H&I Exam 2

A patient is admitted for heatstroke. Which intervention should the nurse include in the patient's plan of care? A) Administer intravenous fluids as ordered B) Administer aspirin as ordered C) Administer ibuprofen as ordered D) Cool the patient rapidly

A) Administer intravenous fluids as ordered

A 60-year-old woman was admitted this morning with vomiting and pain in the midabdominal region caused by a bowel obstruction that will require immediate surgery. The dietary department delivers a regular lunch food tray and asks if you could take it into the room. Which response is most appropriate? A) "I don't think this tray was ordered for her." B) "Thank you so much. She needs her nutrition." C) "That's the wrong consistency, she needs soft foods only." D) "I will give her only the liquids from the tray."

A) "I don't think this tray was ordered for her."

The nurse is instructing a 28 year old married female with a urinary tract infection how to prevent urinary tract infections (UTI's). Which statement indicates a lack of understanding of this teaching? A) "It's okay to soak in the tub with a bubble bath to make sure I am properly cleaned." B) "I will drink cranberry juice daily in an attempt to decrease the number of bacteria in my bladder." C) "I will empty my bladder regularly even if I don't have the urge to go." D) "I will drink 2 liters of fluid every day."

A) "It's okay to soak in the tub with a bubble bath to make sure I am properly cleaned."

The nurse assesses a client in the emergency room who presents with lower abdominal bladder distention. Which question would the nurse ask first? A) "When was the last time you voided?" B) "Are you drinking plenty of water?" C) "What medications are you taking?" D) "Have you tried laxatives or enemas?"

A) "When was the last time you voided?"

Which client would benefit most from anticholinergic medications? A) A client with pelvic floor weakness and stress incontinence. B) A client who is pregnant and leaking urine. C) A client with prostate issues and a distended bladder. D) A client with constipation and a history of fecal impaction.

A) A client with pelvic floor weakness and stress incontinence.

Which statement best describes the clinical manifestations associated with late hypothermia? A) A late sign of hypothermia is confusion, stupor and coma. B) A late sign of hypothermia is delirium and shivering. C) A late sign of hypothermia is skin that is cool and has a fast capillary refill. D) A late sign of hypothermia is flushed diaphoretic skin.

A) A late sign of hypothermia is confusion, stupor and coma.

A nurse cares for a patient who has been diagnosed with an acute small bowel obstruction. Which assessment findings would the nurse correlate with this diagnosis? A) Abdominal pain B) Diarrhea C) Constipation D) Weight loss of 5 pounds over the past 3 months

A) Abdominal pain

A hospitalized child with an infection has a fever. Which actions by the nurse help promote the child's comfort. Select all that apply. A) Administer antipyretics for comfort as needed. B) Sponge bathe the child with rubbing alcohol. C) Change the child's gown when it becomes damp. D) Place ice bags in the armpits and groin.

A) Administer antipyretics for comfort as needed. C) Change the child's gown when it becomes damp.

A nurse in a long-term care facility is caring for a client with Alzheimer's disease who says she saw a little child under the bed, when clearly there was no little child under her bed. How should the nurse respond? A) Ask the client about her past to distract her from what she believes she's seeing. ​ B) State clearly you do not see the child under the bed. ​ C) Explain to the client she needs her eyes rechecked. ​ D) Verify you see the child is under the bed, although you do not actually see it. ​

A) Ask the client about her past to distract her from what she believes she's seeing. ​

Which nursing intervention would be most appropriate to meet safety needs when caring for an older adult with sensory change? ​ A) Assist with preparing a bath because the client may be less able to feel the temperature. ​ B) Use care when administering an injection because older adults experience more pain. ​ C) Massage with additional pressure because perception is diminished. ​ D) Use minimal touch with an older adult because touch may feel uncomfortable.

A) Assist with preparing a bath because the client may be less able to feel the temperature. ​

A 76-year-old woman with Alzheimer's disease was admitted to a memory care facility after falling at home. The family states she has a history of dementia with wandering and cannot be trusted alone. On the first few days, she is restless and agitated, sleeping only 2-3 hours a night. Which interventions would help her to function at the highest level possible? Select all that apply. A) Avoid unfamiliar situations whenever possible. B) Furnishing her room with familiar possessions. C) Reducing overstimulation. D) Having her take part in activities that distract her. E) Encourage her to perform cognitive skills above her level of ability. F) Vary the timing of day-to-day activities.

A) Avoid unfamiliar situations whenever possible. B) Furnishing her room with familiar possessions. C) Reducing overstimulation. D) Having her take part in activities that distract her.

