Practice Quiz for EXAM 1 -FNDS

A registered nurse is teaching a nursing student about when a client with high blood pressure should follow up with the primary healthcare provider. Which statement made by the nursing student indicates effective learning? A) "I will advise a client with a blood pressure of 122/80 mm Hg to follow up in a year." B) "I will advise a client with a blood pressure of 110/70 mm Hg to follow up in a year." C) "I will advise a client with a blood pressure of 150/90 mm Hg to follow up in six months." D) "I will advise a client with a blood pressure of 185/115 mm Hg to follow up in a month."

A. "I will advise a client with a blood pressure of 122/80 mm Hg to follow up in a year."

What finding would be consistent with long-standing hypoxemia in a client who reports shortness of breath? Question 42 options: A) Clubbing B) Bradycardia C) Elevated temperature D) Kyphosis

A. Clubbing

A client vomited on their hospital gown. Which PPE should the nurse wear to change the client's gown? A) Gloves B) Mask C) Gown D) Face Shield

A. Gloves

A primary healthcare provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this prescription? A) Recognizing that PRN prescriptions for restraints are unacceptable B) Implementing the restraint prescription when the client begins to act out C) Ensuring that the entire staff is aware of the prescription for the restraints D) Asking that the prescription indicate the type of restraint

A. Recognizing that PRN prescriptions for restraints are unacceptable

The nurse teaches a client about cleaning the skin to prevent pressure ulcers. Which statement made by the client indicates the nurse needs to follow up? Question 41 options: A) "I should use mild, heavily fatted soap." B) "I should apply powders or talc on a perineum wound." C) "I should wash with tepid rather than hot water." D) "I should gently pat the skin."

B. "I should apply powders or talc on a perineum wound."

Which intrinsic factors may contribute to falls in older adults? Select all that apply. Question 23 options: A) Inappropriate foot wear B) Deconditioning C) Unfamiliar environment of hospital room D) Impaired vision E) Improper use of assistive devices

B. Deconditioning D. Impaired vision

A nursing student under the supervision of a registered nurse is performing a pulse assessment. While preparing to assess the client, the registered nurse asks the nursing student to check the apical pulse after assessing the radial pulse. What could be the reason behind for this change? Question 43 options: A) The client may have physiologic shock B) The client underwent surgery earlier in the day C) The client may have a dysrhythmia D) The client may have peripheral artery disease

C. The client may have a dysrhythmia

A client is admitted with a diagnosis of a ruptured spleen. The client's blood pressure is 100/60 mm Hg. What should the nurse assess in the client as an early sign of decreased arterial pressure? A) Warm, flushed skin B) Increased pulse pressure C) Weak radial pulses D) Lethargy with confusion

C. Weak radial pulses

A nurse is assessing a 78 year old adult. What cognitive changes should the nurse anticipate that the client will report? Question 33 options: A) My short term memory is better than my long term memory. B) I get easily confused. C) My level of intelligence has been decreasing. D) It takes longer for me to learn something new.

D. It takes longer for me to learn something new

Litigation resulting from improper restraint use is a common nursing legal issue. A nursing student is listing points related to the use of restraints. Which factor needs correction? A) Restraints can be used when all other alternatives have been tried and exhausted. B) Restraints can be used when less restrictive interventions are not successful. C) Restraints can be used only to ensure the physical safety of the resident or other residents. D) Restraints can be used anytime without a written order from the healthcare provider.

D. Restraints can be used anytime without a written order from the healthcare provider.

The registered nurse is teaching a student nurse about delegating tasks to the unlicensed assistive personnel (UAP) while caring for a client with a skin disease. Which delegation statement made by the student nurse requires a need for further teaching? Question 36 options: A) "I will advise the UAP to reinforce the client teaching." B) "I will instruct the UAP to report if the client complains of discomfort." C) "I will ask the UAP to assist the client with bathing." D) "I will instruct the UAP to apply lotion to the client's skin."

A. "I will advise the UAP to reinforce client teaching"

A nurse provides discharge teaching to an older adult about care associated with activities of daily living. Which factor should the nurse mainly consider when counseling the client on how often to take a tub bath? Question 35 options: A) Condition of the skin B) Ability of the client to provide self-care C) Degree of orientation to the environment D) Type of allergic reactions experienced by the client

A. Condition of the skin

A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is the most appropriate place to check the client's pulse rate? Question 21 options: A) Femoral B) Brachial C) Radial D) Ulnar

A. Femoral

The registered nurse is assisting a client who is hospitalized with high fever. Which task delegated to the unlicensed assistive personnel (UAP) would be appropriate? Select all that apply. A) Helping the client in changing clothes B) Administering intravenous medications C) Administering oral medications D) Validating vital signs are correct E) Performing all hygiene tasks

