NR 224 - Final Exam Practice Questions

What is the appropriate way to administer eye drops?

Pull the conjunctiva out to form a pouch

The nurse is preparing to instill an otic solution into the adult client's left ear. Which actions should the nurse implement as part of this procedure?

Pull the pinna upward and backward, warm the solution to room temperature, and place the client in a side-lying position with the ear facing up

A client who has never been hospitalized before and is in a hospital room with a roommate is anxious and having trouble initiating a stream of urine. Knowing that there is no pathological reason for this difficulty, which nursing interventions should be included when assisting the client?

Running tap water in the sink, instructing the client to pour warm water over the perineum, and closing the bathroom door and instructing the client to pull the call bell when done

A client is supposed to receive an intramuscular injection. How long should the needle be?

1 inch

A client who suffers from immobility will have the following possible side effects from the lack of movement?

constipation

The client is complaining of dizziness, confusion and poor skin turgor. The probable diagnosis

dehydration

If the stomach can't be used for feeding, what is the next best alternative?

enteral

The best route for getting nutrition into a patient

gastrointestinal tract

A client is prescribed a clear liquid diet after surgery, what foods can the nurse offer the client?

lemon lime soda, hot tea, and flavored gelatin

How do you identify your client prior to giving a medication?

name & DOB

What is the peak of medication?

the highest point of concentration of the drug

How many mL's can be injected into the deltoid site?

2 mL

What currently is the dietary guideline and a visual aide for patient education?

My healthy plate

A client has implemented dietary and other lifestyle changes to manage hypertension. The nurse determines that the client has become most successful when the client has which follow-up blood pressure reading?

128/84 mmHg

When giving a subcutaneous injection, what angle should you use for the needle?

45-90 degrees

The nurse teaches a client with hypertension to recognize the signs/symptoms that may occur during periods of elevated blood pressure. The nurse determines that the client needs additional teaching if the client states that which sign/symptom is associated with this condition?

A feeling of fullness in the head

When a client requests pain medication, the nurse administers a ventrogluteal intramuscular injection. After administration of the injection, what should the nurse do first?

Apply gentle pressure to the injection site.

Which client position should the nurse use to administer a cleansing enema?

Left lateral position with flexed right knee

A client's telemetry monitor displays ventricular tachycardia. Upon reaching the client's bedside, which action should the nurse take first?

Check the client's level of consciousness

The nurse administers an antiemetic to a client prescribed a clear diet who reports nausea and vomits. After sleeping for 3 hours the client awakens and requests something to eat. Which food item would be appropriate for the nurse to give them?

Chicken Broth

The nurse has administered approximately half of a high-cleansing enema when the client reports pain and cramping. Which nursing action is appropriate?

Clamping the tubing for 30 seconds and restarting the flow at a slower rate

The nurse is assessing a client's blood pressure and is not sure where she heard the systolic reading. How can the nurse confirm the systolic blood pressure measurement?

Completely deflate the cuff, wait 2 minutes, and reevaluate the blood pressure reading.

A client diagnosed with chronic obstructive pulmonary disease (COPD) is on home oxygen at 2 L per minute. The nurse assesses the client's respiratory rate at 22 breaths per minute. When the client reports an increase in the dyspnea, what should the nurse do initially?

Conduct further assessment of the client's respiratory status

The nurse reviews wound culture results and learns that an assigned client has methicillin-resistant Staphylococcus aureus (MRSA) in a wound bed. Which type of transmission-based precautions should the nurse implement for this client?

Contact precautions

A client is prescribed a mechanical soft diet. Which foods can the nurse put on the tray for the client?

Cottage cheese, pureed beef, and mashed potatoes

A client is on a clear liquid diet that is being advanced to a full liquid diet. What major food group is added when transitioning from clear to full liquid?

Dairy

A nurse is instructing a client the three point gait using crutches. The nurse knows there is further instruction needed if the client states:

I should alternate legs and putting one leg with one crutch and then put the other one forward. I should only put weight on my unaffected leg. I should use my brother's old crutches so I don't have to buy new ones.

What is the benefit to intravenous medication administration?

Immediate access to the blood stream

Which religious group does not eat pork products?

Jewish

The nurse notes that an older client's current apical pulse is 82 beats per minute, strong but irregular. The nurse notes that prior baseline data indicated that the client's apical pulse ranged from 60 to 90 beats per minute and was strong and regular. On further assessment, the client reports 'feeling tired lately.' Based on this data, what intervention should the nurse implement?

Notify the client's primary health care provider.

What does a fruitarian eat?

Nuts, fruits, olive oil, and honey

The nurse should determine which factors as contributing to stress incontinence in a female client?

Obesity, sneezing, or decreased estrogen.

A client's caregiver is learning to care for their wound at home. How can the nurse ensure the caregiver is trained to be able to care for the wound?

Observe the caregiver perform the wound care independently.

When a hospitalized child develops a rash that covers the trunk and extremities, the nurse notes in the history that the child was exposed to varicella 2 weeks ago. Which nursing intervention has priority?

Place the child in a private room on strict isolation

Which is important for illness recovery and wound healing?

Proteins

When administering a medication intramuscularly, the nurse should document the intervention by including which informations?

The site of the injection, the amount of medication injected, the name of the medication that was injected, and confirmation that the medication was injected intramuscularly.

A clinic nurse is performing an assessment on a client diagnosed with primary hypertension. Which should the nurse do to best assess the client's blood pressure accurately?

Seat the client with the arm bared, supported and at heart level

When a medication is being administered, the safest and most accurate way for the nurse to verify the identity of a client is to implement which action?

Ask the client to state her name and birth date.

A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. What is the nurse's FIRST priority?

Assess the client

What is a key step in using topical patches?

Moving one patch before you apply the next one

The nurse is putting together the supplies to change the linen and give a bed bath. What step of the nursing process is this?

Planning

The nurse is preparing to administer eardrops to an infant. The nurse should plan to proceed by taking which step to assure the appropriate instillation of the medication?

Pull down and back on the auricle, and direct the solution toward the wall of the ear canal.

The nurse prepares to give an intramuscular injection using the z-track technique. Which should the nurse do initially to administer the medication?

Select a large, deep muscle for the intramuscular injection site

A client's prescribed medication is available for injection in an ampule. The nurse determines that which is the most appropriate action when preparing to draw up this medication?

Shake the ampule gently to mix the contents.

How many rights are there in medication administration?

Six (drug, dose, route, time, patient, documentation)

The nurse employed in a preschool agency is planning a staff education program to prevent the spread of an intestinal parasitical disease. Which prevention measure should the nurse include in the educational session?

Standard precautions will be used when assisting children with toileting.

What shot is usually given intradermal?

TB test

The nurse creates a plan of care for a client with a SPICA cast that covers a lower extremity. Which action would the nurse include in the plan of care to promote bowel elimination?

Use a low-profile (fracture) bedpan

The nurse is preparing to administer an intramuscular injection to a toddler. The nurse determines that the safest body site to administer the injection is which location?

Vastus Lateralis muscle

The nurse places a hospitalized client with a diagnosis of active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room?

Wash hands and place a high efficiency particulate air HEPA respirator over the nose and mouth

When should a client start receiving nutrition after a major trauma

Within 72 hours