NUR 256 - Exam 1
A nurse assess a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can cause a decreased respiratory rate? A. The client has been a chronic smoker for 10 years B. The client takes a narcotic pain medication for chronic pain C. The client reports anxiety due to being in a hospital D. The client has a history of anemia
The client takes a narcotic pain medication for chronic pain
A charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For which of the following actions should the charge nurse intervene? A. The nurse asks the client to cough before the auscultation B. The nurse is auscultating through the client's gown C. The nurse places the stethoscope on the intercostal spaces D. The nurse moves down the chest in a ladder sequence
The nurse is auscultating through the client's gown
A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following info should the nurse include as factors that affect BP? Smoking Time of day Obesity Height Diuretic medication
Time of day, obesity, diuretic medicine, and Smoking
After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. Which of the following actions should the nurse take? a. Cleanse their hands with an alcohol based gel b. Wash their hands with soap and water c. Brush off the soil against a cloth surface d. Use a wet paper towel to remove the soil
Wash their hands with soap and water
A nurse is washing their hands with soap and water prior to repositioning a client in bed. During the hand washing procedure, it is important to take which of the following actions? a. Make sure that the water is hot b. Wash for at-least 15 seconds c. Use a liquid soap preparation d. Remove rings and watches first
Watch for at-least 15 seconds
A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs? A. When the atria contracts vigorously B. As the ventricular walls contract C. When the semilunar valves close D. As the mitral valve snaps open
When the semilunar valves close
A nurse is planning to obtain a urinary specimen from a client's closed urinary system. Identify the correct sequence of steps that the nurse should take. Transport the specimen to the lab. Withdraw 3 to 30 mL of urine. Attach a syringe to the collection port of the indwelling catheter. Wipe the port with an alcohol swab or agency specified antiseptic. Transfer the urine to a sterile specimen container.
Wipe the port with an alcohol swab or agency specified antiseptic. Attach a syringe to the collection port of the indwelling catheter. Withdraw 3 to 30 mL of urine. Transfer the urine to a sterile specimen container. Transport the specimen to the lab.
A nurse is caring for a client who has a tracheostomy. Which of the following pieces of equipment should the nurse use when administering oxygen to the client? a) distilled water for humidification b) a tracheostomy collar c) a nasal canula d) an aerosol mask
a tracheostomy collar
Which of the following is an advantage of using alcohol based gel? a. it takes less time to use than washing with soap and water b. it removes gross contamination better than soap and water c. it's protective nature reduces the need for frequent hand washing d. it provides adequate protection before surgical applications
it takes less time to use than washing with soap and water
A nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication which of the following actions demonstrates the use of a nonverbal communication technique by the nurse A. asking the client to clarify a statement B. asking the client open-ended questions C. maintain a fair distance between self and client D. stating the name and providing credentials upon entering the client's room
maintain a fair distance between self and client
A nurse us providing discharge teaching with a client who is going home on continuous liquid oxygen therapy. Which of the following instructions should the nurse include? a) place the oxygen tank in a clutter-free environment b) keep the oxygen tank at least 6 feet away from a heat source c) ensure you are close to electricity to use the oxygen tank d) turn the valve on the oxygen tank until an alarm sounds
place the oxygen tank in a clutter-free environment
A nurse is documenting data about a deep necrotic wound on a patient's left buttock. The nurse observes a yellowish-tan, soft, stingy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. The nurse should document this type of necrotic tissue as.. A. keloid B. slough C. granulation D. eschar
slough
A nurse is caring for a critically ill client who has COPD and requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery devices is indicated for this client? a) simple face mask b) nasal cannula c) venturi mask d) face tent
venturi mask
A nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing? A. Thoracic breathing B. Cheyne-Stokes breathing C. Bradypnea D. Kussmaul breathing
Cheyne-Stokes breathing
A nurse is caring for a client who was admitted with community-acquired pneumonia and has been receiving oxygen therapy for several days. Which of the following findings indicates an adverse effect of oxygen therapy? A. Poor skin turgor B. Copious respiratory secretions C. Cracks in the oral mucosa D. Elevated heart rate
Cracks in the oral mucosa
A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? A. Instruct the client to deep breathe and cough B. Provide the client with an incentive spirometer C. Elevate the head of the bead D. Reassess by auscultating the client's lungs
Elevate the head of the client's bed
A nurse is preparing to conduct an initial survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take? A. Have an informal conversation with the client before beginning the observation of the client B. Complete all focused assessments prior to formulating thoughts regarding the client's general health status C. Sit on the client's bedside with them to have close contact and maintain eye contact whenever possible D. Engage in active listening with the client and allow the client to express concerns early in the assessment process
