NU Practice Questions

A nurse is caring for a very confused client with a diagnosis of dementia of the Alzheimer's type. Which should the nurse say when assisting the client to eat? 1. "Please eat your meat." 2. "It's important that you eat." 3. "What would you like to eat?" 4. If you don't eat, you can't have dessert."

1. "Please eat your meat."

A client is to have arthroscopic surgery of the knee to repair a torn tendon. The client says, "I don't know if I'll make it through this surgery." Which response by the nurse may block further communication by the client? Select all that apply. 1. "The type of surgery you are having is minor." 2. "Surgery often can be frightening." 3. "Everything will be all right." 4. "You are not going to die." 5. "You sound scared."

1. "The type of surgery you are having is minor." 3. "Everything will be all right." 4. "You are not going to die."

A nurse is collecting data from a client for an admission nursing history. Which question by the nurse is BEST to open the discussion? 1. "What brought you to the hospital?" 2. "Would it help to discuss your feelings?" 3. "Do you want to talk about your concerns?" 4. "Would you like to talk about why you are here?"

1. "What brought you to the hospital?"

A client is admitted to the hospital with cirrhosis of liver caused by long-term alcohol misuse. Which is the BEST response by the nurse when the client says, "I really don't believe that my drinking a couple of beers a day has anything to do with my liver problem?" 1. "You find it hard to believe that beer can hurt the liver." 2. "How long is it that you have been drinking several beers a day?" 3. Each beer is equivalent to one shot of liquor, so it's just as damaging to the liver as hard liquor." 4. "Do you believe that beer is not harmful even though research shows that it is just as bad for you as hard liquor?"

1. "You find it hard to believe that beer can hurt the liver."

The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? 1. 30 to 60 2. 22 to 28 3. 16 to 20 4. 10 to 15

1. 30 to 60

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? 1. Assess the apical for a full minute 2. Asses the apical pulse with a Doppler device 3. Asses the pedal pulses for a full minute 4. Assses the pedal pulses with a Doppler device

1. Assess the apical for a full minute

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure? 1. Blood Pressure 2. Respiratory Rate 3. Pulse Rate 4. Temperature

1. Blood Pressure

A nurse is admitting a client to the unit who was transferred from the emergency department. Which should the nurse do to facilitate communication? 1. Ensure that the client has an effective way to communicate with health-care team members 2. Use interviewing techniques to control the direction of the client's communcation 3. Minimize energy spent by the client on negative feelings and concerns 4. Refocus to the positive aspects of the client's situation and prognosis

1. Ensure that the client has an effective way to communicate with health-care team members

A nurse uses reflective technique when communicating with an anxious client. On which does the nurse focus when using reflective technique in this situation? 1. Feelings 2. Content themes 3. Clarification of information 4. Summarization of the topics discussed

1. Feelings

Which interviewing skill is used when the nurse says, "You mentioned before you are having a problem with your colostomy?" 1. Focused 2. Clarifying 3. Paraphrasing 4. Acknowledging

1. Focused

Which should a nurse never do when documenting information on a client's electronic medical record? Select all that apply. 1. Leave the client's medical record open on the computer screen when entering the client's room to administer a medication 2. Share information verbally about a client with another nurse who is also caring for the patient 3. Document nursing care administered to a client immediately after it is completed 4. Give a personal access code to another member of the health-care team 5. Document exact quotes of a client's subjective information

1. Leave the client's medical record open on the computer screen when entering the client's room to administer a medication 4. Give a personal access code to another member of the health-care team

A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply): 1. Place the client in a semi-fowlers position. Facilitates full ventilation and allows for a clear view of chest and abdominal movement 2. Have the client rest an arm across the abdomen. Its easier for the students to see respiratory movements 3. Observing for one full minute cycle before starting to count assists the students in obtaining an accurate rate 4. Count the rate for 30 sec if it is irregular 5. Count and report any signs the client demonstrates

1. Place the client in a semi-fowlers position. Facilitates full ventilation and allows for a clear view of chest and abdominal movement 2. Have the client rest an arm across the abdomen. Its easier for the students to see respiratory movements 3. Observing for one full minute cycle before starting to count assists the students in obtaining an accurate rate

