NUR 212: Final Exam Study Questions

A nurse is caring for a toddler who is having difficulty sleeping during hospitalization. Which of the following actions should the nurse take to promote sleep? A. Explain the source of the toddlers fears B. Turn off the room light C. Provide bedtime rituals D. Encourage play exercises in the evening

C. Provide bedtime rituals

A nurse is caring for a client who has schizophrenia and is having difficulty with performing ADLs. The nurse should consult with which of the following members of the interdisciplinary team to assist the client? A. Occupational therapist B. Psychiatric social worker C. Recreational therapist D. Psychiatric clinical nurse specialist

A. Occupational therapist

A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority? A. Oxygen saturation B. Abdominal dressing C. Urinary output D. Pain level

A. Oxygen saturation

A nurse on a medical-surgical unit is caring for four clients who are 24-36 hour postoperative. Which of the following surgical procedures place the client at risk for deep-vein thrombosis? A. Myringotomy B. Laparoscopic appendectomy C. Hip arthroplasty D. Cataract extraction

C. Hip arthroplasty

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching? A. Expect ringing in your ears B. Take the medication with food C. Store the medication in the refrigerator D. Monitor for weight loss

B. Take the medication with food

A nurse in an urgent care clinic is studying the developmental stages of various clients. In which of the following clients should the nurse expect to see manifestations of autism? A. Neonate B. Toddler C. Middle age D. Geriatric

B. Toddler

A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take? A. Speak to the provider about adding an MAOI to the current medication regimen B. Explain that antidepressants often take several weeks to be fully effective C. Tell the client that the provider will need to change citalopram to a different medication D. Recommend a sleep study be done on the client

B. Explain that antidepressants often take several weeks to be fully effective

A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (SATA) A. Bacteria B. Diuretics C. Aging D. Obesity E. Smoking

C, D, E

A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take? A. Speak loudly and into the clients good ear B. Use sign language when communicating with the client C. Speak directly to the client in a normal, clear voice D. Sit by the clients side and speak very slowly

C. Speak directly to the client in a normal, clear voice

A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture? A. Green-blue discharge in the ear canal B. Increased temperature C. Sudden pain relief D. Popping sensation when swallowing

C. Sudden pain relief

A nurse is assessing a client who is 48 hours post-op following abdominal surgery. Which of the following findings should the nurse report to the provider? A. Blood pressure 102/66 mm Hg B. Straw-colored urine from an indwelling urinary catheter C. Yellow-Green drainage on the surgical incision D. Respiratory rate 18/min

C. Yellow-Green drainage on the surgical incision

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority? A. Pupil reaction B. Urine output C. Bowel sounds D. Respiratory rate

D. Respiratory rate

A nurse is assessing a client who has Paget's disease of the bone. Which of the following should the nurse expect? (SATA) A. Cranial enlargement B. Skeletal pain C. Abnormal gait D. Cold extremities E. Visual loss

A, B, C

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (SATA) A. Contracture of the extremities B. Polyuria C. Diarrhea D. Crackles in the lungs E. Pressure ulcers

A, D, E

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A. "I don't take naps throughout the day" B. "I go to bed and get up routinely at the same time each day" C. "I have a small snack and take a bath before going to bed each day" D. "I watch television until I fall asleep at night"

D. "I watch television until I fall asleep at night"

A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (SATA) A. Restlessness B. Grimacing C. Moaning D. Clenching E. Drowsiness

A, B, D

A nurse is caring for a client who has depressive disorder and is assessing his ability to perform activities of daily living (ADLs) prior to discharge. Which of the following activities should the nurse include in the assessment? A. Ability to perform oral hygiene B. Ability to bathe himself C. Ability to identify how often he should schedule his car for an oil change D. Ability to balance his bank account E. Ability to dress himself

A, B, E

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the clients provider? A. "My eye really itches, but I'm trying not to rub it" B. "I need something for the pain in my eye. I can't stand it" C. "It's hard to see with a patch on one eye. I'm afraid of falling" D. "The bright light in this room is really bothering me"

B. "I need something for the pain in my eye. I can't stand it"

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will walk briskly for 30 minutes before bedtime" B. "I will no longer have a glass of wine before bedtime" C. "I will have a cup of hot cocoa immediately before bedtime" D. "I will do my muscle relaxation techniques each afternoon"

