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NURS 200 Final Exam Chap 11 Question 1 The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process? 1. Deliver care to a client ...

NURS 200 Final Exam Chap 11 Question 1 The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process? 1. Deliver care to a client in an organized way. 2. Implement a plan that is close to the medical model. 3. Identify client needs and deliver care to meet those needs. 4. Make sure that standardized care is available to clients. Question 2 While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Question 3 During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says leave me alone. Which subjective data should the nurse document? 1. Restlessness 2. Leave me alone 3. Not talkative 4. Pale and diaphoretic Question 4 Family of a client demonstrating confusion state that this is not the clients usual behavior. How should the nurse document this data? 1. Inference 2. Subjective data 3. Objective data 4. Secondary subjective data Question 5 The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the clients pain. Which phase of the nursing process is this nurse implementing? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Question 6 A new client has been admitted to the care area. How soon should the nurse plan to complete a physical assessment on this patient? 1. 1 hour 2. 12 hours 3. 48 hours 4. 24 hours Question 7 The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse use as the best source of data for this client? 1. Medical record from the childbirth 2. Grandmother 3. Parents 4. Admitting physician Question 8 A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse respond to this client? 1. In order to make sure all of your information is complete, I need to ask these questions. 2. Youre right. Let me know if theres anything you need right now. 3. Ill be done shortly, just give me a few more minutes. 4. You shouldnt be upset. Were only doing our jobs. Question 9 The nurse documents: Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse. Which method of data collection does this documentation demonstrate? 1. Examining 2. Interviewing 3. Listening 4. Observing Question 10 A nurse has worked in the trauma critical care area for several years. Which noise may become indiscriminate for this particular nurse? 1. A client with audible breathing 2. Moaning of a client in pain 3. Whirring of ventilators 4. Co-orkers discussing their clients conditions Question 11 A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least priority). Standard Text: Click and drag the options below to move them up or down. Choice 1. The family is at the bedside. Choice 2. The IV pump is running on battery. Choice 3. The ECG monitor shows tachycardia. Choice 4. The client reports being restless. Choice 5. O2 tubing is not attached to wall regulator. , 4, 5, 2, 1 Question 12 During an initial interview, the client says I dont understand why I have to have surgery; Im really not that sick or in pain right now. How should the nurse respond to the client? 1. Its OK to be worried. Surgery is a big step. 2. What kind of questions do you have about your surgery? 3. I think these are things you should be asking your doctor. 4. Have you had surgery before? Question 13 The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse use? 1. How would you describe your sleep pattern? 2. Can you describe your coughing pattern? 3. Is there anything that makes your breathing worse? 4. What medications are you on? Question 14 The nurse is assessing a client level of pain. Which open-ended question should the nurse use for this situation? 1. Is your pain worse at night? 2. What brought you to the clinic? 3. How has the pain impacted your life? 4. Youre feeling down about having pain, arent you? Question 15 A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, what should the nurse do? 1. Sit next to the client, a few feet apart. 2. Sit behind a desk. 3. Stand at the side of the clients chair. 4. Stand at the counter to take notes during the interview. Question 16 A client in the emergency department has a non-lifethreatening wound. The unit is busy with other clients, families, and people in the waiting room. How should the nurse conduct an interview with this client? 1. Have the client wait until the department quiets down, as the wound is not too serious. 2. Tell the client to wait in the waiting room and fill out the paperwork. 3. Draw curtains around the client and nurse to provide as much privacy as possible. 4. Make sure the clients back is to the rest of the room so as not to be heard by passersby. Question 17 A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this clients interview? 1. As soon as the client gets to the floor 2. After the client has settled in and been oriented to the room 3. When the family is available to help 4. After the client has been medicated Question 18 A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication with this client? 1. Have a member of the housekeeping staff who speaks the same language translate. 2. Use the translation services supplied by the hospital. 3. Make sure a family member who does speak English is available. 4. Conduct the interview using hand gestures. Question 19 The nurse is greeting a newly admitted client. What statement should the nurse make to establish rapport with this client? 1. Hello, Im your nurse and Ill be taking care of you today. 2. Youre luckythere are no students on the unit today. 3. Good morning, is there anything you need right now? 4. Hi. If you need anything, put on your call light. Question 20 The nurse has just completed an admission interview with a new client. Which nursing statement indicates that the interview is in the closing phase? 1. Im going to set up your physical assessment now. Do you have any questions? 2. Tell me more about how you feel. 3. Could you give examples of what types of other treatments youve had? 4. Is there anything youre worried about? Question 21 During an assessment interview, the client states that an elective surgical procedure will not be done because it does not fit into the clients life goals. Into which of Gordons functional health patterns should the nurse identify this clients comment? 1. Cognitive/perceptual pattern 2. Coping/stress-tolerance pattern 3. Health-perception/health-management pattern 4. Value/belief pattern Question 22 The nurse suspects that a client with a history of injuries is a victim of abuse. What did the nurse use to come to this conclusion? 1. Observation of cues 2. Validation 3. Inference 4. Judgment Question 23 The nurse is reviewing the nursing process with a first-year nursing student. What should the nurse explain as being the purpose of the diagnosis phase? Standard Text: Select all that apply. 1. Develop a list of problems. 2. Identify client strengths. 3. Develop a plan. 4. Specify goals and outcomes. 5. Identify problems that can be prevented. Question 24 The nurse decides to seek wound care alternatives for a clients stasis ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning? 1. Diagnosis 2. Implementation 3. Evaluation 4. Assessment Question 25 While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time? 1. Initial assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed assessment Question 26 Unlicensed assistive personnel measure a newly admitted clients vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data? 1. Retake the vital signs. 2. Call the physician. 3. Continue with the physical assessment as soon as possible. 4. Report the findings to the charge nurse. Question 27 A nurse is performing an initial assessment on a new admission. What information should the nurse consider as being a part of the database? Standard Text: Select all that apply. 1. Reports from physical therapy the client received as an outpatient 2. Documentation of the nurses physical assessment 3. Physicians orders 4. A list of current medications 5. Information about the clients cultural preferences 6. Discharge instructions Question 28 The nurse is conducting an interview with a new client. Which actions indicate that the nurse is implementing effective communication guidelines? Standard Text: Select all that apply. 1. Looking directly at the client to ensure good eye contact 2. Managing the conversation to avoid periods of silence 3. Providing personal experiences to help the client focus 4. Sitting in a chair next to the client who is in bed 5. Keeping arms unfolded and in a relaxed position Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process? 1.Identifying major problems or needs 2.Organizing data in the client’s family history 3.Establishing short-term and long-term goals 4.Administering an antibiotic Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care? 1.Proposes hypotheses. 2.Generates desired outcomes. 3.Reviews results of laboratory tests. 4.Documents care. Which of the following elements is best categorized as secondary subjective data? 1.The nurse measures a weight loss of 10 pounds since the last clinic visit. 2.Spouse states the client has lost all appetite. 3.The nurse palpates edema in lower extremities. 4.Client states severe pain when walking up stairs. The nurse wishes to determine the client’s feelings about a recent diagnosis. Which interview question is most likely to elicit this information? 1.“What did the doctor tell you about your diagnosis?” 2.“Are you worried about how the diagnosis will affect you in the future?” 3.“Tell me about your reactions to the diagnosis.” 4.“How is your family responding to the diagnosis?” The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1.Correlation of the data with other members of the health care team 2.Demonstration of cost-effective care 3.Utilization of creativity and intuition in creating a plan of care 4.Collection of all necessary information for a thorough appraisal Question 29 Nursing activities that represent the various characteristics of the nursing process includes the nurses: Standard Text: Select all that apply. 1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature. 2. Advocating for a client who is mentally incapable of expressing her needs. 3. Deciding to increase a clients nasal oxygen based on his current pulse oxygenation levels. 4. Documenting all clients pain level responses after the administration of pain medication. 5. Attending in-services on a new hydraulic lift to be used to support safe client care. Chap 12 Question 1 After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses? 1. The ones that the nurse is licensed to treat 2. The ones that address other health professionals interventions 3. The ones that focus on the clients primary illness 4. The ones that have standardized care available Question 2 A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client? 1. Risk nursing diagnosis 2. Syndrome diagnosis 3. Wellness diagnosis 4. Actual diagnosis Question 3 A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client? 1. Syndrome diagnosis 2. Risk nursing diagnosis 3. Actual diagnosis 4. Wellness diagnosis Question 4 The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label? 1. Must contain three components 2. Describes the health problem for which nursing therapy is given 3. Helps define medical diagnoses for nursing 4. Promotes a taxonomy of nursing Question 5 An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new nursing diagnosis in this clients plan of care? 1. The clients eyes are closed. 2. The clients skin is pale and mottled. 3. The clients spouse is asleep in the chair next to the bed. 4. The television is on and the volume is turned up. Question 6 The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis? 1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends families. 2. The children attend Sunday school classes, one parent always attends services with the children, and the parents attempt interaction with congregational activities. 3. The grandparents go to weekly services and have formal interaction with clergy. 4. The children have attended private, religious schools, and the parents are involved in the schools activities. Question 7 The graduate nurse is struggling with identifying cues from clustered data. What should the nurse use to recognize data patterns and cues? 1. Depend on knowledge gained from peers experiences. 2. Work with seasoned and experienced nurses and learn from them. 3. Take assessment notes and utilize information from textbooks for comparison. 4. Know that this will take time, and experience is the best teacher. Question 8 The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In looking at the clients coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. Why should the nurse utilize this information? 1. Strengths can be an aid to mobilizing health and the healing process. 2. The client will be more active in the plan. 3. It will be easier for the nurse to educate the client about other interventions. 4. The nurse wont have to spend time going over the pathology of the clients disease. Question 9 A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client? 1. Pain due to unknown factors 2. Pain related to unknown etiology 3. Pain caused by psychosomatic condition 4. Pain manifested by clients report Question 10 A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client? 1. Altered oral mucous membranes, related to dry mouth 2. Activity intolerance, related to oxygen supply imbalance 3. Knowledge deficit, related to medication regimen 4. Ineffective airway clearance, related to increased secretions Question 11 The nurse is caring for a client recovering from a long and difficult childbirth experience. Which nursing diagnosis did the nurse write appropriately for this client? 1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days 2. Risk for infection, because of new incision, related to episiotomy 3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion 4. Altered urinary elimination, secondary to childbirth Question 12 The nurse is formulating a nursing diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood, who is being placed in a long-term, structured institutional environment. Which diagnosis indicates the clients problem is adequately described? 1. Chronic low self-esteem, related to factors too numerous to mention 2. Risk for self-harm, related to many psychiatric problems 3. Impaired social interaction, due to long history of institutionalization 4. Alteration in thought processes, related to complex factors Question 13 After communicating with the client and family, the nurse compares a clients problem list with identified nursing diagnoses. What action is the nurse performing to minimize diagnostic errors? 