Dynamic Testing Questions
supine position
lying on back, facing upward-prevents foot drop
62. A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? carminativeexpels flatus (gas) hypertoniccleanses oil retention sodium polystyrene sulfatehigh potassium levels
oil retention
To ensure proper distribution of ear medication after instillation, what will the nurse instruct an adult patient to do?
Instill the medication after gently pulling the ear up and back.
Describe RACE
Rescue alarm contain evaulate
WBC
carry oxygen
Primary prevention means
decreasing the risk for the development of disease by changing behaviors. lowers the chance a disease will occur
prone position
lying face down-promotes relaxation -promotes drainage from mouth
What is proper body mechanics
Stand as close to the object keep abdominal muscles in contrast look straight ahead bend hips slightly push up from knees
hematocrit
proportion of red blood cells to fluid component, plasma in blood
12. A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teachingT: "Ill wear nonsterile gloves" "Ill use adhesive remover each time" Ill take my pain pill after I change the dressing"expected pain a pain Ill fold the dressing with the soiled surface facing outward"
"Ill wear nonsterile gloves"
41. A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse? "Water helps clear the tube so it doesn't get clogged." "Flushing helps make sure the tube stays in place. "This will help you get enough fluids. Adding water makes the formula less concentrated."
"Water helps clear the tube so it doesn't get clogged."
49.After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." The nurse should document this finding when a client's pulses have which of the following qualities?
Bounding 4+ indicates bounding
Signs of HYPERcalcemia meaning increase in calcium
Depressed deep tendon reflexes too much calcium leads to hypercalcemia meaning depressed deep tenson reflexes, nausea, vomiting, bone pain
20. A nurse is caring for a client who is producing large amounts of urine. the nurse should document this finding as which of the following? Retention Oliguria Diuresis -Dysuria--
Diuresis
54. A nurse is auscultating a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take? Limit the client's fluid intake Assist the client into a supine Administer oxygen at 2 L/min administer to someone who has SOB or displaying oxygen saturation level below Encourage the client to cough
Encourage the client to coughl
10. A nurse is performing eye irrigation for a client who has been exposed to smoke and ash. Which action should the nurse take?
Exert pressure on the bony prominence when holding the eyelids open.hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating
The nurses identifies who has the first nurse pioneer credited with first using evidence based practice in caring for clients?
Florence Nightingale
11. A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following devices can safely undergo an magnetic resonance imaging (MRI)? Coronary artery stent Aneurysm clipt Hearing aids Automated internal defibrillator
Hearing aids
26. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? Hemolytic Febrile Circulatory overload Sepsis
Hemolytic
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? Exhale slowly to reach the goal volume Hold breath for 5 seconds after goal volume is reached. Continue to breathe deeply between each cycle Limit the repeat pattern of breathing to 5 breaths
Hold breath for 5 seconds after goal volume is reached.
60. A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take? Assign the client to a private room Keep 4 side rails up while the client in in bed Monitor the client at least once every hour frequently monitor for fall risk Request a PRN prescription for restraint
Monitor the client at least once every hour frequently monitor for fall risk
A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The patient's family wants the patient to have a new surgical procedure. The nurse explains the risks and benefits of the surgery to the family and discusses the patient's wishes with them. The nurse is acting as the patient's: educator advocate caregiver communicator
advocate
9. A nurse is using a portable ultrasound bladder scanner to measure a clients post void residual volume. Which of the following actions should the nurse take? Have the client urinate 20 mins before the scan F: Assist the client into a semi-fowler's position F: position the scanner head at the symphysis pubis apply light pressure to the scanner head once it is in position
apply light pressure to the scanner head once it is in position
A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? -instruct the client to blink several time after instilling the medication close the eyes gently and avoid blinking after instilling to prevent loss of medications -ask the client to look straight ahead during the instillation of the medication -apply pressure to the puncta after instilling the medication TO ENSURE MEDICATION IS ABSORED -place each drop of the medication directly onto the client's cornea place into the conjunctival sac and take measure to protect the cornea
apply pressure to the puncta after instilling the medication TO ENSURE MEDICATION IS ABSORED
What are the correct steps of the nursing process
assessment analysis planning implentation evaulation
egress assessment
back and forth motion
The nurse should keep their hands _____ the elbows while rinsing off the soap so water flows from the most contaminated to the least
below
Red blood cells
carry oxygen
52. A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?
check the client's perineum
At what stage does the nurse first develop the ability to prioritize tasks based one experience?
