NUR 233 Final Practice ?'s

2. The client with glaucoma asks the nurse if complete vision will return. The most appropriate response is: A. "Although some vision has been lost and cannot be restored, a further loss may be prevented by adhering to the treatment plan." B. "Your vision will return as soon as the medications begin to work." C. "Your vision will never return to normal." D. "Your vision loss is temporary and will return in about 3-4 weeks.

a

20. Which action should the nurse take when beginning bladder training using scheduled voiding? a Offer the patient a bedpan every 2 hours while awake b Increase the voiding interval by 30-60 minutes each week c Frequently ask the patient whether they have the urge to void d Increase the frequency between voiding even if urine leakage occurs

a

24. A client with major depression has not verbalized problem areas to staff or peers since admission to a psychiatric unit. Which activity should the nurse recommend to help this client express himself? A. Art therapy in a small group B. Basketball game with peers on the unit. C. Reading a self-help book on depression. D. Watching a movie with the peer group.

a

6. A patient with a history of alcoholism is disoriented and vacillates between being calm and disruptive and loud. Vital signs are BP 138/84 mm Hg; pulse 135 beats/min, regular and strong; respiratory rate 22 breaths/min; temperature 37.1°C (98.1°F). What electrolyte imbalance might the nurse suspect this patient is experiencing? a Hypomagnesemia b Hypocalcemia c Hyperkalemia d Hypernatremia

a

6. Which of the following tests would you expect a patient with osteoarthritis to have initially? a. x-rays b. synovial fluid aspiration c. magnetic resonance imaging (MRI) d. computed tomography (CT) scan

a

When caring for a client who is receiving enteral feedings, the nurse would take which measure to prevent aspiration? a elevate HOB 30-45 degrees b decrease flow rate at night c check for residual daily d irrigate regularly with warm tap water

a

When caring for a client who was admitted with HF, which action by the nurse will be most effective in determining whether the client's fluid overload is improving? a weighing the client b monitoring the I and O c assessing the extent of pitting edema d asking the client about subjective symptoms

a

Which action by a 70 year old female client would best limit further progression of osteoporosis? a taking supplemental calcium and vitamin D b increasing the consumption of eggs and cheese c taking supplemental Mg and vitamin E d increasing the consumption of milk products

a

Which action will the urgent care clinic nurse anticipate taking for a 24 year old client who is dehydrated after a long run and has a pulse rate of 103 and bp 102/56? a offer oral fluids at frequent intervals b give fluid blouses through a ng tube c administer intravenous antiemetic medications d insert a peripheral intravenous line fine infusion

a

Which actions will the nurse take to support cognitive ability in clients who have Alzheimer disease? select all that apply a encouraging caregivers to support safe independence b using calendars, clocks, and pictures to support memory c providing a limited number of choices to support decision-making d quizzing the client regularly to assess orientation to person, place and time e administering prescribed rivastigmine to clients with severe dementia

a, b, c

Which intervention will the nurse include in a care plan for a client with dementia who wanders? a assess and treat pain b avoid loud music, television, and glaring lights c have family members monitor client activity when possible d use chemical or physical restraint at night to keep the client in bed e place the client at the end of the hall to allow use of the hall for wandering

a, b, c

Which of theses statements are true regarding disinfection and cleaning? (select all that apply) A. Proper cleaning requires mechanical removal of all soil from an object or area B. General environmental cleaning is an example of medical asepis. C. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. D. Cleaning in a direction from the least to the most contaminated area helps reduce infections. E. Disinfecting and sterilizing medical devices and equipment involve the same procedures.

a, b, d

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. a. Closely assess the patient before, during, and after the procedure. b. Hyperoxygenate the patient before and after suctioning. c. Limit the application of suction to 20 to 30 seconds. d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. e. Use an appropriate suction pressure (80-150 mm Hg). f. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

a, b, d, e

Which manifestations are seen in an older adult with the diagnosis of dementia? select all that apply a resistance to change b inability to recognize familiar objects c preoccupation with personal appearance d inability to concentrate on new activities e tendency to dwell on the past

a, b, d, e

13. Select all the following that can trigger an asthma attack: a sulfites b smoke c caffeine d GERD e Cold, windy weather f Beta agonist g Cockroaches

a, b, d, e, g

A student nurse is demonstrating the proper procedure for maintaining a sterile field. Which of the following guidelines should be followed? (Select all that apply.) A. Never reach across a sterile field. B. Objects below the waist are considered unsterile. C. A dry area is micro-organism free. D. A sterile object is still sterile if touched by a nonsterile object. E. One inch around the edges is considered contaminated.

a, b, e

The nurse is cleaning an open abdominal wound that has un approximated edges. What are accurate steps in this procedure? Select all that apply. a. Use standard precautions or transmission-based precautions when indicated. b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c. Clean the wound in full or half circles beginning on the outside and working toward the center. d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e. Clean to at least one inch beyond the end of the new dressing if one is being applied. f. Clean to at least three inches beyond the wound if a new dressing is not being applied.

a, b, e

Which clinical indicators would the nurse expect when assessing a client with Meniere disease? select all that apply a nausea b dizziness c decreased pulse rate d increased temperature e jerky lateral eye movements

a, b, e

15. The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions are examples of subjective data? Select all that apply a a patient tells the nurse that she feels nauseous b a patients ankles are swollen c a patient tells the nurse that she is nervous about her test results d a patient complains of having a rash on her arm that is itchy e a patient rates his pain as a 7 on a scale of 1 to 10 f a patient vomits after eating dinner

a, c, d, e

Which conditions can precipitate delirium? select all that apply a infection b dementia c dehydration d urine retention e medications

a, c, d, e

15. The nurse correlates which data in a female patient's history to an increased risk of urinary tract infection (UTI)? Select all that apply. A.25 year old who is sexually active B.Drinks 2L of water a day C.28 weeks pregnant D.History of back strain E.History of renal calculi

a, c, e

Which of the following organisms may result in the development of a nosocomial infection? (Select all that apply.) A. Staphylococcus aureus B. Mycobacterium leprae C. Pseudomonas aeruginosa D. Neisseria gonorrhoeae E. Escherichia coli

a, c, e

A nurse caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are signs of this serious condition? Select all answers that apply. a. Dyspnea b. Hypotension c. Small pulse pressure d. Decreased respiratory rate e. Pallor f. Increased pulse rate

a, c, e, f

2.Your patient has severe peripheral venous disease. During the head-to-toe nursing assessment, you would expect to find what skin characteristics of the lower extremities? Select all that apply: A. Thick, tough B. Thin, scaly C. Hairless D. Brown pigmented

