NUR 101 Exam 3 Practice Questions
A college student living in the dormitory comes to the school health clinic stating, "I think I have ringworm (tinea pedis) on the bottom of my foot." What education should the nurse reinforce after treatment to prevent reoccurrence? Select all that apply. A. Be sure to wear shower shoes when using a public shower. B. Change socks at least once a day. C. Wear shoes that prevent air from circulating around the feet. D. Keep skin clean and dry. E. Do not cut toenails short.
A. Be sure to wear shower shoes when using a public shower. B. Change socks at least once a day. D. Keep skin clean and dry.
When caring for a client with a traumatic brain injury with a Glasgow Coma Scale score of 10, what nursing interventions are important to implement? Select all that apply. A. Maintain a patent airway B. Address all the clients self-care deficits C. Maintain a stimulating environment for the client D. Report any changes in the Glasgow Coma Scale score immediately E. Call the client's family every 20-30 min with updates on the client's condition.
A. Maintain a patent airway B. Address all the clients self-care deficits D. Report any changes in the Glasgow Coma Scale score immediately
The nurse is preparing to apply a moist dressing to a sacral pressure injury. Which is a priority action by the nurse? A. Medicate with analgesics a half hour prior to the procedure. B. Have the client sign a consent form to perform the procedure. C. Document the procedure so that it will not be forgotten. D. Remove the necrotic tissue with forceps.
A. Medicate with analgesics a half hour prior to the procedure.
The nurse is documenting in the nurses' notes and realizes the entry is incorrect. Which is the appropriate action by the nurse? A. Use "white-out" to block out the entry. B. Draw one line through the entry, enclose it in parentheses, and document the error in charting. C. Draw a large X throughout the entire entry. D. Take out the paper the entry was written on and rewrite it.
B. Draw one line through the entry, enclose it in parentheses, and document the error in charting.
The nurse is preparing literature for a community health fair. What age population does she correctly identify as most at risk for impetigo? A. School age children B. Adolescents C. Equal in all populations D. Daycare/Preschool age
D. Daycare/Preschool age
A client is being prepared for surgery and states, "I am so scared and nervous." Which action by the nurse will help alleviate the anxiety felt by the client? A. Allow the client to express feelings. B. Inform the client there is no time to have second thoughts. C. Tell the client that there is nothing to worry about. D. Inform the client that if unable to calm down, the surgery will be canceled.
A. Allow the client to express feelings.
Client arrives at the ER in what seems to be a hypoxic state. Upon assessment, the client is confused, restless, severely short of breath, agitated, and skin is pale and dusky. Which order should be implemented first? A. Apply supplemental oxygen. B. Place the client on telemetry. C. Complete the admission history. D. Place a peripheral IV.
A. Apply supplemental oxygen.
The nurse knows that her teaching about ringworm has been effective when the client responds with which statement? A. "Ringworm is spread by direct or indirect contact." B. "Ringworm quickly dies on inanimate objects." C. "Ringworm is spread by direct contact only." D."Ringworm dies after the first application of antifungals."
A. "Ringworm is spread by direct or indirect contact."
The nurse is observing a new graduate documenting care for a client. Which documentation error by the graduate requires the nurse to intervene? A. A nurse is documenting on the nurse's notes with a green pen. B. A nurse uses the approved facility abbreviation, "NPO." C. A nurse indicates the time and date of documentation entry. D. The note is signed using the nurse's first and last name and title.
A. A nurse is documenting on the nurse's notes with a green pen.
A nurse is providing care to a patient with a partial rebreather mask. With a partial rebreather mask, the nurse must implement which of these interventions? A. Adjust the oxygen flow rate to keep the bag ⅔ full. B. Deflate the reservoir bag before applying on the patient C. Apply a humidifier to the mask to increase humidity to the patient. D. Place water-based lubricant in the patient's nares to prevent drying.
