ADN 105 Review

The nurse is advised to join a community health center that mainly caters to Latino clients. Which skills should the nurse develop to help reduce health disparities? Select all that apply. 1. Learning to speak basic medical Spanish 2. Updating clinical supplies at the health care facility 3. Learning about the health literacy rate of the community 4. Incorporating the health beliefs of the community in any nursing care plans 5. Learning about and respecting unique beliefs and values prevalent among the group

ANSWER: 1. Learning to speak basic medical Spanish 3. Learning about the health literacy rate of the community 4. Incorporating the health beliefs of the community in any nursing care plans 5. Learning about and respecting unique beliefs and values prevalent among the group

What are factors in setting nursing priorities? Select all that apply. A. Client Condition B. Reassessment Data C. Plan of Care Modifications D. Feedback from the family and health care team

ANSWER: A. Client Condition B. Reassessment Data D. Feedback from the family and health care team

A nurse is assessing the freshly voided urine of a client. What characteristics of the urine would indicate a urinary problem? Select all that apply. 1. The urine is amber colored. 2. The urine smells like ammonia. 3. The urine pH is 6.0. 4. The urine is translucent. 5. There is pus in the urine. 6. The urine is cloudy.

ANSWER: 1. The urine smells like ammonia. 5. There is pus in the urine. 6. The urine is cloudy.

Which of the following are characteristics of culture? Select all that apply. A. Learned B. Dynamic C. Ethnocentric D. Relative to context E. A set of traits

ANSWER: A. Learned B. Dynamic C. Ethnocentric D. Relative to context

The nurse finds that a client with a urinary disorder has very pale-yellow-colored urine. What is the significance of this abnormal finding? 1. It indicates dilute urine. 2. It indicates blood in the urine. 3. It indicates concentrated urine. 4. It indicates the presence of myoglobin.

ANSWER: 1. It indicates dilute urine.

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of: 1. a dysrhythmia. 2. tachycardia. 3. bradycardia. 4. hypertension.

ANSWER: 1. a dysrhythmia.

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make? 1. into a private room 2. with a client with pneumonia 3. with a client with a myocardial infarction 4. with another client with a draining wound

ANSWER: 1. into a private room

Which is not true of urine color? 1. Medications can alter urine's color. 2. Someone's state of hydration affects the color. 3. The color of urine ranges from light yellow to amber. 4. The appearance of urine streaked with blood is always abnormal.

ANSWER: 4. The appearance of urine streaked with blood is always abnormal.

The nurse is choosing a collection device to collect urine from a nonambulatory male client? What would be the nurse's best choice? 1. Specimen hat 2. Large urine collection bag 3. Bedpan 4. Urinal

ANSWER: 4. urinal

WHAT IS THE FIRST ACTION A NURSE SHOULD DO WHEN IMPLEMENTING CLINICAL THINKING AND JUDGEMENT? A. Observe for cues B. Go in the room with a pre-conceived idea C. Start to put together priorities D. Do nothing

ANSWER: A. Observe for cues

WHEN A LANGUAGE DIFFERENCE EXISTS BETWEEN THE NURSE AND CLIENT, THE NURSE SHOULD DO WHICH OF THE FOLLOWING? A. Act in the client's best interest B. Use a bilingual family member to facilitate assessment and care C. Establish whether a trained interpreter is needed D. Obtain a key informant to navigate the client's care.

ANSWER: C. Establish whether a trained interpreter is needed

SHARED CULTURE IS MOST ACCURATELY SEEN AMONG PEOPLE WITH WHICH OF THE SAME TRAITS? A. Ethnicity B. Skin Color C. Rituals D. Language

ANSWER: C. Rituals

Urinary elimination from an ileal conduit can be voluntarily controlled after the stoma heals from the initial surgery. True False

ANSWER: False

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options. 1. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areasCarefully open the inner package taking care not to touch the inner surface of the package or the gloves. 2. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand.With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 3.With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over the hand. 4. Carefully open the inner package taking care not to touch the inner surface of the package or the gloves.

ANSWER: 1. Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 2. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 3.Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. 4. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas

The nurses in a health care facility have developed a new care plan to prevent the risk of infection in clients with an indwelling urinary catheter in place. To determine if the changes prevent infections, the nurse manager uses the plan-do-study-act (PDSA). What is the order of steps that the nurse manager would follow to evaluate the changes? 1. Try out the change 2.Plan to test the change 3. Determine what was learned 4. Analyze what happened from the change

ANSWER: 1. Plan to test the change 2.Try out the change 3.Analyze what happened from the change 4.Determine what was learned

A physician has ordered 500 mg of ampicillin as an intramuscular injection. The vial label reads "250 mg/1 mL". How many mL would the nurse administer?

ANSWER: 2 mL

A nurse is assisting a client when he is draining a continent ileostomy. The catheter suddenly becomes plugged with stool. Which action should the nurse take to rectify the problem? 1. Rotate the catheter tip inside the stoma. 2. Avoid milking the catheter. 3. Wait for 8 hours to obtain drainage. 4. Avoid removing the catheter.

ANSWER: 1. Rotate the catheter tip inside the stoma.

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? 1. "A heart rate of 160 beats/min is normal for a healthy infant." 2. "A heart rate of 160 beats/min is a little too fast for an infant, so I will take it again in 5 minutes." 3. "A heart rate of 160 beats/min is actually slow for an infant, so I will ask the health care provider to reassess." 4. "Every infant's heart rate is different, so you will need to discuss that with the health care provider."

ANSWER: 1. "A heart rate of 160 beats/min is normal for a healthy infant."

