NUR 200 Exam 2 (Units 4, 5, 6, 7, 8)
You are working with a male client who weighs 275 pounds. Using the formula provided in your text, which of the following is his basal metabolic rate in kilocalories (kcal) per day (24 hours)? 1) 3,000 2) 2,800 3) 2,600 4) 2,400
1) 3,000
A client has mentioned that she would like to begin an exercise program that includes cycling and weight lifting. You mention that she should also include exercise that warms the muscles before activity, cools them afterward, limits post-exercise stiffness, and keeps joints mobile. Which type of exercise are you recommending for this client? 1) Flexibility training 2) Resistance training 3) Aerobic conditioning 4) Anaerobic conditioning
1) Flexibility training
As you see various clients throughout the day, you encourage those who are at high risk for pneumonia to be immunized. Which of the following are examples of clients who should be immunized? SELECT ALL THAT APPLY. 1) A 68-year-old in excellent health 2) A 3-year-old who occasionally develops ear infections 3) A 25-year-old with alcoholism 4) A 42-year-old with no chronic diseases 5) A 20-year-old with asthma 6) A 10-year-old with seasonal allergies
1) A 68-year-old in excellent health 2) A 3-year-old who occasionally develops ear infections 3) A 25-year-old with alcoholism 5) A 20-year-old with asthma
You are caring for a client who is confined to bed following back surgery. Which of the following measures should you take to promote normal bowel elimination in this client? SELECT ALL THAT APPLY. 1) Assist the client into a semi-Fowler's position to use the bedpan. 2) Encourage the client to defecate soon after she feels the urge to do so. 3) Encourage the client to drink eight to ten 8-ounce glasses of water daily. 4) Perform range-of-motion (ROM) exercises with the client to promote peristalsis. 5) Encourage the client to eat foods rich in protein, such as red meat. 6) Stand by the client while she defecates to provide encouragement.
1) Assist the client into a semi-Fowler's position to use the bedpan. 2) Encourage the client to defecate soon after she feels the urge to do so. 3) Encourage the client to drink eight to ten 8-ounce glasses of water daily. 4) Perform range-of-motion (ROM) exercises with the client to promote peristalsis.
You are using the MyPlate food guide to provide nutritional teaching to a client. Which of the following points from this food guide should you emphasize with the client? SELECT ALL THAT APPLY. 1) Balance calories by avoiding oversize portions. 2) Choose 2% milk to decrease the amount of fat and number of calories. 3) Make sure that 50% of each meal is composed of fruits and vegetables. 4) Eat protein only two or three times each week. 5) Engage in exercise in addition to eating well. 6) Cut back on whole grains.
1) Balance calories by avoiding oversize portions. 3) Make sure that 50% of each meal is composed of fruits and vegetables. 5) Engage in exercise in addition to eating well.
You are caring for a client who has a dislocated shoulder. Which type of synovial joint is the shoulder? 1) Ball-and-socket 2) Condyloid 3) Hinge 4) Pivot
1) Ball-and-socket
You are caring for a client who is on mechanical ventilation. Which of the following interventions should you perform? SELECT ALL THAT APPLY. 1) Check arterial blood gases and assess respiratory status about 30 minutes after setup. 2) Maintain the patient in a recumbent position (head of the bed all the way down). 3) Drain the condensate from the ventilator tubing into the humidifier. 4) Give sedatives or anti-anxiety drugs as needed. 5) Reposition the patient every 1 to 2 hours. 6) Moisten the lips with a cool, damp cloth and water-based lubricant.
1) Check arterial blood gases and assess respiratory status about 30 minutes after setup. 4) Give sedatives or anti-anxiety drugs as needed. 5) Reposition the patient every 1 to 2 hours. 6) Moisten the lips with a cool, damp cloth and water-based lubricant.
After giving a client the nursing diagnosis of Risk for Falls related to Alzheimer's disease, you write an individualized goal to address this diagnosis. Which of the following would be the most appropriate goal for this client? 1) Client will not experience a fall while in the hospital. 2) Client will explain several strategies for preventing falls while in the hospital. 3) Client will demonstrate clear and focused thinking and thus will avoid falling while in the hospital. 4) Client will be able to move independently around her room without falling.
1) Client will not experience a fall while in the hospital.
You are caring for a client who has been confined to bed for several weeks. Which of the following are effects of immobility that you should assess for and address in this client? SELECT ALL THAT APPLY. 1) Contractures 2) Hypertrophy 3) Ankylosis 4) Tremor 5) Atrophy 6) Osteoporosis
1) Contractures 3) Ankylosis 5) Atrophy 6) Osteoporosis
Which of the following is the flap of connective tissue that closes over the trachea when food is swallowed to prevent choking and aspiration? 1) Epiglottis 2) Gastroesophageal sphincter 3) Ileocecal valve 4) Duodenum
1) Epiglottis
You are providing nutritional counseling to a high school student who decided to stop eating meat a year ago and who has now developed anemia. You explain to the client that it is important for him to consume adequate protein from non-meat sources because this nutrient performs many critical functions in the body. These functions include which of the following? SELECT ALL THAT APPLY. 1) Facilitates growth, maintenance, and repair of body cells and tissues 2) Forms hemoglobin, the oxygen carrier in red blood cells 3) Provides insulation 4) Protects vital organs 5) Defends against foreign invaders in the form of lymphocytes and antibodies 6) Enables accurate nerve-impulse transmission
1) Facilitates growth, maintenance, and repair of body cells and tissues 2) Forms hemoglobin, the oxygen carrier in red blood cells 5) Defends against foreign invaders in the form of lymphocytes and antibodies
Which of the following are functions of the kidneys? SELECT ALL THAT APPLY. 1) Filter metabolic wastes from the bloodstream and excrete them as urine 2) Transport urine to the bladder 3) Regulate blood volume 4) Store urine until it is discharged from the body 5) Regulate electrolyte levels 6) Produce erythropoietin
1) Filter metabolic wastes from the bloodstream and excrete them as urine 3) Regulate blood volume 5) Regulate electrolyte levels 6) Produce erythropoietin
You are teaching a client about how to establish a healthy and effective exercise program. Which of the following should you do? SELECT ALL THAT APPLY. 1) Find out what fitness goals motivate your client. 2) Help the client set personal goals for physical activity. 3) Recommend that the client stick to one activity, to promote discipline. 4) Warn your client that exercise is difficult and that he might not be able to maintain his program. 5) Encourage the client to find physical activities that are enjoyable to him. 6) Discuss barriers to regular activity and ways to overcome these barriers.
