38TH CASE SCENARIO (NURSING)MATERNITY/ PEDIATRIC. QUESTIONS

(1) A 28years old woman delivers an 8lb 2oz baby via spontaneous vaginal delivery. The nurse assists the patient with her first breast feeding experience. Which of the following should be the highest priority?.

Answer:

(A) check to if her bread is adequate.

(B) Talk about her spontaneous vaginal delivery.

(C)Stay with the mother and teach her how to position the baby .

(D ) All of the above.

Correct answer C.

(2)A 40 years old woman is admitted to the hospital with a diagnosis of Meniere’s syndrome. The nurse discusses with the patient how to care for herself at home. The nurse should teach the patient to.

Answer:

(A)Avoid quick movements of her head causes headaches, dizziness, nausea and Vomiting.

(B) Watch your back.

(C) Move steadily and cautiously.

(D) All of the above.

Correct answer A.

Rationale: Signs and symptoms Vertigo (dizziness) hearing loss( unilateral)tinnitus ( ringing in the ear). Meniere’s disease affects the inner ear,impacting hearing ability and balance in most carse.The severity of the disease varies from case to case.Teaching patient to eliminate coffee, tea,alcohol, avoid stimulating drugs. Stop smoking.

(3) A 19years old woman comes to the doctor’s office for a routine prenatal checkup at 34weeks gestation. Abdominal palpitation reveals the fetal position as ROA(Right Occiput Anterior).At which of the following sides would the nurse find the fetal heart tone?.

Answer:

(A) It doesn’t matter the baby keeps on moving.

(B )Tomorrow it will be above the umbilical.

(C) Below the umbilical, on the mother’s right side,the occiput and back are pressing against the right side of the mother’s abdomen. The fetal heart tone would be heard below umbilicus on the right side.

(D). All of the above.

Correct answer C

(4) A 25years old female came to the clinic at 32weeks gestation. A diagnosis of PIH ( Pregnancy induced hypertension) is made.The nurse performs teaching. Which of the following statements if made by the patient indicates to the nurse that further teaching is required?.

Answer:

(A) I have to darken my room and minimize drinking fluids.

(B )I have to darken my room and increase fluid intake.

(C) None of the above.

(D) All of the above.

Correct answer B.

Patient need to increase fluid intake instead of decreasing.

(5) A 35 years old patient with gestational diabetes mellitus (GDM) delivers 10Ibs baby boy at 37weeks gestation. The new born is admitted to the special care nursery for observation.Which of the following nursing diagnosis is most important for the nurse to consider when planning the infant care?.

Answer :

(A) Baby has too much carbon dioxide.

(B) Airway is patent.

(C )A& B

(D)Impaired gas exchange due to respiratory distress syndrome. This involves the most important physical needs for airway synthesis of surfactant that may be altered because of fetal high levels of insulin.

Correct answer D.

Rationale: Surfactant substance like a detergent secreted that reduces the surface tension of the fluids that line the respiratory passages.It causes uniform expansion of the lungs.Without surfactant the INFANT is unable to keep lungs inflated and exerts considerable effort with each respiration to re- expand the alveoli. Inability to maintain lung expansion results in atelcetesis (Collapse of part of the lung)hypoxemia(insufficient 02 in the blood) and hypocapnia (increase in the amount of cow in the blood)Signs and symptoms.

Respiratory distress syndrome.

Cyanosis.

Tachypnea( respiration upto 80 to 120mm).

Grunting

Nasal flaring.

Diminished breathe sounds.

TREATMENTS:

Administration of artificial Surfactant.

Assist with Ventilatory Support.

Provide oxygen.

IVF administration of sodium bicarbonate to correct metabolic acidosis.

Answer:

(6)After delivery the nurse assess the patient for depression .This includes any prior history of depression or any mood changes such as premenstrual irritability. The six weeks follow up visit might be too late to assess for postpartum depression. Why is it important for the nurse to ask these questions about history of depression or mood changes.

(A) The six weeks follow up might be too late especially for a woman who shows the symptoms of depression before delivery or shortly after delivery. It is important to make sure that the new mom can take care of her new born after leaving the hospital.

