exam 2 review questions

The nurse is assigned to a postpartum client. Which method of examination is appropriate for assessing fundal height? 1:palpation 2:inspection 3:percussion 4:auscultation

1 Rationale: fundal height in a postpartum client is measured by palpation. Palpation is the examination of the body using the sense of touch. Sensory nerves in the fingers transmit messages through the spinal cord to the cerebral cortex, where they are interpreted by the nurse. Fundal height is documented in relation to the umbilicus

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? 1:planning 2:evaluation 3:assessment 4:implementation

1 Rationale: planning comes after diagnosis. the nurse cannot plan or interpret correctly if the clients problems are not clear

While assessing the carotid pulses, which term refers to a blowing sound created by turbulence when passing through narrowed arteries? 1:bruit 2:ectropion 3:entropion 4:borborygmi

1 rationale: -ectropion: eyelid turned outward away from eyeball -entropion: malposition resulting in an inversion of the eyelid margin -borborygmi: rumbling or gurgling noises made by the movement of fluid and gas in the intestines

Which action would the nurse take for a client whose right radial pulse is weak and thready? select all that apply 1:assessing all peripheral pulses 2:assessing and comparing both radial pulses 3:asking a second nurse to assess the clients pulse 4:assessing for edema or other issues that may be restricting peripheral blood flow 5:observing for pallor/ skin temp differences distal to the weak pulse

1,2,3,4,5

A nurse is taking care of a client who has chronic back pain. Which nursing considerations would be made when determining the clients plan of care? select all that apply 1:ask the client about the acceptable level of pain 2:eliminate all activities that precipitate the pain 3:administer the pain medications regularly around the clock 4:use a different pain scale each time to promote patient education 5:assess the clients pain every 15 minutes

1,3 Rationale: Considering that the client has chronic, not acute, pain, the goal of pain management is to decrease the pain to a tolerable level instead of eliminating the pain completely. -The same pain scale should be used for assessment of clients pain level for consistency

In which order would you prepare to enter the room of a patient in contact and droplet isolation precautions for MRSA? 1:put on eyewear 2:perform hand hygiene 3:put on gloves 4:put on mask 5:out on gown

2,5,4,1,3

The nurse is assessing a client's heart rate by palpating the carotid artery. Which action should the nurse implement when assessing a pulse at this site? 1:monitor for a full minute 2:palpate just below the ear 3:press gently when palpating the site 4:massage the site before assessing for rate

3

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow up? 1: auscultation of an apical heart rate of 76 2:absence of bowel sounds on abdominal assessment 3:respiratory rate of 8 breaths/min 4:palpation of dorsalis pedis pulses with strength of +2

3

during a physical exam, which assessment would the nurse anticipate when a client is place in the lithotomy position? 1:heart 2:rectum 3:female genitalia 4:musculoskeletal system

3

Which characteristic would the nurse associate with collaborative problems experienced by a client? 1:they are the identification of a disease condition 2:they include problems treated primarily by nurses 3:they are identified by the primary health care provider 4:they are identified by the nurse during the nursing diagnosis stage

4

Which definition does the World Health Organization use to define health 1:a condition when people are free of disease 2:a condition of life rather than pathological state 3:an actualization of inherent and acquired human potential 4:a state of complete physical, mental, and social wellbeing

4

The nurse changed a dressing on a client's wound with vancomycin-resistant enterococci(VRE). which step would the nurse take to ensure proper disposal of the soiled dressing? 1:place the dressing in the bedside trash can 2:place the dressing in a red bag/hazardous materials bag 3:contact environmental services personnel to pick up the dressing 4:transport the dressing to the lab to be placed in the incinerator

2

Which nonpharmacological nursing intervention is effective in helping relieve postoperative pain? 1:ambulation 2:repositioning 3:purse-lipped breathing 4:deep breathing and coughing

2

The nurse is caring for a client with ringworm. Which statement made by the client indicates they understand the mode of transfer? 1:I need to wear gloves when scooping the litter box 2:I will wear gloves when playing with my kitten 3:I will avoid undercooked meat from now on 4:I need to stay at home until I am healed

2 Rationale: Ringworm is a fungal infection of the skin transmitted by direct contact with the infected person or animal. Touching an infected animal can result in transmission of ringworm to humans. Wearing gloves and hand washing can reduce the risk of transmission -ringworm is not transmitted through animal feces -ringworm is not spread through the ingestion of undercooked meat -ringworm does not require quarantine

The nurse is working with an unlicensed assistant. Which of the following tasks can the nurse assign to the assistant? 1:auscultation of breath sounds 2:auscultation of apical pulse 3:inspection of dressing for type of draining 4:inspection of IV site for infiltration

2 Rationale: auscultating the apical pulse is within the scope of the unlicensed assistant when obtaining vital signs

which client assessment finding would the nurse document as subjective data? 1:BP : 120/80 2: pain rate: 5 3: potassium: 4.0 mEq 4:pulse oximetry: 96%

2 Rationale: subjective data comes from the patient

A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient? 1: reverse isolation 2:droplet precaution 3:standard precaution 4:contact precaution

2 rationale: because the patient is diagnosed with meningitis, which can be spread when the patient coughs or sneezes, droplet precautions are most appropriate -standard precaution: strict form of infection control assuming all blood and body fluids are infectious -reverse precaution: used when patient is extremely susceptible (chemotherapy) -contact precautions: practices used to prevent spread of disease by direct or indirect contact

Which action would the nurse take first when caring for a postoperative client who reports pain? 1:provide an ice bag 2:administer pain medication as prescribed 3:perform a focused assessment of the client 4:document the clients complaint in the chart

The first step of the nursing process is assessment; the nurse would assess the client to make sure that the complaint of pain is not indicative of another problem that requires intervention. They would assess to determine the origin of pain -pain medication and documentation comes after assessment

Damage to which cranial nerve may lead to decreased olfactory acuity? 1: I 2:X 3:V 4:VIII

1

How can the nurse evaluate the effectiveness of communication with a client? 1:client feedback 2:medical assessments 3:health care team conferences 4:clients physiological responses

1

The nurse assess a clients pulse rate and recoded the score as 3+. Which descriptor reflects the strength of the pulse? 1:strong 2:bounding 3:expected 4:diminished

1

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? 1:appearance and behavior 2:measurement of vital signs 3:observing specific body systems 4:conducting a detailed health history

1

Which action would the nurse take first if an allergic reaction to a blood transfusion occurs? 1:shut off the infusion 2:slow the rate of flow 3:administer an antihistamine 4:call the health care provider

1

the nurse documents cheyne stokes in a client. Which finding would the nurse note? 1:rhythmic respirations with periods of apnea 2:regular rapid and deep, sustained respirations 3:totally irregular respirations

1

when conducting an assessment of a client who does not speak English and an interpreter is unavailable, which action would the nurse not utilize? 1:using medical terminology 2:proceeding in an unhurried manner 3:speaking in a low and moderate voice 4:pantomiming words and simple actions while verbalizing them

1

Which action would the nurse take INITIALLY to advocate for the client and achieve resolution when caring for a client with terminal cancer who desires to receive hospice care at home rather than pursue further treatment against the advice of both the health care provider and the immediate family? 1:help the client clarify their values to prioritize action 2:brainstorm possible alternative solutions for this issue 3:empower the client to decide to resolve the situation 4:provide support and reassurance as the client makes decisions

1 Rationale: The nursing process as a problem solving approach can be used by the nurse to help the client resolve value or ethically laden issues. In the first step (initially) of the process, the nurse would help the client illuminate values because values influence behaviors, feelings, and goals. -brainstorming occurs in the planning phase and helps generate alternatives -empowering the client to make decisions and providing support and reassurance happens in the implementation stage

The nurse is performing a psychosocial assessment. Which assessment should be identified as a subtle indicator of depression? 1:unkempt appearance 2:anxious behavior 3:tense posture 4:crying

1 Rationale: When people are depressed, they frequently do not have the physical or psychic energy to perform the activities of daily living and often exhibit an unkempt appearance is a covert, subtle indication of depression -anxiety, tense posture, and crying are overt, not covert and subtle

The nurse is caring for a client with a fractured hip. Which is the nurse trying to prevent my placing pillows around the injured area? 1:abduction 2:adduction 3:traction 4:elevation

1 Rationale: abduction means to move the lib away from the median plane, or axis, of the body. With fractured hips, the legs and hip must be aligned in an abducted position to prevent internal rotation, reduce the risk of dislocation, and decrease pain -adduction: means to move the limbs toward the medial plane, or axis of body -traction: involves the process of applying a pulling force in opposite directions using weights

