Final Exam Fundies
place in order the following fine and gross motor skills as they are expected to be achieved A. Head lag is minimal B. Walks while holding onto someone's hand C. Reaches and grasps objects voluntarily D. Transfers objects from one hand to the other hand E. Has developed a neat pincher grasp F. Sits unsupported G. Rolls front to back
A. Head lag is minimal C. Reaches and grasps objects voluntarily G. Rolls front to back D. Transfers objects from one hand to the other hand F. Sits unsupported E. Has developed a neat pincher grasp B. Walks while holding onto someone's hand
A nurse is monitoring respirations for a group of clients. Which of the following clients should the nurse identify as exhibiting tachypnea? A. 2-week-old infant who has a rate of 56/min B. 6-year-old child who has a rate of 29/min C. 17-year-old adolescent who has a rate of 24/min D. 2-year-old toddler who has a rate of 48/min E. 9-year-old child who has a rate of 20/min
B. 6-year-old child who has a rate of 29/min C. 17-year-old adolescent who has a rate of 24/min D. 2-year-old toddler who has a rate of 48/min
a nurse is performing hand hygiene using an alcohol-based sanitizer. the nurse should rub the hands together for which of the following time frames?
15-20 seconds
A nurse is reviewing the medical records of clients. Which of the following clients should the nurse identify as being at risk for experiencing tachycardia? A. 24-year-old long-distance runner who is walking in the hallway of the unit B. 38-year-old client who has a fever due to an infection C. 51-year-old client who received an opioid analgesic 2 hours ago D. 66-year-old client who has heart failure
B. 38-year-old client who has a fever due to an infection
A nurse is caring for a client who can rise to a standing position from a chair with the use of a cane. The nurse should assist the client with ambulation using which of the following equipment? A. No equipment B. Gait belt C. Mechanical sit to stand D. Mechanical lift
B. Gait Belt
Which of the following actions demonstrates the proper use of body mechanics? Select all that apply 1. Balance the knees to improve balance 2. Turn the torso when assisting the client to pivot 3. Maintain good posture at all times 4. Bend at the waist to move heavy objects 5. Position objects to be lifted 12 inches away 6. Place the feet in line with the shoulders
Bend the knees to improve balance Maintain good posture Place the feet in line with the shoulders
A nurse is caring for a client who can move self from a semi-reclining position to sit on the edge of the bed but is unable to hold the position. The nurse should assign the client which of the following activity levels? Maximum, moderate, minimal, no assistance
Maximum assistance
a nurse is caring for a client who is experiencing pain. Which of the following are influencing factors of pain? select all that apply a. client risk factors b. client trends c. anxiety d. type of pain medication used e. moral considerations f. socioeconomic status
a. client risk factors b. client trends c. anxiety d. type of pain medication used
a nurse is caring for a client who is scheduled for an upcoming procedure with sedation. which of the following diets should the nurse expect the provider to prescribe? a. full liquid b. renal c. NPO d. heart-healthy diet
c. NPO
which of the following individuals can provide informed consent to surgery? a. a client who is unemancipated b. an adult who is developmentally disabled c. a legal guardian d. a young child
c. a legal guardian
a nurse is discussing dietary needs with a client. the client states, "I usually eat one or more meals per day from a drive-through restaurant. I know its not the best diet, but I take a vitamin every day" Which of the following responses should the nurse make? a. make sure to not skip your daily vitamin and you should be fine b. try to eat at least one more meal per day c. a vitamin will not replace all the nutrients you need. let's find ways to improve your overall diet d. sounds like you have a good nutritional plan
c. a vitamin will not replace all the nutrients you need. let's find ways to improve your overall diet
A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take when providing discharge instructions to the client? a. have a family member translate the written discharge instructions b. have an AP who is learning to speak the client's language provide teaching c. consult the certified medical interpreter who speaks the client's language d. use a computer application to translate the discharge instructions
c. consult the certified medical interpreter who speaks the clients language
a PN is monitoring a client who has metabolic acidosis after interventions have been initiated. which step of the pn nursing process is next? a. data planning b. planning c. evaluation d. implementation