1) Find out what fitness goals motivate your client. 2) Help the client set personal goals for physical activity. 5) Encourage the client to find physical activities that are enjoyable to him. 6) Discuss barriers to regular activity and ways to overcome these barriers.
You are preparing to use the Morse fall scale to assess a client's risk for falls. Which of the following factors does this scale assess for in the client? SELECT ALL THAT APPLY. 1) History of falling 2) Age 3) Gender4) Presence of more than one medical diagnosis 5) Use of ambulatory aids 6) Mental status
1) History of falling 4) Presence of more than one medical diagnosis 5) Use of ambulatory aids 6) Mental status
You are caring for a client who is experiencing short-term constipation while in the hospital recovering from surgery. Which of the following interventions should you make to treat this condition? SELECT ALL THAT APPLY. 1) Increase the client's intake of fruits and vegetables. 2) Increase fluid intake. 3) Decrease physical activity. 4) Assist the client into a side-lying position whenever possible. 5) Allow the client 5 minutes following a meal to use the toilet. 6) Assess for hemorrhoids.
1) Increase the client's intake of fruits and vegetables. 2) Increase fluid intake. 6) Assess for hemorrhoids.
You are caring for a client who recently experienced a spinal cord injury and is now paralyzed from the waist down. Which type of catheterization will this client likely require? 1) Intermittent self-catheterization with a straight catheter 2) Continuous bladder drainage with an indwelling catheter 3) Continuous bladder drainage with a suprapubic catheter 4) Intermittent self-catheterization with a Foley catheter
1) Intermittent self-catheterization with a straight catheter
You auscultate a client's abdomen as part of a focused physical assessment for bowel elimination. You hear high-pitched sounds, with about 10 gurgles in a minute. Which of the following conditions is most associated with this type of bowel sound? 1) Normal 2) Small bowel obstruction and diarrhea 3) Decreased peristalsis and constipation 4) Paralytic ileus following abdominal surgery
1) Normal
You have decided that as a last resort you must apply physical restraints to a client who is at risk of injuring himself and healthcare team members. Which of the following actions must you take? SELECT ALL THAT APPLY. 1) Obtain a medical order before restraining. 2) Secure restraints in a way that allows for quick release. 3) Check restraints every 2 hours. 4) Remind prescriber to reassess and reorder the restraints every week, as needed. 5) Ensure that the restraints do not impair circulation or tissue integrity. 6) Release restraints and assess every 8 hours.
1) Obtain a medical order before restraining. 2) Secure restraints in a way that allows for quick release. 5) Ensure that the restraints do not impair circulation or tissue integrity.
You are caring for a client who is experiencing fecal impaction. You are planning on administering a cleansing enema to evacuate the intestine of stool, but first you would like to administer a retention enema to soften the hard stool and lubricate the rectum. Which of the following types of retention enema should you use? 1) Oil-retention enema 2) Carminative enema 3) Medicated enema 4) Nutritive enema
1) Oil-retention enema
Following allergy testing with a child, you find that she is allergic to cockroaches. This finding means that the child is at greater risk for which of the following? 1) Severe asthma 2) Rabies 3) Lung cancer 4) Fungal infection
1) Severe asthma
You are teaching a client how to use a peak flow meter at home. Which of the following instructions is accurate? 1) The client should take a deep breath and forcefully exhale. 2) The client should take a series of three readings and record the average. 3) The client should maintain or adjust medication according to the lowest reading. 4) The client's current reading should be compared against the national average reading.
1) The client should take a deep breath and forcefully exhale.
While caring for a client in the hospital, you observe that she has to get up several times during the night to urinate. As you investigate this, you first conduct a nursing history with the client. What is the best rationale for taking a nursing history in this case? 1) This urination pattern might be normal for the client. 2) The underlying urinary problem might be genetic. 3) The underlying urinary problem might be the result of recent trauma. 4) This urination pattern might reflect a psychological disturbance.
1) This urination pattern might be normal for the client.
