NURS 353 Final Exam

A client refuses a blood transfusion, even though it is in his best interest. The client is displaying which ethical principle? A. Fidelity B. Autonomy (Correct) C. Justice D. Nonmaleficence

B

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? A. Encourage the client to take deep breaths B. Observe the rate, depth, and character of the client's respirations C. Prepare to administer oxygen D. Give the client a back rub to help her relax

B

A nurse administers an oral medication to a client. The client reports itching 30 min later. Which of the following represents appropriate documentation of this client finding? A. Client is itching from medication. B. Client states, "I am itching all over." C. It appears that the client has a rash from the medication. D. Rash from medication noted.

B

A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take? A. Restrict the client's visitors to the immediate family. B. Assign the client to a negative airflow pressure room. C. Discard personal protective equipment outside the client's room. D. Assign the client to a positive airflow room.

B

A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm B. Sit at eye level with the child C. Stand facing the child D. Stand with a relaxed posture

B

A nurse is delegating tasks to nursing team members on a medical-surgical unit. Which of the following tasks should the nurse delegate to assistive personnel (AP)? A. Administering sublingual tablets to a client B. Collecting a stool specimen C. Providing instructions about using a glucometer D. Evaluating the effectiveness of a client's pain medication

B

A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm/Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication. B. Ask the client if they are having pain. C. Request a prescription for an antianxiety medication. D. Return in 30 min to recheck the client's blood pressure.

B

A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mmHg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? A) Request a prescription for an antihypertensive medication B) Ask the client if they are having pain C) Request a prescription for an antianxiety medication D) Return in 30 min. to recheck the client's blood pressure

B

A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? A. Pallor B. Cyanosis C. Jaundice D. Erythema

B

A nurse is reinforcing teaching regarding palliative care with a client who has cancer. Which of the following statements by the client indicates a need for further teaching? A."My family will receive emotional support during this process." B."My provider will still attempt to cure my illness." C."I want to feel as comfortable as possible and enjoy the good times" D."My family can set up appointments with a massage therapist for me."

B

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range? A. Pulse rate 90/min B. BP 138/91 mm/Hg C. Rectal temperature 38℃ (100.4℉) D. Pulse oximetry 95%

B

A patient experiences light headedness following an IV infusion. This is a primary symptom of which of the following conditions? A. Infection B. Speed Shock (Correct) C. Fluid overload D. Allergy

B

A patient is admitted with a cough and the physician suspects TB. Which precaution would you place them under? A. Contact B. Airborne C. Droplet D. Protective

B

According to Erikson, young adults must achieve: a) Normalcy vs. Chaos b) Intimacy vs. Isolation c) Generativity vs. Stagnation d) Group vs. Individuality

B

As nurse is admitting an older adult client to the hospital. The client wears glasses and has a hearing aid. Which of the following interventions is appropriate before beginning the interview process? A. The nurse should sit beside the client during the interview. B. The nurse should ensure assistive devices are on and in working order. C. The nurse should ensure lighting in the room is low and soft. D. The nurse should provide a lengthy interview process to allow adequate time to answer questions.

B

Which of the following terms, in relation to culturally responsive care, means that nurses understand and address the entire cultural context of each client? A. Cultural Appropriateness B. Cultural Competence (Correct) C. Cultural Sensitivity D. Cultural Awareness

B

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. Shaking soiled linen before putting it in a hamper B. Removing a face mask when standing 0.5m(1.6ft) from the client. C. Assigning another client with the same infection to share the room with the client. D. Allowing the client to visit a family member in the lobby of the facility.

C

A community health nurse is preparing a disaster preparedness plan for smallpox. Which of the following groups of people should the nurse include for inoculation in the plan? A. Newborns B. Mortuary Workers C. Immunosuppressed Clients D. Clients who have eczema

B

A family loses their home in a hurricane. This type of loss is a: a) Necessary loss b) Perceived loss c) Situational loss d) Anticipatory loss

C

As part of the admission process, a nurse at a long-term facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the clients family? A. BMI B. Usual times for meals and snacks C. Favorite foods D. Any difficulty swallowing

D

All of these are examples of primary prevention except: a) Immunization programs b) Health education in schools c) Nutrition classes d) Communicable disease screening

D

An occupational health nurse is teaching a group of clients about work environment risks. Which of the following actions is the nurse performing? A. Case Management B. Secondary Prevention C. Tertiary Prevention D. Primary Prevention

D

A nurse is preparing to administer dextrose %5 in water (D5W) 1,000 mL IV to infuse over 10 hrs. The nurse should set the IV fusion pump to deliver how many mL/hr? (Round to the nearest whole number. Do not use trailing zero)

100 mL/hr

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening? A. Assume an open position *CORRECT B. Sit upright and lean back into the chair C. Avoid direct eye contact until the client initiates it D. Sit next to the client

A

A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following best describes the client's role problem? A. Role conflict B. Role overload C. Role ambiguity D. Role strain

A

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? A. Sodium 123 mEq/L B. Blood glucose 100 mg/dL C. Potassium 3.5 mEq/L D. Hemoglobin 13 g/dL

A

A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client? A) "Do not measure the client's temperature rectally." B) "Count the client's radial pulse for 30 seconds and multiply it by 2." C) "Do not let the client know you are counting their respirations." D) "Let the client rest for 5 minutes before you measure their blood pressure."