B. "I will no longer have a glass of wine before bedtime"

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the clients recovery? A. It decreases the clients level of anxiety B. It facilitates the clients deep breathing C. It enhances the clients ability to sleep D. It reduces the clients blood pressure

B. It facilitates the clients deep breathing

A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make? A. "Yes, you are free to move around as you wish" B. "No, you are on strict bedrest and must not be up" C. "Please ring for assistance when you wish to get out of bed" D. "We will have to get a prescription from your provider"

C. "Please ring for assistance when you wish to get out of bed"

A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide? A. The medication is to be applied when the client is experiencing eye pain B. The medication will be used until the clients intraocular pressure returns to normal C. The medication should be applied in a regular schedule for the rest of the clients life D. The medication is to be used for approximately 10 days, followed by a gradual tapering off

C. The medication should be applied in a regular schedule for the rest of the clients life

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? A. Electrical cords are placed along the walls B. Scatter rugs are present in the kitchen C. Handrails are present in the bathroom D. Uses a microwave for cooking

B. Scatter rugs are present in the kitchen

A nurse is educating a client who is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages should the nurse recommend? A. Lemon-lime soda B. Brewed iced tea C. Diet cola D. Chocolate milk

A. Lemon-lime soda

A nurse is preparing to administer nalbuphine to a postoperative client who is experiencing pain. The nurse should monitor the client for which of the following potential adverse effects of this medication? A. Miosis B. Joint pain C. Diarrhea D. Oliguria

A. Miosis

A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction? A. "I will clean the hearing aids with alcohol wipes" B. "I will not use hairspray if I am wearing the hearings aids" C. "I will change the batteries once a week" D. "I will expect the hearing aids to whistle when I cup my hand over them"

A. "I will clean the hearing aids with alcohol wipes"

A nurse is teaching a client who is preoperative how to do deep breathing exercises and cough effectively after surgery. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll splint the incision with a pillow to cough" B. "I'll ask for pain medication after I do the exercises" C. "I'll use the incentive spirometer when I can get out of bed" D. "I'll breathe deeply and cough every 4 hours"

A. "I'll splint my incision with a pillow to cough"

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? A. "Without treatment, glaucoma can cause blindness." B. "Double vision is a common symptom of glaucoma" C. "Glaucoma is caused by inadequate production of fluid within the eye" D. "Use of eye drops will improve vision over time"

A. "Without treatment, glaucoma can cause blindness"

A nurse in a long term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? A. A reddened area over the sacrum B. Stiffness in the lower extremities C. Difficulty moving the upper extremities D. Difficulty hearing some types of sounds

A. A reddened area over the sacrum

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings? A. Increased heart rate B. Decreased respiratory rate C. Hyperactive bowel sounds D. Decreased blood pressure

A. Increased heart rate

A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect? A. Tugging on the affected ear lobe B. Clear drainage from the affected ear C. Pain when manipulating the affected ear lobe D. Erythema and edema of the affected ear

A. Tugging on the affected ear lobe

A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include? A. "Rest in bed for at least 2 days" B. "Keep your head up and straight" C. "Deep breathe and cough four times a day" D. "Lie on the side of the surgery when in bed"

B. "Keep your head up and straight"

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? A. Sleep on the abdomen to facilitate wound healing B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week C. Bend at the waist to pick objects up from the floor D. Notify the surgeon if white drainage develops on the eyelids

B. Avoid lifting anything heavier from 4.5 kg (10 lbs) for 1 week

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? A. Vital signs B. Self report of pain C. Severity of the condition D. Nonverbal behavior

B. Self report of pain

A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include? A. "Bloodshot eyes on the day of surgery should be reported to the provider" B. "Warm compresses should be applied to the eye three times daily" C. "Photophobia is expected for 2 to 3 days" D. "Vision will be greatly improved on the day of surgery"

D. "Vision will be greatly improved on the day of surgery"

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first? A. Pain severity B. Wound drainage C. Tissue integrity D. Airway patency

D. Airway patency

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report: A. Loss of central vision B. Having a loss of peripheral vision C. Seeing bright flashes of light and floaters D. Having a decreased ability to perceive colors

