EXAM 2 Question prep

A nurse is assisting with teaching a newly licensed nurse about holistic nursing. Which of the following information should the nurse include:

- use deep breathing to promote relaxation in clients Encourage clients to use guided imagery to decrease pain Apply essential oils to treat anxiety in clients

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include?

-A stable center of gravity increases stability and balance is correct -A wide base lowers the center of gravity -Proper body alignment involves tightening the abdomen

A nurse is assisting with teaching a class about U.S Food and Drug administration (FDA) regulation of nutritional supplements. Which of the following information should the nurse include in the teaching? `

A nutritional supplement contains at least one nutritional component- The FDA states a nutritional supplement must contain at least one or more nutritional component

The nurse is asked "which patient should receive oxygen via a non-rebreather mask" Which statement by the nurse is accurate?

A patient with a CO2 level of 55mmHg

A nurse is caring for a client who has a health care-associated infection. Which of the following describes an exogenous HAI

A salmonella infection that occurs after eating contaminated food from the cafeteria

A pt presents with frostbite to the left ear, nose, and feet. Which intervention should the nurse implement?

Avoid handling affected areas after rewarming

A patient has increased shortness of breath and mucous plugs in the lungs. Which test should the nurse expect to be performed

Bronchoscopy- used to remove mucuous plugs from the lungs

A patient with respiratory difficulties last weight over the last few months. Which action should the nurse take?

Consult with dietary services to provide small, frequent meals

A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first

Develop a plan of care

What should the nurse do to maintain standard precautions

Disinfect hands immediately after removing gloves

A nurse is inspecting the skin of a toddler. Which of the following findings should the nurse report to the provider

Ecchymotic area on the abdomen

An 83 year old man lives alone on a limited income. Which assessment should the nurse perform to determine if the man is at increased risk for hypothermia?

Financial

The nurse is auscultating tracheal lung sounds of a patient. Which sound should the nurse recognize as a normal finding?

Harsh, high-pitched sound

Which cause of an alteration in oxygenation should the nurse consider to be a nonmodfiable risk factor?

Hemoglobin disorder

A nurse is assisting with teaching a class about using holistic nursing interventions to care for clients. Which of the following information should the nurse include?

Holistic nurses empower clients to actively participate in their own care

A nurse is assisting with teaching a client about homeopathy. Which of the following client statements indicates an understanding of the teaching?

Homeopathy believes a substance that can cause a disease can also cure it

The nurse is assessing a patient who works with chemicals and reports having chronic cough. Which question should the nurse ask to determine a contributing factor for the cough

How long have you worked around the chemicals

The nurse is assessing a patient with emphysema. Which symptom of emphysema is not obvious from the inspection and direct observation by the nurse?

Hyperresonanace sounds from the lung

A nurse is performing a focused assessment on an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing an age related change to their musculoskeletal system

Increased curvature of the thoracic spine

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first?

Right lower quadrant

A nurse is performing an annual physical examination on an adolescent. Which of the following should the nurse include on the general survey

The adolescent makes good eye contact. General survey includes: clients demeanor, mood, and interactions with others

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?

mechanical lift

Which of the following products can affect the permeability of latex gloves

petroleum-based hand lotion

The nurse comes upon an older adult patient outside their home who has collapsed, is not wearing a coat, and feels cool to the touch. The temperature outside is cool with a chilly breeze. Which is the priority intervention for the nurse

place a warm towel or a warm plastic bottle on the patients trunk

A nurse is assessing the reflexes of a 6 month old infant. Which of the following reflex findings should the nurse expect

positive babinski reflex: elicited by stroking up the side of the foot and across the ball of the foot. present when this action causes the toes to fan outward

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage

prone

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint

the contraction of a muscle results in flexion of a joint

A pt. presents with superficial frostbite on the nose, ears, and hands. Which assessment finding should the nurse consider consistent with superficial frostbite

white appearance of affected areas

A nurse is explaining the sequence of electrical conduction in the heart to a newly licensed nurse. What should the nurse include as the correct sequence of the transmission of electrical impulses?

