Final Prep NUR-101-01R-02R-50R: Practical Nursing I
A woman arrives at the prenatal clinic stating that her pregnancy test is positive. She asks the nurse for information about an abortion. After verifying that the woman is at 8 weeks' gestation, the nurse counsels her that having an abortion is controversial and that many women have long-lasting feelings of guilt after an abortion. What is the nurse's legal responsibility?
A. To share her own thoughts on abortion with the client. B. To provide the client with correct, unbiased information. C. To ask why the client wants information about abortion.D. To notify the health care provider because this is beyond the scope of nursing practice. Answer. B. To provide the client with correct, unbiased information
A client who recently experienced a brain attack (CVA) and who has limited mobility complains of constipation. What is most important for the nurse to determine when collecting information about the constipation?
A. resence of distention, B. Extent of weight gained, C. Amount of high-fiber food consumed, D. Length of time this problem has existed
The nurse provides a list of foods to prevent constipation to a client who has a history of constipation. The nurse concludes that further teaching is needed when the client says, "I should eat: A. Eggs.", B. Beans.", C. Fresh fruits.", D. Steamed vegetables."
Answer. A. Eggs."
After her child's visit to the pediatrician a mother tells the nurse that she is concerned that an antidepressant has been prescribed for her adolescent son. What is the best response by the nurse?
A. "Tell me more about what's bothering you." B. "You need to speak with the doctor about your concern." C. "Are you sure it's not a medication for attention deficit disorder?" D. "Didn't the doctor tell you why your son needs an antidepressant?" Answer. A. "Tell me more about what's bothering you."
Encouragement and appropriate praise should be given to hyperactive clients to help them increase their feelings of self-esteem. When they have acted appropriately, what is the best statement for the nurse to make in an effort to let them know of their improvement?
A. "You behaved well today." B. "I knew you could behave." C. "Everyone likes you better when you behave like this." D. "Your behavior today was much better than it was yesterday." Answer. A. "You behaved well today."
A client with hypertension has received a prescription for metoprolol (Lopressor). Which information should the nurse include when teaching this client about metoprolol?
A. Consume alcoholic beverages in moderation. B. Do not abruptly discontinue the medication. C. Increase the medication dosage if chest pain occurs. D. Report a heart rate of less than 70 beats per minuteAnswer. B. Do not abruptly discontinue the medication.
On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is: "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use?
A. Focusing, B. Restating, C. Exploring, D. Accepting Answer. A. Focusing
The laboratory reports of a client with a history of congestive heart failure show a blood pH value more than 7.45. Which type of acid-base imbalance may most likely be found in the client?
A. Metabolic acidosis, B. Metabolic alkalosis, C. Respiratory acidosis D. Respiratory alkalosisAnswer. D. Respiratory alkalosis
A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution?
A. No special precautions are required. B. Cover the infected site with a dressing. C. Drape the client with a covering labeled as biohazardous.D. Place a surgical mask on the client. Answer. B. Cover the infected site with a dressing.
A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective?
A. Pain subsides as a result of arteriole and venous dilation. B. Pulse rate increases because the cardiac output has been stimulated. C. Sublingual area tingles because sensory nerves are being triggered. D. Capacity for activity improves as a response to increased collateral circulation. Answer.
After several interactions with a client, the nurse at the mental health clinic identifies a pattern of withdrawal and nonparticipation in situations requiring communication with others. In which area should the nurse expect the client to have difficulty?
A. Personal identity B. Social interaction C. Sensory perception D. Verbal communication Answer . B. Social interaction
A client sustains multiple internal injuries in a motor vehicle accident. While performing the client's initial assessment, the nurse identifies that the client's blood pressure suddenly drops from 134/90 to 80/60 mm Hg. What most likely has caused this drop in blood pressure?
A. Reduction in the circulating blood volume. B. Diminished vasomotor stimulation to the arterial wall. C. Vasodilation resulting from diminished vasoconstrictor tone. D. Cardiac decompensation resulting from electrolyte imbalance. Answer. A. Reduction in the circulating blood volume
When two nurses are getting an older adult out of bed, the client reports feeling lightheaded. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do?
A. Slide slowly to the floor to prevent a fall and injury. B. Sit on the edge of the bed while they hold the client upright. C. Bend forward because this will increase blood flow to the brain. D. Lie down quickly so the legs can be raised above the heart level. Answer. B. Sit on the edge of the bed while they hold the client upright.
On the first postpartum day, a client whose infant is rooming in asks the nurse to return her baby to the nursery and bring the baby to her only at feeding times. How should the nurse respond? A. "It seems that you've changed your mind about rooming in." B. "I think you're having difficulty caring for the baby." C. "All right. I'll inform the other nurses of your decision." D. "You must be tired. I'll bring the baby back at feeding time."