Which of the following are underlying conditions that can cause of fatigue? Select all that apply. A) Cancer B) Surgery C) Anemia D) Mental health conditions E) Blood transfusion

A) Cancer C) Anemia D) Mental health conditions

A patient presents to the clinic complaining of sore thorat, muscle aches, fever and fatigue. The patient is diagnosed with influenza. How would you categorize the fatigue? A) Caused by a secondary condition B) Treatment related cause C) Caused by psychological processes D) Has a chronic cause

A) Caused by a secondary condition

A patient with cancer presents to the clinic complaining of nausea, weakness, and fatigue only after receiving chemotherapy. How would you categorize the fatigue? A) Caused by the treatment B) Caused by physiologic processes C) Has a chronic cause D) Caused by a secondary acute condition

A) Caused by the treatment

The nurse in Urgent Care has four patients waiting to be seen. Which one should be seen first? A) Client reports increased trouble breathing after pneumonia diagnosis B) Client has a ringworm rash on their arm C) Client needs a medication refill D) Client has diarrhea that started two hours ago

A) Client reports increased trouble breathing after pneumonia diagnosis

Which isolation precaution is necessary for a patient with a MRSA skin infection? A) Contact B) Airborne C) Standard D) Droplet

A) Contact

Which patient goal (outcome) should the nurse focus on for the patient with dermatitis from poison ivy? A) Decreasing pruritis B) Preventing pressure ulcers C) Promoting drying of lesions D) Decreasing pain

A) Decreasing pruritis

Which of the following is an accurate statement about the differences between dementia and delirium? ​ A) Delirium is acute and dementia is chronic. ​ B) Dementia can be caused by infection and delirium is caused by heredity. ​ C) Delirium is permanent and dementia is temporary. ​ D) Dementia has an early onset and delirium has a late onset. ​

A) Delirium is acute and dementia is chronic. ​

Which of the following is a consequence of unrelieved pain? A) Developmental delays B) Decreased stress response C) Increased gastric motility D) Increased immune competence

A) Developmental delays

The nurse is caring for an older adult client who is diagnosed with urinary tract infection (UTI). What common urinary signs and symptoms does the nurse expect (typical findings) for an older adult with a urinary tract infection without complications? (Select all that apply.) A) Dysuria B) Frequency C) Burning D) Fever E) Chills F) Hematuria

A) Dysuria B) Frequency C) Burning F) Hematuria

A patient has cellulitis on the right forearm. Which of the following should the nurse expect to be ordered? Select all that apply. A) Elevate right forearm above the level of the heart. B) Limit use of antipyretics. C) Administer antibiotics as prescribed. D) Notify the Provider for increased area of redness, swelling and warmth.

A) Elevate right forearm above the level of the heart. C) Administer antibiotics as prescribed. D) Notify the Provider for increased area of redness, swelling and warmth.

A six-year-old child visiting primary care complains of abdominal pain. The mother states he hasn't had a bowel movement for about a week. Which of the following patient instructions are appropriate? Select all that apply. Correct answer: A) Encourage exercise B) Drink plenty of fluids with a high fiber diet C) Miralax can be given to children D) Laxatives should be used daily

A) Encourage exercise B) Drink plenty of fluids with a high fiber diet C) Miralax can be given to children

The nurse is caring for a long-term care resident who is unable to transfer to the chair without the assistance of staff has stool in his briefs. Which of the following disorders best characterizes the problem? A) Functional incontinence B) Encopresis C) Fecal incontinence D) Fecal impaction

A) Functional incontinence

A client has been diagnosed with C-difficile. Which personal protective equipment (PPE) will the nurse need to put on when preparing to assess the patient? (pre-Covid) A) Gown B) Gloves C) N95 respirator D) goggles

A) Gown B) Gloves

What is the best advice the nurse can give to older adults to improve sleep hygiene? A) Have a bedtime ritual and avoid naps to maintain good sleep hygiene. B) Fall asleep when you are tired to maintain good sleep hygiene, even if it means frequent napping. C) Make sure to get at least 10 hours of sleep a night. D) Develop a habit of getting at least 5 hours of sleep at night.

A) Have a bedtime ritual and avoid naps to maintain good sleep hygiene.

Which action by the infection control nurse would be most effective in reducing the incidence of health care associated infections? A) Have hand sanitizer available inside and outside every patient room. B) Screen all patients for MRSA. C) Require full PPE before entering each patient room. D) Develop a policy on antibiotic therapy.

A) Have hand sanitizer available inside and outside every patient room.

