PN Learning system fundamentals practice quiz 1 & quiz 2

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following action should the nurse take?

D. Clamp the tubing below the collection port

A nurse on a medical surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? a. Data collection for the client b. Plan of care for the client c. Nursing interventions performed for the client d. Evaluation of the client's progress

a. data collection for the client

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? a. Drop the eye medication into the lower conjunctival sac b. Apply gentle pressure in the outer opening of the eye for 2 min c. Hold the eye dropper 0.5 cm from the cornea d. Instruct the client to close eyes tightly after administration

a. drop the eye medication into the lower conjunctival sac

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? a. Change the topic because the client is trying to divert attention from the illness to the nurse b. Encourage the client to express his thoughts about death and dying c. Tell the client that religious beliefs are personal matter d. Offer to contact the client's minister or the facility chaplain

b encourage the client to express his thoughts about death and dying

A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated? a. Push on a finger nail bed until it blanches, release it, and observe how long it takes the skin to become pink b. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back c. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression d. Measure the skin fold thickness at the upper arm using a pair of calibrated skin fold calipers

b. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back {skin turgor, with dehydration the skin will remain tented}

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? a. Lateral thigh b. Lower abdomen c. Mid-abdominal region d. Medial thigh

b. lower abdomen

A nurse on a medial-surgical unit is caring for a client. which of the following actions should the nurse take first when using the nursing process? a. Identify goals for client care b. Obtain client information c. Document nursing care needs d. Evaluate the effectiveness of care

b. obtain client information

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? a. Encourage the child to cough frequently to clear congestion form anesthesia b. Place a heating pad at the child's neck for comfort c. Administer analgesics to the child on a routine schedule through out the day and night d. Provide the child with ice cream when oral intake is initiated

c. Administer analgesics to the child on a routine schedule through out the day and night

A nurse is preparing to preform oral care for a client who is unresponsive. Which of the following actions should the nurse plan to take? a. Place the client supine b. keep both side rails up c. raise the level of the bed d. inspect the client's mouth using a finger sweep

c. raise the level of the bed

A nurse is contributing to the plan of care of a client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? a. Calibrate the scale weekly b. Use a different scale each time c. Weigh the client on arising d. Weigh the client without clothing

c. weigh the client on arising

A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make? a. Ask your provider to prescribe epoetin before the surgery b. you should take iron supplements prior to the surgery c. Request a family member donate blood for you d. Donate autologous blood before the surgery

d. Donate autologous blood before the surgery

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP? a. The reading will be inaudible if the cuff too small for client b. The width of the cuff bladder should be 75 percent of the circumference of the client's arm c. As long as the cuff will circle the arm the reading will be accurate d. using a cuff that is too small will result in an inaccurately high reading

d. using a cuff that is too small will result in an inaccurately high reading

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take. a. Pull suction catheter back 1 cm if the client starts coughing b. Allow 30 seconds between suctioning passes c. Hyperventilate the client with 50% oxygen for 30 seconds d. Perform a maximum of 4 passes with the suction catheter

a. Pull suction catheter back 1 cm if the client starts coughing

A nurse is planning to administer pain medication to a client who has postoperative pain following abdominal surgery. Which of the following actions should the nurse take first? a. Use the pain scale to determine the client's pain level b. Discuss the adverse effects of pain medication with the client c. obtain the client's vital signs d. Check the client's allergies

a. Use the pain scale to determine the client's pain level

A nurse is caring for a client type 1 dm and is resistant to learn self-injection insulin. Which of the following statements should the nurse make? a. tell me what i can do to help you overcome your fear of giving yourself injection b. I ma sure your provider will not be pleased that you reused to give your self insulin injection c. It's ok, I'm sure your partner will be able to learn how to give you int strain injection yuh d. you wont be abled to go home unless you learn to give self insulin injections

a. tell me what can i do to help you overcome your fear of giving yourself injections

