Practice Test #1

Which statement made by the nurse requires correction when discussing registered nurse licensure in the USA with peers?

"Passing the NCLEX-RN examination indicates maximal knowledge base for safe nursing practice."

Arrange the order of donning personal protective equipment (PPE) while caring for a client with isolation precautions.

1.) Apply the gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist. 2.) Apply either a surgical mask or a respirator around the mouth and nose. 3.) Apply eyewear or goggles snugly around the face and eyes 4.) Apply clean gloves. 5.)Bring the glove cuffs over the edge of the gown sleeves

Which description of family-centered care is correct?

A collaborative plan of care is developed to achieve optimal health.

Upon assessing an older adult client with a diagnosis of dehydration, which finding would the nurse identify as an early sign of dehydration?

Change in mental status

When assessing a client's blood pressure, obtained via the client's unsupported left arm, which reading error would the nurse expect?

False high reading

In which instances can an adult give consent for a minor's medical treatment? Select all that apply. One, some, or all responses may be correct.

-As the guardian for a ward -As the parent of an unemancipated minor -As an adult for the treatment of their minor brother or sister (if an emergency and parents are not present)

Which information would the nurse provide to a student about the primary level of prevention? Select all that apply. One, some, or all responses may be correct.

-Known as true prevention -Applied to clients who are considered physically and emotionally healthy -Includes health education programs, immunizations, and physical and nutritional fitness activities

Which variable is an internal variable?

Emotional factors

Which statement made by the client would the nurse consider to be an external variable influencing the client's beliefs?

"Please do not include chicken in my diet plan because my religion forbids me to consume meat."

Which key factor would the nurse consider when assessing how a client will cope with body image changes?

Perception of the change

Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues?

Percussion

Which action would the nurse take first when caring for a postoperative client who reports pain?

Perform a focused assessment of the client.

Which activity places a client at risk for hyperthermia?

Performing strenuous activity in high humidity

Which statement made by the client illustrates the love and belonging need based on Maslow's hierarchy of needs?

"I hardly speak to my children because they live in different countries."

Which statement by the student nurse indicates the need for further education about medication administration?

"I should advise the certified medical assistant to administer intravenous medication."

Which recommendation would the nurse make to the parent of a school-age child regarding medication safety?

"Store medications in a locked storage container."

While assessing a client's vascular system, the nurse finds a diminished and barely papable pulse strength. Which documentation would the nurse utilize in this situation?

1+

A client weighed 210 pounds (95.2 kg) on admission to the hospital. After 2 days of diuretic therapy, the client weighs 205.5 pounds (93.2 kg). Which numerical value reflects the liters of fluid excreted by the client? Record your answer using a whole number.

2 L

A dying client is coping with feelings regarding impending death. During which stage of grieving would the nurse primarily use nonverbal interventions?

Acceptance

Which legal charges may be brought against the nurse who applies restraints to force-feed a client with dementia refusing to eat? SATA

Assault malpractice False imprisonment

Which nursing intervention would be the safety priority when administering medication through a client's implanted port?

Assess patency and adequate noncoring needle placement before medication administration.

Which steps would the nurse take when caring for a client to prevent nursing malpractice? Select all that apply. One, some, or all responses may be correct.

Be alert about common sources of client injuries. Gain knowledge regarding current nursing practices. Communicate with the client regarding tests and treatment plans.

When would the nurse have the laboratory obtain a blood sample to determine the peak level of an antibiotic administered by intravenous piggyback (IVPB)?

Between 30 and 60 minutes after a dose

Which significance would the nurse associate with the procedure depicted in the figure?

Evaluating arterial insufficiency

Which possible legal complication might the nurse face in a situation in which intravenous (IV) therapy was administered to the wrong client?

Malpractice

The nurse concludes that a client with a body temperature of 98.6°F (37°C) is experiencing which condition?

Normothermia

The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is incorrect to teach?

To prevent an adult client from getting up at night when there is insufficient staffing on the unit

When conducting an assessment of a client who does not speak English and an interpreter is unavailable, which action would the nurse not utilize?

Using medical terminology

An older client asks, "How do I know that the medications that I take are safe?" Which response by the nurse is correct? Select all that apply. One, some, or all responses may be correct.