A client is admitted to the hospital with a tentative medical diagnosis, and multiple diagnostic tests are performed. Where in the client's medical record can the nurse find documentation about the current medical diagnosis after the diagnostic test results are reviewed by the primary heath-care provider? 1. Progress Notes 2. Admission Sheet 3. History and Physical 4. Social Service Record

1. Progress Notes

The nurse is admitting a stable client for a minor outpatient procedure. What site would the most commonly use to assess the pulse rate? 1. Radial 2. Apical 3. Carotid 4. Brachial

1. Radial

A risk manager is conducting a retrospective audit of a client's clinical record to identify the use of unacceptable abbreviations. Which abbreviation did the risk manager identify that is on The Joint Commission's official Do Not Use List? 1. U 2. ml 3. mg 4. MS 5. QOD 6. 0800 hour

1. U 4. MS 5. QOD

Which ability of the nurse is important to achieve effective therapeutic communication? Select all that apply. 1. Using interviewing skills 2. Remaining nonjudgmental 3. Sending only verbal messages 4. Being assertive when collecting data 5. Displaying sympathy when communicating

1. Using interviewing skills 2. Remaining nonjudgmental

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take? 1. Wait 30 min and return to measure the oral temperature 2. Provide the client a sip of warm water, wait 5 min, and measure the temperature 3. Document that the nurse was unable to measure the client's temperature 4. Proceed to measure the oral temperature

1. Wait 30 min and return to measure the oral temperature

An agitated 80 year old patient states, "I'm having trouble with my bowels." Which response by the nurse incorporates the interviewing skill of paraphrasing? Select all that apply. 1. "Tell me what you mean by having trouble." 2. " It sounds like your bowels are causing you problems." 3. "You sound upset that your bowels are causing difficulties." 4. "It's common to have problems with the bowels at your age." 5. "When did you first notice having trouble with your bowels?"

2. " It sounds like your bowels are causing you problems."

A client with a newly created colostomy wants to learn how to irrigate the colostomy. The nurse provides this teaching by developing a therapeutic nurse-client relationship and implementing teaching strategies. Identify the statement that is included in the working stage of this therapeutic relationship. Select all that apply. 1. "How do you feel about doing this procedure?" 2. "Would you like to try to insert the cone yourself today?" 3. "You did a great job managing the installation of fluid today." 4. "I am here to help you learn how to irrigate your colostomy." 5. "I'll arrange for a home-care nurse to visit you in your home when you are discharged."

2. "Would you like to try to insert the cone yourself today?" 3. "You did a great job managing the installation of fluid today."

The nurse is taking the blood prssure on multiple clients. Which reading warrants the nurse to contact the doctor? 1. 94/60 2. 98/36 3. 110/50 4. 140/78

2. 98/36

A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94. The client denies any history of hypertension. Which of the following actions should the nurse take first? 1. Request a prescription for an antihypertensive medication 2. Ask the client if she is having pain. The first action the nurse takes using the nursing process is to assess for pain which can cause multiple complications, including elevated blood pressure. Therefore the nurse's first priority is to assess for pain. If the patient's blood pressure is still elevated after a pain assessment the nurse will notify the provider. 3. Request a prescription for an antianxiety medication 4. Return in 30 min to recheck the client's blood pressure

2. Ask the client if she is having pain. The first action the nurse takes using the nursing process is to assess for pain which can cause multiple complications, including elevated blood pressure. Therefore the nurse's first priority is to assess for pain. If the patient's blood pressure is still elevated after a pain assessment the nurse will notify the provider.

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time 1. Brachial 2. Carotid 3. Femoral 4. Popliteal

2. Carotid

A nurse plans to foster a therapeutic relationship with a client. Which is important for the nurse to do? 1. Sympathize with the client when the client communicates sad feelings 2. Demonstrate respect when discussing emotionally charged subjects 3. Use humor to defuse emotionally charged topics of discussion 4. Work on establishing a friendship with the client

2. Demonstrate respect when discussing emotionally charged subjects

Which is the nurse doing when using the interviewing technique of attentive listening? 1. Identifying the patient's concerns and exploring them with why questions 2. Determining the content and feeling of the patient's message 3. Employing silence to encourage the patient to talk 4. Using nonverbal skills to display interest