A. Helping the client in changing clothes E. Performing all hygiene tasks

An older adult experiencing delirium suffers from a leg fracture caused by a fall. Which interventions should the nurse follow to prevent future falls? Select all that apply. Question 29 options: A) Manage foot and footwear problems B) Teaching clients about the safe use of the Internet C) Providing information about the effects of using alcohol D) Modifying the home environment E) Minimizing medications

A. Manage foot and footwear problems D. Modify the home environment E. Minimizing medications

The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider? A) No prescription change B) Start intravenous (IV) infusion of D5 ½ NS to run at 150 mL/hr C) Give 1 L of 0.9% normal saline (NS) bolus over 4 hours D) Increase furosemide from 20 mg by mouth (PO) to 40 mg PO daily

A. No prescription change

A nurse is caring for a client requiring continuous pulse oximetry. What should the nurse do when using this monitoring device? Select all that apply: Question 24 options: A) Ensure that capillary refill is more than 4 seconds. B) Compare the pulse rate on the oximeter with the client's radial rate occasionally. C) Dampen the site slightly before applying the sensor. D) Clean the site for the sensor with an alcohol wipe before applying the sensor. E) Explain that the test is noninvasive but may cause discomfort.

B. Compare the pulse rate on the oximeter with the client's radial rate occasionally. D. Clean the site for the sensor with an alcohol wipe before applying the sensor.

Which statement regarding oral care is accurate? Question 38 options: A) Only alcohol based mouthwash should be used to clean dentures. B) Dentures should be stored in water in a denture cup when not in use. C) Conscious clients should sit at a 45 degree angle to brush their teeth while in bed. D) A gloved finger may be used to gently open the mouth of an unconscious client during oral care.

B. Dentures should be stored in water in a denture cup when not in use.

The registered nurse assigned a task to unlicensed nursing personnel (UNP). The UNP observed a change when measuring a client's blood pressure. What is the responsibility of the UNP in this situation? Question 32 options: A) Administer medication. B) Inform the registered nurse immediately. C) Inform the licensed practical nurse. D) Discuss with other UNP about the problem.

B. Inform the registered nurse immediately

While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in blood pressure. The nurse would report this finding as what? A) Vasomotor instability B) Orthostatic hypotension C) Orthostatic dehydration D) Malignant hypotension

B. Orthostatic hypotension

Which nursing intervention for opening the airway should be performed in an unconscious client with a spinal injury? A) Providing oxygen via a nonrebreather mask B) Performing a jaw thrust maneuver C) Initiating cardiopulmonary resuscitation D) Preparing for a needle thoracostomy

B. Performing a jaw thrust maneuver

Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? Question 28 options: A) Pouring warm water over the perineum B) Removing the catheter within 24 hours C) Cleaning the catheter insertion site D) Ensuring the patency of the catheter

B. Removing the catheter within 24 hrs.

The nurse is caring for a client with a platelet count of 50,000 cells per microliter. Which recommendation is inappropriate for the client? Question 27 options: A) Do not blow nose forcefully B) Shaving with a straight blade razor C) Using a soft-bristle toothbrush D) Walking with sturdy shoes

B. Shaving with a straight blade razor

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past 2 days. What is the first thing the nurse should do when caring for this client? A) Collect a sputum specimen. B) Take the temperature. C) Encourage fluids. D) Administer oxygen.

B. Take the temperature

A new nurse has been assigned to a school-aged child who is in contact isolation for methicillin-resistant Staphylococcus aureus (MRSA). The primary nurse observes the new nurse during morning care. Which behavior should the primary nurse address to improve isolation technique? Question 22 options: A) Equipment brought into the room is disinfected by the nurse before its removal. B) While changing the bed the nurse wears gloves but no gown. C) The nurse wears clean gloves while setting the intravenous pump. D) The nurse is not wearing a mask while in the child's room.

B. While changing the bed the nurse wears gloves but no gown.

A hospitalized client is on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). Which statement by an unlicensed assistive personnel (UAP) indicates a need for further teaching? A) "I will wash my hands before entering and leaving the room." B) "I will put on gloves and a gown before entering the room." C) "I will remove the gown, then the gloves, before washing my hands." D) "I will leave a thermometer, blood pressure cuff, and stethoscope in the room for use for this client only."

