A&C 1 Practice Questions Exam 1
A nurse is planning care for a client who has an absolute neutrophil count (ANC) of less than 1,000/mm3. Which of the following interventions should the nurse include in her plan? A - take the client's rectal temperature each day B - increase raw produce in the client's diet C - limit visitors to healthy adults D - instruct the client to floss his teeth daily
C - limit visitors to healthy adults
A nurse is caring for an older client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A - reposition the client every 3 hrs B - massage the bony prominences to promote circulation C - provide the client with a diet high in protein D - apply cornstarch to keep the skin dry
C - provide the client with a diet high in protein
A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan? A - massage the client's red boy prominences B - assess the client's skin for increased coolness C - reposition the client every 2 hours D - keep the client's skin moist
C - reposition the client every 2 hours
A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following indications that the client has an infection? (Select all that apply) bradycardia an increase in neutrophils an increase in RBCs an increase in platelets localized edema
increase in neutrophils localized edema
Identify this ECG tracing: A - Asystole B - Ventricular fibrillation C - Atrial flutter D - Atrial fibrillation
C - Atrial flutter
A nurse is caring for a client who has methicillin-resistant staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? A - wear an N95 B - wear sterile gloves C - wear clean gloves D - wear protective eyewear
C - wear clean gloves
A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? A - contact B - droplet C - protective D - airborne
D - airborne
A nurse is in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect? A - unequal pupils B - hypertension C - tympany upon chest percussion D - confusion
D - confusion rationale: confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first? A - raise the head of the client's bed 15-20 degrees B - place the client supine with knees bent C - assess the client for manifestations of shock D - cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation
D - cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation
A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as bing at risk for the development of pressure ulcers? (select all that apply) A - is ambulatory following a cardiac catheterization 4 hrs ago B - who has type 1 diabetes and is hyper glycemic C - who has protein calorie malnutrition D - who has right-sided heart failure and 4+ edema to the lower extremities E - who has a postoperative delirium
C, D, E
A nurse is monitoring a child for manifestations of hemorrhage following a tonsillectomy. Which of the following findings is a manifestation of this postoperative complication? A - mouth breathing B - frequent swallowing C - reports of thirst D - reports of pain
B - frequent swallowing
A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? A - apply a heat lamp twice a day B - reposition the client at least every 2 hrs C - clean the wound with hydrogen peroxide solution D - massage reddened areas with dressing changes
B - reposition the client at least every 2 hrs
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following test should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? A - chest x-ray B - sputum culture for acid-fast bacillus C - sputum smear D - mantoux test
B - sputum culture for acid-fast bacillus
A nurse accidentally sticks her hand with a syringe after administering an IM injection to a client. Which of the following actions should the nurse take first? A - report the incident to the charge nurse B - wash the area of the puncture thoroughly with soap and water C - complete an incident report D - go to employee health services
B - wash the area of the puncture thoroughly with soap and water
A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? A - protein B - calcium C - vitamin B1 D - vitamin D
A - protein
A nurse is teaching a client who has TB and is to start combination drug therapy. Which of the following medications should the nurse plan to administer? (select all that apply) A - rifampin B - isoniazid C - acyclovir D - pyrazinamide E - montelukast
A, B, D
Identify this ECG tracing: A - Asystole B - Ventricular fibrillation C - Atrial flutter D - Atrial fibrillation
D - Atrial fibrillation
A nurse is providing teaching to the parents of a child who has streptococcal pharyngitis about the ways to prevent disease transmission. Which of the following responses by the parents indicates an understanding of the teaching? A - "We'll continue to encourage him to drink lots of fluids." B - "We'll take his temperature every 4 hours." C - "We'll give him tylenol for the pain." D - "We'll discard his toothbrush and buy another."
D - "We'll discard his toothbrush and buy another."