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain? 1. reddish-brown, clear 2. clear, light yellow 3. dark brown, cloudy 4. aromatic, green

ANSWER: 3. dark brown, cloudy

Which assessment question is most likely to yield clinically meaningful data about a female client's sexual identity? 1. "How do you feel about yourself as a woman?" 2. "Have you ever had any sexually transmitted infections in the past?" 3. "Are you satisfied with the quality of your relationships right now?" 4. "Do you find that your health allows you to enjoy a meaningful sex life?"

ANSWER: 1. "How do you feel about yourself as a woman?"

A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process? 1. Assessment 2. Diagnosis 3. Planning 4. Implementation

ANSWER: 1. Assessment

A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which nursing intervention best demonstrates caring in this situation? 1. Assisting the client to sit up in a chair 2. Assessing the abdominal incision 3. Monitoring vital signs 4. Notifying the health care provider of lab results

ANSWER: 1. Assisting the client to sit up in a chair

The nurse walks into the client's room and finds her sobbing uncontrollably. When the nurse asks what the problem is, the client responds, "I am so scared. I have never known anyone who goes into a hospital and comes out alive." On this client's care plan, the nurse notes a nursing diagnosis of Ineffective Coping related to stress. What is the best outcome the nurse can expect for this client? 1. Client will adapt relaxation techniques to reduce stress. 2. Client will be stress free. 3. Client will avoid stressful situations. 4. Client will start on an antianxiety agent.

ANSWER: 1. Client will adapt relaxation techniques to reduce stress.

The nurse uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill? 1. Cognitive skill 2. Technical skill 3. Interpersonal skill 4. Ethical or legal skill

ANSWER: 1. Cognitive skill

A client diagnosed with renal failure has been informed he will need to start dialysis. He is concerned because he has been advised to stop working for a couple of months, as his body adjusts to the dialysis. Which nursing diagnosis is most appropriate for this client? 1. Ineffective Role Performance 2. Ineffective Sexuality Patterns 3. Disturbed Sensory Perception 4. Posttrauma Syndrome

ANSWER: 1. Ineffective Role Performance

The nurse manager in an acute care facility has received client evaluations in which the clients have complained about excessive noise that interfered with their rest. The nurse manager and nursing staff plan to take the following actions. Which action will most assist clients in obtaining rest? 1. Post signs for quiet and turn down hall lights during formal quiet times. 2. Ensure clients are offered prescribed sleeping medications at bedtime. 3. Provide a small carbohydrate snack or juice prior to hours of sleep. 4. Adjust the temperature of the room to 74°F (23.3°C) and provide a blanket.

ANSWER: 1. Post signs for quiet and turn down hall lights during formal quiet times.

A nurse has completed an assessment of a family and has identified the family's strengths. Which of the following would the nurse be least likely to identify as a strength? 1. Rigid roles of family members 2. Mutual support of members 3.Intact support support systems 4. Positive communication techniques

ANSWER: 1. Rigid roles of family members

While assessing the spirituality of a client diagnosed with an HIV infection, the client becomes angry and defensive. The client also exhibits signs of anxiety and depression. Which statement by the nurse would be most appropriate to promote the client's comfort? 1. "If only you had tried to be a little careful and safe with yourself." 2. "I can see from your response that you might not have expected these questions." 3. "I am certain that you had expected this kind of situation someday." 4. "Don't worry, God will take care of everything."

ANSWER: 2. "I can see from your response that you might not have expected these questions."

A nurse is preparing to obtain a specimen for an aerobic wound culture. The nurse would obtain the specimen from which area? 1. Edge of the wound 2. Area of active drainage 3. Deep into the cavity 4. Soiled dressing

ANSWER: 2. Area of active drainage

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify: 1. increased humoral immunity response. 2. decreased cellular immunity. 3. increased effectiveness of phagocytosis. 4. decreased susceptibility to infection.

ANSWER: 2. decreased cellular immunity.

A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan? 1. signs and symptoms of infection 2. intravenous antibiotic adminstration 3. hand hygiene measures 4. vital sign monitoring

ANSWER: 2. intravenous antibiotic adminstration

The nurse enters the room of the client diagnosed with a cerebral hemorrhage and immediately states, "This client is getting worse." This is an example of the experienced nurse using: 1. acute observation ability. 2. intuitive problem identification. 3. illogical thinking. 4. an assumption to guide practice.

ANSWER: 2. intuitive problem identification.

The family is organized as a unit for the achievement of certain functions. The nurse is completing data collection about a family and knows that which of the following is the most important primary function of the family? 1. provides everything each member of the family wants 2. provides an environment that supports growth of individual family members 3. ensures that the members are accepted into society as a whole 4. ensures that family economic resources are kept in the nuclear family and not shared with the broader community

ANSWER: 2. provides an environment that supports growth of individual family members

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile? 1. goggles and gloves 2. respirator mask and gown 3. gown and gloves 4. mask and shoe covers

ANSWER: 3. gown and gloves

Critical thinking is important in making an effective nursing judgment. Which technique would be most effective for the nursing student to adopt to improve classroom success? 1. improve reading and writing skills 2. turn errors into learning opportunities 3. build a glossary of new words 4. avoid asking for assistance when possible

ANSWER: 2. turn errors into learning opportunities

A teen is worried that her boyfriend is under "a lot of stress" with his home life, classes, clubs, community service, and part-time work. She asks the nurse what medication he should take to "calm down." Which response would be best? 1. "What medication is he taking now? I can recommend something, but we need to make sure there won't be an interaction with something else." 2. "It sounds like he is in too many extracurricular activities. Can you convince him to drop out of some of those clubs?" 3. "Do you think he would be willing to sit down and talk with me? I'd like to get to know him better so I can suggest some healthy alternatives." 4. "Isn't he passing his classes? Did you tell his parents this was happening?"

