Nursing Practice Test 2

D.) Moisten dentures with water before inserting.

A nurse is caring for a client who has dentures. Which of the following actions should the nurse take when providing denture care? A.) Clean the dentures with a damp cloth after removal. B.) Store the dentures in a dry denture cup. C.) Use a firm-bristled toothbrush to clean the dentures. D.) Moisten dentures with water before inserting.

D.) The client's output was 60 mL for the past 3 hr.

A nurse is caring for a client who has kidney dysfunction. The nurse should recognize that which of the following findings is the priority? A.) Client reports voiding three times during the night. B.) Client reports burning and discomfort with urination. C.) The client's WBC is 12,000/mm3. D.) The client's output was 60 mL for the past 3 hr.

A.) "Tell me what the afterlife means to you."

A nurse is caring for a client who has metastatic cancer and is a practicing Catholic. The client asks the nurse to discuss the afterlife with her. Which of the following statements by the nurse assists in meeting the client's spiritual needs? A.) "Tell me what the afterlife means to you." B.) "You should discuss the afterlife with your priest." C.) "Keep praying. A miracle may happen." D.) "Maybe your condition will lead you closer to God."

D.) Hold sterile package 15 cm (6 in) above the field when adding items

A charge nurse is demonstrating how to prepare a sterile field to a newly licensed nurse. Which of the following actions should the charge nurse include in the demonstration? A.) Place bottle cap sterile side down on clean surface. B.) Don sterile gloves before the field is set up. C.) Turn away from the sterile field to discard an item. D.) Hold sterile package 15 cm (6 in) above the field when adding items

A.) Hold the feeding for two consecutive gastric residuals of 250 mL.

A nurse is caring for a client who has an NG tube and is receiving a continuous tube feeding. Which of the following actions should the nurse take? A.) Hold the feeding for two consecutive gastric residuals of 250 mL. B.) Change the bag and tubing every 12 hr. C.) Flush the tube with normal saline irrigant every 8 hr. D.) Heat the formula before administering.

B.) Drain urine from the tubing before ambulation.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections? A.) Empty the urine drainage bag every 12 hr. B.) Drain urine from the tubing before ambulation. C.) Use clean technique for urine specimen collection. D.) Hang the urine drainage bag at the level of the bladder.

C.) Guided imagery

A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting? A.) Art therapy B.) Tai chi C.) Guided imagery D.) Biofeedback

A.) Have the client sign the consent form after the interpreter has translated the explanation of the procedure.

A 17-year-old client who is non-English speaking is about to undergo a cesarean delivery. The client must sign a consent form, and her English-speaking partner is present. Which of the following is an appropriate action for the nurse to take? A.) Have the client sign the consent form after the interpreter has translated the explanation of the procedure. B.) Have the provider explain the procedure to the client's partner, and allow him to sign the consent form for the client. C.) Obtain the consent and have the provider explain the procedure later. D.) Allow the client's partner to explain the procedure to the client, so she can sign the consent.

B.) Transfer the body to a private room to allow the family members to grieve there.

A client died from injuries sustained in a motor vehicle crash. Members of the client's family have been grieving loudly since they arrived at the emergency department 10 min ago. Which of the following is the appropriate nursing action? A.) Inform the family that they must mourn quietly so as not to disturb others in the hospital. B.) Transfer the body to a private room to allow the family members to grieve there. C.) Encourage the family members to think of the good times they had with the client. D.) Inform the family that there will be time to grieve when the body is removed to the mortuary.

B.) Client states, "I am itching all over."

A nurse administers an oral medication to a client. The client reports itching 30 min later. Which of the following represents appropriate documentation of this client finding? A.) Client is itching from medication. B.) Client states, "I am itching all over." C.) It appears that the client has a rash from the medication. D.) Rash from medication noted.

C.) Allow the visitor to continue with the ceremony.

A nurse enters a client's room to administer morning medication and finds a visitor standing near the bed, praying and chanting with the client. Which of the following is an appropriate nursing action? A.) Interrupt the ceremony briefly to administer the client's medication. B.) Ask the client if the nurse can observe the ceremony. C.) Allow the visitor to continue with the ceremony. D.) Ask the visitor to explain the purpose of the ceremony.

