NUR 112 Exam 3 ALL QUESTIONS

The nurse notes an Si 3 heart sound while performing an assessment on a patient admitted with acute myocardial infarction. What should this finding indicate to the nurse? A) Heart failure B) Coronary artery disease C) Hypertension D) Pulmonic stenosis

A) Heart failure

A client experiences leg pain and edema of both ankles. Which laboratory test should the nurse anticipate being prescribed for this client? A.) Creactive protein (CRP) B.) Coagulation studies C.) Complete blood count D.) Complete metabolism panel

A.) Creactive protein (CRP)

The nurse is discussing the use of adsorbents such as bismuth subsalicylate (Pepto-Bismol) with patient who has diarrhea. The nurse will warn the patient about which possible adverse effects? A.) Dark stools and blue gums B.) Urinary hesitancy C.) Drowsiness and dizziness D.) Blurred vision and headache

A.) Dark stools and blue gums

Which outcome is related to Decreased Cardiac Output? Select all that apply. A) No dyspnea or shortness of breath with exertion B.)Normal skin color C.) Respiratory rate less than 16 breaths/min D.) Brisk capillary refill E.) Urine output > 50 mL/hr

A) No dyspnea or shortness of breath with exertion B.)Normal skin color D.) Brisk capillary refill E.) Urine output > 50 mL/hr

A client recovering from an acute myocardial infarction is experiencing tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which nursing diagnoses is most appropriate for this client? A.) Decreased Cardiac Output B.) Ineffective Peripheral Tissue Perfusion C.) Impaired Cardiac Contractility D.) Activity Intolerance

A.) Decreased Cardiac Output

A client is coughing and has bilateral rhonchi throughout the lung fields. Which nursing diagnosis is most appropriate for these assessment findings? A.)Impaired Gas Exchange B.) Ineffective Airway Clearance C.) Ineffective Breathing Pattern D.) Impaired Spontaneous Ventilation

B.) Ineffctive Airway Clearance

A client had a myocardial infarction that damaged the sinoatrial (SA) node. For which potential complication should the nurse assess this client? Select all that apply. A.) Decreased heart rate B.) Increased heart rate C.) Decreased cardiac output D.) Decreased strength of ventricular contractions. E.) Increased cardiac output

A.) Decreased heart rate C.) Decreased cardiac output

Which consequentialist theory takes the position that the value of an action is determined by its usefulness? A) Ethics of care B.) Utilitarianism C.) Deontology D.) Categorical imperative

B.) Utilitarianism

Which is an example of invasion of privacy by nurses? Select all that apply. A) Searching a patient's belongings without permission B) Reviewing the plan for patient care in the lunchroom C) Discussing healthcare issues for an unconscious patient with his power of attorney D) Releasing patient health information to local newspaper reporters E) Taking a photo of the patient and posting it on Facebook

A) Searching a patient's belongings without permission B) Reviewing the plan for patient care in the lunchroom D) Releasing patient health information to local newspaper reporters E) Taking a photo of the patient and posting it on Facebook

A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Which finding might the nurse expect when assessing the patient's nails? A) Soft, boggy nails B) Brittle nails C) Thickened nails D) Thick nails with yellowing

A) Soft, boggy nails

Which is the most important reason for nurses to be critical thinkers? A.) Nurses need to follow policies and procedures. B.) ) Nurses work with other healthcare team members. C.) Nurses care for clients who have multiple health problems. D.) Nurses have to be flexible and work variable schedules.

C.) Nurses care for clients who have multiple health problems.

The nurse is performing an otoscopic examination on an adult patient. After having the patient tilt the head to the side not being examined and looking into the ear canal to make sure a foreign body is not present, what should the nurse do next? A) Straighten the ear canal by pulling the pinna up and back. B) Insert the speculum into the ear canal slowly. C) Test the mobility of the tympanic membrane. D) Straighten the ear canal by pulling the pinna down and back.

A) Straighten the ear canal by pulling the pinna up and back.

The nurse manager notes an increase in ethical issues related to societal factors. What has the manager identified as causing these issues? Select all that apply. A.) Cost containment B.) Moral developmental stage C.) Technological advances D.) Multicultural population E.) Increased consumer awareness

A.) Cost containment C.) Technological advances D.) Multicultural population E.) Increased consumer awareness

implementing full-spectrum nursing. What should the nurse manager explain to this nurse? A new graduate nurse is having difficulty understanding the importance of "caring" when Select all that apply. A. ) Caring motivates and facilitates doing. B. ) Caring ensures positive client outcomes. C. ) Caring ensures adherence to the care plan, D. ) Caring motivates and facilitates thinking. E. ) Caring replaces steps in the nursing process.

A. ) Caring motivates and facilitates doing. D. ) Caring motivates and facilitates thinking.

The staff development coordinator prepares the Nurse's Bill of Rights for new nursing orientation. What rights should the coordinator emphasize when reviewing this document? Select all that apply. A) Fair compensation for work B) Negotiate terms of employment C) Freely and openly advocate for clients D) Walk off a care area for unsafe conditions E) Work in an environment that supports ethical practice

A) Fair compensation for work B) Negotiate terms of employment C) Freely and openly advocate for clients E) Work in an environment that supports ethical practice

The nurse is counseling a 17-year-old girl on smoking cessation. What should the nurse include when teaching this client? Select all that apply. A) "Keep healthy snacks or gum available to chew instead of smoking a cigarette." B) "Don't tell your friends and I family you are trying to quit, until you feel confident that you'll be SUccessful." C.) "Plan a time to quit when you will not have many other demands or stressors in your life." D) "Reward yourself with an activity you enjoy when you quit smoking." E) "Spend time with friends who do not smoke."

A) "Keep healthy snacks or gum available to chew instead of smoking a cigarette." C.) "Plan a time to quit when you will not have many other demands or stressors in your life." D) "Reward yourself with an activity you enjoy when you quit smoking." E) "Spend time with friends who do not smoke."

The nurse has just been assigned to the clinical care of a newly admitted patient. To know how to best care for the patient, the nurse uses the nursing process. Which step would the nurse probably do first? A) Assessment B.) Diagnosis C.) Plan outcomes D) Plan interventions

A) Assessment

The left pupil of a patient fails to accommodate. This finding may reflect an abnormality in which cranial nerve? A) CN III B) CN V C) CN VIII D) CN X

A) CN III

While driving home from work, the nurse stops to help victims of a motor vehicle crash before an ambulance arrives. Which action ensures the nurse is functioning within the scope of the Good Samaritan laws? A) Contacted 911 immediately upon arriving to the scene B) Received victim's credit card information for payment C) Stayed with the victim after emergency personnel arrived D) Walked a block away from the site to get paper towels and water

A) Contacted 911 immediately upon arriving to the scene

The nurse gives a patient the wrong medication and documents that the correct medication was given. The next staff member recognizes the error and reports the nurse to the state board of nursing. Which action can the state board of nursing take against the nurse in this situation? A) Disciplinary action against the nurse's license to practice B) Criminal misdemeanor charges against the nurse C) Medical malpractice lawsuit against the nurse D) Employment release from the institution

A) Disciplinary action against the nurse's license to practice

abnormal potassium level of 6.8; communication, What does this scenario demonstrate? Select all that apply. however, he fails to notify the physician The nurse notes that a patient with renal failure has an and does not relate the value during hand-off A) Failure to inmplement a plan of care. B) Failure to evaluate C) Malpractice D) Failure to assess and diagnose E) Failure to follow a standard of care

A) Failure to inmplement a plan of care. B) Failure to evaluate D) Failure to assess and diagnose

After receiving a nebulizer treatment with a beta agonist, the patient complains of nervous and wonders if her asthma is getting worse. What is the nurse's best response? A.) "This is an expected adverse effect. Let me take your pulse." B. ) "The next scheduled nebulizer treatment will be skipped." C.) "I will notify the physician about this adverse effect." D.)"We will hold the treatment for 24 hours."

A.) "This is an expected adverse effect. Let me take your pulse."

Which factor influences normal lung volumes and capacities? Select all that apply A.) Age B.)Race C.)Body size D.)Activity level E.) Gender

A.) Age C.)Body size D.)Activity level E.) Gender

A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. Which action must the nurse implement to develop a nursing diagnosis? A.) Analyze the assessment data B.) Consult standards of care C.) Decide which interventions are appropriate D.) ) Ask the client's perceptions of her health problem

A.) Analyze the assessment data

The nurse notes that a client has a prescription for a peak expiratory flow meter. For which health problem should the nurse prepare teaching for this client? A.)Asthma B.) Pneumonia C.)Emphysema D.)Pulmonary edema

A.) Asthma

What is the nurse's obligation in ethical decision making? Select all that apply. A.) Be a patient advocate. B.) Involve institutional ethics committees. C.) Improve one's own ethical decision making. D.) Respect patient confidentiality. E.) Avoid whistleblowers.

