nursing clinical midterm 2023
Which behaviors are characteristic of a nurse who is a critical thinker? Select all that apply. A. Alert to context so that the need for modification can be identified and changes to the plan of care can be made B. Inflexible when it comes to the care of the client to ensure that the client meets the desired outcome C. Overly sensitive so that problems are addressed in a timely fashion D. Persistent when delivering care to all clients to complete all measures during a shift F. Responsible and accountable for own actions
A and F
The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? A. 83 mL/hr B. 103 gtts/hr C. 100 mL/hr D. 13 mL/hr
A. 83 mL/hr When calculating the infusion rate with an electronic device, divide the total volume to be infused (1,000 mL) by the total amount of time in hours (12). This is 83 mL/hr. Other options are incorrect.
A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function? A. Pleural effusion B. Tachypnea C. Wheezes D. Pneumonia
A. Pleural effusion - Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion).
A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action? A. Suspect an inflamed pleura rubbing against the chest wall. B. Document normal breath sounds. C. Recommend testing for pneumonia. D. Assess for asthma.
B. Document normal breath sounds.
A nurse is caring for a client with paraplegia. Using observation to examine the client's skin, what finding might indicate the presence of a pressure injury? A. A circular red, scaly area that itches on the top of the forearm arm. B. An intact faded purple area on the shoulder blades, with a yellowish tint. C. An intact red area on the buttocks. D. An area of swollen, pale red bumps on the front of the neck.
C. An intact red area on the buttocks.
a nurse administers medications to a client. which step of the nursing process would the nurse perform next? A. assessing B. diagnosing C. Evaluating D. Planning
C. Evaluating
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will: A. decrease the blood glucose. B. decrease the blood volume. C. decrease the apical pulse. D. decrease the respiratory rate.
C. decrease the apical pulse.
The primary extracellular electrolytes are: A. potassium, phosphate, and sulfate. B. magnesium, sulfate, and carbon. C. sodium, chloride, and bicarbonate. D. phosphorous, calcium, and phosphate.
C. sodium, chloride, and bicarbonate. The primary extracellular electrolytes are sodium, chloride, and bicarbonate.
What percentage of weight change in 6 months is considered abnormal? A. 1% B. 2% C. 5% D. 10%
D. 10%
A health care provider orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? A. 20 gtt/min B. 30 gtt/min C. 40 gtt/min D. 50 gtt/min
D. 50 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. 250 X 20 / 100 = 50gtt/min
The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention? A. blood pressure 116/80 mm Hg B. respirations 18 breaths/min C. pulse rate 70 beats/min D. temporal temperature 100.8º F (38.2º C)
D. temporal temperature 100.8º F (38.2º C)
communication communic/o- -ation
communic/o: impart; transmit -ation: being; having; process
etymology etym/o- -logy
etym/o: word origin -logy: study of
Which response(s) will the nurse provide to a client concerned about developing chronic bronchitis due to smoking cigarettes, working with printing chemicals, and living near a paper mill? Select all that apply. A. "Have you tried to stop smoking? This can reduce your risk?" B. "Living near a paper mill increases the risk the risk for mesothelioma, so maybe you should consider moving." C. "We can refer you to a smoking cessation program to help reduce developing any future pulmonary issues." D. "How long have you lived near the paper mill? This can increase you risk for chronic bronchitis and asthma." E. "Exposure to printing chemicals increases the risk for allergies which can trigger chronic bronchitis, so wearing a breathing mask may be needed."
A, C, D, and E
While recording the pulse of an infant at 160 beats/min, the parent asks if it is normal for the infant's pulse rate to be so high. Which statement by the nurse best answers the parent's question? A. "A heart rate of 160 beats/min is normal for a healthy infant." B. "A heart rate of 160 beats/min is a little too fast for an infant, so I will take it again in 5 minutes." C. "A heart rate of 160 beats/min is actually slow for an infant, so I will ask the health care provider to reassess." D. "Every infant's heart rate is different, so you will need to discuss that with the health care provider."
A. "A heart rate of 160 beats/min is normal for a healthy infant."
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? A. Ask the client what factors contribute to nonadherence. B. Contact the health care provider to report the client's current status. C. Explain the use of a BiPAP mask instead of a CPAP mask. D. Document outcomes of modifications in care.
A. Ask the client what factors contribute to nonadherence.
A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? A. Discontinue the IV and relocate it to another site. B. Call the primary care provider to see whether anti-inflammatory drugs should be administered. C. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV D. Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site.
A. Discontinue the IV and relocate it to another site. The nurse should inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleansing will not resolve this common complication of therapy.
A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)? A. Inflate the blood pressure cuff while palpating the client's brachial or radial artery. B. Simultaneously compare the amplitude of the client's left and right radial pulses. C. Palpate the client's brachial pulse while having the client slowly raise his or her arm. D. Note the SBP that was documented during the client's last vital signs assessment.
A. Inflate the blood pressure cuff while palpating the client's brachial or radial artery.
The nurse is observing the unlicensed assistive personnel (UAP) perform oropharyngeal suctioning on a client. Which action, performed by the UAP, would indicate to the nurse that suctioning is being properly performed? A. The UAP advances the catheter approximately 3 to 4 inches to reach the pharynx. B. The UAP advances the catheter approximately 5 to 6 inches to reach the pharynx. C. The UAP applies lubricant to the first 2 to 3 inches of the catheter. D. The UAP allows 30-second to 1-minute intervals between suctioning passes.