A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. Which of the following statement indicates a lack of readiness to learn by the client? a. The client asks the nurse to repeat the instructions before attempting the exercises b. The client reports severe pain c. The client asks the nurse how ofter deep breathing should be done after surgery d. The client tells the nurse that this exercise will probably be painful after surgery

b. The client reports severe pain

A nurse is drawing blood for laboratory testing form a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? a. Wash the gloved hands and then throw the gloves away b. Prepare an incident report to document the event c. Carefully remove the gloves and follow with hand hygiene d. Ask the provider to order a blood culture to determine the risk of infection

c. Carefully remove the gloves and follow with hand hygiene

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frighted . Which of the following actions should the nurse take first? a. Place an oxygen mask on the client b. Check the client's pulse c. determine whether the client is able to breathe d. Wrap arms around the client from behind

c. Determine whether the client is able to breathe

A nurse is reviewing adult cardiopulmonary resuscitation(CPR) with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when preforming CPR? a. Call for assistance b. begin chest compression c. confirm unresponsiveness d. Give rescue breaths

c. confirm unresponsiveness

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take collecting the specimen? a. Instruct the client to defecate into the toilet bowl b. Transfer the specimen to a sterile container c. Refrigerate the collected specimen d. Place the stool specimen collection container in a biohazard bag

d. Place the stool specimen collection container in a biohazard bag

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? a. Turn on the machine every 15 mins to measure the client's blood pressure b. Recored only blood pressure readings needed for the 15min intervals c. Obtain manual and automatic reading and compare them d. Disconnect the machine

d. disconnect the machine and measure the blood pressure manually every 15 mis

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube b. Position the client on his right side c. Insert the tip of the tubing 8 cm (3.1in) d. Hold the enema container 61 cm (24in) above the rectum

c. insert the tip of the tubing 8 cm (3.1in)

A nurse is assisting with planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy? a. Holding a community clinic to administer influenza immunization b. Screening groups of older adults in nursing care facilities for early influenza c. Educating parents of young children about the dangers of influenza d. Finding rehabilitation programs for older adults who complications form influenza

b. Screening groups of older adults in nursing care facilities for early influenza

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? a. Open all sterile supplies and solutions b. Stabilize the tracheostomy tube c. Don sterile gloves d. Perform hand hygiene

d. perform hand hygiene

A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high-pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. Which of the following heart sounds should the nurse document? a. Audible click b. Murmur c. Third heart sound d. Pericardial friction rub

d. pericardial friction rub {murmur is a swishing sound or whistling. third heart sound is caused by rapid ventricular filling during diastole}

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? a. Auscultate for the blood pressure at the dorsalis pedis artery. b. Measure the blood pressure with the client sitting on the side of the bed c. Place the cuff 7.6 cm above the popliteal artery d. Place the bladder of the cuff over the posterior aspect of the thigh

d. place the bladder of the cuff over the posterior aspect of the thigh

A nurse is collecting data for a client who has a decreased circulation in his left leg. Which of the following actions should the nurse take first? a. Evaluate pedal pulses b. Obtain a medical history c. Measure vital signs d. Ask the client if he is experiencing any pain in the leg

a. evaluate pedal pulse

A nurse is changing the dressings for a client who has two penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? a. Abdominal binder b. Montgomery straps c. Hypoallergenic tape d. Plastic tape

b. Montgomery straps

A nurse is an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? a. My parents are retired, and they have come to help out with our children b. I am going to ask my husband to go to counseling with me c. I keep having nightmares about upcoming surgery d. My girlfriend bought me a nice wig

c. I keep having nightmare about my upcoming surgery

A nurse is caring for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse plan to take when obtaining the specimen? a. Collect the specimen upon arising in the morning b. Force fluids during the day and collect the specimen in the evening c. Collect the specimen after antibiotics have been started d. collect 2 mL of sputum before sending the specimen to the laboratory

a. Collect the specimen upon arising in the morning

A nurse is reinforcing teaching with a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? a. I should expect my heart rate to take longer to return to normal after exercise as i get older b. Urinary incontinence is something i will have to live with as i grow older c. I can expect to have less ear wax as i get older d. My stomach will empty more quickly after meals as i grow older

a. I should expect my heart rate to take longer to return to normal after exercise as i get older

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed? a. Lock the wheels on the bed and stretcher b. Instruct the client to raise his arms above his head c. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. d. Log roll the client

a. Lock the wheels on the bed and stretcher

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first? a. Remove the sleeve of the gown from the arm without the IV line b. slow the infusion using the roller clamp c. Disconnect the IV line from the pump d. Bring the IV solution and tubing from the outside to the end side of the sleeve

a. Remove the sleeve of the gown from the arm without the IV line

A nurse is instructing an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? a. There are times i should use soap and water rather than an alcohol based hand rub to clean my hands b. I will use cold water when i wash my hands to protect my skin from becoming too dry c. I will apply friction for at lease 10 seconds while washing my hands d. After washing my hands i will dry them from the elbows down

a. There are times i should use soap and water rather than an alcohol based hand rub to clean my hands

A nurse is caring for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. client who has heart failure and is receiving 100% oxygen via a partial rebreather mask b. A client who has emphysema and is receiving humidified oxygen at 3 L/min via a transtracheal oxygen cannula c. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar d. A client who has COPD and is receiving oxygen at 2L/min via nasal cannula

a. a client who has heart failure and is receiving 100% oxygen via a partial rebreather mask

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? a. Attempt to increase the clients self motivation b. Keep detailed records of each client's progress c. Test client learning after each teaching session d. Avoid discussing areas that might cause client anxiety

a. attempt to increase the client's self motivation

A nurse is reinforcing teaching with a client who is recovering from gallbladder surgery about how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? a. Exhale slowly to reach goal volume b. Hold breath for 5 seconds after goal volume is reached c. Continue to deep breathe between each cycle d. Limit repeat pattern fo breathing to 5 breaths

b. Hold breath for 5 seconds volume is reached

A charge nurse is observing a newly licensed nurse perform tracheostomy fro a client. Which of the following actions by the newly licensed nurse requires intervention? a. Obtaining hydrogen peroxide for the tracheostomy care b. Obtaining cotton balls for the tracheostomy care c. Obtaining sterile gloves for hte tracheostomy care d, Obtain a sterile brush for the tracheostomy care

b. Obtaining cotton balls for the tracheostomy care

A nurse is preparing to administer an intramuscular injection to a client who is overweight . Which of the following sites should the nurse select fro the injection? a. The lower, medial quadrant of the buttock near the coccyx b. The side hip between the iliac crest and anterior iliac spine c. The tissue of the posterior upper arm d. The lower , inner thigh, 2 finger widths above the patella

b. The side hip between the iliac crest and anterior iliac spine

A nurse is performing a straight urinary catheterization for a female client who has urinary retention> which of the following actions indicates the nurse is maintaining sterile technique? a. Applies sterile gloves to open catheter package b. Wipes the labia minora in an anteroposterior direction c. Spreads the labia with the dominant hand d. Uses one cotton ball to wipe the right and left labia majora

b. Wipe the labia minora in an anteroposterior direction

A nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect? a. frequent bowel sounds with flatus b. absent bowel sounds with distention c. Hyperactive bowel sounds with diarrhea d. Normal bowel sounds with increased peristalsis

b. absent bowel sounds with distention

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed bed to a wheelchair. Which of the following techniques should the nurse use? a. stand toward the client's stronger side b. Instruct the client to lean backward form the hips c. Place the wheelchair at a 45 degree angle to the bed d. Assume a narrow stance with feet 15 cm (6 in) apart

c. Place the wheelchair at a 45degree angle to the bed

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? a. Auscultate for bowel sounds after each feeding b. ensure the formula is cold before administering c. Elevate the clients head of bed 45 degree before the feeding d. Flush the tubing with 15mL of water after the enteral feeding

c. elevate the client's head of bed 45 degree before the feeding

A nurse at a screen clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? a. Fifth intercostal space just medial to the midclavicular line b. Second intercostal space to the left of the sternum c. Fifth intercostal space to the left of the sternum d. Second intercostal space to the right of the sternum

d. Second intercostal space to the right of the sternum

A nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and who may have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? a. Rectal b. Tympanic c. Oral d. Temporal

d. Temporal { not as accurate temperature, in a toddler who may have ear infection and who is having diarrhea}

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? a. The nurse washes each part of her hands with five strokes b. The nurse washes from the elbows down to the hands c. The nurse washes with her hands held higher than her elbows d. The nurse uses minimal friction when washing her hands

d. The nurse washes with her hands held higher than her elbows. { a surgical hand washing technique should was hands held higher than elbows so that water and soapsuds drain away from the clean area toward dirty area}