Which precaution would the nurse implement for herpes zoster? select all that apply 1:airborne 2:contact 3:droplet 4:standard

1 Rationale: airborne precautions are used for clients known or suspected to have infections transmitted by the airborne transmission route. this route refers to the spread of small particles in the air such as herpes zoster, chickenpox, measles, tuberculosis -contact precautions are used for clients know infections transmitted by direct contact or contact with items in the environment. Infections spread by skin to skin contact. EX: C difficle, MRSA, VRE -droplet precautions: used for infections spread in large droplets by coughing, talking, or sneezing. EX: influenza and bacterial meningitis

The nurse applies an ice pack to a client's leg for a total of 20 minutes. Which physiological effect would occur because of applying cold therapy? 1:local anesthesia 2:peripheral vasodilation 3:depression of vital signs 4:decreased viscosity of blood

1 Rationale: cold reduces the sensitivity of pain receptors in the skin. Local blood vessels constrict, limiting the amount of edema and its related pressure and discomfort

The nursing student, under the supervision of the RN, plans to perform a pulse assessment. While preparing to assess the client, the RN asks the student to check the apical pulse after assessing the radial pulse. Which rational supports the RNs request? 1:the may have dysrhythmia 2:they client may have physiologic shock 3:the client underwent surgery earlier in the day 4:the client may have peripheral artery disease

1 Rationale: dysrhythmia results in abnormal radial pulse. You must then listen to the apical pulse if the radial pulse is abnormal.

The school nurse is teaching a class of adolescents about the function of the integumentary system. Which fact about how the skin protects the body against infection is important to include in this discussion? 1: cells of the skin are constantly being replaced, thereby eliminating external pathogens 2:epithelial cells are loosely compacted in the skin, providing a barrier against pathogens 3:moisture on the skin surface prevents colonization of pathogens 4:the alkalinity of the skin limits the growth of pathogens

1 Rationale: epithelial cells of the skin are regularly shedding, along with potentially dangerous microorganisms that adhere to the skins outer layers, thereby reducing the risk of infection -epithelial cells are closely, not loosely packed -the acidity, not alkalinity, of the skin limits the growth of pathogens -moisture on the skin surface facilitates, not prevents the colonization of pathogens

Upon noticing a client with heart disease has digital cyanosis, which site would the nurse assess to confirm cyanosis? 1: lips 2:sclera 3:conjunctiva 4:mucus membrane

1 Rationale: lips and nail beds are the best sites to assess for cyanosis -the sclera and mucous membrane are assessed in juandice -the conjunctiva is assessed for the presence of pallor

The nurse educator is evaluating whether a new staff nurse understands the relationship between a fever and an infection. Which statement by the new staff nurse indicates an understand of this relationship? 1:Phagocytic cells release pyrogens that stimulate the hypothalamus 2:Leukocyte migration precipitates the inflammatory response 3:erythema increases the flow of blood throughout the body 4:pain activates the sympathetic nervous system

1 Rationale: microorganisms or endotoxins (lipopolysaccharides that are a component of the cell wall of gram neg bacteria) stimulate phagocytic cells, which release pyrogens that stimulate the hypothalamic thermoregulatory center, causing fever -leukocyte does not precipitate the inflammatory response, but it is a phase of the inflammatory response. WBS reach a wound within a few hours after the injury to ingest bacteria and clean wound of debris through the process of phagocytosis -erythema does not increase the flow of blood throughout the body. Increased blood flow to a localized area causes diffuse redness (erythema) -pain does not cause an increase in body temperature directly

The client reports difficulty in breathing. The nurse auscultates lung sounds and assess the respiratory rate. Which is the purpose of the nurses action? 1:data collection 2:data validation 3:data clustering 4:data interpretation

1 Rationale: the nurse is gathering objective data to support the subjective data. The subjective data is the client reporting difficult breathing which must be supported by data obtained during the physical exam (objective data) -Data validation: the nurse reviews the database after data collection to decide if it is accurate and complete -data clusters: the grouping of data that forms a pattern -data interpretation: nurse uses critical thinking to interpret the data and analyze it before it is classified and organized into data clusters

upon assessing a client who underwent abdominal surgery 10 days ago, the client reports abdominal pain. Which type of pain would the client experience? 1:visceral pain 2:somatic pain 3:referred pain 4:intractable pain

1 Rationale: visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. -somatic pain: arises from bone, joint, muscle, skin, or connective tissue -referred pain: experienced in clients with tumors, in which pain is felt in a part of body other than its actual source -intractable pain: neuropathic pain that is severe, constant pain that is not curable

The nurse is teaching unlicensed assistant personnel about ways to prevent the spread of infection. The nurse decides to emphasize the need to break the cycle of infection. Which teaching would be priority? 1: hand washing before and after providing client care 2:cleaning all equipment with an approved disinfectant after use 3:wearing personal protective equipment (PPE) when providing client care 4:using medical and surgical techniques at all times

1 Rationale: washing hands is the single most effective means of preventing the spread of infection by break the cycle of infection.

When conducting a client interview, which nurses response is an example of back channeling? 1:all right, go on.. 2:what else is bothering you 3:tell me what brought you here 4:how would you rate your pain on a scale of 0-10

1 rationale: back channeling involves the use of listening prompts such as "Go on...", "all right", "uh-huh". Such prompts encourage the client to complete the full story -the nurse uses probing/open ended question by saying: what else is bothering you -open ended statement: tell me what brought you here -close ended question: how would you rate your pain 0-10

The client is on neutropenic precautions. From which direction does the protective environment isolation help prevent the spread of infection? 1:to the client from outside sources 2:from the client to others 3:from the client by using special techniques to destroy infectious fluids and secretions 4:to the client by using special sterilization techniques

1 rationale: protective environment isolation implies that the activities and actions of the nurse will protect the client from infectious agents because the client's own immune defense ability is compromised (neutropenia) it is also referred to as reverse isolation

A patient who has been placed on contact precautions for clostridium difficle ask you to explain what he should know about the organism. What is the most appropriate information to include in patient teaching? (select all that apply) 1:the organism is usually transmitted through the fecal-oral route 2:hands should always be cleaned with soap and water versus alcohol based hand sanitizers 3:everyone coming into the room must be wearing a gown and gloves 4:while the patient in the contact precautions, he cant leave 5:C difficile dies quickly once outside the body

1,2,3 rationale: C difficle is transmitted through the oral-fecal route and spread through contact with contaminated feces or surfaces touched by hands no appropriately cleaned after providing care to a patient infected. -The organism develops a hard spore and can live for a long time on surfaces, making it very hard to eradicate. As long as the patient is continent of stool and first cleans hands and changes gown, a patient with c difficile can leave the room

The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.) 1:Teaching correct handwashing to assigned patients 2:Using correct procedures in starting and caring for an intravenous infusion 3:Providing perineal care to a patient with an indwelling urinary catheter 4:Isolating a patient on antibiotics who has been having loose stool for 24 hours 5:Decreasing a patient's environmental stimuli to decrease nausea

1,2,3 rationale: nausea is not typically associated with transmission of infection, and loose stools are a common side effect with antimicrobials. All the other interventions break the cycle of infection transmission

When assessing a client after abdominal surgery, which cue would the nurse use to form a data cluster? Select all that apply. 1:the client reports pain with movement 2:the client has pain over the surgical area 3:the client wants to know when he can go home 4:the client rates the pain as 8 on a scale of 0-10 5:the client has concerns about caring for the wound

1,2,4

Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) 1:Proper cleaning requires mechanical removal of all soil from an object or area. 2:General environmental cleaning is an example of medical asepsis 3:When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4: Cleaning in a direction from the least to the most contaminated area helps reduce infections. 5:Disinfecting and sterilizing medical devices and equipment involve the same procedures

1,2,4 rationale: Proper cleaning and disinfection are processes that occur prior to sterilization, with cleaning always done from dirty to clean to decrease the risk of further infection and contamination.