(B )It is better to wait until when patient call to complain.

( C)The six weeks follow up is the best time to take care of such things.

(D) All of the above.

Correct answer A.

(7)The nurse planned care for a 27years old female admitted with toxic shock syndrome. The nurse should give which of the following nursing diagnosis is the highest priority?.

Answer:

(A) Knowledge deficit related to disease process.

(B )Ineffective coping mechanism

( C)Fluid volume deficit related to Vomiting. Her physical needs are very important.

(D) All of the above.

Correct answer C.

(8)The nurse teaches a 20years old primigravida how to measure the frequency of uterine contractions. The nurse should explain to the patient that the frequency of uterine contractions is determined?.

Answer:

(A)By the number of contractions that occur within a given period of time. There must be at least three contractions to establish frequently.

(B)Contraction is every five minutes.

(C)Then it decreases to every three minutes.

(D) None of the above is correct.

Correct answer A

(9) A woman at 32 weeks gestation visits her doctor for prenatal care. The doctor finds that her blood pressure is 140/90 and that she has protein in her urine and +2 pedal edema. The nurse teaches the patient on how to care for herself at home. Which of the following statement if made by the patient will indicate that further teaching is needed.

Answer:

(A)I shall decrease my fluid intake and increase my complex carbohydrate.

(B)I don’t think that the result is correct.

(C) None of the above.

(D) A& B.

Correct answer A.

Rationale: Incorrect response by the patient. She should increase her fluid intake to 8glasses a day.And should add roughage,bran,fruits, leafy vegetables to prevent constipation due to inactivity, not increase intake of complex carbohydrate rather she should eat a nutritionally balanced diet.

(10) A 37 years old primigravida at 28weeks gestation takes a three hour glucose tolerance test.The result indicates a fasting blood sugar of 100mg/dl,and a two hour post load blood sugar of 300mg/dl.Which of the following nursing diagnosis should be considered the highest nursing priority?.

Answer:

(A) My blood sugar is always weird anyway.

(B )My blood sugar check is done three times a day.

(C) Potential noncompliance related to lack of knowledge or lack of adequate support system. Patient may not ne able to meet physical needs because of lack of knowledge.

D All of the above.

Correct answer C.

(11) At term a 21years old woman is admitted to the hospital in active labor. The nurse assesses the patient and note that the heart rate is 132.During a contraction the fetal heart rate drops to 127.When the contraction is completed,the fetal heart rate is 130.The nurse should recognize that the fetal heart rate response to the contraction.

Answer:

(A) The fetal heart is too high.

(B)The fetal heart rate is abnormal

(C) The fetal heart rate is within normal limits. Variability is normal, no indication of fetal distress.

(D) None of the above.

Correct answer C.

(12) A 23years old primipara comes to the hospital in active labor. The patient labor began at 8pm.The cervix was completely dilated at 12:45 am. The baby was delivered at 02:43am.The placenta was expelled at 03.06am.Which of the following actions should the nurse record as the length of the patient’s second stage of labor.

Correct answer: 1 hour 55minutes upto 2hours is normal.

First Stage of Labor:From the onset of contractions to the dilatation of cervix.

Second Stage:Pushing Stage from complete dilation of the cervix until expulsion of the fetus.

The Third Stage – This is from delivery of the fetus to complete expulsion of the placenta.

(13) The nurse is caring for Rh negative mother who has delivered an Rh positive child. The mother states ” .The doctor told me about RhoGam but I am still a little confused “.Which of the following responses if made by nurse is most appropriate.

Answer:

(A) RhoGam is given to mother to prevent the formation of antibodies.This will prevents maternal circulation from developing antibodies.

( B)This is expected.

(C) None of the above.

(D) All of the above.

Correct answer: A

(14) A 22years old female is admitted to the hospital and she delivers a healthy baby girl 7lb 2oz.Teh mother decided to bottle feed her infant. On her second postpartum day, the mother attends on education session on breast care for none breast feeding mothers. Which of the following statements if made by the mother after the teaching session indicates to the nurse that the patient need further instruction?.