D.) Donning a mask to measure the vital signs of a client who has pertussis

A nurse has delegated various client care tasks to the assistive personnel (AP) on her care team. Which of the following actions by the AP is appropriate? A.) Using hand sanitizer to cleanse her hands of spilled food from a client's meal tray B.) Setting aside her gown for future use in the room of a client who has a wound infection C.) Removing her gloves after exiting the client's room D.) Donning a mask to measure the vital signs of a client who has pertussis

C.) Increase the client's vitamin D supplements.

A nurse in long-term care facility is providing care for an older adult client who has minimal exposure to sunlight. Which of the following is an appropriate nursing action? A.) Reduce the client's intake of calcium-rich foods. B.) Provide the client with sunscreen with skin protection factor (SPF) of 5. C.) Increase the client's vitamin D supplements. D.) Expose the client's extremities to an indoor sunlamp daily.

C.) Release of personal belongings form

A nurse in the acute care setting is documenting postmortem care for a client. Which of the following information should the nurse include in the documentation? A.) Completion of an incident report B.) Name of the nurse certifying the client's death C.) Release of personal belongings form D.) Listing of one identifier at the client's time of death

B.) Lubricate the gloved index finger of the dominant hand.

A nurse is administering a rectal suppository to an adult client who has constipation. Which of the following is an appropriate nursing action? A.) Position the client on the right side for 3 min. B.) Lubricate the gloved index finger of the dominant hand. C.) Insert the suppository in the center of the rectum. D.) Insert the suppository 7 cm (2.8 in) into the rectum.

C.) Pale, scaly skin

A nurse is admitting a client to the medical-surgical unit. Which of the following findings can indicate that the client is malnourished? A.) Heart rate 89/min B.) Pink mucous membranes C.) Pale, scaly skin D.) Body mass index 23

D.) "Describe your concerns about sleeping to me."

A nurse is admitting an older adult client to an acute care facility. The client states that she is afraid to go to sleep, fearing she will not wake up. Which of the following responses by the nurse is therapeutic? A.) "I will have the nursing staff check on you frequently during the night." B.) "You are right to be afraid. This is a new place for you." C.) "I will give you your prescribed sleeping medication to help you fall asleep." D.) "Describe your concerns about sleeping to me."

A.) Move the client's feet to the edge of the bed.

A nurse is assisting a client to sit up and dangle her feet on the edge of the bed. Which of the following actions should the nurse take? A.) Move the client's feet to the edge of the bed. B.) Stand with her feet together. C.) Place one arm under the client's armpit. D.) Position the head of the client's bed at a 15° angle.

B.) Flashing smoke alarm

A nurse is assisting in teaching a client who has hearing loss how to modify his home environment. Which of the following is a priority modification that the nurse should include in the teaching? A.) Alarm clock that shakes the bed B.) Flashing smoke alarm C.) Low-pitched buzzer doorbell D.) Telephone with an amplified receiver

B.) Cover the client's head with a cap.

A nurse is assisting with the care of a client who has hypothermia. Which of the following actions should the nurse take? A.) Apply a cooling blanket. B.) Cover the client's head with a cap. C.) Provide a tepid sponge bath. D.) Check laboratory reports for indications of dehydration.

A.) Ambulate the client.

A nurse is caring for a client who has a distended abdomen following surgery, reports gas pain, and has been unable to pass any flatus. Which of the following actions should the nurse take? A.) Ambulate the client. B.) Administer an opioid analgesic. C.) Instruct the client to deep breathe. D.) Provide a carbonated beverage.

C.) "What frightens you about the future?"

A nurse is caring for a client who has a new diagnosis of breast cancer and expresses fear about the future. Which of the following is an appropriate response by the nurse? A.) "There was an interesting study about hormones and breast cancer several years ago. Did you read it?" B.) "Why would you be frightened? Breast cancer is very curable." C.) "What frightens you about the future?" D.) "Would you like to speak to a chaplain?"

0.8 mL

A nurse is caring for a client who has a prescription for enoxaparin 1 mg/kg per dose. The client weighs 77 kg. The vial contains 100 mg/1 mL. How many mL should the client receive per dose? (Round to the answer to the nearest tenth. Use a leading zero when applicable. Do not use a trailing zero.)

A.) Ensure that the client is wearing nonskid slippers. C.) Place the client in a room near the nurses' station. E.) Reinforce teaching on how to use the call light.

A nurse is caring for a client who is disoriented and at risk for falls. Which of the following actions should the nurse plan to take? (Select all that apply.) A.) Ensure that the client is wearing nonskid slippers. B.) Move the bedside table away from the bedside. C.) Place the client in a room near the nurses' station. D.) Keep the bed's full side rails in the up position. E.) Reinforce teaching on how to use the call light.

