W Practice Test - #3

A client states during the interview that he has pain in his lower back. He states it is a 10 on a scale of 0 to 10 when he is asked to turn. The nurse should: A - avoid a position change that requires turning. B - have the client turn from side to side and assess pain. C - elevate the legs, bending at the knee while the client is supine. D - have the client lay on his right side, then palpate the area.

A - avoid a position change that requires turning.

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. A - simple mask B - T-piece C - Venturi mask D - nonrebreather mask E - partial rebreather mask

A - simple mask E - partial rebreather mask

The nurse assessing a client with chronic obstructive pulmonary disease (COPD) suspects chronic hypoxia based on which assessment finding? A - Edema B - Frequent urination C - Clubbing fingers D - Cyanosis

C - Clubbing fingers

The nurse is assessing a client's ability to use a walker. The nurse would provide additional information if which behavior were observed? A - When arising from a chair, the client puts one hand at a time on the walker. B - The client steps into the walker before moving the walker forward. C - The client pushes the walker ahead, following behind it. D - The client uses the arms of the chair as support when standing up to use the walker.

C - The client pushes the walker ahead, following behind it.

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing? A - Congestive heart failure B - Malnutrition C - Anemia D - Poor tissue perfusion

D - Poor tissue perfusion

The nurse is asking questions about the client's pain experience during the interview. Which questions are important to address when assessing pain? Select all that apply. A - "What seems to make the pain worse?" B - "How long does the pain last?" C - Intensity D - "Why do you have the pain?" E - "Where is the pain located and does it move anywhere else?" F - "Have you taken acetaminophen for the pain?"

A - "What seems to make the pain worse?" B - "How long does the pain last?" C - Intensity E - "Where is the pain located and does it move anywhere else?"

What is the priority goal of interventions for a risk diagnosis? A - Prevent an actual problem B - Reduce or eliminate contributing factors C - Promote higher level wellness D - Collect additional data

A - Prevent an actual problem

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? A - Pulmonary function tests B - Skin tests C - Chest x-ray D - Bronchoscopy

A - Pulmonary function tests

A nurse is caring for an adolescent who has just lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address? A - Self-esteem needs B - Safety and security needs C - Love and belonging needs D - Self-actualization needs

A - Self-esteem needs

The nurse prepares to apply the pulse oximeter to the client's hand. The fingers are edematous, cool to touch, and have black nail polish. Which actions should the nurse take? Select all that apply. A - Use alternate site: earlobe or bridge of nose. B - Apply to warm, swollen finger. C - Auscultate lungs. D - Assess mental status. E - Remove black nail polish and assess circulation.

A - Use alternate site: earlobe or bridge of nose. C - Auscultate lungs. D - Assess mental status. E - Remove black nail polish and assess circulation.

A 7-year-old child suffered an injury on the playground at school that resulted in a fracture to the left forearm. The child reports to the nurse's office the next day for neurovascular assessment of the extremity. For each activity, click to specify whether it fulfills the circulation, motor function, or sensation section of the assessment. 1. Pallor - 2. Paralysis - 3. Numbness - 4. Pain - 5. Temperature -

1. Pallor - circulation 2. Paralysis - motor function 3. Numbness - sensation 4. Pain - motor function 5. Temperature - circulation

Nurses assess clients who have physiologic responses to pain. Which examples of pain response are physiologic responses? Select all that apply. A - Nausea and vomiting B - Exaggerated weeping and restlessness C - Increased blood pressure D - Grimacing and moaning E - Muscle tension and rigidity F - Protecting the painful area

A - Nausea and vomiting C - Increased blood pressure E - Muscle tension and rigidity

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. A - "I will only use an electrical instead of gas stove." B - "I will keep the oxygen tank away from direct sunlight or heat." C - "I will not allow smoking within 10 feet (3 m) of my oxygen." D - "I will adjust the oxygen flow according to my needs." D - "I will secure my tank by placing it flush against the wall."

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

When performing fall risk assessments, which client does the nurse determine is most at risk for falls? A - 50-year-old male being cared for in an unfamiliar health care environment B - 70-year-old female with postural hypotension who wears eyeglasses C - 80-year-old female with a history of falling last year D - 60-year-old male with weakness in his left side and slowed reaction time

B - 70-year-old female with postural hypotension who wears eyeglasses

A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: A - diminished stroke volume. B - adequate tissue perfusion. C - heart failure. D - high cardiac output.

B - adequate tissue perfusion.

In which situation would the SBAR technique of communication be most appropriate? A - A nurse is teaching a client about the benefits of smoking cessation and the risks of continuing to smoke. B - A nurse is explaining the process of bone marrow biopsy to a client who is scheduled for the procedure. C - A nurse is calling a health care provider to report a client's new onset of chest pain. D - A nurse is facilitating a family meeting to coordinate a client's discharge planning.

C - A nurse is calling a health care provider to report a client's new onset of chest pain.

Which activity is the clearest example of the evaluation step in the nursing process? A - Recognizing that the client's blood pressure of 172/101 is an abnormal finding B - Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading C - Checking the client's blood pressure 30 minutes after administering captopril D - Taking a client's blood pressure on both arms at the beginning of a shift

C - Checking the client's blood pressure 30 minutes after administering captopril

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

CORRECT ORDER - 1st - note the goal for inhalation 2nd - exhale normally 3rd - seal the lips around the mouthpiece 4th - inhale slowly until reach desired volume 5th - hold breath for 4 seconds 6th - remove mouthpiece and breathe normally