Answer. A. "It seems that you've changed your mind about rooming in."
Trimethoprim-sulfamethoxazole (Septra) is prescribed for a client with cystitis. When teaching about the medication, the nurse instructs the client to: A. Drink 8 to 10 glasses of water daily B. Drink two glasses of orange juice daily C. Take the medication with meals D. Take the medication until symptoms subside
Answer. A. Drink 8 to 10 glasses of water daily
In the second stage of labor the nurse should plan to discourage a client from holding her breath longer than 6 seconds while pushing with each contraction. What complication does this prevent? A. Fetal hypoxia B. Perineal lacerations C. Carpopedal spasms D. Maternal hypertension
Answer. A. Fetal hypoxia
A client with a terminal illness creates a legal document that requests that he not be given intravenous nutrition and hydration if he becomes permanently unconscious. What is this document known as? A. Living will. B. "Tail" agreement. C. Informed consent. D. Durable power of attorney
Answer. A. Living Will
Which cell organelle is responsible for the digestion of microbes that have invaded the cell? A. Lysosomes B. Ribosomes C. Mitochondria D. Endoplasmic reticulum
Answer. A. Lysosomes
A client is receiving total parenteral nutrition. The nurse assesses for which client response that indicates hyperglycemia? A. Polyuria B. Paralytic ileus C. Respiratory rate below 16 D. Serum glucose of 105 mg/100 mL
Answer. A. Polyuria
What can be a cause of metabolic acidosis? A. Severe diarrhea B. Cushing disease C. Hyperaldosteronism D. Consumption of too much baking soda
Answer. A. Severe diarrhea
Which systems regulate acid-base balance? Select all that apply A. Urinary system, B. Digestive system' C.Lymphatic system, D. Respiratory system E. Cardiovascular system
Answer. A. Urinary system, D. Respiratory system
When suctioning a client with a tracheostomy, an important safety measure for the nurse is to: A. Hyperventilate the client with room air prior to suctioning. B. Apply suction only as the catheter is being withdrawn. C. Insert the catheter until the cough reflex is stimulated. D. Remove the inner cannula before inserting the suction catheter.
Answer. B. Apply suction only as the catheter is being withdrawn.
A nurse is assessing the urine of a client with a urinary tract infection. What appearance should the nurse expect this client's urine to have? A. Smoky B. Cloudy C. Orange-amber D. Yellow-brown
Answer. B. Cloudy
Which fluid has an acidic pH level? A. Borax ,B. Coffee, C. Coconut water, D. Milk of magnesia
Answer. B. Coffee
A client arrives at a health clinic reporting hematuria, frequency, urgency, and pain on urination. What does the nurse suspect is the cause of these signs and symptoms? A. Chronic glomerulonephritis, B. Cystitis C. Nephrotic syndrome, D. Pyelonephritis
Answer. B. Cystitis
A client with respiratory disorder complains of fatigue. Which nursing intervention will be beneficial for this client? A. Assessing the degree of dyspnea B. Encouraging adequate periods of rest C. Instruction in effective breathing techniques D. Monitoring for nasal flaring and sternal retractions
Answer. B. Encouraging adequate periods of rest
Which is a clinical manifestation of respiratory acidosis? A. Tetany B. Tremors C. Bradycardia D. Hypertension
Answer. B. Tremors
The mother of a preschool-age child tells the nurse that her husband is dying of cancer and that she is worried about how her child will cope. As part of their discussion, the nurse includes that preschool-age children view death as: A. Universal B. Irreversible C. A form of sleep D. A frightening ghost
Answer. C. A form of sleep
A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. What is the goal of the medical regimen for this client? A. Increase left ventricular filling and improve cardiac output. B. Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias. C. Decrease the workload on the heart and promote maximum coronary artery filling. D. Increase venous return to the right atrium and increase pulmonary arterial blood flow.
Answer. C. Decrease the workload on the heart and promote maximum coronary artery filling.
Which type of documentation uses a modified list of nursing diagnoses as an index for nursing documentation instead of a problems list? A. Incident report B. Charting by exception C. Focus charting format D. Problem-oriented medical record
Answer. C. Focus charting format
A nurse is teaching a class to parents about keeping medications and household cleaning supplies out of the reach of toddlers. The nurse explains that this is necessary because toddlers: A. Have increased appetites. B. Are developing a sense of taste. C. Have a high level of oral activity. D. Are rebelling against parental authority
Answer. C. Have a high level of oral activity
The nurse caring for a client with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is: A. White blood cell (WBC) count of 8200/mm 3 B. Bilateral 3+ pitting pedal edema C. Oral temperature of 101.3º F D. Pale skin and nail beds
Answer. C. Oral temperature of 101.3º F
A health care provider writes prescriptions addressing the needs of a client with Addison disease. Which outcome does the nurse conclude is the main focus of treatment for this client? A. Decrease in eosinophils B. Increase in lymphoid tissue C. Restoration of electrolyte balance D. Improvement of carbohydrate metabolism
Answer. C. Restoration of electrolyte balance
A nurse determines that a client exhibits the characteristic gait associated with Parkinson disease. How should the nurse describe this gait when recording on the client's progress report? A. Spastic B. Steppage C. Shuffling D. Scissoring
Answer. C. Shuffling
A client signs a legal consent for hip replacement surgery. Shortly before surgery, the client states, "I decided not to go through with the surgery." What is the best initial response by the nurse? A. "Then you shouldn't have signed the consent." B. "I can understand why you changed your mind." C. "Tell me why you decided to refuse the operation." D. "Let's talk about your concerns regarding the procedure."