Answer:

(A) I am not sure if my baby cares about breast.

(B) I will pump if my husband wants me to pump my breast milk.

(C)I will pump my breast and use warm pack to relieve breast pain .

(D) All of the above.

Correct answer C .

Rationale :Stimulates hormonal responses increases production of milk causing engorgement, Stimulation of breast tissue by pumping of breast, suckling of infant, running warm over breast is avoided.

TREATMENTS

Treatment of engorgement in non breastfeeding mothers. Tight binder,icepack, and mild analgesia.

Care of breast for breast feeding mothers.

Wash breast daily with plain water.

Prepare nipples by exposing it to air and sun.

Wear loose clothing. Redness and swelling indicate infect.

(15) A 20years old female is admitted to the hospital in premature labor has been treated successfully. The patient is to be sent home on oral regimen of ritodrine(yutopar).The nurse prepares the patient for discharge and teaches the patient about this medication. Which of the following statements if made by the patient would indicate to the nurse that the patient understands the discharge teaching about this medication?.

(A) I may feel a rapid heartbeat and some muscle tremors while on this medication.

(B) I may feel weak and tired.

(C )I will not feel anything.

(D )None of the above.

Correct answer A.

Rationale Since the medication causes rapid heartbeat and muscle tremors. Closely monitor blood pressure, maternal and fetal heart rate.

(16) A nurse in the postpartum unit cares for a 27years old female who delivered her first child the previous day.During the assessment of the patient, the nurse notes multiple varicosities on the patient lower extremities. Which of the following activities would be most effective in preventing postpartum Thrombophlebitis?.

(A )Encourage early and frequent ambulation.Because it facilitates emptying of blood vessels in lower extremities.

(B) Patient will be too tired to ambulate.

(C) All of the above.

(D) None of the above.

Correct answer A.

Rationale: High risk of developing Thrombophlebitis during pregnancy and immediately postpartum period.

Thrombophlebitis is inflammation of vein associated with formation of a thrombus blood clot. Other risk factors are prolonged immobility, use of oral contraceptives, sepsis, smoking, dehydration and CHF.

SIGNS AND SYMPTOMS.

Pain in the calf

Localized edema of of one extremity,

Positive Horman’s sign.

Pain in the calf when foot dorsiflexed.

TREATMENT:

Bedrest and elevation of Extremity.

Anticoagulants (Heparin)

(1 7)The first discharge composed of blood, shredded fetal membranes, decidua,vernix caseosa,lanugo and membranes. Is known as ?.

(A) Serosa pink.

(B) lochia alba.

(C )Locia rubra.

(D) All of the above.

Correct answer: C.

(18) It is red in color because of the large amount of blood it contains and it last for?.

(A )10 to 14 days.

(B )1 to 3 days

(C) 3 to 10 days.

(D) All of the above.

Correct answer B.

(19) A patient had a c-section and three days after delivery. She developed a positive Homan sign .Which is an indicative of a possible blood clot and should be reported to?

A The nurse manager.

B The charge nurse.

C The supervisor.

D The Physician.

(20) The boggy fundus and increased lochia may be the result of uterine atony.And this may God lead to the postpartum hemorrhage. This must be immediately reported to?.

(A )Patient family.

(B )The doctor.

(C )The charge nurse.

(D )All of the above.

Correct answer B

(21)In the first 3 to 10days.Lochia is?

(A) Non- existence.

(B )Serous.

(C)Alba.

(D) Rubra.

Correct answer B.

Rationale: By the third day to 10 days bleeding has decreased. So you will see serosa pink.

(22) The Narcotics should not be given for how many hours after receiving Duramorph?.

(A)After 24hours.

(B) After 6hours.

(C) After 12 hours.

(D )None of the above.

Correct answer A.

(23) Patient with a third or forth degree laceration. Should not be given?.

(A) Dulcolax suppositories.

(B) Ferous sulfate.

(C) Tylenol #3

(D) Colace.

Correct answer A.

(24)During the BUBBLER ,it should be completed every four hours. And this includes?.

(A) Assessment of the breasts,uterus, bowel,bladder, lochia episiotomy and patient response.

