Practice Test

A nurse is using the nursing process to provide care to a client admitted to the facility. During the assessment phase, which activities would the nurse likely perform? Select all that apply. Obtain a baseline oxygen saturation level. Check the results of the client's blood work. Administer prescribed medications. Perform passive range of motion exercises. Obtain a weight

Obtain a baseline oxygen saturation level. Check the results of the client's blood work. Obtain a weight

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client? Opioid analgesic to treat pain Septic workup due to blood pressure and heart rate elevation Isolation for suspected respiratory illness Acetaminophen to treat pain and fever

Opioid analgesic to treat pain

A nurse identifies an area where client care has been compromised. What steps should the nurse take to improve performance? Select all that apply. Plan a strategy using indicators. Assess the change. Discover a problem. Ask the client if there is a problem. Implement a change.

Plan a strategy using indicators. Assess the change. Discover a problem. Implement a change.

A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process? Diagnosis Planning Implementation Evaluation

Planning

Which purpose of the evaluation phase of the nursing process is a priority during client care? To examine the client's behavioral response to the care received To provide basis for the revision of plan of care To limit assessment to only the beginning phase of the nursing process To appraise the collaboration of the client and family

To examine the client's behavioral response to the care received

The home health nurse is visiting a new client who has recently started using an oxygen concentrator. After assessing the home environment, which comment should the nurse prioritize? "Have you discussed a back-up system with your health care provider in case your electricity goes out?" "Does your family help you with the concentrator?" "Are you sleeping better now that you are using the concentrator?" "Have you noticed an improvement in how you are feeling?"

"Have you discussed a back-up system with your health care provider in case your electricity goes out?"

The nurse is providing discharge teaching to a client going home with oxygen therapy. Which statements made by the client would indicate to the nurse that the teaching was effective? Select all that apply. "I will not allow smoking within 10 feet (3 m) of my oxygen." "I will keep the oxygen tank away from direct sunlight or heat." "I will secure my tank by placing it flush against the wall." "I will adjust the oxygen flow according to my needs." "I will only use an electrical instead of gas stove."

"I will not allow smoking within 10 feet (3 m) of my oxygen." "I will keep the oxygen tank away from direct sunlight or heat."

Which question would be most helpful to the nurse in facilitating critical thinking during outcome identification and planning? "How do I best cluster these data and cues to identify problems?" "What problems require my immediate attention or that of the team?" "What major defining characteristics are present for a nursing diagnosis?" "How do I document care accurately and legally?"

"What problems require my immediate attention or that of the team?"

The nurse is preparing to flush a client's peripheral venous access device. Which observable intervention best assures continued effective venous access at this location? Wearing gloves when preforming the intervention Using a 10 ml syringe to introduce the flushing solution Aspirating to determine positive blood return Anchoring extension tubing near entry site with tape

Anchoring extension tubing near entry site with tape

A client is receiving a transfusion of packed red blood cells, and the nurse has obtained the first set of vital signs after initiating the transfusion. These closely match the pretransfusion vital signs with the exception of a 1°F (0.5°C) increase in the oral temperature. The client denies other symptoms and is not in distress. What is the nurse's most appropriate action? Call the blood bank and obtain diagnostic tubes. Administer acetaminophen as prescribed. Discontinue transfusion immediately, and infuse normal saline with new tubing. Promptly discontinue the transfusion, and remove the client's IV.

Administer acetaminophen as prescribed.

Which actions would a nurse perform after selecting a site and palpating accessible veins in order to start an IV infusion? Select all that apply. Clean the entry site with saline, followed by an alcohol swab according to agency policy. Place the dominant hand about 4 in (10 cm) below the entry site to hold the skin taut against the vein. Enter the skin gently with the catheter held by the hub in the non-dominant hand, bevel side down, at a 10- to 30-degree angle. Advance the needle or catheter into the vein. A sensation of "give" can be felt when the needle enters the vein. When blood returns through the lumen of the needle or the flashback chamber of the catheter, advance device into the vein until the hub is at the venipuncture site. Release the tourniquet, quickly remove the protective cap from the IV tubing, and attach the tubing to the catheter or needle.

