Final Exam

A client is brought to a health care facility for treatment of a bleeding cut. The client was injured by a sharp knife. How can the nurse describe this clients wound?

A clean separation of skin and tissue with smooth even edges

A nurse is caring for four adult clients. Which client would the nurse assess first?

A client with a respiratory rate of 32 per minute

A terminally ill client at a health care facility has been referred for hospice care, which client is eligible for hospice care?

A client with less than 6 months to live

The nurse is preforming a physical assessment on an older adult female client. The nurse documents scoliosis as part of the spinal assessment. What is scoliosis?

A pronounced lateral curvature of the spine

The nurse is caring for a client who has a long history of using opioid pain medication, when the client reports back pain "10" on a scale of 1-10, what is the appropriate nursing action?

Acknowledge pain as the client reports it

The nurse is caring for a client with tuberculosis, which precautions will the nurse select for the client?

Airborne

A nurse is assisting the physician in applying an emergency splint to the injured leg of a client. Which action should the nurse remember when applying an emergency splint?

Avoid changing the position of the injured part

A health care facility has experienced a recent outbreak of infection that is attributable to an antibiotic resistant microorganism. Which type of client is most likely at increased risk for infection?

Elderly

A nurse is caring for an elderly client at a health care facility which should the nurse do to provide an appropriate environment for the client?

Ensure that the environment is warmer than normal

The nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?

Nasal canula

A client is being prepared for cardiac catheterization. The nurse preforms an initial assessment and records the vital signs, Which data collected can be recorded as subjective data?

Nausea

The health care provider has placed an order for a clients nasogastric tube to be clamped. Which assessment finding indicates to the nurse that the clients condition has improved?

No nausea or vomiting

A nurse is caring for a client with psudoconstipation, what can cause psudoconstipation in a client?

Over use of suppositories

A nurse is caring for a client who has stage IV pressure ulcer, what is a characteristic of this type of ucler?

Presence of deeply ulcerated tissue exposing muscles and bones

A nurse is caring for a client with severe back pain. The client has been lying flat on his back in bed for a long time. Which body position has the highest potential for causing foot drop in a bedridden client?

Supine

When instructing a client regarding sublingual application, the nurse should inform the client that which action is contraindicated when administering the drug?

Swallowing the medication

A middle aged client with cancer has been prescribed patient controlled analgesia (PCA) The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA?

The client is actively involved in pain management

A nurse needs to preform the heimlich maneuver on an 8 month old infant with a partial airway obstruction. Which action should the nurse preform?

Use the heal of one hand to administer back blows

When collecting a urine sample from a client for examination the nurse notes that the sample appears reddish-brown in color. What would cause the variation in color of this urine?

Blood

The nurse is teaching a client about proper use of a glucometer. Which teaching will the nurse provide?

Blood glucose levels are obtained 30 minutes before eating, and before bed time

A nurse needs to count a clients apical heart rate. Which assessment site is most suitable for counting the apical heart rate?

Chest

A client who visits a health care facility for a routine assessment reports to the nurse that he is unable to control his urinary elimination. This has resulted in him soiling his clothes and has led to a lot of embarrassment. How should the nurse document the clients condition?

Incontinence

An 18 year old is brought into the emergency department with a head injury. The nurse knows that the adolescence are vulnerable to injuries related to:

automobile accidents

A nurse has replaced the bag and tubing set that are being used to administer intermittent tube feedings to an elderly client with modest nutritional needs. How often should the nurse change the tubing and the bag that are used to administer this clients tube feedings?

After 24 hours

Missed the first question**

Answer has to do with allergies**

The nurse is caring for a 7 year old client with a fractured wrist. Which of the following is the best method to determine if the client has retained the information taught?

Ask the client to recall after approximately 15 minutes

When caring for a client at the health care facility the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate?

Assess for cultural differences

A nurse is interviewing an American Indian client who has come to the clinic for a follow up visit. The nurse notices that the client does not make eye contact and speaks while looking down. How should the nurse respond?