Engage in active listening with the client and allow the client to express concerns early in the assessment process
A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? A. Deduct the client's shoe height from the measurement B. Have the client gently life their chin and look toward the ceiling C. Ensure the client's feet are in contact with the wall or measuring pole D. Pull up the measuring pole and extend the headpiece after the client steps on the scale
Ensure the client's feet are in contact with the wall or measuring pole
A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe the involuntary movement? A. Fasciculation B. Spasticity C. Tic D. Myoclonus
Fasciculation
A nurse is assessing a client who is dark-skinned. In which of the following areas of the client's body should the nurse assess the client for adequate oxygenation? (Select all that apply.) A. Cheeks B. Nail beds C. Oral mucosa D. Sclerae E. Nasal cavity
Nail beds Oral mucosa
A nurse is performing an assessment on a client the client states "I have a dry cough every morning when I wake up" which of the following is the type of date the nurse is collecting? A. Subjective B. Social determinants of health C. Objective D. Olfactory
Objective
A nurse is conducting a health history interview and asks the client to describe the pain that they are experiencing. This is an example of what type of question? A. leading question B. closed ended question C. direct question D. open ended question
Open ended question
A nurse is performing a physical assessment of a client who has reported abdominal tenderness which of the following actions should the nurse take? A. Use the soft end of a cotton swab over the client's abdomen B. Auscultate the tender areas of the client's abdomen through clothing C. Palpate the tender areas of the client's abdomen last D. Use deep palpation when assessing the client's abdomen
Palpate the tender areas of the client's abdomen last
A nurse is collecting information about a client's family history. The nurse should plan to collect information about the health of which of the following client relatives? (select all that apply) A. parents B. siblings C. aunts & uncles D. cousins E. grandparents
Parents Siblings Grandparents
A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify that which of the following factors can interfere with obtaining a pulse ox reading? A. Hypertension B. Fever C. Recent scan with contrast dye D. Thin, brittle nails
Recent scan with contrast dye
A nurse is assessing a client's respiration and notes they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings? A. Tachypnea B. Bradypnea C. Apnea D. Hypervenilation
Tachypnea
A nurse is performing a head-to-toe assessment of a client. Which of the following findings indicate the client might be experiencing respiratory difficulty? (Select all that apply.) A. The client occasionally sighs B. The client is sitting in a tripod position C. The client's respiratory rate is 18/min D. The client is using pursed lipped breathing E. The client appears confused
The client is sitting in a tripod position The client is using pursed lipped breathing The client appears confused
A nurse is conducting a general survey on a client who is being admitted to a long-term care facility.. The nurse is assessing the client's emotional state. Which of the following findings should the nurse record as a subjective, unexpected finding? A. The client is sitting in a relaxed posture B. The client is cooperative in answering the nurse's questions C. The client tells the nurse that visits from their family and friends make them smile D. The client reports they feel sad and lonely most of the time
The client reports they feel sad and lonely most of the time
A nurse is conducting a health history interview with a client. which of the following is accurate about a directive interview technique? A. this technique consists of mostly closed ended questions B. this technique enables the client to control the pace of the interview C. This technique is used to gather general information about a client's condition D. this technique is effective for determining a client's emotional responses
This technique consists of mostly closed ended questions
A nurse is preparing to assess a newly admitted client which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? Electrocardiogram monitor Tongue Depressor Doppler Penlight Tape measure
Tongue depressor, penlight, tape measure
A nurse should recognize that which of the following findings is an indication for oxygen therapy? a) Respiratory rate 32/min b) PaO2 90 mm Hg c) Fraction of inspired oxygen (FiO2) 65% for 4 days d) oxygen saturation (SaO2) 90%
oxygen saturation (SaO2) 90%
A charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "A client using thoracic breathing is experiencing a lack of oxygen" B. "A pulse oximeter reading of 95% indicates respiratory distress" C. "Clubbing of the fingers indicates a chronic state of impaired perfusion" D. "A pinkish hue on the cheeks of a client with light skin tone indicates they are struggling to breathe"
"Clubbing of the fingers indicates a chronic state of impaired perfusion"
A nurse is conducting a review of systems with a client during a health history interview. Which of the following responses by the client requires additional investigation? A. "I had a rash from poison ivy on my arms last week, but it's gone now" B. "I wear a hearing aid" C. "I had a negative tuberculosis screening test last month" D. "I have a cough"
"I have a cough"
A nurse is collecting biographic data from a client who reports they are seeking health care due to a persistent cough. The client states they identify as transgender. Which of the following questions should the nurse ask? A. "How does your family feel about your gender identity?" B. "What pronouns do you use?" C. "when did you transition?" D. "Are you planning to ever have surgery to change your biological sex?"
