Exam 1: Practice questions
Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?
1100 0300 1700 1500 ANSWER: C- Temperature is usually lowest around 0300 and highest from 1700 to1900.
During an assessment of a newly admitted client the nurse asks the client many questions. The nurse begins the assessment by asking, "Have you been hospitalized this year for your back pain?" This is an example of which type of question?
Reflective question Sequencing question Closed question Open-ended question ANSWER: C
After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?
To aid the nurse's recall of client information To provide protection from liability in the case of a lawsuit To avoid penalties imposed by the federal government To communicate effectively with other health care team members ANSWER: D
A client receives morphine, 4 mg I.V., for relief of surgical pain. Thirty minutes later, the nurse asks the client whether the pain is relieved. Which step of the nursing process is the nurse using?
assessment diagnosis implementation evaluation ANSWER: D
During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?
"Client visibly agitated during assessment and unwilling to continue." "Client became upset and terminated assessment." "During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." "During chest auscultation, client decided that she could no longer participate in assessment and removed herself from the room." ANSWER: C
Paramedics arrive in the emergency department with a client who was in a motor vehicle collision. The paramedic reports that the driver was restrained, the car was traveling about 30 miles per hour (48 km/hr), and the air bags were not deployed. The paramedic continues to report that the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic?
"Did a police officer take a report at the accident scene?" "All of the people got themselves out of the car?" "Was there any cracking of the windshield?" "Were there any fatalities in the other vehicle?" ANSWER: B
When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?
"I will administer the enema while lying on my left side with my right knee flexed." "I will administer the enema while sitting on the toilet." "I will administer the enema while lying on my back with both knees flexed." "I will administer the enema while lying on my right side with my left knee flexed." ANSWER: A- Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel.
The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply.
*Faxing the results of blood chemistry levels to the provider's office Placing a note on the computer terminal with the client's name and information *Showing the provider the trends from baseline to present in blood pressure *Informing the provider of the client's present heart rate of 116 beats/min Writing the hemoccult result on a piece of paper and leaving it at the desk ANSWER: A,C, D
The nurse is assigned to the care of an 89-year-old client for whom a documented "do not resuscitate" order exists. The nurse answers a call light and finds the client not breathing. The family member at the bedside demands that the nurse "do something." Which action best demonstrates the nurse's responsibility to the client?
Ask the family member if they want the "do not resuscitate" order changed. Contact the health care provider to clarify the "do not resuscitate" status. Explain to the family member the client's wishes regarding "do not resuscitate." Call a code blue and begin rescue breathing. ANSWER: C- The nurse has a responsibility to protect the rights of the client and advocate for the wishes of the client. The nurse would best demonstrate responsibility to the client by explaining the "do not resuscitate" status to the family member. Calling a code blue and beginning rescue breathing is following the family member's wishes, not the client's.
The nurse caring for six clients enters the room of a client who underwent gastrointestinal surgery and assesses vital signs, the abdominal wound, and auscultates bowel sounds before seeing the next client. Which type of assessment did this nurse perform on the client?
Comprehensive Shift Focused Head to toe ANSWER: C- The nurse performed a focused assessment to quickly assess for anticipated problems related to the medical diagnosis. This client underwent gastrointestinal surgery; therefore a focused abdominal assessment is warranted.
A student nurse is learning to document an initial assessment. What would theinstructor tell the student that accurate documentation of this specific assessment best provides?
Data on the client's prognosis for recovery Information on the nurse's cultural competence Information on the effectiveness of interventions A baseline for comparison with future findings ANSWER: D
What are the types of nursing assessments? (Select all that apply.)
Emergency Comprehensive Mental Physical Focused ANSWER: ,B,DE
The nurse has completed instilling fluid with a bladder irrigation and does not have a return of the fluid into the catheter bag. What is the next action the nurse should do?
Ensure there are no kinks in the catheter tubing. Notify the healthcare provider about the lack of drainage. Palpate the client's bladder for distention. Change the urinary catheter. ANSWER: A- The simplest method to ensure drainage of the catheter is to check the tubing for kinks in the tubing that would affect drainage. After this, palpating the bladder for distention, notifying the healthcare provider, and changing the urinary catheter would be the next steps in troubleshooting this situation.
Which source of information helps a nurse formulate nursing diagnoses for a specific client?
Essential assessment data Outcome criteria Research articles Admission criteria ANSWER: A
A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next?
Evaluate outcome. Implement an intervention. Cluster client cues. Identify client concerns. ANSWER: A- Because the nurse implemented an intervention (in this case, applied oxygen), the nurse would next evaluate the effectiveness of the intervention.
A nurse observes an unlicensed assistive personnel (UAP) taking a blood pressure reading on a client. The cuff wraps around the client's arm nearly twice. What is the best action of the nurse?
Instruct the UAP to raise the arm above the heart. Inform the UAP that the blood pressure reading will be higher using that cuff. Thank the UAP for taking the blood pressure. Obtain a smaller cuff for the UAP. ANSWER:D
A nurse observes that a client is out of breath from running up a flight of stairs just prior to conducting a general survey. What is the best action of the nurse?
Instruct the client to remain standing. Have the unlicensed assistive personnel take the client's vital signs. Plan to take vital signs at the end of the assessment. Ask the client to make another appointment. ANSWER: C- Activity, emotions, room temperature, smoking, and/or hot or cold products can affect vital signs. The nurse should conduct the general survey and assessment first, allowing sufficient time to pass for the client to rest so that vital signs can return to baseline.
Nurses at a healthcare facility maintain client records using a method of documentation known as charting by exception. Which is a benefit of this method of documentation?