Which methods qualify as alternative therapies for pain? Select all that apply 1:prayer 2:hypnosis 3:medication 4:aromatherapy 5:guided imagery

1,2,4,5 Rationale: analgesics, both opioid and nonopioid, have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy

Which type of personal protective equipment should the nurse wear when caring for a pediatric patient who is placed on Airborne Precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1:disposable gown 2:N95 respirator mask 3:face shield or goggles 4:disposable mask 5:gloves

1,2,5 Rationale: chicken pox is an airborne organism that can travel distances, so it is important that the air breathed by the nurse is filtered, and hands and clothes are covered

Which scenario would the nurse consider an example of the feedback component of the nursing process? select all that apply 1:the nurse notices that the clients pain has decreased after giving a back massage 2:the caregiver says that the clients body temp has decreased after administering the prescribed meds 3:the RN instructs the nursing assistive personnel to use a shower chair to give a bath to a client with activity intolerance 4:the nursing supervisor asks the nurse to keep the side rails of the bed up when providing care for an older adult who has a history of falls 5:the nurse finds the client has developed breathing issues after administering meds through the central venous access device

1,2,5 rationale: the feedback component in the nursing process is the outcome that is reflected by the clients responses to nursing interventions. This component also includes responses from family members and consultations from other health care professionals

When obtaining a health history from the newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include? select all that apply 1:pain history, including location, intensity, and quality of pain 2:clients purposeful body movement in arranging the papers on the bedside table 3:pain pattern, including precipitating and alleviating factors 4:vital signs, such as increased blood pressure and heart rate 5:the clients family statement about increases in pain with ambulation

1,3 Rationale: the initial pain assessment should include info about the location, quality, intensity, onset, duration, and frequency of pain, as well as factors that relieve the pain. -vital signs are a secondary assessment

Which scenario would the nurse label as the "input" component of the nursing process? select all that apply 1: the nurse checks the clients health history for allergy to iodine before inserting a urinary catheter 2:the nurse finds that the clients urine has the presence of blood after the urinary catheter is removed 3:the nurse checks for whether the client has a history of substance abuse before administering nasal medications 4:the nurse finds that the clients skin color changed to bluish purple after applying cold therapy to reduce swelling 5:before placing an internal fecal catheter, the nurse checks the clients medical records for any rectal surgery within the past year

1,3,5 Rationale: the input component of the nursing process is known as the data or information obtained from a patients assessment. When the nurse checks the clients health history for an iodine allergy, or for the presence of substance abuse before administering medicine, or checking for any rectal surgeries in the last year; they are using the input component -The output component is finding blood in urine or blue skin

Put the following steps for removal of protective barriers after leaving an isolation room in order. 1: Remove and dispose of gloves. 2:perform hand hygiene 3:remove eyewear or goggles 4:unite top and then bottom mask strings and remove from face 5:unite waist and neck strings of gown. remove gown, rolling it onto itself without touching the contaminated side

1,3,5,4,2 rationale: Removing isolation PPE correctly decreases the risk of self-contamination. The gloves are considered the most contaminated pieces of PPE and are therefore removed first. The face shield or goggles are next because they interfere with removal of other PPE. The gown is third, followed by the mask or respirator.

The nurse is collecting information from a client who has arthritis by posing questions to the client. Which questions asked by the nurse are closed-ended questions? select all that apply 1:Are you having pain? 2:tell me how your pain has been. 3:describe how your spouse is helping you at home 4:do you think the medication is helping you get pain relief? 5:give me an example of a method that helps you get pain relief at home

1,4 Rationale: close ended questions limit the clients response to one or two word answers

Which feature distinguishes nursing diagnoses from medical diagnoses? select all that apply 1:nursing diagnoses involve the client when possible 2:nursing diagnoses are based on results of diagnostic tests and procedures 3:nursing diagnoses are the identification of a disease condition in the client 4:nursing diagnoses involve the sorting of health problems within the nursing domain 5: nursing diagnosis involve clinical judgement about the clients response to health problems

1,4,5 rationale: medical diagnosis is based on the results of diagnostic tests and procedures, whereas a nursing diagnosis is based on the results of the nursing assessment.

The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. 1:XII Hypoglossa 2:V Trigeminal 3:VI Adducens 4:IV Trochlear 5:X Vagus A:Motor innervation to the muscles of the jaw B:Lateral movement of the eyeballs C:Sensation of the pharynx D:Downward, inward eye movements E:Position of the tongue

1e:XII Hypoglossa= position of tongue 2a: V Trigeminal= Motor innervation to the muscles of the jaw 3b: VI Adducens= Lateral movement of the eyeballs 4d: IV Trochlear= Downward, inward eye movements 5c: X Vagus= Sensation of the pharynx

The nurse performed physical assessments for four female clients during their general checkup. Which client is most at risk of developing breast cancer? 1: age:60, family history of breast cancer: yes, children:2, age of onset of menopause:45 2:age:60, family history of breast cancer:yes, children: none, age of onset of menopause: 50 3:age:60, family history of breast cancer: no, children: none, age of onset of menopause: 50 4:age:60, family history of breast cancer:no, children: 2, age od onset of menopause: 45

2 Rationale: Women over the age of 40 with a family history of breast cancer, late age menopause (age after 50), who have not had children or who conceived after the age 30 years, or women with excessive oral contraceptives are at the risk of breast cancer

Which step would the nurse take first when preparing a concept map for a assigned client? 1:assess the client and gather information 2:arrange cues into clusters that form patterns 3:identify patterns reflecting the clients problem 4:identify specific nursing diagnoses for the client

2 Rationale: a concept map is a visual representation of the connection between the client's many health problems. The first step is to arrange all the cues into clusters that form patterns. This helps the nurse identify specific nursing diagnoses for the client -During the assessment stage, the nurse assess the client and gathers information. This step is preformed before preparing the concept map -After placing all cues into cluster, the nurse begins to identify patterns reflecting the client's problem. The concept map helps the nurse obtain a holistic view of the clients needs -The next step is to identify specific diagnoses so that appropriate nursing interventions can be provided

The nurse is planning care for a client who has intolerance to activity. Which is the first assessment that should be made by the nurse? 1:range of motion 2:pattern of vital signs 3:impact on functional health patterns 4:influence on the other family members

2 Rationale: activity intolerance is related to the inability to maintain adequate O2 to body cells, which is associated with respiratory and cardiovascular problems. Obtaining the VS will provide valuable information about these systems -range of motion refers to the nervous and musculoskeletal system, not the cardiovascular and respiratory systems

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, and the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of which? 1:binder 2:ice bag 3:elastic bandage 4:warm compress

2 Rationale: application of ice to a soft tissue injury causes vasoconstriction, which results in decreasing hemorrhage, edema, and pain -binder or elastic bandage on the area of a soft tissue injury is contraindicated and may cause compartment syndrome -a warm compress would result in vasodilation and cause increased hemorrhage, edema, and pain

Which condition places a client at the highest risk for developing infections? 1:implantation of prosthetic device 2:burns over more than 20 percent of the body 3:presence of an indwelling urinary catheter 4:more than two puncture sites from laparoscopic surgery

2 Rationale: burns on more than 20 percent of a persons total body surface generally are considered major burn injuries. When the skin is damaged by a burn, the underlying tissue is left unprotected, and the individual is at risk for infection. The greater the extent and the deeper the depth of the burn, the higher the risk is for infection.

A client has a wound that is healing by secondary intention. Which solution to cleanse the wound and dressing should the nurse expect will be prescribed to support wound healing? 1:normal saline and gauze dressing 2:normal saline and a wet to moist dressing 3:povidone-iodine and a dry sterile dressing 4:half peroxide and half normal saline and a wet to dry dressing

2 Rationale: cleaning with normal saline will not damage fibroblasts. wet to damp dressing allow epidermal cells to migrate more rapidly across the wound surface than dry dressings, thereby facilitating wound healing.