"What pronouns do you use?"
A nurse is discussing a client's tobacco usage during a health history interview. Which of the following questions should the nurse ask to maintain nurse-client rapport? A. "You are worried about the amount that you smoke, right?" B. "Did you know that smoking can lead to a decreased lung recoil, which results in hyperinflation and dyspnea?" C. "Would you like any information on smoking cessation?" D. "Why do you think that you are smoking so much?"
"Would you like any information on smoking cessation?"
A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse suspect to receive a prescription for urinary catheterization? A. A client who has a persistent urinary tract infection. B. A client who has urge incontinence. C. A client who is in the ICU for a gastrointestinal bleed. D. A client who has incontinence due to cognitive decline
A client who is in the ICU for a gastrointestinal bleed
A nurse is caring for a patient who is admitted with multiple wounds sustained in a motor-vehicle crash. Understanding the patient's specific needs during this initial stage of wound healing, the nurse should incorporate which of the following into the patient's plan of care to prevent a prolongation of this phase? A. Leave nonbleeding wounds open to air B. Administer a corticosteriod medication C. Initiate mechanical debridement D. Apply oxygen at 2 L/min via nasal cannula
Apply oxygen at 2 L/min via nasal cannula
A nurse is gathering information during a health history interview from a client who reports they have type 1 diabetes mellitus. Which of the following actions should the nurse take? A. asses the client's blood glucose level B. ask the client for additional information regarding the management of their diabetes C. encourage the client to join a diabetic support group D. provide education for the client on the management of diabetes
Ask the client for additional information regarding the management of their diabetes
A nurse is preparing to measure a client's vital signs. The nurse should identify that which of the following factors will affect the methods that are used? A. The client who has a BMI of 35 B. The client has had nausea for 2 days C. The client is reporting a stuffy nose D. The client has been fasting for blood tests E. The client is taking digoxin for an irregular heart rate F. The client had a mastectomy 2 years ago
Client who has a BMI of 35 Client is reporting a "stuffy nose" The client is taking digoxin for an irregular heart rate Client had a mastectomy 2 years ago
A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub? (Select all that apply.) A. Coarse grating tone B. Intermittent popping or bubbling sound C. Heard on inspiration and expiration D. Snoring sound on expiration E. Pain with breathing
Coarse grating tone Heard on inspiration and expiration Pain with breathing
A nurse is caring for a patient who has multiple sclerosis and has a chronic nonhealing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing? A. Tricyclic antidepressants B. Corticosteroids C. Beta blockers D. Anticholinergics
Corticosteroids
A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy? A. Close the examination room door but do not pull the curtain in the examination room B. Remain in the client's room while the client is getting undressed C. Ask the client if they would like to empty their bladder or bowels before the physical examination begins D. Do not expose any more of the client's body than required at a time
Do not expose any more of the client's body than required at a time
A nurse is collecting information about a client's spirituality using the FICA spiritual History tool. Based on this tool, which of the following information should the nurse gather? (select all that apply) A. does the client identify spiritual or religious beliefs that are of importance to them? B. what impact does the client's spiritual or religious beliefs have on their health care decision making? C. are there any spiritual or religious practices that should be included when planning the clients care? D. what is the address of the client's identified religious or spiritual gathering place? E. is there a spiritual or religious group that the client identifies as having an importance in their life?