1. Understanding what is normal vs. what is not normal 2. Verifying 3. Consulting resources 4. Basing diagnoses on patterns Question 14 After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the clients lab values and diagnostic tests, when comparing to norms and standards. Which action should the nurse take? 1. Verify the information with the client. 2. Compare all findings to the national norms and standards. 3. Consult other professionals and colleagues. 4. Improve critical thinking skills so answers come more easily. Question 15 The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should the nurse complete next in the diagnostic process? 1. Formulate a diagnosis. 2. Verify the data. 3. Research collaborative and nursing-related interventions. 4. Identify the clients problem, health risks, and strengths. Question 16 The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label? 1. Activity intolerance 2. Weakness and debilitation 3. Reports of fatigue 4. Physical activity Question 17 A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. What is the etiology of this diagnosis? 1. Unfamiliarity of disease process 2. Anxiety 3. Restlessness 4. Tachycardia Question 18 The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction. Which collaborative action would be appropriate for this client? 1. Provide a calm, quiet atmosphere in the clients room. 2. Administer pain medication. 3. Educate the client and family regarding treatment and therapies. 4. Monitor for changes in the clients condition. Question 19 The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions for a client. Which data did the nurse use to support this diagnosis? Standard Text: Select all that apply. 1. The client has dry, cracked skin. 2. The client has one large and several smaller open, ulcerated areas on his right leg. 3. The client does not drive. 4. The client states that he does not use alcohol or drugs. 5. The clients clothes are soiled. 6. The client has obvious body odor. , 2, 5, 6 Question 20 The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems? 1. Mental status of the client 2. Chronic nature of the illness 3. Nursing care focus 4. Prognosis Question 21 The nurse is using the Taxonomy II nursing diagnoses system. What axes should the nurse realize are coded within this system? Standard Text: Select all that apply. 1. Gordons health pattern groupings 2. Age 3. Time 4. Health status 5. Gender 6. Location , 3, 4, 6 Question 22 The nurse is reviewing assessment data collected for a clients care plan. What criteria should the nurse use when formulating this clients nursing diagnoses? Standard Text: Select all that apply. 1. Nonjudgmental statements 2. Stated in terms of a need 3. Must be legally advisable 4. Cause/effect correctly stated 5. Medical terminology used to describe the cause 6. Diagnosis worded specifically and precisely Question 23 The nurse wants to propose a new nursing diagnosis. What action should the nurse take first? 1. Using the proposed nursing diagnosis when constructing client care plans 2. Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility 3. Submitting the diagnosis to NANDAs Diagnostic Review Committee 4. Presenting the proposed nursing diagnosis at the local AMA (American Medical Association) meeting. Question 24 The nurse is providing care to a client. Which nursing diagnoses can the nurse apply when providing client care? Standard Text: Select all that apply. 1. Ineffective Breathing Pattern 2. Risk of Infection 3. Readiness for Enhanced Nutrition 4. Readiness for Enhanced Family Coping 5. Anxiety Question 25 A nursing diagnosis that was written according to the PES format model would include: Select all that apply. 1. Ineffective coping related to depression as evidenced by suicide attempt 2. Noncompliance (DASH diet) related to denial of having disease 3. Risk for infection related to recent surgery 4. Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds 5. Ineffective Breathing Pattern as evidenced by cyanotic lips Chap 13 Question 1 A client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care, but who will be involved with the ongoing planning of this clients care? 1. The admitting nurse 2. All nurses who work with the client 3. Everybody involved in this clients care 4. The client and the clients support system Question 2 A client is admitted for complications following a routine diagnostic procedure of the colon. Which type of care plan will most likely be implemented for this client? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan Question 3 A client is scheduled for elective hip replacement and will be admitted postoperatively to the orthopedic unit for care. What should the nurses use to help plan this clients care? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan Question 4 The nurse being oriented to a new position is reviewing the hospitals standards of care, standardized care plans, protocols, policies, and procedures. For which reasons should the nurse realize that these documents are being used by the nursing staff? SAP 1. Making sure all clients have the same types of care 2. Ensuring that minimally accepted standards are met 3. Promoting efficient use of the nurses time 4. Eliminating care disparities among clients 5. Ensuring medication errors do not occur Question 5 The neonatal intensive care nurse implements several actions to prevent further complications in a newly admitted premature infant. Which type of document did the nurse use to find these actions? 1. Standardized care plan 2. Protocol 3. Standards of care 4. Policy and procedure manual Question 6 A nurse in the intensive care unit consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension. What did the nurse implement in this situation? 1. A STAT order 2. A one-time order 3. A prn order 4. A standing order Question 7 According to the care plan, a client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. What should the home care nurse do when setting priorities for this client? 1. Make sure that he or she is able to get to the clients home. 2. Assist the client in finding an alternative plan for the achieving the therapys outcomes. 3. Tell the client that this therapy will be impossible to receive. 4. Make arrangements to have the client moved to a long-term care facility. Question 8 A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately? 1. Client will ambulate without a walker by 6 weeks. 2. Client will ambulate freely in house. 3. Client will not fall. 4. Client will have freer movement in daily activities. Question 9 The nurse identifies for a client the nursing diagnosis Fluid volume deficit, related to active fluid loss, secondary to diarrhea. What would be and appropriate goal statement for this diagnosis? 1. Client will drink more fluids by tomorrow. 2. Client will have good skin turgor. 3. Client will have moist mucous membranes. 4. Client will have intake of at least 1000 mL within 24 hours. Question 10 The nurse is reviewing the Nursing Outcomes Classification (NOC) taxonomy system. To what can the nurse compare this taxonomy? 1. Nursing diagnosis statement 2. Planning portion of the care plan 3. Goal statement of the traditional care plan 4. Implementation phase of the care plan Question 11 The nurse is caring for a client with Parkinsons disease who desires to improve fine motor skills. Which statement should the nurse identify as an appropriate collaborative intervention for this client? 1. Provide assistance as needed with dressing and grooming. 2. Provide assistive devices and educate client to use grab bar and large handled utensils. 3. Make sure lighting and space are adequate for client. 4. Administer medications to improve muscle tone. Question 12 The nurse is reviewing interventions written for a clients plan of care. Which intervention should the nurse recognize as being dependent? 1. Repositioning the client every 2 hours 2. Assisting the client with transfers to the bathroom 3. Providing ongoing physical assessment, especially of the incisional sites 4. Administering medications for pain Question 13 One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention? 1. 60 to 90 degrees during feeding times 2. Position in chair 3. Upright in a chair 4. Impaired swallowing Question 14 A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Which should the nurse identify as an observation intervention? 1. Turn and reposition client every 2 hours. 2. Cushion bony prominences with soft foam while in bed. 3. Provide ongoing assessment for skin breakdown every shift. 4. Apply lotion to dry skin twice daily. Question 15 The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention? 1. Assist client with ambulation. 2. Ambulate with client, using a gait belt, twice daily for 15 minutes. 3. Make sure client understands the rationale for using the gait belt. 4. Client will ambulate in hallway twice daily. Question 16 A hospital is implementing the use of the NIC (Nursing Interventions Classification) taxonomy. What purpose will the implementation of this taxonomy serve? 1. Help the nurse with documentation of the care plan 2. Require that the nurse use sound judgment and knowledge of the client 3. Match nursing diagnoses to exact interventions 4. Help the nurse choose activities that are individualized to the client Question 17 The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale? 1. Have suction equipment available at all times. 2. Clear secretions from oral/nasal passageways as needed. 3. Keep client in low-Fowlers position to prevent reflux. 4. Provide frequent assessment for presence of obstructive material in mouth and throat. Question 18 The nurse manager is implementing computerized care plans for the care area. Which guidelines should the manager emphasize when the staff is writing care plans? Standard Text: Select all that apply. 1. Plans must be dated and signed. 2. Categories must have headings. 3. Plans must be specific. 4. Plans must include preventive care and health maintenance. 5. Plans must include interventions for ongoing assessment. 6. Plans are standardized and generalized for all clients. Question 19 The nursing staff is reviewing standards of care, standardized care plans, protocols, policies, and procedures for a multi-system health care facility. Why are these documents important to the nursing staff when providing client care? Standard Text: Select all that apply. 1. To make sure all clients have the same type of care 2. To ensure that minimally accepted standards of care are met 3. To promote efficient use of the nurses time 4. To eliminate care disparities among clients 5. To minimize health care costs Question 20 The nurse is devising a care plan for a client with complex health issues and current acute health problems. Which criteria should the nurse ensure is used when planning interventions for this client? Standard Text: Select all that apply. 1. Congruent with the clients values, beliefs, and culture 2. Are within established standards of care 3. Based on scientific and medical knowledge 4. Achievable with the resources available 5. Must be safe and appropriate for the clients age Question 21 The nurse is reviewing a clients plan of care. Which statements indicate that this care plan has been completed accurately and appropriately? Standard Text: Select all that apply. 1. Ineffective coping related to drug abuse as evidenced by drug overdose. 2. The client will identify two healthy coping mechanisms by time of discharge. 3. The client has identified two health coping mechanisms to replace inappropriate drug use. 4. The client will be provided with guidance in identifying healthy coping mechanisms. 5. The client has apologized to his family for drug abuse behaviors. Question 22 The nurse attends an educational program that provides information about the Nursing Intervention Classifications (NIC) system. Which statements made by the nurse indicate that teaching has been effective? Standard Text: Select all that apply. 1. I can look up interventions according to the nursing diagnosis that Ive selected. 2. The interventions connected to a diagnosis are appropriate for any client with that diagnosis. 3. If there is a NANDA diagnosis, I should be able to find some appropriate interventions. 4. Care plans are best written when the interventions are broad and flexible. 5. I find NIC interventions a really good place to start when Im working on client interventions. Question 23 The nurse is collecting information to plan care for a client with a heart problem. Which information indicates that planning for this clients discharge was started by the nurse? Standard Text: Select all that apply. 1. The client is scheduled for cardiac catheterization and echocardiogram. 2. Recent laboratory data indicates the development of heart failure. 3. The client does not have a scale to perform daily weights at home. 4. The clients spouse has care needs that the client will not be able to complete going forward. 5. The client is pleasant and eager to learn how to control newly diagnosed health problem. After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? 1.Initial 2.Ongoing 3.Discharge 4.Strategic The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following? 1.Hospital policies 2.Standardized care plans 3.Orthopedic protocols 4.Standards of care The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The cli-ent’s pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but skin is very dry. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan? 1.Pain 2.Nausea 3.Constipation 4.Potential for wound infection The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated goal/outcome? The client will 1.Turn in bed q2h. 2.Report the importance of applying lotion to skin daily. 3.Have intact skin during hospitalization. 4.Use a pressure-reducing mattress. The care plan includes a nursing intervention “4/2/15 Measure client’s fluid intake and output. F. Jenkins, RN.” What element of a proper nursing intervention has been omitted? 1.Action verb 2.Content 3.Time 4.None The nurse recognizes which of the following as a benefit of using a standardized care plan? 1.No individualization is needed. 2.The nurse chooses from a list of interventions. 3.They are much shorter than nurse-authored care plans. 4.They have been approved by accrediting agencies Which of the following is likely to occur if a goal statement is poorly written? 1.There is no standard against which to compare outcomes. 2.The nursing diagnoses cannot be prioritized. 3.Only dependent nursing interventions can be used. 4.It is difficult to determine which nursing interventions can be delegated When written properly, NOC outcomes and indicators 1. Do not require customization. 2. Address several nursing diagnoses. 3. Are broad statements of desired end points. 4. Reflect both the nurse’s and the client’s value Which of the following principles does the nurse use in selecting interventions for the care plan? 1. Actions should address the etiology of the nursing diagnosis. 