c. evaluation
a nurse is monitoring a client who has metabolic acidosis after interventions have been initiated. which step of the nursing process is next? a. assessment b. planning c. evalaution d. Implementation
c. evaluation
place the steps for obtaining a wound culture in the correct order a. place sterile swab into the wound bed b. remove swab from culture tube c. label culture tube d. note if client has received any recent antibacterial or antifungal therapy e. rotate swab stick in an area of drainage f. rinse wound with 0.9% chloride g. activate the culture medium h. remove old dressing
c. label culture tube h. remove old dressing f. rinse wound with 0.9% chloride b. remove swab from culture tube a. place sterile swab into the wound bed e. rotate swab stick in an area of drainage g. activate the culture medium d. note if client has received any recent antibacterial or antifungal therapy
A nurse is taking care of a client who has a PICC line in place. the client is due for a medication to be given through the PICC line, along with a dressing change to the site. the nurse is unsure if this is within their scope of practice. which of the following actions should the nurse take? a. administer the medication so it will not be administered late b. change the dressing and ask another nurse to give the medication c. refers to the state nurse practice act d. refuse to carry out the orders
c. refers to the state nurse practice act
Place the steps a nurse would take for fecal occult blood testing in the proper order (drag the following options into the desired order) a. open the front flap of the test book b. don clean gloves c. wash hands d. appy 2 drops e. wait 30 to 60 seconds for result f. turn test book over g. apply drops to control panel h. apply small smear to test window 1 i. open back flap j. apply small smear to test window 2
c. wash hands b. don clean gloves a. open the front flap of the test book h. apply small smear to test window 1 j. apply small smear to test window 2 f. turn test book over i. open back flap d. apply 2 drops on each smear g. apply drops to control panel e. wait 30-60 seconds for result
The nurse is preparing to conduct a mobility assessment for a client. Place the following steps in the correct order 1. Instruct the client to sit on the edge of the bed for 2 minutes 2. Extend the arm to shake hands with the client's farther upper extremity 3. Instruct client to extend one leg, flex ankle, and point toes 4. request client to stand at bedside for at least 5 seconds 5. ask client to take a few steps forward and the backwards 6. request client to walk in place
1. Extend arm to shake hands with the client's farther upper extremity 2. instruct client to sit on edge of bed for at least 2 minutes 3. instruct client to extend one leg, flex ankle, and point toes 4. request client to stand at the bedside for at least 5 seconds 5. request client to walk in place 6. ask client to take a few steps forward and then backward
A nurse is caring for a client who will require a mechanical lift to transfer from the bed to a reclining chair. The nurse should follow the recommendation of asking how many personnel to assist with this task? A. 2 or more B. 1 to 2 C. 0 to 1
A. 2 or more
Place the physiological responses that occur during the three stages of the general adaptive syndrome in order A. A perceived stressor arouses the central nervous system B. rising hormone levels result in increased blood pressure and heart rate, blood glucose levels, oxygen intake, pupil dilation, and mental alertness C. hormones released from the adrenal cortex create a state of readiness D. the parasympathetic nervous system attempts to return physiological functions to normal levels E. the body remains on alert while hormonal and other bodily functions return to normal F. if the body is unable to effectively resist or adapt to the stressor, or if resources become exhausted, prolonged exposure to stress may result in illness or disease
A. A perceived stressor arouses the central nervous system C. hormones released from the adrenal cortex create a state of readiness B. rising hormone levels result in increased blood pressure and heart rate, blood glucose levels, oxygen intake, pupil dilation, and mental alertness D. the parasympathetic nervous system attempts to return physiological functions to normal levels E. the body remains on alert while hormonal and other bodily functions return to normal F. if the body is unable to effectively resist or adapt to the stressor, or if resources become exhausted, prolonged exposure to stress may result in illness or disease