-"Ask your health care provider how and when you should be taking your medications." -"Check the name, dose, and instructions about administration of medications each time before leaving the pharmacy." -"Inform your health care provider of the over-the-counter medications, recreational drugs, and amount of alcohol you ingest."

Which question would the nurse ask the client when obtaining their health history? Select all that apply. One, some, or all responses may be correct.

-"Tell me about your food habits. -""Do you use alcohol or tobacco?" -"Have you ever experienced any allergic reactions?"

Which activities would the nurse participate in while providing a primary level of preventive care? Select all that apply. One, some, or all responses may be correct.

-Education about adequate housing and recreation -Education about attention to personality development -Instructions about good standard of nutrition adjusted to developmental phases of life

When the defining characteristics of a client's assessment data apply to more than one diagnosis, which action would the nurse take? Select all that apply. One, some, or all responses may be correct.

-Gather more information. -Identify related factors. -Review all defining characteristics.

Which instructions would the nurse provide an individual about the role an individual plays in health and wellness and its effect? SATA

-Lifestyle choices affect quality of life and well-being. -Individuals should take responsibility for health and wellness by making proper lifestyle choices. -Individuals should realize that illness prevention has a positive economic effect on their lives.

Which feature distinguishes nursing diagnoses from medical diagnoses? Select all that apply. One, some, or all responses may be correct.

-Nursing diagnoses involve the client when possible. -Nursing diagnoses involve the sorting of health problems within the nursing domain. -Nursing diagnoses involve clinical judgment about the client's response to health problems.

Which signs and symptoms are observed in the human body with a decrease in body temperature? Select all that apply. One, some, or all responses may be correct.

-Shivering -Contraction of blood vessels

Which points about restorative care are accurate? SATA

-The restorative health care team consists of health professionals, clients, and the caregiver(s) -Success depends on effective and early collaboration with client and their families Clients and families follow treatment plans better when they are involved in restorative care -restorative care is provided through home health care, rehabilitation, or extended care facilities.

During a falls risk assessment, which action would the nurse take after learning the client experienced a recent fall?

Assess the circumstances of the fall, including feelings and setting

Which figure depicts the nurse locating the client's fifth intercostal space (ICS)?

Client 3

While providing care for four different clients, the nurse assesses their breathing pattern. Which client's assessment findings indicate Cheyne- Stokes respiration?

Client 3

To meet the criteria of ethical practice, which action would the nurse who witnessed the spouse of a client fall take?

Initiate an agency incident report.

Which description does beneficence in health ethics refer to?

Taking positive actions to help others

Which related factor would the nurse attach to a nursing diagnosis?

Trauma of incision

Which information is appropriate to include in education about sentinel events?

Undesirable and largely avoidable

Which nurse's action would prevent aspiration when administering medications through a nasogastric tube?

Verify placement of the nasogastric tube

Which activities are involved in providing a secondary level of preventive care? Select all that apply. One, some, or all responses may be correct.

-Preventing the spread of communicable disease -Providing facilities to limit disability and prevent death -Providing adequate treatment to arrest the disease process

Which information would the registered nurse provide when educating a nursing student about living wills? Select all that apply. One, some, or all responses may be correct.

-Health care workers would always follow the directions of a client's living will. -Clients use living wills to declare any medical procedures they want or do not want when terminally ill. -Living wills are written documents that direct the client's treatments in the event of a terminal illness or condition.

Which fine motor skills may be observed in an 8- to 10-month-old infant? Select all that apply. One, some, or all responses may be correct.

-Using pincer grasp well -Picking up small objects -Showing hand preference

Place the steps of the nursing process in the correct order.

-identify the client's health care needs by collecting subjective and objective data. -Define the nursing diagnoses or collaborative problems clearly. -Plan the care by determining priorities, goals, and expected outcomes of care. -Perform the nursing interventions competently. -Evaluate the effects of the nursing interventions performed.

A client who has liver failure says, "I have complete trust in God, and I am sure he will take care of my family even if I am not here." Which concept would this exemplify?

Faith

While caring for a middle-aged adult client after emergent placement of a colostomy as a result of colorectal cancer, the nurse encourages the client's family members to have a colonoscopy done before age 50 years and annually depending on health care provider recommendations. Which concept is the primary basis for the nurse's recommendations to the client's family?