Advance the needle or catheter into the vein. A sensation of "give" can be felt when the needle enters the vein. When blood returns through the lumen of the needle or the flashback chamber of the catheter, advance device into the vein until the hub is at the venipuncture site. Release the tourniquet, quickly remove the protective cap from the IV tubing, and attach the tubing to the catheter or needle

A client reports to the nurse quitting smoking 6 months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome? Affective Cognitive Psychomotor Physiologic

Affective

Which behaviors are characteristic of a nurse who is a critical thinker? Select all that apply. Alert to context so that the need for modification can be identified and changes to the plan of care can be made Inflexible when it comes to the care of the client to ensure that the client meets the desired outcome Overly sensitive so that problems are addressed in a timely fashion Persistent when delivering care to all clients to complete all measures during a shift Responsible and accountable for own actions

Alert to context so that the need for modification can be identified and changes to the plan of care can be made Responsible and accountable for own actions

The nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair and holds the client's hand while listening to the client's concerns. What additional type of nursing supportive intervention could the nurse provide? Arranging for clergy to visit with the client Teaching the client how to administer medications Providing humor in conversation to assist in alleviating stress Arranging appointments with a specialist after the client is discharged

Arranging for clergy to visit with the client

A nurse demonstrates critical thinking when applying the nursing process to client care. Which behavioral components would the nurse likely use during the assessment phase? Select all that apply. Asking relevant questions Exploring ideas Recognizing issues Interpreting evidence Recognizing assumptions

Asking relevant questions Exploring ideas Recognizing issues

When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next? Assess the client's interactions with the newborn. Direct all education of infant care to the client's mother. Initiate referrals to available community services. Develop a comprehensive education plan for infant care.

Assess the client's interactions with the newborn.

The nurse is conducting a nursing history of a client with a respiratory rate of 30 breaths per minute, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next in regard to the discrepancy? Clarify discrepancies of assessment data with the client. Validate client data with members of the health care team. Document objective data collected in the physical examination; there is no need to document the discrepancy. Seek input from family members regarding the client's breathing at home.

Clarify discrepancies of assessment data with the client.

The nurse is preparing to interview several clients during clinic hours. What language difficulty might a nurse encounter while performing various interviews in a diverse population of clients? Clients not being fluent in the same language as the nurse Clients having a limited education Clients speaking the same language as the nurse Clients demonstrating mild anxiety. Clients fearing saying the wrong thing

Clients not being fluent in the same language as the nurse Clients having a limited education Clients fearing saying the wrong thing

The nurse is creating a concept map to plan for the care of a client. Place in order the steps the nurse will perform to create the concept map. 1Collect client problems and concerns on a list. 2Connect and analyze the relationships. 3Create a diagram. 4Keep in mind key concepts. 5Apply the concept map to client care.

Collect client problems and concerns on a list. Connect and analyze the relationships. Create a diagram. Keep in mind key concepts. Apply the concept map to client care.

he nurse is monitoring a client with continuous pulse oximetry. What action(s) by the nurse are important to obtain accurate results? Select all that apply. Correlate the pulse oximetry reading with the client's heart rate. Use the forehead sensor if cardiac output is low. Assess client for factors affecting circulation. Prepare the client to have an arterial line inserted. Determine if the client has a pre-existing condition affecting the oxygen saturation. Observe the monitor to record the respiratory rate.

Correlate the pulse oximetry reading with the client's heart rate. Use the forehead sensor if cardiac output is low. Determine if the client has a pre-existing condition affecting the oxygen saturation.

Which nursing diagnoses are stated correctly? Select all that apply. Deficient Fluid Volume related to abnormal fluid loss Risk for Impaired Skin Integrity Grieving related to Body Image Disturbance Possible Chronic Low Self-Esteem Nutrition Deficit related to inability to eat a balanced diet Knowledge Deficit related to noncompliance with physical therapy routine

Deficient Fluid Volume related to abnormal fluid loss Nutrition Deficit related to inability to eat a balanced diet

A nurse has developed a plan of care for a client whose spouse recently died. The nurse assigned the client a nursing diagnosis of: Risk for Loneliness. When the nurse is evaluating the plan, the client tells the nurse new information about having an active social life and being satisfied with social activities. What should the nurse do next? Continue with the plan. Delete the nursing diagnosis. Tell the client that the client is lonely. Adjust the time criteria.