A.) Be a patient advocate. B.) Involve institutional ethics committees. C.) Improve one's own ethical decision making. D.) Respect patient confidentiality.

activities. Which age-related change in the cardiovascular system might the client be An older client reports fatigue when walking upstairs and when performing normal household experiencing? Select all that apply. A.) Cardiac contractile strength is reduced. B.) Heart valves become more rigid. C.) Peripheral vessels lose elasticity. D.) Heart responds to increased oxygen demands. E.)There is reduced tolerance to exercise.

A.) Cardiac contractile strength is reduced. B.) Heart valves become more rigid. C.) Peripheral vessels lose elasticity. E.)There is reduced tolerance to exercise

Three days after cardiac surgery, the client's leg used for harvesting veins for the bypass is warm and tender and has a 3-cm area of erythema and swelling at the distal end of the incision. The incision staples are intact without drainage and vital signs are stable. Which type of complication is this client most likely experiencing? A.) Deep vein thrombosis (DVT) B.) Dehiscence of the wound C.) Internal bleeding D.) Infection at the incisional site

A.) Deep vein thrombosis (DVT)

A client is prescribed an ACE inhibitor. What should the nurse explain as the reason for this medication? A.) Dilate vessels to ease the workload of the heart B.) Increase venous return to raise the blood pressure C.) Decrease the heart rate and reduce heart contractility D.) Increase removal of sodium and water from the body

A.) Dilate vessels to ease the workload of the heart

The staff development instructor plans a training session on full-spectrum nursing. Which concept should the instructor include in this information? Select all that apply. A.) Doing B. ) Caring C. ) Thinking D. ) Collaboration E. ) Patient situation

A.) Doing B. ) Caring C. ) Thinking E. ) Patient situation

Which term describes the ability of nurses to base their practice on professional standards of ethical conduct and to participate in ethical decision making? A.) Ethical agency B.) Attitudes C.) Belief D.) Value neutrality

A.) Ethical agency

A patient is taking guaifenesin (Humibid) as part of treatment for a sinus infection. Which instruction will the nurse include during patient.teaching? A.) Force fluids to help loosen and liquefy secretions. B.) Report clear-colored sputum to the prescriber. C.) Avoid driving a car or operating heavy machinery because of the sedating effects. D.) Report symptoms that last longer than 2 days.

A.) Force fluids to help loosen and liquefy secretions.

In caring for a patient with comorbidities, the nurse draws upon her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. Which best describes these activities? A.) Full-spectrum nursing B.) Critical thinking C.) Nursing process D. ) Nursing knowledge

A.) Full-spectrum nursing

A patient with a tracheostomy has difficulty removing excessive, thick mucus from the respiratory tract. The nurse expects that which drug will be ordered to aid in the removal of mucus? A.) Guaifenesin (Humibid) B.) Benzonatate (Tessalon Perles) C.) Diphenhydramine (Benadryl) D.) Dextromethorphan (Robitussin DM)

A.) Guaifenesin (Humibid)

The nurse examines the site of a client's tuberculin skin test as being 5 mm induration and documents that the test is positive. Which information in the client's history did the nurse use to make this clinical determination? A.)HIV positive B.)Type 2 diabetes mellitus C.) Lives in a skilled nursing facility D.)Recent immigrant to the United States

A.) HIV positive

nurse A patient is receiving lactulose (Enulose) three times a day. The nurse knows that the patient is not constipated and is receiving this drug for which reason? A.) High ammonia levels due to liver failure B.) Prevention of constipation C.) Chronic renal failure D.). Chronic diarrhea

A.) High ammonia levels due to liver failure

Which aspects of healthcare are affected by a client's culture? Select all that apply. A.) How the client views healthcare B.) How the client views illness C. ) How the client will pay for healthcare services D. ) The types of treatments the client will accept E.) When the elient will seek healthcare services

A.) How the client views healthcare B.) How the client views illness D. ) The types of treatments the client will accept E.) When the elient will seek healthcare services

A patient will be taking bismuth subsalicylate (Pepto-Bismol) to control diarrhea. When reviewing the patient's other ordered medications, the nurse recognizes that which medication or medication class will interact significantly with the Pepto-Bismol? A.) Hypoglycemic drugs B.) Antibiotics C.) Acetaminophen (Tylenol) D.) Antidepressants

A.) Hypoglycemic drugs

A patient who has severe nausea and vomiting following a case of food poisoning comes to the urgent care center. When reviewing his medication history, the nurse notes that he has an allergy to procaine. The nurse would question an order for which antiemetic drug if ordered for this patient? A.) Metoclopramide (Reglan) B.) Promethazine (Phenergan) C.) Phosphorated carbohydrate solution (Emetrol) D.) Palonosetron (Aloxi)

A.) Metoclopramide (Reglan)

What do negligence and malpractice have in common? Select all that apply. A.) Negligence and malpractice are unintentional torts. B.) Negligence and malpractice are felonies. C.) Malpractice is the professional form of negligence. D.) Negligence and malpractice involve the intent to do harm to a patient. E.) Breach of duty must be present for negligence to occur

A.) Negligence and malpractice are unintentional torts. C.) Malpractice is the professional form of negligence.

Which term refers to the ethical questions that arise out of nursing practice? A.) Nursing ethies B.) Bioethics C.) Ethical dilemma D.) Moral distress

A.) Nursing ethies

What is rationale for wrapping petroleum gauze around a chest tube insertion ? A.) Prevents air from leaking around the size. B.) Prevents infection at the insertion site. C.) Absorbs drainage from the insertion site. D.) Protects the tube from becoming dislodged.

A.) Prevents air from leaking around the site.

A patient is receiving a tube feeding through gastrostomy. The nurse expects that which type of drug will be used to promote gastric emptying for this patient? A.) Prokinetic drugs, such as metoclopramide (Reglan) B.) . Serotonin blockers, such as ondansetron (Zofran) C.) Anticholinergic drugs, such as scopolamine (Transderm-Scop) D.) Neuroleptic drugs, such as chlorpromazine (Thorazine)

A.) Prokinetic drugs, such as metoclopramide (Reglan)

A patient is in an urgent care center with an acute asthma attack. The nurse expects that which medication will be used for initial treatment? A.) An anticholinergic such as ipratropium(Atrovent) B.) A short-acting betaz agonist such as albuterol (Proventil) C.) A long-acting beta, agonist such as salmeterol (Serevent) D.) A corticosteroid such as fluticasone (Flovent)

B.) A short-acting betaz agonist such as albuterol (Proventil)

The preceptor explains full-spectrum nursing to a new graduate nurse. What should the preceptor include when discussing patient situation? Select all that apply. A.) Refers to the context for care B. ) Includes the client's relationships C.) Addresses the resources for client care D. ) Ensures the same nurse provides care to the client E.) Focuses on the patient's environment outside the care setting

A.) Refers to the context for care B. ) Includes the client's relationships C.) Addresses the resources for client care E.) Focuses on the patient's environment outside the care setting

Which is an example of whistleblowing? Select all that apply. A.) Reporting fraudulent billing practices B.) Reporting patient's health status against the patient's wishes C.) Reporting unsafe work practices D ) Reporting a coworker for working under the influence of drugs E.) Reporting a hospital to The Joint Commission for substandard care

A.) Reporting fraudulent billing practices C.) Reporting unsafe work practices D.) Reporting a coworker for working under the influence of drugs

Which characteristic do the various definitions of critical thinking have in common? A.) Requires reasoned thought B.) Asks the questions "why?" or "how?" C.) ) Is a hierarchical process D.) Demands specialized thinking skills

A.) Requires reasoned thought

The nurse considers using a deontological theory for an ethical issue. What should the nurse have in anticipation of using this theory? A.) Rules B.) Beliefs C.) Values D.) Expenses

A.) Rules

A healthcare provider prescribes a one-time ASAP dose of intravenous morphine sulfate of 25 mg for a client with a terminal illness. Which law should the nurse consult prior to responding to this healthcare provider's prescription? A.) Safe Harbor B.) Good Samaritan C.) Americans With Disabilities Act (ADA) D.) Health Insurance Portability and Accountability Act (HIPAA)

A.) Safe Harbor

The nurse is preparing an educational session that focuses on the difference between professional and personal values. What should the nurse use as an example of a professional Select all that apply. A.) Service B.) Loyalty C.) Altruism D.) Beneficence E) Human dignity

A.) Service B.) Loyalty C.) Altruism E) Human dignity

A patient tells the nurse that she wants to start taking the herbal product goldenseal to improve her health. The nurse will assess for which potential cautions or contraindications to goldenseal? (Select all that apply.) A.) Taking a proton-pump inhibitor B.) Nasal congestion C.) Нурothyroidism D.) Hypertension E.) Sinus infections F.) . Pregnancy

A.) Taking a proton- pump inhibitor D.) Hypertension F.) . Pregnancy

The nurse identifies that a client is at risk for developing cardiovascular system problems. Which information did the nurse use to make this clinical determination? A.) Works as a computer operator B.) Stopped smoking decades ago C.) Drinks coffee without cream or sugar D.) Ingests fresh fruit and vegetables daily

A.) Works as a computer operator

When administering mineral oil, the nurse recognizes that it can interfere with the absorption of which substance? A.). Fat-soluble vitamins B.). Water-soluble vitamins C). Minerals D.) Electrolytes

A.). Fat-soluble vitamins

Which statement is accurate about nasotracheal suctioning? Select all that apply. A.)Apply suction for no longer than 10 to 15 seconds during a single pass. B.)Apply suction while inserting and removing the catheter. C.)Reapply oxygen between suctioning passe for ventilator patients. D)Gently rotate the suction catheter as you remove it. E.)Allow intervals of at least 30 seconds between suctioning.

