيحة
    B Take a warm shower right after feedings.
    C Apply breast milk to the nipples and allow them to air dry.
    D Use the various infant positions for feedings.
  430. 430

    What is the first step the nurse should take to reduce stigma of mental health clients?

    A Increase social contact with mental health clients
    B Attend on-the-job training about mental health clients
    C Have a willingness to interact with mental health clients الإجابة الصحيحة
    D Understand the person as a mental health client
  431. 431

    Which maternal condition always necessitates delivery by cesarean birth?

    A Partial abruptio placentae
    B Total placenta previa الإجابة الصحيحة
    C Ectopic pregnancy
    D Eclampsia
  432. 432

    The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid should the nurse anticipate the practitioner to order initially to replace fluids?

    A D5W
    B 0.9 percent Normal Saline (NS) الإجابة الصحيحة
    C Albumin
    D D5 0.2 percent (1/4) Normal Saline
  433. 433

    Which assessment finding would the nurse document as subjective evidence of anorexia nervosa?

    A Lanugo
    B Bradycardia
    C 25-lb weight loss
    D Patient states fear of gaining weight. الإجابة الصحيحة
  434. 434

    A nurse is preparing to care for a patient with active tuberculosis (TB). Which of the following infection control measures should the nurse implement?

    A Place the patient in a positive-pressure isolation room.
    B Wear an N95 respirator when entering the room. الإجابة الصحيحة
    C Require visitors to wear surgical masks.
    D Implement contact precautions.
  435. 435

    A prenatal client tells the nurse about her craving for laundry starch. How should the nurse respond?

    A This craving is called pica. Try nonfat powdered milk to see if it satisfies your craving. الإجابة الصحيحة
    B You have a condition called bulimia. You must stop the ingestion of laundry starch immediately.
    C You have a condition called anorexia. This disorder will compromise fetal weight gain.
    D Since you are a vegan, the ingestion of laundry starch is considered normal.
  436. 436

    A client on an inpatient psychiatric unit tells the nurse, 'I don't want to be here anymore. None of this is helping, and I've been thinking about ending it.' What should be the nurse's first response?

    A Assign the client to 1:1 observation and document the order.
    B Encourage the client to attend a group therapy session for support.
    C Notify the health care provider of the client's suicidal ideation.
    D Ask the client if they have a specific plan to harm themselves. الإجابة الصحيحة
  437. 437

    A nurse is caring for a client with Type 1 diabetes who has nausea, vomiting, abdominal pain, and Kussmaul respirations. Which condition should the nurse suspect?

    A HHS
    B DKA الإجابة الصحيحة
    C SIADH
    D Myxedema coma
  438. 438

    While caring for an infant, which method should the nurse adopt to prevent heat loss caused by evaporation?

    A Wrap the infant in a cloth
    B Place the infant in a warm crib
    C Place the crib away from the windows
    D Dry the infant immediately after the bath الإجابة الصحيحة
  439. 439

    The nurse is planning postoperative care for an infant after a cleft-lip repair. Which nursing intervention is most appropriate for this infant?

    A Prone positioning
    B Suctioning with a Yankauer device
    C Supine or side-lying positioning الإجابة الصحيحة
    D Avoidance of soft elbow restraints
  440. 440

    Which of the following actions should a nurse take after witnessing a breach of a client's confidentiality in a provider's office?

    A Complete a health information privacy complaint form. الإجابة الصحيحة
    B Anonymously notify the proper governmental agency.
    C Notify the client and ask them to complete a health information privacy complaint form.
    D Inform the provider that a formal complaint will be submitted if another breach is committed.
  441. 441

    The nurse administers an incorrect medication to a client and realizes the error a few minutes later. Which action should the nurse perform?