A nurse in the emergency department is engaging in an initial assessment of a client. Which assessment takes priority? 1:blood pressure 2:airway clearance 3:breathing pattern 4:circulatory status

2 Rationale: client assessment must always be conducted in order of priority of needs. In an emergency, the ABCs of an assessment are airway, breathing, and circulation. A clear airway is essential for life and therefore is the first priority

when evaluating the vital signs of a group of client's, the nurse takes into consideration the circadian rhythm of body temperature. At which time of day is body temperature usually at its lowest? 1:4pm-6pm 2:4am-6am 3:8pm-10pm 4:8am-10am

2 Rationale: diurnal variations (circadian rhythms) vary throughout the day, with the lowest body temp usually occurring between 4-6am. The metabolic rate is at its lowest while the person is sleeping (as temperature increases so does the metabolic rate)

The nurse working in a clinic is assessing clients of a variety of ages. Which age group should the nurse particularly assess for subtle clinical manifestations (observable signs/symptoms of an infection) of subclinical infections (infections that show few to no signs) 1:children of school age 2:older adults 3:adolescents 4:infants

2 Rationale: infections are more difficult to identify in older adults because the clinical manifestations are not as acute and obvious as the other age groups. This outcome occurs as a result of the decline in all body systems related to aging

After an eye assessment, the nurse finds that the clients eyes are not focusing on an object simultaneously and appear crossed. Which potential cause would the nurse associate with this condition? 1:loss of elasticity of lens 2:impairment of the extraocular muscles 3:obstruction of the aqueous humor outflow 4:progressive degeneration of the center of the retina

2 Rationale: starbismus is a condition where the eyes appear crossed; this condition is caused by the impairment of the extracular muscles -loss of lens elasticity may lead to presbyopia, which causes impaired near vision -An obstruction of the aqueous humor outflow may lead to glaucoma -the progressive degeneration of the center of the retina indicates macular degeneration and leads to blurred central vision

Which definition is correct to explain the nursing process? 1:procedures used to implement client care 2:sequence of steps used to meet the client's needs 3:activities employed to identify a clients problems 4:mechanisms applied to determine nursing goals for the client

2 Rationale: the nursing process is a step by step method that scientifically provides for a client's nursing needs. -1,3,4 are only steps in the nursing process, not the actual definition

A client has had a 101 fever for the past 24 hours. How often should the nurse monitor this client's temperature? 1:every 2 hours 2:every 4 hours 3:every 6 hours 4:every 8 hours

2 Rationale: this is an appropriate interval of time for routine monitoring of body temperature. It is frequent enough to identify trends in changes in body temperature while limiting unnecessary assessments

An adolescent client with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. The current pain rating is 5 on a scale of 1-10 at the right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. Which action would the nurse implement? 1:turning on the TV for diversion 2:Placing the prescribed as-needed warm, wet compress on the elbow 3:calling the primary health care provider for another analgesic prescription 4:informing the client gently that they must wait until the pump reactivates to get more medication

2 Rationale: vasodilation should help reduce pain from cellular clumping; applying a warm, wet compress will address the pain until the pump

While examining a client, the nurse finds a 0.6 cm circumscribed elevation of the skin filled with serous fluid on the cheek. Which term best describes this? 1:papule 2:vesicle 3:nodule 4:pustule

2 rationale: -papule: palpable, has a solid elevation and a size smaller than 1 cm -a nodule: elevated solid mass, deeper and firmer than a papule -pustule: similar to a vesicle but filled with pus in varies sizes

While assessing a client, the nurse identifies the ratio of anteroposterior diameter and transverse diameter of the chest as 1:1. Which findings support this conclusion? select all that apply 1: client has lordosis 2:client is an older adult 3:client has osteoporosis 4:client has a history of smoking 5:client has chronic lung disease

2,4,5 Rationale: the 1:1 ratio of anteroposterior diameter and transverse diameter of the chest indicates a barrel-shaped chest. This is a characteristic feature in older adults who smokes and has chronic lung disease. -In lordosis, there is an increase in lumbar curvature. -Osteoporosis is a systemic skeletal condition in which there is a decreased bone mass and deterioration of bone tissue

Which nurse action reflects the evaluation phase of the critical thinking process? select all that apply 1: collecting all the data in order 2:looking at all the situations objectively 3:supporting the findings and drawling conclusions 4:being open minded to information about the client 5:using several criteria to determine the effectiveness of a nursing intervention

2,5 Rationale: during the EVALUATION phase of the critical thinking process, the nurse would look at the situation objectively and use several criteria to determine the effectiveness of a nursing intervention (as well as reflect on own behavior) -interpretation phase: orderly collecting date, apply reasoning, categorize the data, and gather additional data and clarify any data that you are uncertain about -analysis phase: be open minded, avoid making carless assumptions, and look for any trends -inference: look at the meaning, significance, and relationships of findings -Evaluation stage here -explanation: support your findings and draw conclusions. Use knowledge and experience to choose strategies -self-regulation: reflect on own experiences (I, Am, Interfering, Every, Explanation, Sorry)

In which sequence of techniques would the nurse assess a clients abdomen? 1:palpation 2:inspection 3:auscultation 4:percussion

2-3-4-1 rationale: -inspection of the contour, symmetry, and surface motion of the abdomen -auscultation done before palpation because it reduces the chance of altering the frequency of bowel sounds -percussion is used to assess kidney inflammation -palpation detects areas of abdominal tenderness, distention, or massess

Which category of isolation would the nurse implement for a client who is positive for clostridium difficile 1:airborne precautions 2:droplet precautions 3:contact precautions 4:protective environment

3 Contact precautions should be used for direct client or environmental contact with blood or body fluids from an infected client. This includes colonization of infection with multidrug-resistant organisms such as methicillin-resistant staphylococcus aureus, stool infected with clostridium difficile, draining wounds where secretions are not contained, or scabies.

The nurse is caring for a client who sustained trauma in an automobile collision. The nurse makes the following assessments: does not open eyes when asked a question but opens eyes and withdraws from painful stimulus when turned and positioned; makes sounds but does not speak words. The nurse used the Glasgow Coma Scale (GCS) to rate the clients level of consciousness. Which point total on the GCS should the nurse document the clients clinical record to indicate the clients level of consciousness? 1: 4 2:6 3:8 4:10

3 Rationale: eye-opening points: -eye opens spontaneously: 4 -eyes open in response to voice: 3 -eyes open in response to pain: 2 -eye does not open to responses: 1 best verbal response points: -oriented: 5 -confused, speaks but is disoriented: 4 -inappropriate but comprehensible words:3 -incomprehensible sounds, but no words are spoken: 2 -none: 1 Best motor response points: -obeys commands to move: 6 -localizes painful stimulus:5 -withdraws from painful stimulus: 4 -flexion: 3 -extension: 2 -none: 1 His score is 8 because he opens eyes to pain (2), makes sounds but not words (2), and withdraws from painful stimulus(4)

For which involuntary physiologic response would the nurse monitor development in a clients experiencing pain? 1:crying 2:splinting 3:perspiring 4:grimacing

3 Rationale: (sweat) an involuntary physiologic response. It is mediated by the ANS under a variety of circumstances: rising temps, high humidity, stress, and pain

The nurse is educating a client about immunity. Which client statement reflects an understanding of how vaccines provide protection against pathogens? 1:the vaccine antibodies surround and destroy the virus 2:my body produces antigens to fight the pathogens 3:my cells are stimulated to produce antibodies 4:the vaccine reacts to the virus to destroy it

3 Rationale: B lymphocytes are stimulated by vaccines to make the antibodies (immunoglobulins) and work together with T cells to destroy the pathogen. Vaccines introduce the body to antigens that cause the immune system to produce antibodies to fight them. ACTIVE immunity occurs by exposure to a pathogen via vaccine or acquired infection. PASSIVE immunity is achieved by another person or animal (breastfeeding, serum for treatment of rabies)

The nurse is concerned about a clients ability to withstand exposure to pathogens. Which blood component should the nurse monitor? 1:platelets 2:hemoglobin 3:neutrophils 4:erythrocytes

3 Rationale: Neutrophils, the most numerous leukocytes (WBCs) are a primary defense against infection because they ingest and destroy microorganisms (phagocytosis). When the leukocyte count is low, it indicates a compromised ability to fight infection

Which action would the nurse take first for a postsurgical client who is still intubated but becoming restless, with an increased pulse rate and blood pressure, when it has been 4 hours since the last dose of pain medication? 1:notify the provider 2:perform a full physical assessment 3:administer the prescribed pain medication 4:play soft, relaxing music to help calm the client

3 Rationale: Since it has been several hours, the nurse would administer the prescribed pain medication. -because the client is intubated, the nurse cant fully assess the patient for pain

The nurse is obtaining a clients blood pressure. Which information is most important for the nurse to document? 1:staff member who took the blood pressure 2:clients tolerance to having blood pressure done 3:clients body position if the client is not in sitting position 4:which head of a dual head stethoscope was used to obtain the reading

3 Rationale: The clients position when the blood pressure is measured may influence results. Generally, systolic and diastolic readings are lower in the horizontal than in the sitting position. There is also a lower reading in the upper arm when a person is in a lateral recumbent position. A change from the lay down to sitting position may decrease 10 mmhg. This is called orthostatic hypotension

planning to provide self care health information for several clients, which client would the nurse anticipate will be most motivated to learn? 1:a 55 year old who had a mastectomy and is very anxious about her body image 2: an 18 year old client who smokes cigarettes and is in denial about the dangers of smoking 3:a 56 year old client who had a heart attack last week and is requesting information about exercise 4: a 47 year old client who has a long leg cast after sustaining a broken leg and is still experiencing severe pain