Which of the following clinical manifestations are associated with small bowel obstruction? Select all that apply. A) High pitched bowel sounds B) Vomiting C) Non-distended abdomen D) Abnormal electrolyte values

A) High pitched bowel sounds B) Vomiting D) Abnormal electrolyte values

The nurse caring for patients understands which factors must be present to transmit infection. Select all that apply. A) Host B) Mode of transmission C) Portal of entry D) Reservoir E) Poor hygiene F) Colonization

A) Host B) Mode of transmission C) Portal of entry D) Reservoir

During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. Which of the following suggestions would improve the quality of his bowel movement? (Select all that apply.) A) Increase fiber intake B) Increase water consumption C) Refrain from alcohol D) Increase protein in the diet E) Restrict fluid intake

A) Increase fiber intake B) Increase water consumption

A nurse is caring for a client who has a non-healing pressure injury. Which assessment finding indicates it is a non-healing wound? A) Increased size in the length and in the width of the wound B) Patient is requesting pain medication C) Decrease in the depth of the wound D) Color of the wound is red and beefy

A) Increased size in the length and in the width of the wound

The nurse teaches a client who has stress incontinence how to regain more control over the bladder. Which health teaching is the most important for the nurse to include for this client? A) Kegel exercises to strengthen muscles B) Types of incontinence pads to use C) Types of liquids to drink and when D) Need to perform intermittent catheterizations.

A) Kegel exercises to strengthen muscles

The nurse is caring for a postsurgical patient who is being discharged with antibiotics, oral opioid analgesics, and stool softeners. Which of the following is important to include in the discharge instructions? A) Monitor for both constipation and diarrhea B) Decrease fluid intake C) Maintain a low fiber diet D) Take a laxative if constipated

A) Monitor for both constipation and diarrhea

A client on antibiotics develops diarrhea three times a day for three days. Which action by the nurse is most important? A) Notify the provider and recommend stool cultures B) Place the client on NPO until the diarrhea resolves C) Delegate skin care to the nursing assistant D) Notify the provider and recommend Imodium

A) Notify the provider and recommend stool cultures

A student asks the nurse why older adults have a greater risk to getting Covid infection than younger adults. Which explanation about infections is accurate? Select all that apply. A) Older adults have a higher rate of chronic illnesses, placing them at greater risk. B) Older adults have a decrease in immune function. C) Older adults have decreased cough and gag reflexes. D) Older adults are less likely to wear a mask in public.

A) Older adults have a higher rate of chronic illnesses, placing them at greater risk. B) Older adults have a decrease in immune function. C) Older adults have decreased cough and gag reflexes.

Which of the following is a common risk factor for impaired sleep? A) Pain B) Osteoporosis C) Undernutrition D) Immobility

A) Pain

A nurse is caring for a client whose Braden scale score indicates a high risk for pressure ulcer development. Which interventions are evidence-based practices (EBP) to prevent or treat skin breakdown? Select all that apply. A) Perform perineal cleansing every 2 hours. B) Assess the skin daily. C) Request a referral to the nutritionist. D) Keep the head of bed (HOB) elevated. E) Use barrier cream for incontinence.

A) Perform perineal cleansing every 2 hours. B) Assess the skin daily. C) Request a referral to the nutritionist. E) Use barrier cream for incontinence.

A nurse plans care for several patients who are immobile. Which interventions should the nurse include to prevent pressure injuries for this group of patients? Select all that apply. A) Place a pillow under the lower extremity to elevate the heels. B) Ask the patient to "off load" their weight while sitting in a chair. C) Limit fluid and protein in the diet. D) Use a "donut" for sitting in the chair. E) Avoid shearing when moving patients.

A) Place a pillow under the lower extremity to elevate the heels. B) Ask the patient to "off load" their weight while sitting in a chair. E) Avoid shearing when moving patients.

The nurse is caring for a client in long term care who has been receiving antibiotics for a urinary tract infection (UTI). The client complains of watery, odorous diarrhea. Which interventions should the nurse plan for this client? A) Place the client on contact isolation. B) Monitor for signs of dehydration. C) Wash hands thoroughly with hand sanitizer. D) Insert a catheter to obtain another urine specimen. E) Encourage client to push fluids.

A) Place the client on contact isolation. B) Monitor for signs of dehydration. E) Encourage client to push fluids.

A client works for the city shredding wood, with a potential for flying wood debris. Which of the following is the most important thing for the industrial nurse to emphasize? A) Protective eye wear should always be worn. B) Workplace policies for handling chemicals should be followed. C) Know where the emergency wash stations are located at work. D) Have a first aid kit available in your locker.

A) Protective eye wear should always be worn.

A patient taking antibiotics experiences liquid, odorous diarrhea three times a day. Which of the following interventions is most important for the nurse to implement? A) Put a sign in the room reminding staff to wash hands with soap and water. B) Put a sign in the room reminding staff to use hand sanitizer. C) Encourage the use of briefs. D) Instruct the patient to stop taking the antibiotics.

A) Put a sign in the room reminding staff to wash hands with soap and water.

The nurse must awaken the patient from question 2 in order to prepare the patient for a procedure. The patient is disoriented. What is the nurse's best action? A) Re-assess the patient orientation B) Administer anti-anxiety medication C) Cancel the patient's procedure D) Notify the healthcare provider

A) Re-assess the patient orientation

Which of the following statements is true about sleep for toddlers and preschoolers? A) Require approximately 12 hours of sleep at night. B) Require approximately 8 hours of sleep at night. C) Enter REM sleep immediately. D) Their normal biologic pattern is to sleep later and wake later than previously.

A) Require approximately 12 hours of sleep at night.

A 76-year-old woman with Alzheimer's disease was admitted to a memory care facility after falling at home. The family states she has a history of dementia with wandering and cannot be trusted alone. On the first few days, she is restless and agitated, sleeping only 2-3 hours a night. As you develop a plan for her care, which of the following has the highest priority? A) Safety B) Chronic confusion C) Elimination D) Impaired communication

A) Safety

Which of the following statements about elimination across the lifespan are true? Select all that apply. A) School aged children who have a busy schedule will often forget to use the bathroom. B) Older male adults are more likely to develop benign prostatic hyperplasia. C) Older adults have a greater risk for constipation due to medications. D) The risk of functional incontinence increases with age because of slowed peristalsis. E) Newborns are at high risk for constipation. F) Constipation is common with pregnancy due to the elevated progesterone.

A) School aged children who have a busy schedule will often forget to use the bathroom. B) Older male adults are more likely to develop benign prostatic hyperplasia. C) Older adults have a greater risk for constipation due to medications. F) Constipation is common with pregnancy due to the elevated progesterone.

Which of the following is the most important barrier to infection? A) Skin and mucous membranes B) Inflammatory process C) Colonization by host bacteria D) Gastrointestinal secretions

A) Skin and mucous membranes

Which description best matches the type of pressure injury? A) Stage 1: nonblanchable tissue B) Stage 2: may have visible adipose tissue and slough C) Stage 3: may have a pink or red wound bed D) Stage 4: wound is obscured with eschar or slough

A) Stage 1: nonblanchable tissue

The nurse is teaching members of the community how to prevent heat-related illnesses. Which of the following statements should the nurse include in the teaching. Select all that apply. A) Take cool baths or showers after outdoor activities. B) Drink plenty of fluids throughout the day. C) Check with the older person during hot weather. D) Wear dark colored clothing. E) Use sunscreen with SPF of 8.

A) Take cool baths or showers after outdoor activities. B) Drink plenty of fluids throughout the day. C) Check with the older person during hot weather.

Which of the following situations places a child at risk for constipation? Select all that apply. A) The child is engaged in an after school activity. B) The child doesn't like to take a shower. C) The child doesn't like to drink fluids. D) The child has food preferences include mostly fast foods. E) The child likes to go to bed early and wake up early.

A) The child is engaged in an after school activity. C) The child doesn't like to drink fluids. D) The child has food preferences include mostly fast foods.

A client is disoriented to person, place and time. Which of the following observations made by the nurse indicate the client is experiencing delirium? A) The client has disorganized thinking. B) The client remains awake and alert. ​ C) The confusion began 5 months ago. ​ D) The client's pupils are 4mm in diameter and respond equally to light. ​

A) The client has disorganized thinking.

The nurse is caring for a client with functional urinary incontinence. Which of the following instructions are appropriate for this client's condition? Select all that apply. A) The importance of having a a commode near the client at night. B) To have scheduled toileting practices. C) The potential side effects of antispasmodic medications. D) To avoid drinking more than 2 liters per day.

A) The importance of having a a commode near the client at night. B) To have scheduled toileting practices.

The nurse is caring for a client who is prescribed habit training to manage incontinence. Which of the following interventions should the nurse implement? Select all that apply. A) Toileting the client after breakfast B) Encourage the use of an incontinence brief instead of toileting the patient. C) Encouraging the client to drink fluids D) Recording the client's incontinence episodes

A) Toileting the client after breakfast C) Encouraging the client to drink fluids D) Recording the client's incontinence episodes

A truck driver routinely refuses to stop to use the restroom on his route. Which of the following is the most serious complication associated with intentionally holding urine? A) Urinary retention leading to hydronephrosis B) Loss of urine with sneezing C) Functional bladder incontinence D) Delay in urine flow

A) Urinary retention leading to hydronephrosis

When working with severe dementia residents, which of the following interventions should be avoided? A) Use restraints B) Adjust your approach if the resident seems upset C) Don't argue with the resident D) Talk calmly

A) Use restraints

The nurse working in-home care is giving patient teaching on safety to the older diabetic client. Which of the following instructions should the nurse include? Select all that apply. A) Wearing proper foot wear will reduce the risk of trauma. B) Use adaptive devices as needed. C) Place cold fingers in hot water to warm them. D) Inspect the feet once a month

A) Wearing proper foot wear will reduce the risk of trauma. B) Use adaptive devices as needed.

