final exam practice questions
A nurse on a telemetry unit is caring for a client who had a myocardial infraction. The client states "All this equipment is making me nervous". Which of the following responses should the nurse make? "You won't need the equipment for long" "Why does the equipment bother you" "All of this equipment can be frightening" "Let me tell you about what each machine does"
"All of this equipment can be frightening"
A nurse is assessing a client who came to the emergency department reporting chest pain. The client tells the nurse they have hearing loss and forgot their hearing aids. Which of the following actions should the nurse take to improve communication with the client? Select all that apply. move the client to a quiet area or private room speak at a slower pace delay the assessment until the client's family can bring the hearing aids have a sign language interpreter translate the communication to the client stand next to the client when talking avoid using medical terminology
move the client to a quiet room or private area, speak at a slower pace, avoid using medical terminology
A nurse is assessing a client who has a calcium level of 80 (8.5-10). Which finding should the nurse expect to observe? depressed reflexes polyuria muscle termors nausea
muscle tremors
A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? encourage the client to take deep breaths observe the rate, depth, and character of the client's respirations give the client a back rub to help her relax prepare to administer oxygen
observe the rate, depth, and character of the client's respirations
The nurse is caring for a client with lower extremity paralysis who uses a wheelchair and is non-weight baring. Which of the following actions will promote a safe transfer to the wheelchair? obtain a mechanical lift use a slide board use a two-person assist have the client stand and pivot
obtain a mechanical lift
A nurse is planning to insert a nasogastric tube for a client after explaining the procedure, the client states "You are not putting that hose down my throat". Which of the following statements should the nurse make? "I can see why this is upsetting you." "Why don't you want the tube inserted?" "I would try to get it over with because you won't get better without this tube" "You should talk to your provider about it"
"I can see why this is upsetting you."
A nurse in a long-term facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? "A lot of clients who are cared for at home have the same problem" "Don't worry about it. He will get a bath, and that will take care of the odor" "When was the last time he had a bath?" "It must be difficult to care for someone who is confined to bed"
"It must be difficult to care for someone who is confined to bed"
A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "People who practice the Islam faith pray over the decreased for a period of 5 days before burial" "People who practice the Hindu faith bury the decrease with their head facing north" "People who practice Judaism stay with the body of the decreased until burial" "People who are practicing the Buddhist faith have the female family members prepare the body following death"
"People who practice Judaism stay with the body of the decreased until burial"
An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? "Don't worry, teenagers often have friends who gave them bad advice" "Tell me where you met these friends" "I think you should stop seeing those friends since they discourage you from following your treatment plan" "Tell me more about how your friends discourage you"
"Tell me more about how your friends discourage you"
A nurse is discussing culturally competent care with another nurse. Which of the following statements should the nurse include? "Use a medical interpreter for a client who does not speak the same language" "Provide the client with information in print only so they have it as a resource" "Provide standard education materials to all clients for continuity" "Limit communication with the client if there is a language barrier"
"Use a medical interpreter for a client who does not speak the same language"
A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? SC for subcutaneously BT for bedtime PC for after meals HS for half-strength
PC for after meals
An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? The AP ensures that there are no kinks in the drainage tubing The AP hangs the collection bag at the level of the bladder The AP tapes the catheter to the client's inner thigh The AP uses soap and water to clean the perineal area
The AP hangs the collection bag at the level of the bladder
A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? urine specific gravity 1.0064 urine pH 7.2 WBC 15,000 erythrocyte sedimentation rate (ESR) 15 mm/hr
WBC 15,000
A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? a client who has a prescription for a transfusion of packed red blood cells a client who has a distended bladder and needs urinary catheterization a client who has a prescription for a tuberculin skin test a client who is being transported for a radiography of the kidneys, uterus, and bladder
a client who has a prescription for a transfusion of packed red blood cells
A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? pain level hydration status airway urinary output
airway
A nurse is preparing to obtain a young adult's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse? apex of the heart right side of the sternum 4th intercostal space midclavicular line below right clavicle
apex of the heart