    A Complete an incident report but do not document the report in the medical record. الإجابة الصحيحة
    B Document the error but do not complete an incident report unless the client has an adverse reaction.
    C Complete an incident report and document the report in the medical record.
    D Do not complete an incident report because the client did not experience any adverse effect.
  442. 442

    While donning sterile gloves for a client's dressing change, the nurse rips the cuff while pulling it over a wristwatch. What is the appropriate nursing action?

    A Use the ripped glove for nonsterile actions.
    B Continue with the dressing change.
    C Place a new sterile glove over the ripped glove.
    D Obtain a new pair of sterile gloves. الإجابة الصحيحة
  443. 443

    A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met?

    A Ambulates with assistance
    B Oxygen saturation of 98% الإجابة الصحيحة
    C Pain of 2/10 after medication
    D Verbalizing risk factors
  444. 444

    The nurse prepares to administer a vitamin K injection during the admission assessment for a newborn. The father asks, 'Why does my baby need a shot?' Which rationale for administering this injection should the nurse include in the response?

    A Activates clotting factors الإجابة الصحيحة
    B Dissolves blood clots
    C Promotes gas exchange
    D Promotes the production of hemoglobin
  445. 445

    The nurse is assessing a patient with chronic heart failure. Which abnormal chest sound would the nurse most likely auscultate?

    A Expiratory wheezes
    B Friction rub
    C Harsh vesicular
    D Crackles الإجابة الصحيحة
  446. 446

    Thomas has been a nurse in your ICU for 10 years. In facilitating Thomas' professional development, the nurse manager would focus on:

    A Certification for the ICU environment.
    B Discussions about how Thomas can fit with role expectations and relationships.
    C Possible changes to other ICU environments.
    D Encouraging him to lead changes that leave long-term impacts after his retirement. الإجابة الصحيحة
  447. 447

    A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and 216 is a private, positive-pressure airflow room. To which room should the nurse assign the client?

    A 208 الإجابة الصحيحة
    B 212
    C 214
    D 216
  448. 448

    The nurse is caring for a client who is admitted to the unit with tuberculosis (TB). Which type of isolation room is most appropriate?

    A Single-door room with positive airflow
    B Isolation room with an anteroom and negative airflow الإجابة الصحيحة
    C Isolation room with an anteroom and normal airflow
    D Single-door room with normal airflow
  449. 449

    The nurse assesses a newborn's penis 2 days after a circumcision and notes a yellow exudate around the head. Which is the appropriate nursing intervention?

    A Wash the penis with soap and a warm washcloth.
    B Take the newborn's temperature to determine if an infection is present.
    C Leave the area alone, as this is a normal finding. الإجابة الصحيحة
    D Report the finding to the health care provider.
  450. 450

    The nurse has recently been promoted to nurse manager on an oncology unit and has decided to be the sole decision maker regarding issues that concern the unit. Which type of leadership style is the nurse embodying?

    A Quantum
    B Democratic
    C Autocratic الإجابة الصحيحة
    D Laissez-faire
  451. 451

    The nurse manager plans to develop a unit-based council to assist in decision-making. The nurse manager is demonstrating which leadership style?

    A Authoritative
    B Democratic الإجابة الصحيحة
    C Laissez-Faire
    D Transactional
  452. 452

    Which classic symptom is most associated with pyloric stenosis in an infant?

    A Projectile, nonbilious vomiting الإجابة الصحيحة
    B Bilious green vomiting
    C Bloody diarrhea
    D Abdominal pain relieved by eating
  453. 453

    The nurse caring for a 3-year-old child plans to assess the child's pain using the Wong-Baker FACES Pain Rating Scale. Which accompanying assessment question would be the most useful?

    A If number 0 were no pain and number 10 were a big pain, what number would your pain be?
    B Can you point to the face picture with one finger and tell me what that pain feels like inside of you?
    C The smiling face has no hurting; the crying face has a really big hurting. Which face is most like your hurting? الإجابة الصحيحة
    D If you look at these faces and I give you a paper and pencil, can you draw for me the face that looks most like your pain?
  454. 454

    A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would be most appropriate?