A 90-year-old patient is hospitalized with a history of 10 liquid stools per day for 3 days in a row. What is the priority nursing concept to consider when planning interventions? A) Elimination B) Fluid and electrolytes C) Pain D) Tissue Integrity

B) Fluid and electrolytes

Which of the following are factors that affect bowel elimination? Select all that apply. A) Laxative use B) Age C) Fiber intake D) Privacy E) Neuromuscular disorders F) Exercise

ALL OF THE ABOVE

How can nurses facilitate sleep for the patient in the hospital setting? Select all that apply. A) Close the drapes in the evening and nighttime hours. B) Address pain issues. C) Cluster nursing duties to limit times entering the room. D) Put a "do not disturb" sign outside the patient's door.

ALL OF THE ABOVE A) Close the drapes in the evening and nighttime hours. B) Address pain issues. C) Cluster nursing duties to limit times entering the room. D) Put a "do not disturb" sign outside the patient's door.

Which interventions prevent infection in the hospital setting? Select all that apply. A) Disinfect all frequently touched surfaces B) Monitor white blood cell counts for patients on the unit. C) Screen all visitors for symptoms of infection prior to visiting patients. D) Screen all patients for covid while they are still in the emergency room

ALL OF THE ABOVE A) Disinfect all frequently touched surfaces B) Monitor white blood cell counts for patients on the unit. C) Screen all visitors for symptoms of infection prior to visiting patients. D) Screen all patients for covid while they are still in the emergency room

Which of the following conditions or persons are at greatest risk for impaired sleep? Select all that apply. A) Older adults with chronic conditions B) Pregnant women C) A nurse who works days one week and nights the next week. D) Truck drivers who cross multiple time zones.

ALL OF THE ABOVE A) Older adults with chronic conditions B) Pregnant women C) A nurse who works days one week and nights the next week. D) Truck drivers who cross multiple time zones.

Which of the following are used to determine the risk for Obstructive Sleep Apnea (OSA) prior to surgery using the STOPBANG questionnaire? Select all that apply: A) Snoring B) Daytime tiredness C) History of hypertension D) Gender- male

ALL OF THE ABOVE A) Snoring B) Daytime tiredness C) History of hypertension D) Gender- male

Which of the following recommendations should the nurse give to a patient who complains of difficulty sleeping at night? Select all that apply. A) Use the bed for sleeping only B) Avoid smoking C) Avoid alcohol D) Avoid caffeine

ALL OF THE ABOVE A) Use the bed for sleeping only B) Avoid smoking C) Avoid alcohol D) Avoid caffeine

Which of the following is a potential cause of constipation for older adults? Select all that apply. A) anticholinergics B) opioids C) medical conditions D) gastroenteritis E) slowed peristalsis

ALL OF THE ABOVE (EXCEPT gastroenteritis) A) anticholinergics B) opioids C) medical conditions E) slowed peristalsis

A nurse plans care for an older adult patient in long term care. Which interventions should the nurse include in this client's plan of care to promote urinary health? (Select all that apply.) A) Ensure adequate fluid intake. B) Leave the bathroom light on at night. C) Encourage use of the toilet every 1-2 hours while awake. D) Provide thorough perineal care after each voiding E) Assess for urinary retention and urinary tract infection. F) Request indwelling catheter placement for incontinence. G) Make sure the call light is within the patient's reach.

ALL OF THE ABOVE EXCEPT F: (Request indwelling catheter placement for incontinence) A) Ensure adequate fluid intake. B) Leave the bathroom light on at night. C) Encourage use of the toilet every 1-2 hours while awake. D) Provide thorough perineal care after each voiding E) Assess for urinary retention and urinary tract infection. G) Make sure the call light is within the patient's reach.

The most common causes of delirium for an older person include (select all that apply): A) Urinary tract infection B) Opioid analgesic medications C) Recent hip fracture D) Pneumonia E) Foley catheter F) Being placed in a new environment G) Exposure to air pollution

ALL OF THE ABOVE EXCEPT G: (Exposure to air pollution) A) Urinary tract infection B) Opioid analgesic medications C) Recent hip fracture D) Pneumonia E) Foley catheter F) Being placed in a new environment

Which of the following are risk factors for UTI? Select all that apply. A) Postmenopausal women B) Wiping from back to front after toileting C) Female D) Being an older age E) Having an Indwelling catheter F) Having dehydration G) Having a history of sexually transmitted disease at a young age

ALL OF THE ABOVE EXCEPT G: (Having a history of sexually transmitted disease at a young age) A) Postmenopausal women B) Wiping from back to front after toileting C) Female D) Being an older age E) Having an Indwelling catheter F) Having dehydration

Who is at highest risk for treatment related fatigue? Select all that apply. A) Pregnant 25 year-old B) An older adult taking sedatives C) A 78 year old who can only walk a half a mile a day. D) Business man who consumes six cups of coffee per day. E) A hypertensive patient taking beta blockers.