A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? background assessment situation recommendation
assessment
A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? bounding pulse poor skin turgor hypotension sunken egg balls
bounding pulse
A nurse is caring for a client who has a terminal illness. Which of the following findings indicate that the client's death is imminent? cold extremities hypertension tachycardia urinary retention
cold extremities
A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the include? blow into the spirometer to elevate the balls in the device clean the mouthpiece with an alcohol swab after each use use the spirometer every 8 hour cough deeply after each use
cough deeply after each use
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? reassure the client call the client's surgeon have the client lie on his back with his knees flexed cover the incision with a moist sterile dressing
cover the incision with a moist sterile dressing
While administering an antibiotic to a patient with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection, the nurse notices that the patient's neck and face are becoming flushed and the patient complains of feeling itchy. Which action should the nurse take next? discontinue the vancomycin infusion slow the rate of the vancomycin infusion obtain an order for an antihistamine check the patient's temperature
discontinue the vancomycin infusion
A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration. oozing of blood at the infusion site warmth at the infusion site edema at the infusion site redness at the infusion site
edema at the infusion site
A nurse is applying an ince bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? leave the bag in place for 45 minutes fill the bag two-thirds full with ice place the ice bag uncovered on the client's ankle tell the client that it is expected to feel numbness when the ice bag is in place
fill the bag two-thirds full with ice
A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? cream of rice cottage cheese ice cream gelatin
gelatin
A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? ask the client if he wants to self-administer insulin have the client list the steps of the procedure have the client demonstrate the procedure ask the client if he understands the purpose of insulin
have the client demonstrate the procedure
In which order will the nurse perform an abdominal inspection? palpate, auscultate, percuss, inspect inspect, auscultate, percuss, palpate auscultate, inspect, palpate, percuss inspect, palpate, auscultate, percuss
inspect, auscultate, percuss, palpate
A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe ateletasis. Which of the following actions should the the nurse plan to make? perform percussions directly over the client's bare skin use a flattened hand to perform percussions place the client in Trendelenburg's position remind the client that chest percussions can cause mild pain
place the client in Trendelenburg's position
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? wear sterile gloves to insert the tubing position the client on his left side hold the solution bag 91 cm above the client's rectum insert the rectal tube 15.2 in
position the client on his left side
A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? two-point discrimination test glasgow coma scale babinski reflex romberg test
romberg test
A nurse is caring for a client who has prescription for a vest restraint. Which of the following actions should the nurse take? fasten the ties on the restraint to the side rails of the bed allow one finger's breadth between the restraint and the client's chest tie the restraint with a quick-release knot place the restraint under the client's clothing
tie the restraint with a quick-release knot
A nurse is assessing the skin of an immobilized patient. What will the nurse do? limit the amount of fluid intake use a standardized tool such as the Braden Scale assess the skin every 4 hours have special times for inspection so as not to interrupt routine care
use a standardized tool such as the Braden Scale
A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? ventrogluetal deltoid dorogluteal vastus lateralis
ventrogluetal
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? sweeping the floor shoveling snow cleansing windows washing dishes
washing dishes
A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? use battery-operated equipment for personal care apply mineral oil to protect the facial skin from irritation remove the television set from the client's bedroom wear cotton clothing to avoid static electricity
wear cotton clothing to avoid static electricty
A nurse is caring for a client who has Clostridium Difficile and is in contact isolation. Which of the following actions should the nurse take? wear gloves when changing the client's gown use alcohol-based sanitizer to cleanse the hands wear a mask when assisting the client with his meal tray place the client on complete bed rest
wear gloves when changing the client's gown
A nurse is teaching a client who has lower extremity weakness how to use four-point crutch gait. Which of the following instructions should the nurse include in the teaching? "Move both crutches forward at the same time" "Bear weight on both of your legs" "Keep your elbows extended" "Support the majority of your weight on the axillae"
"Bear weight on both of your legs"
A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of client's fluid status? daily weight blood pressure specific gravity intake and output
daily weight
