NACE PN TO RN Exam Questions with 100% correct Answers

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To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following? - ANSWER-Correct Answer: Organs The purpose of de... ep palpation, in which the nurse indents the client's skin approximately 1-1/2", is to assess underlying organs and structures such as the kidneys and spleen. Skin turgor, hydration, and temperature can be assessed using light touch or light palpation. A client is brought to the emergency department and the physician determines he has gastrointestinal (GI) bleeding. In planning for his care, which of the following would be first priority? - ANSWER-The Correct answer is: assessment of vital signs Vital sign assessment would be the priority nursing intervention. This would provide an indication of the amount of blood loss that has occurred and also provide a baseline by which to monitor the progress of treatment. The other answers (b, c, and d) are important but not priority actions. When providing instructions to the adolescent regarding physical development of her body, the RN should do all of the following EXCEPT - ANSWER-Correct Answer: Discuss the importance of avoiding social events in order to stay out of trouble. Socialization is very important to teenagers and is a normal part of their development. The other answers (b, c, and d) are all accurate instructions and discussions for the adolescent regarding development. The nurse is developing discharge plans for a 65-year-old client. The discharge plans indicate the client will be discharged home with home health nursing care. The nurse provides the home health agency with details regarding the needs of the patient. The nurse made which of the following to the home health agency? - ANSWER-Correct answer: A referral. A referral is recommending home care services or giving information to an home care service regarding the client and the client's needs. Typically the sources of referral to a home care agency are family members, nurses, physicians, social workers, discharge planners or therapists. Which of the following is the normal serum electrolyte level for magnesium? - ANSWER-Correct answer: 1.6 to 2.4 mEq/L The school nurse is approached by a mother who explains that her kindergarten child is constantly scratching the perianal area and that the area is irritated. The RN understands that she should instruct the mother to obtain a rectal specimen by a tape test and that the mother should obtain the specimen when? - ANSWER-The Correct answer is: in the morning, when the child awakens Visualization of pinworms by means of a tape test is necessary for the diagnosis. Transparent tape is lightly touched to the anus and then applied to a slide for microscopic examination. The best specimen is obtained as the child awakens, before toileting or bathing. A 20-year-old patient is admitted to the hospital with respiratory failure. He's intubated, given oxygen, and is coughing with copious secretions in his lungs. What should be done first? - ANSWER-Correct Answer: Suction the lungs The first priority is to make sure the client's airways are clear and that he can breathe. The other choices can be addressed after ensuring the client can breathe. A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and intervention, what would be the MOST desirable outcome? - ANSWER-Correct Answer: The student accepts a referral to a substance abuse counselor. All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor. The RN is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse use to dilute this medication? - ANSWER-Normal saline (0.9%) solution. Phenytoin (Dilantin) should be administered by injection into a large vein by intermittent intravenous infusion. Normal saline (0.9%) solution is the preferred solution. Dextrose should be avoided because of medication precipitation. Which of the following terms corresponds with the phrase: a woman that is pregnant? - ANSWER-Gravida Gravida is another word for pregnancy. Spermatogonia refers to male sperm cells. Placenta previa is when the placenta is too close to the cervix. A healthy first time pregnant client asks the nurse, "How long will I stay in the hospital after my baby is born." The client is scheduled for a Caesarean section. The nurse understands the average timeframe for the hospital stay for a Caesarean section is what? - ANSWER-Correct Answer: 72 hours. The hospital stay for a healthy mother who has delivered an infant varies depending on the type of delivery. The length of stay in the hospital for a vaginal birth is typically 24 to 48 hours. The length of stay in the hospital for a Caesarean section that does not have any complications is 72 hours. The community nurse is planning a smoking cessation program. What would be the first step in developing a health promotion program? - ANSWER-Correct Answer: Conducting health risk surveys First conduct initial assessments to determine if there is a health risk. Then follow the course of action in place in this event. A woman is two months pregnant when her five-year-old child develops rubella. What is most likely to be given to the mother? - ANSWER-Correct Answer: Immune serum globulin Immune serum globulin gives her a passive immunity and helps keep her from developing rubella, which can have devastating effect on her unborn child. MMR is a live virus and is not given to pregnant women. RhoGam prevents anti Rh antibody development. There is no such thing as rubella antitoxin. What is the normal value of urine potassium? - ANSWER-25-120 mEq/24 hr The normal value for urine potassium is 25-120 mEq/24 hr Before applying a cord clamp, the nurse assesses the umbilical cord for the presence of vessels. The findings that are often associated with genitourinary abnormalities are what? - ANSWER-Correct Answer: one artery, one vein. Two arteries and one vein are present in a normal umbilical cord. The presence of one artery in the umbilical cord is associated with genitourinary abnormalities. You are assigned to educate the nursing assistants regarding caring for the older adult. It is important that the assistants understand that which of the following situations portrays ageism? - ANSWER-The Correct answer is: Advising older adults to forgo aggressive treatment. Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older persons are different from "me" and will remain different from "me." Advising older adults to forgo (go without) aggressive treatment, when such a treatment would be offered as a possibility to the general population, displays ageism by treating the older adults as fundamentally different from the general population. The other answers identify supporting roles of the nurse for the older person. When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen? - ANSWER-The correct answer is strawberries. Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots and oranges rarely cause allergic reactions. A nurse who violates the civil rights of an individual may be committing what? - ANSWER-Correct answer: A tort. A tort is the process of violating civil law when dealing with an individual or an individual's property. The types of torts are commission and omission. Further, negligence and malpractice are not the best choices as these deal with unintentional torts. A patient with Addison's disease has been given an inadequate steroid dosage. Which of the following are NOT symptoms the patient could experience? - ANSWER-Correct Answer: Weight gain. Weight loss is more likely. Fatigue, weakness, and dizziness are often indicated. Which of the following behaviors does NOT show improvement in a client with Obsessive Compulsive Disorder? - ANSWER-Correct answer: Client uses "will power" to stop rituals. The client can employ appropriate intervention techniques and more about the disease process such as B, C and D. "Will power" alone will not be effective in dealing with Obsessive Compulsive Disorder. The client can employ appropriate intervention techniques by refraining from rituals during times of stress, using the "thought-stopping" strategy when experiencing obsessive thoughts, and verbalizing rituals and stress relationships. Of the following, which is the normal range of respiration rate, in breaths per minute, for an adult? - ANSWER-12-20 30-45 breaths per minute is the normal range for an 3-6 month old babies. 24-32 is normal for a toddler, and 20-24 for a small child. The average breath rate drops with age and levels off during adolescence, to approximately 12-20 breaths per minute. Which of the following is the generic name for Nizoral? - ANSWER-Ketoconazole. Isotretinoin is the generic name for Accutane. Nystatin is the generic name for Mycostatin and Flucinonide, a generic name for Lidex. Which of the following is not a goal for a client with social phobia? - ANSWER-Correct answer: Use suppression. A client needs concrete goals to pursue. These goals might include managing fear in groups, verbalizing feelings in stressful situations, and developing a plan for stressful situations. Suppression, or avoidance of thoughts and feelings, would be very counterproductive to a person with social phobia. A client has had pain in the right leg for 3 weeks. The nurse understands that the MOST LIKELY effect of this pain is? - ANSWER-Correct Answer: The disruption of sleep. Pain can have many effects on the human body. Clients with acute pain may have a decrease in appetite, decrease in fluid intake, nausea, vomiting and disruption in sleep. Which of the following is the sixth provision of the Code of Ethics for Nurses? - ANSWER-Correct Answer: "The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action." Which of the following is a brand name for Rabeprazole? - ANSWER-Correct answer: Aciphex. Aciphex is a brand name for Rabeprazole. Carafate is a brand name for Sucralfate and azulfidine for Sulfasalazine. Zantac is Ranitidine. Which of the following is MOST likely a characteristic found with individuals who are diagnosed with borderline personality disorder? - ANSWER-The correct answer is: identity disturbance. Individuals with borderline personality have an identity disturbance where the individual has difficulty keeping a stable mood and self image. Characteristics of personality disorders are unpredictable behavior, impulsiveness, and irritability. Timidness, social discomfort and fear of negative feedback are not typical with borderline personality but are found in individuals diagnosed with avoidant personality disorder. The nurse at the family planning clinic has performed teaching on oral contraceptives. The nurse knows that the teaching has been effective when one of the clients responds: - ANSWER-Correct Answer: "I can't take 'the pill' if I have gallbladder disease." Oral contraceptive is contraindicated in women with gallbladder disease and those who are heavy smokers. There is not an age specification. Menstrual flow is decreased with the use of oral contraceptives. Which of the following clinical signs would the nurse expect to see in a child with respiratory depression? - ANSWER-Correct answer: Shallow breathing. Respiratory depression is the breaths per minute that are less than 12 breaths per minute in a child who is two years of age and younger. Respiratory depression is one of the complications associated with opioids (for example morphine, codeine, Demerol, Oxycodone), which are a common analgesic given to client's after surgery or to treat a severe injury. Children who experience respiration depression exhibit clinical signs such as shallow breathing, sleepiness and small pupils. Which of the following blood transfusion reactions is a rare, but severe reaction in which the donated blood type is not compatible with that of the patient? - ANSWER-Correct Answer: Hemolytic A hemolytic transfusion reaction is a serious complication that occurs when the red blood cells that were given during a transfusion are destroyed by the person's immune system. An allergic transfusion reaction is usually due to a patient's sensitivity to the plasma proteins of the donor's blood. A febrile transfusion reaction is caused by the incompatibility of leukocytes. A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stool to look like which of the following? - ANSWER-Correct answer: Black and tarry. Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes in the blood. Vomitus associated with upper GI tract bleeding is commonly described as coffee ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding. A client is scheduled to have a blood transfusion. The client asks the nurse, "What types of diseases are transmitted through blood transfusions?" The nurse should respond that there is a low risk of contracting diseases through blood transfusions. However, a possible illness is which of the following? - ANSWER-Correct answer: CytomegalovirusBlood borne diseases and diseases that are transmitted through a transfusion are Hepatitis B, Hepatitis C, HIV, Cytomegalovirus and Malaria, to name a few. Also, the nurse should assure the client that the transmission of these diseases is low since blood banks have rigorous screening procedures to test blood. In which of the following stages of reaction toward stress does a body increase in hormone levels in order to mobilize for a fight? - ANSWER-Correct answer: Alarm. During the exhaustion stage, the body becomes "exhausted" because it did not positively respond to the stress. The body undergoes many physiological changes such as taking more air into the lungs in order to prepare for fight or flight during the resistance stage. In a client with acute hepatitis, the nurse assesses the client's aspartate aminotransferase (AST) range on the laboratory test at 520 units. What should the nurse understand about this test value? - ANSWER-Correct Answer: The AST is elevated. In clients with acute hepatitis, liver disease and myocardial infarction, the aspartate aminotransferase (AST) is elevated. The normal range for this enzyme in the blood is 10 to 26 units per liter. In clients with acute hepatitis, the enzyme may be elevated four times above the normal range. The nurse who teaches nutrition at a community center is asked "how much water does a person need to drink daily". The nurse's best response would be: - ANSWER-The correct answer is two quarts. The average adult needs eight glasses, or two quarts, of water per day. The remaining answer choices are not correct. Which of the following tasks can a registered nurse delegate to a nursing assistant in an acute mental health setting? - ANSWER-Correct answer: Checking for sharp objects. A nursing assistant may be assigned to search a client's luggage or room for potentially harmful objects, such as glass or sharp metal. A mental status assessment should be conducted by the nurse on admission. Administering medication cannot be delegated to an unlicensed person. A nurse or physician must discuss the treatment plan with the client The nurse observes a child's nasal discharge. The discharge is clear in both nasal cavities. The discharge most likely indicates what type of condition? - ANSWER-Correct Answer: allergy. A child who has clear, watery discharge is associated with allergies. The remaining answer choices are not the best options as bloody discharge is indicative of a nosebleed or a trauma. Itchy mucus containing discharge indicates an upper respiratory infection. If there is mucoid or purulent nasal discharge in one side of the nostrils, the child may have a foreign body lodged in the nostril. A female client who complains of chest pain is admitted. The nurse can expect which of the following laboratory tests ordered by the physician to confirm a myocardial infarction diagnosis? - ANSWER-Correct Answer: creatine kinase The physician orders laboratory tests and diagnostic tests to confirm a diagnosis of myocardial infarction. Creatine kinase is an enzyme located in the cardiac muscle, brain and skeletal muscle. As this enzyme rises, there is injury to the muscle cells. Further, the higher the serum CK, the more the muscle tissue that is damaged. Electrocardiogram, radionuclide imaging and hemodynamic monitoring are used to diagnosis a myocardial infarction. However, these are diagnostic tests and not laboratory tests. The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammograms - ANSWER-The correct answer is yearly after age 40. The American Cancer Society recommends a mammogram yearly for women over age 40. The other statements are not correct. It is recommended that women between ages 20 and 40 have a professional breast examination (not a mammogram) every 3 years. The client had a nephrectomy for the removal of kidney due to major lacerations two hours ago. What is a nursing priority? - ANSWER-Correct answer: Maintain the drainage tube patency The nurse should monitor the drainage tube patency every 4 hours for 24 to 48 hours after the client's nephrectomy procedure. By doing so, the nurse can ensure the client's tubes drain freely and help prevent hydronephrosis, which is urine collected in the renal pelvis because of obstruction with the outflow of the urine. A client is admitted with tuberculosis. The client should be placed in which type of precaution based isolation? - ANSWER-Correct answer: Airborne. The nurse should use airborne precautions when caring for a client with known or suspected tuberculosis to reduce the spread of the tuberculosis. Precautions that are employed are private room that has its own hand washing station and bathroom, special ventilation system that is separate from the hospital wide ventilation system and providing masks for anyone entering the room to see the client. Which clinical indicator is the nurse most likely to identify when exploring the history of a client with insomnia? - ANSWER-Correct answer: Irritability. Insomnia is the inability to fall asleep or stay sleep. Individuals who experience insomnia complain of unrefreshed sleep, daytime sleepiness, trouble concentrating, irritabilit [Show More]

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