a, d

During an outpatient visit you are assessing the patient's understanding about the signs and symptoms associated with osteoporosis. Select all of the signs and symptoms stated by the patient that are correct: a a hump at the base of the neck b loss of 0.5inches in height compared to young adult height c swelling and warmth at the bone site d some patients are asymptomatic e fractures most commonly in the hips, wrist, and spine

a, d, e

Which factors contribute to development of osteoporosis in female clients? select all that apply a cigarette smoking b moderate exercise c use of street drugs d familial predisposition e inadequate intake of dietary calcium

a, d, e

In distinguishing between dementia and delirium, which factors are unique to delirium? select all that apply a slurred speech b lability of mood c long-term memory loss d visual or tactile hallucinations e insidious deterioration of cognition f a fluctuating level of consciousness

a, d, f

14. A client's family member says to the nurse, "The doctor said he will provide palliative care. What does that mean?" The nurse's best response is: A. "Palliative care is given to those who have less than 6 months to live." B. "Palliative care aims to relieve or reduce the symptoms of a disease." C. "The goal of palliative care is to affect a cure of a serious illness or disease." D. "Palliative care means the client and family take a more passive role and the doctor focuses on the physiological needs of the client. The location of death will most likely occur in the hospital setting."

b

18. A patient is admitted to the emergency department reporting a burning pain in the chest of a 7 on a 0 to 10 pain scale and diagnosed with gastroesophageal reflux disorder (GERD) secondary to hiatal hernia. Based on this data, what is the priority nursing diagnosis? a Fluid volume deficit b Acute pain c Ineffective health maintenance d Dysfunctional gastrointestinal motility

b

20. Which of the following nursing actions may prevent medication errors? a Taking all medications out of the unit-dose wrappers before entering the client's room. b Checking with the provider when a single dose requires administration of multiple tablets. c Giving the prescribed medication and then looking up the usual dosage range. d Relying on another nurse to clarify a medication prescription.

b

21. A clients with Parkinson's disease is experiencing tremors, rigidity, and bradykinesia. The nurse anticipates that the physician will prescribe which medication to control these symptoms? A. Phenytoin (Dilantin) B. Carbidopa-levodopa (Sinemet) C. Pyridostigmine (Mestinon) D. Warfarin (Coumadin)

b

23. The home health nurse visits a 40-year-old breast cancer patient with metastatic breast cancer who is receiving palliative care. The patient is experiencing pain at a level of 7 (on a 10-point scale). In prioritizing activities for the visit, you would do which of the following first? a Auscultate for breath sounds. b Administer prn pain medication. c Check pressure points for skin breakdown. d Ask family members about patient's dietary intake.

b

23.A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming: A. Fresh, green vegetables B. Bananas and oranges C. Lean red meat D. Creamed corn

b

24. The nurse is caring for a patient admitted with severe dehydration secondary to gastroenteritis. Which item on the patient's meal tray does the nurse question? a Apple juice b Coffee c Broth d Caffeine-free soda

b

25. During morning rounds, the nurse notes that the unlicensed assistive personnel is assisting a patient with Parkinson's disease with breakfast. Which observation requires an immediate intervention? a Patient sitting out of bed in a chair b Head of the bed raised to 30 degree c Thickener added to liquid menu items d Oral suction catheter equipment turned on

b

3. The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test? A. Stand 4 feet away from the client to ensure that the client can hear at this distance. B. Whisper a statement and ask the client to repeat it. C. Whisper a statement with the examiners back facing the client. D. Whisper a statement while the client blocks both ears.

b

7. Your patient is receiving Alphagan-P(Brimonidine) 0.01%, 1 drop q12 hours in both eyes for glaucoma. What action by the nurse demonstrates improper technique while administering this medication? a Patient placed in lying position b Drops placed directly over cornea c Lower eyelid retracted to expose conjunctiva d Explanation of medication action prior to administration

b

9. The nurse educator is developing a class on pain assessment and incorporates which information regarding the Wong-Baker FACES tool? a This tool is effective for patients who do not speak English b This tool is effective for patients with expressive aphasia c This tool is effective for patients from other cultures d This tool is effective for patients with cognitive impairments

b

A client asks the nurse to explain how to perform a proper handwashing procedure. Which of these responses would be the most appropriate for the nurse to make? A. "Running water helps to wash away the dirt on your hands." B. "Be sure to wet your hands thoroughly before using soap." C. "It is okay to use your washed hands to turn off the faucet." D. "You should wash your hands for at least 30 seconds before rinsing them."

b

A client has a ng feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. Which action would the nurse take first? a instill normal saline into the tube to maintain patency b obtain an x ray to verify that the tube is in the stomach c auscultate the epigastric area while instilling 30ml of air d withdraw stomach contents to observe color and consistency

b

A patient is diagnosed with MRSA. Which type of isolation precaution is most appropriate for this patient? A. Reverse isolation B. Droplet precautions C. Standard precautions D. Contact precautions

b

A patient is post-op from surgery. The patient has a history of gout. While performing a head-to-toe assessment, you assess the patient for signs and symptoms of gout. As the nurse, you know that gout tends to start at what site? a elbow b big toe c thumb or index finger d knees

b

The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should: A. Formulate post-discharge nursing diagnoses B. Draw conclusion about resolution of current client problems C. Assess the client for baseline data to be used at the LTC facility D. Plan the care that is needed in the LTC facility

b

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data? a client is 151 lbs b client's pain is 7/10 c client's fasting glucose is 95 mg/dL d client's bp is 140/90

b

The nurse is preparing to initiate antibiotic therapy for a client who developed an incisional infection. Which task would the nurse ensure has been completed before starting the first dose of intravenous antibiotics? a RBC count b would culture c knee x ray d urinalysis

b

The nurse is providing care to a client who is receiving enteral feedings via a ng tube. Which serious complication would the nurse take measures to prevent? a skin breakdown b aspiration precautions pneumonia c retention ileus d profuse diarrhea

b

The nurse is reviewing orders prescribed for a client with osteomyelitis of the left anterior lower extremity. Which order should the nurse complete first for this client? a medicate for pain b send would culture c measure body temperature d insert an intravenous access device

b

The nurse notes an elderly client has a reddened area on the coccyx. Which action does the nurse take first? A) continues assessment of the area B) repositions the client every 1-2 hours C) massages the reddened area four times per day D) place the client in a semi reclining position

