Health & Healing Practice Questions
What are the 48/6?
1. Mobility and Risk for Falls 2. Pain Management 3. Bowel and Bladder Management 4. Psychosocial 5. Nutrition and Swallowing 6. Cognition
The nurse has been reviewing the vaccination status of a client in a community clinic. Which of the following statements by a 69-year-old client with no major health problems requires further teaching? a. "I need to make sure that I get my flu shot at least every 2 years." b. "I don't think I need to get vaccinated against hepatitis A unless I plan on doing some travelling to risky areas." c. "I had one dose of vaccine against pneumonia when I turned 65, so I think I am fine with that." d. "I need to get a tetanus booster every 10 years."
a. "I need to make sure that I get my flu shot at least every 2 years."
The nurse records the client's breakfast intake as "tea 240 mL, milk 125 mL, 1 egg, 2 slices of toast." The nurse knows that the documentation is part of which phase of the nursing process? a. Assessment b. Diagnosis c. Planning d. Evaluation
a. Assessment
Which infections require contact precautions? Select all that apply. Select one or more: a. Methicillin-resistant staphylococcus aureus b. Tuberculosis c. Measles d. Clostridium difficile
a. Methicillin-resistant staphylococcus aureus d. Clostridium difficile
The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? Select one: a. Red blood cells and hemoglobin count findings b. Oxygen saturation level c. Arterial blood gas (ABG) findings d. white blood cell differential
c. Arterial blood gas (ABG) findings
Which of the following would most likely be included in the evaluation of the client goal of "demonstrate adequate tissue perfusion"? a. Symmetrical chest expansion b. Pursed-lip breathing c. Brisk capillary refill d. Decreased activity tolerance
c. Brisk capillary refill
A nurse is caring for a client with deep vein thrombosis. Which change in assessment findings does the nurse find most concerning? Select one: a. Bradypnea and bradycardia b. Nonproductive cough and abdominal pain c. Chest pain and dyspnea d. Hypertension and lack of fever
c. Chest pain and dyspnea
A client has received numerous different antibiotics and now is experiencing diarrhea. The health care provider (HCP) has prescribed a transmission-based precaution. The nurse should institute: Select one: a. Airborne precautions b. Droplet precautions c. Contact precautions d. Needlestick precautions
c. Contact precautions
The nurse selects the nursing diagnosis "risk for impaired skin integrity," related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated outcome or goal? a. The client will turn in bed every 2 hours. b. The client will report the importance of applying lotion to skin daily. c. The client will have intact skin during hospitalization. d. The client will use a pressure-reducing mattress.
c. The client will have intact skin during hospitalization.
A client with chronic pulmonary disease has a bluish tinge around the lips. This would most accurately be documented as which of the following? a. Hypoxia b. Hypoxemia c. Dyspnea d. Cyanosis
d. Cyanosis
Which of the following clients should be watched most closely for a problem with the transport of O2 from the lungs to tissues? a. A client who has anemia b. A client who has an infection c. A client who has a fractured rib d. A client who has a tumour of the medulla
a. A client who has anemia
The nurse is preparing the room for a client diagnosed with Varicella. Identify which sign the nurse would place on the room door. Select all that apply. *IMAGES OF PRECAUTIONS the answer is _________ and _____________ precautions
CONTACT AND AIRBORNE
The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the medical record for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 1530 is 75%. What should the nurse do first? Select one: a. Administer oxygen via mask b. Swaddle the neonate in heated blankets c. Draw blood gases for oxygen and carbon dioxide levels. d. Reassess the oximetry reading in 30 minutes
a. Administer oxygen via mask
Which client is at risk for pulmonary embolism? A client with: Select one: a. Deep vein thrombosis (DVT) b. A small abdominal aneurysms c. Varicose veins d. Arteriosclerosis
a. Deep vein thrombosis (DVT)
The nurse is caring for a single client during one shift. Which of the following personal protective equipment is it appropriate for the nurse to reuse? a. Goggles b. Gown c. Surgical mask d. Clean gloves
a. Goggles
The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Which of the following should the nurse consult before determining whether or not this request can be honoured? a. Hospital policies b. Standardized care plans c. Orthopedic protocols d. Standards of care
a. Hospital policies
Which of the following behaviours is most representative of the nursing diagnosis (nursing analysis) phase of the nursing process? a. Identifying major problems or needs b. Organizing data in the client's family history c. Establishing short-term and longterm goals d. Administering an antibiotic
a. Identifying major problems or needs
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? Select one: a. Initiate oxygen therapy. b. Perform nasopharyngeal suctioning. c. Administer analgesics as ordered d. Administer a heparin bolus and being an infusion at 500 units/hr.
a. Initiate oxygen therapy.