Assume a position at eye level with the client and continue the interview

A client is wearing a holter monitor in order to undergo a prescribed ambulatory electrocardiogram. Which precaution should the client take during an ambulatory electrocardiography test?

Avoid a shower or swim

When treating a client at a health care facility with nitroglycerine paste, how can the nurse prevent self contamination during the application?

Avoid touching the application with bare fingers

A nurse is explaining the need for bathing to an elderly client who has been avoiding a bath. Which benefit of bathing should the nurse explain to the client?

Bathing reduces the possibility of infection

Two nurses are discussing appropriate care of culturally diverse populations and a nurse has made the point the United States is diverse but anglicized. Why is the united states considered to be anglicized?

Because the United States culture revolved primarily from the early english settlers

A nurse is caring for an elderly client with muscle atrophy. Which considerations can lead to muscle atrophy in elderly clients?

Being bedridden for 1-2 days

The nurse at a health care facility is caring for a client who requires an artificial airway. The nurse could use an oral airway for which client?

Client who is recovering from general anesthesia

The nurse notes that a clients temperature has increased from 102 degrees to 103.6 degrees. What is the most appropriate action for the nurse to take during this situation?

Consult the physician and give antipyretics to the client

One of the nursing achievements in the Cimeron War was the death rate of soldiers dropped from 60% to 1%, what is the most appropriate reason for the fall in the death rate?

Decrease rate of infection and gangreen

A nurse is caring for an older adult client at a home health care facility. What should the nurse consider to be normal age related change?

Decreased sensory preception

A nurse is providing nail care to clients admitted to a health care facility. The nurse should know that which clients are most susceptible to nail problems?

Diabetics

The client is admitted to the hospital with pneumonia along with various other signs and symptoms. Which is the priority for the nurse to manage?

Difficulty breathing

The client with crones disease in remission is admitted to the nursing unit for follow up care, the remission state is characterized by?

Disappearance of signs and symptoms associated with the disease

A man with numerous comorbid health problems has presented to the clinic for a scheduled appointment. The man states that he has been awakening frequently during the night to void. The nurse should inquire about the time of day the client is taking his prescribed:

Diuretic

The nurse is caring for a client who has been prescribed an enteri-coated drug. What should the nurse inform the client about administration of this drug?

Do not crush or chew

A client with an infection on the genitalia visits a health care facility in order to inspect the infection. The nurse assists the client into a reclining position with both knees bent. What type of position has the nurse placed the client in for inspection?

Dorsal recumbent

The nurse is administering a prescribed hypertonic saline solution to a client with constipation. Which is a function of hypertonic saline enema?

Draws fluid from body tissues into the bowel

A nurse is preparing a discharge note for an older adult client with constipation. Which suggestion should the nurse write in the clients discharge note for a healthier bowel elimination habit?

Drink 8-10 glasses of liquid daily

The client at a health care facility has been prescribed scopolamine to be administered transdermally. Which statement describes transdermal application?

Drugs bound to an adhesive and applied to the skin

An unconscious client is brought to the emergency department after ingesting too much prescribed medication, What is the highest priority nursing intervention?

Establish a patent airway

The medical order for a client indicates that the medication is to be administered with the abbreviation "q4h". How often should the medication be given?

Every 4 hours

A health care agency is applying for accreditation and the accrediting agency is conducting audits of randomly selected medical records. These medical records should include:

Evidence that nursing interventions have been evaluated in terms of the clients response

The nurse is caring for a client who has undergone total hip replacement and is advised to undergo physiotherapy after discharge. Which level of care is the physiotherapy center?

Extended care

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

Flow meter

The nurse is assessing a client with dental problems including irritation, inflammation and bleeding gums. The nurse recognizes that what condition may be contributing to these signs and symptoms?

Gingivitis

A client at a health care facility has been diagnosed with polyuria. How would the nurse describe the clients condition in the medical record?