A nurse is discussing factors affecting blood pressure with an assistive personnel. Which of the following factors should the nurse identify as potential causes for an increase in a client's blood pressure? select all that apply. A. Anxiety B. Use of nicotine C. Young adult age D. Obesity E. Fear
A. Anxiety B. Use of nicotine D. Obesity E. Fear
A nurse is caring for an adolescent client who has recently shared they are bisexual. Which of the following factors is the client at risk for? A. being bullied at school B. depression C. STIs D. use of illicit drugs E. suicide F. increased need for prescription opioids
A. being bullied at school B. depression D. use of illicit drugs E. suicide
Strategies for a nurse to take to facilitate closure following the loss of a client include which of the following? Select all that apply A. establish a bedtime routine to get 6-8 hours of sleep nightly B. discover a new hobby C. invite the family over for dinner D. talk to an experienced nurse about the loss E. journal your feelings F. ask the nurse manager for unit transfer
A. establish a bedtime routine to get 6-8 hours of sleep nightly B. discover a new hobby D. talk to an experienced nurse about the loss E. journal your feelings
A nurse is preparing to check the rectal temperature of an adult client. Place the following steps the nurse should take in the order of their performance. A. inform the client of the need for a rectal measurement B. discard the probe cover in the trash C. insert the temperature probe approximately 1 inch D. coat the temperature probe with a liberal amount of lubricant E. Assist the client into a position that allows access to the rectum F. use the non-dominant hand to gently separate the client's buttocks G. apply the disposable probe cover to the temperature probe H. Document findings
A. inform the client of the need for a rectal measurement E. Assist the client into a position that allows access to the rectum G. apply the disposable probe cover to the temperature probe D. coat the temperature probe with a liberal amount of lubricant F. use the nondominant hand to gently separate the client's buttocks C. insert the temperature probe approximately 1 inch B. discard the probe cover in the trash H. Document findings
The role of a nurse during the postmortem period in supporting a surrogate and family members who are considering organ donation consists of which of the following? select all that apply A. assure them you are experienced in organ donation B. consult with interfaith personnel C. discuss personal experience with organ donation D. referral to the organ procurement coordinator E. provide information on organ donation F. allow time for expression of family feelings
B. consult with interfaith personnel D. referral to the organ procurement coordinator F. allow time for expression of family feelings
A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take? A. use loud tone when speaking B. face client when speaking c. communicate by writing everything on paper d. speak at a faster pace
B. face client when speaking
Place the following organs in the correct order in which they produce and transport urine along the urinary tract (put in the correct order) A. bladder B. kidneys C. ureters D. urethra
B. kidneys C. ureters A. bladder D. urethra
Which of the following concerns contribute the most of criticisms related to nursing care at the end of life? A. poor pain management B. lack of caring by nursing staff C. client loss of control D. being dishonest with family
B. lack of caring by nursing staff
Which of the following beliefs can negatively influence a client's or family member's willingness to agree to the use of opioids for pain management? A. opioids will lengthen the dying process B. opioids are the same as euthanasia C. opioids are nonaddictive D. opioids increase the amount of medication that can be used in the future
B. opioids are the same as euthanasia
A nurse is discussing tachycardia with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as exhibiting tachycardia? A. newborn who has a pulse of 158/min B. preschooler who has a pulse of 142/min C. adolescent who has a pulse of 98/min D. older adult who has a pulse of 88/min
B. preschooler who has a pulse of 142/min
A nurse is caring for a client who reports dizziness when standing up. The client's blood pressure after lying supine for 15 minutes is 136/86mm hg in the left arm. Which of the following findings would indicate the client is experiencing orthostatic hypertension? A. 128/84 mm hg, left arm, sitting for 2 minutes B. 120/78 mm hg, left arm, immediately after sitting C. 114/72 mm hg, left arm, immediately after standing D. 124/80 mm hg, left arm, standing for 3 minutes
C. 114/72 mm hg, left arm, immediately after standing