1) SA node 2) AV Node 3) Bundle of His 4)Right and left bundle branches 5) Purkinje Fibers

The nurse is assessing a group of patients. Which patient should the nurse consider to be at the greatest risk for an alteration in oxygenation?

67 year old patient

A nurse is caring for a client who had a stroke and is immobile the nurse should identify that the client is at risk for which of the following conditions

DVT

The nurse is caring for an older adult with a decreased gag reflex. Which nursing intervention is a priority

Have suction equipment available

A nurse is performing a complete, head to toe physical examination for a client- which of the following physical assessment techniques should the nurse perform first

Inspection

The healthcare provider orders a creatine kinase level analysis for a patient who has moderate hypothermia. The patient asks why this test is needed. Which response by the nurse is accurate?

The test is to monitor for muscle breakdown, which may lead to kidney injury or failure

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include?

The top of the walker should be at the level of your wrist

A college student, brought to the emergency department by his girlfriend has a body temperature of 94.8 degrees f Which question is most important for the nurse to ask the gf to help determine the patients condition

Was he drinking alcohol

A patient who takes an inhaled corticosteroid reports dizziness and heart palpations and has a heart rate of 110beats/min and a blood pressure of 88/44mmHg. Which question should the nurse ask first?

When did you last take your inhaled corticosteroid

A nurse is caring for a client who has a sunburn. The nurse should identify that which of the following herbal supplements is used to treat sunburns

aloe vera

A nurse is teaching a client about food choices that promote immunity when healing. Which of the following foods is best source of vitamin C

1 cup of strawberries

A nurse is preparing to lift a heavy object off of the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics?

1- Stand as close to object as possible 2-Keep abdominal muscles contracted and the lower back straight 3-Look straight ahead with shoulders raised up 4-Bend hips slightly and squat 5-Push up from the knees when lifting the object

A nurse is inspecting the thorax of an infant. Which of the following findings should the nurse expect?

A barrel-shaped chest in which the anterior-posterior are equal

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect?

A brief thump felt near the fourth- fifth intercostal space near the left midclavicular

A nurse is assisting a massage therapist to identify the best client for massage therapy. Which of the following clients should the nurse recommend

A client who has postpartum depression

A nurse is assisting in recommending clients for chiropractic treatment. Which of the following clients should the nurse recommend

A client who has shoulder pain

A patient with respiratory distress is showing signs of decreasing cardiac output and hypoxemia. Which action should the nurse take first?

Administer oxygen via face mask

An older adult patient with mild hypothermia and has been initially treated with blankets and forced warm air. Which intervention should the nurse expect to implement next

Administer warm IV fluids

A patient i s experiencing decreased tissue perfusion, hypovolemia, and hypoxemia. Which action by the nurse is most important?

Administering fluids

The nurse is conducting a teaching session with a group of college students reporting alcohol consumption and the risk of hypothermia. Which info should the nurse include in the teaching

Alcohol causes peripheral vasodilation which increases the rate of cooling

A nurse is preparing to transfer a client who has left-sided weakness from the bed to the chair. Which of the following actions by the nurse demonstrates correct transfer techniques

Aligning the nurse's knees with the clients knees just before the transfer

A woman who is 26wks gestation presents with a temperature of 93.9 F and severe shivering. Which nursing intervention is the priority

Applying warm pads and begin fetal monitoring

A nurse is performing an abdominal examination on a preschooler. Which of the following actions should the nurse take during the assessment

Ask the child to help with the exam by placing their hand on top of the nurses hand

The nurse is assessing an older adult patient at home who has suctioning equipment at the bedside. The patient has a history of aspiration pneumonia. Which action is the priority

Assessing the gag reflex

A nurse is performing a screening for scoliosis on a school-aged child. Which of the following instructions should the nurse provide

Bend forward with your knees straight and your arms dangling: this view allows for visualization to detect any asymmetry of the spine or the rib cage

An older adult was found unresponsive in-the home. The heat was off and the environment was cold. The patient has cyanotic nail beds, a weak pulse, and slow cap refill. Which finding should the nurse anticipate?