You are caring for a client with chronic obstructive pulmonary disease (COPD) who is short of breath. Which of the following positions would be best for this client? 1) Tripod, leaning on an overbed table 2) Semi-Fowler's 3) Side lying with pillows to support the upper arm 4) Supine, with the knees bent
1) Tripod, leaning on an overbed table
You are caring for an older patient in the hospital who is at risk for falling. The client is cognitively normal but lacks coordination. Which of the following are interventions you should take to help prevent the client from falling? SELECT ALL THAT APPLY. 1) Use quarter-length siderails on the patient's bed. 2) Keep the bed in a low position. 3) Provide nonskid slippers. 4) Keep water, urinal, bedpan, and tissues out of reach so that the patient must have assistance to get them. 5) Encourage the patient to move to and from the bathroom independently, to build confidence. 6) Provide a night light
1) Use quarter-length siderails on the patient's bed. 2) Keep the bed in a low position. 3) Provide nonskid slippers. 6) Provide a night light
You are providing nutritional counseling to the mother of an infant. She is wondering at what age she should start feeding her child solid food. Which of the following should you tell her? 1) 2 to 4 months 2) 4 to 6 months 3) 6 to 8 months 4) 8 to 10 months
2) 4 to 6 months
A client coughs up some rust-colored sputum. Which of the following conditions should you most suspect based on this finding? 1) Viral infection 2) Pulmonary edema 3) Tuberculosis 4) Soot inhalation
3) Tuberculosis
Which of the following are "never" events—events that can cause serious injury or death to a patient and should never happen in a hospital? SELECT ALL THAT APPLY. 1) Myocardial infarction resulting from atherosclerosis 2) A surgical sponge left in a patient after surgery 3) Anaphylactic response to latex gloves 4) The wrong type of blood given to a patient 5) Severe pressure ulcers 6) Injuries from restraints
2) A surgical sponge left in a patient after surgery 4) The wrong type of blood given to a patient 5) Severe pressure ulcers 6) Injuries from restraints
A child has just been brought into the emergency room for suspected poisoning. Which of the following interventions should you most expect to be ordered? 1) Administering ipecac syrup to induce vomiting 2) Administering activated charcoal 3) Mechanically inducing vomiting by triggering the child's gag reflex 4) Performing the Heimlich maneuver
2) Administering activated charcoal
You are caring for an ambulatory male client and would like to promote normal urination in him. Which of the following actions should you take? SELECT ALL THAT APPLY. 1) Stand outside the bathroom door while he is urinating and ask, "Are you okay?" occasionally to reassure him of your presence in case he needs you. 2) Allow the client to stand and use the toilet in the bathroom for urination, if he is able, instead of using the urinal in bed. 3) Prompt the patient to urinate at different times each day for the sake of variety. 4) Encourage the client to drink eight to ten 8-ounce glasses of fluid daily. 5) Excuse visitors from the room when discussing care related to urination. 6) Explain to the client that the diuretic he will be taking will cause him to urinate more often.
2) Allow the client to stand and use the toilet in the bathroom for urination, if he is able, instead of using the urinal in bed. 4) Encourage the client to drink eight to ten 8-ounce glasses of fluid daily. 5) Excuse visitors from the room when discussing care related to urination. 6) Explain to the client that the diuretic he will be taking will cause him to urinate more often.
The tiny air sacs that compose the lungs and are the site of gas exchange are known as which of the following? 1) Bronchi 2) Alveoli 3) Cilia 4) Hypoxemia
2) Alveoli
You are conversing with a 13-year-old client while reviewing his health history before a physical examination. The client mentions to you that he went shooting with his father last weekend. After listening to his story, you ask him whether he knows the rules for safe gun handling. He stammers a minute and then tells you he can't remember them. Which of the following rules should you tell him? SELECT ALL THAT APPLY. 1) Keep your finger on the trigger until you are ready to shoot. 2) Always keep the gun pointed in a safe direction. 3) Assume that a gun is unloaded until you have checked the chamber. 4) Always keep the gun unloaded until ready to use it. 5) Before cleaning a gun make sure that it is loaded. 6) If you do not know how to open the gun and inspect the chamber or chambers, leave it alone and get help from someone who does.
2) Always keep the gun pointed in a safe direction. 4) Always keep the gun unloaded until ready to use it. 6) If you do not know how to open the gun and inspect the chamber or chambers, leave it alone and get help from someone who does.