2. Always select independent interventions when possible. 3. There is one best intervention for each goal/outcome. 4. Interventions should be “doing,” not just “monitoring Chap 14 Question 1 The home health nurse uses creativity and critical thinking to devise a way for a client to receive intravenous medication while sitting outside on the porch. Which skill did the nurse use for this situation? 1. Technical 2. Interpersonal 3. Creativity 4. Cognitive Question 2 A home care client must correctly self-administer insulin injections before being discharged from the agency. On what skill is this client being evaluated? 1. Technical 2. Cognitive 3. Interpersonal 4. Academic Question 3 The nurse provides care to clients admitted to a mental health facility who exhibit paranoid behavior. Which skill should the nurse use when caring for these clients? 1. Cognitive 2. Interpersonal 3. Technical 4. Therapeutic Question 4 The nurse is preparing to provide care planned for a client. What actions should the nurse complete during this phase of client care? SAP 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing interventions Question 5 Upon entering a room, a client and spouse are found crying. The nurse decides to sit with both of them, offering presence and listening to their fears instead of providing the planned education. What action did the nurse perform? 1. Implementing nursing intervention 2. Determining the nurses need for assistance 3. Supervising delegated care 4. Reassessing the client Question 6 The nurse is caring for a new mother and infant. Which action should the nurse take that allows the new parents to feel in control when being taught how to bathe their infant? 1. Telling the parents everything the nurse is doing and why 2. Letting the parents watch a video after the bath 3. Letting the parents bathe the baby with direction and guidance from the nurse 4. Giving lots of advice and suggestions about different methods Question 7 During teaching, the nurse makes sure the client understands how to activate the safety mechanism on the syringe to prevent needlestick injuries when self-administering insulin. Which guideline of implementing interventions is the nurse using? 1. Adapt activities to the individual client. 2. Encourage clients to participate actively in implementing nursing interventions. 3. Base nursing interventions on scientific knowledge, research, and standards of care. 4. Implement safe care. Question 8 On one of the first days working alone, the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse. What action should the nurse take? 1. Ask the nurse mentor to assist with the teaching after reviewing the procedure. 2. Read the policy and procedure manual before the teaching session. 3. Do the best the nurse can by remembering what was taught in nursing school. 4. Ask for a different assignment until the nurse feels comfortable with this one. Question 9 A client is prescribed a medication that the nurse has never administered and information about the medication is not in the drug reference manual. What should the nurse do? 1. Follow the physicians orders as written and give the medication. 2. Call the pharmacy and do further investigating before administering the medication. 3. Ask the client about this medication. 4. Call the physician and ask what the medication is and what it is for. Question 10 The nurse is providing care to an assigned client. Which action indicates that the nurse supports the clients respect for dignity? 1. Allowing the client to complete hygienic care when possible 2. Providing all care to the client whenever possible 3. Telling the other staff that the client is demanding, so they are able to meet the clients needs 4. Presenting information to the clients family about the clients condition Question 11 The nurse provides routine morning care to a client, including all the medications and scheduled treatments. What action should the nurse make next? 1. Move on to the next assignment to increase the nurses efficiency. 2. Report this to the charge nurse. 3. Document all care in the progress notes. 4. Get supplies organized for the next clients medications and treatments. Question 12 The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process? 1. Assessment is done at the beginning of the process. 2. Evaluation is completed at the end of the process. 3. They are the same and there is no need to differentiate. 4. The difference is in how the data are used. Question 13 The nurse notes that a client has the outcome goal Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic. Which client statement should the nurse use to evaluate this goal? 1. Im getting really sleepy from that medication. I think Ill take a nap. 2. My pain is a 4. 3. I still have some pain. 4. Will the pain ever go away? Question 14 A client has the goal statement Client will be able to state two positive aspects of rehab therapy by the end of the week. What statement demonstrates that the nurse appropriately evaluated this goal? 1. Goal not met, client able to state one positive aspect by the end of the week. 2. Goal met, client able to state one positive aspect by the end of the week. 3. Goal met, client able to state two positive aspects of therapy by weeks end. 4. Goal incomplete, client not able to positively state anything about rehab. Question 15 A client has the goal statement Client will have clear lung sounds bilaterally within 3 days. One intervention to meet this goal is for the nurse to teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the clients lungs are indeed clear. What should the nurse do to relate the intervention to the outcome? 1. Ask how many times per day the client practiced the coughing and deep breathing exercises. 2. Tell the client that the lungs are clear. 3. Document the assessment findings to show the effectiveness of the intervention. 4. Write this evaluation statement: Goal met, lung sounds clear by third day. Question 16 A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the clients symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. What should the nurse do? 1. Keep the problem on the care plan, in case the symptoms return. 2. Document that the problem has been resolved and discontinue the care for the problem. 3. Assume that whatever the cause was, the symptoms may return, but document that the goal was met. 4. Document that the potential problem is being prevented because the symptoms have stopped. Question 17 A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: Client will be free of pain within 48 hours. As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan? 1. The goal statement is written inaccurately. 2. The interventions are dependent of nursing. 3. The goal is unrealistic. 4. The interventions are not clear enough. Question 18 A teenage client has been having problems with peer support, school performance, and parental expectations, all of which contributed to an eating disorder. After gathering this assessment data, the nurse formulates the diagnosis Activity Intolerance related to weakness. What should the nurse realize after evaluating this diagnosis? 1. The data collected would support the diagnosis. 2. The diagnosis is directly related to the data presented. 3. The nursing diagnosis is not relevant to the data. 4. The data are not sufficient enough to support this diagnosis. Question 19 A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated. A goal for this client is not to sustain any injuries for the next month; however, the client has fallen several times. In this situation, what should the nurse do? 1. Review the data and make sure that the diagnosis is relevant. 2. Investigate whether the best nursing interventions were selected. 3. Modify the whole nursing plan. 4. Discard the nursing plan and start over from the assessment phase. Question 20 The nurse manager has been appointed to implement a quality assurance program at the hospital. Which components should the manager prepare to evaluate for this program? 1. Methods 2. Structure 3. Finances 4. Process 5. Outcome Question 21 A care area has been short staffed for the past month with a heavy client load and high acuity. The nurses have been working extra as well as double shifts and often do not have time to make sure that properly working equipment is cleaned, returned, and stored in the appropriate areas. At what level should this care area be evaluated? 1. Management 2. Structure 3. Process 4. Outcome Question 22 A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter. When evaluating this care area, on which care component should the quality assurance officer focus? 1. Competency 2. Structure 3. Process 4. Outcome Question 23 A nursing units records of client care have been reviewed for accuracy in documentation. Which type of review is being completed on these records? 1. Nursing audit 2. Peer review 3. Individual audit 4. Concurrent audit Question 24 The nurse reviews clients records and the care they received while in the hospital for an insurance company. Part of the job description requires the nurse to make sure that the client and insurance company were billed for services and treatment/therapies rendered and that there were no errors in billing. Which type of audit is the nurse completing? 1. Concurrent 2. Peer review 3. Nursing audit 4. Retrospective Question 25 The nurse assigns unlicensed assistive personnel to measure vital signs for several clients. The task is completed and documented correctly; however, one of the clients had a blood pressure reading of 180/110. The nurse learns this information at the end of the shift. Which responsibility of delegation did the nurse fail to carry out? 1. Delegating to the appropriate staff 2. Delegating the appropriate task 3. Selecting the appropriate client 4. Appropriately supervising care Question 26 The nurse is implementing care and treatments for assigned clients. What actions should the nurse prepare to complete during this phase of the nursing process? Standard Text: Select all that apply. 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing intervention Question 27 After implementing interventions and reassessing the clients response, the nurse completes the process by evaluating. What attributes of evaluation should the nurse include when completing this step of the nursing process? Standard Text: Select all that apply. 1. Purposeful activity 2. Nursing accountability 3. Continuous 4. Judgments 5. Opinion Question 28 The nurse is preparing to evaluate care provided to a client. What behaviors should the nurse demonstrate that show an understanding of the relationship of evaluation to the other phases of the nursing process? Standard Text: Select all that apply. 1. Effectively assessing the clients needs 2. Selecting the appropriate nursing diagnosis related to the clients needs 3. Collecting client-focused data with a specific need in mind 4. Evaluating by using assessment data to determine effective achievement of goals and outcomes 5. Basing evaluation on assessment data collected during the admission phase Question 29 The nurse notes that assessment data indicate a change in a clients condition. What should the nurse ask before changing this clients plan of care? Standard Text: Select all that apply. 1. How difficult will it be to change the care plan? 2. Are the new data complete? 3. Are the new data accurate? 4. Do the new data require a change in the care plan? 5. Will the primary medical provider agree with the need to alter the care plan? Question 30 The nurse is evaluating care provided to a client. Which nursing actions indicate that the phases of evaluation were completed by the nurse appropriately? Standard Text: Select all that apply. 1. Client problems updated 2. Data linked to NOC indicators 3. Data compared to desired outcomes 4. Interventions changed on the care plan 5. Physician notified of changes in the care plan Question 31 A client recovering from total knee replacement surgery falls out of bed on the night shift and dies. Which quality improvement actions should the nurse manager expect to complete for this client occurrence? Standard Text: Select all that apply. 1. A root cause analysis 2. Paperwork about a sentinel event 3. Analysis of the nurse assigned to the client 4. Number of times the client was observed on the night shift 5. Number of hours since the client last received pain medication Chap 15 Question 1 A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him, as its his record. How should the nurse respond to this clients request? 1. Youll have to ask your doctor for permission to do that. 2. Actually, the original record is the property of the hospital, but you are welcome to copies of your records. 3. Well make sure that all of your records are sent ahead to the rehab hospital, so you dont really have to worry about those details. 4. Theres a new law that protects your records, so youre not going to be able to have access to them. Question 2 After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why its permissible for them to review and have access to client records in the clinical area. How should the nursing instructor respond? 1. Confidentiality and privacy laws dont apply to students. 2. Most students review so many records and charts that they could not possibly remember details from any one of them. 3. Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence. 4. As long as the clinical instructor is in the area, accessing client records is part of the education process. Question 3 The nurse works at an organization that is installing a new computerized record system. What should the nurse learn that has been implemented to help ensure the security of client records? 1. A firewall to protect the server from unauthorized access 2. One unit password to protect the units information 3. Expectation to log off a terminal after using it 4. Expectation to turn the monitor away from view when unattended 5. Requirement to shred all computer-generated worksheets Question 4 A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. Which problem with documentation might have caused the lack of reimbursement? 1. The clients record contained an incorrect DRG. 2. The client was charged for an ECG. 3. A code cart was opened and the client was charged for medications opened but not used. 4. The physician made a diagnostic mistake. Question 5 When attempting to locate recent lab results, the new nurse employee notices that each department has a separate section in the clients chart. Which type of documentation system is the nurse using? 1. Source-oriented record 2. Problem-oriented record 3. Case management 4. Focus charting Question 6 The nurse makes chronological entries in a clients chart that include documentation about the routine care provided, assessment findings, and client problems during a 12hour shift. Which type of charting is this nurse completing? 