b

The nurse noticed the rr as regular and slow while assessing a client. Which would be the condition of the client? a apnea b bradypnea c tachypnea d hyperpnea

b

The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term correctly describes the findings? a rhonchi b wheezes c pleural friction rub d bronchovesicular

b

The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? A. Formulate a nursing diagnosis of impaired gas exchange B. Record in the medical record the distance a client ambulate in the hall C. Write individualized nursing orders in the care plan D. Compare client responses to the desired outcomes for pain relief

b

The nurse, caring for a client with full-thickness burns of the anterior trunk and thigh, is monitoring fluid balance during the first 2-3 days after the burn. Which area is the most important for the nurse to assess for fluid balance in this client? a daily weight b urinary output every hour c blood pressure every 15 min d extent of peripheral edema every 4 hours

b

The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan? A. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay C. Client will state pain relieved within 30 minutes after medication D. Pressure will be prevented by repositioning client every 2 hours

b

The nursing instructor teaches wound healing. Which outcome would the nurse recognize as an indication of normal wound healing after surgery? A) a tender localized point beneath the wound. B) the wound is reddened and warm C) dehiscence has begun D) hematoma has begun to form

b

When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect? a. The oxygen must be humidified. b. The rate will be no more than 2 to 3 L/min or less. c. Arterial blood gases will be drawn every 4 hours to assess flow rate. d. The rate will be 6 L/min or more.

b

Which clinical finding would the nurse nurse expect for a client with hypertensive emergency? a increase urine output b sever pounding HA c hr 110 d weak and thready radial pulses

b

Which desired outcome written by the nurse is correctly written and measurable? A. Client will have a normal bowel pattern by April 2 B. The client will lose 4 lbs. within next 2 weeks C. The nurse will provide skin care at least 3 times each day D. The client will breathe better after resting for 10 minutes

b

Which is the priority nursing action for a client admitted to the hospital in a coma after having a stroke? a monitor vital signs b maintain an open airway c maintain fluids and electrolytes d monitor pupil size and response

b

Which life-threatening complication may occur in clients taking high-dose or long-term ibuprofen? a anaphylaxis b GI bleeding c cardiac dysrhythmias d disulfiram reaction

b

Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis? A. Grimacing B. Anxiety C. Oxygenation saturation 93% D. Output 500 mL in 8 hours

b

Which position is indicated to assess the musculoskeletal system but is contraindicated in clients with respiratory difficulties? a left lateral recumbent position b prone position c supine position d knee-chest position

b

Which statement by the student nurse indicates the need for further education about medication administration? a I should set up and prepare medications in distraction-free areas b I should advise the certified medical assistant to administer intravenous medication c I should be vigilant during the entire process of medication administration d I should identify each client using at least two identifiers before administering medications

b

You are caring for a patient who has just been diagnosed with type 1 diabetes. This patient needs to be educated as to how to be able to cope with this diagnosis. What is the first thing that you should do for this patient? a Show the patient how to inject himself with insulin. b Evaluate what this patient already knows about diabetes and the administration of insulin. c Establish a plan for management of the diabetes with the patient. d Observe the patient as he administers an insulin injection himself.

b

The nurse is caring for a client who may have Paget's disease and osteomalacia. Elevations of which laboratory tests would confirm the nurse's suspicion? a aldolase b serum calcium c alkaline phosphatase d lactic dehydrogenase e aspartate aminotransferase

b, c

Which of the following actions by the nurse comply with core principles of surgical sepsis? (select all that apply) A. Set up sterile field before patient and other staff come to the operating suite B. Keep the sterile field in view at all times. C. Consider the outer 2.5 cm (1") of the sterile field as contaminated. D. Only health care personnel within the sterile field must wear personal protective equipment. E. The sterile gown must be put on before the surgical scrub is performed.

b, c

17. You want to make sure that your patient will not suffer from pressure ulcers because he is not able to position himself effectively. You would do which of the following as part of an early intervention? check all answers that apply a Discourage protein in the patient's diet b Take steps to reduce shearing and friction. c Clean skin as soon as it becomes wet. d Use the sheet to lift or reposition the patient in bed.

b, c, d

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a. Refrain from exercise. b. Reduce anxiety. c. Eat meals 1 to 2 hours prior to breathing treatments. d. Eat a high-protein/high-calorie diet. e. Maintain a high-Fowler's position when possible. f. Drink 2 to 3 pints of clear fluids daily.

b, d, e

After reviewing a client's reports, the primary health care provider suggests palliative care for the client. Which conditions would qualify the client for this type of care? select all that apply a peptic ulcer b chronic renal failure c cognitive impairment d congestive HF e chronic obstructive lung disease

b, d, e

When should a nurse wear a mask? (Select all that apply) A. The patient's dental hygiene is poor B. The nurse is assisting with an aersolizing respiratory procedure such as suctioning. C. The patient has acquired AIDS and a congested cough D. The patient is in droplet precautions E. the nurse is assisting a health care provider in the insertion of a central line catheter.

b, d, e

The functional health pattern assessment data states: "Eats three meals a day and is of normal weight for height." The nurse should draw which of the following conclusions about this data? Select all that apply. A. Client has an actual health problem B. Client has a wellness diagnosis C. Collaborative health problem needs to be written D. Possible nursing diagnosis exists E. Specific questions about the diet should be asked next

b, e

12. Which nursing intervention reduces the risk of clot formation in the legs? Select all that apply. a Keep the patient's hips and knees flexed while the patient is in bed. b Apply compression devices (e.g., sequential compression devices [SCDs]). c Turn the patient frequently or encourage frequent position changes. d Promote adequate hydration by encouraging oral intake. e Elevate the patient's legs above the level of the heart.

b-e

Which clinical manifestations would lead the nurse to contact health care provider regarding the potential development of acute osteomyelitis? select all that apply a presence of a foot ulcer b temp of 102 c erythema of the affected area d tenderness of the affected area e drainage of the affected area

b-e

17. The nurse is discussing osteoporosis with a group of women. Which factor will the nurse identify as nonmodifiable risk factor? A. Calcium deficiency B. Tobacco use C. Female Gender D. High alcohol intake

c

20. The 65- year old client is diagnosed with macular degeneration. Which statement by the client indicates the client needs more discharge teaching? a "I should use magnification devices as much as possible." b "I will visit my opthamologist as directed." c "I need to use low-watt light bulbs in my house." d "I am going to contact a low-vision center to evaluate my home."