Does the client identify spiritual or religious beliefs that are of importance to them? What impact does the client's spiritual or religious beliefs have on their health care decision making? Are there any spiritual or religious practices that should be included when planning the clients care? Is there a spiritual or religious group that the client identifies as having an importance in their life?
To decontaminate their hands with an alcohol based gel, the nurse should rub their hands together until all of the gel has evaporated and their hands dry. Which of the following is correct rationale for why hands should be rubbed together until dry? a. Drying provides the full antiseptic effect b. Residual alcohol can easily stain clothing c. Excess gel could transfer to the client d. Slippery gel can make the nurse drop supplies
Drying provides the full antiseptic effect
A nurse is assessing a client's respiration. Which of the following actions should the nurse take? A. Have the client lie flat in bed with their head on a pillow B. Elevate the head of the client's bed 45 degrees to 60 degrees C. Encourage the client to breathe shallowly D. Ask the client to take several deep breaths prior to the assessment
Elevate the head of the client's bed 45 degrees to 60 degrees
Oxygen therapy is prescribed for a client who is brought to an emergency department in the early stages of hypoxia. When assessing this client, a nurse should expect which of the following? A. Elevated blood pressure B. Decreased respiratory rate (the late stages of hypoxia) C. Cyanosis (a bluish discoloration of the skin and mucous membranes, the late stages of hypoxia) D. Peripheral edema (a sign of chronic hypoxia)
Elevated blood pressure
A nurse is preparing to auscultate a client's posterior and lateral chest. In which order should the nurse perform the following actions? Auscultate 8 cm (3 in) to one side of the spine around C7, then auscultate the other side of the spine in the same location Auscultate the lateral sides slightly below the axillary area Auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine Expose the posterior chest with the client sitting with their arms folded across their chest is the first step
Expose the posterior chest with the client sitting with their arms folded across their chest Auscultate 8 cm (3 in) to one side of the spine around C7, then auscultate the other side of the spine in the same location Auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine Auscultate the lateral sides slightly below the axillary area, then down to the seventh or eighth rib
A nurse is planning to conduct a health history interview with a client. which of the following actions should the nurse plan to take? (select all that apply) A. gather supplies to take notes B. review the client's medical record at the conclusion of the interview C. conduct the interview in an open area such as the receptions area or hallway D. select a position that is 0.6 to 0.9 m (2 to 3 feet) from the client during the interview E. ensure a face to face contact is at eye level
Gather supplies to take notes Select a position that is 0.6 to 0.9 m (2 to 3 feet) from the client during the interview Ensure a face to face contact is at eye level
After completing a procedure that required donning personal protective equipment (PPE) consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately? a. gloves b. gown c. face shield d. N95 respirator
Gloves
A nurse is preparing to irrigate a client's leg wound what PPE should the nurse wear? surgical cap gown goggles gloves N95 mask
Goggles, gown, gloves
A nurse is documenting information in a client's medical record during an initial assessment. Which of the following information did the nurse collect during the general survey? Height and weight Use of assistive devices Behavior and mood Past medical history Current medication list
Height and weight Use of assistive device Behavior and mood
A patient who has a full-thickness wound continues to experience considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes? A. wet-to-dry B. abdominal pads (ABD) C. dry gauze D. hydrogel
Hydrogel
A nurse is preparing to collect a health history from a client. Which of the following should the nurse plan to assess as a component of a functional assessment? (select all that apply) A. the reason that the client is seeking health care B. if the client is experiencing abuse or human trafficking C. the environment in which the client resides D. the client's use of substances E. client's ability to perform activities associated with daily living
If the client is experiencing abuse or human trafficking The environment in which the client resides The client's use of substances Client's ability to perform activities associated with daily living The client's use of substances
A nurse is assisting a client with ambulating around the nurses' station. which of the following steps of the nursing process is the nurse performing? A. Implementation B. Evaluation C. Analysis D. Planning
Implementation
Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following? a. Hepatitis B b. Measles c. Meningitis d. Infectious diarrhea
Infectious diarrhea
A nurse is conducting a health history interview. Which of the following type of information is the nurse gathering when using the acronym "OLD CARTS"? A. Information about the clients presenting problem B. Information about the client's spirituality C. Information about the client's obstetrical history D. Information about the client's family history
Information about the clients presenting problem
A nurse is taking an adult client's temperature rectally. Which of the following actions should the nurse take? A. Rotate the probe if any resistance is met as the thermometer is inserted B. Insert the probe to aim at the client's pelvic area C. Dip the probe about 0.58 cm into a tube of lubricant D. Insert the probe about 2.5 cm into the client's anus
Insert the probe about 2.5 cm into the client's anus
A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant which of the following is the first step the nurse should perform during the abdominal assessment? A. Palpation B. Percussion C. Auscultation D. Inspection
Inspection
A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries made by the newly licensed nurse is an example of correct documentation? A. I cannot sleep at night because I get short of breath B. Client seems to not like certain staff members C. Client's partner does not visit the client enough D. Inspiratory wheeze auscultated at left lateral chest
Inspiratory wheeze auscultated at left lateral chest
A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to? A. It corresponds to the client's systolic pressure B. It is the second diastolic pressure to read C. It is the loudest of the Korotkoff sounds D. It might not follow with a fifth Korotkoff sound
It might not follow with a fifth Korotkoff sound
A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take? A. Stretch the sheath portion of the condom catheter along the length of the penis. B. Secure the sheath portion with adhesive tape. C. Leave a space between the penis and sheath portion tip. D. Reposition the foreskin after application.
Leave a space between the penis and sheath portion tip.
When conducting a general survey of a client, the nurse should assess ___, ___, and ___. Respiratory rate Speech Temperature Gait Pain Pupils Level of consciousness Skin turgor
Level of consciousness, speech, and gait
A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take? A. Grasp the penis at its base. B. Lift the penis perpendicular to the body. C. Hold the penis parallel to the client's body. D. Lift the penis to a 45° angle to the client's body.
Lift the penis perpendicular to the body.
A nurse has collected biographic data from a client. Which of the following findings in the client's community is considered a social determinant of health that can negatively impact the client's health? A. limited access to convenience foods B. a park available within walking distance from a client's residence C. limited access to a pharmacy D. a neighborhood population that has a high rate of obesity & smoking
Limited access to a pharmacy
A nurse is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestations should the nurse expect during hyperventilation? (Select all that apply.) A. Numbness and tingling of extremities B. Decreased chest wall expansion C. Lightheadedness D. Periods of apnea E. Chest pain
Numbness and tingling of extremities Lightheadedness Chest pain
A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respiration? A. Observe the degree of chest-wall movement during inspiration and expiration B. Count how many breathing cycles are observed per minute C. Notice whether or not expiration takes longer than inspiration D. Measure the precise amount of air the client takes in and breathes out
Observe the degree of chest-wall movement during inspiration and expiration
A nurse is preparing to auscultate a client's apical pulse at the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope? A. Over the right midclavicular line B. Over the angle of Louis C. Over the fifth intercostal space at the left midclavicular line D. Over the suprasternal notch
Over the fifth intercostal space at the left midclavicular line
A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record? A. Fever 101 B. Pulse rate is tachycardic C. Oxygen saturation 96% on oxygen 2 L/min via cannula D. BP 108/65 mm Hg
Oxygen saturation 96% on oxygen 2 L/min via cannula
A nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is subjective data? (Select all that apply.) A. Pulse oximeter reading is 89% on O2 L/min via nasal cannula B. Report from client says they sleep while propped on two pillows at night C. Client says they quit smoking 2 years ago D. Respiratory rate increases to 28/min when client ambulates to restroom E. Client states, "Being short of breath all the time is making me depressed"
Report from client says they sleep while propped on two pillows at night Client says they quit smoking 2 years ago Client states, "Being short of breath all of the time is making me depressed