(B) Lochia rubra and episiotomy.

(C) Patient response and bowel.

(D )Assessment of uterus, breast, bladder,and patient response.

Correct answer A.

(25)If lochia has a foul smell. This may be an indication of what?.

(A) Bleeding a lot.

(B )Normal postpartum findings.

(C) Uterine atony.

(D) An infection.

Correct answer D.

(26) A 18years old female heroine addicted mother delivered 5lbs baby girl. The newborn infant is transferred to the nursery where the nurse performs an initial assessment. How soon after birth would the nurse expect the infant to manifest clinical symptoms of withdrawal ?.

(A) Right at birth.

(B) One hour after birth.

(C) 12 to 24hours may appear normal at birth, mother often has taken heroin, morphine or alcohol just before seeking help for delivery, will delay symptoms of withdrawal in both the mother and infant.

(D) All of the above.

Rationale:

Narcotic such as heroin, readily cross over the placenta to the fetus. An infant is born passively addicted to the drug.Signs and symptoms of narcotics withdrawal are high pitched cry, tachypnea (respiratory rate in excess of 60),frequently sneezing, and yawning, sweating, irritability and tremors. Symptoms may persist for 3 to 4months.

TREATMENT:

Decrease external stimuli.

Good nutrition and hydration.

Administration of phenobarbital,Chlorpromazine, diazepam, or paregoric.

Promote mother and infant bonding.

Create quiet environment.

Swaddle or wrap the infant snugly.

PEDIATRICS

(1)During a well baby check up the nurse evaluate the reflexes of a six months old baby. Which of the following reflexes would be abnormal to observe.

Answer:

A Extrusion reflexes disappears at birth.

(B) Extrusion reflexes last for a year.

(C)Extrusion reflexes occurs when feeding. The extrusion reflexes suppose to disappear between three months and four months.

(D) All of the above.

Correct answer C.

(2)Phenobarbital is ordered for a five years old boy with a Convulsive disorder. The nurse teaches the child’s parents about the medication .The nurse should tell the parents that a common side effect of phenobarbital is:

Answer:

(A)Decreased activity level.

B Increased activity level.

(C) Normal activity level.

(D)None of the above.

Correct answer A.

(3) A six weeks old infant is brought to the hospital for treatment of pyloric stenosis. The nurse enters the following nursing diagnosis on the infant’s care plan. Fluid volume deficit related to Vomiting. Which of the following assessment supports this diagnosis?.

Answer:

(A)The infant anterior fontanelle is depressed.

(B) patient is dehydrated.

(C )Patient is not keeping food down.

(D) All of the above.

Correct answer A.

(4)Intravenous fluids are ordered for an infant with a diagnosis of pyloric stenosis. The infant intravenous fluid include potassium chloride to replace that which was vomited.Which of the following symptoms would indicate to the nurse that the infant is hyperkalemic.

Answer:

(A)Twitching.

(B) Tachycardia.

(C )Nauseated.

D All of the above.

Correct answer A.

Rationale: Neuromuscular irritability, muscular weakness, flaccid, paralysis, bradycardia, ventricular fibrillation, oliguria,respiratory arrest.

The infant vomited because the pyloric muscles blocks food from entering the small intestine. It occurs often in male infants.

(5) A five month old infant is brought to the clinic by the parents for a routine visit .Which of the following behaviors, if observed by the nurse would indicate a delay in the child’s development?.

Answer:

(A) None moro reflexes.

(B )The moro reflex is present.

(C) All of the above.

(D) None of the above.

Correct answer B.

Indicates delay, reflex is strongest during the first 2months,and should disappear after 3 to 4months.

(6) A 3100gm infant is born after 30 hours of labor. The delivery was spontaneous and the apar at one minute is 8.At 5mins of age ,the newborn apgar score remain unchanged. Which of the following actions should the nurse do first?.

Answer:

Chart the apar score and continue to observe the infant.

Rationale: Infants that are in no acute distress needs no intervention. Apgar is test performed immediately as soon as the baby is born in 1 minutes of birth and in 5 minutes of birth.The 5 minutes test tells the healthcare provider how the baby is doing outside the mother’s womb.That is the overall health of the baby.