1. Problem-oriented recording 2. Source-oriented recording 3. Narrative charting 4. Plan of care Question 7 The nurse is reviewing a clients chart in a facility that utilizes problem-oriented recording. In which section would the nurse find the most recent physician orders? 1. Database 2. Problem list 3. Plan of care 4. Progress notes Question 8 A client has specific cultural needs that affect the plan of care. In which part of the clients problem-oriented medical record should the nurse document this information? 1. Database 2. Problem list 3. Plan of care 4. Progress notes Question 9 The client states: I really dont want anyone to visit me who has not been cleared by me first. If utilizing SOAP format, in which category should the nurse document this statement? 1. Subjective data 2. Objective data 3. Assessment 4. Planning Question 10 The nurse administered analgesic medications to an assigned client via central line. In which section of PIE charting should the nurse document this information? 1. Plan 2. Intervention 3. Evaluation 4. Progress notes Question 11 The nurse is documenting client care on flow sheets that identify abnormal assessment findings. Which type of documentation system is the nurse using? 1. Computerized documentation 2. Focus charting 3. SOAP charting 4. Charting by exception Question 12 The nurse working in a hospital that utilizes a charting by exception (CBE) documentation system notes that a client did not require care in all of the areas identified on a flow sheet. What action should the nurse take? 1. Leave the areas blank. 2. Leave the areas blank, but then add an extensive explanation in the progress notes section of the chart. 3. Write N/A on the flow sheet in the areas that are not applicable to that client. 4. Make sure this information gets passed along in the shift report. Question 13 A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager using a critical pathway should identify this outcome as being which of the following? 1. An unattainable goal 2. A variance 3. An error in care planning 4. An error in intervention implementation Question 14 A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. Which type of form is this hospital utilizing? 1. Standardized care plans 2. Traditional care plans 3. Critical pathways 4. Kardex Question 15 Before providing care, the nurse reviews the clients pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information. Which form should the nurse review to learn all of this information? 1. The clients medical record 2. The MAR (medication administration record) 3. The written care plan 4. The Kardex Question 16 The nurse is teaching medication administration to a client being discharged. Which instruction should the nurse rewrite for this client? 1. Lasix, 20 mg, po bid 2. Lasix, 20 mg tablet, twice daily 3. Lasix, 20 mg by mouth, two times a day a day 4. Lasix, 20 mg by mouth 8 AM and 2 PM Question 17 A client in long-term care is scheduled for a review of the assessment and care screening process. Where should the nurse document this information? 1. MDS 2. OBRA 3. CBE 4. Kardex Question 18 When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding? 1. Client fell out of bed, but did push the call button for assistance. 2. Client became tangled in the bed linens, then called for assistance after falling out of bed. 3. Recorder responded to clients call light, upon entering the room, found client on floor. 4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens. Question 19 After completing the client care and documenting it in the progress notes, the nurse realizes that documentation was placed on the wrong medical record. What should the nurse do? 1. Use white-out over the mistake. 2. Take a wide permanent marker and blacken out all the documentation. 3. Put an X through the entire page, identify it as an error, initial, and move on to the correct chart. 4. Draw a single line through the documentation, write mistaken entry next to the original entry, and initial it. Question 20 The nurse manager is conducting a survey of personnel to see what the general feeling is before implementing computerized charting in an acute care hospital. What should the nurse select as positive aspects of implementing this type of system? Standard Text: Select all that apply. 1. The system is relatively inexpensive to maintain. 2. Bedside terminals eliminate worksheets and note taking. 3. The system links to various sources of client information. 4. The system better protects client privacy. 5. Information is legible. 6. Results, requests, and client information can be sent and received quickly. , 3, 5, 6 Question 21 Type: MCSA The client had diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack. When utilizing focus charting, this information would be included in the section identified as: 1. Data (D). 2. Action (A). 3. Response (R). 4. Planning (P). Question 22 Evidence that a nurse adheres to practice guidelines that result in documentation that meets legal and ethical standards is shown when: Standard Text: Select all that apply. 1. Charting the clients response to pain medication taken. 2. Describing the client as appearing to be comfortable. 3. Leaving sufficient charting space for the previous shift to chart client teaching. 4. Documenting that the client reports, Im so afraid of tomorrows surgery. 5. Making a late entry regarding a clients request for pain medication. ,4,5 Question 23 The nurse shows an understanding of the importance of avoiding potentially confusing abbreviations when: Standard Text: Select all that apply. 1. Documenting vital signs as TPR. 2. Charting that the drsg was dry and intact. 3. Transcribing a verbal order as Carbamazepine 12 mg/ml IV push daily. 4. Documenting Client consistently requesting IM MS for pain well before prescribed time. 5. Charting, Client to be ambulated q.i.d. ,2,5 Chap 26 Question 1 A nurse explains to a client that he will need to have a bowel prep before going to his esophagogastroscopy. On what should the nurse focus to improve communication skills? 1. Pace 2. Intonation 3. Simplicity 4. Clarity Question 2 The nurse observes during a dressing change that the clients wound has become infected. When asked by the client how the wound looks, the nurse says it looks fine but the nurses facial expression doesnt support the response. Which aspect of communication should this nurse improve? 1. Adaptability 2. Credibility 3. Timing and relevance 4. Clarity and brevity Question 3 A nurse is working on a telemetry unit when one of the clients has a cardiac arrest. The clients spouse is in the room when the code team arrives. Which statement by the nurse to the spouse is the best in this situation? 1. I know youre worried about your loved one. Im sure this is a difficult situation for you. Do you have any questions right now? 2. Your spouses heart stopped. All these people are here to help get it started. 3. Your spouses physician will be here shortly and explain all of the medication and treatment that your spouse is receiving right now. 4. Is there someone you would like to call? Im sure this is a scary situation and you may feel more comfortable if someone were with you during this time. Question 4 The nurse enters a clients room and finds that the telephone is lying in the clients lap, tissues are wadded up on the bed, and the clients eyes are red and watery. What is the best response by the nurse? 1. Can I hang that phone up for you? 2. Well, its a beautiful day outside. Lets open the blinds. 3. Has your doctor been in to talk to you yet? 4. You look upset. Is there anything youd like to talk about? Question 5 A client has been sullen and withdrawn since receiving the news of her cancer diagnosis. As the nurse enters the room, the client asks for assistance with a shower. Which comment by the nurse is the most appropriate? 1. If you look better, you might feel better. 2. Taking a shower might wash away some of that gloom and doom. 3. This is a positive sign. Ill be right back with your supplies. 4. Your spouse will be glad to see that youre feeling better. Question 6 A nurse is working in a pediatric clinic and has to explain a nebulizer treatment to a child. Which approach should the nurse use? 1. Give the childs parent a full explanation, but make sure the child hears what is said. 2. Let the child handle the equipment first, then demonstrate on the childs doll. 3. Start the treatment, but make sure that the parent is there to comfort the child if she becomes afraid. 4. Make sure that the physician is available for questions. Question 7 A nurse is giving a demonstration of new equipment to the rest of the nursing unit. Which level of proxemics should the nurse use? 1. Intimate 2. Personal 3. Social 4. Public Question 8 A nurse must perform a catheterization on a male client. Which zone of proximity should the nurse use for this intervention? 1. Personal distance 2. Intimate distance 3. Social distance 4. Public distance Question 9 A nurse enters a clients room and asks about his level of pain. The client, grimacing, says Its fine. Which communication factor is the client struggling with? 1. Territoriality 2. Environment 3. Congruence 4. Attitude Question 10 A nurse is working with an elderly male client on a medical unit. Which statement demonstrates elderspeak by the nurse? 1. Its time for us to go to physical therapy. 2. I think it would be better if you were planning to go to a nursing home after discharge. 3. Your children must really love their dad. 4. Your wife must be having trouble adjusting to your illness. Question 11 A client has just lost her second baby to preterm complications. Which statement demonstrates the best therapeutic response for the nurse to make? 1. Dont be so sad. You can always try again. 2. Didnt your doctor advise you about genetic counseling? 3. I know how you feel. I have children of my own. 4. I am so sad for you. Ill stay with you for a while if you need to talk. Question 12 The nurse is conducting an admission interview. Which response indicates that the nurse is attentively listening to the clients explanations? 1. Can you explain what your symptoms are like? 2. When was the last time you saw a doctor for this? 3. Uh-huh, while nodding the head 4. Im sorry, say that again? Question 13 The nurse is engaging a client in the introductory phase of the helping relationship. Which stages will be completed during this phase? Standard Text: Select all that apply. 1. Opening the relationship 2. Clarifying the problem 3. Structuring and formulating the contract 4. Planning before the interview 5. Understanding thoughts and feelings , 2, 3 Question 14 During an interaction between a nurse and client, the nurse conveys respect and an attitude that shows the nurse takes the clients opinions seriously. In which stage of the working relationship are the nurse and client engaged? 1. Exploring and understanding thoughts and feelings 2. Facilitating and taking action 3. Confrontation 4. Concreteness Question 15 Several nurses have been assigned to develop a rotation schedule that provides adequate staffing of all shifts. In which type of group are these nurses functioning? 1. Self-help group 2. Task group 3. Teaching group 4. Therapy group Question 16 The nurse is identifying communication strategies for a client unable to speak. What would be appropriate for the client in this situation? 1. Using a picture board to facilitate communication 2. Facing the client when speaking 3. Employing an interpreter 4. Making sure that the language spoken is the clients dominant language Question 17 A nurse needs to evaluate the effectiveness of a teaching session with a client. Which approach would provide the best feedback? 1. Client communication 2. Process recording 3. Therapeutic communication 4. Verbal communication Question 18 During a health history, a client admits to taking nutritional supplements instead of prescribed medication. Which responses by the nurse indicate effective communication? Standard Text: Select all that apply. 1. What you did was wrong. 2. Who do you think you are? 3. You shouldnt have done that. 4. Tell me more about the supplements. 5. Explain the reasoning behind your decision. , 5 Question 19 The nurse needs to communicate information about a clients status to a physician. Which approach demonstrates assertive communication by the nurse? 1. You need to check the laboratory results of the client in room 423. 2. You should visit with the clients family about the upcoming procedure. 3. We need to be more aware of the situation among the client and the clients family. 4. I am concerned that the client does not have adequate pain management. Question 20 The nurse wants to gain information about a clients situation. Which question should the nurse use to maximize communication with this patient? 1. What brings you to the hospital? 2. Are you having pain? 3. Does your pain feel better or worse today? 4. Is there anything I can do for you? Question 21 The nurse is communicating with an older client. Which actions demonstrate that the nurse understands the best approaches to communicate with this client? Standard Text: Select all that apply. 1. Asking, What can I do to make you feel safe? 2. Observed intently listening to the client describe how being alone makes her feel 3. Offering to take the client out for a walk 4. Consistently arranging for the client to have her hair done 5. Managing to get a copy of the clients favorite magazine , 2, 5 Question 22 The nurse is beginning a helping relationship with a newly admitted client. Which behaviors should the nurse demonstrate that support this type of relationship? Standard Text: Select all that apply. 1. Becoming familiar with the clients social history by reading the admission interview 2. Orienting the client to the physical layout of the facility as well as to the facilitys policies 3. Gaining the clients trust by consistently keeping promises to return and visit 4. Respecting the clients wish to be alone after hearing about the loss of a family friend 5. Asking to remain with the client when he is experiencing symptoms of the flu , 3, 4, 5 Question 23 The graduate nurse is thinking about leaving a new job because of actions demonstrated by the nurse manager. Which actions should the graduate nurse identify as bullying? Standard Text: Select all that apply. 1. Pairing the graduate with a seasoned nurse to assist with learning new skills 2. Asking the graduate to participate in client rounds with the new interns on the care area 3. Confronting the graduate by stating that refusing an assignment is grounds for dismissal 4. Stating that requests for vacation time will be denied because the nurse asks too many questions 5. Assigning the graduate nurse a complicated client with needs that the graduate is not comfortable performing , 4, 5 Chap 27 Question 1 The nurse has completed client teaching regarding medication administration. Which client statement best illustrates compliance? 