2. Determining the content and feeling of the patient's message

The nurse understands that which statement is correct regarding respiratory rates? 1. Infants have a lower respiratory rate than adults 2. Healthy adults breathe between 12 and 20 times a minute 3. A compensatory response to a fever is to breath at a slower rate 4. An increase in intracranial pressure results in an increased rate

2. Healthy adults breathe between 12 and 20 times a minute

A nurse is developing a therapeutic relationship with a client with emotional needs. Which nursing intervention is ESSENTIAL during the working stage of the relationship? 1. Establish a formal or informal contract that addresses the client's problems. 2. Implement nursing actions that are designed to achieve expected client outcomes 3. Develop rapport and trust so the client feels protected and an initial plan can be identified 4. Clearly identify the role of the nurse and establish the parameters of the professional relationship

2. Implement nursing actions that are designed to achieve expected client outcomes

Which statement describes the following proverb? What you do speaks so loudly I cannot hear what you say. 1. Hearing ability is an important factor in communicating 2. Nonverbal messages are often more meaningful than words 3. Listening to what people say requires attention to what is being said 4. When people talk too loudly, it is hard to understand what is being said

2. Nonverbal messages are often more meaningful than words

Which stage of an interview establishes the relationship between the nurse and the patient? 1. Preinteraction stage 2. Orientation stage 3. Examining stage 4. Working stage

2. Orientation stage

A client appears tearful and is quiet and withdrawn. The nurse says, "You seem very sad today." Which interviewing approach did the nurse use? 1. Examining 2. Reflecting 3. Clarifying 4. Orienting

2. Reflecting

A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition? 1. Stethoscope 2. Thermometer 3. Blood pressure cuff 4. Sphygmomanoter

2. Thermometer

A client who has had postoperative complications appears upset and agitated yet withdrawn. Which is the MOST appropriate statement by the nurse? 1. "You seem distressed. Tell me why you are upset." 2. You've been having a pretty rough time recovering since surgery." 3. "It's not uncommon to have a complications after the kind of surgery that you had." 4. "I'm not sure that I know everything that has been happening. Tell me what has happened to you since surgery."

2. You've been having a pretty rough time recovering since surgery."

A young adult who had a leg amputated because of trauma says, "No one will ever choose to love a person with one leg." Which is the BEST response by the nurse? 1. " You are a good-looking person, and you will have no trouble meeting someone who cares." 2. "You may feel that way now, but you will feel differently as time passes." 3. "Do you feel that no one will marry you because you have one leg?" 4. "How do you see your situation at this point?"

3. "Do you feel that no one will marry you because you have one leg?"

The clients blood pressure is being taken at a screening clinic. Which statement to the nurse demonstrates awareness of having a risk factor for hypertension? 1. "My doctor told me my weight is good and my blood pressure is 118/70" 2. "I usually have a glass of wine to unwind when I get home from work" 3. "I plan to get my blood pressure checked more often , as I am African American 4. "I have colds during the winter, so I plan to get the influenza vaccine each year."

3. "I plan to get my blood pressure checked more often, as I am African American

A client with chest pain is being admitted to the emergency department. When asked about next of kin, the client states, "Don't bother calling my daughter; she is always too busy." Which is the BEST response by the nurse? 1. "Your daughter might be upset if you don't call." 2. "What does your daughter do that makes her so busy?" 3. "Is there someone else besides your daughter that I can call?" 4. "I think that your daughter would want to know that you are sick."

3. "Is there someone else besides your daughter that I can call?"

A client states, "I am surprised that I couldn't even eat half my breakfast." Which statement by the nurse uses the interviewing skill of reflection? Select all that apply. 1. "Let's talk about your inability to eat." 2. What part of your breakfast were you able to eat?" 3. "You appear startled that you did not finish your tray of food." 4. "How long have you been unable to eat most of your breakfast?" 5. "You seem surprised that you were unable to eat all your breakfast."

3. "You appear startled that you did not finish your tray of food." 5. "You seem surprised that you were unable to eat all your breakfast."