You are caring for a client who has undergone a total colectomy with ileoanal reservoir. With this type of bowel diversion, how will the client accomplish bowel elimination? 1) By inserting a tube through an external stoma into an internal pouch to drain it several times per day 2) By evacuating the bowel on a commode in the usual way; however, the feces will still be liquid 3) By emptying an external ostomy bag attached to a stoma 4) By receiving total parenteral nutrition, completely bypassing the gastrointestinal system
2) By evacuating the bowel on a commode in the usual way; however, the feces will still be liquid
You are caring for a client who is a sprinter on her high school track team. You should especially encourage her to consume which of the following nutrients to provide plenty of energy before running? 1) Protein 2) Carbohydrate 3) Lipid 4) Water
2) Carbohydrate
A client is returning to your clinic 3 days after having received an intradermal injection of antigen as part of a tuberculin skin test. As you palpate the injection site, you find that it has become hard. Which of the following should you anticipate as the next intervention ordered by the primary care provider? 1) No further intervention, as the test is negative for tuberculosis 2) Chest x-ray and sputum culture 3) Pulse oximetry 4) Spirometry
2) Chest x-ray and sputum culture
You are providing safety promotion counseling to the mother of a 2-year-old. Which of the following should you warn her is the leading cause of death in children her child's age? 1) Motor vehicle accidents2) Drowning3) Poisoning4) Homicide
2) Drowning
A female client complains of a stinging sensation when she urinates. You suspect a urinary tract infection (UTI). Which of the following are additional signs and symptoms of UTI that you should assess for in this client? SELECT ALL THAT APPLY. 1) Decreased urge to urinate 2) Foul-smelling urine 3) Blood in the urine 4) Back pain 5) Headache 6) Abdominal cramps
2) Foul-smelling urine 3) Blood in the urine 4) Back pain
You are performing a physical examination on an obese client. Which of the following findings would most cause you to suspect that the client might be diabetic? 1) Sweating 2) Fruity breath 3) Shakiness 4) Anxiety
2) Fruity breath
When you ask an older client about his urinary health, he admits to you that he cannot always get to the restroom in time to urinate because of his impaired mobility and use of a walker. Which type of incontinence is this an example of? 1) Urge incontinence 2) Functional incontinence 3) Stress incontinence 4) Reflex incontinence
2) Functional incontinence
One of your clients has recently taken a job in road construction. Which of the following are adverse health effects associated with substantial exposure to loud noises that you should warn the client about, to encourage him to use hearing protection? SELECT ALL THAT APPLY. 1) Respiratory disease 2) Hearing loss 3) Stress 4) Cancer 5) Elevated blood pressure 6) Loss of sleep
2) Hearing loss 3) Stress 5) Elevated blood pressure 6) Loss of sleep
You receive laboratory test results for a client and note that her creatinine level is increased above normal. This finding most likely points to which of the following? 1) Diabetes mellitus 2) Impaired kidney function 3) Malnutrition 4) Inadequate iron intake
2) Impaired kidney function
You are teaching a client about the benefits of regular aerobic exercise. Which of the following should you mention? SELECT ALL THAT APPLY. 1) Decreases risk of musculoskeletal injury 2) Improves the pumping action of the heart 3) Decreases heart rate 4) Decreases risk of dehydration 5) Dilates bronchioles to increase ventilation 6) Improves bone mass with aging
2) Improves the pumping action of the heart 3) Decreases heart rate 5) Dilates bronchioles to increase ventilation 6) Improves bone mass with aging
You are caring for a client who is receiving morphine for pain relief. After the latest dose, you notice that the client's respiratory rate has declined to 10 breaths per minute. Which of the following nursing diagnoses would be most appropriate for this client? 1) Ineffective Airway Clearance (respiratory depression) related to overdose of morphine 2) Ineffective Breathing Pattern (hypoventilation) related to overdose of morphine 3) Impaired Gas Exchange related to respiratory depression secondary to overdose of morphine 4) Impaired Spontaneous Ventilation related to hypoventilation secondary to overdose of morphine
2) Ineffective Breathing Pattern (hypoventilation) related to overdose of morphine
You are providing nutritional counseling to a vegan client. You encourage the client to include sources rich in vitamin C in her diet. Which of the following is the best rationale for this advice? 1) Vegans tend not to eat foods that contain vitamin C. 2) It is easier to absorb iron from plant sources when it is eaten with foods containing vitamin C. 3) Foods rich in vitamin C are also typically excellent sources of protein. 4) Vitamin C is an excellent substitute for animal protein.
2) It is easier to absorb iron from plant sources when it is eaten with foods containing vitamin C.
You are performing a physical examination of a client when she begins to become agitated. When you ask what is wrong, she says, "I think I'm having a panic attack." Her respirations increase in rate and depth but remain regular. Which breathing pattern is this? 1) Bradypnea 2) Kussmaul's respirations 3) Biot's respirations 4) Cheyne-Stokes respirations
2) Kussmaul's respirations
You are caring for a client who frequently experiences urinary stress incontinence. She has a body mass index (BMI) of 32. Which of the following lifestyle modifications should you encourage the client to make? SELECT ALL THAT APPLY. 1) Decrease fluid intake to three or four 8 ounce glasses per day. 2) Limit caffeine intake to less than 100 mg daily.3) Lose weight. 4) Engage in high-impact exercise. 5) Take prescribed diuretics at night. 6) Avoid constipation.
2) Limit caffeine intake to less than 100 mg daily. 3) Lose weight. 6) Avoid constipation.
You are preparing to perform routine nutritional screening on an older client who was just admitted to the hospital. Which of the following tools would be best for this purpose? 1) Cursory screening 2) Mini Nutritional Assessment 3) Food frequency questionnaire 4) Food record
2) Mini Nutritional Assessment
You are caring for a client with emphysema who frequently experiences shortness of breath. Which of the following positions would be best to place the client in? 1) Semi-Fowler's 2) Orthopneic 3) Lateral 4) Sims'
2) Orthopneic
You are helping an obese client develop an exercise plan. Which of the following is a likely barrier to exercise that is associated with obesity? 1) Muscle wasting 2) Osteoarthritis 3) Negative nitrogen balance 4) Inadequate protein stores available to maintain or repair body tissue
2) Osteoarthritis
You are providing care to a client with pneumonia. Which of the following interventions would be most appropriate for helping this client mobilize and expel secretions? 1) Use a dehumidifier in the client's room. 2) Position the client for postural drainage and perform chest percussion. 3) Administer oxygen at 95% via a Venturi mask. 4) Discourage the client from taking fluids by mouth.
2) Position the client for postural drainage and perform chest percussion.