    A Have the patient rest in bed with the head elevated to 15 to 20 degrees.
    B Ask the patient to rest in bed in a high-Fowler's position with the knees flexed.
    C Encourage the patient to sit up at the bedside in a chair and lean slightly forward. الإجابة الصحيحة
    D Place the patient in the Trendelenburg position with several pillows behind the head.
  455. 455

    The pediatric nurse is providing education to a new mother regarding ways to decrease the risk of sudden infant death syndrome (SIDS). Which statement by the nurse is appropriate?

    A You should keep the baby with you at all times to assess for apnea.
    B Make sure the baby has a soft blanket and pillow when sleeping.
    C It is recommended that you place your baby on his back for sleep. الإجابة الصحيحة
    D SIDS has been linked to immunizations. I recommend that you avoid immunizing your baby.
  456. 456

    During a 'tet spell,' which action should the nurse perform first?

    A Place the child in a knee-to-chest position الإجابة الصحيحة
    B Administer oxygen
    C Call the provider
    D Administer IV fluids
  457. 457

    The public health nurse provides care for a client on a directly observed therapy (DOT) program to treat tuberculosis. Which option best describes the care the nurse provides?

    A Follows the client until 3 sputum cultures are normal
    B Gives the client bus tokens or cab fare vouchers to attend scheduled clinic visits
    C Provides and watches the client swallow every prescribed medication الإجابة الصحيحة
    D Screens all of the client's close contacts
  458. 458

    Which client would the nurse suspect to have pyloric stenosis?

    A A 7-month-old with choking episodes
    B An 11-year-old with an olive-shaped abdominal mass
    C A 5-week-old infant with projectile vomiting الإجابة الصحيحة
    D A 2-year-old with a harsh cough
  459. 459

    A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad saturated approximately 12 cm with bright red lochia containing small clots. Which finding should the nurse document?

    A Moderate lochia rubra الإجابة الصحيحة
    B Excessive lochia serosa
    C Light lochia rubra
    D Scant lochia serosa
  460. 460

    The nurse working on the burn unit is interested in understanding the rate of renal compromise with a burn. Which step should the nurse take first?

    A Complete a literature review.
    B Work with a medical librarian to identify key words.
    C Develop a clinical question that can guide further research. الإجابة الصحيحة
    D Join the policy and procedure committee to evaluate care in the hospital.
  461. 461

    Which following level of evidence includes systematic reviews of multiple studies?

    A Level IV
    B Level III
    C Level II
    D Level I الإجابة الصحيحة
  462. 462

    Periodically, the nurse would return to work as a per diem nurse in the CCU. The staff was impressed with the nurse's performance; however, one staff member complained that the RN was unfamiliar with the new telemetry monitors when they first returned to work several months ago. This comment showed up in the annual evaluation, resulting in a poorer overall evaluation from the nurse manager compared with previous evaluations. This is an example of?

    A contrast bias.
    B a horn effect. الإجابة الصحيحة
    C recent behavior bias.
    D similar-to-me effect.
  463. 463

    A nurse is reinforcing discharge teaching with a client who has borderline personality disorder. The client reports being a single parent caring for two toddlers. Which of the following actions should the nurse take?

    A Notify child protective services.
    B Suggest the children live with other relatives.
    C Encourage the children to visit the psychiatric unit when the client is leaving.
    D Offer the client information about a support group for parents. الإجابة الصحيحة
  464. 464

    In quality improvement models, policies and procedures would represent an example of?

    A Process
    B Structure الإجابة الصحيحة
    C Outcomes
    D Direction
  465. 465

    Several nurses on a medical-surgical unit have been asked by the nurse manager to form a group and gather data regarding patient complaints of late meals. When the nurses meet and establish ground rules, this would be what phase of group development?

    A Forming الإجابة الصحيحة
    B Storming
    C Norming
    D Performing
  466. 466

    Which following medication is commonly administered to reduce intracranial pressure in patients with brain injuries?