B.)Decreased skin turgor D.) Orthostatic hypotension E.) Flat neck veins

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. Which of the following findings indicate that the client is experiencing fluid volume deficit? (Select all that apply.) A.) Full, bounding pulse B.)Decreased skin turgor C.) Moist crackles in the lungs D.) Orthostatic hypotension E.) Flat neck veins

D.) Actual loss

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should understand that the client is experiencing which of the following? A.) Complicated grief B.) Maturational loss C.) Disenfranchised grief D.) Actual loss

C.) Document the client's refusal of the treatment.

A nurse is caring for a client who is refusing medical treatment. Which of the following is an appropriate action by the nurse? A.) Explain the negative consequences of the refusal. B.) Discuss with the client's partner why the treatment is necessary. C.) Document the client's refusal of the treatment. D.) Try to convince the client that the treatment is needed.

A.) "It must be difficult facing this type of surgery."

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements by the nurse is appropriate? A.) "It must be difficult facing this type of surgery." B.) "Other clients who have had this surgery have done just fine." C.) "This facility is known for providing excellent care for people who need this type of surgery." D.) "I can request a sleeping pill, if you think that will help."

B.) Apply a moisture barrier to the perineal area. C.) Turn the client every 1.5 to 2 hr. D.) Perform passive range-of-motion exercises every 8 hr. E.) Use a draw sheet when repositioning the client.

A nurse is caring for an older adult client who is immobile. The client has urinary and stool incontinence. Which of the following actions should the nurse take to prevent impaired skin integrity? (Select all that apply.) A.) Use hot, soapy water when cleansing the skin. B.) Apply a moisture barrier to the perineal area. C.) Turn the client every 1.5 to 2 hr. D.) Perform passive range-of-motion exercises every 8 hr. E.) Use a draw sheet when repositioning the client.

A.) a purple-colored stoma.

A nurse is changing a colostomy bag for a client who is 2 days postoperative. The nurse should report A.) a purple-colored stoma. B.) protrusion of the stoma. C.) a small amount of bleeding from the stoma. D.) intestinal gas in the pouch.

A.) Have an assistive personnel (AP) take the radial pulse simultaneously.

A nurse is checking for a pulse deficit on a client who has a newly detected abnormal heart rate. Which of the following is an appropriate action by the nurse? A.) Have an assistive personnel (AP) take the radial pulse simultaneously. B.) Count the pulse for 30 seconds and multiply by 2. C.) Assist the client to a side-lying position. D.) Auscultate the area of the client's chest over the Erb's point of the heart.

D.) Positive Chvostek's sign

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia? A.) Bone pain B.) Drowsiness C.) Bowel hypomotility D.) Positive Chvostek's sign

D.) The client has redness and warmth in his calf.

A nurse is collecting data from a client. Which of the following findings is the priority for the nurse to report to the provider? A.) The client reports a pain level of 7 out of 10. B.) The client reports increased nausea and chills. C.) The client has an oral temperature of 39° C (102.2° F). D.) The client has redness and warmth in his calf.

C.) The client reports urinary incontinence.

A nurse is collecting data from a newly admitted older adult client. Which of the following findings should the nurse report to the provider? A.) The client has smooth, brown, irregular lesions on the back of each hand. B.) The client has glossy, white circles around the periphery of the corneas. C.) The client reports urinary incontinence. D.) The client reports a decrease in the sense of taste.

B.) Ensure the client wears a surgical mask when transport outside of the room is required.

A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? A.) Place the client in a room with another client who has pharyngitis. B.) Ensure the client wears a surgical mask when transport outside of the room is required. C.) Limit the client's family member visitations to 30 min. D.) Provide the client a room with negative-pressure airflow of 6 air exchanges per hr.

A.) Young adults should receive a vaccination for the human papilloma virus (HPV) prior to becoming sexually active.

A nurse is discussing health and wellness with a group of young adults. Which of the following pieces of information should the nurse include? A.) Young adults should receive a vaccination for the human papilloma virus (HPV) prior to becoming sexually active. B.) Bulimia increases in incidence in young adult women. C.) Prostate cancer increases in incidence in young adult males. D.) Young adults should receive a pneumococcal polysaccharide vaccination (PPSV) annually.

