Midterm Review
A nurse is measuring the BP of several clients. which of the following results is within the expected reference range for normal BP?
120/80
A nurse is preparing to administer sotalol 320 mg/day divided equally every 12 hours. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose? (Fill in the blank with a numeric value only. Round the answer to the nearest tenth. Use a leading zero if applicable but do not use a trailing 0.
2 tablets
A nurse is reinforcing discharge teaching with a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?
A nurse will show me how to care for my wound
A nurse is assisting with an admission of a client who has tuberculosis. In addition to standard precaution which of the following transmission based precautions does she add to the plane of care?
Airborne
A nurse is planning weight loss strategies for a group of clients who are obese Which of the following actions by the nurse will improve the clients' commitment to a long -term goal of weight loss?
Attempt to increase the client's self-motivation
A nurse collecting data from a client who is undergoing a physical examination. Following inspection, which of the following techniques should the nurse use next when evaluating the clients abdomen?
Auscultation
The charge nurse is providing teaching to a newly licensed nurse about removing sutures from a clients laceration. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?
I will clip each suture close to the skin and pull it through from the other side
A nurse is collecting baseline data of a clients penpheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse?
Below the medial malleolus
A nurse is taking a clients vital signs which of the following findings is outside the expected reference range?
Blood pressure 145/90
After collecting data on a clients radial pulses, the nurse documents "radial pulses 4+ bilaterally". This finding indicates which of the following pulse qualities
Boundy
A nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which of the tollowing actions should the nurse take first?
Identify the client using 2 identifiers
A nurse is assisting with the care of a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect an injury to which of the following areas of the brain?
Cerebellum
A nurse enters a clients room and finds the client sitting on the floor leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first?
Check the client for injuries
A nurse is caring for a client that has transferred to the surgical unit by a stretcher from the PACU. Which of the following actions should the nurse perform first after the transfer?
Check the clients vital signs
A nurse is helping a client perform range of motion exercises of the neck for evaluating the next selection which of the following motions should the nurse instruct the client to perform?
Chin to chest
A nurse is assisting with an admission interview for a client which of the following items of data should the nurse collect during the introduction phase?
Clients comfort and ability to participate
A nurse is reviewing adult CPR with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when pertorming CPR?
Confirm unresponsiveness
A nurse is measuring vital signs for a client and notices a pulse irregularity. Which of the following actions should the nurse take?
Count the apical pulse rate for 1 full min and describe the rhythm in the chart
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take?
Disconnect the machine and measure the blood pressure manually every 15 minutes
A nurse is replacing the surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take?
Don clean gloves to remove the old dressing
A new provider asks the nurse for an access code to review a clients online record. The provider is not scheduled to attend the facility's computer orientation class until next week. Which of the following actions should the nurse take?
Explain that sharing access code is against policy and refer resident to supervisor
A nurse is caring for a client who has the head of the bed elevated to 45 degrees his knees are slightly flexed. Which of the following positions should the nurse document that this client is in?
Fowlers
A nurse is collecting data as part of a comprehensive physical exam the nurse should use inspection to evaluate which of the following?
Gait
A nurse is caring for a client who has a stage 2 pressure ulcer. Which of the following wound dressings should the nurse apply to the client?
Hydrocolloid dressing
A nurse is collecting data from a client. Which of the following statements by the nurse requests the communication technique of clarifying?
It sounds like your pain is intermittent
A nurse is recieving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse make to transfer the client from the stretcher to a bed?
Lock the wheels on the bed and the stretcher
A nurse is reviewing lab results of a client and notes a WBC count of 360. The nurse should indicate this result of which of the following conditions
Lucopinea
A nurse is measuring a clients vital signs the clients resting radial pulse is 55 beats per minute. Which of the following actions should the nurse take next?
Measure the clients apical pulse
A nurse Is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take?
Monitor the client at least once every hour
A nurse on a MedSurg unit is caring for a client. Which of the following actions should the nurse perform first when assessing the nursing process?
Obtaining client information
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?
Place the wheelchair at a 45 degree angle
A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to assistive personal?
Provide oral care to a client who cannot take oral fluids
A nurse is changing the dressing for a client who is 3 days postoperativefollowing a cholecystectomy. Ine nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the followina of drainage?
Purulent exudate
A nurse collecting baseline data about a clients respirations is part of comprehensive physical exam which of the following types of breath sounds should the nurse report to the provider?
Ronchi
A nurse is preparing to administer a medication to a client. Which of the following administration schedule indicates that the nurse should administer the medication once and as soon as possible?
STAT
A nurse is caring for a client who is in a terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?
Sit and hold the client's hand
A nurse is caring for a client who has a history of dysrhvthmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respiration, and is pulseless. Which of the following actions should the nurse take first?
Start chest compressions
A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions shoudl the nurse take?
Support the clients decision
A nurse is planning to vitamin the vitamin signs of a 2 year old child who is experiencing diarrhea and has a right ear infection. Which of the following rates should the nurse use to obtain the temperature?
Temporal
A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse beain assisting with discharge planning?
Upon admission to the care facility
A nurse is planning to administer pain medication to a client who has postoperative pain following abdominal surgery. Which of the following actions should the nurse take first?
Use the pain scale to determine the client's pain level
A nurse observes an N.A preparing to obtain blood pressure with a regular size cuff with a client who is obese. Which of the following explanation should the nurse give to the N.A?
Using a cuff that is too small will result in inaccurate high reading
A nurse is caring for an older client who becomes agitated when the nurse requests the clients dentures to be removed prior to surgery. Which of the following responses should the nurse offer?
What worries you about being with out your teeth?
A nurse is reinforcing teaching with a client about lifestyle changes to manage chronic illness. Which of the following strategies should the nurse use first to helo the client make a commitment to these lifestyle changes?
help the patient identify ways that these changes will result in positive personal outcomes
A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve!
second intercostal space to the right of the sternum