Greater than normal urinary volume

The nurse is caring for a client that developed a UTI while hospitalized. How will the nurse document this condition?

Healthcare associated infection (HCAI)

A nurse is using a mechanical lift to assist an obese client with limited mobility. Which client will benefit the most from a mechanical lift?

Heavy

A nurse is caring for an elderly client with an upper extremity fracture. Which therapy can be given to elderly clients to treat fractures of the upper extremities?

Imobilization

A nurse is assisting a physician during a sectarian section for a client. The client is administered epidural anesthesia. What is the advantage of epidural anesthesia?

It decreases the risk of gastrointestinal complications

A nurse is attending to a client with an infectious disease. After changing the linen and caring for the patient the nurse does a hand asepsis with an alcohol based hand rub. Which of the following is a reason for the nurse to use an alcohol based hand rub?

It provides the greatest reduction in microbial counts

A client informs the nurse that he wants to discontinue his treatment and go home, later the nurse finds the client dressed to leave. Which action should the nurse take in this situation?

Let the client go after signing a document stating he is leaving against medical advice (AMA)

When treating a client for a sprained ankle, the nurse wraps the clients ankle in a bandage. What is the purpose of wrapping the clients ankle in a bandage?

Limits movement in the wounded area

During the physical assessment of a client, the nurse observes flat round colored nonpalpable areas on the face. How should the nurse document this finding?

Macule

A nurse applied an automated external defibrillator (AED) to a victim found unconscious on the floor at a mall. The AED advises a shock to the victim. What is the nursing priority?

Make sure that noone is touching the victim or the area around the client

The nurse is assisting a physician who is placing a clients dislocated arm in its original position. Which type of traction is being applied to the client?

Manual traction

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to insure electrical safety?

Obtain a 3 prong grounded plug adapter

A nurse at a health care facility uses a tonsil tip catheter to remove the secretions from the mouth of a client with chest congestion. What suction technique is the nurse using in this case?

Oral suctioning

A nurse is caring for a client with an amputated limb. The client tells the nurse that he has a burning sensation in his amputated limb. How should the nurse document this pain?

Phantom pain

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis, which precaution should the nurse take when transporting the specimens?

Place the specimens into plastic biohazard bags

A nurse is caring for a client with Parkinsons disease. Which nursing diagnosis identified by the nurse should be the highest priority?

Potential of injury

The nurse is examining the anus of a client with a history of chronic constipation, what is indicative of chronic constipation?

Presence of rectal fissures

The nurse is applying a pneumatic compression device to a client. What is the purpose of a pneumatic compression device?

Promote circulation of venous blood

The nurse is caring for a client with multiple areas of breakdown on the back. In which position will the nurse choose to place the client to improve arterial oxygenation?

Prone position

The scope and character of nursing practice underwent significant changes in the years following the Civil War. Which activity exemplifies nursing practice in the early years of the 20th century?

Providing basic health care to recent immigrants to the United States

The nursing student has begun a clinical placement at a large hospital that serves a diverse population. The student has consequently acquired a new appreciation for the fact that nurse combines art with science. What is the clearest manifestation of the science base for nursing?

Providing evidence based nursing care

A laboratory test of a clients urine indicates the presence of pus in the urine. Which term is used to describe this type of urine?

Pyuria

A hospital client has illuminated the call light and told the nurse "I cant quite seem to catch my breath". The client appears to be in no visible distress. What is the first intervention that the nurse should perform?

Raise the head of the clients bed and put the client in high fowlers position

The nurse is caring for an arthritic client who needs administration of enema. Which position should the nurse ask the client to maintain to administer the enema solution?

SIMS position

When recording date regarding the clients health record, the nurse mentions the analysis of the subjective and objective data in addition to the detailing the plan for care of the client. Which of the following styles of documentation is the nurse implimenting?

SOAP charting

When assessing a clients wound the nurse observes that the damaged tissue is being replaced with fibrous tissue. How should the nurse document this restoration of tissue integrity?