(7)A 7lbs 8oz newborn baby girl in transferred to the new born nursery. The nurse performs an initial assessment. Which of the following observation should the nurse consider abnormal?.

Answer:

(A)The skin is blanchable.

(B)Blanch test is not needed.

(C)There is a yellow coloration over the bridge of her nose when she is blanched.

(D) None of the above.

Correct answer C

Rationale: Abnormal jaundice appears first on head progresses cephacaudal( from head to toe)Blanch test differentiates jaundice from skin color. Blanch test applies pressure with thumb on infant forehead causing emptying of capillaries in the skin. If jaundice skin will appear yellow before capillary refill. Best to do test using day lights instead of artificial light. Checking immediately if infant has jaundice will discriminate between pathological and physiological jaundice. If jaundice appears during the first 24hours, this is pathological and could indicate blood dyscrasia. If jaundice occurs between 48 to 72hours is physiological jaundice and results from normal breakdown of fetal RBC and immature liver.

(8) An 8lb 6oz Male infant is admitted to the newborn nusery.During the initial assessment the nurse observes edema of the infant scalp. The first action of the nurse should be to?.

Answer:

(A)Documentation might not be needed as long as you know it.

(B )Document in mother’s chart.

(C)Document the finding in the neonates record.This is a normal findings.

Rationale Caput Succedaneum that is edematous area of the scalp usually found on the occiput.This is caused by the sustained pressure of the presenting vertex against the cervix. The edemaous area extends across the suture line of the skull and disappears spontaneously within 3 to 4 days.

(9) A father brings his four months old son to the clinic for his DPT and TOPV immunization. During the visit the nurse discusses with the father the routine immunization schedule. Which of the following statement if made by the father would indicate to the nurse that he understands when to bring the child in for the next DPT?.

Answer:

(A)I will make appointment in six months.

(B)I will make appointment six months, 15months and 24months

(C)I will make appointments for two months from now. To be given 2 months, 4months, and repeated at 6months.

(D) All of the above.

Correct answer C.

(10) A nurse conducts a health promotion class at a local junior college and teaches male students how to perform testicular self examination. The nurse should emphasize that this routine examination should be performed?.

Answer:

Once in a month. And should be performed to familiarize with his normal anatomy. And will be able to detect abnormality should he perform after a warm shower by applying firm gentle pressure on each testicle with the thumb and fingers. The testicles should have a smooth flat contour.

(11)A 15years old girl is seen in the outpatient clinic.She is 5ft 6inches tall,and Weigh’s 95lbs.Her mother states that my daughter lost 25lbs in six months and she wouldn’t eat.The nurse would expect the patient to make which of the following statement.

Answer:

(A) I am still too fat.Look how big my legs are.

(B) Yes I am really fat.

(C) My mother is too much.

( D) All of the above.

Correct answer A.

(12)A nurse on the Pediatric unit is performing a quality assurance evaluation. Part of the program is the evaluation of the patient assignments given to members of the nursing staff. At the time of evaluation, the nursing teaching includes 3 RN and one LPN.The nurse should consider the assignments appropriate if the LPN is assigned to care for?.

Answer: A six years old child who had Appendectomy two days ago.There is less acute complications indicated.

Do not assign a patient based on equipment, make assignment based on patient’s needs.

(13) A nurse enters the room of a four months old infant and discovers that the infant is not breathing. The nurse hears no air movement and observes no chest movement. To assess for a heart beat the nurse place his or her fingers over the?.

Answer:

Brachial artery located on the inner side of the upper arm, midway between the elbow and the shoulder.

(14) The nurse plans care for a 14years old girl with an eating disorder. On admission the girl weight is 92lb and she is 5feet 4inches tall.Laboratory results indicate severe, hypokalemia, anemia and dehydration. The nurse should give which of the following nursing diagnoses the highest priority?.

Answer:

Alteration in cardiac output related to the potential for dysrhythmias.EkG changes- ST depression, inverted T waves,prominent u wave heart block,interferes with oxygenation.