A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process? A. Enlist the aid of the client's school-aged child to interpret for the nurse and the client B. Ask the client's best friend to interpret for the nurse and client C. Use jokes and laughter to make the client feel more at ease D. Request assistance from an interpreter during the assessment
Request assistance from an interpreter during the assessment
A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider? A. Oral Temp 100 degrees F B. Respirations 30/min C. BP 148/88 mm Hg D. Radial pulse rate 45 beats/30 seconds
Respirations 30/min
A nurse is caring for a client who has been receiving oxygen via nasal cannula for 4 hours. Which of the following assessment findings helps indicate that oxygen therapy has been effective? A. Respiratory rate 14/min B. SaO2 90% (this level indicates hypoxemia.) C. Cardiac output 5.6 L/min D. PaCO2 68 mm Hg
Respiratory rate 14/min
A nurse is documenting data about a healing wound on a patient's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document this exudate as... A. Serosanguineous B. Sanguineous C. Serous D. Purulent
Serosanguineous
A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure which of the following actions should the nurse take to display empathy towards the client? A. Tell the client that everything will be fine B. Change the subject while the client is discussing their feelings C. Show interest in the client's feelings by acknowledging that they are upset D. Tell the client that it is wrong to be crying over this situation
Show interest in the client's feelings by acknowledging that they are upset
A nurse is collecting a healthy history from a client who is accompanied by an interpreter. Which of the following actions should the nurse take? A. speak directly to the client throughout the interview B. ensure the interpreter is positioned behind the client for privacy C. ask the interpreter to summarize a group of questions for the client D use accurate medical terminology when gathering information
Speak directly to the client throughout the interview
A nurse assessing a pressure ulcer over a patient's right heel area observes a deep crater with no eschar or slough and no exposed muscle or bone. The nurse should document that this patient has a pressure ulcer that is.. A. Unstageable B. A suspected deep tissue injury C. Stage 4 D. Stage 3
Stage 3
A nurse is performing auscultation during a client's physical assessment which of the following tools should the nurse use for this part of the assessment? A. Tongue Depressor B. Penlight C. Reflex hammer D. Stethoscope
Stethoscope
A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings? A. Bradycardia B. Tachycardia C. Fasciculation D. Tachypnea
Tachycardia
A nurse in the emergency department is assessing a client who has experienced thoracic trauma from a motor-vehicle crash. Which of the following findings is an indication of a pneumothorax? A. The client's ribs slope downward at a 45 degree angle B. The client is making a high-pitched crowing sound that can be heard in the neck area C. The diameter of the chest appears barrel-like with horizontal ribs D. The client is experiencing unequal movement of the posterior chest
The client is experiencing unequal movement of the posterior chest
A nurse is completing documentation in a client's medical record. Which of the following entries display proper documentation by the nurse? A. The client is feeling better B. The client's abdomen is soft and distended C. The client's status is unchanged D. The client appears in pain
The client's abdomen is soft and distended
A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately? A. Obtain the reading in the early morning B. Use a cuff of the appropriate size for the client C. Assist the client to the bathroom to void D. Apply the cuff loosely around the client's arm
Use a cuff of the appropriate size for the client
Administering oxygen therapy with a non-rebreather mask has which of the following advantage? a) offers the highest oxygen concentration of the low-flow systems b) provides oxygen concentrations of 40% to 60% c) incorporates a design that requires minimal monitoring of the client d) is designed for safety once the mask's valves and flaps are sealed
offers the highest oxygen concentration of the low-flow systems
A nurse is caring for a client who has "mycoplasma pneumoniae". The client has been placed on a droplet precautions. Which of the following actions should the nurse take when caring for the client? a. wear a respirator b. protect the eyes c. put on clean gloves d. wear shoe covers
protect the eyes
A home health nurse is teaching a client who has just started receiving oxygen therapy via mask. The nurse should emphasize that the client must: a) clean the mask with soapy water once every other day b) reposition the elastic band frequently c) apply petroleum jelly around and inside the nose d) make sure there is adequate condensation in the tubing