A.)Apply suction for no longer than 10 to 15 seconds during a single pass. D.)Gently rotate the suction catheter as you remove it. E.)Allow intervals of at least 30 seconds between suctioning.

A patient diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE) inhibitor. When planning care, which outcome would be appropriate for the patient? A.)BP will be lower than 135/85 mm Hg on all occasions. B.) BP will be normal after 2 to 3 weeks on medication. C.) Patient will not experience dizziness on rising. D.) Urine output will increase to at least 50 mL/hr.

A.)BP will be lower than 135/85 mm Hg on all occasions.

A patient with COPD has a pulse oximetry reading of 97%. What other finding would indicate adequate tissue and organ oxygenation? Select all that apply. A.)Normal urine output B.)Strong peripheral pulses C.)Clear breath sounds bilaterally D.)Normal muscle strength E.)Orientation

A.)Normal urine output B.)Strong peripheral pulses D.)Normal muscle strength E.)Orientation

A client has a chest drainage system. What should the nurse include when teaching the client about this system? Select all that apply. A.)Perform frequent coughing and deep-breathing exercises. B.) Sit up in a chair but do not walk while the drainage system is in place. C.)Get out of bed without assistance as much as possible. D)Immediately notify the nurse if experiencing increased shortness of breath. E.)Make sure the collection device is above the level of the chest tube insertion site.

A.)Perform frequent coughing and deep-breathing exercises. D)Immediately notify the nurse if experiencing increased shortness of breath.

The nurse is caring for a patient who is experiencing dyspnea. Which position would be the most effective if incorporated into the patient's care? A.)Supine B.) Head of bed elevated 80 degrees C.) Head of bed elevated 30 degrees D.) Lying on left side

B.) Head of bed elevated 80 degrees

Which portion of the ear is responsible for maintaining equilibrium? A.) External ear B.) Inner ear C) Middle ear D) Ossicles

B) Inner Ear

Which assessment question helps assess immediate memory? A) "How did you get to the hospital today?" B) "Can you repeat the numbers 2, 7, 9 for me?" C) "Do you recall the three items I mentioned earlier?" D) "What was your birth date including the year?"

B) "Can you repeat the numbers 2, 7, 9 for me?"

A patient asks the nurse about the difference between diphenoxylate with atropine (Lomotil) and the over-the-counter drug loperamide (Imodium). Which response by the nurse is correct? A.) "Lomotil acts faster than Imodium." B) "Imodium does not cause physical dependence." C.) "Lomotil is available in suppository form." D.) "Imodium is a natural antidiarrheal drug."

B) "Imodium does not cause physical dependence

When should the nurse instruct a new mother to expect the anterior fontanel of her infant to fuse? A) At about 8 weeks B) At about 14 months C) By 6 months of age D) Before I year of age

B) At about 14 months

Which assessment should the nurse perform if a palpable thyroid gland is present? A.) Illuminate the thyroid gland for the presence of fluid. B) Auscultate the thyroid gland for bruits. C ) Percuss the thyroid gland for mass size. D.) Measure the thyroid gland to assess change.

B) Auscultate the thyroid gland for bruits.

Which abnormal laboratory value is associated with icteric sclerae? A) Bleeding time B) Bilirubin C) Hemoglobin D) Glucose

B) Bilirubin

The mother of a 4-year-old child with painful bruises and facial contusions explains that the mother's significant other pushed the child down the stairs in anger. What should the nurse do first? A) Notify the nursing supervisor of the suspected physical abuse. B) Complete a physical assessment of the child. C) Obtain an order for pain medication. D) Notify Child Protective Services of the suspected abuse.

B) Complete a physical assessment of the child.

When the nurse assesses the patient's tongue, she notes that it appears dry and An 85-year-old patient is brought to the emergency department with lethargy and furry. What does this finding indicate to the nurse? A) Fungal infection B) Dehydration C) Allergy D) Iron deficiency

B) Dehydration

The nurse manager suspects that a staff nurse is taking narcotics from the care area. If reported, of what will this staff nurse be accused? A) Libel B) Felony C) Battery D) Misdemeanor

B) Felony

A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. The nurse should have a critical attitude because it helps the manager to do which item? A) Consider all the possible advantages and disadvantages. B) Maintain an open mind about the proposed change, C) Apply the nursing process to the situation. D) Make a decision based on past experience with documentation.

B) Maintain an open mind about the proposed change,

Upon initial assessment, the nurse notes bruises and scratches on the arms, legs, and trunk an older client. With which state law is the nurse complying when the supervisor is notified regarding this patient as a potential victim of abuse? A) Good Samaritan Law B) Mandatory Reporting Law C) Nurse Practice Act D) Nursing Standards of Practice

B) Mandatory Reporting Law

Assuming that all are accurate, which documentation about a patient's level of consciousness is best? A) Patient is lethargic and slept when undisturbed. B) Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped. C) Patient slept throughout the day, missing his meals and bath. D) Patient appears to be tired as he slept throughout the day except when bathed.

B) Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped.

Which test should the patient undergo when the Weber test is positive? A) Romberg test B) Rinne test C) Pure tone audiometry D) Tympanometry

B) Rinne test

Which is an example of theoretical knowledge? A) A nurse uses sterile technique to catheterize a patient. B) Room air has an oxygen concentration of 21%. C) Glucose monitoring machines should be calibrated daily. D) An irregular apical heart rate should be compared with the radial pulse.

B) Room air has an oxygen concentration of 21%.

The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient is obese. The nurse has been overweight at one time and works very hard now to maintain a healthy weight. She immediately thinks, "I know I tend to feel negatively about obese people; I figure if I can stop eating, they should be able to. I must remember how very difficult that is and be very careful not to be judgmental of this patient." Which is the nurse illustrating? A) Theoretical knowledge B) Self-knowledge C) Using reliable resources D) Use of the nursing process

B) Self-knowledge

In which circumstance might the nurse defer obtaining informed consent for care and treatment of a patient? A) The patient is confused and cannot understand or sign the consent form. B) The patient is brought to the emergency department in cardiac arrest; no family is present. C) The surgeon requests that the patient be sent to the surgical suite before you get the consent form signed. D) An unconscious patient is admitted to your unit; he is alone.

B) The patient is brought to the emergency department in cardiac arrest; no family is present.

Which statement about the nursing process is correct? A.) It was developed from the ANA Standards of Care. B. ) It is a problem-solving method to guide nursing activities. C.) It is a linear process with separate, distinct steps. D. ) It involves care that only the nurse will give.

B. ) It is a problem-solving method to guide nursing activities.

The nurse maintains eye contact while a client explains the symptoms of a current health problem. Which critical-thinking skill is the nurse using? A.) Separating relevant from irrelevant data B. ) Listening carefully; reading thoughtfully C.) Organizing or grouping information in meaningful ways D.) Making inferences about the meaning of the information

B. ) Listening carefully; reading thoughtfully

The nurse is teaching a pregnant woman about the increased oxygen demand that develops during pregnancy. Which client statement indicates that teaching has been effective? A.) "I may need to drink more fluids in order to make more oхуen." B.) "I may need to take an iron supplement so that I am not anemic." C) "I will necd a multivitamin supplement for several months." D.) "I will need to cat more fruits and vegetables."

B.) "I may need to take an iron supplement so that I am not anemic."

The nurse is providing instructions to a patient who has a new prescription for a corticosteroid metered-dose inhaler. Which statement by the patient indicates that further instruction is needed? (Select all that apply.) A.) "I will rinse my mouth with water after using the inhaler and then spit out the water." B.) "I will gargle after using the inhaler and then swallow." C.) "I will clean the plastic inhaler casing weekly by removing the canister and then washing the casing in warm soapy water. I will then let it dry before reassembling." D.)"I will use this inhaler for asthma attacks. E.) "I will continue to use this inhaler, even if I am feeling better." F.) "I will use a peak flow meter to measure my response to therapy."