A client with a chronic lung disorder requires supplemental oxygen (O2). Which of the following should the nurse consider as safe delivery? a. O2 at 2 L/min per nasal cannula b. O2 at 6 L/min per facemask c. O2 at 8 L/min per partial rebreather mask d. O2 at 10 L/min per nonrebreather mask
a. O2 at 2 L/min per nasal cannula
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? Select one: a. Oxygen saturation of 89% b. Decreased cough and gag reflexes c. Heart rate of 94 beats/min d. Blood tinged stools
a. Oxygen saturation of 89%
The nurse is planning to perform percussion and postural drainage with a client. Which of the following is an important aspect of the planning? a. Percussion and postural drainage should be done before lunch on an empty stomach. b. The order should be coughing, percussion, positioning, and then suctioning. c. Percussion and postural drainage should be done in the morning after breakfast when the client is well rested. d. Percussion and postural drainage should always be preceded by 3 minutes of 100% oxygen.
a. Percussion and postural drainage should be done before lunch on an empty stomach.
The student nurse is starting a placement on a medical- surgical unit. The student understands that the most effective nursing action for controlling the spread of infection includes which of the following? a. Performing hand hygiene before and after client contact b. Wearing gloves and masks for all client care c. Implementing isolation precautions d. Administering broad-spectrum prophylactic antibiotics
a. Performing hand hygiene before and after client contact
Which of the following areas are considered sterile on health care providers in the operating room? Assume that all articles were sterile when applied. a. The chest area of the surgeon's sterile gown b. The back area of the circulating nurse's sterile gown c. The sterile face mask on the scrub nurse's face d. The full arm of the anaesthetist's sterile gown
a. The chest area of the surgeon's sterile gown
Following abdominal surgery, which factor predisposes a client to deep vein thrombosis? Select one: a. The client will be immobile during and shortly after surgery b. The client usually walks 3 miles (4.8 kilometers) a day. c. The client is 5 feet 9 inches (172.5) tall and weighs 128lb (58kg). d. The client has been pregnant four times.
a. The client will be immobile during and shortly after surgery
A nurse on the medical-surgical unit just received report on her client care assignment. Which client should she assess first? Select one: a. The client with unilateral leg swelling who's complaining of anxiety and shortness of breath. b. The client with anorexia, weight loss and night sweats. c. The client who had difficulty sleeping, daytime fatigue and morning headache. d. The client with crackles and fever who is complaining of pleuritic pain.
a. The client with unilateral leg swelling who's complaining of anxiety and shortness of breath.
Which precautions should the health care team observe when caring for clients with hepatitis A? Select one: a. Wearing gloves when giving direct care. b. Gowning when entering a client's room. c. Wearing a mask when providing care. d. Assigning the client to a private room.
a. Wearing gloves when giving direct care.
The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should first: Select one: a. administer oxygen b. institute rewarming c. start and intravenous infusion d. prepare for intubation
a. administer oxygen
Which of the following statements by the client indicates successful teaching regarding the proper use of an incentive spirometer? a. "I should breathe out as fast and hard as possible into the device." b. "I should inhale slowly and steadily to keep the balls up." c. "I should use the device three times a day, after meals." d. "The entire device should be washed thoroughly in sudsy water once a week."
b. "I should inhale slowly and steadily to keep the balls up."
The nurse has taught a client and family general infection prevention strategies. Which of the following statements by the client indicates effective learning has occurred? a. "We will use antimicrobial soap and hot water to wash our hands at least three times per day." b. "We must wash or peel all raw fruits and vegetables before eating." c. "A wound or sore is not infected unless we see it draining pus." d. "We should not share toothbrushes, but it is OK to share towels and washcloths."
b. "We must wash or peel all raw fruits and vegetables before eating."
