Set 2

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment

A. Airborne Airborne precautions are required for clients who have infections that spread via droplet nuclei that are smaller than 5 µm in diameter, including varicella, tuberculosis, and measles.

A nurse is performing a neurological assessment for a client. By asking the clients to get his time, which of the following cranial nerves is the nurse testing? A. Cranial nerve XII B. Cranial nerve X C. Cranial nerve VIII D. Cranial Nerve V

A. Cranial verve XII The nurse is checking the function of cranial nerve XII (Hypoglossal), which innervates the tongue, by observing a range of tongue movements.

A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group? A. Independent moral development B. Acceptance of body changes C. Strengthening ties with the family of origin D.Development of concrete reasoning

A. Independent moral development According to Kohlberg's theory of moral development, making individual decisions about moral issues is a function of the highest level of moral development, the postconventional level. Young adults who have reached this level separate themselves from the rules and tenets of others and make their own decisions according to personal beliefs and principles.

A nurse is assessing a client respiratory system. Which of the following breath sounds are the nurse expect to hear over the periphery of the major lung fields? A. Vesicular B. Bronchial C. Ronchi D. Bronchovesicular

A. Vesicular The nurse will hear vesicular sounds over the periphery of the major lung fields. The sounds are soft and low pitched

A nurse is preparing to irrigate a clients mood. Which of the following actions should the nurse take? A. Use a 10 mL syringe B. Attach a 22 gauge catheter to the syringe C. Warm the irrigation solution to 37°C or 98.6°F D. Administer an analgesic 10 minutes before the irrigation

C. Warm the irrigation solution to 37°C or 98.6°F The nurse should prepare about 200 mL of irrigation solution and warm it to body temperature to minimize discomfort in vascular constriction

A nurse is preparing to administer it tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take? A. Select a 23 gauge needle B. Insert the needle into the skin at 25° angle C. Massage the area of injection following removal of the needle D. Circle the injection area with a pen

D. Circle the injection area with a pen Circling the area with a pen and choose the nurse will examine the correct site when reading the test 48 to 72 hours later

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? A. Identify the risk of non-adherence B. Schedule learning sessions to demonstrate the psycho motor skills the client will need C. Provide clearly written and easy to understand materials D. Help the client identify ways that these changes will result in positive personal outcomes

D. Help the client identify ways that these changes will result in positive personal outcomes According to evidence-based practice, the motivation to change must proceed taking steps to make the change. Therefore, helping clients identify ways that the changes will promote positive outcomes should proceed other educational strategies for making the changes. The client should first see how the changes directly affect his/her life, does enhancing the motivation to make the changes.

A nurse is instructing a client about a 24 hour urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands this procedure? A. The next time I urinate will be the first specimen of the collection B. I'll make sure to keep the collection bottle in the container of ice they gave me C. Once the container is half full I no longer have to add any more urine D. It's OK if a piece of toilet paper gets in the bottle the lab people remove it when they do the test

B. I'll make sure to keep the collection bottle in the container of ice they gave me The urine collection must remain chilled to prevent any change in your own composition during the collection

A nurse is changing the dressings for a client who has to Penrose drains near an abdominal incision. Which of the following and hearing devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

B. Montgomery straps The nurse should apply the least restrictive priority setting framework, which assigns priority to nursing interventions that are the least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff members, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation of the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using cars to tie the dressing securely. When the dressing is changed, the ties are released, the dressing is replace, and the ties are secured again without removing the adhesive strips.

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? A. Have the client urinate 20 minutes before the scan B. This is the client into a semi Fowler's position C. Position a scanner head at the symphysis pubis D.Apply light pressure to the scanner head once it is in position

D.Apply light pressure to the scanner head once it is in position The nurse should apply light pressure and hold a scanner steadily while pointing it slightly down toward the clients bladder