NUR 321 FUND PRACTICE TEST 1 QUIZ BANK

A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment.

1. Inspection 2. Auscultation 3. Percussion 4. Palpation The appropriate sequence for the nurse to perform the abdominal assessment is to inspect, auscultate, percuss, and then palpate. This sequence prevents altering the bowel sounds and causing false results. The appropriate sequence for any other assessment for an adult client is inspection, palpation, percussion, and auscultation

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh. This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure.

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?

The signature on the preoperative consent form is the client's. The nurse acts as a witness to attest that it is the client's signature on the preoperative consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risks and benefits.

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client?

"Donate autologous blood before the surgery." Autologous blood transfusion is the collection and reinfusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection.

A nurse is teaching 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?

"I should expect my heart rate to take longer to return to normal after exercise as I get older." Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise.

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Center for Disease Control and Prevention recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids.

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?

"Using a cuff that is too small will result in an inaccurately high reading." Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client.

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 clients' commitments to a long-term goal of weight loss?

Attempt to increase the clients' self-motivation. Motivation to learn is important in improving a client's commitment to achievement of a health goal, as well as increasing the amount and speed of learning.

A nurse is inserting an IV catheter for 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?

Carefully remove the gloves and follow with hand hygiene. Standard precautions require the use of gloves and hand hygiene in the care of all clients.

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?

Confirm unresponsiveness. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team.

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?

Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record.

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?

Disconnect the machine, and measure the blood pressure manually every 15 min. If the nurse questions the reliability of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed.

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses. For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client.

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?

Identify the client using two identifiers. Once the client's identity is determined, the nurse can then proceed with the other options. This action is the priority action because it provides for the safety of the client. It is a nursing responsibility to be certain that each client receives only what has been prescribed. The nurse must assure that the correct client is being transported for a chest x-ray.

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?

Lock the wheels on the bed and stretcher. Locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client.

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

Perform hand hygiene According to evidence-based practice, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. This is vital because contamination of the nurse's hands is a primary source of infection.

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward.

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level of the bed. The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-injury.

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?

Screening groups of older adults in nursing care facilities for early influenza manifestations. Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe.

A nurse at a screening clinic is assessing 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?

Second intercostal space to the right of the sternum. The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

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?

Sit and hold the client's hand. With this action, the nurse uses the therapeutic communication techniques of silence, touch, and offering of self to the client

A nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and might have a right ear infection. Which route should the nurse use to obtain the temperature?

Temporal The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic, but should avoid placing it over an area covered with hair.

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

The client reports severe pain. A client who is experiencing severe pain is not able to concentrate and therefore, is not ready to learn a new activity.

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. The nurse who is performing a surgical hand-washing technique should wash with her hands held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area.