B) An older adult taking sedatives E) A hypertensive patient taking beta blockers.

A nurse is teaching home safety to the family of a client with Alzheimer's disease. The client has begun wandering around the house at night. Which of the following statements made by the family indicates an understanding of the teaching? ​ A) "I will keep the room dark at night to improve sleep." ​ B) "I have new locks at the tops of all outside doors." ​ C) "I will make sure he knows his address in case he wanders outside" ​D) "I will place restraints to remind him not to get out of bed." ​

B) "I have new locks at the tops of all outside doors." ​

After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statements made by the client indicate an understanding of the instructions? Select all that apply. A) "I will limit my total intake of fluids." B) "I must avoid drinking alcoholic beverages." C) "I must avoid drinking caffeinated beverages." D) "I should try to lose about 10% of my body weight."

B) "I must avoid drinking alcoholic beverages." C) "I must avoid drinking caffeinated beverages." D) "I should try to lose about 10% of my body weight."

A patient was recently discharged from the hospital after receiving treatment for sepsis. She wonders why she remains fatigued one week after discharge. The nurse provides instructions to lessen the fatigue. Which of the following patient statements indicate an understanding of these instructions? A) "I will increase my sleep to 12 hours a day." B) "I will start by walking each day." C) "I will increase my caffeine intake." D) "I will eat more carbohydrates to improve the fatigue."

B) "I will start by walking each day."

A patient asks why it is so important for oral care to be completed at least twice a day. what is the nurse's best response? A) "Cleaning the surface of the teeth will prevent discoloration." B) "It keeps the bacteria in the oral cavity under control to prevent infection." C) "Oral care is important to all of our clients." D) "Oral care is performed mostly for the client's comfort."

B) "It keeps the bacteria in the oral cavity under control to prevent infection."

A nurse teaches a client with functional urinary incontinence. Which statement would the nurse include in this client's teaching? A) "You must clean around your catheter daily with soap and water." B) "You might want to get pants with elastic waistbands." C) "You will need to be on your drug therapy for life." D) "Operations to repair your bladder are available, and you can consider these."

B) "You might want to get pants with elastic waistbands."

The heat index is well over 100 degrees Fahrenheit and the emergency room has several patients with heat-related injuries. Which patient should be seen first? A) A homeless person looking for a cool place to stay. B) A marathon runner with altered muscle coordination, confusion, and hot dry skin. C) An obese adult whose air conditioner is not working. D) An older adult watching a parade outside on a lawn chair.

B) A marathon runner with altered muscle coordination, confusion, and hot dry skin.

What type of dressing is needed for a wound with a stage 3 pressure injury with a large amount of exudate? A) Tegaderm (transparent dressing) B) An absorbent dressing C) Wet to dry saline gauze dressing D) Use a large bandaid

B) An absorbent dressing

A patient has progressive functional impairment and personality changes. Is this behavior associated with dementia, delirium, neither or both? A) Delirium B) Dementia C) Both dementia and delirium D) Neither dementia or delirium

B) Dementia

A nurse is teaching older adults at a senior center about changes to the ears and hearing that can occur with aging. What statements should the nurse include? (Select all that apply.) A) All adults may have some degree of hearing loss. B) Hearing aids can contribute to cerumen impaction. C) Hearing function may be reduced because cerumen is drier and impacts more easily. D) Use cotton swabs to clean the ears or remove cerumen.

B) Hearing aids can contribute to cerumen impaction. C) Hearing function may be reduced because cerumen is drier and impacts more easily.

Which patient population is at greatest risk of life-threatening complications from diarrhea because they have a greater portion of their bodies are made from water? A) Adult B) Infant C) School age child D) Older adult

B) Infant

A hospitalized patient is on Contact Precautions for MRSA. The physician ordered a CT scan. What action by the nurse is most appropriate? A) Have the aid go with the patient to the CT scan. B) Notify the CT scan staff about the isolation precautions. C) Notify the physician the patient cannot leave the room. D) No special precautions are needed when this patient leaves the unit.

B) Notify the CT scan staff about the isolation precautions.

Which of the following statements is true about fever? A) Adults are likely to have a fever with every infection. B) Older adults are less likely to develop a fever when ill. C) Those individuals who are immunocompromised are most likely to develop a fever. D) Younger children are less likely to develop a fever when ill.

B) Older adults are less likely to develop a fever when ill.

What is an expected outcome for an adult patient using a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea (OSA)? A) The patient will have fewer than 3 awakenings at night. B) The patient has no periods of apnea. C) The patient has a blood pressure of 150/80. D) The patient requires two naps per day instead of three.