Delete the Nursing dx

Using the nursing process, place in order the steps in concept map care planning. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Develop a graph that has boxes for key problems and nursing diagnoses. 2Analyze and categorize the client data, including prioritizing nursing diagnoses. 3Analyze relationships among the nursing diagnoses and draw lines among the boxes. 4Identify goals or outcomes and interventions for each nursing diagnosis. 5Evaluate the client's response

Develop a graph that has boxes for key problems and nursing diagnoses. Analyze and categorize the client data, including prioritizing nursing diagnoses. Analyze relationships among the nursing diagnoses and draw lines among the boxes. Identify goals or outcomes and interventions for each nursing diagnosis. Evaluate the client's response.

An older adult client visits a health care facility for a scheduled physical assessment. During the assessment, the client reports difficulty breathing. Which suggestion could the nurse make to improve the client's respiratory function? Avoid strenuous exercises. Use a nasal strip. Drink liberal amounts of fluids. Receive annual immunizations.

Drink liberal amounts of fluid

A nurse is caring for a client who breathes very shallowly and has been reporting severe back pain. What suggestion could the nurse make to help the client breathe efficiently? Encourage the client to take deep breaths. Instruct the client in the use of pursed-lip breathing technique. Inform the client about nasal strips. Teach the client diaphragmatic breathing.

Encourage the client to take deep breaths.

The nurse performed a physical lung assessment on a client who reports shortness of breath. The nurse collected the following data. What is the proper sequence of data collection? Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Exhalation is prolonged. Respirations are 24 breaths/minute. Chest is barrel shaped. 2Skin on chest is warm and dry. Decreased tactile fremitus is present. 3Percussion reveals hyperresonant sounds. Chest excursion is less than normal. 4Breath sounds are adventitious in lower lobes.

Exhalation is prolonged. Respirations are 24 breaths/minute. Chest is barrel shaped. Skin on chest is warm and dry. Decreased tactile fremitus is present. Percussion reveals hyperresonant sounds. Chest excursion is less than normal. Breath sounds are adventitious in lower lobes.

A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding? Select all that apply. Fever Facial flushing Low back pain Urticaria Hematuria

Fever Facial flushing Low back pain Hematuria

Which nursing diagnosis(es) is correctly written with its three parts? Select all that apply. Ineffective Health Maintenance related to lack of motivation as evidenced by client's statement of lack of interest in improving health Constipation related to side effects of antidepressants as evidenced by passage of hard, dry stool Bowel Incontinence related to inflammatory bowel disease as evidenced by persistent fecal odor Asthma related to allergic response as evidenced by wheezes in lower lobes of the lungs Activity Intolerance related to compromised oxygen transport secondary to anemia

Ineffective Health Maintenance related to lack of motivation as evidenced by client's statement of lack of interest in improving health Constipation related to side effects of antidepressants as evidenced by passage of hard, dry stool

The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply. Inhale slowly through the nose for a count of three. Keep abdominal muscles in a relaxed state. Shape the lips as if you were about to blow a whistle. Over time, begin to increase the length of the exhale. Exhale slowly through pursed lips. Ensure that the exhale lasts twice as long as the inhale.

Inhale slowly through the nose for a count of three. Shape the lips as if you were about to blow a whistle. Over time, begin to increase the length of the exhale. Exhale slowly through pursed lips. Ensure that the exhale lasts twice as long as the inhale.

Which nursing actions would be performed when preparing an IV solution and tubing to initiate intravenous therapy? Select all that apply. Maintain aseptic technique when opening sterile packages and IV solution. Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. Squeeze drip chamber and allow it to fill one-quarter full. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. Allow fluid to flow and cap at end of tubing before all air bubbles have disappeared. Apply label to tubing reflecting the day/ date for next set change, per facility guidelines.