Answer. D. "Let's talk about your concerns regarding the procedure."
A nurse instructs a client to breathe deeply to open collapsed alveoli. What should the nurse include in the explanation of the relationship between alveoli and improved oxygenation? A. "The alveoli need oxygen to live." B. "The alveoli have no direct effect on oxygenation." C. "Collapsed alveoli increase oxygen demands." D. "Oxygen is exchanged for carbon dioxide in the alveolar membrane."
Answer. D. "Oxygen is exchanged for carbon dioxide in the alveolar membrane."
A female client receiving cortisone therapy for adrenal insufficiency expresses concern about why she is developing facial hair. How should the nurse respond? A. "It is just another sign of the illness." B. "Do not worry because it will disappear with therapy." C. "This is not important as long as you are feeling better," D. "The drug contains a hormone that causes male characteristics."
Answer. D. "The drug contains a hormone that causes male characteristics."
A health care provider prescribes enoxaprarin (Lovenox) 30 mg subcutaneously daily. To ensure client safety, which measure would the nurse take when administering this medication? A. Remove air pocket from prepackaged syringe before administration. B. Rub site after administration. C. Push over two minutes. D. Administer in the abdomen
Answer. D. Administer in the abdomen
A nurse providing care in a hospital witnesses a client's spouse shaking the client vigorously because the client has had an episode of incontinence. Because of the suspicion of physical abuse, legally, the nurse should discuss the concerns with: A. The client B. The client's spouse C. The client's primary health care provider D. Adult Protective Services
Answer. D. Adult Protective Services
A client with a fractured head of the right femur and osteoporosis is placed in Buck's extension before surgical repair. What should the nurse do when caring for this client until surgery is performed? A. Remove the weights from the traction every two hours to promote comfort. B. Turn the client from side to side every two hours to prevent pressure on the coccyx. C. Raise the knee gatch on the bed every two hours to limit the shearing force of traction. D. Assess the circulation of the affected leg every two hours to ensure adequate tissue perfusion.
Answer. D. Assess the circulation of the affected leg every two hours to ensure adequate tissue perfusion.
A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? A. Productive cough B. Clubbing of the fingertips C. Crackles at the height of inhalation D. Diminished breath sounds on auscultation
Answer. D. Diminished breath sounds on auscultation
A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish normal bowel pattern? A. Administer a mineral oil enema. B. Offer one cup of fluid every hour. C. Manually remove fecal impactions. D. Offer a cup of prune juice.
Answer. D. Offer a cup of prune juice.
Which client-made, legally enforceable document contains the instructions of the client regarding his or her refusal to receive cardiopulmonary resuscitation upon admission to a hospital for surgery? A. Informed consent B. Occurrence basis policy C. Resident Assessment Instrument aka R.A.I D. Physician Orders for Life-Sustaining Treatment aka P.O.L.S.T
Answer. D. Physician Orders for Life-Sustaining Treatment aka P.O.L.S.T
When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client states that the preferred breakfast cereal is: A. Froot Loops, B. Corn Flakes, C. Cap'n Crunch, D. Shredded Wheat
Answer. D. Shredded Wheat
A client is experiencing chronic constipation and the nurse discusses how to include more bulk in the diet. The nurse concludes that learning has occurred when the client states, "Bulk in the diet promotes defecation by: A. Irritating the bowel wall." B. Stimulating the intestinal mucosa chemically." C. Acting on the microorganisms in the large intestine." D. Stretching intestinal smooth muscle, which causes it to contract."
Answer. D. Stretching intestinal smooth muscle, which causes it to contract."
Which nursing action would be appropriate to decrease carbon dioxide for a client with respiratory acidosis? A. Administering sodium bicarbonate B. Sedating the client to slow the breathing C. Helping the client breathe into a paper bag D. Using continuous positive airway pressure (CPAP)
Answer. D. Using continuous positive airway pressure (CPAP)
A registered nurse is discussing with a licensed practical nurse (LPN) the state health department's recently issued safety precautions regarding flu in the community. Which statement made by the LPN about this agency indicates effective learning? A. "It's a private institution-based health agency."