reposition the elastic band frequently
A nurse is providing discharge teaching to a client who will continue oxygen therapy at home. The nurse should instruct the client that turning the knob on the oxygen flow meter all the way to the right: a) starts the flow of oxygen (Turning the knob on the flow meter to the left begins the flow of oxygen) b) provides the maximal oxygen flow (Turning the knob on the flow meter all the way to the left provides the maximal oxygen flow.) c) provides minimal oxygen flow (Starting at the off position, turning the knob on the flow meter slightly to the left provides a minimal oxygen flow.) d) stops the flow of oxygen
stops the flow of oxygen
A nurse is caring for a client who is experiencing severe pain. Which of the following statements indicates that the client is experiencing chronic pain? "The pain from my car accident 2 months ago will not go away" "The pain has been off and on for about a year now" "The pain isn't always in the same place" "I still have pain since the surgery last month, but it is getting better" "I have had this pain for 9 months"
"I have had this pain for 9 months" "The pain isn't always in the same place" "The pain has been off and on for about a year now"
A nurse is providing teaching to a client who has a new diagnosis of asthma and reports a smoking history of 20 years. Which of the following statements should the nurse make when counseling the client about their tobacco use? (Select all that apply.) A. "Smoking is linked to various forms of cancer" B. "There is no risks associated with exposure to secondhand smoke" C. "It might take several attempts to finally stop smoking" D. "Smoking will cause you to die earlier than if you don't smoke" E. "There are pharmacologic therapies that can help a person stop smoking"
"There are pharmacologic therapies that can help a person stop smoking" "It might take several attempts to finally stop smoking" "Smoking is linked to various forms of cancer"
A nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine. Which of the following statements should the nurse make? A. "It's just a small number of people that get the flu from receiving the vaccine" B. "Call your provider immediately if you have flu-like symptoms after receiving the vaccine" C. "You should make every effort to receive a flu vaccine every year" D. "The vaccine becomes effective immediately after the injection"
"You should make every effort to receive a flu vaccine every year"
A nurse is about to irrigate a client's open wound. Besides gloves, which of the following personal protective equipment should the nurse wear? A. A sterile gown B. Googles C. A face shield D. An N95 respirator
A face shield
A nurse is caring for a client who has a health care-associated infection (HAI). Which of the following describes an exogenous HAI? a. A salmonella infection that occurs after eating contaminated food from cafeteria b. An infection that occurs during a therapeutic procedure c. A yeast infection that occurs while receiving broad spectrum antibiotics d. A urinary tract infection that occurs after sterile catheter insertion
A salmonella infection that occurs after eating contaminated food from cafeteria
A nurse is caring for a patient who has a heavily draining wound that continues to show evidence of bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis? A. Transparent B. Hydrogel C. Alginate D. Dry gauze
Alginate
A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39° C (102° F). Which of the following other vital signs should the nurse expect? A. An elevated pulse rate B. A decreased blood pressure C. An elevated BP D. A decreased pulse rate
An elevated pulse rate
A nurse is providing perineal care for a female client who has an indwelling urinary catheter. Which of the following areas should the nurse cleanse last? A. Urethral meatus B. Labia minora C. Perineum D. Anus
Anus
A nurse in the emergency department has received report on a child who has a laceration to the right calf which of the following steps of the nursing process should the nurse perform first? A. Assessment B. Analysis C. Evaluation D. Planning
Assessment
A nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states " I have changed my mind; Ido not want to have this surgery" which of the following ethical principles is the client using? A. Nonmaleficence B. Autonomy C. Justice D. Fidelity
Autonomy
A nurse is caring for a patient who has developed a stage IV pressure ulcer in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the ulcer? A. Barrier creams B. Antifungal ointment C. Chemical debridement D. Antibiotic agent
Barrier creams
A nurse is preparing to insert an indwelling urinary catheter. Which of the following actions should the nurse instruct the client to perform during the insertion procedure? A. Bear down B. Take deep breaths C. Sip water D. Tighten the perineum
Bear down
A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first? A. Irrigate the catheter. B. Assess for peripheral edema. C. Palpate for bladder distention. D. Check the catheter for kinks.