It records progress under problems, intervention, and evaluation. It provides quick access to abnormal findings. It documents assessments on separate forms. It provides and refers to a client's problem by a number. ANSWER: B- Charting by exception provides quick access to abnormal findings because it does not describe normal and routine information.
A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent?
Keep the client in the emergency department until the family is contacted. Take the client to the operating room for surgery without informed consent. Ask the nursing supervisor to contact the hospital lawyer. Contact the hospital chaplain to sign the consent on the client's behalf. ANSWER: B- All attempts should be made to contact the family, but delaying life-saving surgery is not an option. The other options are not correct because the surgeon can perform surgery without consent if there is a risk of loss of life or limb if the surgery is not performed.
A nurse is scheduled to perform an initial home visit to a new client who is beginning home intravenous therapy. As the nurse is getting out of the car and beginning to approach the client's building, a group of people begin following and jeering at the nurse. Which is the nurse's best response to this situation?
Leave the area in the car, provided the nurse can get to it safely. Call out to attract attention from bystanders. Perform the home visit and ensure that the group is gone before leaving. Confront the group of people in an assertive but non-aggressive manner. ANSWER: A
A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?
Sympathy Empathy Palpation Inspection ANSWER: B
A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify?
The client's nutritional status Preferred site for temperature assessment The client's wellness goals The client's most recent temperature ANSWER: D
Which statement describes diastolic blood pressure?
The flow of blood is produced by contractions of the heart and by the resistance to blood flow through the vessels. The pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. To assess diastolic pressure, the blood pressure measured during ventricular contraction. During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. ANSWER: D
A nurse is assessing the blood pressure of a client using the Korotkoff's sounds technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
There is an auscultatory gap There is a widening in the diameter of the artery There is a nonauscultatory gap There is an adult diastolic ANSWER: A- An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff's sounds technique.
When charting by exception is used in a health care agency, the most important aspect of this method is what?
Training new nurses in writing charting by exception notes Identifying the standards and norms for the institution Pulling together a group of experts to teach agency staff Organizing new forms for the nursing staff ANSWER: B- Clearly identifying the standards and norms and educating all users takes time and significant commitment from the agency using charting by exception.
The nurse working in the emergency room has been assigned the following clients. Which client requires an ongoing assessment?
a client admitted with a leg fracture who is reporting sudden shortness of breath and a rash a newly admitted client who was involved in a motor vehicle incident with a head injury and reports a headache of 3 on a scale of 1-10 a client admitted 2 days ago with exacerbation of chronic obstructive pulmonary disease with an oxygen saturation of 90% on 2L nasal cannula who reports ease of breathing a client admitted with acute atrial fibrillation who has a heart rate of 150 bpm and irregular heart rhythm ANSWER: C- A client with improvement of symptoms would need ongoing assessments. Because it can be life-threatening for the client to have an irregular, fast heart rate (atrial fibrillation) of 150 BPM, an emergency assessment should be conducted for that client.
The nurse is caring for a client. When does the nurse determine that nursing care will be most effective related to nurse-client communication?
common understanding similar values compatible realities similar personality traits ANSWER: A
An experienced nurse has been working with a client with heart failure. The client's lungs were clear to auscultation during the morning assessment; however, the afternoon assessment revealed bibasilar crackles and tachypnea. The nurse calls to give SBAR report to the covering health care provider. In the final step of the report the nurse should:
detail the client's past medical history and active medication orders. recommend 40 mg of furosemide be administered because the client had improvement with past administration. discuss the client's situation and request a chest x-ray to assess lung function. provide detailed findings of the head-to-toe assessment. ANSWER: B
The result of a nursing assessment is the:..
prescription of treatment. formulation of nursing diagnoses. client's physiologic status. documentation of the need for a referral. ANSWER: B- The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment data.
The nurse is assigned the following clients. Which client requires an emergency assessment?
the client admitted with small bowel obstruction who underwent surgery this morning and is now reporting incisional pain 7 out of 10 the client admitted with a fractured arm who reports some numbness and tingling in the fingers the client admitted with chest pain yesterday who now denies pain after nitroglycerin administration the client who underwent a hysterectomy yesterday and is now reporting shortness of breath and has decreased oxygen saturations D- A client reporting difficulty breathing and who has decreased saturations requires an emergency assessment. This client might be suffering from a pulmonary embolism.
The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate?
Explain that only a paper copy of the health care record can be viewed by the client. Access the health care record at the bedside and show the client how to navigate the electronic health record. Review the hospital's process for allowing clients to view their health care records. Discuss how the hospital can be fined for allowing clients to view their health care records. ANSWER: C
When doing an overall assessment of a client, the nurse is able to use findings for which primary purpose?
Identify the client's medical diagnosis. Identify in what areas the client needs the most care. Identify in what areas the client can educate the family. Identify conditions that the health care provider may have missed. ANSWER: B- During the overall assessment of the client, the nurse is able to use the findings and decide in which areas the client is in need of the most care. The nurse should not identify conditions that the health care provider may have missed or identify the client's medical diagnosis, as making medical diagnoses are not within the nursing scope of practice.
The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client?
Moderate amount dark blood on dressing Cyanotic left lower extremity Heart rate of 105 beats per minute Temperature 37.5 Celsius ANSWER: B
Each morning, a nurse-manager assigns clients and additional tasks for the staff nurses to complete that day. During the shift, a crisis develops and one staff nurse doesn't complete the additional tasks. The next day, the nurse-manager reprimands this nurse. When the nurse tries to explain, the nurse-manager interrupts, saying that the nurse should have completed the tasks no matter what happened. Which leadership style is the nurse-manager exhibiting?
laissez-faire democratic autocratic permissive ANSWER: C- An autocratic leader retains all authority and responsibility and is concerned primarily with completing tasks and meeting goals