B) The patient has no periods of apnea.

What happens during the sleep cycle? A) Immune response is suppressed. B) The restoration of brain tissue occurs. C) Muscles become tense. D) Regulation of electrolytes occurs.

B) The restoration of brain tissue occurs.

The nurse working in memory care is caring for a patient with dementia who has periodic episodes of incontinence of the bowel and bladder. Which intervention is most important for improving elimination? A) Speak with the family about past elimination habits. B) Toilet the patient upon waking, at bedtime, after meals and every two hours. C) Speak with the patient's family about food choices. D) Establish a bedtime ritual for the patient.

B) Toilet the patient upon waking, at bedtime, after meals and every two hours.

A nurse cares for a client who has severe dementia from Alzheimer's disease. Which communication techniques would the nurse implement? A) Ask open-ended questions B) Validate client feelings C) Avoid using pictures when giving instructions D) Provide multiple choices

B) Validate client feelings

A client with benign prostatic hyperplasia (BPH) asks the nurse why he should avoid taking cold medications. These medications should be avoided because they are associated with: A) impotence B) urinary retention C) incidence of bladder cancer D) increases the size of the prostate

B) urinary retention

A nurse witnesses a client with dementia eat breakfast. Afterward the client states, "I am hungry and want breakfast." How would the nurse respond? A) "It appears you are confused this morning." B) "Your family will be here soon. Let's get dressed." C) "I see you are still hungry. I will get you some toast." D) "You ate your breakfast 30 minutes ago."

C) "I see you are still hungry. I will get you some toast."

A nurse cares for a patient who is scheduled for the surgical creation of a Urostomy. The patient is anxious, stating "what is it like to have this?" How would the nurse respond? A) "I will ask the provider to prescribe you an anti-anxiety medication." B) "I think it would be nice to not have to worry about finding a bathroom." C) "I think it would be helpful for you to speak to an Ostomy nurse." D) "I will ask the provider if you really need this procedure."

C) "I think it would be helpful for you to speak to an Ostomy nurse."

A patient who was diagnosed with dementia has become incontinent of urine. When the patient's daughter asks the nurse why this is happening. What is the nurse's best response? A) "She is angry about the dementia diagnosis." B) "She doesn't want to use the commode because it is unfamiliar." C) "The brain doesn't send the message for the need to urinate." D) "She is uncooperative because of the dementia."

C) "The brain doesn't send the message for the need to urinate."

Which client is at greatest risk for developing delirium? A) A 65-year-old man taking opioid analgesics for pain after a motor vehicle accident. B) A 59-year-old man with a history of heart disease who just had surgery. C) A 70-year-old woman just admitted to the hospital for pneumonia who has a history of dementia. D) A 10-year-old child on the pediatric floor who has a Foley catheter in place.

C) A 70-year-old woman just admitted to the hospital for pneumonia who has a history of dementia.

A nurse is planning care for an older long-term care resident who has diarrhea. The resident is incontinent. Which nursing action should the nurse include in this patient's plan of care? A) Keeping broken skin areas open to air to promote healing. B) Repositioning the patient every four hours. C) Applying a barrier cream to the skin after cleaning. D) Use hand sanitizer over soap and water when washing your hands

C) Applying a barrier cream to the skin after cleaning.

A nurse assess an older client who has a rash on both hands and complains of itching. Which should the nurse do first? A) Apply gloves to minimize friction B) Administer an antihistamine C) Ask the patient what they were doing when they developed the rash D) Apply moisturizing lotion

C) Ask the patient what they were doing when they developed the rash

Which of the following diagnostic test is used to visually examine the large intestine? Correct answer: A) Cystoscopy B) Uroscopy C) Colonoscopy D) Stool for occult blood

C) Colonoscopy

A patient tells the nurse that he experiences daytime fatigue even after 7-8 hours of sleep at night. What is the best assessment question for the nurse to ask? A) How long are you in the rapid eye movement (REM) stage? B) Have you tried getting 10 hours of sleep instead of 8? C) Do you have any recent lifestyle or behavior changes? D) Do any of your close relatives have sleep disorders?

C) Do you have any recent lifestyle or behavior changes?

