1. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis.

Which of the following nursing measures should the nurse do FIRST? a. Institute seizure precautions b. Assess neurologic status c. Place in respiratory isolation d. Assess vital signs 2. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is MOST appropriate for this client? a. Reverse isolation b. Respiratory isolation c. Standard precautions d. Contact isolation 3. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions? a. A diagnosis of AIDS and cytomegalovirus b. A positive PPD with an abnormal chest x-ray c. A tentative diagnosis of viral pneumonia d. Advanced carcinoma of the lung 4. a. b. c. d. Which of the following is the FIRST priority in preventing infections when providing care for a client? Handwashing Wearing gloves Using a barrier between clients furniture and nurses bag Wearing gowns and goggles

5. An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected during a preemployment physical. Although frightened about her diagnosis, she is anxious to cooperate with the therapeutic regimen. The teaching plan includes information regarding the most common means of transmitting the tubercle bacillus from one individual to another. Which contamination is usually responsible? a. Hands. b. Droplet nuclei. c. Milk products. d. Eating utensils. 6. A 2 year old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action? a. Order a stat admission CBC. b. Place a urine collection bag and specimen cup at the bedside. c. Place a cooling mattress on his bed. d. Pad the side rails of his bed. 7. A young adult is being treated for second and third degree burns over 25% of his body and is now ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound care and is satisfied that he is prepared for home care when he makes which statement? a. I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water. b. If any healed areas break open I should first cover them with a sterile dressing and then report it. c. I must wear my Jobst elastic garment all day and can only remove it when Im going to bed. d. I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours. 8. An eighty five year old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm an agitated client is a. limit visits by staff. b. encourage family phone calls.

c. d.

position in a bright, busy area. speak soothingly and provide quiet music.

9. Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands the procedure when she makes which of the following remarks the night before the procedure? a. She says to her husband, Please bring me a hamburger and french fries tomorrow when you come. I hate hospital food. b. I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital. c. I understand it will be several weeks before all the radiation leaves my body. d. I brought several craft projects to do while the radium is inserted. 10. The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff? a. The nurse aide is not wearing gloves when feeding an elderly client. b. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing. c. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care. d. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation. 11. The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in preparation for cleaning and redressing the wound. The most appropriate action for the charge nurse is to: a. interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old dressing. b. congratulate the nurse on the use of good technique. c. discuss dressing change technique with the nurse at a later date. d. interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves. 12. Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is: a. Correct illumination of the environment. b. amount of regular exercise. c. the resting pulse rate. d. status of salt intake. 13. Mrs. Jones will have to change the dressing on her injured right leg twice a day. The dressing will be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which statement best indicates that Mrs. Jones understands the importance of maintaining asepsis? a. If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled. b. If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline. c. If I question the sterility of any dressing material, I should not use it. d. I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s. 14. A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation? a. Masks should be worn with all client contact. b. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items. c. Isolation gowns are not needed. d. A private room is always indicated. 15. A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation? a. Masks should be worn with all client contact.

b. c. d.

Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items. Isolation gowns are not needed. A private room is always indicated.

16. The nurse is evaluating whether nonprofessional staff understand how to prevent transmission of HIV. Which of the following behaviors indicates correct application of universal precautions? a. A lab technician rests his hand on the desk to steady it while recapping the needle after drawing blood. b. An aide wears gloves to feed a helpless client. c. An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy. d. A pregnant worker refuses to care for a client known to have AIDS. 17. Jayson, 1 year old child has a staph skin infection. Her brother has also developed the same infection. Which behavior by the children is most likely to have caused the transmission of the organism? a. Bathing together. b. Coughing on each other. c. Sharing pacifiers. d. Eating off the same plate. 18. Jessie, a young man with newly diagnosed acquired immune deficiency syndrome (AIDS) is being discharged from the hospital. The nurse knows that teaching regarding prevention of AIDS transmission has been effective when the client: a. verbalizes the role of sexual activity in spread of the disorder. b. states he will make arrangements to drop his college classes. c. acknowledges the need to avoid all contact sports. d. says he will avoid close contact with his three-year-old niece. 19. a. b. c. d. Which question is least useful in the assessment of a client with AIDS? Are you a drug user? Do you have many sex partners? What is your method of birth control? How old were you when you became sexually active?

20. Mrs. Parker, a 70-year-old woman with severe macular degeneration, is admitted to the hospital the day before scheduled surgery. The nurses preoperative goals for Mrs. M. would include: a. independently ambulating around the unit. b. reading the routine preoperative education materials. c. maneuvering safely after orientation to the room. d. using a bedpan for elimination needs

1. A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), the physician orders diagnostic testing of vaginal discharge. Which STD must be reported to the public health department? a. Bacterial vaginitis b. Gonorrhea c. Genital Herpes d. Human papillomavirus (HPV)

2. When reporting to the outpatient cancer center for his first chemotherapy treatment, a client appears anxious and apprehensive. Which statement by the nurse may help allay the clients anxiety? a. You may have a seat over here. b. We wear gowns and gloves to administer chemotherapy drugs because theyre very dangerous. c. You look anxious, dont worry you will get used to this place. d. As a precaution, we wear gowns, goggles, and gloves to administer the medication.