ANSWER: 3. "Do you think he would be willing to sit down and talk with me? I'd like to get to know him better so I can suggest some healthy alternatives."

The nurse is educating the client on culture and sensitivity test. The client wants know to when the nurse could get the results back. Which response should the nurse use? 1. "Cultures can have results as early as 30 minutes and sensitivity results come in after 24 hours." 2. "Culture and sensitivity test depend on what is being grown." 3. "It could take 24 to 36 hours to grow cultures and about 48 hours for sensitivity." 4. "There is no definite time for results to be ready. Nurses just wait for the laboratory to call.'

ANSWER: 3. "It could take 24 to 36 hours to grow cultures and about 48 hours for sensitivity."

A nurse in an oncology care unit is reviewing the laboratory test results of several clients scheduled to receive chemotherapy. The nurse determines that the client with which leukocyte count will most likely have the chemotherapy withheld? 1. 7,500 cells/mm3 2. 5,800 cells/mm3 3. 2,500 cells/mm3 4. 9,800 cells/mm3

ANSWER: 3. 2,500 cells/mm3

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate? 1. Allow many family members to visit at once. 2. Deliver flowers and balloons to the room. 3. Remove fresh fruit from the room. 4. No special precautions are required.

ANSWER: 3. Remove fresh fruit from the room.

The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the physician should be notified immediately? 1. The client feels restless and hungry. 2. The client exhibits an increased urinary output. 3. The client's heart rate is greater than 90 bpm. 4. The client's respiratory rate is less than 20 breaths/min.

ANSWER: 3. The client's heart rate is greater than 90 bpm.

Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup? 1. Bacteria 2. Fungi 3. Virus 4. Parasites

ANSWER: 3. Virus

The nurse is caring for a female 29 years of age who is admitted with chronic pain secondary to rheumatoid arthritis. She confides in the nurse that she would like to be able to have sex with her husband but it just "hurts too much." The nurse's best response is: 1. "After a time that sort of thing doesn't matter." 2. "Is your husband willing to forgo sex?" 3. "It may be time to put that behind you." 4. "Modified positions may be possible."

ANSWER: 4. "Modified positions may be possible."

A client has been prescribed a clear liquid diet. What food or fluids will be served? 1. milk, frozen dessert, egg substitutes 2. high-calorie, high-protein supplements 3. hot cereals, ice cream, chocolate milk 4. Jell-O, carbonated beverages, apple juice

ANSWER: 4. Jell-O, carbonated beverages, apple juice

After teaching a group of students about transmission-based precautions, the instructor determines that the education was successful when the students identify which medical condition as requiring airborne precautions? 1. Rubella 2. Impetigo 3. Clostridium difficile diarrhea 4. Varicella

ANSWER: 4. Varicella

Which group of terms best describes anxiety? 1. cognitive, known threat, depression 2. cognitive, visible threat, anger 3. known source, prolonged, solely physical 4. unknown cause, emotional, apprehensive

ANSWER: 4. unknown cause, emotional, apprehensive

WHICH OF THE FOLLOWING ARE PART OF MARJORIE GORDON'S HEALTH PATTERNS? SELECT ALL THAT APPLY A. Health Perception and Health Management B. Activity and Exercise C. Change Theory D. Roles and Relationships

ANSWER: A. Health Perception and Health Management B. Activity and Exercise D. Roles and Relationships

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options. 1. Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 2. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 3.Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. 4. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas

ANSWER: 1. Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 2. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 3.Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. 4. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply. 1. Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. 2. Change the dressing midway between meals. 3. Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. 4. Apply another layer of protective ointment or paste on top of the previous layer when changing dressings. 5. Apply an absorbent dressing material as the first layer of the dressing. 6. Apply a nonabsorbent material over the first layer of absorbent material.

ANSWER: 1. Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. 2. Change the dressing midway between meals. 4. Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound.

The nurse is preparing to administer heparin to prevent deep venous thrombosis in a client who has had surgery. What is the appropriate nursing action? Select all that apply. 1. Change the needle after filling the syringe. 2. Use the area 2 inches around the umbilicus for injection. 3. Aspirate with the plunger. 4. Leave needle in place for 15 seconds. 5. Press on the injection site with gauze following administration.

ANSWER: 1. Change the needle after filling the syringe. 5. Press on the injection site with gauze following administration.

Which nursing interventions support infection control in the hospital setting? Select all that apply. 1. Regularly turn bedridden clients. 2. Apply lubricants to the nares (nostrils) to avoid cracking. 3. Avoid the use of hot compresses when possible. 4. Dry in-between the skin folds after bathing. 5. Use special mattress for immobile clients.

ANSWER: 1. Regularly turn bedridden clients. 2. Apply lubricants to the nares (nostrils) to avoid cracking. 3. Avoid the use of hot compresses when possible. 4. Dry in-between the skin folds after bathing. 5. Use special mattress for immobile clients.

The nurse is assessing a client's bladder volume using an ultrasound bladder scanner. Which nursing actions are performed correctly? Select all that apply. 1. The nurse gently palpates the client's symphysis pubis. 2. The nurse places a generous amount of ultrasound gel or gel pad midline on the client's abdomen, about 1 to 1.5 in (2.5 to 4 cm) above the symphysis pubis. 3. The nurse places the scanner head on the gel or gel pad, with the directional icon on the scanner head pointed away from the client's head. 4. The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx). 5. The nurse adjusts the scanner head to center the bladder image on the crossbars. 6. The nurse presses and holds the END button until it beeps 3 times and then reads the volume measurement on the screen.