D.) "Restraints can be used to prevent a confused client from pulling out an IV line."

A nurse is discussing the use of wrist restraints with an assistive personnel (AP). Which of the following statements by the nurse is correct? A.) "Restraints can be used at the nurse's discretion." B.) "Policies for restraints are set by the Patient Self-Determination Act." C.) "Restraints can be prescribed as PRN." D.) "Restraints can be used to prevent a confused client from pulling out an IV line."

D.) Autonomy

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles? A.) Confidentiality B.) Nonmaleficence C.) Accountability D.) Autonomy

B.) Remove the cover gown in the client's room after providing care.

A nurse is planning to administer medication to a client who has Clostridium difficile (C. difficile) infection. To prevent the spread of this infection to others, which of the following actions should the nurse plan to take? A.) Cleanse hands with an alcohol-based hand rub immediately after removing gloves. B.) Remove the cover gown in the client's room after providing care. C.) Place the client in a room with negative air pressure. D.) Wear a mask when administering oral medications to the client.

C.) Sodium Chloride

A nurse is preparing to perform a wound irrigation for a client who has a Stage 3 pressure ulcer. Which of the following supplies should the nurse plan to use? A.) A bulb syringe B.) Petroleum jelly C.) Sodium chloride D.) Sterile cotton balls

D.) Turning off the faucet with a clean paper towel after drying hands.

A nurse is preparing to take a client's vital signs. The nurse knows that handwashing before caring for a client should include which of the following? A.) Rinsing the forearms with running water before applying soap. B.) Holding the hands above elbow level while washing and rinsing. C.) Working up a lather by rubbing the hands together vigorously for 5 seconds. D.) Turning off the faucet with a clean paper towel after drying hands.

B.) Performing an amniocentesis

A nurse is providing care for a group of clients awaiting treatment. The nurse should identify that which of the following procedures requires written informed consent? A.) Administering an enema B.) Performing an amniocentesis C.) Inserting an indwelling urinary catheter D.) Placing an NG tube

Validate the request for organ donation Collect specimens Remove all equipment, tubes, and indwelling lines Cleanse the body

A nurse is providing postmortem care. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.) Cleanse the body Collect specimens Validate the request for organ donation Remove all equipment, tubes, and indwelling lines

B.) Ask the client what he already knows about meal planning.

A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first? A.) Use pictures of different food groups to help the client plan a daily menu. B.) Ask the client what he already knows about meal planning. C.) Give the client a brochure with sample menus for all meals. D.) Involve the family in the discussion of the client's meal plan.

C.) "You should cleanse the eye from the inner to outer canthus prior to administering the drops."

A nurse is reinforcing teaching with a client about the self-administration of ophthalmic drops. Which of the following instructions should the nurse include? A.) "You will need to look to the side when you administer the drops in your eye." B.) "You should administer the drops directly on the cornea of the eye." C.) "You should cleanse the eye from the inner to outer canthus prior to administering the drops." D.) "You should avoid pressing on the nasolacrimal duct after administering the drops in the eye."

D.) "When lifting a heavy object, keep it close to your body."

A nurse is reinforcing teaching with a client regarding the prevention of stress injuries. Which of the following instructions should the nurse include? A.) "Keep your knees in a locked position when standing for prolonged periods." B.) "Bend at the waist when lifting a heavy object." C.) "Keep your feet close together when lifting a heavy object." D.) "When lifting a heavy object, keep it close to your body."

C.) "I will drink a cup of green tea at bedtime to help me sleep."

A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements by the client indicates a need for further teaching regarding the importance of good sleep habits? A.) "I should turn on the ceiling fan to block out unwanted noise." B.) "I will limit my daily nap to 20 minutes." C.) "I will drink a cup of green tea at bedtime to help me sleep." D.) "I should limit my fluid intake starting 2 hours before bedtime."

C.) The stronger leg should advance past the cane.

A nurse is reinforcing teaching with a client who has left-sided weakness and is learning to use a quad cane. Which of the following instructions should the nurse include? A.) The cane should be on the left side of the body. B.) The right leg should move forward with the cane. C.) The stronger leg should advance past the cane. D.) The cane length should be equal to the distance between the waist and the floor.

B.) "I should position the handgrips so that my axillae are supporting my bodyweight."