3. To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client clean the area? a. By swabbing the labia minora from front to back

b. c. d.

By cleaning the labia minora from back to front By cleaning the labia majora from back to front By swabbing the entire perineal area

4. After administering an I.M. injection, a nurse notices there isnt a sharps-disposal container nearby. Which action should the nurse take? a. Hold the barrel of the syringe in one hand. With the other hand, push the cap into place over the needle. b. With one hand, use the needle to sccop up the cap. Holding the barrel in one hand, carry the syringe to the closest sharps-disposal container. c. With one hand, use the needle scoop up the cap. Holding the barrel in one hand, carry the syringe to the closest trash container. d. Hold the barrel of the syringe in one hand. With the other hand, push the cap into place over the needle. Carry the syringe to the closest sharps-disposal container.

5. a. b. c. d.

Which nursing diagnosis takes highest priority for a client with a compound fracture? Imbalanced nutrition: Less than body requirements related to immobility Impaired physical mobility related to trauma Risk for infection related to effects of trauma Activity intolerance related to weight-bearing limitations

6. a. b. c. d.

After a traumatic back injury, a client requires skeletal traction. Which intervention takes priority? Monitoring the client for skin breakdown Maintaining traction continuously to ensure its effectiveness Supporting the traction weights with a chair or table to prevent accidental slippage Restricting the clients fluid and fiber intake to reduce the movement required for bedpan use.

7. a. b. c. d.

A nurse is about to give a full-term neonate his first bath. How should the nurse proceed? Bathe the neonate only after his vital signs have stabilized Clean the neonate with medicated soap Scrub the neonates skin to remove the vernix caseosa Wash the neonate from feet to hand

8. A 3-year-old child is admitted to the hospital with an acute exacerbation of asthma. The childs history reveals that the child was exposed to chickenpox 1 week ago. When would this child require isolation? a. Isolation isnt required b. Immediate isolation is required c. Isolation is required 10 days after exposure d. Isolation is required 12 days after exposure

9. The nurse is reassigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice? a. An 18 month-old who ate an undetermined amount of crystal drain cleaner b. A 14 month-old who chewed 2 leaves of a philodendron plant c. A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium) d. A 30 month-old who has swallowed a mouthful of charcoal lighter fluid

10. The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mothers lap. Which of the following should the nurse do first? a. Elicit reflexes b.Measure height and weight c. Auscultate heart and lungs d. Examine the ears

11. Which of these principles should the nurse apply when performing a nutritional assessment on a 2 year-old client? a. An accurate measurement of intake is not reliable b.The food pyramid is not used in this age group c. A serving size at this age is about 2 tablespoons d. Total intake varies greatly each day

12. The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. What action should the nurse take? a. Notify the health care provider b. Palpate the anterior fontanel c. Feel the posterior fontanel d. Record these normal findings

13. An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the childs question, Where do babies come from? What is the nurses best response to the parent? a. When a child asks a question, give a simple answer. b. Children ask many questions, but are not looking for answers. c. This question indicates interest in sex beyond this age. d. Full and detailed answers should be given to all questions.

14. A client has a soft wrist-safety device. Which assessment finding should the nurse consider normal? a. A palpable radial pulse b. A palpable ulnar pulse c. Cool pale fingers d. Pink nail beds

15. The nurse is performing wound care using surgical asepsis. Which practice violates surgical asepsis? a. Holding sterile objects above the waist b. Pouring solution onto a sterile field cloth c. Considering a 1 edge around the sterile field contaminated d. Opening the outermost flap of a sterile package away from the body

16. Which assessment finding by the nurse contraindicates the application of a heating pad? a. Active bleeding b. Reddened abscess c. Edematous lower leg d. Purulent wound drainage

17. A positive Mantoux test indicates that the client: a. Is actively immune to tuberculosis b. Has produced an immune response c. Will develop full-blown tuberculosis d. Has an active case of tuberculosis

18. Which action by the nurse is essential when cleaning the area around a Jackson-Pratt wound drain? a. Clean from the center outward in a circular motion b. Removing the drain before cleaning the skin c. Cleaning Briskly around the site with alcohol d. Wearing sterile gloves and mask

19. An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant? a. Single-hole nipple b. Plastic spoon c. Paper straw d. Rubber dropper

20. What is the first action that a nurse should take after omitting an ordered medication? a. Notify the prescriber, nursing supervisor, and pharmacist b. Document the omission and reason c. Write an incident report d. Give an extra dose at the next scheduled time.