competent
75. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take ? Consult the medication reference book available on the unit Ask a more experienced nurse for information Call the provider and verify prescription Ask the client if she takes medication at home
consult the medication reference book available on the unit
A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the laboratory findings should the nurse expect? Chvostek is contraction of facial muscles. Positive sign means HYPOcalcemia
decreased calcium is necessary for nerve conduction and muscle. If muscles twitches this is a sign
Nurse Practice Act (NPA)
defines the scope and limitations of professional nursing practice; vary from state to state-overseen by State Boards of nursing -protect public health, safety and welfare
dysphagia
difficulty swallowing
Describe Flank pain
discomfort, distress, or agony
Secondary prevention is what
discovering disease before they progress example blood pressure, mammogram
droplet precautions
droplets > 5 um, being w/in 3 feet of pt- mask or respirator- flu, pertussis
55. 7. A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body? heart uses inspection, palpation, and auscultation for the heart lungs determines the density of the underlying tissue. Produces resonance or dullness normal sound is tympanic thyroid gland inspection and palpation skin inspection and palpation
lungs-determines the density of the underlying tissue
31. A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next? document the findings measure the client's apical and radial pulse rate to determine if there is pulse deficit Talk with the client about factors that affect the pulse rate Notify the provider about the client's radial pulse rate
measure the client's apical and radial pulse rate to determine if there is pulse deficit
44. A nurse is caring for a client who is postop following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions? From the middle of the thigh toward the wound From the left lower abdominal quadrant toward the wound From the left hip towards the wound From the wound toward the surrounding skin
nurse should cleanse surgical wound from the least contaminated location (inside) towards the most contaminated (surrounding skill) to avoid the spread
19. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? auscultate for the blood pressure at the dorsails pedis artery should auscultate the BP at the popliteal artery measure the blood pressure with the client sitting on the side of the bed Why because be measured with the client prone or supine with knee flexed place the cuff 7.6 cm (3") above the popliteal arteryshould be placed ABOVE 2.5 the popliteal artery place the bladder of the cuff over the posterior aspect of the thigh correct position when measuring a lower extremity blood pressure
place the bladder of the cuff over the posterior aspect of the thigh correct position when measuring a lower extremity blood pressure
When using the five rights of delegation which of the following should the nurse use to ensure safety?
right task
59. A nurse is evaluating a clients use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment? the client places crutches on each side when assuming a sitting position place crutches in one hand and use the other hand to grip a chair the client moves the affected side first when descending move onto a step when descending then move follow affected leg the client places weight on the axillae when walking avoid placing weight the client has slightly flexed elbows when ambulating slightly flexed elbows when ambulating with crutches.
the client has slightly flexed elbows when ambulating slightly flexed elbows when ambulating with crutches.
Normal lung sounds are
tympanic
Clara Barton is responsible for
the Red Cross
airborne precautions
- droplets < 5 um- private room negative-pressure airflow mask or respiratory protection device (N95)- TB, measles, chickenpox, disseminated herpes zoster,
23. A nurse is assessing a client's nutritional status. The nurse determines the client is consuming 500 calories more per day than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5 kg (10 lb)? 10 month- 5 months 5 weeks 10 weeks
10 weeks
7. A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?T. Vesicular F. Bronchial F. Rhonchi/gurgling sounds: F. Bronchovesicular:
Vesicular
8. A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client? - Test for the presence of the clients gag reflex Place the client in the supine position. Use a firm toothbrush for tooth and gum care Use a 2 gauze wrapped fingers to hold the mouth open
- Test for the presence of the clients gag reflex
contact precautions
- direct patient or environmental contact- gloves, gown- colonization of infection with multb drug-resistant organisms (MRSA, VRE, C.Diff, major wound infections, herpes, etc)
Romberg test
-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed-expected finding: client should be able to stand with minimal swaying for at least 5 seconds
A nurse is teaching a client how to use an albuterol metered dose inhaler. After removing the cap from the inhaler and shaking the canister, identify the sequence of instructions the nurse should give the client.