B. "It's supported by tax-deductible contributions." C. "It's governed by the hospital board of directors." D. "It's been given the tax status of a nonprofit health agency."Answer. D. "It's been given the tax status of a nonprofit health agency."
A client who is scheduled to have a hysterectomy starts to sob and says, "I told my husband that after this operation, I'll be only half a woman. He told me not to worry, but I know that he was just putting up a front." How should the nurse respond? A. "It's frightening to think that your husband rejects you as a woman."
B. "You think this operation will affect how your husband feels about you as his wife."C. "Try not to worry about it right now. The most important thing is for you to get well." D. "I'll try to have your surgery postponed. You both need time to adjust to the effects of a hysterectomy." Answer. B. "You think this operation will affect how your husband feels about you as his wife."
A husband is upset that his wife's alcohol withdrawal delirium has persisted for a second day. What is the most appropriate initial response by the nurse? A. "I see that you're worried. We're using medication to ease your wife's discomfort." B. "This is expected. I suggest that you go home, because there's nothing you can do to help."
C. "Are you afraid that your wife will die? I assure you, very few alcoholics die during the detoxification process." D. "Are you worried that your wife is uncomfortable while she's going through withdrawal? I'm sure that she's not in pain." Answer. A."I see that you're worried. We're using medication to ease your wife's discomfort."
During labor a client states that she does not want eyedrops or ointment placed in her baby's eyes immediately after birth. How should the nurse respond? A. "The medicine protects your baby — that's why it's used." B. "You'll have to check with your baby's doctor about this."
C. "Let's talk about why you don't want the medicine to be put into your baby's eyes." D. "This medicine is required by law and should be administered right after the baby is born."Answer. C. "Let's talk about why you don't want the medicine to be put into your baby's eyes."
The parents of a 3½ -year-old tell the nurse that their child has become a "picky eater" and has not gained much weight. How should the nurse respond? A. "This is not expected; your child may be sick." B. "This is a fast growth period; you need to give your child vitamins."
C. "Your child is growing slower; preschoolers don't have large appetites." D. "Preschoolers enjoy gifts; offer a reward when your child eats an entire meal." Answer. C. "Your child is growing slower; preschoolers don't have large appetites."
A client is scheduled for surgery. Legally, the client may not sign the operative consent if ? A. Ambivalent feelings are present and acknowledged. B. Any sedative type of medication has been given recently.
C. A discussion of alternatives with two health care providers has not occurred. D. A complete history and physical has not been performed and recordedAnswer. B. Any sedative type of medication has been given recently
The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? A. Except with rare blood disorders, hemoglobin seldom affects oxygenation status. B. There are many other factors that impact oxygenation status more than hemoglobin does.
C. A low hemoglobin level causes reduced oxygen-carrying capacity. D. Hemoglobin reflects the body's clotting ability and may or may not impact oxygenation status.Answer. A low hemoglobin level causes reduced oxygen-carrying capacity.
The diet prescribed for a client with diverticulosis includes 30 grams of fiber a day. What breakfast items should the nurse encourage the client to select? A. Cream of wheat, milk, and cranberry juice B. Unstrained orange juice, pancakes, and bacon
C. Oatmeal, sliced bananas, whole-wheat toast, and milk D. Poached eggs on whole-wheat toast, tomato juice, and tea Answer. C. Oatmeal, sliced bananas, whole-wheat toast, and milk
A nurse applies a heating pad to a client's buttocks. Upon removal of the heating pad, the nurse discovers that the client has received burns due to incorrect settings when use of the heating pad was initiated. Which principle would legally apply? A. No one could be held liable for new equipment. B The nurse could be held liable for the injury that occurred.
C. The nurse did what a reasonable, prudent nurse would do. D. The manufacturer is liable for new equipment Answer. B. The nurse could be held liable for the injury that occurred.
A licensed practical nurse (LPN) assigns the task of measuring temporal artery temperature to an unlicensed assistive personnel (UAP). Which action of the UAP indicates the need for the LPN to intervene during the measurement? A. Ensuring that the client's forehead is dry B. Placing the probe flush on the client's forehead
C. Wiping the probe with water and disposing of the probe cover D. Sweeping the probe across the forehead and continuing behind the earlobe Answer. Wiping the probe with water and disposing of the probe cover
A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching has been understood when the client makes what statements? (Select all that apply.) A. "I may eat potatoes at dinner daily." B. "I should drink eight glasses of water every day." C. "I must eat eggs for breakfast three times a week."
D. "I can include bran muffins in my breakfast daily."c E. "I will walk every day as part of my exercise regimen."Answer. B. "I should drink eight glasses of water every day.". D. "I can include bran muffins in my breakfast daily.", E. "I will walk every day as part of my exercise regimen."