3 Rationale: a client requesting information is indicating a readiness to learn

The nurse is caring for a group of client experiencing various medical conditions. Which condition places the client at the highest risk for a wound infection? 1:Surgical creation of a colostomy 2:first degree burn on the back 3:puncture of the foot by a nail 4:paper cut on finger

3 Rationale: a nail is a soiled object that has the potential of introducing pathogens into deep surfaces of the skin, a favorable environment for multiplication. -no break in skin in a first degree burn -surgeries use sterile tools

The nurse concludes that a client is experiencing pyrexia. Which client assessment precipitated this conclusion? 1:mental confusion 2:increased appetite 3:rectal temp of 101 4:heart rate of 50 beats per minute

3 Rationale: a rectal temperature of 101 or an oral temperature above 100.4 is a common response that indicates pyrexia (fever)

While assessing a client, the nurse identifies adventitious breath sounds. Upon further evaluation, the nurse finds loud, low-pitched, rumbling coarse sounds during inspiration. This sound is clearly heard while the client is coughing. which condition would the nurse associate these sounds? 1:inflammation of the pleura 2:reinflation of groups of alveoli 3:muscular spasms in the larger airways 4:high-velocity airflow through an obstructed airway

3 Rationale: adventitious breathing sounds (rhonchi) can be heard when there are loud, low-pitched, rumbling, and coarse sounds during inspiration. Heard clearly while person is coughing and is caused by muscular spasms in larger airways -inflammation of pleura leads to a pleural friction rub sound -a crackling sound can be heard when there is reinflation of groups of alveoli -high velocity airflow through an obstructed airway causes wheezing

A client, transferred to the postanesthesia care unit after a transurethral resection of the prostate, has an intravenous (IV) line and a urinary retention catheter. During the immediate postoperative period, for which potentially critical complications would the nurse monitor? 1:sepsis 2:phlebitis 3:hemorrhage 4:leakage around urinary catheter

3 Rationale: after transurethral surgery (surgery used to treat urinary problems), hemorrhage is common because of venous oozing and bleeding from many small arteries in the area. -sepsis is unusual, and if it occurs, it will manifest later in the postoperative course -phlebitis: (inflammation of veins) the nurse assesses this but it is not the most important complication -leaking around the catheter is not as important as hemorrhage

The nurse is interviewing a client for admission to the hospital. Which phase of the nursing process is being used in this situation ? 1:planning 2:evaluation 3:assessment 4:diagnosis

3 Rationale: assessment involves taking the history of and verbally interviewing the client.

The nurse must assess for the presence of bowel sounds in a postoperative client. Which technique should the nurse empty to obtain accurate results when auscultating the client's abdomen? 1:listen for several minutes in each quadrant for the abdomen 2:place a warmed stethoscope on the surface of the abdomen 3:perform auscultation before palpation of the abdomen 4:start at the left lower quadrant of the abdomen

3 Rationale: bowel sounds are auscultated before palpation and percussion because these techniques stimulate the intestines and thus cause an increase in peristalsis (involuntary constriction and relaxation of the muscles of the intestine) and a false increase in bowel sounds

A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1:Provide a dark, quiet room to calm the patient. 2:Reduce the level of precautions to keep the patient from becoming angry. 3:Explain the reasons for isolation procedures and provide meaningful stimulation. 4:Limit family and other caregiver visits to reduce the risk of spreading the infection.

3 Rationale: by providing a rationale for the isolation, the patient is able to better understand the safety risks and cooperate with care.

The nurse is caring for a client with a high fever secondary to septicemia. The primary health care provider prescribes a cooling blanket (hypothermia blanket). Through which mechanism does the hypothermia blanket achieve heat loss? 1:radiation 2:convection 3:conduction 4:evaporation

3 Rationale: conduction is the transfer of heat from a warm object (skin) to a cooler object (hypothermia blanket) during direct contact -radiation: heat loss from one surface to another surface without direct contact -convection: loss of heat as a result of the motion of cool air flowing over a warm body. The heat is carried away by air currents that are cooler than the warm body -evaporation: the conversion of a liquid to a vapor

Which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)? 1:insert a urinary catheter 2:initiate droplet precautions 3:move the client to a private room 4:use a high efficiency particulate air (HEPA) respirator during care

3 Rationale: contact precautions are used for clients with known or suspected infections transmitted by direct/indirect contact in the environment; therefore infectious clients must be placed in a private room.

The nurse assess the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which term would the nurse use to document these sounds? 1:vesicular 2:bronchial 3:crackles 4:rhonchi

3 Rationale: crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. -vesicular breath sounds are normal, quiet, soft, and short on inspirations/silent on expirations -bronchial breath sounds are normal and consists of full inspiration and expiratory phases -rhonchi breaths are abnormal and low pitch

Which significance would the nurse associate with the procedure depicted in the picture? (flip slide to view picture) 1:evaluating heart rate 2:evaluating popliteal occlusion 3:evaluating arterial insufficiency 4:evaluating the blood pressure

3 Rationale: in the given photo, the nurse is assessing the ULNAR pulse of the client. This procedure helps to evaluate arterial insufficiency to the hand -radial pulse is used to assess heart rate -popliteal artery, which is in the knee, is used to evaluate popliteal aneurysms and peripheral vascular disease. -Brachial pulse is used to note the blood pressure

The nurse assess the skin turgor of the patient by: 1:inspecting the buccal mucosa with a penlight 2: palpating the skin with the dorsum of the hand 3:grasping a fold of skin on the back of the forearm and releasing 4:pressing the skin for 5 seconds, releasing, and noting each centimeter and depth

3 Rationale: normally, the skin lifts easily and saps back immediately to its resting position; the back of the hand is not the best place to test turgor

When assessing technique involves tapping a clients skin with the fingertips to cause vibrations in the underlying tissues? 1:palpation 2:inspection 3:percussion 4:auscultation

3 Rationale: percussion is the process of tapping the body parts with the fingers or hands to determine the consistency and borders of the body organs

A client with latent tuberculosis is prescribed rifampin. Which client statement warrants further education by the nurse? 1:my urine might turn orange 2:i should use a backup birth control method 3:i can still have a glass of wine with dinner 4:it is better to wear my glasses rather than my contacts

3 Rationale: rifampin can cause liver injury, and drinking alcohol while on this medication can increase the risk. It is advised to avoid alcohol during the course of treatment -rifampin can cause bodily fluids to turn yellow, orange, red, or brown -rifampin can interfere with the effectiveness of birth control. Client must use backup BC -rifampin can cause tears (bodily fluid) to turn a different color resulting in a contact lenses stain

Which nursing intervention would prevent septic shock in the hospitalized client? 1:maintain the client in a normothermic state 2:administer blood products to replace fluid losses 3:use aseptic technique during all invasive procedures 4:keep the critically ill client immobilized to reduce metabolic demands

3 Rationale: septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices

When developing a nursing diagnosis for a client after surgery, the nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to draw this conclusion? 1:the nurse notes nonverbal signs of discomfort 2:the nurse observes the clients position in bed 3:the nurse asks the client to explain the surgery 4:the nurse asks the client to rate the severity of pain

3 Rationale: the nurse must assess the clients knowledge about the surgery to determine if the client is aware of the outcome of surgery.

A child becomes cyanotic during a generalized tonic-clonic seizure. What is the most appropriate action by the nurse? 1:insert an oral airway 2:administer O2 by mask 3:continue to observe the seizure 4:notify the health care provider immediately

3 Rationale: the progression of the seizure should be monitored; the child will not breathe until the seizure is over, and cyanosis should be subside at that time

The nurse notes a client has dependent edema around the area of feet and ankles. To characterize the severity of the edema, the nurse presses the medical malleolus area, noting an 8 MM depression after release. In which way would the nurse document the edema? 1: +1 2: +2 3: +4 4: +8

3 Rationale: this is a grade 4 because: -0+=0 -1+=2mm -2+=4mm -3+=6mm -4+=8mm

When performing an assessment of the client's reproductive system, which finding in the past medical history indicates the client is at risk of cervical cancer? 1:vaginal discharge 2:ovarian dysfunction 3:human papilloma virus infection 4:hematuria and urinary incontinence

3 rationale: HPV infection increases the risk of cervical cancer. -vaginal discharge may indicate a sexually transmitted infection. -ovarian dysfunction may increase the risk of ovarian cancer -hematuria and urinary incontinence indicates urinary problems associated with gynecological disorders

The nurse is performing a neurological assessment on a client and notes a positive rombergs test .he nurse makes this determination based on which observation? 1: involuntary rhythmic, rapid, twitching of the eyeballs 2:a dorsiflexion of the great tow with fanning of the other toe 3:a significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

3 rationale: In the rombergs test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position. A positive test means there is a vestibular neurological sign that is found when a client exhibits a loss of balance

The faith community nurse is teaching the community center women's group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.) 1. First child at the age of 26 years 2.Menopause onset at the age of 49 years 3.Family history with BRCA1 inherited gene mutation 4.Age over 40 years 5.Onset of menses before the age of 12 6.Recent use of oral contraceptives

3, 4, 5, 6 rationale: These are all risk factors for development of breast cancer. Onset of menopause after the age of 55, not at the age of 49, is a risk factor. First child after the age of 30, not birth of a child at 26, is a risk factor.