B.) "I will gargle after using the inhaler and then swallow." D.)"I will use this inhaler for asthma attacks.

A patient has been advised to add a nasal spray (an adrenergic decongestant) to treat a cold. The nurse will include which instruction? A.) "You won't see effects for at least 1 week." B.) "Limit use of this spray to 3 to 5 days." C.) "Continue the spray until nasal stuffiness has resolved." D. ) "Avoid use of this spray if a fever develops."

B.) "Limit use of this spray to 3 to 5 days."

A mother calls the pediatrician's office to report that her 18-month-old child has eaten half of a bottle of baby aspirin. She says, "I have a bottle of syrup of ipecac. Should I give it to him? He seems fine right now. What do I do?" What is the nurse's best response? A.) "Go ahead and give him the ipecac, and then call 911. B.) . "Don't give him the ipecac. Call the Poison Control number immediately for instructions." C. ) "Please come to the office right away so that we can check him." D. ) "Go ahead and take him to the emergency room right now."

B.) . "Don't give him the ipecac. Call the Poison Control number immediately for instructions."

The nurse is preparing to administer methylnaltrexone (Relistor), a peripherally acting opioid antagonist. This drug is appropriate for which patient? A.) A patient with diarrhea B.) A terminally ill patient who has opioid-induced constipation C.) A patient who is scheduled for a colonoscopy D.) A patient who will be having colon surgery in the morning

B.) A terminally ill patient who has opioid-induced constipation

The nurse manager documents that a staff nurse uses effective critical-thinking skills when planning and providing client care. What did the manager observe to make this decision? Select all that apply. A. ) Documents client responses to care B.) Addresses the most acute client care issues first C. ) Utilizes knowledge of past client care situations D. ) Articulates potential solutions to client problems E. ) Studies the pros and cons of individual interventions

B.) Addresses the most acute client care issues first C. ) Utilizes knowledge of past client care situations D. ) Articulates potential solutions to client problems E. ) Studies the pros and cons of individual interventions

A patient is on a chemotherapy regimen an outpatient clinic and is receiving a chemotherapy drug that is known to be highly emetogenic. The nurse will implement which interventions regarding the pharmacologic management of nausea and vomiting? (Select all that apply.) A.) Giving antinausea drugs at the beginning of the chemotherapy infusion B.) Administering antinausea drugs 30 to 60 minutes before chemotherapy is started C.) For best therapeutic effects, medicating for nausea once the symptoms begin D.) Observing carefully for the adverse effects of restlessness and anxiety E.) Instructing the patient that the antinausea drugs may cause extreme drowsiness F.) Instructing the patient to rise slowly from a sitting or lying position because of possible orthostatic hypotension

B.) Administering antinausea drugs 30 to 60 minutes before chemotherapy is started E.) Instructing the patient that the antinausea drugs may cause extreme drowsiness F.) Instructing the patient to rise slowly from a sitting or lying position because of possible orthostatic hypotension

The nurse is reviewing medications for the treatment of asthma. Which drugs are used for acute asthma attacks? (Select all that apply.) A.) Salmeterol (Serevent) inhaler B.) Albuterol (Proventil) nebulizer solution C.) Epinephrine D.) Montelukast (Singulair) E.). Fluticasone (Flovent) Rotadisk inhaler

B.) Albuterol (Proventil) nebulizer solution C.) Epinephrine

A client recovering from a respiratory infection is concerned about a new onset of diarrhea. What should the nurse assess in this client? A.) Last use of steroids B.) Amount of vitamin C ingested C.) Frequency of decongestant use D.) Use of over-the- counter antitussives

B.) Amount of vitamin C ingested

The nurse is reviewing the mechanism of action of antidiarrheal drugs. Which type of antidiarrheal medication works by decreasing the intestinal muscle tone and peristalsis of the intestines? A.). Adsorbents such as Pepto-Bismol B.) Anticholinergics such as belladonna alkaloids C.) Probiotics such as Lactinex D.) Lubricants such as mineral oil

B.) Anticholinergics such as belladonna alkaloids

Which nursing intervention reduces the risk of clot formation in the legs? Select all that apply. A.)Keep the patient's hips and knees flexed while the patient is in bed. B.) Apply compression devices (e.g., sequential compression devices [SCDS]). C.)Turn the patient frequently or encourage frequent position changes. D.) Promote adequate hydration by encouraging oral intake. E.) Elevate the patient's legs above the level of the heart.

B.) Apply compression devices (e.g., sequential compression devices [SCDS]). C.)Turn the patient frequently or encourage frequent position changes. D.) Promote adequate hydration by encouraging oral intake. E.) Elevate the patient's legs above the level of the heart.

After the ventilator is discontinued from a client with a cervical injury, the nurse stays with the client to provide support. Which moral principle is the nurse demonstrating? A.) Nonmaleficence B.) Autonomy C.) Beneficence D.) Fidelity

B.) Autonomy

Which medication would the nurse expect to be prescribed for a patient with heart failure? Select all that apply. A.) Nitrates B.) Beta-adrenergic agents C.) Diuretics D.) Anticoagulants E. ) Anticholesterol agents

B.) Beta-adrenergic agents C.) Diuretics

A patient asks the nurse about the uses of echinacea. Which use will the nurse include in the response? A.) Memory enhancement B.) Boosting the immune system C). Improving mood D.) Promoting relaxation

B.) Boosting the immune system

A patient wants to prevent problems with constipation and asks the nurse for advice about which type of laxative is safe to use for this purpose. Which class of laxative is considered safe to use on a long-term basis? A.) Emollient laxatives B.) Bulk-forming laxatives C.) . Hyperosmotic laxatives D.) Stimulant laxatives

B.) Bulk-forming laxatives

Chronic stress may lead directly to cardiovascular disease because of the repeated release of which chemical? A.) Histamine B.) Catecholamines C.) Cortisol D.) Protease

B.) Catecholamines

The nurse prepares material to teach a group of family members on cardiopulmonary resuscitation. Which information should the nurse emphasize in this teaching? A.) Give rescue breaths over 3 seconds. B.) Deliver 100 compressions a minute. C.) Support the head before calling for help. D.) Ensure rescue breathing occurs every 10 compressions.

B.) Deliver 100 compressions a minute.

A patient on chemotherapy is using ondansetron (Zofran) for treatment of nausea. The nurse will instruct the patient to watch for which adverse effect of this drug? A.) Dizziness B.) Diarrhea C.) Dry mouth D.) Blurred vision

B.) Diarrhea

A patient who has AIDS has lost weight and is easily fatigued because of his malnourished state. The nurse anticipates an order for which antinausea drug to stimulate his appetite? A.) Metoclopramide (Reglan), a prokinetic drug B.) Dronabinol (Marinol), a tetrahydrocannabinoid C.) Ondansetron (Zofran), a serotonin blocker. D.) Aprepitant (Emend), a substance P/NK1 receptor antagonist

B.) Dronabinol (Marinol), a tetrahydrocannabinoid

The nurse notes that a client's troponin level is elevated. What should this finding indicate to the nurse about the client? A.) Has a high risk for cardiovascular disease B.) Experienced a recent myocardial infarction C.) Had a myocardial infarction several months ago D.) Reduced amount of oxygen carrying capacity in the blood

B.) Experienced a recent myocardial infarction

for new graduate nurses. Which statement should the instructor emphasize being the key The staff development instructor prepares an in-service presentation on full-spectrum nursing point about this delivery approach? A.) It encourages collaboration when planning care. B.) It is a unique blend of thinking, doing, and caring. C.) It focuses on assessment as the cornerstone of care. D.) It relies on client responses to guide interventions.

B.) It is a unique blend of thinking, doing, and caring.

The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. The the evaluation phase of the nursing process, which would the nurse do first? nurse ensured the nursing assistive personnel changed the patient's position every 2 hours. A. ) Determine whether she has gathered enough assessment data. B.) Judge whether the interventions achieved the stated outcomes. C. ) Follow up to verify that care for the nursing diagnosis was given. D. ) Decide whether the nursing diagnosis was accurate for the patient's condition.

B.) Judge whether the interventions achieved the stated outcomes.

Which is true about a nursing code of ethics? A.) Legally binding B.) Not legally binding C.) Legally binding in some circumstances D.) Not admissible in court

B.) Not legally binding

The family of an alert, oriented, and competent client does not agree with the client's decision to have a do not resuscitate order and asks the healthcare team to ignore the decision. The nurse asks the hospital chaplain to come and help the family and the team understand each other's opposing views. Which step of the MORAL model does this illustrate? A.) M-Massage the dilemma B.) O- Outline the options C.) R - Resolve the dilemma D) L-Look back and evaluate

B.) O- Outline the options

A patient is taking a xanthine derivative disease. The nurse will monitor for which adverse effects associated with the use of xanthine as part of treatment for chronic obstructive pulmonary derivatives? A.) Diarrhea B.) Palpitations C.) Bradycardia D.) Drowsiness

B.) Palpitations

A client with pulmonary hypertension and right sided heart failure has conversational dyspnea and shortness of breath. What is the first action the nurse should take? A.) Review and implement the primary care provider's prescriptions for treatments. B.) Perform a quick physical examination of breathing, circulation, and oxygenation. C.) Gather a thorough medical history, including current symptoms, from the family. D.) Administer oxygen to the patient through a nasal cannula.