ANSWER: 1. The nurse gently palpates the client's symphysis pubis. 2. The nurse places a generous amount of ultrasound gel or gel pad midline on the client's abdomen, about 1 to 1.5 in (2.5 to 4 cm) above the symphysis pubis. 4. The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx). 5. The nurse adjusts the scanner head to center the bladder image on the crossbars.

The nurse triaged a number of clients in the emergency department. Which clients would the nurse identify as Risk for Infection? Select all that apply. 1. the client who is taking antihypertensive medications and experienced orthostatic hypotension 2. the client who has AIDS and is taking antiretroviral medications 3. the client who reports abdominal pain for 1 day and exhibits an elevated white blood cell count 4. the client who has breast cancer, is receiving chemotherapy, and has a low white blood cell (WBC) count 5. the older adult client who is cachetic in appearance 6. the client whose electrocardiogram (EKG) and cardiac enzymes are normal

ANSWER: 2. the client who has AIDS and is taking antiretroviral medications 3. the client who reports abdominal pain for 1 day and exhibits an elevated white blood cell count 4. the client who has breast cancer, is receiving chemotherapy, and has a low white blood cell (WBC) count 5. the older adult client who is cachetic in appearance

Which clients are ideal candidates for interpreter service in order to prevent contributing health disparities? Select all that apply. 1. An English-speaking client with a speech disorder 2. An African American client with a hearing impairment 3.A non-English-speaking client in the emergency department 4. A Spanish-speaking client ready to be discharged from the facility 5. An Indian American who does not speak the language used at the facility

ANSWER: 3. A non-English-speaking client in the emergency department 4. A Spanish-speaking client ready to be discharged from the facility 5. An Indian American who does not speak the language used at the facility

Which nursing actions help improve listening skills when conversing with clients? Select all that apply. 1. Sitting with the arms crossed 2. Always maintaining eye contact with the client in a face-to-face pose 3. Using facial expressions and body gestures to indicate attention to what the client is saying 4. Thinking before responding to the client, even if this creates a lull in the conversation 5. Listening for themes in the client's comments 6. Pretending to listen to the client while performing a task rather than interrupting the client's conversation

ANSWER: 3. Using facial expressions and body gestures to indicate attention to what the client is saying 4. Thinking before responding to the client, even if this creates a lull in the conversation 5. Listening for themes in the client's comments

A toddler who lacks toilet training is admitted to a hospital. What does the nurse need to do when collecting urine samples from the toddler? Select all that apply. 1. Squeeze urine from the diaper. 2. Place a hat under the toilet seat. 3. Convince the child to void in the unfamiliar receptacle. 4. Attach single-use bags over the child's urethral meatus. 5. Use the terms for urination that the child can understand

ANSWER: 4. Attach single-use bags over the child's urethral meatus. 5. Use the terms for urination that the child can understand

Nontherapeutic communication interferes with client care and hinders the client nurse relationship. Identify nontherapeutic communication types from below. A. A nurse provider education on smoking cessation. "The same thing happened to me and I was able to quit." B. A nurse attempts to distract a client at the end of life. "Let's focus on your walking not your worries about death." C. A nurse states during a report "My client should not get the abortion for it is wrong." D. A nurse is discussing care options with the family. " What have your experiences been with health care in the past?"

ANSWER: A. A nurse provider education on smoking cessation. "The same thing happened to me and I was able to quit." B. A nurse attempts to distract a client at the end of life. "Let's focus on your walking not your worries about death." C. A nurse states during a report "My client should not get the abortion for it is wrong."

An antibiotic is ordered for a client that has had a allergic reaction in the past. Which would be an appropriate nursing action as determined by the professional nursing role? Select all that apply. A. Identify that the antibiotic is inappropriate B. Document the allergy and call the provider C. Administer the drug as ordered D. Complain to the other nurses about the provider's poor judgement

ANSWER: A. Identify that the antibiotic is inappropriate B. Document the allergy and call the provider

WHAT ARE SOME GUIDELINES FOR FACILITATING COMMUNICATION BETWEEN A NURSE AND THE CLIENT? SELECT ALL THAT APPLY A. Speak in a normal tone B. Reduce or eliminate environmental noises C. Maintain eye contact with the client D. Do not rush the client - give them adequate time to respond

ANSWER: A. Speak in a normal tone B. Reduce or eliminate environmental noises C. Maintain eye contact with the client D. Do not rush the client - give them adequate time to respond

What does SBAR stand for? S B A R

ANSWER: SITUATION BACKGROUND ASSESSMENT RECOMMENDATION

The parents of an adolescent ask the nurse for suggestions in helping to promote his identity. Which statement by the nurse would be most appropriate? 1. "Be sure your adolescent has support from others." 2. "Disruptions in the home will help the adolescent solve problems." 3. "Limit the amount of time your adolescent spends with his peers." 4. "Try to limit the changes that occur in your adolescent's relationships."

ANSWER: 1. "Be sure your adolescent has support from others."

The nurse is caring for a client who has an infection spread by respiratory droplets and is under droplet precautions. The client asks, "Can my spouse visit me?" Which response is correct? 1. "Yes, as long as your spouse wears a mask and stays at least 3 feet (1 meter) away from you." 2. "No, the chance of spreading your infection to the community is too great." 3. "Yes, but only if your spouse stays outside of the room and speaks to you from the doorway." 4. "No, the supplies used for this type of infection are too expensive to provide to family members."

ANSWER: 1. "Yes, as long as your spouse wears a mask and stays at least 3 feet (1 meter) away from you."