You are caring for a client who has recently been diagnosed with diabetes. On questioning the client, you learn that she is sexually active and that in the past she has experienced a stinging sensation while urinating, although she currently is not experiencing any such symptoms. Which of the following nursing diagnoses would be most appropriate for this client? 1) Readiness for Enhanced Urinary Elimination 2) Risk for Infection (Urinary Tract) 3) Risk for Urge Urinary Incontinence 4) Functional Urinary Incontinence
2) Risk for Infection (Urinary Tract)
You are discussing the benefits of smoking cessation with a client who has been smoking for 30 years. He says, "After all these years, will it even make a difference?" Which of the following facts about smoking cessation should you communicate to this client? SELECT ALL THAT APPLY. 1) Risk of lung cancer remains the same. 2) Risk of heart attack returns to that of a nonsmoker in 1 year. 3) Life expectancy increases. 4) Oxygen levels in the blood begin to improve within 8 days. 5) Blood pressure and heart rate decrease. 6) Coughing, congestion, and shortness of breath decrease.
2) Risk of heart attack returns to that of a nonsmoker in 1 year. 3) Life expectancy increases. 5) Blood pressure and heart rate decrease. 6) Coughing, congestion, and shortness of breath decrease.
A client recently sustained a back injury from improper lifting while at work. You are instructing him on how to achieve proper balance when lifting to avoid injury in the future. Which of the following instructions should you give him? SELECT ALL THAT APPLY. 1) Place your center of gravity farthest from your base of support. 2) Stand with your head erect. 3) Pull in your buttocks. 4) Keep your abdominal muscles tight. 5) Roll your shoulders forward. 6) Keep your feet together.
2) Stand with your head erect. 3) Pull in your buttocks. 4) Keep your abdominal muscles tight.
A client with heart disease is describing his bowel function to you during a nursing history interview. Which of the following should you be concerned about? SELECT ALL THAT APPLY. 1) Bowel movements occur every other day. 2) The client has to rush to the toilet often to defecate. 3) The client often has to use the Valsalva maneuver when defecating. 4) There is bright red blood mixed with the stool. 5) The stool is soft and semisolid. 6) The client frequently uses laxatives.
2) The client has to rush to the toilet often to defecate. 3) The client often has to use the Valsalva maneuver when defecating. 4) There is bright red blood mixed with the stool. 6) The client frequently uses laxatives.
You are measuring the intake and output of a client. Which of the following should you include in the patient's output? SELECT ALL THAT APPLY. 1) Irrigations 2) Urine3) Emesis 4) Intravenous (IV) fluids 5) Liquid feces 6) Drainage from a wound
2) Urine 3) Emesis 5) Liquid feces 6) Drainage from a wound
Below are the step-by-step instructions for collecting a 24-hour urine specimen. Put them in the correct order. 1. Collect all urine voided during the next 24 hours. 2. Ask the patient to void. 3. Transport the specimen to the laboratory. 4. Label the storage container with the patient's name, the date, and the time the test ended. 5. Record the time. 6. Discard the voiding.
2. Ask the patient to void. 5. Record the time. 6. Discard the voiding. 1. Collect all urine voided during the next 24 hours. 4. Label the storage container with the patient's name, the date, and the time the test ended. 3. Transport the specimen to the laboratory.
You are obtaining a focused nursing history related to bowel elimination. Which of the following questions should you ask the client related to possible causes of constipation? 1) "How do you normally care for your stoma?" 2) "Is there any history of colorectal cancer in your family?" 3) "What medications are you currently taking?" 4) "To what are you allergic?"
3) "What medications are you currently taking?"
You are working with a female client who weighs 200 pounds. Using the formula provided in your text, which of the following is her basal metabolic rate in kilocalories (kcal) per day (24 hours)? 1) 1,835.8 2) 2,060.2 3) 1,963.4 4) 2,181.6
3) 1,963.4
You are working with a male client who weighs 330 pounds and is 74 inches tall. Which of the following is his body mass index (BMI)? 1) 37.8 2) 39.4 3) 41.6 4) 43.2
3) 41.6
You are in a restaurant when you see a diner having difficulty breathing. Which of the following is the first thing you should do? 1) Perform the Heimlich maneuver. 2) Perform the choking rescue maneuver. 3) Ask the person, "Are you choking?" 4) Have someone call 911.
3) Ask the person, "Are you choking?"