Maintain aseptic technique when opening sterile packages and IV solution. Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. Apply label to tubing reflecting the day/ date for next set change, per facility guidelines.

A specially trained nurse has inserted a PICC line. What would be done next? Start administration of prescribed fluids. Explain the procedure to the client and family. Place the client on restricted oral fluids. Send the client to the radiology department.

Send the client to the radiology department.

The nurse provides care for a client with chronic bronchitis and a decreasing oxygen saturation. Which factor(s), if assessed, indicate a deteriorating condition? Select all that apply. Tachypnea Tachycardia Bradycardia Shortness of breath Wheezing and crackles in lungs

Tachypnea Tachycardia Shortness of breath Wheezing and crackles in lungs

Which examples are essential components for delegating nursing care to an unlicensed assistive personnel (UAP)? Select all that apply. The UAP has sufficient knowledge and skill for completing the task. The nurse has clearly communicated instructions to the UAP. The UAP can verbalize what information to report to the nurse. The nurse seeks input from the UAP in planning the client's care for the shift. The UAP evaluates the client's response after implementing the task and then reports findings to the nurse.

The UAP has sufficient knowledge and skill for completing the task. The nurse has clearly communicated instructions to the UAP. The UAP can verbalize what information to report to the nurse.

The nurse is assessing an adult client who has presented to the emergency department with general weakness. The nurse reviews the client's health record to find there is no history of underlying health conditions. The nurse will begin preparing for the insertion of a peripheral intravenous line if which assessment finding(s) are present? Select all that apply. The client has experienced 24 hours of diarrhea. The client reports using laxative substances daily. The client has been vomiting for several days. The client is only willing to drink juices. The client has a serum potassium level of 2.0 mEq/l (2.0 mmol/l). The client has severe iron-deficiency anemia.

The client reports using laxative substances daily. The client has been vomiting for several days. The client has a serum potassium level of 2.0 mEq/l (2.0 mmol/l). The client has severe iron-deficiency anemia.

Which actions should a nurse perform when inserting an oropharyngeal airway? Select all that apply. Use an airway that reaches from the nose to the back angle of the jaw. Wash hands and put on PPE, as indicated. Position client flat on his or her back with the head turned to one side. Insert the airway with the curved tip pointing down toward the base of the mouth. Rotate the airway 180 degrees as it passes the uvula. Remove airway for a brief period every 4 hours or according to facility policy.

Wash hands and put on PPE, as indicated. Rotate the airway 180 degrees as it passes the uvula. Remove airway for a brief period every 4 hours or according to facility policy.

The nurse observes a client practice pursed-lip breathing in preparation for discharge. Which action should the nurse point out needs correcting? exhales to a count of 4 inhales slowly through the nose to a count of 3 contracts abdominal muscles to exhale holds lips as though to whistle

exhales to count of 4

The nurse is caring for a client who has just had a lower leg amputation following a motor vehicle accident. During the planning phase of the nursing process, the nurse will prioritize which problem(s) on the first postoperative day? Select all that apply. infection risk altered body image perception feelings of loss of power caregiver fatigue impaired coagulation potential

infection risk impaired coagulation potential

The nurse is teaching a client and caregiver how to properly use an incentive spirometer. Place the following steps in the correct order. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1 note the goal for inhalation 2 exhale normally 3 seal the lips around the mouthpiece 4 inhale slowly until reach desired volume 5 hold breath for 4 seconds 6 remove mouthpiece and breathe normally

note the goal for inhalation exhale normally seal the lips around the mouthpiece inhale slowly until reach desired volume hold breath for 4 seconds remove mouthpiece and breathe normally

A health care provider has prescribed oxygen to be delivered at 8 L/minute for a client who does not have a tracheostomy. Which oxygen delivery device(s) will the nurse consider using? Select all that apply. simple mask partial rebreather mask Venturi mask nonrebreather mask T-piece

partial rebreather mask, simple mask

A nurse selects the basilic vein as the intended site for the insertion of an IV catheter. The nurse understands that which bone would act as natural splints to allow the client greater freedom of movement? Select all that apply. Radius Ulna Humerus Carpal Scaphoid

ulna radius