A client has an order for chloramphenicol, 500 mg every 6 hours. The drug comes in 250 mg capsules. What would the nurse administer? 1. 4 tab 2. 2 tabs 3. 1 tabs 4. 3 tabs

ANSWER: 1. 2 tabs

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? 1. 24-hour specimen 2. clean-catch specimen 3. random specimen 4. intermittent specimen

ANSWER: 1. 24-hour specimen

The nurse is preparing to insert an indwelling urinary catheter into a 3-year-old child. Which size of urinary catheter should the nurse plan to use? 1. 6 Fr 2. 10 Fr 3. 16 Fr 4. 24 Fr

ANSWER: 1. 6 Fr

Which medication interaction illustrates a synergism? 1. A client takes acetaminophen to help her sleep. She also takes an oxycodone for pain related to recent hip surgery, which makes her even more drowsy. 2. A client is taking doxycycline, an antibiotic, for rosacea. She takes this with her morning vitamins, which includes calcium carbonate. She has not noticed a change in her symptoms. 3. A client is taking metoprolol for her blood pressure and metformin for her diabetes. Her provider has told her that these are safe to take together. 4. A client was told not to take tretinoin topical if she is pregnant because it may be teratogenic.

ANSWER: 1. A client takes acetaminophen to help her sleep. She also takes an oxycodone for pain related to recent hip surgery, which makes her even more drowsy.

Which parameter does the nurse assess first while assessing a client with severe trauma? 1. Airway 2. Disability 3. Breathing 4. Circulation

ANSWER: 1. Airway

After meeting with the family to give an update on the surgical client, the nurse shakes their hands before leaving. Which method of hand hygiene is most appropriate following this encounter? 1. Alcohol-based hand rub 2. Soap and water hand washing technique 3. Scrubbing hands with soap, water, and brush 4. Mixture of soap and alcohol-based hand rub techniques

ANSWER: 1. Alcohol-based hand rub

An oral medication has been ordered for a client who has a nasogastric tube in place. Which nursing activity would increase the safety of medication administration? 1. Check the tube placement before administration. 2. Have the client swallow the pills around the tube. 3. Flush the tube with 30 to 40 mL saline before medication administration. 4. Bring the liquids to room temperature before administration.

ANSWER: 1. Check the tube placement before administration.

When caring for a transgender client, which would the nurse use to decide how to address the client? 1. Client's preference 2. Client's appearance 3. Client's clothing 4. Client's identity document (e.g., birth certificate)

ANSWER: 1. Client's preference

A client who has liver failure says, "I have complete trust in God and I am sure he will take care of my family even if I am not here." Which concept does this most exemplify? 1. Faith 2. Religion 3. Connectedness 4. Transcendence

ANSWER: 1. Faith

The nurse is admitting a client who has been receiving prescribed antibiotics for pneumonia. The client reports experiencing loose, watery stools for the past 4 days. What would be the initialaction for the nurse to take? 1. implementing contact isolation 2. informing the health care provider that the antibiotic should be changed 3. instructing the client to collect a stool sample 4. modifying the client's diet to clear liquids

ANSWER: 1. Implementing contact isolation

The nurse is caring for several postoperative clients prescribed "hydrocodone-acetaminophen 5/300 mg 1-2 tabs q6h" which has already been administered at different times during the shift. When one client requests pain medication, which important medication administration "right" would the nurse check first before administering the medication? 1. Is it time for the client to have more medication? 2. Is this the right client? 3. How much medication should be given? 4. Did the pharmacy provide the correct medication?

ANSWER: 1. Is it time for the client to have more medication?

A nurse is preparing a prescribed dosage of an inhalant medication for a client with asthma. Which statement explains why inhalation is a good route for medication administration? 1. It allows the lungs to quickly absorb the medication. 2. It eliminates bad breath. 3. It prevents unpleasant aftertastes associated with oral medications. 4. It eliminates the potential of suffocation and asphyxia.

ANSWER: 1. It allows the lungs to quickly absorb the medication.

A nurse is educating a client about smoking cessation. The nurse determines that the client has high self-efficacy. Which outcome would the nurse expect to occur? 1. The client will be able to stop smoking. 2. The client will voice reasons for not being able to quit. 3. The client will focus on another activity. 4. The client will refrain from participating in trying to quit.

ANSWER: 1. The client will be able to stop smoking.

Why is communication important to the "assessment" step of the nursing process? 1. The major focus of assessing is to gather information. 2. Assessing is primarily focused on physical findings. 3. Assessing involves only nonverbal cues. 4. Written information is rarely used in assessment.

ANSWER: 1. The major focus of assessing is to gather information.

While performing the discharge assessment of a client who has undergone abdominal surgery, the nurse finds that the client exhibits good health and is able to perform activities without assistance. Which nursing action during the discharge indicates failure to promote appropriate continuity of care? 1. The nurse asks the client to get a chest X-ray in one week. 2. The nurse asks the client to schedule a follow-up visit once in two weeks. 3. The nurse asks the client to perform breathing exercises on a regular basis. 4. The nurse asks the client to follow the dietary recommendations made by the dietitian.