A. Adjust the oxygen flow rate to keep the bag ⅔ full.
The nurse requests that a postoperative client dorsiflex the foot. While performing this task, the client reports having pain in the calf. Which potential complication of the immobility related to surgery does the nurse suspect has occurred? A. Deep vein thrombosis B. Fractured leg C. Muscle atrophy D. Dislocated hip
A. Deep vein thrombosis
An elderly, long- term care client suddenly becomes confused, not knowing where they are and asking for their mother (who has been dead for 40-years). Cranial nerve VII intact, PERRLA present, speech is clear, and grips are equal at 4+. Which condition does the registered nurse suspect? A. Delirium B. Stroke C. Dementia D. Bell's palsy
A. Delirium
The pathophysiology behind the structural changes within the brain of a client with Alzheimer's disease includes: A. Deposition of amyloid plaques and neurofibrillary tangles B. Atrophy of the basal ganglia C. Demyelination of the central and peripheral nervous system D. Sulci that becomes filled with fluid giving the brain a flattened appearance.
A. Deposition of amyloid plaques and neurofibrillary tangles.
The Glasgow Coma Scale (GSC) assesses clients according to three aspects of consciousness. What are those three aspects of consciousness? Select all that apply. A. Eye-opening response B. Verbal response C. Motor response D. Sensory response E. Sensorium response
A. Eye-opening response B. Verbal response C. Motor response
A 5-year-old child is brought to the emergency room with severe atopic dermatitis on the face, back, and extremities. The child's parents are very upset and ask the nurse what keeps causing the child's flare-ups of this. What is the best response by the nurse? Select all that apply. A. Hot and cold temperatures. B. Aquaphor healing ointment. C. Certain laundry detergents. D. Pet fur from house animals. E. Bubble bath soaps and shampoos.
A. Hot and cold temperatures. C. Certain laundry detergents. D. Pet fur from house animals. E. Bubble bath soaps and shampoos.
When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? A. Ineffective airway clearance related to edema of the respiratory passages B. Impaired physical mobility related to the disease process C. Impaired skin integrity related to disease process D. Risk for infection related to breaks in the skin
A. Ineffective airway clearance related to edema of the respiratory passages
A nurse is caring for a child with eczema. What are appropriate measures to take? Select all that apply A. Keep the child's fingernails cut short B. Put extra covers on the child to preserve warmth C. Try to identify what is in contact with the child's skin to cause the reaction and eliminate it D. Try to identify any dietary triggers for the reaction E. Keep the child's skin moist
A. Keep the child's fingernails cut short D. Try to identify any dietary triggers for the reaction E. Keep the child's skin moist
The nurse prepares which teaching points for a client with eczema? Select all that apply. A. Nails should be trimmed and filed B. Soaking in hot, long baths will help C. Moisturize the skin prior to bathing D. Rub the skin dry to maintain moisture E. Short, tepid baths are best F. Moisturize following a bath
A. Nails should be trimmed and filed E. Short, tepid baths are best F. Moisturize following a bath
A nurse is asked by a young client how to keep her skin young looking for longer. What can the nurse recommend? Select all that apply. A. Protect skin from the sun B. Use the most expensive moisturizer they can afford C. Avoid smoking D. Take several showers a day E. Eat a balanced diet and drink plenty of fluids
A. Protect skin from the sun C. Avoid smoking E. Eat a balanced diet and drink plenty of fluids
The nurse received a report from the emergency department (ED) that the admission arriving on his unit was having multiple grand mal seizures in the ED. Which of these actions should the nurse perform to prepare the client's room for seizure precautions before arrival to the unit? Select all that apply. A. Provide a visble airway at the bedside. B. Place a padded tongue blade at the bedside C. Place the bed in the highest position. D. Place Oxygen in the client's room. E. Place suction equipment in the client's room.
A. Provide a visble airway at the bedside. D. Place Oxygen in the client's room. E. Place suction equipment in the client's room.
A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. A. Reposition the client every 2 hours. B. Perform range-of-motion exercises. C. Use commercial soaps to keep the skin dry. D. Tuck bed covers tightly in the foot of the bed. E. Encourage the client to eat a well-balanced diet.
A. Reposition the client every 2 hours. B. Perform range-of-motion exercises. E. Encourage the client to eat a well-balanced diet.