1. Im glad to know about my medications. It makes taking them a lot easier. 2. I already knew most of what you told me. 3. I think you should have waited until I was ready to go home. Maybe Id remember better. 4. If I take my medications as prescribed, Ill feel better. Question 2 A nurse is planning a community health education project that deals with organ donation, and the target audience is a group of adults. When following andragogy concepts, the nurse should make sure that the teaching includes which information? 1. Past statistics about organ donors 2. Written pamphlets 3. Directions about how to become an organ donor 4. Information on how this group can influence their children Question 3 The nurse is instructing a client on self-administration of a subcutaneous injection. The nurse is using which theoretical construct of learning? 1. Thorndikes behaviorism 2. Skinners positive reinforcement 3. Pavlovs conditioning response 4. Banduras imitation Question 4 A nursing student is presenting a teaching project to the class using each of Blooms domains. The student has several activities included in the project. Which activity is an example of the affective domain? 1. Each member of the class must identify two attitudinal changes that have occurred in their lives since beginning their nursing education. 2. All members must list the technical skills theyve learned. 3. Members must demonstrate a favorite nursing skill at the end of the class period. 4. Members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class. Question 5 A client is practicing using an incentive spirometer after surgery. The nurse has explained the use, demonstrated how it works, and also given the rationale for the client to continue to use this device. When mastering the use of this device, the client will demonstrate learning in which of Blooms domains? 1. Cognitive 2. Psychomotor 3. Affective 4. Imitation Question 6 A nurse is presenting teaching sessions to a group of residents in a home for long-term physical rehabilitation. Which client exhibits the highest motivation? 1. An individual who has been struggling with following nursing directives regarding discharge goals 2. The client who has just moved in and is already waiting for discharge 3. A client who is excited to learn about his new prosthesis 4. A client who has been there the longest and is a great coach for newcomers Question 7 A nurse is working in a neonatal intensive care unit, teaching parents how to care for their tiny babies while they are still in the hospital. Which statement by a parent reflects a readiness to learn? 1. Im so afraid Ill hurt my baby with all these tubes. 2. I want to make sure my spouse is here, in case I dont hear everything thats said. 3. When my baby is just a little bigger, Ill be able to handle him. 4. Youll give us written instructions before we go home, correct? Question 8 The nurse is instructing a client on self-administration of insulin. Which statement regarding feedback will be most beneficial to the client? 1. You know, there are children who can learn to do this. 2. Maybe it would be better if we taught your spouse to help you with this. 3. Next time, dart the needle in your skin, instead of pushing it in. 4. If you dont learn this, you cant be discharged. Question 9 A home health client having difficulty keeping his medication schedule organized says There are so many pills and the names are all confusing to me. I dont even understand what theyre for. What should the nurse do? 1. Help the client remember color and size in relationship to dosing time. 2. Write out the generic and trade name of all the pills for the client. 3. Fill a pill bar and tell the client not to worry, and just take the pills according to that system. 4. Have the physician talk to the client about his medications. Question 10 At the end of a busy clinical day a staff nurse asks the instructor if a student would like to administer a Z-track injected medication. This is a skill that the students have not yet been exposed to yet. What should the instructor respond to the staff nurse that supports timing and learning environment? 1. It will take me a moment to explain the procedure to the students because weve not practiced this, but Ill find somebody to administer it. 2. Would it be OK if the students observed today? Then, well do it next time were here. 3. Were leaving now, but thanks for asking. 4. Ill check with the students and see if one of them would like to volunteer. Question 11 A client with an incision necessitating a complex dressing change is being discharged and will require continued dressings at home. Which statement by the client indicates a need to postpone teaching? 1. Its going to take time for me to understand this whole thing. 2. Lets make sure my spouse is around before you start explaining. 3. I wish my doctor would have explained this more in depth. 4. Im feeling nauseous, but go ahead and start anyway. Question 12 A nurse is working with the family of a child who is hospitalized with asthma. The family members speak little English, and the child is being sent home on nebulizer treatments as well as an inhaler. In addition to enlisting an interpreter to help with the language barrier, the nurse should 1. provide written instructions before discharge. 2. address any healing beliefs the family has. 3. make sure the child comes back for the follow-up appointment. 4. make sure the parents can set up the treatments for their child. Question 13 A client who is legally blind requires vitamin B12 injections every 2 weeks and insists on self-administration. What is the best way for the nurse to assist this client? 1. Teach the spouse to draw up the medication, then the client can give the injection. 2. Make sure that the injection is scheduled during a visit, so the nurse can supervise. 3. Prefill syringes with the correct dose, so the client can use them for self-administration. 4. Schedule the clients clinic appointments in accordance with the dosing schedule, then give the injection when the client is at the clinic. Question 14 A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the clients motivation to learn? 1. Demonstrating the finger stick on the nurse 2. Offering to do the procedure for the client each time it is scheduled 3. Teaching the clients support system how to perform the procedure 4. Encouraging the clients participation each time the procedure is performed Question 15 The nurse is working with a group of older clients through a community senior citizens center. Utilizing an understanding of health literacy, the nurse will make sure that 1. information given to this group is written at a third-grade level. 2. teaching includes a variety of approaches. 3. information includes pictures. 4. there is ample time for teaching. Question 16 A client being discharged after a myocardial infarction has been prescribed several new medications and a low-fat diet. The client states: Im never going to understand what to do, when to do it, and why I should be doing all these things. Which nursing diagnosis should the nurse formulate for this client? 1. Health-Seeking Behavior related to desire to prevent heart problems 2. Deficient Knowledge (diet and medication regimen) related to inexperience 3. Noncompliance related to situational factors 4. Risk for Myocardial Infarction related to deficient knowledge Question 17 The nursing diagnosis Readiness for Enhanced Knowledge (Nutrition) related to desire to improve nutritional intake has been formulated for a client who has decided to change his eating habits to be more nutritionally sound. What would be an appropriate outcome for this client? 1. Client will understand the importance of eating healthy. 2. Client will be able to lose weight. 3. Client will list foods that are nutritionally sound, low fat, and high fiber. 4. Client will appreciate the value of using the Food Guide Pyramid. Question 18 A home health nurse is working with a client who has pulmonary fibrosis. Of the following teaching priorities, which will take the highest priority? 1. Client will be able to set up and administer a nebulizer treatment by the end of the day. 2. Client will have increased activity level by the end of the week. 3. Client will be able to do activities of daily living (ADLs) without shortness of breath in 3 days. 4. Client will have a positive attitude about the diagnosis by the end of the month. Question 19 A school nurse is putting together a program for adolescents about positive lifestyle choices. What should the nurse keep in mind when preparing content to present to this age group? Standard Text: Select all that apply. 1. Based on learning outcomes 2. Current 3. Adjusted to the adolescent client 4. Based on sources available within the school system 5. Consistent with the teaching topics , 2, 3, 5 Question 20 The nurse is going to be working with a client who has a permanent colostomy and is ready to go home within the next several days. When organizing the teaching/learning experience, the nurse should 1. start from the beginning and proceed through all material. 2. break up sessions into shortened time periods. 3. discover what the learner knows before proceeding with further teaching. 4. make sure the clients spouse is present before the teaching session begins. Question 21 A client needs discharge teaching regarding the use of a walker before going home. The clients room is small and adjacent to a soda machine and small lounge area. In planning a teaching session, which is the best thing the nurse can do? 1. Wait until just prior to discharge, then do the teaching in the hospital lobby. 2. Close the door to the clients room and make sure there is no clutter on the floor before the teaching session begins. 3. Take the client to a larger area (treatment room, for example) for teaching, then evaluate on the way back to the clients room. 4. Make sure a physical therapist is available to do the teaching and can see the client before discharge. Question 22 A community health nurse runs a clinic that provides health screening to mainly Mexican American and Native American clients. The nurse wants to have a class on smoking cessation for interested adults of this group. In order to adjust to their time orientation, what is the best action of the nurse? 1. Make sure that the classes are held at specific times. 2. Begin classes when a group of clients are gathered. 3. Mail letters ahead of time to make sure clients are informed about the upcoming class. 4. Make posters and place them in areas of the community frequented by these groups. Question 23 At the completion of a teaching session, the nurse wants to evaluate the effectiveness of instruction. In a situation where the client was learning a bandaging technique, which would be the most effective evaluation? 1. Shared by the nurse and client 2. A return demonstration by the client 3. When the nurse is satisfied that the client can complete the technique 4. If the wound heals Question 24 The nurse has completed a teaching session for a client with a tracheostomy. Documentation of the session should include what information? Standard Text: Select all that apply. 1. Diagnosed learning needs 2. Supplies required 3. Client outcomes 4. Need for additional teaching 5. Topics taught , 3, 4, 5 Question 25 When making an assessment of the clients learning needs, the nurse will focus on which elements? Standard Text: Select all that apply. 1. Nurses own knowledge 2. Clients age 3. Clients understanding of health problem 4. Sensory acuity 5. Learning style , 3, 4, 5 Question 26 A school nurse is planning a program for adolescents about positive lifestyle choices. The nurse should keep in mind that content presented to this age group must be Standard Text: Select all that apply. 1. based on learning outcomes. 2. current. 3. adjusted to the adolescent client. 4. based on sources available within the school system. 5. accurate. , 2, 3, 5 Question 27 A client is being discharged after a 23-hour stay for a surgical procedure. When preparing the instructions for this client, what does the nurse need to do? Standard Text: Select all that apply. 1. Ensure the clients safe transition to home. 2. Include information about what the client has been taught. 3. Include what the client still needs to learn when discharged. 4. Check the clients insurance for hospitalization coverage. 5. Call the clients prescriptions in to the clients local pharmacy. , 2, 3 Question 28 The nurse serves as an educator of other health care personnel. In what capacity will this nurse participate in education? Standard Text: Select all that apply. 1. Preceptor of new graduate nurses 2. Instructing a part of the critical care course 3. Clinical instruction of nursing students 4. One-to-one teaching of clients 5. Teaching grandparents how to care for children , 2, 3 Question 29 The nurse planning an educational session for adult clients should include which andragogy concepts? Standard Text: Select all that apply. 1. People move from dependence to independence with maturity. 2. Previous experiences can be used as a resource for learning. 3. Learning is related to an immediate need or problem. 4. Learning is reinforced by prompt feedback. 5. Adults are oriented to learning when the material is useful sometime in the future. , 2, 3, 4 Question 30 The nurse is utilizing humanistic theory when instructing a client. What will the nurse demonstrate when utilizing this theory? Standard Text: Select all that apply. 1. Empathy 2. Encouraging the client to establish goals 3. Encouraging the client to participate in self-directed learning 4. Multisensory teaching strategies 5. Providing a physical environment conducive to learning , 2, 3 Question 31 A client tells the nurse that he has no questions about his illness, as he did a search for information on the Internet. What should the nurse do? 1. Ask the client to share the information obtained from the Internet search. 2. Document that the client has received instruction. 3. Tell the client that the Internet is a form of entertainment, not instruction. 4. Document that the client refused instruction. Question 32 The nurse instructs the older client to access the Internet to complete a post-hospitalization survey and update health information. The client tells the nurse that he does not have a computer and would not know how to use one. What should the nurse do? Standard Text: Select all that apply. 1. Suggest the client learn how to use a computer through classes held at a local library. 2. Provide times for the client to attend basic computer use classes through the community learning center. 3. Document that the client is resistant to instruction. 