In which order would the nurse assess the visual level of a client? 1: ask the client to report when he or she is able to see the finger 2:close the opposite eye to superimpose the field of vision 3:direct the client to stand or sit 60 cm away from eye level 4:ask the client to close his or her left/right eye gently and look directly at the nurses opposite eye 5:move a dinger equidistant between the nurse and the client outside the field of vision

3,4,2,5,1

The nurse is caring for a group of clients with infections. Which infection is classified as a health care associated infection? 1:respiratory infection contracted from a visitor 2:vaginal infection in a postmenopausal woman 3:urinary tract infection in a client who is sedentary 4:wound infection caused by unwashed hands of a caregiver

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the nurse creates a plan of care for a client with a risk of infection. Which is the desirable expected outcome for the client? 1:all nursing function will be completed by discharge 2:All invasive intravenous lines will remain patent 3:the client will remain awake, alert, and oriented at all times 4:the client will be free of signs and symptoms of infection by discharge

4

Which statement made by a patient who is at average risk for colorectal cancer indicates an understanding about teaching related to early detection of colorectal cancer? 1: "I'll make sure to schedule my colonoscopy annually after the age of 60." 2:"I'll make sure to have a colonoscopy every 2 years." 3:"I'll make sure to have a flexible sigmoidoscopy every year once I turn 55." 4:"I'll make sure to have a fecal occult blood test annually once I turn 45.

4 Rationale: American cancer society guidelines state that people of average risk, beginning at the age of 45, an annual fecal occult blood test is recommended. Flexible sigmoidoscopy is recommended every 5 years in the population.

The component that should receive the highest priority before a physical exam is? 1:preparation of the equipment 2: preparation of the environment 3:physical preparation of the patient 4:psychological preparation of the patient

4 Rationale: a thorough explanation of the purpose and steps of each assessment lets patients know what to expect and what to do so they can cooperate

according to the nursing process, which action would the nurse take after administering pain medication to a postoperative client? 1: administer nonpharmacological comfort measures 2:inform the health care provider of the nursing action 3:create a care plan that addresses the clients pain level 4:determine whether the pain medicine relieved the patients pain

4 Rationale: administering pain medication is the implementation stage; therefore, the nurse must evaluate the interventions effectiveness

The second sound (s2) occurs when: 1:systole begins 2:there is rapid ventricular filling 3:the mitral and tricuspid valves close 4:the aortic and pulmonic valves close

4 Rationale: after the ventricles empty, ventricular pressure falls below that in the aorta and pulmonary artery, allowing the valves to close and causing the second heart sound

The emergency department nurse is caring for a client who is diagnosed with hypothermia. Which factor present in the client's history may have precipitated this condition? 1:heatstroke 2:inability to sweat 3:excessive exercise 4:high alcohol intake

4 Rationale: excessive alcohol intake interferes with thermoregulation by providing a false sense of warmth, inhibiting shivering, and causing vasodilation, which promotes heat loss. In addition, it impairs judgment, which increases the risk of making inappropriate self-care decisions

Which skill in critical thinking requires the nurse to be orderly in data collection 1:analysis 2:inference 3:evaluation 4:interpretation

4 Rationale: interpretation is involved in orderly collection of data. -Analysis: info collected about patient with an open mind -inference: data collected about the client helps in solving an existing problem -evaluation: used when the results of nursing actions are determined (I, Am, Interfering, Every, Explanation, Sorry)

which amount would the nurse recognize as the normal value of a clients inspiratory reserve volume? 1:0.5 L 2:1.0L 3:1.5 L 4:3.0L

4 Rationale: normal IRV is 3L -tidal volume=0.5L -expiratory reserve volume:1L -residual volume :1.5L

Which does the nurse determine is a specific line of defense against infection? 1:mucous membrane of the respiratory tract 2:urinary tract environment 3:integumentary system 4:immune response

4 Rationale: the immune response is a specific defense against pathogenic microorganisms. The production of antibodies to neutralize and eliminate pathogens and their toxins (immune response) is activated when phagocytes fail to completely destroy invading microorganisms.

A client is hospitalized with a left pneumothorax, and when assessing the left chest area, the nurse would expect to identify which findings? 1:dull sound on percussion 2:vocal fremitus on palpation 3:rales with rhonchi on auscultation 4:absence of breath sounds on auscultation

4 Rationale: the left lung is collapsed; therefore, there are no breath sounds. -A tympanic not a dull sound will be heard -there is no vocal fremitus because there is not airflow to the lunch -rales with rhonchi will not be heard because there is no airflow

According to the nursing process, which action would the nurse take after administering pain medication to a postoperative client? 1:administer nonpharmocological comfort measures 2:inform the health care provider of the nursing action 3:create a care plan that addresses the client's pain level 4:determine whether the pain medicine relieved the clients pain

4 Rationale: the nurse must evaluate the intervention's of effectiveness

Which step in the nursing process would involves promoting a safe environment for the client 1: planning 2:diagnosis 3:assessment 4:implementation

4 Rationale: the nurse promotes a safe environment during the implementation stage -planning stage: the nurse develops an individualized care plan for the client. The plan contains strategies and alternatives to achieve specific outcomes -diagnosis stage: the nurse analyzes the assessment data to determine the issue -assessment stage: the nurse collects comprehensive data pertinent to the clients situation

Which physical examination method should a nurse use when assessing a client for borborygmi (rumbling/growling noises made in the stomach) 1:palpation 2:inspection 3:percussion 4:auscultation

4 Rationale: the process of listening to sounds produced in the body. Active intestinal peristalis causes rumbling abdominal sounds

Which nursing process involves delegation and verbal discussion with the healthcare team? 1:planning 2:evaluation 3:assessment 4:implementation

4 Rationale: this process involves delegation (shifting responsibility to another nurse on shift) and verbal discussion with the health care team -planning involves interpersonal or small group health care team sessions -evaluation involves the acquisition of verbal and nonverbal feedback -assessment involves verbal interviewing and talking with clients

Which complication would the nurse monitor in a client who sustained a transection of the spinal cord, but no other injuries 1:hemorrhage 2:hypovolemic shock 3:gastrointestinal atony 4:autonomic hyperreflexia

4 autonomic hyperreflexia is an uninhibited and exaggerated response of the autonomic nervous system to stimulation, results in a blood pressure greater than 200mmhg systolic; it is a medical emergency

While assessing a client for the dorsalis pedis pulse, the nurse documents the readings as 1+. which conclusion can be inferred from this finding? 1: pulse is absent 2:pulse is normal 3:pulse is bounding 4:pulse is barley palable

4 rationale: 0=absent 1=barley palable 2=normal 3=full and strong 4=bounding

The nurse is teaching a community health class about cancer prevention for people who are asymptomatic and not at risk for cancer. Which screening guideline for this group of people should the nurse include? 1: paper smear annually for people with a cervix age 13 and older 2:prostate specific antigen yearly for men 30 years and older 3:mammogram annually for women 30 years and older 4: colonoscopy at 50 years of age and every 10 years after

4 rationale: a colonoscopy should be performed at age 45 and every 10 years after because this is the age colon cancer increases

The nurse applies a cold pack to relieve musculoskeletal pain. Which rationale explains the analgesic properties of cold therapy? 1:promotes analgesia and circulation 2:numbs the nerves and dilates the blood vessels 3:promotes circulation and reduces muscle spasms 4:causes local vasconstriction, preventing edema and muscles spasms

4 rationale: cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and muscle spasms -cold does promote analgesia but not circulation -may numb nerves but does not dilate blood vessels