D. Having a decreased ability to perceive colors

A nurse on a long term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? A. Rotate assignment of daily caregivers B. Provide an activity schedule that changes from day to day C. Limit time for the client to perform activities D. Talk the client through tasks one step at a time

D. Talk the client through tasks one step at a time

A nurse is assessing a client who is 24 hr postoperative following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of acute compartment syndrome (ACS)? A. Dyspnea B. Red brown petechiae C. Headache D. Agitation

A. Dyspnea

A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis? A. Increase ambulation B. Decrease fluid intake C. Increase protein intake D. Offer the client the bedpan every 2 hours

A. Increase ambulation

A nurse is collaborating on care for a client who has COPD. Which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance? A. Instructing how to measure oxygen saturation B. Instructing how to use kitchen tools to prepare a meal C. Instruction how to plan a diet based on individual caloric needs D. Instructing how to perform pursed lip breathing

B. Instructing how to use kitchen tools to prepare a meal

A nurse is assessing a client following a natural disaster who is experiencing difficulty sleeping due to nightmares, feelings of survivor guilt, and difficulty concentrating. Which of the following diagnoses describe the clients symptoms? A. Generalized anxiety disorder B. Post traumatic stress disorder C. Histrionic personality disorder D. Dissociative identity syndrome

B. Post traumatic stress disorder

A nurse is caring for a client whose right leg is in Bucks traction. Which of the following interventions should the nurse implement to promote the clients mobility? A. Log rolling every 2 hr B. Isometric exercises of both legs C. Active range of motion exercises of the left leg D. Passive range of motion to the right lef

C. Active range of motion exercises of the left leg

A nurse at an opthalmology clinic is providing teaching to a client who has open angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide? A. Administer the medications by touching the tip of the dropper to the sclera of the eye B. Hold pressure on the conjunctiva sac for 2 min following application of drops C. Administer the medications 5 min apart D. It is not necessary to remove contact lenses before administering medications

C. Administer the medications 5 min apart

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? A. Check the clients vital signs B. Assess the clients pain level C. Cover the wound with a moist, sterile gauze dressing D. Obtain a culture and sensitivity of the wound drainage

C. Cover the wound with a moist, sterile gauze dressing

A nurse is administering timolol eye drops who has glaucoma. Which of the following actions should the nurse take? A. Apply pressure to the bridge of the nose after administration B. Wipe the eye from the outer canthus to the inner canthus before instillation C. Drop prescribed amount of medication into the conjunctival sac D. Protect the distal portion of the eye dropper using clean technique

C. Drop prescribed amount of medication into the conjunctival sac

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. Perform range of motion exercises B. Place suction equipment at the bedside C. Encourage the use of an incentive spirometer D. Administer an expectorant

C. Encourage the use of an incentive spirometer

A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? A. "It might help if I tried sleeping only on my back" B. "I'll sleep better if I take a sleeping pill at night" C. "I'll get a humidifier to run at my bedside at night" D. "If I could lose about 50 pounds, I might stop having so many apneic episodes"

D. "If I could lose 50 pounds, I might stop having so many apneic episodes"

A nurse is admitting a client who has partial hearing loss. Which of the following is the priority action by the nurse? A. Speak using his usual tone of voice B. Stand directly in front of the client C. Rephrase statements the client does not hear D. Determine if the client uses hearing aids

D. Determine if the client uses hearing aids

A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The client reports being nervous about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings? A. Call the anesthesiologist to sedate the client B. Notify the surgeon of the clients food and fluid consumption C. Witness the surgical consent D. Document the findings in the clients medical record

D. Document the findings in the clients medical record

A nurse is caring for a 6 month old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure? A. Decreased heart rate B. Decreased respiratory rate C. Increased formula consumption D. Increased crying episodes

D. Increased crying episodes

A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions? A. Mastoiditis B. Ménière's disease C. Acoustic neuroma D. Perforated tympanic membrane

D. Perforated tympanic membrane

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation? A. The client not been taking the medication properly B. The client is experiencing episodes of confusion C. The client has become addicted to the medication D. The client developed a tolerance to the medication

D. The client developed a tolerance to the medication

A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching? A. Take ibuprofen for eye discomfort B. Creamy white drainage is an indication of infection C. Notify the provider immediately if the operative eye itches D. The client should wear dark glasses while outdoors

D. The client should wear dark glasses while outdoors