(15 ) Mrs Vivian Nguyen calls the well baby clinic to report that her son David Nguyen 4months old has a upper respiratory infection with a temperature of 104°F(40°c).David is scheduled to receive DTP and TOPV immunization that day.Mrs Nguyen asks the nurse if she can bring David in for his scheduled immunization. Which of the following responses would be most appropriate?.

Answers:

(A) Yes bring David in,we have room for him.

(B )Keep David at home until his temperature and infection resolve.

(C )Give him a cold wipe and children’s tylenol.

(D) All of the above.

Correct Answer B.

(16) Before administering David’s immunization, which information will be very important for the nurse to know?.

(A) The details of any any adverse reaction David experienced as a result of his previous immunization.

(B )Do nothing as long as the baby is healthy.

(C )None of the above.

(D) All of the above.

Correct answer A.

CONGESTIVE HEART FAILURE IN CHILDREN.

It is the heart inability to meet up with the body oxygen and nutrients needs.It can be further described as severe decreased in myocardial contractility making it difficult for the heart to pump enough blood to meet up with the body demands.The major causes of CHF in the first 3years of life if Congenital heart disease. The other factors are Cardiomyopathy,hypertension, dysrhythmias,pulmonary embolism,arteriovenous fistula,infection, fever,physical distress,adverse drug reaction. More than 75% of CHF in children occur before 1year of age.

Nursing Diagnosis:

Ineffective breathing pattern.

Alteration in nutrition, less than body requirements.

Activity intolerance related to disease process.

Nursing Responsibilities :

Provide oxygen, and pulmonary hygiene given as needed.

Monitor cardiac output.

Strict record of intake and output.

Keep infant warm, reduce cardiac demand. Side and symptoms depend on the location of CHF.

Questions:

(18)What is Pulmonary stenosis?.

That vessel that comes from both the right ventricle and left side ventricle.

The obstruction of blood flow from the right ventricle.

Obstruction of blood flow from the left ventricle.

All of the above.

Correct answer: B.

(19) The infant is diagnosed by the Pediatrician as having ductus arteriosus.The experience Pediatric nurse should know that that this congenital heart defect involves ?.

(A)That this is the persistence of the fetal opening between the pulmonary artery and the aorta.

(B )obstruction of the right and left ventricle.

(C )All of the above.

(D)None of the above.

Correct answer A.

(20) The nurse should emphasize the importance of prophylactic administration of antibiotics before surgery, dental work or laceration repair to minimize the risk of what?.

(A)Patient does not need prophylactic. The recovery is 99.9%.

(B)Giving infant antibiotics is wrong.

( C)Prophylactic administration of antibiotics as a preventative treatment of Carditis ( popularly known as endocarditis)

( D) All of the above.

Correct answer C.

Rationale: The use of prophylactic antibiotics before surgery or oral dental procedure is to prevent bacteria infection from occurring. For example the dentist might give amoxicillin before dental procedure.And there is no follow up antibiotics.For surgery,depending on the type of surgery, the doctor will order for example Ancef 1gm IV before surgery,during surgery and after surgery. That is Ancef 1gm x3 doses.

Nursing Responsibilities:

Follow doctors orders and give the antibiotic on time so the it will be effective.

Explain procedure to the patient.

Access the IV site to make sure that it is not infiltrated.

Monitor the infusion and patient reaction

(21) A 17years old boy is seen in the clinic for treatment of attention deficit disorder (ADD)Medication is prescribed for the child along with family counseling. The nurse teaches the parents about the medication and discusses parenting strategies. Which of the following statements if made by the parents would indicate that further teaching is necessary?.

Answer :

We will give the medication at night so it doesn’t decrease his appetite.

Incorrect answer because Ritalin is a stimulant used and the side effects are insomnia, palpitations, growth suppression, nervousness, decreased appetite, give 6hours before bestime.

(22)An 11 years old boy is admitted to the hospital for evaluation for a kidney transplant. During the initial assessment, the nurse learns that the patient received Hemodialysis for 3years due to renal failure. The nurse knows that his illness can interfer with this patient achievement of ?