Core body temperature 82.6 F

Which observation should lead the nurse to expect hemodialysis will be ordered to treat this pt.

Damage to the hypothalamus

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage?

Damage to the skin layer- the wound can be lighter in color than the skin tone along with temp differences and an intact or open blister

A nurse is caring for a client who asks about naturopathy. The nurse should include which of the following components of naturopathy?

Dietary supplements Exercise Traditional Chinese medicine Homeopathy Naturopathy is a medical system that is based on the principle that healing can be achieved through diet, supplements, medicinal plants, exercise, traditional Chinese medicine and homeopathy

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following?

Diminished awareness of body position and balance

The nurse is assessing a patient with a cough. Which question about the cough, if answered in, the affirmative, is most concerning to the nurse?

Do you cough up blood anf how often

A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the clients foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following

Dorsalis pedis

To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has evaporated and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry?

Drying provides the full antiseptic effect

A nurse is explaining the practice of Ayurveda to a newly licensed nurse. The nurse should include that Ayurveda is based on establishing a balance between the body, mind, and spirit of which of the following elements

Earth sky and water

A nurse is preparing to perform a physical examination on a 10yr old child. which of the following interventions should the nurse plan to implement

Explain how the equipment works using correct medical terminology

A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the actions should the nurse take?

Extend one leg and allow for the client to slide down the leg to the floor

A nurse is caring for a client who has been hospitalized and is performing active ROM exercises. Which of the following body movements should indicate the the nurse that the client has full ROM of the shoulder?

Flexing the shoulder by raising the arm from a side position to a 180 degree angle

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?

Fowlers

A nurse is completing a preoperative health history for a client who reports taking several herbal supplements. Which of the following herbal supplements is the priority for the nurse to report

Ginkgo Biloba

The nurse is teaching a new parent about how to avoid hypothermia in their infant. Which statement by the parent indicates to the nurse that the teaching was effective

I keep my baby wrapped in a blanket when we go outside

The nurse taught a patient with alterations in the respiratory system about lifestyle alterations. Which patient statement indicates an understanding of the teaching?

I should space activities with plenty of rest periods when i am short of breath

The nurse provided discharge teaching to a patient with frostbite of their nose. Which pt response indicates the teaching was successful

I will not touch my nose until is is fully healed

A nurse is assisting with teaching a client, who has a history of alcohol use disorder and is to be discharged following cataract surgery, about non-pharmacological therapies. Which of the following indicates the clients understanding of the treatment?

I will practice meditating when i feel stressed

A nurse is teaching about traditional Chinese medicine to a client. Which of the following statements by the client demonstrates an understanding of the teaching?

I will practice tai chi everyday

A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include?

Insert the earpieces at a downward angle toward your nose

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include?

Kyphosis is a rounded upper back with the pelvis tilted forward

A nurse is observing an assistive personnel who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene?

Leaves the bed in lowest position throughout the procedure

A patient asks, "Why do i need to have my position changed every 2 hours"? Which response should the nurse provide

Low oxygen in the tissues increases the risk of skin breakdown

A nurse is caring for a client who has a prescription for knee length anti-embolic stockings. Which of the following actions should the nurse take?

Measure the client's calf circumference and leg length from heel to knee

A nurse is caring for a client who requires total assistance with mobility. When using the mobility assessment tool- which of the following pieces of equipment should the nurse use to transfer the client

Mechanical lift

The nurse is completing the health history for a newly admitted patient diagnosed with hypothermia. Which should the nurse identify as the most important health history data to assess?

Medications

Where should the nurse feel the strongest vibration when performing tactile fremitus on a patient

Over the trachea

A patient presents with chest congestion and a cough. Which skill should the nurse expect to use to specifically assess for chest congestion

Percussion and auscultation

Which independent nursing intervention is a priority for a patient who is experiencing dyspnea?