4. Notify the physician that the client will not be adhering to medical instruction as planned. 5. Identify the client as being noncompliant with instruction. , 2 Question 33 The nurse suspects a client has low literacy. What did the nurse assess to come to this conclusion? Standard Text: Select all that apply. 1. Incorrect completion of previous hospitalizations form 2. Client refusing to sign forms because eyeglasses are at home 3. Client saying he forgot to report for laboratory testing 4. Score of 6 on the Newest Vital Sign assessment tool 5. Questioning the dosage pattern on a newly prescribed medication , 2, 3 Question 34 The nurse is designing a teaching plan for a client to learn a new psychomotor skill. What strategies can the nurse use to facilitate learning for this client? Standard Text: Select all that apply. 1. Demonstration 2. Practice 3. Modeling 4. Discovery 5. Role playing , 2, 3 Question 35 The nurse instructs a client on self-care for a new ostomy. Which client behaviors demonstrate that instruction has been effective? Standard Text: Select all that apply. 1. Client provides skin care and changes ostomy device. 2. Client states what items are needed to perform ostomy care. 3. Client is unable to identify changes in skin around the stoma. 4. Client tells the nurse that he does not want to do the care. 5. Client asks his wife to learn how to perform the care so he will not have to do it. , 2 Question 36 The nurse is documenting the teaching plan for a client. What should be included in this documentation? Standard Text: Select all that apply. 1. Actual information to be taught 2. Teaching strategies to use 3. Skills to be taught 4. Amount of time needed to teach each topic 5. Vital signs before and after each teaching session , 2, 3, 4 Question 37 The nurse has completed a teaching session for a client with a tracheostomy. What should the documentation include? Standard Text: Select all that apply. 1. Diagnosed learning needs 2. Supplies required 3. Client outcomes 4. Need for additional teaching 5. Topics taught , 3, 4, 5 Question 38 The nurse is creating a teaching plan for a client recovering from total hip replacement surgery. What should the nurse include in this clients plan? Standard Text: Select all that apply. 1. The content to be included 2. The outcome for the teaching 3. The approaches used to teach the content 4. The evaluation of the effectiveness of teaching 5. The amount of time needed to cover the content , 2, 3, 5 The nurse is preparing to teach a client on skin care and application of a stoma device. What should the nurse keep in mind when teaching the client this information? Standard Text: Select all that apply. 1. Address the clients concerns first. 2. Assess what the client knows already. 3. Address anxiety producing issues last. 4. Teach the basics before complicated tasks. 5. Leave time for review and answering questions. , 2, 4, 5 Chap 29 Question 1 An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this clients low temperature could be due to which observation? 1. The anxiety level of the client has increased. 2. Hormones have fluctuated in this client. 3. Muscle activity has increased during the clients therapy session. 4. Loss of subcutaneous fat is noted. Question 2 The nurse is preparing to measure a clients temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading? 1. Assess that the equipment used is working properly. 2. Place the client in a position that is most comfortable for the health care provider. 3. Take the temperature with a chemical disposable thermometer when the client is perspiring. 4. Wait at least 10 minutes before taking the temperature after a client has been smoking. Question 3 The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use? 1. Axilla 2. Oral 3. Popliteal 4. Rectal Question 4 While waiting for the physician to respond regarding a clients elevated temperature, what can the nurse do to assist the client? 1. Bathe the client with ice water. 2. Give the client an antipyretic. 3. Increase fluid intake. 4. Lower the room temperature. Question 5 While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. How would the nurse explain these findings? 1. A change in the clients health status has occurred. 2. The client has thrown a blood clot in that extremity. 3. The RNs watch has stopped working. 4. Too much pressure was applied over the pulse site. Question 6 The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use? 1. Ask another nurse to assess the pulses. 2. Document the findings. 3. Obtain a Doppler ultrasound stethoscope. 4. Wait and try again later. Question 7 When assessing a clients peripheral pulse, the health care provider is also assessing which of the following? 1. Depth 2. Rhythm 3. Sound 4. Stress Question 8 The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN use to make this decision? 1. A forceful radial pulse is much too difficult to count correctly. 2. Both arteriole and venous sounds were heard simultaneously. 3. The pulse was bounding and easily obliterated. 4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site. Question 9 A client is unconscious and in respiratory distress after being in a motor vehicle crash. Which should the nurse realize as being a factor that caused a change in this clients respiratory rate? 1. Exercise 2. Increased intracranial pressure 3. Increased environmental temperature 4. Stress Question 10 The nurse needs to assess a clients respiratory status. Which client position would be the best for this assessment? 1. Prone 2. Semi-Fowlers 3. Side-lying 4. Supine Question 11 A client is being treated for congestive heart failure. Which physical finding would lead the RN to believe the clients condition has not improved? 1. Temperature of 98.6F (37C) 2. Moderate amount of clear thin mucus 3. Pulse oximetry reading of 96% 4. Wheezing of breath sounds in all lobes Question 12 Which determinant of blood pressure would explain a clients blood pressure reading of 120/100? 1. Blood viscosity 2. Blood volume 3. Pumping action of the heart 4. Peripheral vascular resistance Question 13 The nurse is assessing a clients blood pressure. What should the nurse hear during phase 2 of Korotkoffs sounds? 1. A muffled, whooshing, or swishing sound 2. Disappearance of sound 3. Faint, clear tapping sound 4. Increased intensity of sound Question 14 The nurse is preparing to assess a clients blood pressure. Which artery will the nurse use for this assessment? 1. Brachial 2. Femoral 3. Radial 4. Ulnar Question 15 In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the pressure from the sphygmomanometer? 1. When the cuff is applied 2. When the cuff is being deflated 3. When the first pulsation is felt 4. When the second pulsation is felt Question 16 Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the clients status? 1. Altered level of consciousness 2. Decreased urine output 3. Irregular radial pulse 4. Toes cool to touch Question 17 When assessing a clients oxygen saturation reading, the nurse realizes that what will affect this reading? 1. Activity 2. Environmental conditions 3. Nutrition 4. Skin color Question 18 As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What should the nurse do? 1. Allow the client to take some extra deep breaths. 2. Continue to suction but only intermittently. 3. Keep the catheter in place and wait a few minutes. 4. Stop suctioning and give supplemental oxygen. Question 19 The RN needs vital signs assessed for four clients. Which client should the nurse address and not assign to the UAP? 1. Cardiac catheterization client returning to the nursing unit 2. COPD client on 2 Lpm oxygen via nasal cannula 3. Pneumonia client nearing discharge 4. Post-op client of 2 days from gallbladder surgery Question 20 Prior to assessing a clients blood pressure, the nurse reviews factors that could affect the reading. Which factors could impact blood pressure? Standard Text: Select all that apply. 1. Stress 2. Race 3. Obesity 4. Medications 5. Employment , 2, 3, 4 Question 21 The nurse is planning to assess a clients pulse. What characteristics should the nurse include in this assessment? Standard Text: Select all that apply. 1. Rate 2. Rhythm 3. Volume 4. Tone 5. Viscosity , 2, 3 Question 22 When assessing a clients respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in which factors? Standard Text: Select all that apply. 1. Oxygen concentration 2. Carbon dioxide concentration 3. Hydrogen ions 4. Potassium level 5. Serum calcium level , 2, 3 Question 23 Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments independently in which situations? Standard Text: Select all that apply. 1. Client who complains of chest pain 2. Client returning from surgery 3. Prior to administering a medication that affects blood pressure 4. Client who complains of dizziness after ambulating. 5. Client being admitted to the care area , 2, 3, 4 Question 24 When documenting a clients axillary temperature on the graphic sheet, how should the nurse identify the method of assessing the temperature? 1. AX 2. O 3. R 4. SL Question 25 The nurse assesses phase 1 Korotkoffs sound occurring at 136 and phase 5 Korotkoffs sound occurring at 72. How should the nurse document this clients blood pressure reading? 1. 136/72 2. 72/136 3. 136 72 4. 72 136 Question 26 A client comes to the emergency department with a temperature of 104F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke? Standard Text: Select all that apply. 1. Delirious 2. Pale and dizzy 3. Skin warm and flushed 4. No evidence of sweating 5. Had been playing tennis in the sun , 3, 4, 5 Question 27 The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision? Standard Text: Select all that apply. 1. The valve on the bulb was closed. 2. The client was sitting with the legs crossed. 3. The arm was below the level of the heart. 4. The UAP waited 2 minutes before re-measuring. 5. The cuff bladder was placed over the brachial artery. , 3 Chap 30 Question 1 The nurse is preparing to perform a health assessment of the abdomen. In which order should the nurse perform the assessment? 1. Auscultate, percuss, palpate, inspect 2. Inspect, auscultate, palpate, percuss 3. Inspect, auscultate, percuss, palpate 4. Palpate, percuss, auscultate, inspect Question 2 The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse should document this as being 1. cyanosis. 2. jaundice. 3. pallor. 4. erythema. Question 3 While performing an assessment of the integument system, the nurse notes the clients eyeballs are protruding and the upper eyelids are elevated. What term should the nurse use to document this finding? 1. Erythema 2. Cyanosis 3. Exophthalmos 4. Normocephalic Question 4 The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed assistive personnel? 1. Vital signs 2. Filling of water pitchers 3. Skull and face assessment 4. Ambulation of surgical clients Question 5 The nurse is performing a lung assessment on a client with suspected pneumonia. Which finding should the nurse report to the physician immediately? 1. Chest symmetrical 2. Breath sounds equal bilaterally 3. Asymmetrical chest expansion 4. Bilateral symmetric vocal fremitus Question 6 While performing a health assessment, in which position should the nurse place the client for inspection of the jugular veins? 1. 90-degree angle 2. 30- to 45-degree angle 3. 15-degree angle 4. 60-degree angle Question 7 The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which finding should the nurse report to the physician immediately? 1. Pulses equal bilaterally 2. Full pulsations 3. Thready pulses 4. Pulses present bilaterally Question 8 During the assessment of a clients breasts, the nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What should the nurse do next? 1. Notify the charge nurse. 2. Notify the physician. 3. Document the findings in the nurses notes as normal. 4. Document the findings in the nurses notes as abnormal. Question 9 The nurse is preparing a client for an abdominal examination. What should the nurse done before beginning the examination? 1. Ask the client to urinate. 2. Ask the client to drink 8 ounces of water. 3. Assess vital signs. 4. Assess heart rate. Question 10 The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When testing for muscle grip strength, the nurse should ask the client to perform which action? 1. Grasp the nurses index and middle fingers while the nurse tries to pull the fingers out. 2. Hold an arm up and resist while the nurse tries to push it down. 3. Flex each arm and then try to extend it against the nurses attempt to keep the arm in flexion. 4. Shrug the shoulders against the resistance of the nurses hands. Question 11 The nurse is preparing to conduct a mental status assessment. What should the nurse include in this assessment? 1. Cognitive and affective functions 2. Cognitive and effective functions 3. Affective and memory functions 4. Affective and knowledge functions Question 12 The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to comprehend what is being said to him; however, he is unable to respond by speech or writing. What type of aphasia should the nurse realize this patient is demonstrating? 1. Auditory aphasia 2. Acoustic aphasia 3. Sensory aphasia 4. Expressive aphasia Question 13 The nurse is preparing to assess a clients reflexes. What equipment should the nurse gather before entering the room? 1. Sterile gloves 2. Clean gloves 3. Percussion hammer 4. Penlight Question 14 The nurse is assisting the physician who is preparing to test a sexually active female client for cervical cancer. What should the nurse expect the health care provider to perform? 1. Pap test 2. Breast exam 3. Rectal exam 4. Abdominal exam Question 15 The nurse is preparing the morning assignments. Which assessment could the nurse delegate to unlicensed assistive personnel? 1. Neurological assessment 2. Musculoskeletal assessment 3. Vital signs assessment 4. Female genital assessment Question 16 The nurse is preparing to administer a cardiotonic drug to a client. Which assessment should the nurse perform before administering the medication? 1. Respiratory rate 2. Apical pulse 3. Popliteal pulse 4. Capillary blanch test Question 17 The nurse is preparing to complete a physical examination on a client. What should the nurse realize as being the purpose for this examination? Standard Text: Select all that apply. 1. Obtain baseline data. 2. Obtain data to help determine nursing diagnoses. 3. Identify areas for disease prevention. 4. Identify the clients employment status. 5. Obtain data about the clients leisure activities. , 2, 3 Question 18 A client has been receiving a new medication to address specific symptoms. The nurse will perform a physical examination to determine Standard Text: Select all that apply. 1. the progress of the clients health problem. 2. the physiological impact of the prescribed medication. 