c

21. The charge nurse from the unit receives a call from the pediatrician wanting to admit an 8-year-old child with rubeola (measles). Which of the following is of most concern in deciding whether to admit the child to the unit? a The unit is not staffed with the usual number of RNs. b There are several children receiving chemotherapy on the unit. c No negative-airflow rooms are available on the unit. d The infection control nurse liaison is not on the unit today.

c

22. Nurse Isabelle enters the room of a client with a cognitive impairment disorder and asks what day of the week it is; what the date, month, and year are; and where the client is. The nurse is attempting to assess: A. Confabulation. B. Delirium. C. Orientation D. Perseveration.

c

22. Which condition would Nurse Jade suspect when a client complains of a runny nose, itching and burning eyes, and sneezing since visiting a friend who had a cat in the home? a Anaphylaxis. b Bronchitis c Allergic rhinitis. d Asthma

c

27. A competent older adult patient has an advance directive that expresses the patient's desire to avoid resuscitation and heroic life support measures. The patient's family, however, is not supportive of this directive and plans to contest the living will. Which nursing action is appropriate based on the current situation? a Notify the hospital attorney b Contact the social services department c Place the document in the patient's medical record d Explain to the patient that the conflict could invalidate the document

c

3. The nurse has implemented a care plan for an adult patient with gastroesophageal reflux disorder (GERD). On the next clinic visit, which statement by the patient indicates adherence to the plan of care? a "I still like wearing my Spandex camisoles." b "I have switched from margaritas to wine." c "I've lost 6 pounds because I eat every 3 hours and never before bed." d "I lay down flat after eating to promote digestion."

c

7. An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms is to teach the patient to a. keep both feet flat on the floor when prolonged standing is required. b. twist gently from side to side to maintain range of motion in the spine. c. keep the head elevated slightly and flex the knees when resting in bed. d. avoid the use of cold packs because they will exacerbate the muscle spasms.

c

7. Your patient has a PEG tube and you are about to administer a feeding. What is not a symptom that would cause you to hold off the required feeding? A. Nausea B. Increased bloating C. Skin irritation D. Emesis

c

A client present with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Lab results indicate metabolic alkalosis. A diagnosis of gastric ulcer is made. Which is the primary nursing concern? a chronic pain b risk for injury c electrolyte imbalance d inadequate gas exchange

c

A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview? A. Help the client to get settled and do the interview the next morning when the client is rested B. Do the interview immediately, directing the majority of the questions to the client's spouse C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication

c

A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. For which potential life-threatening complication would the nurse assess the client postop? a wound infection b ischemia of the stoma c fluid deficit and electrolyte imbalance d excoriation of skin around the stoma

c

A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client's progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write? A. Client understands the signs of impaired circulation B. Goal met: Client cited numbness and tingling as sign of impaired circulation C. Goal not met: Client able to name only two signs of impaired circulation D. Goal not met: Client unable to describe signs of impaired circulation

c

A health care provider prescribes enalapril for a client. Which nursing action is important? a assess the client for hypokalemia b monitor for adverse effects on renal function c monitor the client's BP during therapy d assess the client for hypoglycemia

c

A patient with COPD is unable to perform activities of daily living (ADLs) without becoming exhausted. Which nursing diagnosis best describes this alteration in oxygenation as the etiology? a. Decreased Cardiac Output related to difficulty breathing b. Impaired Gas Exchange related to use of bronchodilators c. Fatigue related to impaired oxygen transport system d. Ineffective Airway Clearance related to fatigue

c

After cataracts surgery, the nurse teaches a client how to self-administer eyedrops. The nurse would reinforce the use of which technique? a placing the drops on the cornea of the eye b raising the upper eyelid with gentle traction c holding the dropper tip above the conjunctival sac d squeezing the eye shut after instilling the medication

c

After turning and repositioning, a client recovering from hip replacement surgery complains of severe hip pain. Which observation indicates that the prosthesis has dislocated from the hip joint? a edematous groin area b respiratory rate of 24 and labored c shorter length of the operative limb d pedal pulse thready with operative limb

c

For a client with difficultly swallowing, the nurse will crush which medication? a metoprolol extended release b felodipine sustained release c acetaminophen extra strength d potassium chloride extended release

c

Gout is a type of arthritis that occurs due to the accumulation of ____________ in the blood that causes needle-like crystals to form around the joints. a purines b creatinine c uric acid d amino acids

c

The nurse assesses the lungs of a client and auscultates soft crackling, bubbling breath sounds that are more obvious on inspiration. Which would nurse document these sounds as? a vesicular b bronchial c crackles d rhonchi

c

The nurse cares for the client with a pressure ulcer on the sacrum that is 3 cm deep and 2 cm wide with an irregular border. The muscular tissue is eroded. Which classification does the nurse give this ulceration? A) grade I B) grade II. C) grade III D) grade IV

c

The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time? A. Assessment B. Planning C. Implementation D. Evaluation

c

Which action would the home health nurse take when caring for a client with a pink and moist left left venous stasis ulcer? a teach the client to keep the left leg in a dependent position to improve blood flow b monitor for increases in bruising or bleeding caused by use of anticoagulant medications c clean the wound with normal saline and apply prescribed hydrocolloid dressings weekly d educate the client about the need for vascular surgery to improve blood flow to the wound

c

14. When you receive the shift report, you learn that you patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate? a correct the initial assessment form b redo the initial assessment and document current findings c conduct and document an emergency assessment d perform and document a focused assessment of skin integrity

d

18. The client is to receive a sedative via the buccal route. Which of the following is true? a The medication is placed under the tongue. b This route is probably more expensive than the intramuscular route. c The nurse should offer the client a glass of orange juice after taking the sedative. d This method of administration would be avoided in the event of facial injuries.

d

19. A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? A. Seating the client with arm bared, supported, and at heart level. B. Measuring the blood pressure after the client has been seated quietly for 5 minutes. C. Using a cuff with a rubber bladder that encircles at least 80% of the limb. D. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.

d

23. The nurse is caring for a client that is hearing impaired. Which of the following approaches will facilitate communication? A. Speak frequently. B. Speak loudly. C. Speak directly into the impaired ear. D. Speak in a normal tone.

d

24. The nurse is giving morning medications to patient who refuses to take an oral dose of docusate (Colace). What is the nurse's best response? a your prescriber ordered that you must take this drug twice a day. b docusate will soften your bowel movements so that you do not strain c this drug will help prevent constipation while you are on bed rest. d can you tell me why you do not want to take the docusate?