C. "I will remove the gown, then the gloves, before washing my hands."

A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report? A) The potential reasons why the restraints were not in place at the time of the fall B) A statement that the nursing staff was not at fault because the client initiated the accident C) A listing of facts related to the incident as witnessed by the nurse D) The name of the nurse who was responsible for implementing the restraints

C. A listing of facts related to the incident as witnessed by the nurse

A 32 year old client is on bed rest for tachycardia. The nurse provides the client with wash clothes, towels, soap and water. The client bathes while in bed. What type of bath would the nurse document? Question 37 options: A) Assist Bath B) Complete Bed Bath C) Bed Bath D) Partial Bath

C. Bed bath

What is the priority nursing action for a client with delirium? A) Planning for behavioral interventions B) Maintaining skin integrity C) Creating a calm and safe environment D) Maintaining personal contact through touch

C. Creating a calm and safe environment

Which action would be most important for the nurse to perform when providing hygiene for an obese patient? Question 39 options: A) Using a basin, soap and water for the bath. B) Cleansing all skin with chlorhexidine wipes. C) Ensuring that areas between skin folds are dry. D) Applying lotion to knees and elbows.

C. Ensuring that areas between skin folds are dry.

The nurse enters the client's room to do the beginning of shift assessment and notices the client has no pulse. What should be the nurse's first intervention? Question 20 options: A) Applying oxygen B) Administering intravenous normal saline C) Initiating cardiopulmonary resuscitation D) Obtaining blood samples for further assessment

C. Initiating cardiopulmonary resuscitation

Sitz baths are prescribed for a client with an episiotomy during the postpartum period. How do the sitz baths aid the healing process? Question 40 options: A) Cleansing perineal tissue B) Tightening the rectal sphincter C) Promoting vasodilation D) Softening the incision site

C. Promoting vasodilation

A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The healthcare provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? Question 30 options: A) Droplet precautions B) Reverse isolation C) Surgical asepsis D) Medical asepsis

C. Surgical asepsis

During a health fair, the nurse takes an adult's blood pressure, and it is 200/120 mm Hg. The nurse should base the next nursing intervention on what understanding? A) Walking around the fair probably raised the blood pressure. B) Information should be obtained regarding prescribed medications. C) There is an increased risk for having a cerebrovascular accident (brain attack). D) The elevated blood pressure reflects the "white coat syndrome."

C. There is an increased risk for having a cerebrovascular accident (brain attack)

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client? Question 31 options: A) Discourage long visits from family members. B) Employ airborne precautions. C) Use standard precautions. D) Plan interventions to limit direct contact.

C. Use standard precautions

A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution should the nurse take? A) Put on a gown when entering the room B) Don a surgical mask with a face shield when entering the room C) Wear a particulate respirator when caring for the client D) Place the client with another client who has TB

C. Wear a particulate respirator when caring for the client

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do? A) Have the prescription renewed every 48 hours. B) Provide range of motion to the client's elbows every shift. C) Document output from the tube and catheter every 2 hours. D) Assess the client's condition every hour.

D. Assess the client's condition every hour

A client had an open reduction and internal fixation of the head of the femur. In the postanesthesia care unit, the client's vital signs remained stable for 1 hour, with a blood pressure (BP) 130/78 mm Hg, pulse (P) 68, and respiration (R) 16. One hour after returning to the postsurgical unit, the client's vital signs are BP 100/60 mm Hg, P 74, and R 22, and the client is restless. What should the nurse do first? A) Elevate the head of the client's bed B) Continue monitoring the client's vital signs C) Increase the intravenous flow rate D) Check the dressing on the incision

D. Check the dressing on the incision

A client who is 5 feet, 8 inches tall (173 cm) and weighs 220 lb (99.8 kg) is admitted to the hospital with a kidney stone, blood in the urine, and a blood pressure of 150/90 mm Hg. The client is lying in bed crying and grasping her left flank area. Which is the priority objective of nursing care for this client? A) Decrease hypertension B) Decrease hematuria C) Decrease weight D) Decrease pain

D. Decrease pain

Which is an example of indirect contact transmission of microorganisms? Question 25 options: A) Contaminated water B) Deer tick C) Kissing D) Dirty hands

D. Dirty hands

A healthcare provider asks the nurse for a report on the quality of a client's pulse. Which information collected by the nurse will answer this question? Question 34 options: A) The pulse rate is slower than the heart rate B) The pulse has 2 beats that repeatedly occur together C) The pulse rate is 65 beats per minute D) The pulse volume is full and bounding

D. The pulse volume is full and bounding

A client comes to the emergency department because of minimal urinary output despite drinking adequate fluid. The client's blood pressure is 190/94 mm Hg. For what additional clinical manifestation associated with this data should the nurse assess the client? A) Thirst B) Urinary hesitancy C) Urinary retention D) Weight gain

D. Weight gain

For which illness should airborne precautions be implemented? A) Chickenpox B) Pneumonia C) Influenza D) Respiratory syncytial virus

A. Chickenpox