A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary TB? (select all that apply) A - night sweats B - low-grade fever C - weight gain D - flushed cheeks E - blood in the sputum
A, B, E
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (select all that apply) A - poor nutritional state B - altered mental status C - obesity D - pain medication administration E - wound infection
A, C, E
A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate? A - droplet B - contact C - airborne D - protective
B - contact
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? A - cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen B - irrigate the wound with an antiseptic prior to obtaining the specimen C - include intact skin at the wound edges in the culture D - swab an area of skin away from the wound to identify the usual flora
A - cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen
A nurse is presenting information to the public about preventive measure to reduce the risk for contracting West Nile Virus. Which of the following instructions should the nurse include? A - encourage the use of mosquito repellant B - wait until dusk to go for a walk C - increase standing pools of water around the home D - check perts for ticks before bringing them into the home
A - encourage the use of mosquito repellant
A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing? A - serum albumin 3.2 g/dL B - hemoglobin 16 g/dL C - WBC count 8,000/mm3 D - PTT 1.8
A - serum albumin 3.2 g/dL
A nurse is caring for a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse plan to apply? A - transparent dressing B - wet-to-dry gauze dressing C - hydrogel dressing D - alginate dressing
A - transparent dressing
A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A - use a transfer device to lift the client up in bed B - apply cornstarch to keep sensitive skin areas dry C - massage the skin over the client's bony prominences D - elevate the head of the bed no more that 45 degrees
A - use a transfer device to lift the client up in bed
A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored? A - visual acuity B - skin color C - urine output D - cardiac rhythm
A - visual acuity rationale: a significant side effect is optic neuritis, vision loss, and loss of color discrimination, especially red and green. Baseline vision testing should be performed before use, and visual acuity monitored at regular intervals
What would you do first if you saw this ECG tracing upon entering a patient's room? A - Wet yourself B - Call for help C - Notify the physician D - Initiate CPR
B - Call for help
Which symptoms most clearly relate to kidney stones in the immobilized patient? A - Tachycardia and shortness of breath. B - Hematuria and flank pain. C - Abdominal pain and positive Homan's sign. D - Urinary retention after voiding.
B - Hematuria and flank pain.
Negative nitrogen balance results when: A - More nitrogen is gained than is lost. B - More protein is excreted than consumed. C - Albumin levels are depleted. D - Plamsa protein level exceeds 10 mcg/100cc blood.
B - More protein is excreted than consumed.
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A - give morphine IV B - administer oxygen therapy C - start an IV infusion of lactated Ringer's D - initiate cardiac monitoring
B - administer oxygen therapy
A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take fist? A - insert an oral airway B - administer the abdominal thrust maneuver C - turn the client to the side D - perform a blind finger sweep
B - administer the abdominal thrust maneuver
A nurse is monitoring an infant who is 3 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. The nurse should recognize these findings are associated with which of the following diagnoses? A - influenza B - bronchiolitis C - croup D - epiglottis
B - bronchiolitis
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A - nausea B - dysphagia C - agitation D - hypotension
C - agitation
A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? (select all that apply) A - providing hygiene care to a client who is HIV-positive B - emptying a urinary drainage bag for a client who has pneumonia C - irrigating a client's abdominal wound D - transporting a cerebrospinal fluid specimen to the laboratory E - suctioning a client's new tracheostomy tube
C and E
A nurse in a community health center is assessing the results of a TB test she performed on a client. Which of the following results indicates exposure to and a possible infection with TB? A - 4 mm erythema B - 5 mm induration BC- 10 mm wheal D - 15 mm induration
D - 15 mm induration
A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measure on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care? A - properly disposing of contaminated equipment B - discarding used syringes in appropriate containers C - changing soiled linens daily for clients who have draining wounds D - performing hand hygiene frequently & consistently
D - performing hand hygiene frequently & consistently
A nurse in an ED is assessing a 3 yr old who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse's priority? A - insert an IV catheter B - obtain blood culture specimens C - administer an antipyretic D - prepare for nasotracheal intubation
D - prepare for nasotracheal intubation rationale: the client's manifestations suggest epiglottitis, which is a respiratory emergency. Airway obstruction is imminent, and that is the greatest risk to the client's safety at this time, so the priority action is to prepare for intubation to maintain airway patency.