B.) Perform a quick physical examination of breathing, circulation, and oxygenation.

When using sterile technique to perform tracheostomy care of a new tracheostomy, which action is correct? A.) Apply sterile gloves B.) Place the patient in semi-Fowler's position, if possible. C.) Clean the stoma under the faceplate with hydrogen peroxide. D.) Cut a slit in sterile 4 x 4 gauze halfway through to make a dressing.

B.) Place the patient in semi-Fowler's position, if possible.

A client with a tracheostomy being mechanically ventilated has a pulse oximetry reading of 85% heart rate of 113 beats/min, and respiratory rate of 30 breaths/min. The client is restless, and crackles and rhonchi are auScultated over both lungs. Which action should the nurse take? A.) Call the respiratory therapist to check the ventilator settings. B.) Provide endotracheal suctioning. C.) Provide tracheostomy care D.) Notify the physician of the patient's signs of fluid overload.

B.) Provide endotracheal suctioning

Which part of the electrocardiogram (ECG) tracing represents ventricular repolarization? A.) P wave B.) QRS complex C.) ) T wave D.) U wave

B.) QRS complex

Which is the third step in the MORAL decision- making model? A.) Reassess the dilemma. B.) Resolve the dilemma. C.) Review the problem. D.)) Recall the history of the problem.

B.) Resolve the dilemma.

The nurse is experiencing moral distress over an ethical issue with a client. What should the nurse do to help reduce this distress? Select all that apply. A) Consider terminating employment. B.) Seek spiritual guidance and support. C.) Make a commitment to care for self. threatened. D.) Analyze personal values that are E.) View the situation from the other perspective.

B.) Seek spiritual guidance and support. C.) Make a commitment to care for self. threatened. D.) Analyze personal values that are E.) View the situation from the other perspective.

A patient is taking chemotherapy with a drug that has a high potential for causing nausea and vomiting. The nurse is preparing to administer an antiemetic drug. Which class of antiemetic drugs is most commonly used to prevent nausea and vomiting for patients receiving chemotherapy? A.) Prokinetic drugs, such as metoclopramide (Reglan) B.) Serotonin blockers, such as ondansetron (Zofran) C.) Anticholinergic drugs, such as scopolamine D.) Neuroleptic drugs, such as promethazine (Phenergan)

B.) Serotonin blockers, such as ondansetron (Zofran)

A client has a heart rate of 112 beats per minute. Which type of dysrhythmia should the nurse suspect this client is experiencing? A.) Brady B.) Tachy C.) Junctional D.) Supraventricular

B.) Tachy

A patient who has been newly diagnosed with vertigo will be taking an antihistamine antiemetic drug. The nurse will include which information when teaching the patient about this drug? A.) The patient may skip doses if the patient is feeling well. B.) The patient will need to avoid driving because of possible drowsiness. C.) The patient may experience occasional problems with taste. D.) It is safe to take the medication with a glass of wine the evening to help settle the stomach.

B.) The patient will need to avoid driving because of possible drowsiness.

What do critical thinking and the nursing process have in common? A.) They are both linear processes used to guide one's thinking. B.) They are both thinking methods used to solve a problem. C. ) They both use specific steps to solve a problem. D. ) They both use similar steps to solve a problem.

B.) They are both thinking methods used to solve a problem.

The nurse is reviewing the uses of oral laxatives. Which conditions are general contraindications to or cautions about the use of oral laxatives? (Select all that apply.) A.) Irritable bowel syndrome B.) Undiagnosed abdominal pain C. Nausea and vomiting D.) Fecal impaction E.) Ingestion of toxic substances F.) Acute surgical abdomen

B.) Undiagnosed abdominal pain C. Nausea and vomiting D.) Fecal impaction F.) Acute surgical abdomen

A patient has prescriptions for two inhalers. One inhaler is a bronchodilator, and the other is a corticosteroid. Which instruction regarding these inhalers will the nurse give to the patient? A.) "Take the corticosteroid inhaler first." B.)"Take the bronchodilator inhaler first." C."Take these two drugs at least 2 hours apart." D) . "It does not matter which inhaler you use first."

B.)"Take the bronchodilator inhaler first."

The nurse instructs the mother of a toddler on safety. What information about the toddler's developmental stage and factors that influence oxygenation should the nurse include? Select all that apply. A.)Frequent, serious respiratory infections B.)Airway obstruction from aspiration of small objects C.)Drowning in small amounts of water around the home D.)Development of asthma E.)Develop shortness of breath with extreme activity

B.)Airway obstruction from aspiration of small objects C.)Drowning in small amounts of water around the home

For which condition is obesity associated with a higher risk of conditions that affect the pulmonary and cardiovascular systems? Select all that apply. A.)Reduced alveolar- capillary gas exchange B.)Lower respiratory tract infections C.)Sleep apnea D.)Hypertension E.)Dyspnea on exertion

B.)Lower respiratory tract infections C.)Sleep apnea D.)Hypertension E.)Dyspnea on exertion

A patient sues the nurse for a fall that occurred because the bed's siderails were not in the upright position. The judgment is for the patient to receive $2 million; however, the nurse has an occurrence policy with double limit coverage of $3 million/$10 million that covered the time period when the incident occurred. What will the nurse's insurance pay to the patient? A) Nothing B) $4 million C) $2 million D) 75% of the $2 million

C) $2 million

A patient is taking linaclotide (Linzess) to treat irritable bowel syndrome (IBS). The nurse will monitor this patient for which adverse effect? A.) Chest pain B.) Chronic constipation C) Abdominal pain D.) Elevated blood glucose levels

C) Abdominal pain

The nurse manager receives a note from a staff member's healthcare provider outlining physical limitations at work. Which information should the manager review to ensure the employee's and organization's rights are not violated? A) Nursing scope of practice B) Policy and procedure manual C) Americans With Disabilities Act (ADA) D) Health Insurance Portability and Accountability Act (HIPAA)

C) Americans With Disabilities Act (ADA)

An adolescent in labor arrives at the hospital emergency department (ED) with her mother who states the family has no medical insurance or money to pay for the delivery. What is the first step that the ED staff should take? A.) Arrange for an ambulance to transport her to the nearest public hospital. B) Explain to the girl and her mother that the hospital only accepts patients who can pay the hospital bill. C) Examine her to determine whether her condition is stable or whether she requires immediate medical attention. D) Inform her mother that she will need to transport her daughter to the nearest public hospital.

C) Examine her to determine whether her condition is stable or whether she requires immediate medical attention.

Bronchovesicular breath sounds are best heard over which area? A) Midline over the trachea just below the larynx B) Fourth intercostal space, in the midclavicular line C) First and second intercostal spaces next to the sternum D) At the base of the lungs near the diaphragm

C) First and second intercostal spaces next to the sternum

A patient argues that a statement made in the medical record is incorrect and wants it corrected. Which regulation provides the patient with the right to have the documentation corrected? A) Americans With Disabilities Act (ADA) B) Patient Self-Determination Act (PSDA) C) Health Insurance Portability and Accountability Act (HIPAA) D) Health Care Quality Improvement Act (HCQIA)

C) Health Insurance Portability and Accountability Act (HIPAA)

A patient's jugular venous pressure measures 5 cm. What should this finding indicate to the nurse? A) A normal finding B) Hypovolemia C) Heart failure D) Dehydration

C) Heart failure

The mother of a school- age child is distressed because the child does not seem to "value" anything. What should the nurse recommend to this mother? A) Consider moralizing. B) Implement punishment. C) Model the desired behavior. D) Use a laissez- faire approach.

C) Model the desired behavior.

The charge nurse assigns the care of a patient receiving hemodialysis to a newly hired licensed practical nurse (LPN) who has no experience caring for hemodialysis patients. The LPN fails to inform the charge nurse of not having experience with this type of patient. What should the actions of the charge nurse be considered? A) Malpractice B) Incompetence C) Negligence D) Abandonment

C) Negligence

21. The nurse assesses a 4-vear-old child's vision as 20/40, What should the purse realize this finding indicates? A) Myopia B) Нуperopia C) Normal D) Presbyopia

C) Normal

The nurse notes a small pulsation at the fifth intercostal space midelavicular line. How should nurse document this finding? A) Thrill B) Murmur C) Normal finding D) Heave

C) Normal finding

The nurse receives a document from an attorney that states a former client is suing for injuries obtained when receiving care, What should the nurse do first? A) Call a lawyer. B) Contact the client. C) Notify the organization. D) Contact the insurance company.