A client is prescribed hydroxyzine HCl (Atarax) for the treatment of pruritus. Which information should the nurse provide to the client? Select all that apply. A. The medication may cause drowsiness. B. Drink water, juice, and other fluids. C. Use sunscreen when exposed to the sun. D. Administer medication on an empty stomach. E. Discontinue medications 1 week before skin testing.
A. The medication may cause drowsiness. B. Drink water, juice, and other fluids. C. Use sunscreen when exposed to the sun.
The nurse is gathering data from a client with a loss of melanin production from age-related changes. What observation made by the nurse correlates with this change? A. White hair B. Freckles on the nose and cheeks C. Ridges on the skin surface D. Thickened areas on the palms and heels
A. White hair
The pediatric client cries when he hears the word ringworm and exclaims, "I don't want a worm in me." The nurse correctly educates the client with which response? A. "Don't worry. You will get better soon." B. "It's actually named ringworm but it is caused by a fungus." C. " Don't worry. It won't hurt you. It just may itch. D. "This cream will help it get better soon."
B. "It's actually named ringworm but it is caused by a fungus."
A client arrives at the clinic and the nurse is performing an assessment. The client has silver plaques with reddening skin with rough raised flat tops on the scalp, creases of elbows, knees, and buttocks greater than 1 cm in diameter. The client asks the nurse, "Do I have some kind of fungus growing on my skin? It itches a lot and I am embarrassed to go anywhere." What is the nurse's best response? A. "You have an autoimmune disease called lupus, where the immune system attacks itself." B. "You have an autoimmune disease called psoriasis, where the immune system attacks the skin." C. "You have an autoimmune lifelong disease where the skin plus connective tissue hardening and contraction causing thickness and finger swelling called scleroderma." D. "You have an autoimmune disease called celiac disease where the small intestines are damaged."
B. "You have an autoimmune disease called psoriasis, where the immune system attacks the skin."
A client with a sacral pressure ulcer is limited to 2 hours of sitting in a chair twice per day. She is scheduled for physical therapy three times per day and dressing changes twice per day. How can a nurse best coordinate this client's care? A. Ask the physician if physical therapy can be changed to twice a day, so the client will only need to get out of bed twice a day. B. Coordinate physical therapy with getting the client out of bed for breakfast and dinner; then request bedside physical therapy for the third session. C. Request bedside physical therapy for all three session, so the client can get out of bed when she wants. D. Ask the physician to discontinue physical therapy until the client has no activity limitations.
B. Coordinate physical therapy with getting the client out of bed for breakfast and dinner; then request bedside physical therapy for the third session.
The nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first? A. Explain to the client what is happening and provide support. B. Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. C. Push the protruding organs back into the abdominal cavity. D. Ask the client to drink as much fluid as possible.
B. Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.
The nurse observes facial wrinkling on a 35-year-old client. What questions should the nurse ask pertaining to this finding? Select all that apply. A. What type of moisturizer do you use? B. Do you smoke? C. Do you spend a lot of time outdoors? D. Did either of your parents wrinkle in early aging E. Do you drink alcohol?
B. Do you smoke? C. Do you spend a lot of time outdoors? D. Did either of your parents wrinkle in early aging
The nurse is providing post-mortem care to a client diagnosed with and treated for tuberculosis. Which action by the nurse is most appropriate? A. Don a gown, mask, eye protection and gloves before entering the room. B. Don a gown, respirator, eye protection, and gloves before entering the room. C. . Wait 60 minutes until the room has been decontaminated. D. . Wait 45 minutes until the room has been decontaminated.
B. Don a gown, respirator, eye protection, and gloves before entering the room.
An 81-year-old client recently diagnosed with Alzheimer's disease has become forgetful and has been experiencing short-term memory loss. Which of the following effects of Alzheimer's is an indication of the next stage of the disease? A. No impairment B. Long-term memory loss C. Uncontrolled bowels D. Lack of awareness of surroundings
B. Long-term memory loss
A nurse notes that a client has developed urticaria, pruritus and angioedema after taking a new medication. What is a priority consideration for the nurse in this case? A. Encourage the client to drink plenty of fluid B. Maintain the patient's airway C. Give a topical antihistamine for the itching and hives D. Administer prescribed anti-anxiety medication for the itching
B. Maintain the patient's airway
The nurse is preparing to bathe a client. The client states, "I feel embarrassed that I can't do this myself." Which action by the nurse can assist with maintaining the client's dignity? A. Avoid bathing the client until a family member comes in to do it. B. Provide as much privacy as possible during the bath. C. Administer sedation prior to giving the client a bath. D. Inform the charge nurse the client refuses the bath.