A nurse is reviewing the medical record for a client who has a health-care associated infection (HAI). The nurse should identify which of the following findings as ra risk for acquiring an HAI? A - the client had an appendectomy 6 months ago B - the client has bipolar disorder C - the client is male D - the client is 71 years old
D - the client is 71 years old
A nurse is caring for a client who asks about the functions of the thymus, spleen, and lymph nodes. Which of the following responses should the nurse make? A - "these organs support immunity" B - "these organs are used in digestion" C - "these organs regulate electrolyte balance" D - "these organs assist in vitamin absorption"
A - "these organs support immunity"
A nurse is assisting with the admission of a child who has measles. Which of the following isolation precautions should the nurse include? A - airborne B - contact C - protective environment D - droplet
A - airborne
A nurse is reviewing lab results of an adolescent female client and notes a WBC count of 16,000/mm3 with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results? A - an acute infectious process B - neutropenia C - allergic reaction D - a resolving inflammatory process
A - an acute infectious process
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? A - apply a moisture barrier ointment to the client's skin B - clean the client's skin and perineum with hot water after each episode of incontinence C - check the client's skin every 8 hrs for sign of breakdown D - request a prescription for the insertion fo an indwelling urinary catheter
A - apply a moisture barrier ointment to the client's skin
A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? A - auscultate breath sounds at least every 2 hrs B - perform range-of-motion (ROM) exercises at least 2-3 times daily C - make sure the client has an intake of 2-3,000 mL of fluid/day D - apply antiembolic stockings
A - auscultate breath sounds at least every 2 hrs
A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first? A - auscultate lung fields B - assess pulse & respirations C - assess characteristics of her sputum D - instruct to slowly exhale with pursed lips
A - auscultate lung fields
A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor this client for which of the following conditions? A - dehydration B - fungal infection C - compartment syndrome D - pleural effusion
B - fungal infection
A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first? A - gown B - gloves C - face shield D - mask
B - gloves
A nurse is caring for a client who has a lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? A - kidney beans B - grilled salmon C - peanut butter D - raw spinach
B - grilled salmon
A nurse is planning care for a client who has manifestations of C. difficile infection. Which of the following actions should the nurse plan to take? A - place a surgical mask on the client during transport B - place the client on contact precautions C - use an alcohol-based agent to perform hand hygiene when caring for the client D - obtain a blood specimen to test for C. difficile
B - place the client on contact precautions
A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? A - check the client's vital signs B - assess the client's pain level C - cover the wound with a moist, sterile gauze dressing D - obtain a culture and sensitivity of the wound drainage
C - cover the wound with a moist, sterile gauze dressing
A nurse is caring for a toddler who has acute laryngotracheobronchitis (croup) and has been placed in a cool mist tent. Which of the following findings indicates that the treatment has been effective? A - barking cough B - improved hydration C - decreased stridor D - decreased temperature
C - decreased stridor
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? A - furosemide B - dexamethasone C - heparin D - atropine
C - heparin
A nurse is completing a physical examination of a client and notes that laboratory values indicate leukocytosis. The nurse should recognize that which of the following manifestations is associated with leukocytosis? A - anemia B - coagulation disorders C - inflammation D - renal disorder
C - inflammation
A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in the plan? A - initiate standard precautions B - initiate airborne precautions C - initiate droplet precautions D - initiate contact precautions
C - initiate droplet precautions
The physician orders bed rest for a client after surgery. The nurse is aware that the most beneficial method of preventing skin break- down while the client is confined to bed is to: A - Massage the skin with cream. B - Use a sheepskin pad on the bed. C - Promote passive range of motion. D - Encourage independent movement.
D - Encourage independent movement.
A charge nurse is planning to admit several clients to the medical unit. Which of the following clients should the nurse assign to a private room? A - who has a fever of unknown origin B - who had a total hip arthroplasty C - a client who is HIV positive D - a client who is neutropenic
D - a client who is neutropenic
A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestations of a stage 3 pressure ulcer? A - exposed bone B - blood filled blisters C - partial-thickness skin loss D - necrotic subcutaneous tissue
D - necrotic subcutaneous tissue