C) Notify the organization.

A 48-year-old patient comes to the physician's office complaining of diminished near vision, which the nurse confirms with testing. How should the nurse document this finding? A) Myopia B) Diplopia C) Presbyopia D) Mydriasis

C) Presbyopia

The adult daughter of an older client with an inoperable brain tumor asks the nurse to tell her what is wrong with the client even though the client has specifically said that no one is to know the diagnosis. What should the nurse say to the adult daughter? A) The client has an inoperable brain tumor, but does not wish anyone to know. B) The daughter needs to speak to the physician in charge of the client's care. C) The client has requested that the case not be discussed with anyone, not even family. D.) The client is very sick with a serious case of pneumonia that could lead to death.

C) The client has requested that the case not be discussed with anyone, not even family.

A patient asks the nurse to explain an advance directive. What should the nurse explain about this document? Select all that apply. A) If the patient is unable to communicate, the family may make changes to the advance directive. B) Once an advance directive is signed, no further care will be provided. C) The patient may change the advance directive by telling the physician or by making changes in writing. D) An advance directive will ensure the patient gets as much or as little desired. E) An advance directive is overruled by the healthcare provider's prescriptions

C) The patient may change the advance directive by telling the physician or by making changes in writing. D) An advance directive will ensure the patient gets as much or as little desired.

The nurse prepares information to document a client's care. What should the nurse do to ensure that the documentation is complete? A) Review the medical record for new prescriptions. B) Ask nursing assistive personnel for report on delegated tasks. C) Use the mnemonic F-A-C-T-U-A-L as a reminder when charting. D) Complete all documentation immediately before hand-off communication.

C) Use the mnemonic F-A-C-T-U-A-L as a reminder when charting.

Which is an example of self-knowledge if thought or stated by the nurse? A.) "I know that I should take the client's apical pulse for1 minute before giving digoxin." B.) "I know that I should follow the client's wishes even though it is not what I would want." C.) "I know that I have religious beliefs that may make it difficult to take care of some clients." D.) "I know that I need to honor the client's request not to discuss his health concern with the family."

C.) "I know that I have religious beliefs that may make it difficult to take care of some clients."

a scopolamine transdermal patch (Transderm-Scop). The nurse provides teaching for the use of A patient with motion sickness is planning a cross-country car trip and has a new prescription for this patch medication. The patient shows a correct understanding of the teaching with which statement? A.) "I will change the patch every day." B.) "I will change the patch every other day." C.) "I will change the patch every 3 days." D.) "I will remove the patch only if it stops working."

C.) "I will change the patch every 3 days."

A 62-year-old man with emphysema does not understand the need to stop smoking at this age because lung problems already exist. Which would be the best response to his statement? A.) "You should quit so your family does not get sick from expOsure to secondhand smoke." B.) "You will need to use oxygen, but remember it Is is a a fire hazard to smoke with oxygen in your home." C.) "Once you stop smoking, your body will begin to repair some of the e damage to your lungs." D.) You should ask your primary care provider for a prescription for a nicotine path to help you quit."

C.) "Once you stop smoking, your body will begin to repair some of the damage to your lungs."

A woman who is in the first trimester of pregnancy has been experiencing severe morning sickness. She asks, "I've heard that ginger tablets may be a natural way to ease the nausea and vomiting. Is it okay to try them?" What is the nurse's best response? A.) "They are a safe and natural remedy for nausea when you are pregnant. B.) "Go ahead and try them, but stop taking them once the nausea is relieved." C.) "Some health care providers do not recommend ginger during pregnancy. Let's check with your provider." D.) . "You will need to wait until after the first trimester to try them."

C.) "Some health care providers do not recommend ginger during pregnancy. Let's check with your provider."

When teaching a patient who will be receiving antihistamines, the nurse will include which instructions? (Select all that apply.) A.) "Antihistamines are generally safe to take with over-the-counter medications." B.) "Take the medication on an empty stomach to maximize absorption of the drug." C.) "Take the medication with food to minimize gastrointestinal distress." D.) "Drink extra fluids if possible." E.) "Antihistamines may cause restlessness and disturbed sleep. F.. "Avoid activities that require alertness until you know how adverse effects are tolerated."

C.) "Take the medication with food to minimize gastrointestinal distress." D.) "Drink extra fluids if possible. F.. "Avoid activities that require alertness until you know how adverse effects are tolerated."

A laxative has been ordered for a patient. The nurse checks the patient's medical history and would be concerned if which condition is present? A.) High ammonia levels due to liver failure B.) Diverticulosis C.) . Abdominal pain of unknown origin D.). Chronic constipation

C.) . Abdominal pain of unknown origin

The nurse is preparing to assess a client's cardiovascular system. Which technique should be used when assessing the carotid arteries? A.) Perform capillary refill B.) Palpate for lifts and heaves C.) Auscultate each side for hums D.) Assess skin color and temperature

C.) Auscultate each side for hums

The ethics committee is consulted because an older client asked for a do not resuscitate order; however, the family does not agree. Which model will the ethics committee most likely use in this spatient's case? A.) Social justice B.) Patient benefit C.) Autonomy D.) DNAR determination

C.) Autonomy

A client is prescribed continuous cardiac monitoring. Which action should the nurse take to ensure an accurate electrocardiogram tracing? A.) Select electrode placement sites over bony prominences. B.) Apply the electrodes immediately after cleansing the skin, before the alcohol evaporates. C.) Before applying the electrodes, rub the placement sites with gauze until the skin reddens. D.) Ensure that the gel on the back of the electrodes is dry.

C.) Before applying the electrodes, rub the placement sites with gauze until the skin reddens.

Which information provides the most reliable data about the effectiveness of airway suctioning? A.) The amount, color, consistency, and odor of secretions B.) The patient's tolerance for the procedure. C.) Breath sounds, vital signs, and pulse oximetry before and after suctioning D.) The number of suctioning passes required to clear secretions.

C.) Breath sounds, vital signs, and pulse oximetry before and after suctioning.

During a routine checkup, a patient states that she is unable to take the prescribed antihistamine because of one of its most common adverse effects. The nurse suspects that which adverse effect has been bothering this patient? A.) Constipation B.) Abdominal cramps C.) Drowsiness D.) Decreased libido

C.) Drowsiness

The nurse administers an antitussive/expectorant Cough preparation to a patient with bronchitis. Which response indicates to the nurse that the medication is effective? A.) The amount of sputum decreases with each dose administered. B.) Cough is completely suppressed, and the patient is able to sleep through the night. C.) Dry, unproductive cough is reduced, but voluntary coughing is more productive. D.) Involuntary coughing produces large amounts of thick yellow sputum.

C.) Dry, unproductive cough is reduced, but voluntary coughing is more productive.

The nurse applies bilateral wrist restraints to a client threatening to leave the hospital against medical advice. What is the nurse's action considered? A.) Assault and battery B) Felony C.) False Imprisonment D) Quasi-intentional tort

C.) False Imprisonment

When giving dextromethorphan, the nurse understands that this drug suppresses the cough reflex by which mechanism of action? A.) Causing depression of the central nervous system B.) Anesthetizing the stretch receptors C.) Having direct action on the cough center D.) Decreasing the viscosity of the bronchial secretions

C.) Having direct action on the cough center

A client receives treatment for heart failure. Which information in the client's health history contributed the development of this health problem? A.) Plays golf twice a week B.) Works as a home contractor C.) Ingests a six pack of beer a day D.) Coaches Little League in the summer

C.) Ingests a six pack of beer a day

A patient has been treated with alosetron (Lotronex) for severe for 2 weeks. She calls the clinic and tells the nurse that she has been irritable bowel syndrome (IBS) experiencing constipation for 3 days. The nurse will take which action? A.) Advise the patient to increase intake of fluids and fiber. B.) Advise the patient hold the drug for 2 days. C.) Instruct the patient to stop taking the drug and to come to the clinic right away to be evaluated. D.) Instruct the patient to continue the alosetron and to take milk of magnesia for the constipation.

C.) Instruct the patient to stop taking the drug and to come to the clinic right away to be evaluated.

The prescriber has changed the patient's medication regimen to include the leukotriene receptor antagonist (LTRA) montelukast (Singulair) to treat asthma. The nurse will emphasize which point about this medication? A.) The proper technique for inhalation must be followed. B.) The patient needs to keep it close by at all times to treat acute asthma attacks. C.) It needs to be taken every day on a continuous schedule, even if symptoms improve. D.) When the asthma symptoms improve, the dosage schedule can be tapered and eventually discontinued.

C.) It needs to be taken every day on a continuous schedule, even if symptoms improve.

A patient has just had a chest tube inserted to dry-seal suction drainage. Which is a correct nursing intervention for maintenance? A.) Keep the head of the bed flat for 6 hours. B) Immobilize the patient's arm on the affected site. C.) Keep the drainage system lower than the insertion site. D.) Drain condensation into the humidifier when collects in the tubing.