A client has just been prescribed an iron supplement to treat anemia. You should warn the client that use of this medication will likely cause which of the following conditions? 1) Ulcers 2) Diarrhea 3) Constipation and black stool 4) Dependence on the medication and failure of the intestine to work properly
3) Constipation and black stool
You are helping a client who has been confined to bed for over a week prepare for walking again. Which of the following measures should you specifically take to help prevent orthostatic hypotension in the client? 1) Quadriceps and gluteal drills 2) Pull-ups using a trapeze bar 3) Dangling the feet 4) Brushing the hair
3) Dangling the feet
You are providing nutritional counseling to a young woman who is trying to get pregnant. Which of the following vitamins should you especially encourage her to take? 1) Vitamin K 2) Vitamin B12 3) Folic acid 4) Vitamin D
3) Folic acid
You are assessing a 1-month-old breastfed baby. You ask the child's mother about his bowel movements and she describes them to you. Given the child's diet and stage of development, which of the following types of stool should you most expect? 1) Green-black, tarry, sticky, and odorless 2) Yellow-green 3) Golden yellow 4) Tan
3) Golden yellow
You are talking with a client who recently started lifting free weights three days a week to improve strength. Which of the following types of exercise is this? 1) Isometric anaerobic 2) Isotonic aerobic 3) Isotonic anaerobic 4) Isokinetic aerobic
3) Isotonic anaerobic
You are working with a female client who weighs 110 pounds and is 65 inches tall. Based on her body mass index, which of the following classifications applies to this client? 1) Severely underweight 2) Moderately underweight 3) Mildly underweight 4) Healthy weight
3) Mildly underweight
You are flexing and extending a client's forearm at the elbow as far as it will comfortably go without any assistance from the client. This activity is known as which of the following? 1) Body alignment 2) Line of gravity 3) Passive range of motion 4) Active range of motion
3) Passive range of motion
You are working with a client who claims to be constipated and who uses laxatives and enemas daily to ensure that she has a bowel movement. Which of the following nursing diagnoses would be most appropriate for this client? 1) Constipation 2) Risk for Constipation 3) Perceived Constipation 4) Dysfunctional Gastrointestinal Motility
3) Perceived Constipation
You are caring for a patient who has a chest tube and a water-seal drainage system. The end of the chest tube is inserted into which of the following? 1) Bronchi 2) Lung 3) Pleural space 4) Trachea
3) Pleural space
A client you are caring for seems to produce little urine. You suspect that the client's diet is the cause. A diet heavy with which of the following foods would explain this decreased urine production? 1) Beer 2) Coffee 3) Salty potato chips 4) Chocolate
3) Salty potato chips
Most digestion and absorption of food occurs in which of the following structures of the gastrointestinal system? 1) Esophagus 2) Stomach 3) Small intestine 4) Large intestine
3) Small intestine
One of your clients, a 5-year-old boy, sleeps restlessly at night in his hospital room and scratches around his anal area incessantly. You suspect that he might have pinworms. Which of the following actions should you take to confirm this suspicion? 1) Perform a fecal occult blood test at the patient's bedside. 2) Notify the primary care provider and prepare the patient for an x-ray of the abdomen. 3) Spread the child's buttocks while he is sleeping and visually examine for the worms. 4) Notify the primary care provider and prepare the patient for endoscopy by a gastroenterologist.
3) Spread the child's buttocks while he is sleeping and visually examine for the worms.
A client explains that she has begun to "wet herself" when she laughs too hard or sneezes. Which type of incontinence is this an example of? 1) Urge incontinence 2) Functional incontinence 3) Stress incontinence 4) Reflex incontinence
3) Stress incontinence
You are caring for an older client with Alzheimer's disease. You are concerned about this client getting out of bed unassisted and falling. Which of the following would be the best intervention to prevent this from occurring? 1) Install full-length siderails on the client's bed and raise them all the way up. 2) Apply a cloth vest restraint to the client. 3) Use a bed alarm with the client and conduct hourly rounds to observe her. 4) Explain the risk of falling to the client and ask her to call for assistance when she needs to get up.
3) Use a bed alarm with the client and conduct hourly rounds to observe her.
You are caring for an older client who has lost 5 pounds since being admitted to the hospital and is significantly underweight. Which of the following measures should you take to help stimulate this client's appetite? SELECT ALL THAT APPLY. 1) Offer less frequent, larger meals. 2) Encourage greater liquid intake with meals. 3) Warm the client's food if it cools off before the client has a chance to eat it. 4) Vary the textures, colors, and flavors of the food served. 5) Position the person comfortably. 6) Encourage meals with friends.
3) Warm the client's food if it cools off before the client has a chance to eat it. 4) Vary the textures, colors, and flavors of the food served. 5) Position the person comfortably. 6) Encourage meals with friends.
You are caring for a client who has been prescribed antibiotics. Knowing that this type of medication often causes diarrhea, which of the following foods should you encourage the client to consume to prevent this side effect? 1) Fresh fruits and vegetables 2) Coffee 3) Yogurt 4) Whole grain bread
3) Yogurt
Below are the steps for administering oxygen via a nasal cannula. Put them in the correct order. 1. Turn on the oxygen using the flow meter, and adjust according to the prescribed flow rate. 2. Assess the patient's respiratory status. 3. Attach the flow meter to the oxygen source. 4. Assemble and apply the nasal cannula. 5. Check that the oxygen equipment is set up correctly and functioning properly.
3. Attach the flow meter to the oxygen source. 4. Assemble and apply the nasal cannula. 1. Turn on the oxygen using the flow meter, and adjust according to the prescribed flow rate. 5. Check that the oxygen equipment is set up correctly and functioning properly. 2. Assess the patient's respiratory status.
Below are the step-by-step instructions for collecting a clean-catch urine specimen from a male client. Put them in the correct order. 1. Allow the flow of urine to pass into the toilet. 2. Do not touch the inside of the container or allow pubic hair in the urine sample. 3. Have the client wash the end of the penis with antiseptic solution. 4. Place the lid on the container. 5. Ask the client to begin voiding. 6. Transport the specimen to the laboratory as soon as possible. 7. Collect a 30- to 60-mL specimen of urine in a container. 8. Label the container with the patient's name, the date, and the time of collection.
3. Have the client wash the end of the penis with antiseptic solution. 5. Ask the client to begin voiding. 1. Allow the flow of urine to pass into the toilet. 7. Collect a 30- to 60-mL specimen of urine in a container. 2. Do not touch the inside of the container or allow pubic hair in the urine sample. 4. Place the lid on the container. 8. Label the container with the patient's name, the date, and the time of collection. 6. Transport the specimen to the laboratory as soon as possible.
You are teaching a group of older adults in a senior center about the hazards of carbon monoxide poisoning and methods to prevent it. Which of the following interventions should you mention related to this hazard? 1) Avoid smoking in the home. 2) Avoid exposing oxygen administration equipment to an open flame. 3) Avoid contact with clothing contaminated by toxins from industrial workplaces. 4) Avoid using your gas range to heat your home.