A nurse is using military time when entering information into a client's clinical record. For example, the clock below indicates that the time is 0708 a.m. Which number in the military time should the nurse enter to document a wound irrigation that was implemented at 9 p.m.? 1. 0900 2. 1900 3. 2100 4. 2300

3. 2100

A nurse is caring for a group of patients. Which patient will the nurse see first? 1. A crying infant with P-165 and R-54 2. A sleeping toddler with P-88 and R-23 3. A calm adolescent with P-95 and R-26 4. An exercising adult with P-108 and R-24

3. A calm adolescent with P-95 and R-26

The nurse can best determine adequate arterial oxygen of the blood by assessing: 1. Heart Rate 2. Hemoglobin level 3. Arterial oxygen level 4. Arterial carbon dioxide level

3. Arterial oxygen level

The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? 1. Ulnar site 2. Radial site 3. Brachial site 4. Femoral site

3. Brachial site

A nurse must conduct a focused interview to complete an admission history. Which interviewing technique should the nurse use? 1. Probing 2. Clarification 3. Direct Questions 4. Paraphrasing Statements

3. Direct Questions

Which is being communicated when the nurse leans forward during a patient interview? 1. Aggression 2. Anxiety 3. Interest 4. Privacy

3. Interest

A nurse is changing a client's dressing over an abdominal wound. Which level of space around the client's is entered during the dressing change? 1. Public 2. Social 3. Intimate 4. Personal

3. Intimate

A client says, "I am really nervous about having a spinal tap tomorrow." Which is the BEST response by the nurse? 1. "I'll ask the doctor for a little medication to help you relax." 2. "Clients who have had a spinal tap say it is not that uncomfortable." 3. It's all right to be nervous, and I don't remember anyone who wasn't." 4. "Your physician is excellent and is very careful when spinal taps are done."

3. It's all right to be nervous, and I don't remember anyone who wasn't."

Which is the purpose of the use of humor by a nurse when interacting with a client? 1. Diminish feelings of anger 2. Refocus the client's attention 3. Maintain a balanced perspective 4. Delay dealing with the inevitable

3. Maintain a balanced perspective

A patient has a head injury and damages the hypothalmus. Which vital sign will the nurse monitor most closely? 1. Pulse 2. Respirations 3. Temperature 4. Blood Pressure

3. Temperature

A nurse is attempting to develop a helping relationship with a client who was recently diagnosed with cancer. Which factor is unique to this helping relationship? Select all that apply. 1. The client should always assume the dominant role 2. The nurse and the client equally share information 3. The interaction is specific to the client 4. The interaction is guided by a purpose 5. The needs of both participants are met

3. The interaction is specific to the client 4. The interaction is guided by a purpose

It is 6am and the UAP reports to the nurse that the patient has a temp of 96.7 tympanic which factor would explain this reading? 1. The patient's room is cold 2. The patient was drinking cold water 3. The patient is exhibiting a normal circadian rhythm 4. The patient just completed a warm shower

3. The patient is exhibiting a normal circadian rhythm

A client is extremely upset and mentions something about a work-related issue that the nurse cannot understand. Which is the nurse's BEST response? 1. "It's natural to worry about your job." 2. "Your job must by very important to you." 3. "Calm down so that I can understand what you are saying." 4. "I'm not quite sure I heard what you were saying about your work."

4. "I'm not quite sure I heard what you were saying about your work."

A mother whose young daughter has died of leukemia is crying and is unable to talk about her feelings. Which is the best response by the nurse? 1. "Everyone will remember her because she was so cute. She was one of our favorites." 2. "As hard as this is, it is probably for the best because she was in a lot of pain." 3. "She put up the good fight but now she is out of pain and in heaven." 4. "It must be hard to deal with such a precious loss."

4. "It must be hard to deal with such a precious loss."

A client is exhibiting anxious behavior and states, "I just found out that I have cancer everywhere, and I don't have very long to live. My life is over." Which is the BEST response by the nurse? 1. "It might be good if your family were here right now. Shall I call them?" 2. What might be the best way to approach this terrible new?" 3. "That is so sad. You must feel like crying." 4. "It sounds like you feel hopeless."

4. "It sounds like you feel hopeless."

A client states, "My wife is going to be very upset that my prostate surgery probably is going to leave me impotent." Which is the BEST response by the nurse? 1. "I'm sure your wife will be willing to make this sacrifice in exchange for your well-being." 2. "The surgeons are getting great results with nerve-sparing surgery today." 3. "Your wife may not put as much emphasis on sex as you think." 4. "Let's talk about how you feel about this surgery."