A nurse is reinforcing teaching with a client who is unable to bear weight on one leg about the use of crutches. Which of the following statements by the client indicates a need for further teaching? A.) "When I go up stairs, I should begin by stepping onto the stair with my unaffected leg." B.) "I should position the handgrips so that my axillae are supporting my bodyweight." C.) "When sitting down in a chair, I need to hold both crutches in one hand." D.) "I need to use a three-point gait when walking with crutches."

C.) "I should have 3 to 4 finger widths between the crutch pad and my armpit."

A nurse is reinforcing teaching with a client who is using crutches. Which of the following statements by the client indicates an understanding of the teaching? A.) "I will lean on my crutches so they can support my body weight." B.) "When going down the stairs, I will first advance my affected leg." C.) "I should have 3 to 4 finger widths between the crutch pad and my armpit." D.) "As I walk, I should place the crutches about 12 inches in front of me"

B.) "I should avoid giving my baby a pacifier."

A nurse is reinforcing teaching with a new parent who is breastfeeding her infant and is concerned about SIDS. Which of the following statements by the client indicates a need for further teaching? A.) "I will place my baby on his back to sleep." B.) "I should avoid giving my baby a pacifier." C.) "I will remove all stuffed animals from my baby's crib." D.) "I need to take away my baby's blanket when he sleeps."

D.) BUN 8 mg/dL

A nurse is reviewing the medical record of a client who has heart failure. Which of the following laboratory results indicates fluid volume excess? A.) Urine specific gravity 1.015 B.) Hematocrit 42% C.) Urine pH 6.5 D.) BUN 8 mg/dL

C.) "I see that you are angry. Let's talk about how you are feeling about this."

A nurse is speaking with a client who has a prescription for insulin for type 2 diabetes mellitus. The client displays anger about having to take insulin. Which of the following is an appropriate response by the nurse? A.) "You'll feel much better if you take your insulin." B.) "I know how you feel because diabetes runs in my family." C.) "I see that you are angry. Let's talk about how you are feeling about this." D.) "Insulin is effective at lowering your blood glucose level."

B.) Attend an exercise program.

A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for an older adult client. Which of the following activities should the nurse recommend as the priority for this client? A.) Volunteer at the local food pantry. B.) Attend an exercise program. C.) Find an enjoyable hobby. D.) Support environmental conservation.

B.) Wash hands after removing examination gloves. C.) Use antimicrobial hand gel after refilling the client's water pitcher. D.) Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.

A nurse is working in a long-term care facility. Which of the following actions should the nurse take to prevent nosocomial infections? (Select all that apply.) A.) Place immunocompromised clients in the same room. B.) Wash hands after removing examination gloves. C.) Use antimicrobial hand gel after refilling the client's water pitcher. D.) Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. E.) Give a prophylactic dose of antibiotics prior to discharge.

A.) Provides protection of the client's confidential health care information B.) Sets standards for the electronic exchange of health care information E.) Ensures the client's right to inspect and copy one's own medical record

An assistive personnel asks a nurse for information about HIPAA. Which of the following statements by the nurse about the purpose of HIPAA is correct? (Select all that apply.) A.) Provides protection of the client's confidential health care information B.) Sets standards for the electronic exchange of health care information C.) Mandates that health care facilities ask a client on admission about the existence of an advance directive D.) Requires do-not-resuscitate orders to be reviewed on a regular basis E.) Ensures the client's right to inspect and copy one's own medical record

D.) Choose a private room for the interview.

An older adult client who uses a hearing aid is being admitted to a long-term care facility. Which of the following actions by the nurse is appropriate when collecting admission data? A.) Sit beside the client. B.) Speak slowly and loudly to the client. C.) Dim the lights in the client's room. D.) Choose a private room for the interview.

B.) Stand with one foot ahead of the other close to the head of the bed.

Two nurses are preparing to reposition a client in bed who is able to provide some assistance. Which of the following actions should be included? A.) Ask the client to raise the head of the bed to a 45° angle. B.) Stand with one foot ahead of the other close to the head of the bed. C.) Keep hips straight while bending forward toward the client. D.) Instruct the client to keep his legs straight.

A.) Place the diaphragm of the stethoscope directly over the site of brachial pulsation.

When measuring a client's blood pressure, which of the following actions should the nurse take to obtain an accurate reading? A.) Place the diaphragm of the stethoscope directly over the site of brachial pulsation. B.) Ensure that the bladder of the cuff encircles 60% of the client's upper arm. C.) Position the cuff 2 inches above the area of brachial artery pulsation. D.) Position the client's arm above the level of the heart.