The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis? Select one: a. Contact precautions b. Airborne precautions c. Droplet precautions d. Hand Hygiene
b. Airborne precautions
A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute? Select one: a. Contact precautions b. Airborne precautions and contact precautions c. Droplet precautions d. Contact and droplet precautions
b. Airborne precautions and contact precautions
The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight circumoral cyanosis is developing. Which laboratory test best measures the adequacy of tissue oxygenation? Select one: a. Red blood cell count b. Arterial blood gases c. Hemoglobin level d. Pulmonary function test
b. Arterial blood gases
The nurse is caring for a client who is a carrier of a chronic infection. To prevent the spread of the infection to other clients and health care providers, the nurse emphasizes interventions that do which of the following? a. Eliminate the reservoir b. Block the portal of exit from the reservoir c. Block the portal of entry into the host d. Decrease the susceptibility of the host
b. Block the portal of exit from the reservoir
A nurse is caring for a client admitted to the hospital because of chest pain. The client's condition has deteriorated, and he develops crackles in his lower lobes of the lungs. He is feeling short of breath and anxious. The health care provider prescribes morphine sulphate (mor- phine) 4 mg IV and furosemide (Lasix) 40 mg IV. Which of the following changes in condition best indicates that the client is responding favourably to the medications? a. Decreased respiratory rate, decreased crackles b. Decreased crackles, large diuresis c. Increased pulse, increased respiratory rate d. Decreased respiratory rate, decreased blood pressure
b. Decreased crackles, large diuresis
Following a total joint replacement, which complication has the greatest likelihood of occurring? Select one: a. Deep vein thrombosis (DVT) b. Displacement of the new joint c. Wound evisceration d. Polyuria
b. Displacement of the new joint
The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated? Select one: a. Contact precautions b. Droplet precautions c. Standard precautions d. Airborne precautions
b. Droplet precautions
An unconscious client with multiple injuries arrives in the emergency department. What should the nurse do first? Select one: a. Stop bleeding from open wounds b. Establish an airway c. Check for neck fracture d. Determine the identity of the client
b. Establish an airway
A nurse manager is auditing the nursing unit's adherence to infection control practices. Which of the following observations causes the nurse manager to be most concerned that the clients on the unit are at risk for infection? Select one: a. A nurse does not use sterile scissors to cut the tape for a wound dressing. b. Hand hygiene is forgotten between clients by several nurses on the unit. c. A nurse does not wear a mask when entering the room of a client on contact precautions. d. A client receives a prophylactic antibiotic 20 minutes late.
b. Hand hygiene is forgotten between clients by several nurses on the unit.
A client has undergone a cesarean section. She and her baby have just been brought to the recovery room. What is the nurse's initial action? a. Perform a newborn assessment b. Inspect the client's dressing and lochia c. Assess the client's level of pain d. Ask the client if she would like to feed her baby
b. Inspect the client's dressing and lochia
A clinically obese client with moderately painful varicose veins chooses self-care options for managing the varicosities. The nurse should coach the client to follow which health care practices? Select all that apply. Select one or more: a. Sleep with pillows under the knees. b. Lose weight c. Elevate legs d. Wear compression stockings e. Apply lotion to the veins
b. Lose weight c. Elevate legs d. Wear compression stockings
After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. What is the expected outcome of this exercise? Select one: a. Prepare client for ambulation b. Prevent thrombophlebitis and blood clot formation c. Promote urinary and intestinal elimination d. Decrease the likelihood of pressure ulcer formation
b. Prevent thrombophlebitis and blood clot formation
The nurse is caring for a client with Clostridium difficile infection. Upon entering the room, which of the following steps should the nurse take? Select one: a. Wear a face mask and goggles. b. Put on an isolation gown and gloves. c. Use sterile gloves and foot protection. d. Take antiseptic wipes into the room.
b. Put on an isolation gown and gloves
The nurse is caring for a client with chest tubes. During ambulation, the connection between the tube and the water seal comes apart. Which of the following actions is most appropriate? a. Assisting the client with ambulation back to bed b. Reconnecting the tube to the water seal c. Assessing the client's lung sounds with a stethoscope d. Having the client cough forcibly several times
b. Reconnecting the tube to the water seal
A nurse administers albuterol, as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? Select one: a. Urine output of 40 ml/hr b. Respiratory rate of 22 breaths/min c. Dilated and reactive pupils d. Heart rate of 100 beats/min
b. Respiratory rate of 22 breaths/min
Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel and a compound fracture of the right tibia and fibula and multiple lacerations and contusions. The priority for care is first to: Select one: a. maintain adequate circulating volume b. maintain adequate oxygenation c. decrease chest pain d. reduce the client's anxiety
b. maintain adequate oxygenation
A client is admitted with an infectious wound. Contact precautions are initiated. To help the client cope with staff using isolation procedures, which nursing action is most helpful? Select one: a. Don gloves when providing all client care b. Put stickers on the face mask to increase conversation c. Discuss the rationale for contact precautions d. Speak to the client from the doorway unless needing close contact
c. Discuss the rationale for contact precautions
The nurse is caring for a client on contact precautions for a draining infected foot ulcer. The nurse should perform which of the following? a. Wear a mask during dressing changes b. Provide disposable meal trays and silverware c. Follow routine practices in all interactions with the client d. Use aseptic technique for all direct contact with the client
c. Follow routine practices in all interactions with the client
To prevent postoperative complications, the nurse assists the client with coughing and deep-breathing exercises. Which of the following would the nurse recommend to the client? a. Performing coughing exercises 1 hour before meals and deep breathing 1 hour after meals b. Coughing forcefully as many times as tolerated throughout the day c. Performing huff coughing every 2 hours or as needed d. Using diaphragmatic and pursed-lip breathing 5 to 10 times, four times a day
c. Performing huff coughing every 2 hours or as needed
Which of the following steps should the nurse perform first when initiating the implementation phase of the nursing process? a. Carrying out nursing interventions b. Determining the need for assistance c. Reassessing the client d. Documenting interventions
c. Reassessing the client
A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which of the following would be the priority for this client after the stockings are applied? Select one: a. Teach the client isotonic leg exercises b. Order a second pair of stockings to be rotated each day. c. Remove elastic stockings once per day and observe lower extremities. d. Elevate the client's legs while out of bed.
c. Remove elastic stockings once per day and observe lower extremities.