4. "Let's talk about how you feel about this surgery."

The unlicensed assistive personnel reports vital signs for a patient to the nurse. Temp 99.2F oral, Pulse 88 and regular, Resp 18 regular, Blood Pressure 178/112 , O2 saturation of 96%, and 3/10 headache what should the nurse be most concerned about? 1. Temperature 2. Pulse 3. Respirations 4. Blood Pressure

4. Blood Pressure

Which statement about communication should the nurse consider to be accurate? 1. Verbal communication is essential for human relationships 2. Hands are the most expressive part of the body 3. Behavior clearly reflects feelings 4. Communication is inevitable

4. Communication is inevitable

A nurse is caring for a client who is blind in the left eye and visually impaired in the right eye. Which actions should the nurse employ to promote communication with this client? 1. Touch the client's left arm before initiating a conservation 2. Ensure that the door to the client's room is on the client's left side 3. Close the window curtains and dim the lights before speaking with the client 4. Knock on the door and request permission to enter before approaching the client

4. Knocking on the door and request permission to enter before approaching the client

A client states, "Do you think I could have cancer?" The nurse responds, "What did the doctor tell you?" Which interviewing approach did the nurse use? 1. Paraphrasing 2. Confrontation 3. Reflective Technique 4. Open-ended Question

4. Open-ended Question

A client states, "I think that I am dying." The nurse responds, "You believe that you are dying?" Which interviewing approach did the nurse use? 1. Focusing 2. Reflecting 3. Validating 4. Paraphrasing

4. Paraphrasing

The nurse is performing an initial assessment of a patient with a severe infection at hospital admission. Vital signs for the patient indicate hypotension and tachycardia. Which data pair would support this evaluation? 1. Pulse 88, BP 140/88 2. Pulse 96, BP 120/76 3. Pulse 100, BP 118/80 4. Pulse 114, BP 98/60

4. Pulse 114, BP 98/60

The client is admitted with chest pain, which should be the nurse's priority assessment? 1. Pain 2. Blood Pressure 3. Heart Rate 4. Respiratory Rate

4. Respiratory Rate

The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next? 1. Ask the NAP retake the blood pressure 2. Instruct the NAP to assess the patient's other vital signs 3. Disregard the report and have it rechecked at the next scheduled time 4. Retake the blood pressure personally and assess the patient's condition

4. Retake the blood pressure personally and assess the patient's condition

Which nursing action should the nurse implement when speaking with an older adult whose hearing is impaired? Select all that apply. 1. Limit background noise 2. Enunciate words without exaggeration 3. Use gestures to augment exaggeration 4. Stand directly in front of the client when speaking 5. Talk in a normal rate and volume when speaking with the client

ALL 1. Limit background noise 2. Enunciate words without exaggeration 3. Use gestures to augment exaggeration 4. Stand directly in front of the client when speaking 5. Talk in a normal rate and volume when speaking with the client

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure (BP)? A.Smoking increases BP for up to 3 hours B. Caffeine increases BP for up to 15 minutes C. Smoking result in vasoconstriction, falsely elevating BP D. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement

C. Smoking result in vasoconstriction, falsely elevating BP

A nurse in a subacute unit in a skilled nursing facility is caring for a client who recently had the surgical creation of a colostomy. Place the following nursing actions in the order that reflects the nurse-client therapeutic relationship, beginning with the first stage and progressing to the last stage. 1. Provide positive feedback to the client for successful performance of a colostomy irrigation 2. Assist the client to learn how to perform colostomy self-care 3. Review all the information on the client's clinical record 4. Explore the reasons for the nurse-client interaction 5. Summarize the goals and objectives achieved 6. Introduce self to the client

First to Last: 3. Review all the information on the client's clinical record 6. Introduce self to the client 4. Explore the reasons for the nurse-client interaction 2. Assist the client to learn how to perform colostomy self-care 1. Provide positive feedback to the client for successful performance of a colostomy irrigation 5. Summarize the goals and objectives achieved

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse.

Left Side of the Sternum to the Fifth Intercostal Space, Midclavicular Line