A

A nurse is performing a neurological assessment on a client. The nurse understands that the purpose of asking the client to stick out his tongue is to A. assess the function of the cranial nerve XII B. assess the function of the cranial nerve X C. assess the function of the cranial nerve VIII D. assess the function of the cranial nerve V

A

A nurse is planning care for a toddler who is scheduled for a diagnostic procedure. The nurse should identify that the toddler is in which of the following of Erikson's psychosocial stages of development? A. Autonomy vs Shame and Doubt B. Initiative vs Guilt C. Trust vs Mistrust D. Industry vs Inferiority

A

A nurse is planning to assess the client's abdomen. After inspection what should the nurse do next? a. auscultation b. percussion c. light palpation d. deep palpation

A

A nurse is responding to a parent's question about his infants expected physical development during the first year of life. Which of the following pieces of information should the nurse include? A. A 10-month-old infant can pull up to a standing position. B. A 2-month-old infant can turn from his abdomen to his back. C. A 4-month-old infant can sit up without support. D. A 6-month-old infant can crawl on his hands and knees.

A

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A. Sodium 150 mEq/L B. Potassium 4 mEq/L C. Calcium 9.5 mg/dL D. Magnesium 1.5 mEq/L

A

The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell the staff which child behavior is characteristic of the formal operations stage? A. The child has the ability to think abstractly B. The child begins to understand the environment C. The child is able to classify, order, and sort facts D. The child learns to think in terms of past, present, and future

A

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? A. Increasing restlessness B. A pulse of 86 beats/minute C. Blood pressure of 110/70 mm Hg D. Hypoactive bowel sounds in all 4 quadrants

A

What type of O2 delivery system is a patient with Chronic Obstructive Pulmonary Disease most likely to be prescribed? A. Venturi Mask B. Non-rebreather Mask C. Nasal Cannula D. Continuous positive airway pressure machine

A

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply) A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temperature. E. Discard any residual gastric contents.

A, B, C

A nurse is reviewing CDC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catch-up, during young adulthood? (Select all that apply.) A. Influenza B. Measles, mumps, rubella C. Pertussis D. Tetanus E. Polio

A, C, D

A nurse is talking with a mother of a two-month-old infant about fine motor development. Which of the following fine motor skills are expected in the next two months? (select all that apply) a. keeps hands loosely open b. holds hands in an open position c. grasps objects with both hands d. places objects in the mouth

A, C, D

Which of the following require completion of an incident report? (Select all that apply) A. Client Fall (Correct) B. Altercation with co-worker C. Needlestick (Correct) D. Missed Medication (Correct)

A, C, D

A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3 degrees Celsius (101 degrees Fahrenheit), a pulse rate of 114/min, and a respiratory rate of 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply) A) Obtain culture specimens before initiating antimicrobials B) Restrict the client's oral fluid intake C) Encourage the client to rest and limit activity D) Allow the client to shiver to dispel excess heat E) Assist the client with oral hygiene frequently

A, C, E

A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following psychologic functions? (Select all that apply.) A. Metabolism B. Ability to hear low-pitched sounds C. Far vision D. Glomerular filtration

A, C, E

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (Select all that apply.) A. Gingivitis B. Dry, brittle hair C. Edema D. Spoon shaped nails E. Poor wound healing

B, C, E

What normal physiological changes would you expect from an 80-year old patient? (Select all that apply) A. Increased peristalsis B. Decreased bone density C. Increased agitation D. Decreased intelligence E. Increased skin fragility

B, E

A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. Exhaustion stage B. Resistance stage C. Alarm reaction D. Recovery reaction

C

A nurse is caring for a client who had methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement? A. Place the client in a semi-private room B. Wear a mask when providing care C. Wear a gown when in the clients room *CORRECT D. Dispose of all bed linens used by the client

C

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction

C

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure ulcer D. Fecal impaction

C

A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled on the floor. Which of the following solutions should the nurse use to clean the spill? A.Isopropyl Alcohol B. Chlorhexidine Gluconate C. Chlorine (bleach) D. Iodophor

C

A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group? A. "I love my work so much that it is difficult to think about retirement." B. "As I look back over my life, I can see that I have achieved most of the goals I set for myself." C. "I think I have done a good job with my children since they are all independent now." D. "I am comfortable with my decision to choose a lifelong partner."