The nurse is caring for a client who is experiencing an increase in clinical manifestations associated with multiple sclerosis. Which term describes this recurrence of clinical manifestations? 1:variance 2:remission 3: adaptation 4:exacerbation

4 rationale: exacerbation is the period during a chronic illness when clinical manifestation reappear after a reduction or absence of clinical manifestation

When identifying an inaccurate match between clinical cues and the nursing diagnosis, in which category would the nurse place this diagnostic error? 1:labeling 2:collecting 3:clustering 4:interpreting

4 rationale: interpreting errors include failing to consider conflicting cues, using an insufficient number of cues, and using unreliable or invalid cues errors -labeling error: failure to validate data -collecting error: inaccurate data, missing data, or disorganization -clustering errors: insufficient cluster of cues, premature or early closure, or incorrect clustering

Which usually is unrelated to a nursing physical assessment? 1. Posture and gait 2. Balance and strength 3. Hygiene and grooming 4. Blood and urine values

4 rationale: prescribing and assessing urine and blood values are not in the independent practice of nursing. These assessments are dependent or interdependent functions

To assess the status of circulation to the foot, which site would the nurse monitor for a pulse? Select all that apply 1:carotid artery 2:femoral artery 3:popliteal artery 4:dorsalis pedis artery 5:posterior tibial artery

4,5 Rationale: posterior tibial artery is located on the inner side of ankle and dorsalis pedis is located on top of foot -the femoral artery pulse and popliteal artery pulses are used to assess circulation in the lower leg

Which site would the nurse prefer to assess for determining the turgor of an older adult? select all that apply 1:back of neck 2:back of hand 3:palm of hand 4:on the sternal area 5:back of forearm

4,5 Rationale: turgor indicates the elasticity of skin. The ideal site to assess turgor in an older adult is back of forearm and sternal area.

Which term would the nurse use to document a client with drooping of the eyelid over the pupil? 1:ptosis 2:ectropion 3:entropion 4:nystagmus

1 rationale: -nystagmus: involuntary oscillation of the eyes, and usually occurs after an eye injury

The nurse is teaching a patient how to perform a testicular self-examination. Which of the following statements made by the patient indicates a need for further teaching? 1: ill recognize abnormal lumps because they are very painful 2: Ill start performing testicular self exams monthly after i turn 15 3:Ill perform the self exam in front of a mirror 4: ill gently roll the testicle between my finger

1 rationale: The examination should be performed monthly in all men 15 years of age and older. Feel for small, pea-size lumps on the front and side of the testicle. Abnormal lumps are usually painless

the nurse is unable to palpate a clients brachial pulse. Which pulse should the nurse assess to determine adequate brachial blood flow in this client? 1:radial 2:carotid 3:femoral 4:popliteal

1 rationale: the brachial artery splits (bifurcates) into the radial and ulnar arteries. When there is an adequate radial pulse, the brachial artery must be patent

Which position would the nurse utilize to assess the clients hip joint extension and buttocks? 1:dorsal recumbent 2:prone 3:lateral recumbent 4:supine

2 Rationale: to assess the extension of hip join and buttocks, the client should be placed in the prone position. -dorsal recumbent is used for abdominal assessment -lateral recumbent is used to assess murmurs -supine is used to asses the heart, abdomen, extremities, and pulses

When assessing the patients thorax, the nurse should: 1:complete the left side then the right side 2: compare symmetrical areas from side to side 3:begin with the posterior lobes on the right side 4:change the position of the stethoscope between inspiration and expiration

2 Rationale: use a systematic pattern when comparing the left and right sides. You need to compare lung sounds in one region on one side of the body with sounds in the same region on the opposite side of the body

While assessing a client after surgery, which finding would the nurse obtain from the primary source? 1:x ray reports 2:severity of pain 3:results of blood work 4:family caregiver interview

2 rationale: the primary source of information during an assessment is the client. the nurse gathers information about the clients pain from the client -all other options are secondary sources

During orientation, a RN reviews content about the third heart sound (S3) with recently employed nurses. Which participants statement indicates ineffective learning? 1:S3 is heard in clients with heart failure 2:S3 is normal in pregnant women 3:S3 is abnormal in adults over 31 years of age 4:S3 is normal in children and young adults

2 rationale: the third heart sound (S3) can be heard when the heart attempts to fill an already distended ventricle. This sound may be common and normal in the last stages of pregnancy but NOT in all stages. -this sound is heard in heart failure clients, is abnormal in adults over the age of 31, and is normally heard in children and young adults

which of the following clients requires further assessment by the nurse? 1:18 year old woman with a pulse rate of 140 after riding 2 miles on a bike 2:50 year old man with a BP of 112/60 mmhg on awakening in the morning 3:65 year old man with a respiratory rate of 10 4:40 year old woman with a pulse of 88

3 rationale: a respiratory rate of 10 is below the expected RR for an adult and should be further assessed. The expected RR for an adult is 12-20 breaths per minute

The nurse instructs a client who avoids bathing to take a bath or shower each day as a means of maintaining hygiene and preventing infection. Which of these reactions would the nurse expect if the client is in the action stage? select all that apply 1:I only take a bath once a week, but i dont see any infections on my skin 2:I try to take a shower every day, but I skip it sometimes because of my tight work schedule 3:I understand that bathing regularly is a good habit, but my bathroom is very cold in the morning 4:please tell me how to get into the habit of taking a bath daily so that i can keep myself clean and healthy 5:I want to take a bath regularly but i dont have time because i need to look after my kids and parents

2,3,5 rationale: in the action stage, the client notices the old habits are hindering them from engaging in new behaviors. The words "I try", "I understand", "I want" indicate that the client is in the action stage

the nurse is assessing a client with arthritis. Which statement made by the client indicates a precipitating factor? 1: the pain is usually present in my fingers and knees 2:i observed swelling and redness near the pain area 3:I feel the pain in each and every joint of my hands and legs 4:I run for 30 minutes every day; this exercise increases my pain

4 rationale: precipitating factor is an activity or factor that worsens the symptoms

Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis? (Select all that apply.) 1: the front and sides of the sterile gown are considered sterile from the waist up 2:keep the sterile field in view at all times 3:Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. 4:Only health care personnel within the sterile field must wear personal protective equipment. 5:After cleansing the hands with antiseptic rub, apply clean disposable gloves.

2,3 rationale: Maintaining sterility throughout the procedure requires constant vigilance and strict rules to ensure sterility, such as keeping the sterile field in sight at all times, making sure everyone in the room is in protective clothing like gowns, masks, eyewear and gloves, and considering anything beyond the front or below the waist of the gown to be contaminated. To make sure the sides of the sterile field are not contaminated, there is an outer one-inch border not considered sterile.

The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.) 1:Add salt to every meal. 2:Talk with your health care provider about taking a daily low dose of aspirin 3:Work with your health care provider to develop a regular exercise program 4:Limit daily intake of fats to less than 25% to 35% of total calories. 5:Review strategies to encourage the patient to quit smoking.

2,3,4,5 Raitonale: Teaching about prevention of heart disease focuses on risk factor reduction. Smoking, lack of regular aerobic exercise, and a diet high in sodium and fats are three major risk factors that can be modified. Quitting smoking, regular exercise, and a diet with lower sodium and fat intake are preventive measures. Low-dose aspirin has been shown to be beneficial in reducing the risk of heart disease.

Which statements describes accurate completion of a vascular assessment? select all that apply 1: simultaneously palpate the carotid arteries 2:measure blood pressure 3:ask about pain, cramping, or discomfort in legs 4:count an irregular pulse for 30 seconds and multiply it by 2 5:rate the strength of a pulse on a scale of 0-4

2,3,5

A patient is diagnosed with a multidrug-resistant organism (MDRO) in his surgical wound and asks the nurse what this means. What is the nurse's best response? (Select all that apply.) 1: There is more than one organism in the wound that is causing the infection 2: The antibiotics the patient has received are not strong enough to kill the organism 3:The patient will need more than one type of antibiotic to kill the organism. 4:The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. 5:There are no longer any antibiotic options available to treat the patient's infection.

2,4 rationale: An MDRO is a single organism that is resistant to one or more classes of antibiotics, which makes it harder to treat, but there is treatment available.

Which question is open-ended? 1:who helps you at home 2:are you having pain now 3:how are you feeling 4:do you think the medication is helping you?

