NURSING QUESTION ANSWERS WITH RATIONALE

Question No. 1. A client has been receiving cyanocobalamine (B12) injections forthe past 6 weeks. Which laboratory finding indicates that the medication is having the desired effect?
❍ A. Neutrophil count of 60%
❍ B. Basophil count of 0.5%
❍ C. Monocyte count of 2%
❍ D. Reticulocyte count of 1%
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Question No. 2. During the change of shift, the oncoming nurse notes a discrepancy in the number of Percocet (Oxycodone) listed and the number present in the narcotic drawer. The nurse’s first action should
be to:
❍ A. Notify the hospital pharmacist
❍ B. Notify the nursing supervisor
❍ C. Notify the Board of Nursing
❍ D. Notify the director of nursing
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Question No. 3. The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture?
❍ A. Blood
❍ B. Nasopharyngeal secretions
❍ C. Stool
❍ D. Genital secretions
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Question No. 4. Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction?
❍ A. AST
❍ B. Troponin
❍ C. CK-MB
❍ D. Myoglobin
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Question No. 5. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client’s ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge?
❍ A. “I live by myself.”
❍ B. “I have trouble seeing.”
❍ C. “I have a cat in the house with me.”
❍ D. “I usually drive myself to the doctor.”
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Question No. 6. The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by the registered nurse?
❍ A. A client 2 days post-appendectomy
❍ B. A client 1 week post-thyroidectomy
❍ C. A client 3 days post-splenectomy
❍ D. A client 2 days post-thoracotomy
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Question No. 7. Which action by the novice nurse indicates a need for further teaching?
❍ A. The nurse fails to wear gloves to remove a dressing.
❍ B. The nurse applies an oxygen saturation monitor to the ear lobe.
❍ C. The nurse elevates the head of the bed to check the blood pressure.
❍ D. The nurse places the extremity in a dependent position to acquire a peripheral blood sample.
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Question No. 8. The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention?
❍ A. Suggest that the client take warm showers B.I.D.
❍ B. Add baby oil to the client’s bath water
❍ C. Apply powder to the client’s skin
❍ D. Suggest a hot-water rinse after bathing
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Question No. 9. The nurse is obtaining a history of an 80-year-old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance?
❍ A. “My skin is always so dry.”
❍ B. “I often use a laxative for constipation.”
❍ C. “I have always liked to drink a lot of ice tea.”
❍ D. “I sometimes have a problem with dribbling urine.”
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Question No. 10. The nurse is making initial rounds on a client with a C5 fracture and crutch field tongs. Which equipment should be kept at the bedside?
❍ A. A pair of forceps
❍ B. A torque wrench
❍ C. A pair of wire cutters
❍ D. A screwdriver
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ANSWERS FOR THE ABOVE QUESTIONS WITH RATIONALE

Q1. Answer D is correct. Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect.Answers A, B, and C are white blood cells and have nothing to do with this medication.

Q2. Answer B is correct. The first action the nurse should take is to report the finding to the nurse supervisor and follow the chain of command. If it is found that the pharmacy is in error, it should be notified, as stated in answer A. Answers C and D, notifying the director of nursing and the Board of Nursing, might be necessary if theft is found, but not as a first step; thus, these are incorrect answers.

Q3. Answer D is correct. A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea. Answers A, B, and C are incorrect because these cultures do not test for gonorrhea.

Q4. Answer A is correct. Answer A, AST, is not specific for myocardial infarction. Troponin, CK-MB, and myoglobin, in answers B, C, and D, are more specific, although myoglobin is also elevated in burns and trauma to muscles.

Q5. Answer B is correct. A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. Answers A, C, and D will not prevent the client from being able to care for himself and, thus, are incorrect.

Q6. Answer D is correct. The most critical client should be assigned to the registered nurse; in this case, that is the client 2 days post-thoracotomy. The clients in answers A and B are ready for discharge, and the client in answer C who had a splenectomy 3 days ago is stable enough to be assigned to an LPN.


Q7. Answer A is correct. The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction. Answers B, C, and D are incorrect because they indicate an understanding of the correct method of completing these tasks.

Q8. Answer B is correct. Oils can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. Answer A is incorrect because bathing twice a day is too frequent and can cause more dryness. Answer C is incorrect because powder is also drying. Rinsing with hot water, as stated in answer D, dries out the skin as well.

Q9. Answer B is correct. Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers A, C, and D are not of particular significance in this case and, therefore, are incorrect.

Q10. Answer B is correct. A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect.