ate practice test

A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following? Bone density Joint flexibility Muscle strength Muscle mass

Joint flexibility

A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome?

Planning

A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?

Tachycardia Manifestations of circulatory overload can include tachycardia, crackles in lungs, cough, pallor, and edema.

A nurse is reviewing the medical history of a client who is scheduled for surgery. Which of the following findings places the client at risk for an incisional hematoma?

The client takes anticoagulant medications. Anticoagulant medications interfere with blood clotting mechanisms and place the client at risk for a he

A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first?

Check the blood pressure with the client in a supine position.

a nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

the client who has a nasogastric tube to suction

Which of the following teaching methods is based on the cognitive domain of learning? Give the client printed information describing diabetes mellitus. Engage in a question-and-answer session with the client. Ask the client how they feel about checking their blood glucose. Ask the client to demonstrate checking their blood glucose level. Give the client a fill-in-the blank quiz. Ask the client to describe the manifestations of hypoglycemia and hyperglycemia.

When taking actions, the nurse should identify that giving the client printed information describing diabetes mellitus, engaging in a question-and-answer session with the client, giving the client a fill-in-the blank quiz, and asking the client to describe the manifestations of hypoglycemia and hyperglycemia are teaching methods based on the cognitive domain of learnin

A nurse is preparing to administer an ophthalmic medication to a client. Which of the following actions should the nurse plan take?

Apply pressure to the client's nasolacrimal duct after instillation.

A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take?

Choose a finger with a capillary refill less than 2 sec. The nurse should choose a site with adequate perfusion to obtain an accurate reading.

A nurse is assessing a client who has an oral temperature of 39? C (102.2? F). Which of the following findings should the nurse expect?

Heart rate 108/min

A nurse is observing a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? Holds their hands below the elbows while rinsing off soap Uses hot water to wash their hands Turns off the faucet with their hands Washes their hands for 10 seconds

Holds their hands below the elbows while rinsing off soap

A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Obtain a daily weight on a client who has heart failure. they can't do much

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

Partial-thickness skin loss with red tissue in wound bed.

A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication?

The client reports dizziness when ambulating to the bathroom.

A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply. Grab bar in bathroom Electrical cord on floor over walkway Uses a cane to ambulate Macular degeneration Throw rugs in kitchen

When analyzing cues, the nurse should identify that macular degeneration, electrical cord on floor over walkway, and throw rugs in the kitchen are findings that increases the client's risk for falls

A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments? Diabetic retinopathy Glaucoma Macular degeneration Cataracts

cataracts

A nurse is teaching a class about routes of medication administration. The nurse should include that which of the following routes has the fastest rate of absorption?

intravenous

A nurse is teaching a client who has a new prescription for zolpidem. The nurse should instruct the client that which of the following is an adverse effect of zolpidem? Hypertension Urinary retention Memory loss Dry mouth

memory loss

A nurse is teaching a client how to walk using a walker. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse utilizing?

return demonstration

A nurse is teaching a class about pharmacodynamics. The nurse should include that which of the following medication levels occurs when a medication is at the lowest serum concentration?

trough

A nurse is caring for a client whose partner has recently died. The client states, "I am learning how to pay my own bills." The nurse should identify that the client is experiencing which of the following tasks in Worden's Four Tasks of Grieving? Experiencing the pain of grief Finding an enduring connection while embarking on a new life Adjusting to an environment without the deceased Accepting the reality of the loss

Adjusting to an environment without the deceased

A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?

The client seems to be more comfortable performing self-administration of insulin. This statement reflects the nurse's opinion and should be revised. The American Nurses Association standards for documentation state that entries into a client's medical record must be factual, accurate, complete, timely and organized.

A nurse is using the NURSE mnemonic when speaking with a client who is experiencing grief. The client reports that they are feeling overwhelmed. Which of the following responses by the nurse demonstrates the "E" in the NURSE mnemonic? "You have so much to deal with. How can I be of help to you?" "Tell me more about how you are feeling." "It sounds like you are exhausted." "It is impressive how you have managed to deal with this situation."

