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CCNS PDF DEMO:
QUESTION NO: 1
Who among the following pediatric patients should be assessed first by the nurse?
A. A child with skin rashes on his face and trunk
B. A child with two episodes of inconsolable crying while the knees are drawn over the abdomen and then
plays between the episodes
C. A child with two episodes of soft stools during the shift
D. A child who had a cough for the past three days, with clear nasal discharge and is irritable
Answer: B
Explanation: The pediatric patient that the nurse should assess first is a child with two episodes of inconsolable crying while the knees are drawn over the abdomen and then plays between the episodes.
This indicates appendicitis. The pattern of abdominal pain in appendicitis is as follows: pain occurs for two
to three hours, pain is relieved in two to three hours, and then pain recurs and persists. During the time
that pain subsides, the rupture of appendicitis may occur unnoticed.
QUESTION NO: 2
A mother of a newborn baby Roger is asking the neonatal care nurse at what stage of development is
normal for when baby Roger is 2 months of age?
A. Oral
B. Anal
C. Phallic
D. Latency
Answer: A
Explanation: The neonatal care nurse should inform the stage of development that is normal for baby
Roger when he is 2 months of age is oral. This is the first stage of development and can last up to 1 year
after birth.
QUESTION NO: 3
A nurse is coaching a group of student nurses about the anatomy and physiology of the head.
The nurse
asks one of the students what to do if she observes that there is blood coming from a patient's ear after a
head injury sustained following a motor vehicle collision. The correct response by the student nurse should be:
A. Cleanse the ear with sterile gauze
B. Put sterile cotton loosely in the external ear
C. Turn the patient to the unaffected side
D. Test the drainage with dextrostix
Answer: B
Explanation: The correct response by the student nurse should be to put sterile cotton loosely in the external ear. This will absorb the drainage without causing further trauma. Additionally, the nurse should
notify the attending physician immediately, as this could be a sign of a life threatening condition.
QUESTION NO: 4
Rudy is a 55-year-old patient who was diagnosed with Hepatitis A.
After three weeks, the patient developed hepatic cirrhosis and ascites with an elevated serum ammonia level. What would be the
priority nursing intervention, considering that the patient has high ammonia levels?
A. Oral fluid intake restrictions
B. Obtaining a daily weight
C. Observe for signs of increasing confusion
D. Measurement of urine specific gravity
Answer: C
Explanation: The priority nursing intervention considering that the patient has a high ammonia level is to
observe for any signs of increasing confusion. The patient's safety will be the priority since the patient has
altered level of consciousness caused by an increased serum ammonia level that impairs the cranial nerve system.
QUESTION NO: 5
A clinical nurse specialist is monitoring the blood glucose level of a neonate who was born to a diabetic mother.
The nurse determined that the blood glucose level is 50 mg/dL. What would be the action of the nurse?
A. Feed the baby orally with 10% dextrose in water
B. Monitor the neonate continuously for the next twenty-four hours
C. Alert the physician and request an order of glucose 50%
D. Assess the cord serum glucose level
Answer: B
Explanation: The action of the nurse should be to monitor the neonate continuously for the next twenty-four hours. The blood glucose level is within the normal range for neonates, so it doesn't require
any measure aside from continuously monitoring the patient for the next twenty-four hours.
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Updated: May 25, 2022