d

4. A patient is prescribed 20 mEq of potassium chloride because of excessive vomiting. The nurse includes which information in explaining the rationale for this medication? A. It controls and regulates water balance in the body B. It is used in the body to synthesize ingested protein C. It is vital in regulating muscle contraction and relaxation D. It is needed to maintain skeletal, cardiac, and neuromuscular activity

d

4. Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, and/or muscle are exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. a stage 1 b stage 2 c stage 3 d stage 4

d

8. The nurse gathers the following data: BP = 150/94 mm Hg; neck veins distended; P = 104 beats/min; pulse bounding; respiratory rate = 20 breaths/min; T = 37°C (98.6°F). What disorder should the nurse suspect? A. Hypovolemia B. Hypercalcemia C. Hyperkalemia D. Hypervolemia

d

A client has a large, open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing? a use two square pads to cleanse the wound, one for each half of the wound b apply new Montgomery straps each time the dressing is changed c hold the wet gauze with the tips of the forceps higher than the wrist d cleanse the wound with wet, sterile gauze from the center of the wound outward

d

A health care provider prescribes daily docusate sodium for a client. The nurse explains to the client that this medication has which action? a lubricates the feces b creates an osmotic effect c stimulates motor activity d softens feces

d

A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client B. Nurse reviews the client's history on the medical record C. Nurse explains to the client the purpose of each administered medication D. Nurse rapidly reset priorities for client care based on a change in the client's condition

d

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a. The patient vomits during suctioning. b. The secretions appear to be stomach contents. c. The catheter touches an unsterile surface. d. Epistaxis is noted with continued suctioning.

d

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? a. Notify the physician. b. Apply an occlusive dressing on the site. c. Assess the patient for signs of respiratory distress. d. Put on gloves and insert the chest tube in a bottle of sterile saline.

d

A nursing diagnosis, Risk for Infection, has been established for a client with pneumonia. Which of the following nursing interventions would not be appropriate when planning care for this client? A. Dispose of feces appropriately. B. Wash hands before and after client contact. C. Cover the mouth and nose when coughing. D. Empty drainage bags when they become full.

d

The nurse at the community health care center focuses on providing primary preventive care. Which is the focus of primary preventive care? a rehabilitating the client b treating early stages of disease c preventing complications from illness d promoting health in healthy individuals

d

The nurse cares for the client who is 5'7 tall, weights 300 pounds, and is recuperating from an exploratory laparotomy. The client cooperates w/ coughing and deep breathing exercises and ambulates a distance of 25 feet in the hallway. For which postoperative complications should the nurse most vigilantly assess the client? A) pneumonia B) fat emboli C) pulmonary emboli D) wound dehiscence

d

1. The nurse is concerned that a patient with heart failure is decompensating. Which assessment finding requires an immediate intervention? A. Dyspnea at rest B.Dry persistent cough C. Weak peripheral pulses D. Jugular vein distention

a

For which care activities should the nurse apply a mask, eye protection (goggles), or a face shield? Select all that apply. 1 Changing an infusion bag 2 Preparing an enteral feeding 3 Suctioning a nasotracheal tube 4 Irrigating an abdominal wound 5 Inserting an intravenous catheter

3,4

Which action would the nurse include in the plan of care for a client admitted with HF who has gained 20lbs in 3 weeks? select all that apply a diuretics b low salt diet c daily weight checks d fluid restriction e I and O d O2 adminstration

all

13. The nurse is creating a pain management plan using the three-step approach for a patient with intractable pain. Which interventions should the nurse include in this plan? Select all that apply. a Administer opioid analgesic first b Administer nonopioid analgesic first c Administer mild opioid analgesic last d Administer analgesics on patient request e Administer a combination opioid/nonopioid second

b, c, e

The nurse expects a client with an elevated temperature to exhibit which indicators of pyrexia? select all that apply a dyspnea b flushed face c precordial pain d increased pulse rate e increased bp

b, d

25. Which statements by the patient diagnosed with celiac disease indicate the need for further teaching? Select all that apply. a "I am glad this can be cured with surgery" b "I cannot have any gluten in my diet" c "I wash all my dishes with water only" d "I may become anemic because of this disease" e "I am at risk for osteoporosis"

a, c

6. Risk factors for pressure ulcers include... (select all that apply) a Immobility b Adequate nutrition c Incontinence d Decreased sensation and pain perception e Using a fitted sheet

a, c, d

A client reports feeling nauseated immediately after cataract surgery. Which action would the nurse take? a provide some dry crackers to eat b administer the prescribed antiemetic c explain that this is expected after surgery d encourage deep breathing until the nausea subsides

b

A client with HTN tells the nurse, 'I took the BP pills for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick.' Which is the best action for the nurse to take? a educate the client about the complications associated with HBP b ask the client questions to determine the current understanding of HBP c emphasize the importance of taking BP medications now to continue feeling well d show the client the current BP and compare that with normal BP levels

b

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use? a. The age of the patient b. The size of the endotracheal tube c. The type of secretions to be suctioned d. The height and weight of the patient

b

A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lobe of the lung? a. High Fowler's position b. Left side with pillow under chest wall c. Lying position/half on abdomen and half on side d. Trendelenberg position

b

8. Which of the following are true regarding patients who have clostridium difficile-associated diarrhea? a Droplet precautions are required b Contact precautions are required c Hand sanitizer cannot skill clostridium difficile spores d They can use bathrooms shared with other patients

b,c

3. Level of prevention that aims to soften the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries (example: chronic diseases, permanent impairments) in order to improve as much as possible their ability to function, their quality of life, and their life expectancy. a primary b secondary c tertiary d treatment

c

5. A patient has an arterial ulcer on the lower extremity. What risk factors for peripheral arterial disease are in the patient's health history? Select all that apply: A. Pregnancy B. Being Female C. High Cholesterol D. Diabetes Mellitus E. Uncontrolled hypertension F. Varicose veins G. Smoking

c, d, e, g

4. A client with osteoporosis asks the nurse why it is important to take vitamin D. Which response by the nurse is correct? A. Vitamin D minimizes the risk of kidney stones B. Vitamin D helps prevent constipation from increased calcium intake C. Vitamin D reduces excretion of calcium in the kidneys D. Vitamin D improves the absorption of calcium

d

5. After a patient has a total hip replacement, the nurse is vigilant in monitoring for complications. Which of the following immediate postoperative findings must be reported immediately? a. nonproductive cough b. vomiting c. 50 ml of bloody fluid in the Hemovac d. absent pedal pulses on the operative side

d

8. Which patient statement indicates the need for additional teaching for the patient being discharged after total knee placement (TKR)? a "Narcotics may cause constipation, so I will increase my water intake." b "I will use an electric razor while I am on the blood thinners after surgery." c "I will report pain, tenderness, or warmth in my calf to my doctor immediately." d "I need to increase my intake of green, leafy vegetables to aid healing."