    A Morphine
    B Aspirin
    C Marinol
    D Mannitol الإجابة الصحيحة
  467. 467

    A nurse is caring for a 12-month-old infant following the surgical repair of a cleft palate. The nurse should plan to feed the infant using which of the following instruments?

    A Spoon
    B Straw
    C Firm nipple
    D Cup الإجابة الصحيحة
  468. 468

    A female patient asks the nurse for ways to prevent recurrent urinary tract infections. How should the nurse respond?

    A Avoid douching. الإجابة الصحيحة
    B Clean the perineal area from back to front.
    C Use feminine hygiene sprays.
    D Wear clean nylon underpants.
  469. 469

    Using the Rule of Nines to assess a client with burn injuries to the entire back region and all of the left arm, how should the nurse document the percentage (TBSA) of the patient's body that sustained burns?

    A 18%
    B 36%
    C 9%
    D 27% الإجابة الصحيحة
  470. 470

    A community health nurse is planning a public service campaign to decrease the transmission of influenza. Which of the following interventions should the nurse include as a primary prevention?

    A Going to the hospital for dehydration after getting influenza
    B Obtaining an immunization الإجابة الصحيحة
    C Staying home when sick
    D Getting tested for influenza when you have symptoms
  471. 471

    The nurse is designing a quantitative research study. What is the purpose of this type of study in nursing?

    A Determine how patients feel about prescribed treatments.
    B Answer questions about statistically measurable concepts. الإجابة الصحيحة
    C Understand the nursing process in relation to the scientific method.
    D Identify interventions that are based upon the best evidence from research.
  472. 472

    The nurse is caring for a terminally ill pediatric client. The parents have decided to remove their child from life support. Which action by the nurse displays the role of client advocate?

    A Respecting the parents' decision الإجابة الصحيحة
    B Telling the parents they are making the right decision
    C Asking to be assigned to a different client
    D Referring the parents to social services
  473. 473

    A client with COPD is short of breath. Which position should the nurse encourage to ease the work of breathing?

    A Supine with a single pillow
    B Side lying (Sims) position
    C Sitting upright and leaning forward over a bedside table (tripod/orthopneic position) الإجابة الصحيحة
    D Trendelenburg position
  474. 474

    Which primary prevention nursing intervention would be implemented by the community nurse to decrease the risk of community members contracting sexually transmitted infections (STIs)?

    A Provide treatment for the infected population
    B Hand out a risk survey for the adult population
    C Screen for sexually transmitted disease infections
    D Educate about the importance of safe sex practices الإجابة الصحيحة
  475. 475

    The patient tells the nurse, 'I'm going to call you Stella because you remind me so much of my granddaughter.' Which barrier to therapeutic communication is the patient displaying?

    A Defending
    B Resistance
    C Transference الإجابة الصحيحة
    D Countertransference
  476. 476

    The Centers for Disease Control and Prevention has predicted that the flu will be very contagious this season. Based on this information, nurses set up flu vaccine clinics in local churches and senior citizen centers. Which level of prevention is this an example of?

    A Primary الإجابة الصحيحة
    B Secondary
    C Tertiary
    D Restorative
  477. 477

    After discussing various methods of contraception with a client and her partner, the nurse determines that the teaching was successful when they identify which contraceptive method as providing protection against sexually transmitted infections (STIs)?

    A oral contraceptives
    B tubal ligation
    C condoms الإجابة الصحيحة
    D intrauterine system
  478. 478

    You are caring for a patient with a diagnosis of iron-deficiency anemia. Which clinical manifestations are you most likely to observe when assessing this patient?

    A Convex nails, bright red gums, and alopecia
    B Brittle nails; smooth, shiny tongue; and cheilosis الإجابة الصحيحة
    C Tenting of the skin, sunken eyes, and complaints of diarrhea
    D Pale pink tongue; dull, brittle hair; and blue mucous membranes