Genomics

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, and the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of which?

Ice bag

Which intervention would the nurse implement to develop a caring relationship with the client's family?

Identifying the client's family members and their roles

Two nurses are planning to help a client with one-sided weakness move up in bed. Which principle of body mechanics would the nurses observe?

Position the nurses on either side of the bed with their feet apart, gather the turn sheet close to the client, turn toward the head of the bed, and then move the client.

Which act protects a person who is HIV positive?

The Americans with Disabilities Act (ADA)

The nurse is caring for a client who had head and neck surgery. Which complication will the nurse try to prevent by positioning the client's head in functional alignment after surgery?

Wound dehiscence

During an assessment, which client statement may indicate to the nurse that the client is experiencing spiritual distress?

"I deserve a better life than this. I don't understand why God decided to make me ill."

The registered nurse (RN) is evaluating the statements of a new nurse about wound dressings. Which statement made by the new nurse is incorrect?

"I should use the cotton swab placed on the table."

The registered nurse (RN) is teaching a nursing student how to communicate with a client who is cognitively impaired. Which statement(s) made by the nursing student is (are) incorrect? Select all that apply. One, some, or all responses may be correct.

"I should use visual cues." "I should speak in a normal tone of voice." "I should face the client so that my mouth can be seen."

The new nurse is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. Which answer by the nurse is correct?

"Wash your hands before and after any client care."

Which information would the registered nurse provide to a nursing student about licensure? Select all that apply. One, some, or all responses may be correct.

-"The hearing for suspension or revocation of a license is conducted by a panel of professionals." -"Nurses must be notified of any charges they face and given an opportunity to defend themselves." -"The state board of nursing may revoke or suspend a license if a nurse's conduct violates provisions in the licensing statutes."

Which strategies will promote safety and quality of client care on the unit? SATA

-Communicate with clarity and precision when designing multidisciplinary plans of care -Create a safety huddle so all health care professionals are aware of the clinical objectives -Conduct communication simulations to increase knowledge about expertise of other health care disciplines.

The nurse is preparing to insert an intravenous (IV) catheter in a thin, emaciated client who is scheduled to begin intravenous fluid therapy. Which interventions would the nurse follow to provide high-quality care? Select all that apply. One, some, or all responses may be correct.

-Flush the IV line with normal saline -Stop the insertion procedure when there is a break in technique

Which scenarios are examples of slander? Select all that apply. One, some, or all responses may be correct.

-Informing the primary health care provider falsely that a client shows signs of drug abuse -Informing the client's caregivers that the client is aggressive, even though there is no evidence -Warning a colleague that a client displays inappropriate sexual behavior when no such event happened

Which information would the nurse provide to clients regarding benefits of electronic health records (EHRs)? Select all that apply. One, some, or all responses may be correct.

-Obtains Medicare and Medicaid payments -Shares personal health information with selected family members -Provides more accurate diagnoses and treatment in emergency conditions

Which site would the nurse prefer to assess for determing the turgor of an older adult? Select all that apply. One, some, or all responses may be correct.

-On the sternal area -Back of the forearm

Which principle refers to the professional obligation of the nurse to assume responsibility for actions?

Accountability

The registered nurse (RN) is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? Select all that apply. One, some, or all responses may be correct.

Bringing equipment to the client's room Transporting the client to a diagnostic test

Which nursing interventions require the nurse to wear gloves? Select all that apply. One, some, or all responses may be correct.

Cleaning a newborn immediately after delivery Emptying a portable wound drainage system

The nurse assesses four different clients. For which client do the findings indicate the client is at risk for heart disease?

Client 2

Which situation would the nurse address first according to Maslow's hierarchy?

Complains of sleeplessness due to pain postsurgery

The nurse asks an unlicensed assistive personnel (UAP) to provide an ice pack to a client. Which nursing function does this represent?

Delegation

The nurse is preparing to discharge a client who is partially paralyzed after a stroke. Which behaviors would the nurse alert the family of as symptoms of caregiver role strain? Select all that apply. One, some, or all responses may be correct.

Disturbed sleep patterns Reduced appetite and weight Fearful about administering medications to the client

Which nursing behavior is an intentional tort?