d

9. Which question by the nurse below expresses cultural sensitivity? a "Isn't this how it is always done in your culture?" b "How about I show you how to do it?" c "Don't you prefer to do it this way?" d "What is typically done in your culture?"

d

After obtaining client bp of 172/104 and 164/98 during a bp screening, which action would the nurse take next? a provide health teaching about a low sodium diet b call the paramedics for transport to the hospital c suggest ways to decrease the client's stress level d refer the client to a primary health care provider

d

The nurse manager is evaluating current infection control data for the intensive care unit. The nurse compares past patient data with current data to look for trends. The nurse manager examines the infection chain for possible solutions. In which order will the nurse arrange the items for the infection chain beginning with the first step? 1. A mode of transmission 2. An infectious agent or pathogen 3. A susceptible host 4. A reservoir or source for pathogen growth 5. A portal of entry to a host 6. A portal of exit from the reservoir a. 3, 2, 4, 1, 5, 6 b. 1, 3, 5, 4, 6, 2 c. 4, 2, 1, 6, 3, 5 d. 2, 4, 6, 1, 5, 3

d

When a client with a history of HF arrives for a scheduled clinic appointment and has gained 6lb, which action has the highest priority? a check for lower leg swelling b notify the health care provider c take the client's pulse rate d listen to the client's breath sounds

d

When reviewing laboratory results for a client with HF who has been receiving furosemide daily, the nurse notes a blood urea nitrogen of 42 and a creatinine of 1.1. Which action by the nurse is a priority? a administering the furosemide as scheduled b starting strict intake and output measurements c sending a urine specimen for specific gravity testing d notifying the health care provider about the results

d

Which action indicates that the nurse is actively listening to the client? a stating personal opinions when the client is speaking b refraining from telling personal stories to the client c reading the client's health record during conversation d interpreting what the client is saying and restating it for clarification

d

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. a. "I will be careful not to shake up the canister before using it." b. "I will hold the canister upside-down when using it." c. "I will inhale the medication through my nose." d. "I will continue to inhale when the cold propellant is in my throat." e. "I will only inhale one spray with one breath." f. "I will activate the device while continuing to inhale."

d, e, f

A student nurse recalls that the body has nonspecific defense systems to protect against infection. Which of the following is an example of this system? A. Saliva B. Antigens C. B-lymphocytes D. T-cells

a

The nurse is most likely to collect timely, specific information by asking which of the following questions? A. "Would you describe what you are feeling?" B. "How are you today?" C. "What would you like to talk about?" D. "Where does it hurt?"

a

25. The patient is ordered to receive a pain medication patch that is applied to the skin. What route is this medication administered? a Intradermal b Subcutaneous c Transdermal d Dermal

c

26.For what purpose would the nurse use the Mini-Mental State Examination to evaluate a patient with cognitive impairment? a It is a good tool to determine the etiology of dementia b It is a good tool to evaluate mood and thought processes c It can help to document the degree of cognitive impairment d It is a definitive test for Alzheimer's

c

The nurse is discussing the importance of an exercise program for pain control to a client diagnosed with osteoarthritis (OA). Which statement indicates the client understands the teaching? a I will participate in water aerobics three times a week. b I will alternate walking briskly and jogging when I exercise c I should carry a source of simple carbohydrate while exercising d I will wear firm, open-toed shoes with colored socks when I walk

a

A nursing student is preparing a presentation on aseptic techniques. Which of the following statements should be included in the presentation? A. Dirty items contain organisms that have the potential to cause infection. b. Surgical asepsis includes practices that inhibit the growth of organisms. C. Sepsis is the absence of disease-causing microorganisms. D. When dealing with sterile areas, medical asepsis practices may be used.

a

10.Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated? A. Positive Trousseau's sign B. Positive Chvostek's sign C. Tetany D. Paresthesia

a

11. A patient who rates abdominal pain as a 10 on a 1 to 10 numeric scale is experiencing nausea, vomiting, and restlessness. The nurse correlates this clinical presentation to which type of pain? a Acute pain b chronic pain c Neuropathic pain d Fibromyalgia pain

a

19. The client is 12-hours post-lumbar laminectomy. Which nursing interventions should be implemented? A. Assess ability to void and log roll the client every 2 hours B. Medicate with IV steroids and keep the bed in a Trendelenburg position C. Place sandbags on each side of the head and give cathartic medications D. Administer IV anticoagulants and place on O2 as 8 L/min

a

The nurse is planning care for a client admitted to the hospital with abdominal spams and pain associated with severe diarrhea. Which serum blood level would the nurse monitor? a urea b chloride c potassium d creatinine

c

15. All of the following are crucial needs of the dying client except: A. Control of pain B. Preservation of dignity and self-worth C. Love and belonging D. Freedom from decision making

d

Which description of the percussion technique? a listening to sounds that the body makes b using the sense of touch to assess and collect data c carefully looking for abnormal findings d tapping the skin with the fingertips to vibrate underlying tissues

d

Which instruction is important for the nurse to provide to the client after cataract surgery? a remain flat for 3 hrs b eat a soft diet for 2 days c breathe and cough deeply d avoid bending from the waist

d

Which of these is a correctly stated outcome goal written by the nurse? A. The client will walk 2 miles daily by March 19 B. The client will understand how to give insulin by discharge C. The client will regain their former state of health by April 1 D. The client achieve desired mobility by May 7

a

18. During a home health visit you are helping a patient with gout identify foods in their pantry they should avoid eating. Select all the foods below the patient should avoid (Select all the apply): A. Sardines B. Whole wheat bread C. Sweetbreads D. Crackers E. Craft beer F. Bananas

a, c, e

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? select all that apply. A) hemostasis occurs immediately after the initial injury. B) a liquid called exudate is formed during the proliferation phase. C) WBC's move to the wound in the inflammatory phase. D) granulation tissue forms in the inflammatory phase. E) during the inflammatory phase, the patient has generalized body response. F) a scar forms during the proliferation phase.