3. baseline data. 4. data to support nursing diagnoses. 5. areas for health promotion. , 2 Question 19 The nurse is utilizing the technique of inspection during a physical examination with a client. When using this technique, the nurse will take which actions? Standard Text: Select all that apply. 1. Visually observe a body area. 2. Obtain information through the sense of smell. 3. Obtain information through the sense of hearing. 4. Examine the body through the use of touch. 5. Strike the body to elicit a sound from a body part. , 2, 3 Question 20 The nurse is planning to perform indirect percussion on an area of a clients body during a physical examination. Which actions should the nurse take to use this assessment technique? Standard Text: Select all that apply. 1. Place the middle finger of the nondominant hand on the clients skin. 2. Use the tip of the flexed middle finger of the other hand to strike the middle finger of the nondominant hand. 3. Perform a striking motion by moving the wrist. 4. Perform short, rapid, firm blows. 5. Use a stethoscope to transmit sounds to the ears. , 2, 3, 4 Question 21 The nurse is assessing the nose and sinuses of a client. Which findings should the nurse identify as being within normal limits? Standard Text: Select all that apply. 1. Nose straight 2. Nares symmetrical 3. No tenderness over the bridge 4. Air movement restricted in one nare 5. Clear drainage from one nare , 2, 3 Question 22 The nurse is planning a physical examination of a client following a head-to-toe format. In which order should the nurse conduct this assessment? 1. Head, upper extremities, abdomen, lower extremities 2. Neck, head, vital signs, chest and back 3. Lower extremities, abdomen, upper extremities, chest and back 4. Head, neck, lower extremities, abdomen Question 23 The nurse is assessing the peripheral vascular status of an older client. Which finding should the nurse consider as being normal for this client? 1. Easy to palpate upper extremity arteries 2. Easy to palpate lower extremity arteries 3. Reduction in the number of varicosities 4. Increase in diastolic blood pressure Question 24 The nurse is preparing to perform an eye assessment. What equipment should the nurse have available to complete this assessment? Standard Text: Select all that apply. 1. Penlight 2. Snellens chart 3. Sterile gloves 4. Gauze square 5. Millimeter ruler , 2, 4, 5 Question 25 The nurse is preparing to conduct an assessment of the heart. Where should the nurse place the stethoscope to auscultate heart sounds? Standard Text: Select all that apply. 1. Aortic region 2. Pulmonic region 3. Tricuspid valve region 4. Abdomen 5. Mitral valve region , 2, 3, 5 Question 26 The nurse is preparing to assess a client with the Glasgow Coma Scale. Which areas is the nurse assessing in this patient? Standard Text: Select all that apply. 1. Eye response 2. Motor response 3. Verbal response 4. Orientation 5. Musculoskeletal response , 2, 3 Question 27 A client is experiencing abdominal pain. What assessments should the nurse perform to assess this complaint? Standard Text: Select all that apply. 1. Inspect the abdomen. 2. Auscultate the abdomen. 3. Palpate the abdomen. 4. Assess vital signs. 5. Assess peripheral pulses. , 2, 3, 4 Question 28 The nurse is assessing the musculoskeletal status of a 4-year-old child. What findings should the nurse consider as being expected in this client? Standard Text: Select all that apply. 1. Lordosis 2. Genu valgus 3. Genu varum 4. Pronation of the feet 5. Asymmetric leg abduction , 2 Question 29 The nurse is concerned that an older client has nutritional deficiencies. What did the nurse find when assessing this clients nails to make this clinical decision? Standard Text: Select all that apply. 1. White spots 2. Curved nails 3. Deep purple areas 4. Spoon-shaped nails 5. Bands across the nails , 4, 5 Chap 31 Question 1 The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis? 1. Disinfecting an item before adding it to a sterile field 2. Allowing sterile gloved hands to fall below the waist 3. Suctioning the oral cavity of an unconscious client 4. Touching only the inside surface of the first glove while pulling it onto the hand Question 2 The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? 1. Administering parenteral medications 2. Changing a dressing 3. Performing a urinary catheterization 4. Using personal protective equipment Question 3 The nurse is reviewing the care needs for a group of assigned clients. Which client should the nurse recognize as being most at risk for a nosocomial infection? 1. A client in the emergency department with abdominal pain 2. A 19-year-old woman in her first trimester of pregnancy 3. A 72-year-old male client with COPD 4. An 86-year-old female client on steroid therapy Question 4 The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound? 1. Adjust the diet so it contains more fruits and vegetables. 2. Apply lubricating lotion to the edges of the wound. 3. Notify the physician of any edema, heat, or tenderness at the wound site. 4. Thoroughly irrigate the wound with hydrogen peroxide. Question 5 A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client? 1. Edema, rubor, heat, and pain 2. Fever, malaise, anorexia, nausea, and vomiting 3. Palpitations, irritability, and heat intolerance 4. Tingling, numbness, and cramping of the extremities Question 6 An older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client? 1. Active bowel sounds 2. Dry intact skin 3. Intact mucous membranes 4. Susceptibility of the client Question 7 The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the clients body from microorganisms? 1. Heavy smoking 2. Moisturizing the skin 3. Breakdown of skin 4. Voiding quantity sufficient Question 8 The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity? 1. Becoming ill with tetanus and receiving tetanus toxoid 2. Having chickenpox 3. Receiving a rabies shot after being bitten by a rabid dog 4. Receiving an injection of gamma globulin Question 9 A client was bitten by a rabid raccoon. What care should the nurse prepare to provide to this client? 1. A tetanus toxoid injection 2. An immunization for rabies 3. An injection of immunoglobulin 4. Mothers breast milk with antibodies in it Question 10 The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection? 1. Assess vital signs only once daily. 2. Raise the temperature in the clients room. 3. Wash hands. 4. Wear a mask for all client care. Question 11 The nurse wants to protect a client from developing an infection. Which action should the nurse take to break a link in the chain of infection? 1. Cover the mouth and nose when sneezing. 2. Place contaminated linens in a paper bag. 3. Use personal protective equipment (PPE) sparingly. 4. Wear gloves at all times. Question 12 The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper hand-washing technique with this client? 1. Allow the water to splatter forcibly when it is turned on. 2. Clean the faucet after use. 3. Hold the hands upward under the faucet. 4. Use approximately a teaspoon of soap. Question 13 The nurse is removing personal protective equipment. Which nursing action demonstrates the appropriate technique for removing a mask? 1. Bend the strip at the top of the mask. 2. Loop the ties over the ears. 3. Tie the strings in a bow. 4. Touch the mask by the strings only. Question 14 The nurse is preparing to remove soiled gloves. What action should the nurse take first? 1. Drop the gloves into the appropriate waste receptacle. 2. Ease the fingers into the gloves. 3. Grasp the outside of the nondominant glove. 4. Hook the bare thumb inside the other glove. Question 15 The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break? 1. Grasping the edge of the outermost flap and opening it away from oneself 2. Keeping objects on the field 1 inch from the edge 3. Keeping the sterile field in eyesight 4. Transferring a sterile object to a sterile field with a clean gloved hand Question 16 A client needs to be placed in contact isolation. What items should the nurse ensure are included in this clients room? 1. Cabinet stocked with gloves and gowns 2. Cards and records 3. Paper towels, sink, and blood pressure cuff 4. Sign on the door Question 17 The RN has just been stuck with a syringe while dropping it into a sharps container that was too full in a clients room. What action should the nurse take first for this puncture wound? 1. Complete an injury report. 2. Encourage bleeding. 3. Initiate first aid. 4. Wash the area with soap and water. Question 18 The nurse is preparing to leave a clients isolation room. Which action should the nurse take first when removing a grossly soiled gown? 1. Grasp the sleeve of the dominant arm, and remove it with a gloved hand. 2. Release the neck ties of the gown and allow the gown to fall forward. 3. Untie the strings at the neck first. 4. Untie the strings at the waist first. Question 19 The nurse is preparing a presentation on standard precautions. Which statement should the nurse include in the presentation? 1. Cut the needle off a syringe after using it to give a client an injection. 2. Dispose of blood-contaminated materials in a biohazard container. 3. Gloves should not be worn for client care unless body fluids are seen. 4. Wear a mask when in direct contact with all clients. Question 20 A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease? 1. Have the client wear a mask when coming from admission. 2. Stock the supply cart at the beginning of each shift. 3. Wash the hands only after leaving the room. 4. Wear a mask when exiting the room. Question 21 The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Client is receiving intravenous fluids. 2. Client has an indwelling urinary catheter. 3. Client is recovering from surgery. 4. Client is receiving pain medication. 5. Client is ambulating twice a day with assistance. , 2, 3 Question 22 A client diagnosed with an infectious disease asks the nurse how the infection got inside her body. Which responses would be appropriate for the nurse to make? Standard Text: Select all that apply. 1. It depends on the number of organisms present to cause a disease. 2. It depends on how aggressive the organisms are to cause a disease. 3. It depends upon how the organisms get inside the body to cause a disease. 4. It depends upon where the person is at the time the disease is present. 5. It depends upon where the person works. , 2, 3, 4 Question 23 The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client? Standard Text: Select all that apply. 1. Intact and dry skin 2. Intact oral mucous membranes 3. Bowel sounds present in all four quadrants 4. Nasal congestion 5. Urinary retention , 2, 3 Question 24 A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client? 1. Social Isolation 2. Anxiety 3. Acute Pain 4. Imbalanced Nutrition: Less Than Body Requirements Question 25 A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client? 1. Anxiety 2. Acute Pain 3. Social Isolation 4. Low Self-Esteem Question 26 A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the risk of infection? Standard Text: Select all that apply. 1. Hand-washing technique 2. The importance of adequate nutrition 3. Covering the mouth and nose when coughing or sneezing 4. Increasing contact with others 5. Restricting rest period , 2, 3 Question 27 A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed assistive personnel do? 1. Assist the client with hand washing. 2. Assist the client back to bed. 3. Change the clients bed. 4. Leave the clients room. Question 28 While irrigating a clients abdominal wound, the irrigate splashes into the nurses nose and eyes. What should the nurse do? 1. Flush the nose and eyes for 5 to 10 minutes with water or normal saline. 2. Begin HIV high-risk exposure prophylaxis within 24 hours. 3. Wash the areas with soap and water. 4. Have blood drawn for hepatitis B antibodies. Question 29 The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should the nurse consider using? Standard Text: Select all that apply. 1. Triclosan 2. Chlorine (bleach) 3. Isopropyl alcohol 4. Hydrogen peroxide 5. Chlorhexidine gluconate , 3, 5 Question 30 Type: SEQ The nurse needs to apply personal protective equipment before entering a clients room. In which order should the nurse perform the following actions? Standard Text: Place the steps in the order in which they should be performed. 1. Apply gloves. 2. Apply eyewear. 3. Apply the gown. 4. Apply the face mask. 5. Perform hand hygiene. Correct Answer: 5, 3, 4, 2, 1 Chap 32 Question 1 The nurse is planning care for an older client. Which safety hazard should the nurse take into consideration when planning this care? 1. Burns 2. Drowning 3. Poisoning 4. Suffocation Question 2 The nurse is preparing materials to instruct the parents of a newborn. What should the nurse identify as a safety hazard in an infant? 1. Exposure to alcohol consumption 2. Drowning 3. Pedestrian accidents 4. Suffocation in the crib Question 3 The nurse is reviewing safety hazards with a pregnant client. What should the nurse include when instructing this client about safety and the developing fetus? 1. Banging into objects 2. Bicycle rides 3. Recreational activities 4. X-rays Question 4 The nurse would like to improve communication among caregivers. How should the nurse use the Joint Commission 2013 National Patient Safety Goals to achieve this objective? 1. Review a list of look-alike/sound-alike drugs used in the organization. 2. Use a verification process to confirm the correct procedure. 3. Report critical results of tests and diagnostic procedures on a timely basis.. 4. Use the clients room number as an identifier. Question 5 The nurse is planning care for a client who is prone to falling. Which nursing diagnoses should the nurse use for this client? 1. Deficient Knowledge 2. Risk for Injury 3. Risk for Disuse Syndrome 4. Risk for Suffocation Question 6 The nurse is identifying care goals for a client who is prone to getting hurt. Which care goal should the nurse select for this client? 1. Assess the clients mental status. 2. Keep the client dependent on the staff for all care. 3. Make all choices for the client. 4. Remain free from injury. Question 7 As a member of the safety committee, the nurses task is to identify actions to prevent falls within the organization. Which intervention should the nurse emphasize as important to prevent falls? 1. Display the phone number to the nurses station. 2. Keep electrical cords under the bed. 3. Keep the environment tidy. 4. Read label directions. Question 8 The home care nurse wants to ensure the safety of an older client who lives at home alone. Which intervention should the nurse identify as a way to prevent this client from falling? 1. Check vision every 5 years. 2. Exercise regularly. 