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QUESTION NO: 1
Baby Boy Holiday was admitted to the unit due to cancer of the esophagus. The laboratory values show a
hemoglobin of 7g/dL, hematocrit of 25%, and RBC count of 2.5 million/mm3. Considering the data, an appropriate nursing diagnosis for the patient at this time would be:
A. Risk for injury related to possible metastasis and subsequent airway obstruction
B. Imbalanced nutrition; less than body requirements related to dysphagia
C. Ineffective airway clearance related to tumor growth and metastasis
D. Acute pain related to pressure of the tumor on surrounding tissues and nerves
Answer: B
Explanation: Considering the data, an appropriate nursing diagnosis for the patient at this time would be
imbalanced nutrition; less than body requirements related to dysphagia. The decreased hemoglobin and
hematocrit levels and RBC count may be a result of malnutrition; also, cancer of the esophagus can cause dysphagia and anorexia.
QUESTION NO: 2
On a visit to an older adult who has a chronic heart failure, the nurse observes that the infant lies quietly in
a crib and barely has basic needs attended. The older adult is the primary caregiver to the infant. The nurse should:
A. Advise purchasing appropriate toys designed for this age level
B. Inform the older adult that the infant will be retarded if not stimulated
C. Explain the need for the family to hire a mother's helper for the home
D. Initiate a referral to an appropriate agency to assess the need for a home health aide
Answer: D
Explanation: The nurse should initiate a referral to an appropriate agency to assess the need for a home
health aide. This will ensure that a thorough assessment of the family's needs is made and the appropriate assistance is initiated.
QUESTION NO: 3
During a nursing staff meeting, the nurses determine that they will make sure all vital signs are reported
and charted within 15 minutes following assessment. This is an example of:
A. Group Decision Making
B. Group Identity
C. Group patterns of interaction
D. Group leadership
Answer: B
Explanation: Ascertaining that the staff completes a task on time and that all members agree the task is
important is a characteristic of group identity.
QUESTION NO: 4
A patient is scheduled to have a modified radical mastectomy. The physician orders to prepare two "units"
of blood in the event it is needed. The patient said to the nurse that she will only sign the consent for blood
transfusion if it will be coming from her relatives. The patient has type "A" negative blood. The nurse should advise the patient to have a relative whose blood is:
A. Type AB or A negative
B. Type O positive
C. Type A or O negative
D. Type AB positive
Answer: C
Explanation: The nurse should advise the patient to have a relative whose blood is type A or O negative
donate blood for a possible transfusion. These types are both compatible with the patient's blood type.
QUESTION NO: 5
Mr. Davids is admitted to the hospital with a diagnosis of left-sided congestive heart failure.
During an
assessment, the nurse should expect to find:
A. Dyspnea on exertion
B. Peripheral edema
C. Crushing chest pain
D. Neck vein distention
Answer: A
Explanation: During an assessment, the nurse should expect to find dyspnea on exertion. Pulmonary congestion and edema occur because of fluid extravasations from the pulmonary capillary bed, resulting
in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads
to pulmonary congestion.
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Updated: May 25, 2022