"Tell me more about how you are feeling." This statement demonstrates the concept of exploring in the NURSE mnemonic. The nurse asks an open-ended question, providing an opportunity for the client to express their feelings in more detail.

A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first?

A client who has a new onset of atrial fibrillation and a heart rate of 152/min.

A nurse is receiving report on a group of clients. Using the ABCDE priority framework, which of the following clients should the nurse see first?

A client who has pneumonia and has developed wheezing.

A nurse is teaching a client who is at risk for hypokalemia. The nurse should instruct the client that which of the following foods is the best source of potassium? Banana Avacado Spinach Baked potato

Baked potato

A nurse is documenting in a client's health record using the subjective, objective, assessment, and plan (SOAP) charting model. Which of the following information should be included in the subjective component? Client reports chest pain after mowing lawn this morning Client administered nitroglycerin 0.3 mg SL for chest pain Client's blood pressure is 182/98 mm Hg Client's skin is pale and diaphoretic

Client reports chest pain after mowing lawn this morning

A nurse is teaching a class about expected physiological changes in older adult clients. Which of the following changes should the nurse include?

Decrease in body fat

A nurse is teaching a client who wishes to stop smoking cigarettes. Which of the following teaching methods uses the affective domain of learning? Encourage the client to share their feelings about smoking cessation. Create short term goals to assist the client in smoking cessation. Review strategies for smoking cessation with the client. Discuss the benefits of smoking cessation with the client.

Encourage the client to share their feelings about smoking cessation. "affective feelings"

A nurse is teaching a class about sleep disorders. The nurse should include that which of the following conditions can cause obstructive sleep apnea (OSA)?

Enlarged tonsils

A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Inspects the sterile package for holes before opening

A nurse in a community health clinic is interviewing a couple who just lost their house in a fire. Using the priority framework of Maslow's hierarchy of needs, which category should the nurse identify for the clients' situation?

Physiological

A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take? Connect the drain to continuous low-pressure suction. Empty the drainage device when it is half full. Place a perforated gauze pad around the drain. Clean the skin near the drain in a circular motion from the outside to the inside.

Place a perforated gauze pad around the drain.

A nurse on a medical unit is reviewing the laboratory reports for a client. Which of the following laboratory values is the priority to report to the provider? Creatinine 0.4 mg/dL BUN 9.5 mg/dL Potassium level 3 mEq/L Sodium 135 mEq/L

Potassium level 3 mEq/L

A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take? Massage the client's bony prominences. Elevate the head of the client's bed 45° Reposition the client every 4 hr. Provide the client with a high-calorie diet.

Provide the client with a high-calorie diet. The nurse should provide the client with a high-calorie diet to promote wound healing and strengthen tissue to reduce the risk for a pressure injury.

A nurse is teaching a class about reducing the risk of medication errors. Which of the following information should the nurse include?

Provide the nurse administering medications with an identifying vest.

A nurse is preparing to perform hand hygiene with an alcohol-based hand sanitizer. Which of the following actions should the nurse plan to take?

Rub hands together for 20 seconds.

A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

Skin edges of the wound are sutured closed.

A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates an understanding of body mechanics?

They stand close to the object being moved. (bend at the knees)

A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in?

planning

a nurse is caring for a client who is taking lisinopril. what is the therapeutic effect

decreased blood pressure

A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect? Hypothermia Decreased bowel sounds Rigid abdomen Dehydration

dehydration

A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?

"A tuning fork is placed on my head."

A nurse is documenting client care including only unexpected findings related to the client's condition. Which of the following documentation methods is the nurse utilizing?

Charting by exception (CBE) The nurse is utilizing the charting by exception (CBE) method for documenting in the client's health record. CBE focuses on documenting only unusual or unexpected findings related to the client's problem.

A nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). Which of the following roles is the nurse performing?

researcher

A nurse is teaching a client how to use crutches. Which of the following interventions uses the psychomotor domain of learning? Encourage the client to ask questions about walking with crutches. Show the client a video on walking with crutches. Ask the client to demonstrate walking with crutches. Describe the steps of walking with crutches for the client.

Ask the client to demonstrate walking with crutches. Having the client demonstrate walking with crutches utilizes the development of physical movement and coordination associated with the psychomotor domain of learning.