3

During a routine physical, a 50 year old asks why a stool specimen for occult blood testing was prescribed. Which response would the nurse utilize? 1:you will need to ask your health care provider; this test is not part of the usual tests for people your age 2: there must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test 3:starting at your age, this test is preformed routinely as part of an assessment for colon cancer 4:there must have been a positive finding after your health care provider preformed a digital rectal examination

3 rationale: anyone over the age 40 should have regular colon cancer exam

While examining Mr. parker, the nurse notes a circumscribed elevation of skin filled with serous fluid on his upper lip. The lesion is 0.4 cm in diameter. This type of lesion is called a: 1:macule 2:nodule 3:vesicle 4:pustule

3 rationale: circumscribed elevation of skin filled with serious fluid; smaller than 1 cm

In which order would the nurse implement the nursing diagnosis procedure for a client who reports to a health care unit with high fever, chills, and severe body aches? 1:interpret and analyze the data obtained 2:define characteristics and related factors 3:collect info about the clients health status 4:identify client needs and formulate nursing diagnosis 5:organize the data according to signs and symptoms

3-1-5-2-4 -collect info about the clients health status -interpret and analyze the data obtained -organize the data according to signs and symptoms -define characteristics and related factors -identify client needs and formulate nursing diagnosis

The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to? 1:primary 2:secondary 3:superinfection 4:nosocomial

4 Rationale: nosocomial infection is acquired in a health care setting. Also referred to as a hospital-aquired infection

A client has a serious vitamin K deficiency. For which clinical manifestation should the nurse assess this client? select all that apply 1:bone pain 2:skin lesions 3:bleeding gums 4:ecchymotic area 5: muscle weakness

3,4 Rationale: vitamin K helps blood clot. -3: a disruption in the clotting mechanism of the body can result in bleeding. Vitamin K plays an essential role in the production of clotting factors -4:An ecchymotic area is caused by extravasation of blood into the skin or mucous membranes. In this clients situation, it is caused by a disruption in the clotting mechanism of the body as a result of a vitamin K deficiency

When the defining characteristics of a clients assessment data apply to more than one diagnosis, which action would the nurse take? select all that apply 1:reassess the client 2:reject all diagnosis 3:gather more information 4:identify related factors 5:review all defining characteristics

3,4,5

A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) 1. Place the fingers behind and below the medial malleolus. 2. Have the patient slightly flex the knee with the foot resting on the bed. 3. Have the patient relax the foot while lying supine. 4. Palpate the groove lateral to the flexor tendon of the wrist. 5. Palpate along the top of the foot in a line with the grove between the extensor tendons of the great and first toes.

3,5 rationale: To palpate the dorsalis pedis pulses (located in the feet), ask the patient to relax the foot, and then palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes. Placing fingers behind the medial malleolus is a technique for assessing the posterior tibial pulse. Having a patient slightly flex the knee is a technique for assessing the popliteal artery behind the knee. Palpation of the groove lateral to the flexor tendon of the wrist is the technique to assess the radial artery

The nurse is monitoring the status of postoperative clients. Which vital signs will change first when a postoperative client has internal bleeding? 1:body temperature 2:blood pressure 3:pulse pressure 4:heart rate

4 rationale: the initial stage of shock begins when baroreceptors in the aortic arch and the carotid sinuses detect a drop in the mean arterial pressure. The sympathetic nervous system responds by constricting peripheral vessels and increasing the heart and respiratory rates.

which disorder does this image illustrate? (flip card to see picture) 1: angioedema 2:systemic sclerosis 3:systemic sclerosis 4:systemic lupus erythematosus

4 rationale: this disorder is a chronic, progressive, inflammatory connective tissue disorder that causes major body organs and systems to fail. It illustrates a butterfly rash which is a major skin manifestation of this disorder. -angioedema: diffuse swelling of the eyes and lips -oral candidiasis: white plaque like lesions on the tongue -systemic sclerosis: skin thickening

Which number corresponds to the area of the chest where you would auscultate for the tricuspid valve?

4 (All People Enjoy Time Magazine) rationale: -1:aortic (right 2nd intercostal) -2:pulmonic (left 2nd intercostal) -3:ERBs point (s1 and s2) left 3rd intercostal space 4:tricuspid (lower left sternal boarder, 4th intercostal space) 5:Mitral (left 5th intercostal, medial to midclavicular line)

The RN is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel?select all that apply: 1:evaluating vital signs 2:administering injections 3:assessing wound drainage 4:brining equipment to the client's room 5:transporting the client to a diagnostic test

4, 5

During an annual physical assessment, a client reports not being able to smell coffee and most foods. Which cranial verve function would the nurse assess? 1: 1 2: II 3: IX 4: VII

1 Rationale: Cranial nerve I : the olfactory nerve that concerns the sense of smell -Cranial nerve II is the optic nerve and is concerned with sight -Cranial nerve X: vagus nerve and is concerned with gag reflex -Cranial nerve VII is the facial nerve and is concerned with facial expressions

When assessing a client reporting shortness of breath, which activity best ensures the nurse obtains accurate and complete data to prevent a nursing diagnostic error? 1:assess the clients lungs 2:assess the client for pain 3:obtain details of smoking habits 4:ask about the onset of shortness of breath

1 Rationale: RN would assess the client's lungs to gather objective data will support subjective data provided by the client. Nurse can do this by auscultating for lungs songs, RR, and measuring chest excursions.

The RN is evaluating the statements of a new nurse about wound dressings. Which statement made by the new nurse is incorrect. 1:I should wash my hands with alcohol based antiseptic 2:I should use the cotton swab placed on the table 3:I should wash my hands before touching the wound 4:I should wear gloves before touching the site of injury

2

The nurse is assessing a clients pulses bilaterally for symmertry. Which pulse site should not be assessed on both sides of the body at the same time? 1:radial 2:carotid 3:femoral 4:brachial

2

The nurse is preparing discharge instructions for a client who acquired a nosocomial clostridium difficile infection. which would the nurse include in the instructions? 1:anticipate that nausea and vomiting will continue until the infection is no longer present 2:the infection causes diarrhea accompanied by flatus and abdominal discomfort 3:consume a diet that is high in fiber and low in fat 4:other than routine hand washing, it is not necessary to perform special disinfection procedures

2

The nurse is observing as the student nurse performs a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene? 1: The student stands at a midline position behind the patient, observing for position of the spine and scapula. 2:The student palpates the thoracic muscles for masses, pulsations, or abnormal movements. 3:The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds. 4:The student places the palm of the hand over the intercostal spaces and asks the patient to say "ninety-nine."

3 rationale: Breath sounds should be auscultated using the diaphragm of the stethoscope. Auscultate in a systematic pattern over the posterior and anterior chest wall.

Which step of the nursing process involves the nurse interviewing a client about a current health problem and obtaining the clients vital signs 1:planning 2:diagnosis 3:assessment 4:implementation

3 ADPIE Rationale: assessment involves the collect of comprehensive date pertinent to the clients health. (vital signs are the first thing you do when you walk into the doctors office) -planning: prescribes strategies and and alternative to attain expected outcomes -implementation: performs actions, educates patient, experiments, providing a safe environment, and organizing -diagnosis: the nurse analyzes the assessment data to determine the diagnosis.

the nurse finds the clients fever spikes and falls without return to a normal level. Which pattern of fever is this characteristic? 1:relapsing 2:sustained 3:remittent 4:intermittent

3 rationale: remittent patter spikes and falls without returning to normal temp level -sustained: constant body temp continuously above 100.04 with little fluctutation -intermittent: fever spikes and falls back to normal temp

Which documentation would the nurse utilize to report that a clients degree of edema has a depth of 8mm? 1:1+ 2:2+ 3:3+ 4:4+

4 Rationale: edema scale: 1+: 2mm 2+:4mm 3+:6mm 4+:8mm

T/F: Proper cleaning and disinfection are processes that occur prior to sterilization, with cleaning always done from dirty to clean to decrease the risk of further infection and contamination.

false rationale

When assessing levels of consciousness, which one of the four clients would the nurse identify as having the lowest neurological function? 1:eye movement: spontaneous, Motor response: localizes pain, verbal response: inappropriate words 2:eye movement: opens on pain, motor response: flaccid, verbal response: incomprehensible sounds 3:eye movement: spontaneous, motor response: normal flexion, verbal response: oriented 4:eye movement: opens on sound, motor response: abnormal extension, verbal response: confused conversation

client 2 Rationale: the glasgow coma scale (GCS) is used as an objective measurement of consciousness on a numerical scale... a higher score equates to a higher neurological function. -Client 2 is opening eyes to pain stimulus= 2, shows flaccid motor response=1, and incomprehensible=2 making the total score a 5