A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? decreased potassium decreased calcium increased potassium increased calcium
decreased calcium
A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognized these manifestations as which of the following types of transfusion reactions? sepsis circulatory febrile hemolytic
hemolytic
The nurse is caring for a client who has a serum sodium level of 117 (135-145). Which of the following actions is a priority for the nurse to take? place the client on continuous cardiac monitoring restrict the client's oral fluid intake implement seizure precautions provide a high-sodium diet
implement seizure precautions
The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? hypoactive bowel sounds in all 4 quadrants blood pressure of 110/70 a pulse of 86 beats per minute increasing restlessness
increasing restlessness
A nurse receives a laboratory report for a client indicating a potassium level of 5.4 (3.5-5). When notifying the HCP, the nurse should anticipate which of the following actions? start IV infusion of 0.9% sodium chloride initiating continuous cardiac monitoring administer IV potassium prepare client for dialysis
initiating continuous cardiac monitoring
A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? palpation percussion auscultation inspection
inspection
A nurse is provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause when of the following adverse effects? liver damage respiratory depression gastric ulcers constipation
liver damage
A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? loss trust self-disclosure risk-taking
loss
A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enema should the nurse plan to administer to soften the feces? oil retention carminative hypertonic sodium polystyrene sulfate
oil retention
A nurse is assessing the skin of a postoperative client. Which finding would indicate to the nurse a risk for skin breakdown? perspiration that requires frequent linen changes occasional ambulation with minimal assistance frequent repositioning because the bed is uncomfortable client requests snacks as well as scheduled meals
perspiration that requires frequent linen changes
A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? place the client in a lateral position with the head turned to the side before beginning the procedure use the thumb and index finger to keep the client's mouth open rinse the client's mouth with an alcohol-based mouth wash following the procedure cleanse the client's mucous membranes with lemon-glycerin sponges
place the client in a lateral position with the head turned to the side before beginning the procedure
A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? provide a protein intake of 1.5g/kg of body weight per day limit fluid intake to 20mL/kg of body weight per day provide an intake of 500 mg/day of vitamin E limit total caloric intake to 25kcal/kg of body weight
provide a protein intake of 1.5g/kg of body weight per day
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following options should the nurse include in the plan of care? Select all that apply. select suction machine at 120 mm Hg provide oral hygiene frequently measure the amount of drainage from the NG tube every shift secure the NG tube to the client's gown apply petroleum jelly to the client's nares
provide oral hygiene frequently, measure the amount of drainage from the NG tube every shift, secure the NG tube to the client's gown
A charge nurse is reviewing SBAR documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of assessment data? client states they have had abdominal pain for 3 days before being admitted client has a history of chronic constipaiton rebound tenderness noted in the RLQ of the abdomen client has a referral to a dietician
rebound tenderness noted in the RLQ of the abdomen
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? squeeze the handle of the extinguisher aim the hose at the base of the fire remove the safety pin from the extinguisher sweep the hose from side to side to dispense material
remove the safety pin from the extinguisher
A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? repeat the joint motion five times during each session sit approximately 2 feet from the side of the bed closest to the joint being exercised move the joint to the point of considerable resistance exercise the smaller joints first
repeat the joint motion five times during each session
The nurse is assessing a client who has a potassium level of 3.2 (3.5-5). Which finding should the nurse expect to observe? shallow respirations hypoglycemia tetany abdominal pain
shallow respirations
A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? order pureed foods make sure feedings are at room temperature sit at bedside while feeding the client offer the client a drink of fluid after every bite
sit at bedside while feeding the client
A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? warm, dry skin tachycardia increased urinary output bradypnea
tachycardia
The nurse overhears an unlicensed assistive personnel (UAP) tell a family member, "The client that injured your spouse in the motor vehicle accident (MVA) should go to jail, but he just died". Which action should the nurse implement first? interrupt the conversation, and discuss the situation with the UAP privately allow the UAP to finish her conversation, and discuss the situation later apologize to the family member for the UAP's comments tell the UAP that the comment is a violation of confidentiality
tell the UAP that the comment is a violation of confidentiality