ANSWER: 1. The nurse asks the client to get a chest X-ray in one week

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection? 1. an older adult client with a history of heart failure 2. a school-age child who is current with immunizations 3. an adolescent who has a right radial fracture 4. a middle-aged adult who takes prescribed medication to control blood pressure

ANSWER: 1. an older adult client with a history of heart failure

The nurse is preparing to administer a client's intramuscular injection and intends to use the technique shown. What potential benefit of this technique should the nurse describe? 1. decreased irritation and pain in subcutaneous tissue 2. less frequent administration of the medication 3. more rapid administration of the medication 4. decreased risk for infection

ANSWER: 1. decreased irritation and pain in subcutaneous tissue

The family of a client with a severe traumatic brain injury is considering the withdrawal of the client's mechanical ventilation. What is the nurse's primary role in the preparation for terminal weaning? 1. educating the family on what to reasonably expect after ventilation is discontinued 2. assisting with chest physiotherapy before and after ventilation ceases 3. assisting with pulmonary resuscitation if the client is unable to breathe independently 4. preparing the bedside for postmortem care

ANSWER: 1. educating the family on what to reasonably expect after ventilation is discontinued

The nurse and a colleague have admitted a client who is on contact precautions. The nurse and colleague are removing their personal protective equipment and the nurse sees the colleague start to pull off her gloves at the fingers. What is the nurse's most appropriate response? 1. encourage the colleague to remove the glove by grasping the cuff 2. teach the colleague why the gloves should be removed outside the room 3. maintain a distance of at least 5 ft (1.5 m) from the colleague 4. take no action at this time

ANSWER: 1. encourage the colleague to remove the glove by grasping the cuff

A nurse is performing a sensitivity test on a client. What would be the best type of injection to use for this procedure? 1. intradermal 2. intramuscular 3. subcutaneous 4. intravenous

ANSWER: 1. intradermal

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene? 1. removes gloves and walks out of the room 2. asks the client to state name and date of birth 3. applies a mask with face shield 4. performs hand hygiene before donning gloves

ANSWER: 1. removes gloves and walks out of the room

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure? 1. the ability of the arteries to stretch 2. the thickness of circulating blood 3. the oxygen levels in the blood 4. the volume of air entering the lungs

ANSWER: 1. the ability of the arteries to stretch

A client calls a sleep clinic helpline and describes her 46-year-old husband's sleep patterns: snoring loudly, then becoming startled and waking up 5 or 6 times a night. The wife is asking how to improve his sleep patterns. The nurse concludes: 1. the husband may be exhibiting signs of sleep apnea. 2. the wife needs interventions to promote stage 2 sleep for herself. 3. the husband should only eat a small carbohydrate snack before bed. 4. the wife should consider wearing earplugs to bed.

ANSWER: 1. the husband may be exhibiting signs of sleep apnea.

What is the best explanation from the nurse as to why a client must return to the unit in 48 hours after having a tuberculin skin test intradermal? 1. to determine the extent to which the client responded to the drugs 2. to administer timely emergency treatment 3. to implement measures to reduce the transmission of microorganisms 4. to prevent interfering with test results

ANSWER: 1. to determine the extent to which the client responded to the drugs

A nurse needs to send the blood and urine specimen of a client with acute diarrhea to the pathology laboratory. Which precaution is the priority when collecting and delivering the specimens to the laboratory? 1. use sealed containers in a plastic biohazard bag 2. use thoroughly washed gloves 3. use a particulate air filter respirator 4. use disposable cover gowns and goggles

ANSWER: 1. use sealed containers in a plastic biohazard bag

A client has been instructed to increase fluid intake but as a result has lost sleep to get up to void several times a night. What can the nurse recommend to decrease the interruption of sleep? 1. "Drink most of the liquids during the night." 2. "Drink most of the liquids before 5 p.m." 3. "Try drinking coffee instead of water." 4. "Drink the total amount of liquids before noon."

ANSWER: 2. "Drink most of the liquids before 5 p.m."

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing? 1. Take 500 mg 2. Avoid more than 250 mg 3. Consume citrus fruits 4. Drink orange and grapefruit juice

ANSWER: 2. Avoid more than 250 mg

A client with cancer is told by a healthcare provider that the cancer has metastasized to other organs and is untreatable. The client tells the nurse, "I think they made a mistake. I don't think I have cancer. I feel too good to be dying." Which stage of grief does the nurse conclude that the client is experiencing? 1. Anger 2.Denial 3. Bargaining 4. Acceptance

ANSWER: 2. Denial

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? 1. Anger 2. Denial 3. Bargaining 4. Depression

ANSWER: 2. Denial

The nurse is getting ready to perform an initial assessment interview of a Chinese older adult who does not speak English. The client has a tibial fracture and is hard of hearing. Which should be available before starting the interview in order to minimize communication problems that may lead to health disparity? 1. Wheelchair and hearing aid 2. Hearing aid and interpreter 3. Interpreter and sphygmomanometer 4. Wheelchair and sphygmomanometer

ANSWER: 2. Hearing aid and interpreter

Nurse A receives an urgent phone call and hands several medications to Nurse B stating "Please give these to my client. I will be right back." What is the rationale behind Nurse B's response not to administer the medication to the client? 1. The client's allergies are unknown to Nurse B. 2. It violates the rights of medication administration. 3. It violates the rights of the client's privacy. 4. It is not Nurse B's responsibility to administer medications for Nurse A's clients.

ANSWER: 2. It violates the rights of medication administration

A child is admitted to the hospital with a fever, headache, cough, and has had a sore throat for the past week. Three days later, a rash appears at the hairline and spreads rapidly all over the body. What disease does the child have? 1. Mumps 2. Measles 3. Rubella 4. Pertussis

ANSWER: 2. Measles

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? 1. Pulse is strong, and light pressure causes it to disappear. 2. Pulse is felt with difficulty and disappears with slight pressure. 3. Pulse is felt easily, and moderate pressure causes it to disappear. 4. Pulse is strong and remains strong despite moderate pressure.

ANSWER: 2. Pulse is felt with difficulty and disappears with slight pressure.