A. The UAP advances the catheter approximately 3 to 4 inches to reach the pharynx. - the catheter should be placed along the side of the mouth toward the trachea and advanced 3 to 4 inches to reach the pharynx.
A nurse has been working on a telemetry unit for 6 months. The nurse arrives at work in the morning and overhears a night shift nurse talking about the new nurse. The night shift nurse is heard saying, "That new nurse is only here to meet a doctor and get married." The best response by the new nurse would be to: A. ask to speak to the night shift nurse in private and explain how the comment made the new nurse feel. B. approach and tell the night shift nurse that the night shift nurse is "out of line." C. ignore the comment and begin the shift. D. call hospital security and ask them to take a report.
A. ask to speak to the night shift nurse in private and explain how the comment made the new nurse feel.
An ultrasonic Doppler is used for: A. auscultating a pulse that is difficult to palpate. B. auscultating diastolic blood pressure. C. aiding palpation of pulse and rhythm. D. aiding palpation of diastolic blood pressure.
A. auscultating a pulse that is difficult to palpate. - A Doppler device can be used to detect a pulse that is not easily palpable.
A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that they had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? A. banana B. milk C. yogurt D. turkey
A. banana Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.
A client's body mass index (BMI) categorizes the client as obese. Thc client comes to the clinic to start on a weight loss plan. The client loves to eat, does not like to exercise, and their favorite food is hamburgers. The nurse creates a care plan focused on the nursing concern altered health maintenance. What is the most appropriate outcome for this concern? The client will: A. create an exercise plan that is realistic and valued. B. exercise every day for at least 30 minutes. C. only eat three meals per day. D. stop eating meat and walk every day after dinner.
A. create an exercise plan that is realistic and valued.
Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: A. phlebitis. B. an infiltration. C. a systemic blood infection. D. rapid fluid administration.
A. phlebitis. Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? A. platelets B. granulocytes C. albumin D. cryoprecipitate
A. platelets
A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply. A. Prescribing the kind of IV solution. B. Deciding the location of the IV catheter. C. Deciding the size of the IV catheter. D. Administering the IV solution. F. Determining the amount of IV solution.
B, C, and D The nurse is responsible for deciding the location and size of the IV catheter, as well as for administering the solution. The primary care provider is responsible for prescribing the kind and amount of solution.
A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: A. "He will require additional testing to determine the cause." B. "He is using his chest muscles to help him breathe." C. "His infection is causing him to breathe harder." D. "His lung muscles are swollen so he is using abdominal muscles."
B. "He is using his chest muscles to help him breathe."
A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min? A. 42 gtt/min B. 83 gtt/min C. 167 gtt/min D. 5,000 gtt/min
B. 83 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. 250 mL × 20 gtt/mL ÷ 60 min = 83 gtt/min
Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound? A. Take the measurement with the client in a standing position with the appropriate limb exposed. B. Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. C. If using a mercury manometer, check to see that the manometer is in the horizontal position and that the mercury is within the zero level. D. Using your nondominant hand, place the Doppler tip in the gel and adjust the volume as needed; move the Doppler tip around until you hear the pulse.
B. Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery.
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? A. asking the client to pump their fist several times B. placing the tourniquet on the upper arm for 2 minutes C. asking if the client is right or left-handed D. palpating the veins on the nondominant hand
B. placing the tourniquet on the upper arm for 2 minutes The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture.
The nurse is teaching an adult client how to monitor the pulse rate. Which statement by the client demonstrates understanding of a normal pulse rate? A. "The normal pulse rate is 12 to 20 beats/min." B. "I will call the health care provider if my pulse is below 80 beats/min." C. "If my pulse is higher than 100 beats/min at rest, that is considered abnormal." D. "It is normal for my pulse to be lower than 40 beats/min while sleeping."
C. "If my pulse is higher than 100 beats/min at rest, that is considered abnormal."
A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? A. Inflammation B. Arthritis C. Crepitus or crepitation D. Fremitus
C. Crepitus or crepitation - a crackling or grating sound usually of bones
A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen? A. Place the client in the dorsal recumbent position to collect the specimen. B. Have the client clear the nose and throat and gargle with salt water before beginning the procedure. C. Instruct the client to inhale deeply and then cough. D. Discard the first sputum produced by the client.
C. Instruct the client to inhale deeply and then cough.
A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record? A. There is a nonauscultatory gap. B. There is a widening in the diameter of the artery. C. There is an auscultatory gap. D. There is an adult diastolic pressure.
C. There is an auscultatory gap.
Which is a common anion? A. magnesium B. potassium C. chloride D. calcium
C. chloride Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.
In which client should the nurse prioritize assessments for respiratory depression? A. A client taking a beta-adrenergic blocker for hypertension B. A client taking antibiotics for a urinary tract infection C. A client taking insulin for type 1 diabetes D. A client taking opioids for cancer pain
D. A client taking opioids for cancer pain
A nurse is assisting with assessment of the internal eye structures of clients in an ophthalmologist's office. What would the nurse document as a normal finding? A. A uniform yellow reflex B. A blurred optic disc C. Dark-red arteries and light-red veins D. A reddish retina
D. A reddish retina
A nurse assesses a client for blood pressure. Which technique would be used for this assessment? A. inspection B. palpation C. percussion D. auscultation
D. auscultation
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? A. oxygen analyzer B. nasal strip C. nasal cannula D. flow meter
D. flow meter - A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen.
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? A. calcium B. chloride C. phosphorous D. potassium
D. potassium Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium. Signs of potassium defecit, or hypokalemia, include muscle weakness and leg cramps, fatigue, paresthesias, and arrythmias.