B. Provide as much privacy as possible during the bath.
A client presents at the health care provider's office with gray-brown burrows, epidermal curved ridges, and follicular papules of the skin. The primary care provider diagnoses scabies. Which teaching points should a nurse review with the client? Select all that apply. A. The disease is only actively contagious when the lesions are open. B. Scabies is transmitted by close person-to-person contact or contact with infected linens and clothing. C. The most commonly infected areas are the hands, feet, and neck. D. Severe itching of the affected areas, especially at night, is a common finding. E. Only the infected individual needs to use the prescribed medication. F. All of the client's linens and clothing should be washed immediately in hot water.
B. Scabies is transmitted by close person-to-person contact or contact with infected linens and clothing. D. Severe itching of the affected areas, especially at night, is a common finding. F. All of the client's linens and clothing should be washed immediately in hot water.
Which of the following characteristics in a pigmented lesion would increase the suspicion that it might be malignant? Select all that apply. A. Both sides of the lesion appear the same B. The borders are irregular and notched C. The lesion has some areas with very dark color, but other areas are lighter D. The lesion is size of a dime. E. It has remained the same for months
B. The borders are irregular and notched C. The lesion has some areas with very dark color, but other areas are lighter D. The lesion is size of a dime.
A client has itching, red areas on his scalp. What would glowing white areas on the scalp seen under a Wood's lamp indicate? A. The client has head lice B. The client probably has a fungal infection of the scalp C. The client probably has a bacterial infection of the scalp D. The client is having an allergic reaction
B. The client probably has a fungal infection of the scalp
A long-term elderly resident is experiencing some confusion. The nurse suspects delirium instead of dementia by which of these observations? A. The client cannot remember her children's name and her vital signs are normal B. The confusion has come on abruptly and the client has decreased urinary output C. The client gets upset when she does not know the answer to a question D. Client having difficulty buttoning her blouse and brushing her hair
B. The confusion has come on abruptly and the client has decreased urinary output
The nurse is documenting the care provided to a client. Which statements would the nurse need to consider when documenting? Select all that apply. A. The nurse should only document if there is a change in the client's condition. B. The nurse should document the information clearly and legibly. C. The nurse should only document accurate information and not assumptions. D. The nurse should document frequently. E. The nurse should use a black pen if manual entry is required.
B. The nurse should document the information clearly and legibly. C. The nurse should only document accurate information and not assumptions. D. The nurse should document frequently. E. The nurse should use a black pen if manual entry is required.
An older client in for an annual check-up is concerned because their skin has some brown spots, and some areas that have lost their usual color. What teaching can the nurse provide the client? A. These are "liver spots" and mean the client should have his liver checked. B. These changes in pigmentation are a normal part of aging C. These are freckles caused by sun exposure D. The client needs to use a lightening cream
B. These changes in pigmentation are a normal part of aging
An 18-year-old client comes to the clinic complaining of an itchy, scaly, circular raised rash with a clear center on his lower abdomen. Which will likely be his diagnosis? A. Tinea capitis B. Tinea corporis C. Tinea pedis D. Tinea versicolor
B. Tinea corporis
The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it is meant to protect? A. air-fluidized bed B. ring or donut C. gel flotation pad D. water bed
B. ring or donut
The nurse is preparing to perform wound care for a client. What action should the nurse prioritize before changing the dressing? A. put on gloves B. wash hands thoroughly C. slowly remove the soiled dressing D. observe the dressing for the amount, type, and odor of drainage
B. wash hands thoroughly
When collecting data on a client who has just been admitted to the medical-surgical unit, the nurse discovers scabies. To prevent scabies infection in other clients, the nurse should: A. remove any observable mites. B. wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious. C. apply a topical corticosteroid to the lesions. D. place the client on enteric precautions.
B. wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious.
The nurse is caring for a client with tinea pedis. Which interventions should be included in discharge teaching? Select all that apply. A. Wear nylon socks. B.Soak toes in Burow's solution. C.Keep toes and feet clean and dry. D. Apply moisturizers to feet daily after bathing. E. Continue to apply antifungals after symptoms have subsided.
B.Soak toes in Burow's solution. C.Keep toes and feet clean and dry. E. Continue to apply antifungals after symptoms have subsided.
Which client presentation indicates a risk factor for the development of cellulitis? Select all that apply. A. A 48 year old female with a history of rheumatic fever B. A 39 year old female with a history of human immunodeficiency virus C. A 72 year old male with a history of lymphedema D. A 56 year old male with a history of venous insufficiency E. A 68 year old female with a history of diabetes mellitus Type II
C. A 72 year old male with a history of lymphedema D. A 56 year old male with a history of venous insufficiency E. A 68 year old female with a history of diabetes mellitus Type II
Which condition is identified as a cause of the development of delirium? Select all that apply. A. Increased stress B. Depression C. Infection D. Opioid use E. Hypoxia
C. Infection D. Opioid use E. Hypoxia
An older adult client is admitted to the hospital with intact skin. Prior to discharge, the nurse observes a decubitus ulcer on the sacrum but no documentation describes its presence or preventative measures taken. Which outcome does the nurse anticipate? A. The client will be discharged home with instructions for the family to dress the wound. B. The nurses that have been assigned to care for the client will be terminated. C. Payment for care may be denied by third-party payers. D. There is no penalty since skin impairment occurs in all older adults.
C. Payment for care may be denied by third-party payers.
When taking isotretinoin for acne vulgaris, what key points should be implemented in the client's discharge plan of care? Select all that apply. A. Abstain from all sexual activity while taking this medication. B. Avoid vitamin A supplements while taking this medication. C. Report any signs of depression or suicidal ideation while taking this medication. D. Utilize two forms of contraception while taking this medication. E. Visit the tanning bed only three times per week while taking this medication. F. Continue to wear your contact lens while taking this medication.
C. Report any signs of depression or suicidal ideation while taking this medication. D. Utilize two forms of contraception while taking this medication. E. Visit the tanning bed only three times per week while taking this medication.
A client has widespread itching of the skin. The doctor has diagnosed an allergic reaction and given a prescription for an anti-anxiety medication and anti-histamine. In addition to drug teaching, what suggestions can the nurse give to help the client deal with the itching? The nurse can also suggest all of the following EXCEPT: A. Use bath oil or soothing starch solution in cooler water for bathing B. Avoid scented skin products and laundry detergent C. Take hot baths with nice smelling soap D. Wear clothes in natural fabrics that breathe.
C. Take hot baths with nice smelling soap
The nurse is changing a dressing for a client with a burn to the back of the left leg. Which information should the nurse avoid documenting in the chart? A. The wound is pink around the edges. B. The wound has no drainage or odor. C. The client must not have felt the hot object burning the leg. D. The client states, "My pain is a 3 on a 1-10 scale."
C. The client must not have felt the hot object burning the leg.
A client transferred to a long-term care facility has a stage II pressure ulcer on her coccyx. Who should the nurse consult about the care of this client? A. Charge nurse B. Physician C. Wound care nurse D. Risk management
C. Wound care nurse
The nurse completes a wet-to-dry dressing change on a client's lower extremity wound. When should the nurse document the dressing change? A. the next time they access the client's record to update vital signs B. just before the end of the shift, prior to giving a report C. as soon as they finish performing the dressing change D. immediately prior to the next dressing change
C. as soon as they finish performing the dressing change
The nurse is gathering data from a client with an abdominal incision and suspects there is a potential for delayed wound healing. Which observation most likely supports this finding? A. sutures dry and intact B. wound edges in close approximation C. purulent drainage on a soiled wound dressing D. sanguineous drainage in a wound-collection drainage bag
C. purulent drainage on a soiled wound dressing
What is tinea capitis? A. athletes foot B. ringworm of the foot C. ringworm of the scalp D. psorisis
C. ringworm of the scalp
The nurse is testing the function of a client's cranial nerves. Which statement made by the nurse would indicate testing of cranial nerve IX (glossopharyngeal)? A. "Shrug your shoulders and turn your head." B. "Move and clench your jaw." C. "Swallow." D. "Stand with your eyes closed."