4) Avoid using your gas range to heat your home.
The process whereby blood pressure forces plasma, dissolved substances, and small proteins out of the porous glomeruli into Bowman's capsule while large molecules, such as blood cells and blood proteins, are held back is known as which of the following? 1) Tubular reabsorption 2) Tubular secretion 3) Excretion 4) Filtration
4) Filtration
You are caring for a client who recently had a portion of intestine made into a reservoir that is connected to the urethra. The patient will need to void by bearing down or applying manual pressure over the bladder. Which of the following urinary diversions does this client have? 1) Cutaneous ureterostomy 2) Conventional urostomy 3) Continent urinary reservoir 4) Neobladder
4) Neobladder
You are caring for a client who has developed a bone spur in her first vertebra (the atlas), which limits the movement in her atlantoaxial joint. Which type of joint is this? 1) Ball-and-socket 2) Condyloid 3) Hinge 4) Pivot
4) Pivot
You provide home nursing care to an older client who lives alone in a cluttered apartment and who has macular degeneration. You are concerned that the client may fall while at home alone. Which of the following nursing diagnoses would be most appropriate? 1) Risk for Falls related to poor vision and a cluttered home environment 2) Risk for falls related to environmental and physical factors 3) Risk for Falls related to a sensory problem and environment 4) Risk for Falls related to a cluttered home environment and poor vision secondary to macular degeneration
4) Risk for Falls related to a cluttered home environment and poor vision secondary to macular degeneration
You are instructing a client to actively move his arm through its full range of motion. Which division of the client's nervous system is allowing him to move his arm in this way? 1) Autonomic 2) Sympathetic 3) Parasympathetic 4) Somatic
4) Somatic
You are counseling a client with osteoarthritis about possible exercise programs suited to her needs. Which of the following types of exercise would be best for her? 1) Resistance training with free weights 2) Jogging 3) Soccer 4) Swimming
4) Swimming
You are caring for a client who has had an opening surgically made directly into the trachea to bypass an airway obstruction and permit an open airway. Which of the following airway types is this? 1) Nasopharyngeal 2) Orotracheal 3) Nasotracheal 4) Tracheostomy
4) Tracheostomy
You are a member of a sports medicine team that works with U.S. Olympic track and field athletes. Precise measurement of the body composition of the athletes is critical to maximizing their performance. Which method of measuring body composition would be best for this application? 1) Skinfold measurements 2) Body mass index (BMI) calculation 3) Computed tomography (CT) 4) Underwater weighing
4) Underwater weighing
Below are the steps for performing upper airway suctioning (nasopharyngeal). Put them in the correct order. 1. Using your dominant hand, attach the suction catheter to the connection tubing. 2. Don procedure gloves. 3. Lubricate and insert the suction catheter. 4. Position the patient in a semi-Fowler's position with the neck hyperextended. 5. Gently advance the catheter the premeasured distance into the pharynx. 6. Engage the suction and apply it while you withdraw the catheter, using a continuous rotating motion. 7. Approximate the depth that the suction catheter should be inserted. 8. Adjust the suction regulator according to agency policy.
4. Position the patient in a semi-Fowler's position with the neck hyperextended. 8. Adjust the suction regulator according to agency policy. 2. Don procedure gloves. 1. Using your dominant hand, attach the suction catheter to the connection tubing. 7. Approximate the depth that the suction catheter should be inserted. 3. Lubricate and insert the suction catheter. 5. Gently advance the catheter the premeasured distance into the pharynx. 6. Engage the suction and apply it while you withdraw the catheter, using a continuous rotating motion.
Below are the steps for irrigating a colostomy. Put them in the correct order. 1. Prepare the new appliance and remove the existing one. 2. Remove the sleeve and rinse, dry, and store it. 3. Examine the stoma and peristomal skin. 4. Prime the tubing using 500 to 1,000 mL of warm tap water. 5. Allow approximately 30 minutes for evacuation. 6. Position the patient on the toilet. 7. Lubricate the cone at the end of the tubing and insert it gently.
4. Prime the tubing using 500 to 1,000 mL of warm tap water. 6. Position the patient on the toilet. 1. Prepare the new appliance and remove the existing one. 3. Examine the stoma and peristomal skin. 7. Lubricate the cone at the end of the tubing and insert it gently. 5. Allow approximately 30 minutes for evacuation. 2. Remove the sleeve and rinse, dry, and store it.
Below are the top six causes of accidental death. Put them in the correct order, from the most prevalent cause to the least prevalent cause of the six. 1. Fires 2. Falls 3. Motor vehicle accidents 4. Drowning 5. Firearms 6. Poisoning
6. Poisoning 3. Motor vehicle accidents 5. Firearms 2. Falls 4. Drowning 1. Fires
Below are the steps for transferring a patient from a bed to a wheelchair. Put them in the correct order. 1. Instruct the patient to place her arms around you between your shoulders and waist. 2. Place the bed in the low position and lock the wheels. 3. Instruct the patient to pivot and turn with you toward the wheelchair. 4. Ask the patient to stand as you move to an upright position by straightening your legs and hips. 5. Ask the patient to flex her hips and knees as she lowers herself to the wheelchair. Guide her motion while maintaining a firm hold on her. 6. Assist the patient to dangle at the side of the bed. 7. Lock the wheels of the wheelchair. 8. Brace your feet and knees against the patient, bend your hips at the knees, and hold on to the transfer belt.