Place the patient in high fowler position

A patient who has been reciveing intravenous fluids to increase perfusion now has crackles in the lungs. Which action should the nurse perform first?

Place the pt. in high fowler position

A nurse is preparing to obtain a temperature on an 18 month old toddler during a well child examination- Which of the following actions should the nurse take

Place the thermometer tip in the center of the toddler's axilla against their skin- the nurse should use the axillary method to obtain a young child's temperature during a screening assessment

A nurse is caring for a client who has mycoplasma pneumonia. The client has been placed on droplet precaution. Which of the following actions should the nurse take when caring for the client?

Protect their eyes

A 7 year old child presents with decreased pulse and respirations, severe shivering, and chills. The childs parent states the child has been playing outside in the snow without a coat. Which intervention should the nurse implement first

Provide dry clothing and warm blankets

The school nurse is giving a presentation for parents regarding hypothermia. Which statement should the nurse include regarding the first step in treating hypothermia?

Provide dry clothing and warm blankets when your child comes in from outside

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take?

Remind the client to use the incentive spirometer

A nurse is caring for a client who follows a vegan diet and reports lethargy. Which of the following interventions should the nurse implement

Request a prescription for vitamin B12 supplements - Clients that follow a plant based diet have a risk for B12 deficiency

A nurse is assisting with providing an in-service for staff members about complementary and integrative health. Which of the following statements by a staff member indicates understanding of the teaching

Scented oils might decrease discomfort

A nurse is obtaining the blood pressure of a school-age child. Which of the following actions should the nurse take?

Select a cuff that covers 40% of the upper arm

Which of the following is an advantage of using alcohol-based gel

Takes less time than to use than washing with soap and eater

A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include?

Tendons connect muscle to bone

A nurse assessing a client's cranial nerves. Which of the following clients actions is an indication that cranial nerve I is intact?

The client can identify a minty scent

A nurse is performing a general client survey and finds that the client has a body mass index of 23. Which of the following should the nurse document?

The client has a BMI within the expected reference range

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches

The client has the crutches resting 5cm or 2 inches below their axilla-

A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include?

The crutches should be held on the unaffected side when preparing to sit in a chair

An older adult patient presents with hypothermia. The nurse should consider which process as contributing to the risk for this patient

The normal aging process decreases metabolism

A nurse is preparing to transfer a client from a bed to a wheelchair. Which of the following actions by the nurse demonstrates proper use of body mechanics?

The nurse should look at the client face to face when transferring- this prevents twisting or turning of the torso

The nurse is caring for a patient recovering from hypothermia. Which outcome should the nurse expect?

The patient is able to list early signs and symptoms of hypothermia

A nurse is caring for a client who is receiving palliative care. Which of the following non-pharmacological nursing interventions should the nurse provide the client

Therapeutic touch

After rewarming the feet, the nurse elevated the feet on pillows. The patient asks "why are you putting my legs on pillows?" Which statement by the nurse is correct?

This will promote better circulation to your legs and feet

The nurse is caring for a pt with a pleural effusion. Which test should the nurse expect to be ordered?

Thoracentesis

A nurse is teaching a newly hired assistive personnel about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL

Toileting

The nurse is caring for a patient with a pneumothorax. Which factor should the nurse suspect caused this alteration

Trauma

A nurse is caring for a client who is scheduled for an emergency appendectomy and reports increasing anxiety. Which of the following statements should the nurse make to implement a complementary health strategy

Try to take slow, deep breaths in and out

The nurse is caring for a child after a sledding injury. The nurse suspects the child has superficial frostbite. Which assessment finding supports the nurses suspicion?