C.) Keep the drainage system lower than the insertion site.

A gardener needs a decongestant because of seasonal allergy problems and asks the nurse whether he should take an oral form or a nasal spray. Which of these is a benefit of orally administered decongestants? A.) Immediate onset B.) A more potent effect C.) Lack of rebound congestion D.) Shorter duration

C.) Lack of rebound congestion

The nurse is giving oral mineral oil as an ordered laxative dose. The nurse will take measures to prevent which potential problem that may occur with mineral oil? A.) Fecal impaction B.) Electrolyte imbalances C.) Lipid pneumonia D.) Esophageal blockage

C.) Lipid pneumonia

While recovering from surgery, a 74-year-old woman started taking a stimulant laxative, senna (Senokot), to relieve constipation caused by the pain medications. Two weeks later, at her follow-up appointment, she tells the nurse that she likes how "regular" her bowel movements are now that she is taking the laxative. Which teaching principle is appropriate for this patient? A.) She needs to be sure to take this medication with plenty of fluids. B.) It is important to have a daily bowel movement to promote bowel health. C.) Long-term use of laxatives often results in decreased bowel tone and may i I to dependency. D.) She needs to switch to glycerin suppositories to continue having daily bowel movements.

C.) Long-term use of laxatives often results in decreased bowel tone and may i I to dependency.

A patient is severely constipated and needs immediate relief. The nurse knows that which class of laxative will provide the most rapid results? A.) Bulk-forming laxative, such as psyllium (Metamucil) D.ORG B.) Stool softener, such as docusate salts (Colace) C.) Magnesium hydroxide (MOM) D. ) Magnesium oxide tablets

C.) Magnesium hydroxide (MOM)

The nurse prepares material about blood pressure control for a group of community members. What should the nurse include about baroreceptors? A.) Respond to levels of oxygen in the blood B.) Activate the sympathetic nervous system C.) Maintain blood pressure with body position changes D.) Increase respiration based upon carbon dioxide levels

C.) Maintain blood pressure with body position changes

During an assessment of a newly admitted client the nurse measures blood pressure, abdominal circumference, and pulse rate. Which critical-thinking skill is the nurse using? A.) Recognizing gaps in one's own knowledge B.) Recognizing the need for more information C.) Objectively gathering information on a problem or issue D. ) Evaluating the credibility and usefulness of sources of information

C.) Objectively gathering information on a problem or issue

When evaluating a patient's use of a metered-dose inhaler (MDI), the nurse notes that the patient is unable to coordinate the activation of the inhaler with her breathing. What intervention is most appropriate at this time? A.) Notify the doctor that the patient is unable to use the MDI. B.) Obtain an order for a peak flow meter. C.) Obtain an order for a spacer device. D.) Ask the prescriber if the medication can be given orally.

C.) Obtain an order for a spacer device.

A patient with a treatable form of breast cancer has decided not to pursue radiation or chemotherapy; however, the nurse coerces the patient into accepting the treatment by reminding her about her responsibilities with her children. What type of behavior has the nurse displayed? A.) Nonmaleficence B.) Autonomy C.) Paternalism D) Beneficence

C.) Paternalism

Chest percussion and postural drainage would be an appropriate intervention for which condition? A.) Congestive heart failure. B.) Pulmonary edema C.) Pneumonia D.) Pulmonary Embolus

C.) Pneumonia

The staff development trainer considers using a feminist theory to explain the resolution of an ethical dilemma. What will the trainer use when implementing this theory? A.) Rules B.) Principles C.) Relationships D.)) Risk-benefit analysis

C.) Relationships

The nurse is assigned to care for a client with Guillain-Barré syndrome; however, the nurse does not understand the disorder. What is the best way for the nurse to address this gap in knowledge? A. ) Talk with the family. B. ) Complete the client assessment. C.) Research and read about the disorder. D. ) Ask another nurse to explain the disorder.

C.) Research and read about the disorder.

The nurse is assigned to care for a client with Guillain-Barré syndrome; however, the nurse does not understand the disorder. What is the best way for the nurse to address this gap in knowledge? A.) Talk with the family. B.) Complete the client assessment. C.) Research and read about the disorder. D.) Ask another nurse to explain the disorder.

C.) Research and read about the disorder.

The family of an alert, oriented, and competent client does not agree with the client's decision to have a do not resuscitate order and asks the healthcare team to ignore the decision. The healthcare team follows the client's wishes and the family takes the matter to court. The court sides with the family and the order has to be removed, What occurred in this situation? A.) An integrity- producing (good) compromise B.) An ethically sound compromise C.) Settlement of an issue by force D.) An effort to keep peace on the unit

C.) Settlement of an issue by force

When administering a bulk-forming laxative, the nurse instructs the patient to drink the medication mixed in a full 8-ounce glass of water. Which statement best explains the rationale for this instruction? A.) The water acts to stimulate bowel movements. B.) The water will help to reduce the bulk of the intestinal contents.. C.) These laxatives may cause esophageal obstruction if taken with insufficient water. D.) The water acts as a lubricant to produce bowel movements.

C.) These laxatives may cause esophageal obstruction if taken with insufficient water.

A conscious and competent client who is ventilator dependent wants to be removed from the ventilator even though the nurse believes the client is committing suicide. What is the nurse demonstrating when standing at the bedside holding the client's hand? A) Value set B.) Value system C.) Value neutrality D.) Value awareness

C.) Value neutrality

A patient will be taking bismuth subsalicylate (Pepto-Bismol) to control diarrhea. When reviewing the patient's other ordered medications, the nurse recognizes that which medication will interact significantly with the Pepto-Bismol? A.) Acetaminophen (Tylenol), an analgesic B.) Levothyroxine (Synthroid), a thyroid replacement drug C.) Warfarin (Coumadin), an anticoagulant D.) Fluoxetine (Prozac), an antidepressant

C.) Warfarin (Coumadin), an anticoagulant

Which is an example of practical knowledge? A.) The tricuspid valve is between the right atrium and ventricle of the heart. B.) The pancreas does not produce enough insulin in type 1 diabetes. C.) When assessing the abdomen, you should auscultate before palpating. D.) Research shows pain medication given intravenously acts faster than by other routes.

C.) When assessing the abdomen, you should auscultate before palpating.

The nurse is monitoring drug levels for a patient who is receiving theophylline. The most recent theophylline level was 22 mcg/mL, and the nurse evaluates this level to be: A.) below the therapeutic level. B.) at a therapeutic level. C.) above the therapeutic level. D.) at a toxic level.

C.) above the therapeutic level.

A client in labor after 32 weeks' gestation is eager to deliver. Which client statement indicates that teaching provided about fetal development was effective ? A.) "The baby's lung are well developed now, but he will be at increased risk for SIDS if I deliver early." B.) "We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early." C.) "If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening." D.)"Thanks for reassuring me; I was pretty sure there isn't much risk to the baby this far along in my pregnancy."

C.)"If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening."

Which intervention is likely to reduce the risk of postoperative atelectasis? Select all that aply. A.)Administer bronchodilators. B.)Apply low- flow oxygen. C.)Encourage coughing and deep breathing and Coughing. D.)Administer pain medication. E.)Assist to move and reposition in bed.

C.)Encourage coughing and deep breathing and coughing. D.)Administer pain medication. E.)Assist to move and reposition in bed.

The nurse manager learns of a staff nurse's behavior with a client. Which information suggests that nurse has committed a boundary violation? A) Mentioned that a client's birthday was coming up B) Observed talking with a client's spouse in the hallway C) Asked the healthcare provider to change a client's pain medication D) Switched an assignment so that the nurse can take care of the client

D) Switched an assignment so that the nurse can take care of the client

How should the nurse document high-pitehed breath sounds produced by narrowed airways? A) Rales B) Crackles C) Rhonchi D) Wheezing

D) Wheezing

A client asks why a pulse oximeter reading is being done when experiencing a problem with the heart. What should the nurse respond to this client? A. ) "You might not have a heart problem." B.) "I'm just checking it as a routine part of vital signs." C. ) "Heart problems are caused by breathing problems" D. ) "The heart and lungs work together to provide oxygenation." circulation

D. ) "The heart and lungs work together to provide oxygenation." circulation

A client asks why aspirin has been prescribed even though pain is not being experienced. What should the nurse respond to this client? A) "It dilates blood vessels." B ) "It dissolves clots in the body." C) "It keeps blood pressure within normal range." D) "It stops the mechanism that makes blood clots."

D) "It stops the mechanism that makes blood clots."