Which of the following behaviours would indicate that the nurse was using the assessment phase of the nursing process as part of nursing care? a. Proposing hypotheses b. Generating desired health outcomes c. Reviewing results of laboratory tests d. Documenting care
c. Reviewing results of laboratory tests
Which of the following represents proper nasopharyngeal or nasotracheal suction technique? a. Lubricating the suction catheter with petroleum jelly (e.g., Vaseline) before and between insertions b. Applying suction intermittently while slowly inserting the suction catheter c. Rotating the catheter and applying suction while slowly withdrawing the catheter d. Hyperoxygenating the client with 100% oxygen for 30 minutes before and after suctioning
c. Rotating the catheter and applying suction while slowly withdrawing the catheter
Two public health nurses have desks beside each other and share a telephone. One nurse comes to work with a cold, is tired, has a low-grade fever, and is sneezing and coughing frequently. What can the sick nurse do to minimize the risk of developing the same respiratory infection? a. Stay a minimum of 0.5 metres away. b. Take an antipyretic agent to lower fever. c. Sneeze or cough into a tissue or sleeve. d. Stay at home if the symptoms do not subside within 2 days.
c. Sneeze or cough into a tissue or sleeve.
The nurse determines that a field remains sterile if which of the following conditions exist? a. The tips of wet forceps are held upward when held in ungloved hands. b. The field was set up 1 hour before the procedure. c. Sterile items are kept at least 5 cm from the edge of the field. d. The nurse reaches over the field rather than around the edges.
c. Sterile items are kept at least 5 cm from the edge of the field.
clients at the beginning of the second shift. Which client should the nurse plan to assess first after receiving report? Select one: a. A client who is scheduled for an abdominal perineal resection in the morning and is visiting with the family. b. A young client with chest tubes placed for treatment of a pneumothorax who is resting comfortably. c. A client receiving total parenteral nutrition (TPN) via a central line with 400ml remaining in the IV fluid bottle d. An elderly client with pneumonia who is exhibiting periods of confusion
d. An elderly client with pneumonia who is exhibiting periods of confusion
The nurse is caring for a client with bacterial pneumonia. The effectiveness of the client's oxygen therapy can be best determined by the: Select one: a. Absence of cyanosis b. Client's respiratory rate c. Client's level of consciousness d. Arterial blood gas values
d. Arterial blood gas values
What is a benefit of using a conceptual or theoretical framework for collecting and organizing assessment data? a. Correlation of the data with other members of the health care team b. Demonstration of cost-effective care c. Use of creativity and intuition in creating a plan of care d. Collection of all necessary information for a thorough appraisal
d. Collection of all necessary information for a thorough appraisal
To prevent pulmonary embolism in a client who has had abdominal surgery, the nurse should: Select one: a. Massage the client's calves. b. Have the client wear antiembolism stockings when out of bed. c. Encourage the client to cough and deep breathe. d. Have the client perform leg exercises every hour while awake.
d. Have the client perform leg exercises every hour while awake.
The nurse is preparing to change an abdominal dressing. While donning sterile gloves (open method), the cuff of the first glove rolls under itself about 0.5 cm. Which is the best action for the nurse? a. Remove the glove and start over with a new pair b. Wait until the second glove is in place and then unroll the cuff with the other sterile hand c. Ask a colleague to assist by unrolling the cuff d. Leave the cuff rolled under
d. Leave the cuff rolled under
A nursing care plan includes the desired health outcome of "quality of life" for a client with a chronic degenerative illness who is likely to live for many more years. Which of the following is one example that would indicate the outcome has been met? a. The client demonstrates financial resources to pay for health care for many years. b. The client spends the majority of his or her time in spiritual reflection. c. The client has no signs or symptoms of preventative complications of the illness. d. The client verbalizes satisfaction with current relationships with other persons.
d. The client verbalizes satisfaction with current relationships with other persons
A client comes into the doctor's office for re-evaluation of his diabetes. The nurse collects the client's recent blood sugar values, which the client has been recording daily at home. What type of assessment is the nurse performing? a. Initial assessment b. Problem-focused assessment c. Emergency assessment d. Time-lapsed assessment
d. Time-lapsed assessment