Divulging private information about a client's health status to the media

While assessing turgor of a client, which hand position would the nurse utilize?

On the sternum (chest)

When instructing a client to increase his or her potassium intake, which food would the nurse recommend?

Orange

Which client assessment finding would the nurse document as subjective data?

Pain rating of 5

The nurse just arrived on the unit for his shift. Which action would the nurse take first to collect an initial set of data about the clients assigned to the nurse's care?

Participate in the bedside rounds.

The nurse finds that a visually impaired client is having difficulty in determining which medications to take after being discharged from the hospital. Which intervention would be best in this situation?

Recommending that the client's pharmacy relabel the medication in large letters

Which explanation does the nurse use to describe the term "regulatory law" as applied to nursing practice?

Reflects the decisions made by administrative bodies such as state boards of nursing

The nurse is developing a plan of care for the client who has activity intolerance. Which intervention would the nurse do to obtain the desired client outcomes?

Set priorities and outcomes using the client's and family input.

An informed consent has not yet been obtained for an unconscious client scheduled for surgery. Which course of action does the nurse expect to be taken to deal with the situation?

The surrogate decision maker designated by the client will give consent.

The registered nurse (RN) measures the client's blood pressure as 130/80 mm Hg. When the unlicensed assistive personnel (UAP) measured the same client's blood pressure, the measurement was 120/90 mm Hg. Which rationale would explain the measurement difference? SATA

-Poor fitting of the cuff -Deflating the cuff too quickly

Which activities would the nurse perform to meet the client's safety and security needs based on Maslow's hierarchy of needs?

-Positioning the bed in a low position and keeping the side rails up -Monitoring vital signs, such as blood pressure to decrease the risk of falls -Observing a client who has suicidal tendencies to prevent adverse incidents

Which explanation describes a living will?

A written document that directs treatment according to the client's wishes, in case of a terminal illness or condition

The nurse administers an older adult client's medications via gastrostomy tube in the long-term care setting. Which finding would necessitate holding the feedings and medications and notifying the health care provider immediately? Select all that apply. One, some, or all responses may be correct.

Absence of bowel sounds Presence of abdominal distension Residual capacity exceeding 300 mL Positive guaiac test of abdominal contents Seepage of feeding around tracheostomy

The nurse is preparing to perform endotracheal suctioning on a client. Before beginning the procedure, which intervention would the nurse do?

Administer 100% oxygen to the client.

The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+ rating is an expected or normal pulse, and a 4+ rating is a bounding pulse.

An infant receives the rotavirus vaccination in the hospital setting.

A client says, "None of the medications will work on me because I am away from my holy land." Which course of action would the nurse take to comply with teamwork and collaboration competency according to the Quality and Safety Education for Nurses (QSEN)?

Approach the agency chaplain to discuss the spiritual needs of the client.

Which step would the nurse take first when preparing a concept map for as assigned client?

Arrange cues into clusters that form patterns.

When preparing a client for a diagnostic procedure, which action would the nurse take if the client is wearing a religious symbol dangling from a necklace?

Ask the client about the religious symbol and significance of removing it.

Which action by the client indicates the need for further instruction on insulin administration?

Aspirating before administering the dose

When assessing a client reporting shortness of breath, which activity best ensures the nurse obtains accurate and complete data to prevent a nursing diagnostic error?

Assess the client's lungs.

Place the stages of the grieving process according to Kübler-Ross in the correct order.

Denial Anger Bargaining Depression

Which purpose describes the NPA?

Describe and define the legal boundaries of nurse practice w/in each state.

Which factor would the nurse assess for a client reporting constipation? Select all that apply. One, some, or all responses may be correct.

Diet Fluid intake Use of laxatives Date of last bowel movement Use of opioid pain medications

Which information must be clearly described in the medication administration record (MAR) before administering a medication? Select all that apply. One, some, or all responses may be correct.

Dosage and route Client's full name Time to be administered Frequency of administration Full name of prescribed medication

The nurse working in a cardiac center is preparing to enter client data using health information technology. The nurse needs to refer to these data during subsequent follow-up client visits. Which type of record would the nurse use to enter the client's data?

Electronic medical record (EMR)

A 25-year-old client is angry and has several verbal altercations with other clients and then refuses to take prescribed medications. Which intervention is best?