Scar formation

A client visits the medical unit with a clients father for a scheduled checkup. The clients father has been recently been diagnosed with hypertension. The nurse suggests the client gets his blood pressure regularly checked to avoid possible problems. What level of prevention is the nurse following in this case?

Secondary level

A nurse is caring for a client who is administered opioid narcotics. The client reports constipation. What is another potential side effect of opioid narcotics?

Sedation

When documenting information in a client's medical record, what should the nurse do consistently for each entry?

Sign each entry by name and title

A nurse is assessing a client with stress related problems. Which factor influences responses to stressors?

Social support

In a nursing unit a physician is about to defibrillate a client. What is an appropriate action where the client says clear?

Step away from the bed

A nurse is caring for a client who is being tube fed. Which action should the nurse preform when assessing a clients gastric residual volume?

Stop the infusion of the tube feeding formula

When measuring a clients pulse rate the nurse records 125 bpm. How will the nurse document the information in the medical records?

Tachycardia

The nurse is caring for four clients, which client does the nurse identify as the highest risk for social readjustment concerns?

The 77 year old whose spouse just died

A client is admitted with symptoms of psychosis. The nurse hurries to the clients room when she hears the client calling for help. She finds the client lying on the ground, the nurse assists the client back to the bed and preforms a thorough assessment and the nurse informs the physician and completes the incident report. Which statement by the nurse should the nurse document in the incident report?

The client was found lying on the floor

A client severely injured in a motor vehicle accident is rushed to a health care facility with severe head injuries and profuse blood loss. Which sign indicates approaching death?

The clients breathing becomes noisy

A nurse witnesses a traffic accident in which a child is badly hurt. The nurse dresses the open wounds sustained by the child the family tries to give monetary compensation to the nurse which the nurse later refuses. Later in the hospital the child develops complications due to infections in the wound. The family holds the nurse responsible for complications and wants to file a lawsuit.

The good samaritan law will provide legal immunity for the nurse

A client who does not speak english has been admitted to the health care facility reporting chest pain. Since the assigned nurse does not know the clients language, what would be the most appropriate situation in this case?

The nurse should request the help of a professional interpreter

A nurse is preforming cardiopulmonary resuscitation (CPR) on a client with a MI. Which of the following can be a reason for interrupting CPR?

The rescuer becomes exhausted

The nurse who is taking the vitals of a client with acute diarrhea is ordered to attend to another client. What is the highest priority nursing action the nurse must preform before leaving the client's room?

Thorough hand washing

A nurse is caring for a client who is recovering from acute back pain which device will allow the bed ridden client to maintain as much independence as possible?

Trapeze

A physician order for a client states that the administration of a medication "b.i.d." How many times should the client administer this medication to the client?

Twice a day

When caring for a client with a bacterial respiratory infection and an active cough, what action should the nurse take to prevent becoming infected?

Wear a mask when caring for the client

The nurse is planning to provide teaching to a client who is recovering from abdominal surgery. When is the most appropriate time to teach the client?

When the client is quietly sitting reading a book

During the physical assessment of a 12 year old child who sustained injuries in a bicycle fall, the nurse observes an area near the elbow that has been rubbed away by friction. How should the nurse document this finding?

abrasion

A nurse at a health care facility is assisting a client during a prescribed passive therapeutic exercise. Passive exercise is more suitable for clients who:

are paralyzed from a stroke or spinal injury

A client at a health care facility who requires prolonged mechanical ventilation has a tracheostomy tube inserted through a surgically created opening in the trachea. The tracheostomy tube also has a balloon cuff. How does the balloon cuff aid the client?

prevents the aspiration of oral fluids

A nurse has assessed a clients blood pressure near the beginning of a shift and obtained a systolic blood pressure of 138 mm Hg and a diastolic pressure of 71 mm Hg. The systolic blood pressure:

represents peak pressure in the arteries