a, c, e

When a client with HF is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factors that may have contributed to the ankle swelling? select all that apply a intake of salty foods b dietary fat intake c medication compliance d family stresses e recent travel

a, c, e

1.A postoperative patient asks the nurse how the prescribed ibuprofen (Motrin) will control the incisional pain. The nurse will teach the patient that ibuprofen interferes with the pain process by decreasing the A. modulating effect of descending nerves. B. sensitivity of the brain to painful stimuli. C. production of pain-sensitizing chemicals. D. spinal cord transmission of pain impulses.

c

10. What finding should the nurse expect when assessing a patient with osteoarthritis of the knee? a Bouchard's nodes b A fever c Discomfort with joint movement d Redness and swelling of the joint

c

11. The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following prescriptions are written in the client's electronic health record. Which one should the nurse question? A. Administer an IV of D5W at 125 mL/hr. B. Strict I&O monitoring. C.Restrict oral intake to 900 mL every 24 hr. D.Monitor serum electrolytes every 4 hr.

c

The nurse overhears an unlicensed assistive person (UAP) who has just been accepted to nursing school say to a client, "You must be so pleased with your progress." The nurse later explains to the UAP that this is an example of what type of question? A. Close-ended question B. Open-ended question C. Leading question D. Neutral question

c

When an obese client receives a diagnosis of HBP, which topic would be the most important to include in client teaching? a causes of HTN b symptoms of HTN c effect of weight loss in HTN d effect of lowering alcohol intake in HTN

c

Which condition would the home care nurse make regarding an older adult client with mild Alzheimer disease? a must be supervises closely at all times b needs a live-in home health aide to assist with activities of daily living c should be allowed to function independently if therapeutically possible d ought to be responsible for carrying out daily self-care activities without assistance

c

Which factor would the nurse explain as the likely cause of pain to a client who is diagnosed as having a herniated nucleus pulposus? a inflammation of the lamina of the involved vertebra b shifting of two adjacent vertebral bodies out of alignment c compression of the spinal cord by the extruded nucleus pulposus d increased pressure of cerebrospinal fluid within the vertebral column

c

22. In providing care to a patient who is diagnosed with hypertension, which assessment data are risk factors for this disease process? Select all that apply. a Current age 45 b BMI 28 c History of cigarette smoking d Elevated kidney function tests e Concurrent diagnosis of diabetes mellitus

c, d, e

Which intervention would the nurse include when developing a plan of care for an older client with dementia? a explain to the client the details of the regimen b demonstrate interest in the client's various likes and dislikes c be firm when dealing with the client's attitudes and behaviors d provide consistency in carrying out nursing activities for the client

d

Which of these clients seen at a health fair will be most at risk for hypertension? a 23 year old white man b 44 year old white woman c 50 year old mexican american woman d 62 year old african american man

d

Which physical assessment technique involves listening to the sounds of the body? a palpitation b inspection c percussion d auscultation

d

Which assessment finding of the skin refers to elasticity? a turgor b edema c texture d vascularity

a

Which collaborative action would be best to rehydrate an alert client seen in the urgent care center with dehydration, hr of 100, and bp of 104/62? a offer frequent oral fluids for several hours b administer 1 liter of normal saline over 2 hours c give fluid and electrolytes per ng tube d infuse 500ml of lactaid Ringer's solution over 30min

a

Which explanation would the nurse provide a client who asks what a cataract is? a an opacity of the lens b a thin fil over the cornea c a crystallization of the pupil d an increase in the density of the conjunctiva

a

Which information would the nurse include in explaining glaucoma to a client? a an increase in the pressure within the eyeball b an opacity of the crystalline lens or its capsule c a curvature of the cornea that becomes unequal d a separation of the neural retina from the pigmental retina

a

Which pulse site is used for the Allen test? a ulnar b popliteal c brachial d femoral

a

Which findings would the nurse expect when completing an admission physical for a client with a diagnosis of Parkinson disease? select all that apply a muscle rigidity b blank facial expression c leaning toward affected side d intention tremors with movement e hyperextension of the affected extremity

a, b

5. The six rights of medication administration include all of the following except: a right route b right physician c right time d right drug

b

While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning? a I will ask the client to move his/her arm toward the body b I will ask the client to bend his/her limb by decreasing the angle c I will ask the client to move his/her hand so that the ventral surface faces downward d I will ask the client to move his/her head beyond its normal resting extended position

a

The nurse decides it would be beneficial to the client to allow the client's infant granddaughter to visit before the client's scheduled heart transplant. Before implementing this intervention the nurse should collaborate with which of the following? Select all that apply. A. Client and Family B. Other nursing staff on the unit C. Security department D. Hospital administration E. This is not a collaborative intervention so no collaboration will be needed prior to implementation

a, b

11. Which group of clients is at an increased risk for developing a wound infection? a Clients who require frequent pain medication b Clients who are 15 lbs overweight c Clients who ambulate after the first postoperative day d Clients who are undernourished

d

A client with Parkinson disease is admitted to the hospital. Which medication is prescribed to improve the physical manifestations of Parkinson disease? a Carbidopa-levodopa b Isocarboxazid c dopamine d pyridoxine (vitamin B6)

a

A nurse is inserting an oropharyngeal airway for a patient who vomits when it is inserted. Which action would be the first that should be taken by the nurse related to this occurrence? a. Quickly position the patient on his or her side. b. Put on disposable gloves and remove the oral airway. c. Check that the airway is the appropriate size for the patient. d. Put on sterile gloves and suction the airway.

a

A nurse understands that purpose of a drain in a wound is to A) keep the tissues close together so that healing can occur. B) prevent infection by providing a means for bacteria to escape C) evaluate the effectiveness of hemostasis D) create a space that will facilitate reconstructive surgery at a later date.

a

During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?" A. Introduction B. Body C. Closing D. Orientation

a

The nurse is preparing to examine an older client. Which statement should cause the nurse to suspect that the client has osteoporosis? a I am not as tall as I used to be b I have pain in the right big toe c I have low back pain in the morning d I have gained 10 pounds in the last year

a

The nurse teaches the client how to change an abdominal wound dressing using aseptic technique. The client perform a return demonstration. Which action by the client shows an understanding of the procedure? A) washing hands before changing the dressing B) using tissue wipes to cleanse the skin adjacent to the wound. C) donning sterile gloves before each dressing change. D) keeping the dressing moist so it will not adhere to the wound.