1. The client should hold the mouthpiece 2-4 cm (1-2 in) from his mouth 2. Tilt his head back slightly, and then open his mouth 3. Next, he should depress the medication canister while taking a deep breath to facilitate delivery of the medication through the airway 4. After holding his breath for 10 seconds, the client should resume his usual breathing pattern.
45. A nurse is admitting a client who has tuberculosis. In addition to standard precautions which of the following transmission-based precautions should the nurse add to the client's care plan?
Airbourne requires Airbourne precautions (prevents the spread of infection via small droplets
A nurse in an urgent care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection. The clients parent is unavailable, but the clients grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? Explain treatment can wait Inform the grandmother she can give consent Invoke the principle of implied consent and prepare client for treatment client Ask the adolescent to sign in some situations the minor can give consent
Ask the adolescent to sign
72. A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?T--> Ask why the client is refusing the pain medication Administer a PRN antianxiety medication Assist the client in changing positions Offer the client a heat or cold pack to place on painful areas
Ask why the client is refusing the pain medication. According to nurse processing ASSESSMENT should be completed first
A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? Clean the incision from bottom to top Apply sterile gloved prior to opening dressing packages Remove the tape by pulling away from the wound Clean the drain site from the center outward
Clean the drain site from the center outward clean the drain site from the center outwards to avoid spreading microorganisms from the peripheral wound into the center
32. During a physical examination of a client, the nurse suspects strabismus (hypertropia meaning eye crossing over). Which of the following tests should the nurse use to collect additional data? Confrontation compares the visual fields of the client's with that of examiner Symmetry of palpebral fissures space between the eyelids Corneal light reflex Accommodation test determines whether the client's pupil constrict as they focus on an object
Corneal light reflex nurse shines the penlight into at the client's eyes and visualize whether the light shines on the same spot bilaterally. With this disease the client's eye will NOT align
30. A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select? Select a vein in the client's dominant arm choose the most proximal vein in the extremity choose a vein that is soft on palpation select a site distal to previous venipuncture attempts
choose a vein that is soft on palpation
57. A nurse is collecting a specimen for culture from a client infected wound. Which of the following actions should the nurse perform? wear sterile gloves wear cleanse the wound with 0.9% sodium chloride irrigation allow the collection swab to absorb old excudate rotate the collection swab over the edges of the wound
cleanse the wound with 0.9% sodium chloride irrigation
58. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes using an electronic BP machine. The nurse notices the machine begins to measure BP at varied intervals and readings are inconsistent. which action should the nurse take? What keeps the client safest Turn on the machine every 15 minutes to measure the BP. Record only BP readings needed for the 15-min intervals. Obtain manual and automatic readings & compare them.machine is Disconnect the machine, measure the BP manually every 15 minutes if the nurse questions the machine a manual process should be done.
Disconnect the machine, measure the BP manually every 15 minutes if the nurse questions the machine a manual process should be done.
66. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? Auscultate bowel movements AFTER each feeding ensure the formula is cold Elevate the head of the bed to 45 Flush the tubing with 15ml of water after enteral feeding flush with 30ml of water
Elevate the head of the bed to 45
46. A nurse is preparing to administer an otic (ear) antibiotic to an adult who has otitis media. Which of the following actions should the nurse take? Hold the dropper 1cm above the ear canal Because should administer the otic medication by holding it above the ear canal Apply pressure to the nasolacrimal duct following administration Because done during EAR administration NOT ear Place a cotton ball into the ear canal for 30 mins straighten the ear canal by pulling the auricle down and back prior to administration this is used for a child.