The nurse is making rounds on the hospital unit and observes a patient sleeping. The patient is awakened with a startle and is disoriented. Which stage of sleep are they most likely in? A) NREM Stage 2 B) NREM Stage 1 C) NREM Stage 3 or 4 D) REM sleep

C) NREM Stage 3 or 4

The client is admitted with possible sepsis. Which action should the nurse perform first? A) Place the patient in isolation B) Administer antibiotics C) Obtain specified cultures D) Give an antipyretic

C) Obtain specified cultures

A female patient has a history of delivering four babies is now diagnosed with stress incontinence. Which intervention is most appropriate for this condition? A) Insert an indwelling catheter B) Place a commode next to the bedside at night C) Teach the patient Kegel exercises D) Perform a bladder scan

C) Teach the patient Kegel exercises

Which of the following questions is most important to ask the newly admitted patient who may have a bowel obstruction? A) When was the last time you've had diarrhea? B) How often do you use stool softeners, laxatives or enemas? C) When was the last time you moved your bowels? D) Describe your bowel movements.

C) When was the last time you moved your bowels?

Which of the following is a potential consequence of diabetic neuropathy? A) cataracts B) sensorineural hearing loss C) infection D) glaucoma

C) infection

A nurse teaches a patient who is at risk for constipation. Which statements would the nurse include in this patient's teaching? A) "Take a laxative every evening to improve motility." B) "Use an enema to stimulate peristalsis." C) "Take a suppository every day." D) "Eat a high-fiber diet including raw fruits and vegetables."

D) "Eat a high-fiber diet including raw fruits and vegetables."

The nurse is teaching a new nursing assistant about caring for older adults and sensory perception. Which statement should the nurse include in this teaching? A)"Stand over the client and talk down to them." B) "You always need to check for earwax." C) "Assess the client's hearing with the whisper test." D) "Face the client when you are talking to them."

D) "Face the client when you are talking to them."

A mother tells the nurse she is concerned because her 8-month-old infant sleeps all day and night and is only awake about 2-3 hours per day. What is the nurse's best response? A) "Be sure you are laying the child on his back to sleep at night." B) "This sleep pattern is very normal for an infant at this age." C) "Adding an additional feeding will keep the child awake more." D) "I recommend that you notify the child's pediatrician."

D) "I recommend that you notify the child's pediatrician."

The nurse is caring for a client with urinary incontinence. The client states, "I am so embarrassed. I'm just like a baby." How would the nurse respond? A) "More people experience incontinence than you might think." B) "I understand how you feel. I would be mortified." C) "Incontinence pads will minimize leaks in public." D) "Would you like me to teach you strategies to help control your incontinence?

D) "Would you like me to teach you strategies to help control your incontinence?

When assessing patients for pressure injuries, which of the following patients is at greatest risk? A) A 26 year old with a fractured leg from a motor vehicle accident B) A 44 year old with pneumonia C) A 78 year old requiring assistance to ambulate with a walker D) A 65 year old with a stroke and incontinence

D) A 65 year old with a stroke and incontinence

A nurse assesses a patient with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the patient reports constant abdominal pain. Which action would the nurse take next? A) Insert a urinary catheter. B) Position the patient with knees to chest. C) Administer intravenous opioid medications. D) Insert a nasogastric tube for gastric decompression per provider orders.

D) Insert a nasogastric tube for gastric decompression per provider orders.

Which of the following clinical manifestations is associated with glaucoma? A) Eye itching B) Cloudy central vision C) Increased depth perception D) Loss of peripheral vision

D) Loss of peripheral vision

A patient has been placed on Contact precautions. The client's family is very afraid to visit, for fear of "catching something" from the patient. What action by the nurse is best? A) Tell the family how depressed the patient is without seeing them. B) Explain how to perform hand hygiene and use isolation precautions. C) Tell the family they will never get the infection. D) Show the family how to perform hand hygiene and use isolation precautions.

D) Show the family how to perform hand hygiene and use isolation precautions.

Which of the following interventions help to improve communication with the resident with dementia? A) Keep the television on all day to help reorient them. B) Give long explanations with a lot of detail to the resident. C) Ask questions while the resident is completing a task. D) Speak clearly and calmly to the resident.

D) Speak clearly and calmly to the resident.

What is the best goal for a patient with obstructive sleep apnea (OSA) who has approximately 5 hours of restorative sleep per night? A) The patient can teach back the purpose of surgical management. B) The patient has a blood pressure of 160/80. C) The patient's body mass index (BMI) is 37. D) The patient's duration of restorative sleep increases to 8 hours a night.

D) The patient's duration of restorative sleep increases to 8 hours a night.

A client has a wound that is healing by secondary intention. Which statement best describes this type of wound? A) The wound was stapled together after an infection was cleared up. B) Wound edges are well approximated. C) The wound is contaminated with debris and cant' be closed at all. D) The wound is an open cavity that will fill with granulation tissue.

D) The wound is an open cavity that will fill with granulation tissue.

A client reports needing to find the bathroom quickly or she will dribble urine. Which condition should the nurse consider that the client is experiencing? A) polyuria B) dysuria C) enuresis D) urgency

D) urgency

Napping for hours throughout the day will improve the long term care residents' nighttime sleeping. True False

FALSE