Identify the direction of blood flow through the heart after it enters the right atrium A. Blood passes through the pulmonary artery B. Blood collects in the right ventricle C. Blood passes through the tricuspid valve D. Blood enters the left atrium E. Blood passes through the aorta F. Blood passes through the mitral valve G. Blood collects in the left ventricle
C. Blood passes through the tricuspid valve B. Blood collects in the right ventricle A. Blood passes through the pulmonary artery D. Blood enters the left atrium F. Blood passes through the mitral valve G. Blood collects in the left ventricle E. Blood passes through the aorta
A nurse is preparing to manually measure the blood pressure of an adult client. Place the steps that the nurse should take in order of their performance. A. Place the bell or diaphragm of the stethoscope over the brachial artery B. Document the measurement in the client's medical record C. Select the correct size cuff based on the client's arm size D. Position the client's arm at the level of the heart, ensuring it is supported E. inflate the bladder of the cuff to 30 mm hg above the client's baseline systolic pressure F. Auscultate the korotkoff sounds while deflating the cuff G. Apply the cuff snugly to the client's upper arm
C. Select the correct size cuff based on the client's arm size D. Position the client's arm at the level of the heart, ensuring it is supported G. Apply the cuff snugly to the client's upper arm A. Place the bell or diaphragm of the stethoscope over the brachial artery E. inflate the bladder of the cuff to 30 mm hg above the client's baseline systolic pressure F. Auscultate the korotkoff sounds while deflating the cuff B. Document the measurement in the client's medical record
During a well-baby check, a 10 month old infant's parent expresses concern that the baby is not walking independently yet. Which of the following statements should the nurse make? A. That is concerning, I will inform the provider immediately B. I noticed your baby is able to sit unsupported, so i wouldn't worry C. Walking independently is not expected at 10 months of age. At 11 months, an infant is expected to walk while holding your hands D. Was your infant born prematurely? if so, that explains it
C. Walking independently is not expected at 10 months of age. At 11 months, an infant is expected to walk while holding your hands
identify the correct order in which food or liquid contents are transported through the gastrointestinal tract (drag the options into correct order) A. Anus B. Large intestine C. mouth d. esophagus E. small intestine f. stomach
C. mouth d. esophagus f. stomach E. small intestine B. Large intestine A. Anus
A school nurse is reviewing the health records for a group of students who recently had a physical examination. Which of the following students should the nurse identify as having a pulse rate outside of the expected reference range? (select all that apply) A. 6 year old, 106/min B. 17 year old, 102/min C. 3 year old, 96/min D. 10 year old, 118/min E. 15 year old, 40/min
D. 10 year old, 118/min E. 15 year old, 40/min
A nurse is preparing to measure a client's oxygen saturation level using a finger probe. Place the following steps the nurse should take in the correct order of their performance A. place the probe on the client's finger B. instruct the client to hold the finger, hand, and arm still C. confirm the oximeter pulse reading by palpating the client's radial pulse D. check the capillary refill time in the chosen finger E. Document findings
D. check the capillary refill time in the chosen finger A. place the probe on the client's finger B. instruct the client to hold the finger, hand, and arm still C. confirm the oximeter pulse reading by palpating the client's radial pulse E. Document findings
Name the four stages of hypertension, including the blood pressure values that define each stage
Elevated: when the systolic pressure is 120 to 129 and the diastolic is less than 80 Stage 1: when the systolic pressure is 130 to 139 or the diastolic is 80-89 Stage 2: systolic pressure is 140 or greater or the diastolic is 90 or higher Hypertensive crisis: when the systolic is greater than 180 and or the diastolic is greater than 120
A nurse is assessing the competency of a new assistive personnel as they assist in moving a client up in bed. Which of the following actions by the AP demonstrates competence? 1. Lifts with arms fully extended 2. Places feet shoulder width apart 3. Maintains client's bed in a low position during move 4. Twists at the waist during move
Places feet shoulder width apart
A nurse is caring for a client who is scheduled to received a bolus feeding via the NG tube. the nurse checks the pH of the gastric contents and the result is a 6.5. Which of the following actions should the nurse take? A. recheck the pH of the gastric contents B. replace the NG tube c. begin the feeding d. flush the NG tube with 30 mL of water