White appearance of the tip of the nose

Which pt. should the nurse identify as having the greatest risk for hypothermia

a 3 day old infant

The nurse is planning care for a patient with hypothermia. Which independent nursing intervention is appropriate?

administer warm oral fluids

A nurse in a long-term care facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing?

atrophy

A nurse is preparing to conduct a romberg test on a client. The nurse should explain to the client that the romberg test is used to assess which of the following characteristics?

balance

The nurse is caring for a patient diagnosed with hypothermia. Which assessment finding should the nurse expect

cyanotic nail beds

The body's surface temperature changes continuously in response to the environment. When considering the ways in which heat transfer occurs in the development of hypothermia, which situation is the most likely cause of excessive heat loss through convection

falling into the partially frozen lake

A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing

foot drop

After completing a procedure that required donning personal protective equipment consisting of a gown, an N95 respirator, a face shield and gloves, which of the following should the nurse remove firs when removing the PPE separately

gloves- Most contaminated- always removed first- then face and eye- followed by gown, and mask/respirator

Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following?

infectious diarrhea

A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings in common with aging

kyphosis

A nurse is performing a cardiac assessment on a preschooler. The nurse plans to auscultate the apical pulse- at which of the following precordial landmarks

left of the midclavicular line at the fourth intercostal- this is the site where the mitral valve is best auscultated in children

A nurse is planning complementary therapy for a client who has breast cancer. Which of the following treatments is a complementary therapy that the nurse can implement

massage therapy

Which oxygen delivery device should the nurse understand is indicated for a patient with a CO2 level of 55mmHg?

nonrebreather mask

A nurse is assessing a client who is being discharged. The nurse notes the client has regular and quiet breathing. The nurse should identify this breathing pattern as which of the following?

normal breathing

A nurse is caring for a client who requires assistance with ADLs which of the following referrals should the nurse recommend for this

occupational therapist

A nurse is caring for a client who asks about using aroma therapy for nausea. Which of the following scents should the nurse recommend

peppermint, ginger, or orange

A nurse is palpating a tender area of a client's abdomen. The nurse slowly applies pressure over the area with the fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document

rebound tenderness

A patient is being evaluated for the source of a productive cough and SOB. Which diagnostic test should the nurse expect to be ordered first

sputum specimen

A patient with diffuse emphysema asks about the options for improving lung health. Which statement by the nurse is correct

surgical options can be considered to improve lung health with diffuse emphysema

The nurse suggests a consult with a social worker for an older adult patient who is reporting to the clinic for the third time in a month signs of hypothermia. The patient asks "Why are you suggesting this?" Which response by the nurse is correct

the medical social worker will assess the safety of our home environment

The nurse is caring for a patient with hypothermia who is confused and disoriented. Which factor should the nurse identify as the primary reason for the patients disorientation

vasoconstriction of cerebral blood vessels

After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. which of the following actions should the nurse take

wash hands with soap and water

A nurse is about to irrigate a client's open wound. Besides gloves, which of the following personal protective equipment should the nurse wear?

a face shield

A nurse stands facing a client to demonstrate active ROM exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?

Move their leg behind their body

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include which of the following is responsible for body posture

Muscles

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?

Muscles assist with thermoregulation in the body

A nurse is assisting with an inservice for staff members about culturally competent care. Which of the following information should the nurse include about the traditional Native American beliefs

Music can produce healing energy

A nurse is completing the mobility assessment tool for a client and determines that the client is at level 1 mobility. The nurse should identify that the client is unable to perform which of the following tasks

Sit on the edge of the bed for 1 minute

The nurse is caring for a patient with severe frostbite of the feet. Which is the most common cardiac dysrhythmia that occurs with excessive handling of the patients frostbitten extremities

ventricular fibrilation

A nurse is washing their hands with soap and water prior to repositioning a client in bed. During the hand-washing procedure, it is important to take which of the following actions

wash for at least 20 seconds

A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the client's breathing. The nurse should identify this observation as which of the following findings?

Crackles

The nurse is monitoring a patient recovering from moderate hypothermia and suspected of having rhabdomylosis. Which diagnostic test should the nurse anticipate being ordered?

Creatine kinase - will assess for severe muscle breakdown which can lead to kidney injury and renal failure

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?

The use of ergonomics increases job satisfaction along with productivity of staff members