Hold the dropper 1cm above the ear canal Because should administer the otic medication by holding it above the ear canal
A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make? It provides a distraction from the pain"not a TENS method It modulates the transmission of the pain impulse It promotes increased circulation to the painful area it elicits a relaxation response"not a TENs method
It modulates the transmission of the pain impulse
2. A nurse is caring for a client who has a temperature of 38.7 C (101.7 F). Which of the following actions should the nurse take? Apply an alcohol-water solution to the client's skin. Keep the client's bed linens dry. Apply ice packs to the groin Limit the client's fluid intake to 1183ml of fluid per day.
Keep the client's bed linens dry.
Pulse Rate
how fast the rate is going measured at apical and radial
Chvostek is contraction of facial muscles. Positive sign means
hypocalcemia
Hemoglobin
O2-carrying protein in red blood cells
74. A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? Encourage the client to drink fluids before swallowing food. Offer the client tart or sour foods first Tilt the clients head backward when swallowing Turn on the television
Offer the client tart or sour foods first
24. A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings? (determines the STRENGTH not the rate) Peripheral pulses equal bilaterally at a rate of 60/min Radial, brachial, and pedal pulses bilaterally weak Peripheral pulses bilaterally, symmetric, equal, and strong in all 4 extremitiesa Brachial, radial, popliteal and dorsalis pedis pulses regular, 58, and bilaterally palpable.
Peripheral pulses bilaterally, symmetric, equal, and strong in all 4 extremities
Maslow's hierarchy of needs
Physiological safety loving and belonging esteem self actualization
A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurses take? Select all that apply Carefully reinsert the intestine through the opening in the wound Place the client in a supine position with the hips and knees flexed Leave the room to call the surgeon Cover the wound and intestine with a sterile, moistened dressings Monitor the client for manifestations of shock
Place the client in a supine position with the hips and knees flexed Cover the wound and intestine with a sterile, moistened dressings Monitor the client for manifestations of shock
31. A nurse is preparing to administer a partial dose of prefilled opioid analgesic parenterally to a client. Which actions should nurse take? Return the unused portion of the medication to the pharmacy dispose of the waste medication into a sharps container. Record the amount of medication wasted on the controlled substance inventory record Ask an AP to witness the wasting of the controlled substance
Record the amount of medication wasted on the controlled substance inventory record two nurses should sign the controlled substance inventory record to document the medication wasted
30. A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? Select all that apply Coat the tip of the tube with a water-soluble lubricant. Ask the client to swallow water while the tube enters her throat Place the coiled tube in ice chips prior to insertion Tell the client to tilt her head backwards as insertion begins Instruct the client to bear down during insertion
T--Coat the tip of the tube with a water-soluble lubricant Why lubricate the tube to ease the passage. NO petroleum jelly T--Ask the client to swallow water while the tube enters her throat swallowing water reduces the risk of gagging and aspiration and helps propel the tube down esophagus T--Tell the client to tilt her head backwards as insertion begins
18. A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? Increased blood pressure Why: expected result is increased blood pressure and heart rate due to stress Decreased blood glucose level F: Decreased oxygen use an increased of oxygen is an expected finding F: Increased gastrointestinal motility decreased gastrointestinal motility resulting in constipation and flatus (gas)
T: Increased blood pressure
4. A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take?F: Give the client a bronchodilator immediately after the procedure Position the client for drainage of secretions by gravity schedule postural drainage after meals instruct the client regrading the importance of fluid restrictions
T: Position the client for drainage of secretions by gravity
53. 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?