C

A nurse is caring for a patient who has a hearing impairment. Which of the following interventions should the nurse use when speaking to the client? A. Exaggerate lip movements B. Speak directly into the client's impaired ear C. Face the client when speaking D. Speak loudly

C

A nurse is caring for a person who has terminal cancer. Which of the following client statements should the nurse identify as an indication that the client is experiencing the depression stage of Kubler-Ross' stages of grief? A. "What did I do to deserve to be punished like this?" B. "I would give anything to live to see my daughter's graduation." C. "I feel so sad that I will be leaving my partner and children behind." D. "I am planning to seek a second opinion from another doctor."

C

A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion? A.. Determining the client's respiratory rate B. Measuring the client's chest diameter C. Obtaining the clients level of oxygen saturation D. Checking the clients depth of respirations

C

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerveV). Which of the following items should the nurse gather for the test? A.Sugar B. Coffee C. Cotton Wisps D. Snellen chart

C

The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response? A. "You need to be concerned" B. "You need to monitor the child's behavior closely" C. "At this age, the child is developing his own personality" D. "You need to provide more praise to the child to stop this behavior"

C

The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? A. Call security B. Call the police C. Call the nursing supervisor D. Lock the co-worker in the medication room until help is obtained

C

Which IV Fluid is recommended for treatment of acidosis? A. Normal Saline B. D5W C. Lactated Ringers (Correct) D. 3% Sodium Cholride

C

A nurse is giving a presentation about injury prevention to a group of parents of children ranging from 1-3 years of age. Which of the following strategies should the nurse mention? (select all that apply). a. leave children unattended with animals present. b. keep toilet lids open c. keep toys with small parts out of reach d. keep the crib mattress in the lowest position with the rails all the way up e. do not leave toddlers unattended in the bathtub.

C, D, E

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

C, D, E

A nurse is caring for a client who does not want to get out of bed due to pain from arthritis. Which of the following nursing interventions is appropriate? A. Tell the client the provider does not want her remaining in bed. B. Allow the client to remain on bed rest until her pain subsides. C. Instruct the family to perform ADLs for the client. D. Advise the client to perform active ROM exercises while in bed.

D

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional personnel to assist with the transfer. C. Use a transfer belt and assist the client to bed. D. Assess the client's ability to help with the transfer.

D

A nurse is caring for a patient who is at risk for developing hearing loss. Which of the following medication can cause an ototoxic reaction to this patient? a. cimetidine b. amiodarone c. simvastatin d. ibuprofen

D

Contact precautions are initiated for a client with a healthcare-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? A. Gloves and gown B. Gloves and goggles C. Gloves, gown, and shoe protectors D. Gloves, gown, goggles, and a mask or face shield

D

What amount of fluid does an adult need daily from all sources? A. 1200ml B. 1500ml C. 2000ml D. 2500ml (correct)

D

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my child to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have taken during the day."

D

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? A. Remove the NG tube B. Advance the NG tube quickly C. Ask the client to tilt his head backward D. Pull the NG tube back slightly

D

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence

D

A nurse offers pain meds to a client who is post-op prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A) Fidelity B) Autonomy C) Justice D) Beneficence

D

A Nurse is caring for a client who is diagnosed with anemia. Which of the following skin color variations is caused by a reduced amount of oxyhemoglobin? A .Cyanosis B Jaundice C. Erythema D Pallor

D

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? A. Call the nurse to verify that the client received that dosage. B. Give the medication in a safe dosage. C. Give the dose the provider prescribed. D. Call the provider to clarify the dosage. *CORRECT

D

A nurse is preparing to administer a medication. Which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible? a. Stat prescription b. PRN prescription c. Standing prescription d. Single prescription

a

A patient reports abdominal cramping during a cleansing enema. The nurse should know to take which action? a) lower the container b) tell the client that cramping is expected c) raise the container another 15 cm d) remove the enema

a

A nurse is preparing to test a client's cranial nerve function. Which of the following directions should the nurse include when testing cranial nerve XI? (select all that apply) a) clench your teeth b) shrug your shoulders c) turn your head to the right d) raise your eyebrows e) squeeze my fingers

b, c

A nurse is measuring a client's vital signs. The client's heart rate is 105 bpm. What would the nurse document as her findings? a. bradycardia b. arrhythmia c. tachycardia d. dysrhythmia

c

A nurse is preparing to auscultate, percuss and palpate a client's thorax. Which finding would prompt the nurse to investigate further? a) high-pitched clicks b) tympany over the LLQ c) Blumberg's sign d) dullness over the liver

c