a

The nurse would make which of the following inferences after performing the appropriate client assessment? A. Client is hypotensive B. Respiratory rate of 20 breaths per minute C. Oxygen saturation of 95% D. Client relays anxiety about blood work

a

Which information must be clearly documented in the medication administration record before administering a medication? select all that apply a dosage and route b client's full name c time to be administered d frequency of administration e full name of prescribed medication

all

10. You are a new graduate RN working with an experienced nursing assistant or UAP? Which of the following tasks can you delegate to the nursing assistant? a Irrigating a nasogastric (NG) tube. b Assisting a client who had surgery three days ago walk down the hallway. c Helping a client who just returned from surgery to the bathroom. d Administering an antacid to a client complaining of heartburn.

b

13. In providing care to a patient who underwent a colostomy 2 days ago for the treatment of colon cancer, which finding requires an immediate intervention? a Serosanguineous drainage from the stoma b Dark red, purplish color of the stoma c Slight edema of the stoma d Reddish-pink, moist stoma

b

14.In assessing pain in the patient with a urinary tract infection, which clinical manifestation does the nurse correlate to progression of the infection to pyelonephritis? A. Dysuria B. Flank pain C. Hematuria D. Urinary frequency

b

19. The most effective treatments for sleep apnea include all of the following EXCEPT a weight loss b The use of stimulant drugs. c The use of a continuous positive airway pressure (CPAP) mask. d Surgery for breathing obstructions.

b

21. The nurse monitors for which clinical manifestations in the patient diagnosed with acute gastritis? a Eructation b Epigastric pain c Constipation d Peripheral edema

b

A nurse is caring for a 16-year-old male patient who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the patient's oxygen saturation? Select all that apply. a. Thoracentesis b. Spirometry c. Pulse oximetry d. Peak expiratory flow rate e. Diffusion capacity f. Maximal respiratory pressure

b, c, d

The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply. A. Collect and organize client information B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses E. Develop client goals

b, c, d

A nurse is developing a plan of care for an 86 year old woman who has been admitted to right hip arthroplasty (hip replacement). Which assessment findings indicate a high risk for pressure ulcer development for this patient? Select all that applies. A) the patient takes time to think about her responses to questions B) the patient's age of 86 years C) patient reports inability to control urine D) a scheduled hip arthroplasty E) lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 (adult female normal 0.61-1 mg/dL) F) patient reports increased pain in R hip when repositioning in bed or chair.

b, c, d, f

Which clinical manifestations are found in the client diagnosed with stage 3 of Parkinson disease? select all that apply a akinesia b masklike face c postural instability d unilateral limb involvement e increased gait disurbacnes

b, c, e

How would the nurse describe the exudate characteristic of a serosanguinous wound? a greenish-blue pus b creamy yellow exudate c blood-tinged amber fluid d beige pus with a fishy odor

c

12. A patient returns to the clinic for an evaluation 2 weeks after total hip replacement. Which statement by the patient indicates the need for further teaching? a "My daughter helps me put on my elastics stockings every morning." b "Even though I use my walker, I still have a limp." c "Now that I am stronger, I no longer need to use the raised toilet seat." d "Each day I try to increase my walking time by 10 minutes."

c

12. The nurse understands that good hand hygiene involves washing the hands. a Gently without using friction. b And using non antibacterial soap. c For at least 15 seconds. d And ensuring the hands are higher than the elbow.

c

16. A 6 year old female is diagnosed with Varicella. What type of isolation precautions will be initiated for this patient? a Droplet b Airborne c Airborne and Contact d Droplet and Contact

c

16. The nurse is working with a unlicensed assistive personnel (UAP). Which action by the UAP warrants immediate intervention? A. The UAP feeds a client two days postoperative cervical laminectomy a regular diet B. The UAP calls for help when turning to the side a client who is post-lumbar laminectomy C. The UAP is helping the client who weighs 300 pounds and is diagnosed with back pain to the chair D. The UAP places the call light within reach of the client who had a disk fusion

c

16. Which statement by the patient diagnosed with gastritis indicates the need for further teaching? A. "I will eat bland, non spicy foods." B. "I will eat smaller, more frequent meals." C. "I will take aspirin for headaches." D. "I will take an antacid if my symptoms continue."

c

Which statement by the nurse indicates effective technique in assessment of a client's renal system? a I must first palpate the abdomen of the client if a tumor is suspected b I must first listen for normal pulses at the client's wrist region c I must first auscultate the client's abdomen and then proceed to percussion and palpation d I must first examine tender abdominal areas and then proceed to non-tender areas

c

The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. Select the correct order for removal of the personal protective equipment and associated tasks. (All answers are utilized.) a. Remove eyewear/face shield and goggles. b. Perform hand hygiene. c. Remove gloves. d. Untie gown, allow gown to fall from shoulders, and do not touch outside of gown; dispose of properly. e. Remove mask by strings; do not touch outside of mask. f. Dispose of all contaminated supplies and equipment in designated receptacles. g. Leave room and close the door.

c, a, d, e, b, g, f

9. The nurse is assessing a patient, who has many risk factors for the development of a DVT. What signs and symptoms below would possibly indicate a deep vein thrombosis is present? Select all that apply: A. Cool extremity B. Decreases pulses C. Redness D. Pain E. Warm extremity F. Swelling G. Cyanosis

c, d, e, f

A nurse assesses the wound of a patient who cut himself on the upper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. A) enhanced healing due to the presence of sugars and proteins B) delayed healing due to dead tissue present in the wound. C) decreased effectiveness of antibiotics against the bacteria D) impaired skin integrity due to over hydration of the cells of the wound E) delayed healing due to cells dehydrating and drying F) decreased effectiveness of the patient's normal immune process.

c, f

A 50-year-old client is diagnosed with COPD. Theclinical data on admission are as follows: HR 100, BP 138/82mmHg, RR of 32, temp of 98.2F, and O2 of 80%. Which vital signs by the nurse indicates a positive outcome? select all that apply a. radial pule 70 b. temp 98.6 c. rr 14 d. bp 110/70 e. O2 92

c,d,e

The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team? A. Use Liquid PaperTM to "white out" the resolve diagnosis on the care plan B. Recopy the care plan without the resolve diagnosis C. Write a nursing process not indicating that the outcome goals have been achieved D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date

d

The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to? a primary b secondary c superinfection d nosocomial

d

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma? a constant blurring b abrupt attacks of acute pain c sudden, complete loss of vision d impairment of peripheral vision

d

While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment? A. Help client into the chair but more quickly B. Document client's vital signs taken just prior to moving the client C. Help client back to bed immediately D. Observe client's skin color and take another set of vital signs

d

Which site would be monitored for a pulse to assess the status of circulation to the foot? select all that apply a carotid b femoral c popliteal d dorsalis pedis e posterior tibial

d, e