Check the catheter for kinks.
A nurse is preparing to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take? A. Pull the catheter out as quickly as possible. B. Deflate the balloon completely before removal. C. Cut the inflation port to deflate the balloon. D. Tell the client to expect to feel a tugging sensation on removal.
Deflate the balloon completely before removal.
A nurse is caring for a client who has dyspnea, slight cyanosis, and a RR of 28/min. During which of the following phrases of the nursing process will the nurse determine that the client has impaired gas exchange? a) assessment b) diagnose c) planning d) evaluation
Diagnose
What should the nurse do to maintain standard precaution? A. Rinse gloves that become soiled during use B. Use an antimicrobial soap for routine handwashing C. Disinfect hands immediately after removing gloves D. Keep gloves on when touching environmental surfaces
Disinfect hands immediately after removing gloves
A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take? A. Instruct the client to breathe in and to exhale out as they normally do B. Count the client's respirations for 15 seconds then multiply by 4 C. Determine if the client has a history of any chronic respiratory problems D. Observe the client's chest movements while appearing to assess their pulse
Observe the client's chest movements while appearing to assess their pulse
Which of the following products can affect the permeability of latex gloves? A. Antimicrobial soap and water B. Alcohol-based antiseptic gel C. Petroleum-based hand lotion D. Water-based hand lotion
Petroleum-based hand lotion
A nurse is planning on obtaining an orthostatic blood pressure from a client who has syncope. In what order should the nurse take the following steps? Take the client's BP in the supine position Keep the cuff in place and assist the client to a seated position Assist the client to stand and then obtain their BP Place the client in a supine position and allow them to rest Take the client's BP in a seated position
Place the client in a supine position and allow them to rest. Take the client's BP in supine position Keep the cuff in place and assist the client to a seated position. Take the client's BP in a seated position. Assist the client to stand and obtain their BP.
A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take? A. Place the probe in the posterior pocked lateral to the midline B. Rest the probe on the lower lingual frenulum C. Place the probe centrally on top of the client's tongue D. Rest the probe under the tongue just beyond the client's teeth
Place the probe in the posterior pocked lateral to the midline
A nurse is gathering information about a client's personal lifestyle choices. Which of the following information should the nurse seek to gather while investigating substance use? (select all that apply) A. prescription medications taken for recreational purposes B. determination of when the client last had an alcoholic drink C. frequency of consumption of over the counter(OTC) medications D. adverse reactions to medications & environmental substances E. highest level of schooling completed
Prescription medications taken for recreational purposes Determination of when the client last had an alcoholic drink
A nurse is preparing to conduct a health history interview. Which of the following actions should the nurse plan to perform during the closing stage of the interview? A. document client data B. provide an opportunity for client to ask questions C. explain the reason for the insurance D. greet client with an introduction
Provide an opportunity for client to ask questions
A nurse is preparing to use a tympanic thermometer to acquire a client's temperature. Which of the following actions should the nurse take to ensure an accurate reading? A. Attach the disposable probe cover B. Assess the external ear for redness C. Pull the pinna back and upward gently D. Replace the thermometer in its charger
Pull the pinna back and upward gently
A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client t receive? A. Placing a transparent dressing over the pressure injury B. Applying hydrocolloids to the wound bed C. Pulsating lavage D. Using a topical enzyme solution in the wound bed
Pulsating lavage
A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting? A. Auscultatory gap B. Pulse pressure C. Orthostatic hypotension D. Pulse deficit
Pulse pressure
A nurse is caring for a client who is comatose. Which of the following alternative routes should the nurse use to obtain the most accurate core temp of the client? A. Axillary B. Temporal C. Tympanic D. Rectal
Rectal
A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation? A. Unexpected sounds made by tapping on the client's skin B. Skin temperature, moisture, or unexpected findings C. Heart sounds, lunch sounds, and bowel sounds D. The client's cleanliness and grooming
Skin temperature, moisture, or unexpected findings