A nurse is caring for a client who has a major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? a. Apply a fecal collection system b. Apply a barrier cream c. Cleanse and dry the area Check the client's perineum

d. check the client's perineum

A nurse is collecting data for an adult client. Identify the correct sequence of steps used for data collection of the abdomen. ( move the sequence of steps into box) a. inspection b. palpation c. percussion d. Auscultation

a. inspection d. auscultation c. percussion b. palpation

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first ? a. Start chest compressions b. Provide breaths with a manual resuscitation bag c. Administer oxygen d. Establish an airway

a. start chest compression

A nurse is reinforcing teaching with a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? a. The involvement of the client in planning the charge b. The emphasis the provider places on the dietary changes c. The learning theory the nurse uses to teach the dietary changes d. The extent of the dietary changes planned for the client

a. the involvement of the client in planning the change

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? a. use a gait belt during ambulation b. Ensure the client is wearing socks before ambulating c. Instruct the client to sit on the edge of the bed for 15 seconds before ambulating d. Walk 2 feet behind the client during ambulation

a. use a gait belt during ambulation

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? a. Place the soiled linens on the chair while making the bed b. Hold the linens away from the body and clothing c. Place the linens on the floor until able to place it in a linen bag d. Shake the clean linens to unfold

b. hold the linens away from the body and clothing

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? a.. Measure the pulse using a doppler ultrasound stethoscope b. check the client's pedal pulses c. Count the apical pulse rate for 1 min, and full minute. and describe the rhythm in the chart d. Take the pulse at each peripheral site and count the rate for 30 seconds

c. count the apical pulse rate for 1 minute and describe the rhythm in the chart

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? a. Hold the irrigator 1.25 cm (0.5in) above the eye b. direct the irrigation solution upward towards the upper eyelid c. Expert pressure on the bony prominences when holding the eyelids open d. Direct the irrigation from the outer canthus to the inner canthus of the eye

c. exert pressure on the bony prominences when holding the eyelids open

A nurse is caring for an older adult client who is violent and attempting the disconnect her iv lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? a. Tie the restraints the the side rails b. Perform range of motion exercises to the wrists every 3 hr c. Remove the restraint one at a time d. Obtain a PRN prescription for the restraints

c. remove restraints one at a time

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? a. Contact the family and ask them to stay with the client b. Offer to call the client's minister c. Sit and hold the client's hand d. Leave the room and allow the client to cry privately

c. sit and hold the client's hand

A nurse is reinforcing teaching with an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? a. Drink a minimum of 1,000 ml of fluid daily b. Increase your intake of refined -fiber foods c. Sit on the toilet 30 mins after eating a meal d. Take a laxative every day to maintain regularity

c. sit on the toilet 30 minutes after eating a meal

A nurse is collecting data from a client who reports abdominal pain. Further findings reveal the client has a temperature of 39.2 c (102.6f) , a heart rate of 105/min, a soft non-tender abdomen , and menses over due by 2 days. Which of the following findings should be the nurse's priorty? a. Heart rate of 105 b. Soft, non-tender abdomen c. Temperature d. Over due menses

c. temperature

A nurse is collecting data from a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? a. Does the medication you're taking relieve the pain b. can you point to where the pain is the worst? c. What do you think caused the onset of your pain d. Changing positions makes your pain worse, right?

c. what do you think caused the onset of your pain { this is a question that is not a closed conversation cus of the variety of answers}

A nurse is witnessing a client signing an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? a. The client fully understands the providers explanation of the procedure b. The client has been informed about the risks and benefits of the procedure c. The nurse witnessed the provider's explanation of the procedure d. The signature on the preoperative consent form is the client's

d. The signature on the preoperative consent form is the client's

A nurses is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make? a. It's for your safety. Dentures can slip and block your airway during surgery. b. You wouldn't want your teeth to be lost or broken during surgery, would you? c. The anesthesiologist requires everyone to remove their dentures. d. What worries you about being without your teeth

d. What worries you about being without your teeth?

A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? a. Explain the x-ray procedure to the client b. Help the client into a wheelchair before the transporter arrives c. Ask if the client has any questions d. Identify the client using two identifiers

d. identify the client using two identifiers

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take? a. Tell the client it is too late for her to change her mind because the surgery is already scheduled b. Telephone the operating room and cancel the surgery c. Inform the client's family about the situation d. Notify the provider about the client's decision

d. notify the provider about the client's decision {acting as the client advocate, nurse should support client decision}