What is the term for the change that takes place in response to a stressor? 1. rehabilitation 2. adaptation 3. positive movement 4. negative movement

ANSWER: 2. adaptation

A client has arrived in the emergency department by ambulance and is reporting shortness of breath. After placing the client on oxygen and contacting the physician, which is the priority action of the nurse? 1. taking vital signs 2. auscultating anterior and posterior lung sounds 3. percussing the thorax bilaterally 4. transporting the client for a chest x-ray

ANSWER: 2. auscultating anterior and posterior lung sounds

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. What would would the nurse document as an abnormal finding? 1. moist perineal skin 2. reddened meatal skin 3. presence of smegma 4. absence of discharge

ANSWER: 2. reddened meatal skin

A client has been prescribed nasal medication. What care should the nurse take to avoid potential complications due to the administration of this medication? 1. read and compare labels on the medication with the medical record 2. review the client's medication, allergy, and medical history 3. administer medication within 30 to 60 minutes of the scheduled time 4. allow sufficient time to prepare the medication with minimal distraction

ANSWER: 2. review the client's medication, allergy, and medical history

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention? 1. temperature 99°F (37.2°C) 2. skin turgor response 6 seconds 3. blood pressure 120/70 mm Hg 4. heart rate 88 beats per minute

ANSWER: 2. skin turgor response 6 seconds

A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem? 1. "It would be best just to get some adult diapers." 2. "Let's explore structuring activities and toileting breaks." 3. "Let me refer you to a urologist who can help you." 4. "Don't worry, this is a normal condition for older adults."

ANSWER: 3. "Let's explore structuring activities and toileting breaks."

A client tells the nurse, "I increased my fiber, but I am very constipated." What further information does the nurse need to tell the client? 1. "Just give it a few more days and you should be fine." 2. "Well, that shouldn't happen. Let me recommend a good laxative for you." 3. "When you increase fiber in your diet, you also need to increase liquids." 4. "I will tell the doctor you are having problems. Maybe he can help."

ANSWER: 3. "When you increase fiber in your diet, you also need to increase liquids."

The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure? 1. 112 mmHg 2. 224 mmHg 3. 40 mmHg 4. 132 mmHg

ANSWER: 3. 40mmHg

The nurse is concerned that a client is not eating the meals provided on the diet tray. What would be the most effective measure to help increase food consumption? 1. Tell the client it is important to eat. 2. Change the diet to full fluids. 3. Ask the client what foods he or she enjoys. 4. Discourage the family from bringing in food.

ANSWER: 3. Ask the client what foods he or she enjoys

The following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, ten 8-oz glasses (2,500 mL) of fluids. What would the nurse tell the client to change? 1. Decrease high-fiber foods. 2. Decrease amount of fluids. 3. Nothing; this is a good diet. 4. Omit fruits if eating vegetables.

ANSWER: 3. Nothing; this is a good diet.

A geriatric client with hypertension and diabetes mellitus is taking propranolol (Inderal) and insulin (Humulin N) therapy. Which interventions by health care professionals help prevent client medication errors according to the Leapfrog Group? 1. Scheduling regular follow-up visits 2.Prescribing low dosage of medication 3. Using computer physician order entry 4.Closely monitoring the client for 24 hours

ANSWER: 3. Using computer physician order entry

A nurse notes that the volume of the client's urinary elimination is less than 300 mL/day. What could be the possible cause for the low volume of urination by the client? 1. diuretic medication 2. endocrine disease 3. kidney dysfunction 4. liver disease

ANSWER: 3. kidney dysfunction

Which of the following best describes sexuality? 1. external appearance of one's genitalia 2. internal organ structure and function 3. physical, emotional, and mental gender 4. pleasure experienced during sexual activity

ANSWER: 3. physical, emotional, and mental gender

The occupational nurse is assessing a worker's vital signs at rest. Which finding requires nursing intervention? 1. blood pressure 118/70 mmHg 2. respirations 16 per minute 3. pulse rate 120 beats per minute 4. temperature 98.6ºF

ANSWER: 3. pulse rate 120 beats per minute

A client is on a stress management program. She states that she is open to trying a guided meditation class. When helping her get started, a nurse tells her that which of the following is not important? 1. a quiet environment 2. an open attitude 3. soft music 4. a focus of attention

ANSWER: 3. soft music

What philosophy for handling stress can nurses encourage clients to adopt? 1. "One for all and all for one." 2. "Do today so that you do not have to do the same thing tomorrow." 3. "If you have too much to do, just get busy and do it." 4. "Accept what can't be changed, change what can't be accepted."

ANSWER: 4. "Accept what can't be changed, change what can't be accepted."

A nurse educates a mother about the proper administration of oral medication to her 4-year-old child. What statement made by the mother indicates effective learning? 1. "I should administer the medication with a cup or spoon." 2. "I should mix the medicine in a large amount of food." 3. "I should avoid giving a straw to my child to take pills." 4. "I should use a disposable oral syringe to prepare liquid doses."

ANSWER: 4. "I should use a disposable oral syringe to prepare liquid doses."

The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response? 1. "This is extremely abnormal. You will need to see your son's pediatrician." 2. "I would only worry about this if you were raising a daughter." 3. "It would be appropriate to place your son in incontinence undergarments." 4. "Let's review the types of fluids that your child drinks in the morning."

ANSWER: 4. "Let's review the types of fluids that your child drinks in the morning."

A client comes into the urgent care center to have sutures removed on an arm. The nurse finds significant crusting along the suture line. The client claims to have not had time to get the sutures removed a week prior, as directed. The nurse soaks the crust and attempts to remove the sutures. As the nurse attempts the suture removal, the client frequently pulls the arm away and tells the nurse, "You do not know what you are doing." In response, the nurse should answer: 1. "I am sorry this is hurting you but you are hurting my feelings." 2. "You are the cause of the problem here. I do not have to tolerate this behavior, and you are free to leave." 3. "How would you know if I know what I am doing or not?" 4. "Sir, I understand this is uncomfortable, but I assure you I am experienced with this task and would like to continue."