D. "Stand with your eyes closed."
If a client is only responsive to painful stimuli, the client is said to have which of the following? A. Oriented X 4 B. Mental status change C. Responsive to verbal stimuli D. Altered level of consciousnes
D. Altered level of consciousnes
A client lacks the DNA-repair enzyme that helps reverse UV damage. Which information related to this lack of enzyme would the nurse include when teaching the client? A. Wear sunglasses when outdoors. B. Avoid any activities that involve the outdoors. C. Apply aloe vera after a sunburn. D. Closely check the skin for new or changes in moles.
D. Closely check the skin for new or changes in moles.
A child has been treated for head lice but has remaining nits attached to the hair shaft. Which instruction would the nurse provide to the parent? A. Apply petroleum jelly. B. Apply a hair cap to smother them. C. Soak the hair in water. D. Comb the hair with a fine tooth comb.
D. Comb the hair with a fine tooth comb.
The nurse is caring for a client with dementia and is concerned for impaired social interaction. Which intervention should the charge nurse intervene? A. Approaching the client from the front and speaking in short sentences slowly. B. Reminisce with the client about his time in the Army. C. Including the client in a small birthday party for another resident. D. Correcting the client's thought process as it relates to reality.
D. Correcting the client's thought process as it relates to reality.
A client developed angioedema after taking prinivil (Lisinopril). Which priority nursing action is essential when caring for this client? A. Start an IV. B. Insert an indwelling catheter. C. Apply antipruritic lotion. D. Maintain a patent airway.
D. Maintain a patent airway.
Which oxygen delivery system provides 70-100% high concentration oxygen and utilized in emergency situations such as carbon monoxide poisoning when the patients have extremely low levels of blood oxygen? A. Face tent. B. Venturi mask. C. Simple face mask. D. Non-rebreather mask.
D. Non-rebreather mask.
A client is admitted for observation following a motor vehicle accident that occurred on the way to the client's daughter's wedding. The next morning, instead of asking about the wedding, the client tells the nurse "I have to leave now since the wedding is in a few minutes." The client then becomes agitated when the nurse re-orients and states the actual date (which is the day following the wedding). What should the nurse do next? A. Change the date on the hospital room whiteboard to yesterday's date. B. Administer Valium 40 mg IV since the client is about to have a seizure. C. Call the family to see if the wedding can be repeated. D. Perform neurological assessment and assess pupillary response
D. Perform neurological assessment and assess pupillary response
The nurse is obtaining a pulse oximetry reading and vital signs for a client with pneumonia. Which finding would the nurse report immediately to the healthcare provider? A. Temperature of 98 °F B. Heart rate of 72 C. Respiratory rate of 16 D. Pulse oximetry of 89%
D. Pulse oximetry of 89%
A registered nurse (RN) is working with the licensed practical nurse (LPN) to care for a group of clients in a nursing home. How should the RN expect the LPN to communicate changes in the clients' wound status? A. The LPN speaks directly to the physician. B. The LPN informs the RN when a wound heals. C. The LPN informs the RN only if a wound worsens. D. The RN communicates daily with the LPN about the condition of each resident.
D. The RN communicates daily with the LPN about the condition of each resident.
The student knows what type of infection is categorized by the term tinea? A. viral infection B. bacterial infection C. parasitic infection D. fungal infection
D. fungal infection
A nurse is caring for a client with a pressure ulcer on the sacrum. When educating the client about dietary intake, which foods should the nurse plan to emphasize? A. legumes and cheese B. whole-grain products C. fruits and vegetables D. lean meats and low-fat milk
D. lean meats and low-fat milk
A crack in the skin is called a ___?
fissure
A flat dark colored lesion is called a ____?
macule
A raised lesion filled with white cells, bacterial and cellular debris is called a ___?
pustule
A raised lesion filled with serous fluid is called a ___?
vesicle