Answer:

A Happiness.

B Encouragement.

C Industry.

D All of the above.

Correct answer: C.

Rationale : 6 to 12 years aspires to be best, learn social skills how to finish tasks, sensitive,about school expectations, may be impaired due to absence from school,growth retardation and emotional retardation and emotional difficulties.

(23) Jenny White is a 5years old girl is brought to her Pediatrician. Jenny has a fever of 101°F(38.32) and has a rash on her face and proximal extremities. Jenny diagnosis is Chickenpox .(Varicella)Which of the following description of Jenny rash is characteristic of Chickenpox?.

(A) peptic ulcer.

(B) Macular rashes.

(C) Maculopapular rash.

(D )All of the above.

Correct answer C.

(24 )Jenny White has four siblings at home. In order to prevent the spread of Chickenpox to Jenny’s siblings, the nurse has to explain to Jenny’s mother mrs White that Jenny will require Isolation.

(A )Until Jenny stop crying.

(B) Until there is prevention.

(C) Until the vesicles are crushed.

(D )All of the above.

Correct answer C.

(25) Jenny plan of care include antipyretics and skin care. The nurse should instruct the Mrs White to avoid giving Jenny which of the following drugs when she has chickenpox.

(A) Tylenol.

(B )Topical cream.

(C) Aspirin .

(D )None of the above.

Correct answer C.

(26) In evaluating the total outcome of the skin care provided to Kelly. Which of the following would indicate that the nurse’s teaching was successful?.

(A) Abscence of secondary bacteria infection.

B The skin care is great.

I like the outcome.

D All of the above.

Correct answer A.

(27) Ifeanyi Onochie 5years old is brought to the hospital by his parents for a tonsillectomy. Ifeanyi is a bright, articulate child. The nurse planning pre-OP teaching for Ifeanyi should.

(A )Gather hospital equipment for a play session with him.

(B) Let his parents bring toys from home.

(C )That is not in existence.

(D )None of the above.

Correct answer A.

(28) Ifeanyi is brought to the recovery room post operation. Which of the following should the nurse include in his plan of care?.

(A) Minimize infection.

(B) Minimize crying.

(C) Minimize laughing.

(D )None of the above.

Correct answer B.

(29) To exchange drainage of oral secretions the nurse should place Ifeanyi in which of the following positions.

A Place in a side lying position.

B Place in a fetal position.

C Placed in a supine position.

D All of the above.

Correct answer A.

(30)Ifeanyi is returned to his room from the recovery room. During a routine post-operative assessment, the nurse notices that Ifeanyi is restless, agitated and swallowing frequently. The immediate action that the nurse should take?.

(A) Reposition him immediately.

(B ) Observe his throat directly for signs of bleeding.

(C) Call the charge nurse.

(D) call and notify the doctor.

Correct answer B.

(31)Which change in vital signs should cause the nurse to suspect post – operative hemorrhage?.

(A )Increased pulse,increased respiration decreased blood pressure. (>Pulse,>Respiration <BP)

(B) Decreased pulse, oximeter, and BP.

(C) Increased BP,Decreased pulse and increased Respiration.

(D) All of the above.

Correct answer A.

(32) A 3months old infant with talipes equnovarus ( Clubfoot) is been treated with the application of serial casts.The child’s mother asks the nurse. Why can’t the doctor do surgery to correct my child’s deformities. Which of the following response made by the nurse is most appropriate?.

(A) I don’t think that your son needs surgery.

(B) Surgery is performed on older children when the condition is not corrected by conservative measures.

(C) None of the above.

(D) All of the above.

Correct answer B.

(33)The mother of a 12months old girl born with right talipes equnovarus (Clubfoot)verbalized to the nurse that she is concerned about another child. Which of the following statements is the best response for the nurse to make to the mother?.

(A) I don’t think it has to do with genetics.

(B) Don’t worry go aheadwith another child.

(C)Let’s explore the environment and genetic factors that may predispose your child to this condition.

(D) None of the above

Correct answer C.

Rationale:

Genetic tendency, abnormal positioning in uterus, restricted movement utero,abnormal embryonic development.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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