Explain the purpose and benefits of the medication but allow the client to refuse the medication.

Which example describes an intentional tort?

False imprisonment

Which strategy is an example of a passive health promotion?

Fluoridation of municipal drinking water

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. Which pulse strength does this documentation refer to?

Full

Which time would the nurse schedule the blood sample to be obtained when the primary health care provider prescribes trough levels of an antibiotic?

Just before the medication is administered.

A client develops phlebitis after the nurse forgets to monitor the client after administering medication via the central venous access device (CVAD). Which charges may the nurse face for this action?

Malpractice

Which nurse's action is important for establishing good communication with the client who has impaired hearing?

Obtaining the client's attention before speaking

While assessing a client after surgery, which finding would the nurse obtain from the primary source?

Severity of pain

Which variable is an example of an external variable?

Socioeconomic factors

Which scenario is an example of an external variable that influences the health beliefs and practices of clients?

Stops taking medications after the disappearance of symptoms to cut down on medical bills

The nurse creates a plan of care for a client with a risk of infection. Which is the desirable expected outcome for the client?

The client will be free of signs and symptoms of infection by discharge.

When developing a nursing diagnosis for a client after surgery, the nurse documents the "related to" factor as first-time surgery. Which assessment activity enabled the nurse to draw this conclusion?

The nurse asks the client to explain the surgery.

A 3-year-old child with eczema of the face and arms has disregarded the nurse's warnings to "stop scratching, or else!" The nurse finds the toddler scratching so intensely that the arms are bleeding. The nurse then ties the toddler's arms to the crib sides, saying, "I'm going to teach you one way or another." How would the nurse's behavior be interpreted?

These actions can be construed as assault and battery.

While measuring the rectal temperature, the nurse inserts the thermometer probe 2.5 to 3.5 cm int the anus in the direction of the umbilicus. Which is the rationale behind this?

To ensure adequate exposure to the blood vessels

The nurse is caring for a client with a temperature of 104.5°F (40.3°C). The nurse applies a cooling blanket and administers an antipyretic medication. Which is the correct rationale for the nurse's interventions?

To reduce brain metabolism and limit hypoxia

Which information would the nurse provide an older adult and caregivers regarding medication safety? Select all that apply. One, some, or all responses may be correct.

Use a pill organizer. Read all medication labels. Review medications with pharmacist.

The nurse assesses for which client symptoms that indicate hyperthermia? Select all that apply. One, some, or all responses may be correct.

Vasodilation Dry and flushed skin Decreased urinary output

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. Which information would the nurse include in the follow-up incident report?

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

A dying client who has reached the stage of acceptance in the grieving process appears peaceful but demonstrates a lack of involvement with the environment. Which intervention by the nurse would best address this behavior?

Accept the behavior the client is exhibiting.

A registered nurse is teaching a nursing student about the proper techniques of an abdominal assessment. Which order of assessment indicates effective learning?

"I will inspect the surface motion of the abdomen." "I will note the position of the umbilicus." "I will assess for bowel motility by auscultation." "I will palpate to assess for any abdominal tenderness."

The registered nurse (RN) is teaching a nursing student about the process of medication reconciliation for a client who was admitted in a health care setting. Which statement made by the nursing student indicates the need for further teaching?

"I would avoid asking about the client's over-the-counter medications."

The nurse notes a client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8-mm depression after release. In which way would the nurse document the edema?

4+

ction or skill, such as those involved in medication administration. While providing care for a client with heat stroke, the nurse measured and noted the temperature as 109°F. Convert this temperature into Bargaining Depression Celsius and record the number using one decimal place.

42.8°C

A client has a heart rate of 72 beats/min and stroke volume of 70 mL. Which numerical value reflects the client's cardiac output? Record your answer using a whole number.

5040 mL/min

A hospitalized client is scheduled to have a sigmoidoscopy. Which action would the nurse perform before the procedure?

Administering a Fleet enema 1 hour before the procedure

Which is the most important nursing action involved in caring for a client receiving medications?

Administering the medications

Which nursing action establishes the nurse as a caregiver for a client in spiritual distress?

Provides therapeutic treatment to the client

In which scenario is the nurse providing tertiary prevention?

Providing education to a community about the need to integrate individuals' limb amputations into the professional sphere.