ANSWER: 4. "Sir, I understand this is uncomfortable, but I assure you I am experienced with this task and would like to continue."

The nurse is assessing older adult clients at a community health center. Which client is identified as being at the highest risk for developing an infection? 1. Client with immobility, incontinence, and dysphagia following a stroke 2. Client with uncontrolled diabetes and heart failure 3. Client with a history of tuberculosis 4. Client with alcohol and substance use disorders

ANSWER: 4. Client with immobility, incontinence, and dysphagia following a stroke

The nurse is administering a large-volume cleansing enema to a client who reports severe cramping upon introduction of the enema solution. What would be the nurse's next action? 1. Place the client on bedpan in the supine position while receiving enema. 2. Remove the tube and check for any fecal contents. 3. Modify the amount and length of the administration. 4. Lower solution container and check temperature and flow rate.

ANSWER: 4. Lower solution container and check temperature and flow rate.

A nurse is meeting with a young woman who has recently lost her mother, lost her job, and moved with her husband to a new city. She is reporting acute anxiety and depression. What does the nurse know about stress that would be helpful with this client's situation? 1. Adaptation often fails during stressful events and results in homeostasis. 2. Stress is a part of our lives and eventually this young woman will adapt. 3. Acute anxiety and depression are seldom associated with stress. 4. Sometimes too many stressors disrupt homeostasis, and if adaptation fails, the result is disease.

ANSWER: 4. Sometimes too many stressors disrupt homeostasis, and if adaptation fails, the result is disease.

A code is called and Nurse A hands several drugs to Nurse B, stating while rushing off, "Give these to my client while I help with the code." What is Nurse B's appropriate response? 1. Administer the medications. 2. Hold the medications for Nurse A. 3. Ask another staff nurse to give the medications. 4. State, "I cannot give medications for other nurses."

ANSWER: 4. State, "I cannot give medications for other nurses."

A client tells the nurse that she and her husband have selected periodic abstinence as their choice of contraception. Which is the best method for the nurse to recommend to monitor fertility? 1. Temperature method 2. Cervical mucus method 3. Calendar method 4. Symptothermal method

ANSWER: 4. Symptothermal method

A client with terminal cancer is taking high doses of a narcotic for pain. The nurse will teach the client or family about which common side effect of opioids? 1. inability to change positions 2. problems with communication 3. diarrhea 4. constipation

ANSWER: 4. constipation

The nurse is caring for a client with malnutrition due to protein deficiency. Which foods should be included in this client's diet? 1. green vegetables 2. citrus fruits 3. roots and tubers 4. meat and fish

ANSWER: 4. meat and fish

REFLECTION IS A FORM OF THERAPEUTIC COMMUNICATION. HOW DOES A NURSE CONDUCT REFLECTION? A. Identify the main theme of the discussion B. Self reflect on the client's emotion C. Silence D. State what only is medically necessary

ANSWER: A. Identify the main theme of the discussion

A nurse is found guilty of performing procedures outside the nursing scope of practice. Identify which element is true related to nursing practice. A. Scope of practice is defined by each state's nurse practice act B. The ANA sets requirements for licensure C. Scope of practice is defined by CNEA accredited school curriculum D. Reciprocity explains the relationship between scope of practice and state licensure.

ANSWER: A. Scope of practice is defined by each state's nurse practice act

A client reports frustration that she has been usable to sleep while in the hospital. The nurse also is aware the client does not have a reliable social support network and a poor sense of self esteem. Which of these issues would take priority according to Maslow? A. Sleep B. Fall Risk C. Social Support D. Doubt related to self care

ANSWER: A. Sleep

A client is scheduled to receive metoprolol for blood pressure at 09:00. The order reads " for SBP>90 25 mg PO daily." Prior to administering the medication the nurse re-assesses the client's vitals and finds the blood pressure is 90/50 and the heart rate is 60. This is an example of what type of nursing skill? A. The nursing process B. Critical Thinking C. The Nurse Practice Act D. Medical Stimulation

ANSWER: B. Critical Thinking

WHAT DOES DAR STANDFOR AND WHEN IS IS USED? A. Data and Response - communication B. Data, Action, Response - documentation C. Data and Rate - billing D. Decision and Response - communication

ANSWER: B. Data, Action, Response - documentation

A nurse receives a client at handoff who is experiencing acute change in neurological status. Which nursing action should be done FIRST? A. Call the provider B. Perform an in-depth neurologic assessment C. Administer antihypertensive drugs D. Move the client closer to the nursing station

ANSWER: B. Perform an in-depth neurologic assessment

What is the best method of giving report to the next oncoming shift to ensure accurate and complete information? A. DAR B. SBAR C. COPD D. CAD

ANSWER: B. SBAR

AFTER GATHERING DATA, WHAT IS THE NEXT STEP THE NURSE IMPLEMENTS IN CRITICAL THINKING? A. Goes to lunch B. Documents findings C. Interprets the data D. Shares with the provider

ANSWER: C. Interprets the data

A group of nurses are discussing a client's care in the elevator when a group of people enter the elevator. Which aspect of HIPAA is most directly in violation? A. Client education B. Client recourse if privacy protections are violated C. Minimal disclosure of protected health information D. Limit use of information to accomplish intended purpose

ANSWER: C. Minimal disclosure of protected health information

A previously health 31-year-old client with a radical mastectomy snaps at the nurse and asks to be left alone. In interpreting this, the nurse is able to attribute the behavior to which of the following? A. Empathy B. Comfortable sense of self C. Developmental stage of intimacy vs, isolation D. Vulnerability of illness

ANSWER: D. Vulnerability of illness

Use of an indwelling urinary catheter leads to the loss of bladder tone. True False

ANSWER: True