Recheck the pH of the gastric contents
which of the following is a characteristic of mucous membranes that aids in preventing infection? a. secretes a thick liquid that entraps pathogens and small particles b. contains layers of keratin that serve as protection from the outside environment c. alters the body to threats by transmitting signals via nerves d. contains pterygium, which provides another layer of protection against pathogens
a. secretes a thick liquid that entraps pathogens and small particles
A nurse is providing education about pressure injury development to a newly licensed nurse. Which of the following points should the nurse include in the teaching? (select all that apply) a. shear forces occur when the skin and muscles are pulled in opposite directions b. pressure injuries most often develop over bony prominences c. friction is a continuous force exerted on or against an object d. factors contributing to pressure injury development include immobility, malnutrition, reduced perfusion, and sensory loss
a. shear forces occur when the skin and muscles are pulled in opposite directions b. pressure injuries most often develop over bony prominences d. factors contributing to pressure injury development include immobility, malnutrition, reduced perfusion, and sensory loss
a nurse is caring for a client who has hyponatremia. which of the following findings or interventions should the nurse expect? a. sodium level 127 mEq/L b. a prescription for the client to drink as much water as possible c. client reporting headache and fatigue d. sodium level of 147 mEq/L e. prescription for a urine sodium test
a. sodium level 127 mEq/L c. client reporting headache and fatigue e. prescription for a urine sodium test
a nurse is reviewing the medical history of a client who is experiencing hyperkalemia. which of the following findings put the client at a higher risk for hyperkalemia? a. use of potassium supplements b. taking a loop diuretic c. allergy to bananas d. kidney failure e. hemodialysis
a. use of potassium supplements d. kidney failure
Place the steps for moving a client up in bed in the correct order A. locks the wheel of the bed b. assess the client's level of mobility c. position the client's arms across their chest d. raise the client's bed e. get lift assistance f. use the draw sheet to move the client g. lower the client's bed to lowest position
assess the client's level of mobility get lift assistance lock the wheels of the bed raise the client's bed position the client's arms across their chest use the draw sheet to move client lower the client's bed to the lowest position
a nurse is caring for a client who is at risk for aspiration. which of the following actions should the nurse take to prevent aspiration during meals (select all that apply) a. cut food, such as meats, in half for easier chew b. allow extra time for the client to chew and swallow each bite of food c. sit client up at 90 prior to providing the meal d. turn on the tv to provide entertainment for client e. encourage the client to lie flat for 1 hour after eating to promote digestion
b. allow extra time for the client to chew and swallow each bite of food c. sit client up at 90 prior to providing the meal
a nurse is discussing the challenges of assessing pain in children with a group of parents. Which of the following statements should the nurse include? A. the presence of the child's parent can make it more difficult to assess a child's pain b. children may deny pain to avoid IM injection or bad tasting oral medication c. children often cannot identify where the pain is located d. young children do not exhibit pain
b. children may deny pain to avoid IM injection or bad tasting oral medication
a nurse is bathing a client with a basin, soap, water, and towels. which of the following is a risk associated with using a basin to bathe the client? a. skin deterioration b. contamination with pathogens c. protection of skin integrity d. decreased client independence
b. contamination with pathogens
a nurse is caring for a client who is 7 days postoperative following abdominal surgery. the client reports nausea, vomiting, and pain at the incision site. the nurse observes serosanguineous discharge on the client's gown, and the abdominal incision is partly open. which of the following postoperative complication is the client experiencing? a. infection b. dehiscence c. evisceration d. hematoma
b. dehiscence
a nurse is caring for a client who has a visual impairment. which of the following interventions is the nurse's priority a. provide education to client b. ensure the client's safety c. offer to assist client at meal times d. schedule an eye exam
b. ensure the client's safety