When testing near vision, the nurse should position printed text how many inches away from the patient? A) 20 B) 18 C) 16 D) 14

D) 14

The nurse reviews an entry in a medical record before clicking the SAVE button, When performing this review, the nurse analyzes the content for completeness, clarity, accuracy, comprehensiveness, and which other criterion? A) Concise B) Category C) Character D) Chronological

D) Chronological

While palpating the anterior chest, the nurse notes crackling in the skin around the patient's chest tube insertion site. What should the nurse realize this finding indicates? A) Tactile fremitus B) Egophony C) Bronchophony D) Crepitus

D) Crepitus

The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. What should this fin ding indicate about the client's pulses? A) Bounding B) Normal C) Full D) Diminished

D) Diminished

Which law does a hospital use to determine if a patient with no healthcare coverage who secking medical care should receive care or be transferred to another facility? A) Health Care Quality Improvement Act (HCQIA) B) Patient Self-Determination Act (PSDA) C) Newborns" and Mothers" Health Protection Act (NMHPA) D) Emergency Medical Treatment and Active Labor Act (EMTALA)

D) Emergency Medical Treatment and Active Labor Act (EMTALA)

An adult admitted to the hospital after a stroke does not respond to verbal stimuli. What should the nurse do next to try to provoke a response? A) Apply pressure to the mandible at the jaw. B) Rub the patient's sternum. C) Squeeze the trapezius muscle. D) Gently shake the patient's shoulder.

D) Gently shake the patient's shoulder.

A client's pulse oximetry reading is 90%. What action should the nurse take first? A.)Raise the head of the bed. B.)Prepare to administer oxygen. C.)Notify the healthcare provider. D.)Move the sensor to another area.

D) Move the sensor to another area.

The nurse prepares information for a newly admitted client. What should the nurse review to ensure that the client's rights are protected? A) HIPAA laws B) Policy manual C) Advance directives D) Patient Care Partnership

D) Patient Care Partnership

What do nursing codes of ethics support? A) Patients can receive emergency treatment regardless of their ability to pay. B) Nurses will educate patients about advance directives. C) Nurses with HIV must disclose their condition to their employer. D) Patients have the right to dignity, privacy, and safety.

D) Patients have the right to dignity, privacy, and safety

The nurse receives a copy of a client's advance directive. What should the nurse do with this document? A) Return it to the client. B) Give it to the nursing supervisor. C) Hand it to the healthcare provider. D) Place it on the client's medical record.

D) Place it on the client's medical record.

The nurse will instruct patients about a passible systemic effect that may occur if excessive amounts of topically applied adrenergic nasal decongestants are used. Which systemic effect may occur? A.) Heartburn B.) Bradycardia C.) Drowsiness D.) Palpitations

D.) Palpitations

Which is an abnormal capillary refill finding that the nurse should report ? A.) 1 second B.) 2 seconds C.) 3 seconds D.) 4 seconds

D.) 4 seconds

Which differentiates a nursing diagnosis from a medical diagnosis? A.) Terminology for the client's disease or injury B. ) A part of the client's medical diagnosis C. ) The client's presenting signs and symptoms D.) A client's response to a health problem

D.) A client's response to a health problem

A new graduate asks the manager to explain the purpose of full-spectrum nursing. How should the manager respond? A.) Provide care in the most cost-effective manner possible. B.) Minimize the use of overtime when providing client care. C.) Adhere to federal and state regulations when providing care. D.) Achieve safe, effective care and promote good patient outcomes.

D.) Achieve safe, effective care and promote good patient outcomes.

The nurse is reviewing new postoperative orders and notes that the order reads, "Give hydroxyzine (Vistaril) 50 mg IV PRN nausea or vomiting." The patient is complaining of slight nausea, Which action by the nurse is correct at this time? A.) . Hold the dose until the patient complains of severe nausea. B.) . Give the dose orally instead of intravenously. C.) Give the patient the IV dose of hydroxyzine as ordered. D.) Call the prescriber to question the route that is ordered.

D.) Call the prescriber to question the route that is ordered.

Which blood level normally provided the primary stimulus for breathing? A.)PH B.) Oxygen C.) Bicarbonate D.) Carbon dioxide

D.) Carbon dioxide

A client with a closed head injury has a respiratory pattern that progressively increases and then decreases in depth, followed by a period of apnea. What this client's breathing pattern? A.) Biot's breathing B.) Kussmaul's respirations C.) Sleep apnea D.) Cheyne-Strokes respirations

D.) Cheyne-Stokes repirations

A client has lower extremity edema. Which intervention should the nurse implement to help with this client's venous return? A.) Increase the amount of daily exercise. B.) Wear well-fitting shoes with dry socks. C.) Adhere to prescribed medication regimen. D.) Elevate the legs above the level of the heart,

D.) Elevate the legs above the level of the heart,

A client asks the nurse to explain laboratory results; however, the nurse needs to assist another client first. A short while later, the nurse returns to discuss the laboratory results. Which more principle did the nurse demonstrate? A.) Nonmaleficence B.) Autonomy C.) Beneficence D.) Fidelity

D.) Fidelity

A patient is taking intravenous aminophylline for a severe exacerbation of chronic obstructive pulmonary disease. The nurse will assess for which therapeutic response? A.) Increased sputum production B.) Increased heart rate C.) Increased respiratory D.) Increased ease of breathing

D.) Increased ease of breathing

The nurse is providing instructions about the Advair inhaler (fluticasone propionate salmeterol), Which statement about this inhaler is accurate? A.) It is indicated for the treatment of acute bronchospasms. B.) It needs to be used with a spacer for best results. C.) Patients need to avoid drinking water for I hour after taking this drug. D.) It is used for the prevention of bronchospasms.

D.) It is used for the prevention of bronchospasms.

While assessing an older adult patient, the nurse notes clubbing of the fingers. What does this finding indicate to the nurse? A) Fungal infection B) Malnutrition C) Iron deficiency D) Long-term hypoxia

D.) Long-term hypoxia

The nurse administering pain medication every 4 hours is an example of which aspect of patient care? A.) Assessment data B.) Nursing diagnosis C.) Patient outcome D.) Nursing intervention

D.) Nursing intervention

When educating a patient recently placed on inhaled corticosteroids, the nurse will discuss which potential adverse effects? A.) Fatigue and depression B.) Anxiety and palpitations C.) Headache and rapid heart rate D.) Oral candidiasis and dry mouth

D.) Oral candidiasis and dry mouth

While a patient is receiving hygiene care, the chest tube becomes disconnected from the water-seal chest drainage system (CDU). Which action should the nurse take immediately? A.)Clamp the chest tube close to the insertion site. B.) Set up a new drainage system and connect it to the chest tube. C.) Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU. D.) Place the disconnected end nearest the patient into a bottle of sterile water.

D.) Place the disconnected end nearest the patient into a bottle of sterile water.

A patient is about to undergo a diagnostic bowel procedure. The nurse expects which drug to be used to induce total cleansing of the bowel? A.) Docusate sodium (Colace) B.) Lactulose (Enulose) C.) Mineral oil D.) Polyethylene glycol 3350 (GOLYTELY)

D.) Polyethylene glycol 3350 (GOLYTELY)

A patient who has been on antibiotic therapy for 2 weeks has developed persistent diarrhea. The nurse expects which medication class to be ordered to treat this diarrhea? A.) Lubricants B.) Adsorbents C.) Anticholinergics D.) Probiotics

D.) Probiotics

The nurse administers intravenous morphine sulfate to a patient for pain control. For which adverse effect should the nurse monitor this patient ? A.) Decreased heart rate B.) Muscle weakness C.) Decreased urine output D.) Respiratory depression

D.) Respiratory depression

A client has a nursing diagnosis of Ineffective Breathing Pattern identified on the care plan, What should the nurse expect when assessing this client? A.) O Coughing B.) Cold extremities C.) Adventitious breath sounds D.) Respiratory rate of 8 breaths/min

D.) Respiratory rate of 8 breaths/min

The nurse plans to use utilitarianism to address an ethical problem. What analysis will the nurse need to complete when using this framework? A.) Cost B.) SWOT C.) Root cause D.) Risk-benefit

D.) Risk-benefit

The nurse attends an ethics committee to discuss an issue with a client. What should the nurse keep in mind when advocating for the client? A.) Expect confrontation. B.) Prepare for a power struggle. C.) State personal feelings clearly. D.) Support the client's autonomy

D.) Support the client's autonomy

Which skin assessment finding would cause the nurse to suspect dehydration in a middle- aged patient admitted to the hospital with traveler's diarrhea ? A.) Edema B.) Hyperhidrosis C.) Pallor D.) Tenting

D.) Tenting

Which term is defined as a belief about the worth of something that serves as a principle or a standard that influences decision making? A.) Morals B.) Attitudes C.) Beliefs D.) Values

D.) Values

A patient with chronic obstructive pulmonary disease (COPD) is prescribed 02 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient? A.) Nonrebreather mask B.) Nasal cannula C.) Partial rebreather mask D.) Venturi Mask

D.) Venturi Mask