The nurse washes with her hands held higher than her elbows.BECAUSE water and soapsuds can drain away from the clean area towards the dirty
64. A nurse is applying antiembolic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? Roll the stocking partially down if too long.apply another stocking size if too big Remove the stocking once per day.remove each shift to look Bunch and pull the stocking halfway up the calf. Turn the stockings inside out up to the heel before applying.makes the applying the stocking easier and causes fewer constrictive wrinkles
Turn the stockings inside out up to the heel before applying.makes the applying the stocking easier and causes fewer constrictive wrinkles
Fowler's position
a semi-sitting position; the head of the bed is raised between 45 and 60 degrees-useful during procedures -better chest expansion
The nurse is preparing to administer ear drops to a 2 year old client. The nurse would pull the pinna in which direction?
down and backward
To palpate
examine a part of the body by touch
11. A nurse is preparing to insert a NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? Give the client water Assist the client into a sitting position explain the procedure to the client Measure the length of the tube
explain the procedure to the client
Peripheral Pulses
focuses on the strength, equality, and symmetrical includes radial, brachial, ulnar
A client is admitted to a medical unit for a home-acquired pressure ulcer. The client has Alzheimer's disease & has been incontinent of urine. The nurse inserts a Foley catheter. You will identify a link in the infection chain as: A. restraints. B. poor hygiene. C. Foley catheter bag. D. improper positioning
foley catheter bag
A nurse is caring for a client who wants to quit smoking. The nurse provides information about ways to quit smoking. What roles is the nurse playing advocate collaborator change manager health promotor nurse educator
health promoter nurse educator
14. A nurse is caring for a client who is 48 hours postoperative following a small bowel resection. The client reports gain pain in the periumbilical area. The nurse should plan care based on which of the following factors contributing to postoperative complication? Blood Loss;can cause shock but doesn't contribute to findings demonstrated by this client NPO Status after surgery can cause dehydration but doesn't contribute to findings nasogastric tube suctioning keeps the stomach and intestines decompressed and can prevent the findings demonstrated by this client impaired peristalsis of intestines:
impaired peristalsis of intestines: Why because normal bowel movements are delayed for up to several days following bowel resection. If peristalsis is absent or sluggish its causes intestinal gas to build up and produces pain and abdominal distention
42. A nurse is preparing to instill an NG tube for a client who requires eternal feedings. Which of the following instructions should the nurses give the client before procedure? inhale forcefully during insertion insertion of NG tube is painful and gag reflex will be activated so establish communication such as raising a finger Bear downbreath through the mouth and swallow during insertion avoid swallowing
insertion of NG tube is painful and gag reflex will be activated so establish communication such as raising a finger
A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?
liver damage
16. A nurse has received a prescription for dextran to administer for a client. The nurse should recognize that dextran is which of the following functional classifications? skeletal muscle relaxants beta-adrenergic broad spectrum anti-infective agents plasma volume expanders
plasma volume expanders
The American Nurse Association
professional nursing organization Professional organization that represents all registered nurses.-a requirement to be considered a profession
21. A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? lower medial quad of the buttock near the coccyx: side hip between the illiac crest and anterior illiac spine Tissue of the posterior arm Lower inner thigh
side hip between the illiac crest and anterior illiac spine
48. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? drink 1,000mL of fluid drink at least 1500mL of fluid increase intake of refined fiber sit on the toilet take a laxative
sit on the toilet to increased peristalsis occurs after food enters the stomach. Sitting for 30 mins after meal is the recommended route
40. 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? Start Chest compressions Provide breaths with a manual resuscitation bagnot first priority administer oxygen
start chest compressions
A nurse is teaching a client about anti hypertensive medication. This is a measure of what type of prevention
tertiary; its the effect to control a health issue someone who has the condition and wants to improve their lifestyle
A nurse is caring for a client who is receiving an IV that has infiltrated. Which of the following would be an unexpected finding when the nurse assesses the client's infusion line and insertion site?
the area around the infection site feels warm
Semi-Fowler's Position
the head of the bed is raised 30 degrees; or the head of the bed is raised 30 degrees and the knee portion is raised 15 degrees-promote lung expansion-good for feedings
The State Board of Nursing oversees
the scope and standards of nursing
To percuss means
to gently tap a part of the body
A nurse who is caring for a client who reports increased exercise, improved diet, and overall sense of health is displaying what type of positive state of mind?
wellness
68. A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting with which of the following functions?
à Regulation of acid-base balance