a nurse is interviewing a client during the preoperative phase. the client reports smoking 6 to 7 cigarettes per day for the past 4 years. the nurse should identify that tobacco use prior to surgery can increase the client's risk for which of the following complications? a. bleeding b. infection c. hypothermia d. nausea
b. infection
which of the following should be included in a physical examination of a client in whom oliguria is expected? a. skin warmth in upper extremities b. pitting edema around ankles c. abdominal sounds d. dental caries
b. pitting edema around ankles
a nurse is caring for a client who is post-operative. the IV pump and telemetry monitor are alarming. the client's roommate is watching television at a loud volume. the client is experiencing pain at the incision site and discomfort from an indwelling catheter. which of the following sensory alterations is the client at risk of experiencing? a. sensory deprivation b. sensory overload c. sensory deficit d. sensory processing disorder
b. sensory overload
a nurse is discussing an audiometer test with a client. which of the following statements should the nurse make? a. this test measures the brain's electrical responses to sounds b. you will wear headphones during the test c. you will be asleep during the test d. a small probe in your ear will measure the echoed response from your inner ear
b. you will wear headphones during the test
a nurse is caring for a client who reports a recent change in smell and taste. which of the following actions should the nurse take? a. instruct the client to keep a food diary for 1 week b. encourage the client to add more seasoning to food c. recommend the client to stop all medication for a week d. ask the client about any recent illnesses or injuries
d. ask the client about any recent illnesses or injuries
A nurse is caring for an adult client who has bradycardia. Which of the following physical manifestations of bradycardia should the nurse expect? a. vomiting b. dilated pupils c. flushed face d. dizziness
d. dizziness
Which of the following is a common grief reaction of an adolescent? a. tightness in the chest b. looking for the person who had died c. having trouble in school d. failure to express their emotions
d. failure to express their emotions
a client tells the nurse that they rarely floss their teeth because they do not think it is necessary. which of the following responses should the nurse make? a. flossing removes bacteria from the tongue b. flossing teeth should be performed once a week c. flossing removes enamel from the teeth d. flossing removes bacteria between the teeth
d. flossing removes bacteria between the teeth
a nurse is collecting a wound culture from a client's arm wound. The nurse explains to the client the reason for needing to rinse the wound with 0.9% sodium chloride during the procedure. Which of the following statements should the nurse include? a. i am rinsing the wound to make it easier to collect a small sample of skin from the edge of the wound b. i am rinsing the wound to keep it moist c. the solution i am using to rinse the wound will help prevent an infection from developing d. i am rinsing the wound to prevent your normal skin micro-organisms from contaminating the culture
d. i am rinsing the wound to prevent your normal skin micro-organisms from contaminating the culture
a client asks a nurse why a fecal occult blood test is necessary when they have not experienced any bleeding when they have a bowel movement. Which of the following responses from the nurse best answers the client? a. I will need to check your chart again b. this is a test we do on all clients your age c. the physician ordered it based on your recent blood work d. sometimes we can't see blood in the stool
d. sometimes we can't see blood in the stool
a nurse is caring for a client who has a percutaneous endoscopic gastrostomy tube, and the enteral feeding has completed infusion. Which of the following actions should the nurse take? a. flush the tube with 30 mL of water b. lower the head of bed to 15 c. check pH of the gastric contents
flush tubing with 30 ml off water
a nurse is instructing a client how to collect a fecal occult blood test. which of the following responses by the client indicates understanding? a. i will make sure to hold my vitamin c supplements b. i will collect a sample that has a little blood c. i will smear the stool with a cotton swab d. i will collect three samples and then call the nurse
i will make sure to hold vitamin c supplements
which of the following is a preventive measure that can be implemented to decrease the risk of a fall postoperatively? a. ensure extension cords are placed under a throw rug b. install handrails in the bathroom c. mop kitchen floors and allow them to air dry d. keep clutter on the floor
install hand rails in bathroom
How is obstructive sleep apnea diagnosed?
polysomnography