7. Lock the wheels of the wheelchair. 2. Place the bed in the low position and lock the wheels. 6. Assist the patient to dangle at the side of the bed. 8. Brace your feet and knees against the patient, bend your hips at the knees, and hold on to the transfer belt. 1. Instruct the patient to place her arms around you between your shoulders and waist. 4. Ask the patient to stand as you move to an upright position by straightening your legs and hips. 3. Instruct the patient to pivot and turn with you toward the wheelchair. 5. Ask the patient to flex her hips and knees as she lowers herself to the wheelchair.
A nurse is caring for a client who has a history of falls. Which of the following is the nurse's priority? A. Complete a fall-risk assessment B. Educate the client and family about fall risks C. Eliminate safety hazards from the client's environment D. Make sure the client uses assistive aids in his possession
A. Complete a fall-risk assessment
A nurse educator is presenting a module on basic first aid for newly licensed home heath nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea
A. Hypotension
A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? SELECT ALL THAT APPLY A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. C. Keep the knees slightly lower than the hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints and muscles.
A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. D. Use smooth movements when lifting and moving clients.
A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side" B. "I will go to the nurses' station for assistance" C. "I will administer his medications" D. "I will prepare to insert an airway"
B. "I will go to the nurses' station for assistance"
A nurse educator is teaching a module on proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that ab attendee understands the teaching? A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible." E. "When pulling an object, I should move my front foot forward"
B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible."
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? SELECT ALL THAT APPLY A. Most food poisoning is caused by a virus B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high risk should eat or drink only pasteurized dairy products D. Healthy individuals usually recover from the illness in a few weeks E. Handling raw and fresh food separately can prevent food poisoning
B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high risk should eat or drink only pasteurized dairy products E. Handling raw and fresh food separately can prevent food poisoning
A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? SELECT ALL THAT APPLY A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.
B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. E. A fire extinguisher should be readily available in the home.
A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? SELECT ALL THAT APPLY A. Open doors to clients rooms B. Place blankets over clients who are confined to beds C. Move beds away from the windows D. Draw shades and close drapes E. Instruct ambulatory clients in the hallways to return to their rooms
B. Place blankets over clients who are confined to beds C. Move beds away from the windows D. Draw shades and close drapes
A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg
B. Semi-Fowler's
A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? A. A client who received crush injuries to the chest and abdomen and is expected to die B. A client who has a 4-inch laceration to the head C. A client who has partial-thickness burns to his face, neck, and chest D. A client who has a fractured fibula and tibia
C. A client who has partial-thickness burns to his face, neck, and chest
A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? SELECT ALL THAT APPLY A. A client who is dehydrated and receiving IV fluid and electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for a elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mmHg E. A client who has acute appendicitis and is scheduled for an appendectomy
C. A client who is scheduled for a elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mmHg
An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water B. Was the affected area with antibacterial soap C. Brush the chemical off the skin and clothing D. Leave the clothing in place until emergency personnel arrive
C. Brush the chemical off the skin and clothing
A nurse in a provider's office is preparing to asses a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? SELECT ALL THAT APPLY A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on his dominant side
C. Concave lumbar spine posteriorly E. Muscles slightly larger on his dominant side
A nurse is caring for a client who reports pain with internal rotation of her right shoulder. The nurse should identify that this discomfort can affect the client's ability to perform which of the following activities? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her D. Reaching into a cabinet above her sink
C. Fastening her bra behind her
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? SELECT ALL THAT APPLY A. Place a belt restraint on the client when he is sitting on the bedside commode B. Keep the bed in its lowest position with all side rails up C. Make sure that the clients call light is within reach call light. D. Provide the client with nonskid footwear E. Complete a fall-risk assessment
C. Make sure that the clients call light is within reach call light. D. Provide the client with nonskid footwear E. Complete a fall-risk assessment
A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all open doors on the unit
C. Move clients who are nearby
A nurse is completing discharge teaching to a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states will do which of the following when she has difficulty breathing at night? A. Lie on her back with her head and shoulders on a pillow B. Lie flat on my stomach with her head to one side. C. Sit on the side of her bed and rest her arms over pillows on top of her bedside table. D. Lie on her side with her weight on her hips and shoulder with her arm flexed in front of her.
C. Sit on the side of her bed and rest her arms over pillows on top of her bedside table.
A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure? A. "I will get the caller off the phone as soon as possible so I can alert the staff" B. "I will begin evacuating clients using the elevator" C. "I will not ask any questions and just let the caller talk" D. "I will listen for background noises"
D. "I will listen for background noises"
A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? A. "I will set my water heater at 130 F" B. "Once my baby can sit up, he should be safe in the bathtub" C. "I will place my baby on his stomach to sleep" D. "Once my infant starts to push up, I will remove the mobile from over the crib"
D. "Once my infant starts to push up, I will remove the mobile from over the crib"
A charge nurse is assigning rooms for the clients to be to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station? A. A middle adult who is postoperative following a laparoscopic cholecystectomy B. A middle adult who requires telemetry for a possible myocardial infarction C. A young adult who is postoperative following an open reduction internal fixtion of the ankle D. An older adult who is postoperative following a below-the-knee amputation
D. An older adult who is postoperative following a below-the-knee amputation
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional staff to assist with the transfer. C. Use a transfer belt and assist the client into bed. D. Determine the client's ability to help with the transfer.
D. Assess the client's ability to help with the transfer.
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct color B. Water heaters should be inspected every 5 years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds with hemoglobin in the body
D. Carbon monoxide binds with hemoglobin in the body