3. Place socks on feet. 4. Turn the light on after getting out of bed. Question 9 The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. What should the nurse advise the mother to do? 1. Omit the afternoon nap. 2. Place a crib net over the top of the crib. 3. Remove all objects from around the crib. 4. Restrain the child if he gets up more than once. Question 10 While the nurse is performing morning care, a client begins to have a seizure. What should the nurse do to help this client? 1. Insert a tongue blade into the clients mouth. 2. Loosen any clothing around the neck and chest. 3. Restrain the client. 4. Turn the client to the supine position if possible. Question 11 The nurse is considering the use of restraints for a client. In which situation can the nurse apply restraints to a client? 1. Client wanders around the care area. 2. Client is picking at the access site for intravenous infusion of chemotherapy. 3. Client needed to use the bathroom and waited for help but didnt want to soil the bed and fell while attempting to walk to the bathroom. 4. Client does not want to stay in bed but wants to sit in the lounge with others. Question 12 The nurse is applying restraints to a client. After securing a health care providers order, what should the nurse do? 1. Assess the restraints every 10 minutes. 2. Pad bony prominences. 3. Secure the restraint to the side rail. 4. Tie the restraint with a square knot. Question 13 An older client diagnosed with Alzheimers disease continually tries to get out of bed at night. Which safety measure should the nurse consider using with this client? 1. Explain all procedures and treatments. 2. Place a bed safety monitoring device on the bed. 3. Orient the client to surroundings. 4. Use relaxation techniques. Question 14 The nurse is caring for a client who is confused and wanders. Which alternative to a restraint can the nurse use for this client? 1. Assign this client to the farthest room from the nurses station. 2. Place a rocking chair in the clients room. 3. Pull up all of the side rails on the bed. 4. Wedge pillows against the side rails on the bed. Question 15 The nurse is identifying outcomes for an older client prone to injuries. Which outcome should the nurse identify as appropriate for this client? 1. The client will demonstrate an understanding of all limitations. 2. The client will establish a buddy system. 3. The client will make uninformed choices when addressing health issues. 4. The client will take his medication as desired. Question 16 The nurse is reviewing safety with a home-care client. What should the nurse include in this teaching? 1. Always pull a plug at the plug-in from the wall outlet. 2. Keep plants in the home. 3. Use overloaded outlets when necessary. 4. Remove labels from containers and refill for recycling. Question 17 The nurse is attending a seminar on bioterrorism. What should the nurse identify as being the highest concern for homeland security? 1. Cancer 2. Seasonal flu 3. Tuberculosis 4. Smallpox Question 18 While eating in a restaurant, a nurse notices that a customer at the next table begins to clutch his throat while eating a steak. What should the nurse do first? 1. Ask the customer if he is choking. 2. Attempt to give five back blows. 3. Perform the Heimlich maneuver. 4. Start chest compressions. Question 19 The nurse is admitting an older client to the care area. What can the nurse do to promote a safe environment for the client? 1. Keep clutter to a minimum in the clients room. 2. Have the client wear terry-cloth slippers. 3. Provide adequate lighting. 4. Turn off alarms to reduce noise. Question 20 The nurse is determining a clients risk for injury. What should the nurse assess in this client? Standard Text: Select all that apply. 1. Age 2. Mobility 3. Hearing 4. Vision 5. Dietary intake , 2, 3, 4 Question 21 An older client is observed having difficulty moving from a sitting to standing position, and has an unsteady gait. What should the nurse assess in this client to promote home safety? Standard Text: Select all that apply. 1. Presence of grab bars in the bathroom 2. Absence of scatter rugs on the floors 3. Correct use of cane to ambulate 4. Ability to stand in place for a minute before ambulating 5. Alcohol use with prescribed medications , 2, 3 Question 22 A client is being transferred from an acute care facility to a long-term care facility. What information should the nurse provide to the long-term care facility about the clients medications? 1. Nothing, as the medications all need to be reordered at the long-term care facility. 2. Have the clients medication prescriptions filled before going to long-term care facility. 3. Instruct the client to tell the nurses at the long-term care facility what medications are prescribed. 4. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided. Question 23 A client is prescribed seizure precautions. The nurse places functioning oral suction equipment in the clients room for what reason? 1. Suctioning might be needed to prevent the aspiration of oral secretions. 2. The client has difficulty swallowing liquids. 3. There was a spare oral suction set up, and the nurse did not want to return it to the engineering department. 4. It helps when the client is brushing her teeth. Question 24 The nurse is evaluating teaching provided to a client about home safety. Which observation indicates that teaching has been effective? 1. Smoke alarm functioning with new batteries installed 2. Scatter rugs located in the kitchen and bathroom only 3. Cord for a space heater stretched across a hallway 4. Light bulbs burned out in the bathroom and living room Question 25 The nurse is installing a bed safety-monitoring device for a client. What should the nurse do after testing the device and alarm sound? 1. Place the leg band on the client with the leg in a straight horizontal position. 2. Place the sensor under the mattress near the shoulder region. 3. Set a time delay for 30 seconds. 4. Connect the sensor pad to the control unit. Question 26 A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints. Standard Text: Click and drag the options below to move them up or down. Choice 1. Pad bony prominences on the wrist. Choice 2. Apply the padded portion of the restraint around the wrist. Choice 3. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. Choice 4. Attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot. , 2, 3, 4 Question 27 The nurse is identifying activities and skills to delegate to unlicensed assistive personnel (UAP). Which action can the nurse safely delegate? 1. Provide oral fluids to a newly extubated client. 2. Irrigate the indwelling urinary catheter of a client recovering from prostate surgery. 3. Apply a wrist restraint to a client. 4. Administer oral pain medication to a client before the client attends physical therapy. Question 28 A client is prescribed seizure precautions. What can the nurse safely delegate to UAP to complete when implementing the precautions? 1. Placing a tongue blade at the head of the bed 2. Padding the clients bed 3. Installing oxygen 4. Checking the oral suction apparatus Question 29 After ambulating a client to the bathroom, the unlicensed assistive personnel did not reattach the clients bed safety-monitoring device, and the client fell out of bed. What should the nurse document? 1. Client fell out of bed; bed safety-monitoring device malfunctioning. 2. Client fell out of bed; client removed leg band of bed safety-monitoring device. 3. Client fell out of bed; no observable injuries. 4. Client fell out of bed; bed safety-monitoring device not activated. Question 30 A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this clients documentation? Standard Text: Select all that apply. 1. Who assisted the client back to bed 2. Location of the seizure 3. Duration of the seizure 4. Status of airway and use of oxygen 5. Who discovered the client , 3, 4 Question 31 The nurse is preparing to assess a client who has a history of falls. Which methods should the nurse use to assess this clients risk for injury? Standard Text: Select all that apply. 1. Cognitive awareness 2. Mobility 3. Nursing history 4. Physical examination 5. Health status , 4 Question 32 The nurse is appointed to be a member of committee whose focus is to identify and address workplace safety issues. Which issues should the nurse recommend for analysis by this committee? Standard Text: Select all that apply. 1. Lifting clients 2. Inadequate lighting 3. Bending and walking 4. Exposure to infectious agents 5. Exposure to hazardous medications , 3, 4, 5 Question 33 During a home visit, the nurse determines that a toddler is at risk for injury. What did the nurse assess to identify this clients risk? Standard Text: Select all that apply. 1. Unscreened windows 2. Electrical outlets uncovered 3. Yard with a built-in pool unfenced 4. Cleaning solution in the bottom cabinet 5. Pots on stove with handles turned inward , 2, 3, 4 Chap 34 Question 1 The nurse is assisting a client with a diagnostic test. Which role should the nurse expect to perform in the intratest phase? 1. Assess the data. 2. Collect the specimen. 3. Observe the client. 4. Prepare the client. Question 2 The nurse is teaching a client with heart failure about diagnostic tests. Which test should the nurse emphasize in this teaching? 1. BNP 2. CBC 3. LDH 4. PKU Question 3 The nurse is reviewing laboratory results for a client. Which diagnostic study determines how well blood glucose levels have been controlled in the client? 1. Blood chemistry 2. Capillary blood glucose 3. Hemoglobin A1c 4. Serum electrolytes Question 4 Which return demonstration by a client indicates that teaching about performing a blood glucose monitoring test has been effective? 1. The client punctures the fingertip. 2. The client puts on gloves. 3. The client smears the blood on the reagent strip. 4. The client washes the hands. Question 5 A client asks the nurse, Why do I have to monitor my blood glucose levels? What is an appropriate response from the nurse? 1. Because your doctor ordered it. 2. If I were you, I would monitor the blood glucose when I didnt feel good. 3. Monitoring your blood glucose better enables you to manage your diabetes. 4. You can eat anything you want. Question 6 What is the responsibility of the nurse when collecting a specimen from a client? 1. Always accompany the client to collect a specimen. 2. Handle the specimen discreetly. 3. Clean technique should be used with all specimen collection. 4. Use day-old specimens. Question 7 A client is prescribed a diagnostic test requiring a 24-hour stool specimen. What should this test indicate to the nurse? 1. Analyze the stool for dietary products and digestive secretions. 2. Detect the presence of bacteria or viruses. 3. Detect the presence of ova and parasites. 4. Determine the presence of occult blood. Question 8 A client is being treated for tuberculosis, and the doctor writes an order to collect a sputum specimen. What is the rationale behind this order? 1. To test for acid-fast bacillus 2. To assess the effectiveness of therapy 3. To identify origin, structure, function, and pathology of cells 4. To identify the specific organism Question 9 The nurse is collecting a sputum specimen from a client. Which action should the nurse take during the collection of this specimen? 1. Collect at least 30 mL of sputum. 2. Offer mouth care. 3. Take shallow breaths. 4. Wear a mask. Question 10 Which instruction should the nurse give to the client when a stool specimen is to be collected? 1. Defecate in the toilet. 2. Follow sterile technique. 3. Send at least 60 mL of specimen. 4. Void before the specimen is collected. Question 11 What should the nurse instruct a client for obtaining a clean voided urine specimen? 1. Collect at least 5 mL of urine. 2. Collect the first voided specimen in the morning. 3. Keep the specimen on ice. 4. Void in a sterile cup. Question 12 The nurse needs to obtain a sputum specimen from a client. What should the nurse have the client do? 1. Apply sterile gloves. 2. Clear the throat. 3. Cough to bring up secretions. 4. Rinse the mouth with mouthwash prior to the collection. Question 13 The nurse is preparing to collect a throat culture from a client. What client response indicates to the nurse that teaching about this test has not been effective? 1. I need to hyperextend my neck. 2. I need to say ah.’ 3. I will need to sit up. 4. The nurse will use a light. Question 14 A client is scheduled for a barium enema. What is the nursing priority for this client? 1. Assess bowel sounds. 2. Assess for allergies. 3. Cleanse the bowel. 4. Keep the client NPO. Question 15 A client is to have an echocardiogram. Which statement by the client indicates the teaching about the test has been effective? 1. Im told this test causes no discomfort. 2. I will have to walk on a treadmill. 3. I will need to remain NPO. 4. I will need to take my pulse prior to the test. Question 16 The nurse is reviewing instructions provided to a client about an upcoming cystoscopy. Which client response indicates that no further teaching is required? 1. During the procedure the physician will take x-rays. 2. I will be awake for this procedure. 3. The doctor will be able to see my kidneys. 4. The scope is a lighted instrument inserted through the urethra. Question 17 A client with tattooed eyeliner is scheduled for an MRI. What should the nurse instruct the client about this diagnostic test? 1. Earplugs will be provided. 2. Lie very still. 3. Report any burning sensation. 4. Wear goggles. Question 18 A client is having a lumbar puncture. In which position should the nurse place the client? 1. Lateral with head bent toward the chest and knees flexed onto the abdomen 2. Lying prone, with the knees drawn up toward the abdomen 3. Sitting bent over from the waist with legs extended 4. Supine with knees pulled toward the chest Question 19 A client is scheduled to have abdominal ascites fluid removed. What should the nurse instruct the client about this procedure? 1. A catheter will be inserted into the bladder. 2. A liver biopsy will be done. 3. An abdominal paracentesis will be done. 4. A thoracentesis will be done. Question 20 The nurse is providing care to a client during the posttest phase of diagnostic testing. What will the nurse do during this phase? Standard Text: Select all that apply. 1. Provide emotional and physical support to the client. 2. Compare the previous and current test results. 3. Prepare the client for the test. 4. Modify nursing interventions as necessary. 5. Report the results to appropriate health team members. , 4, 5 Question 21 The nurse needs to collect a specimen from a client; however, the nurse has never collected this type of specimen in the past. What should the nurse do? 1. Notify the physician. 2. Ask another nurse to collect the specimen. 3. Consult the nursing procedure manual. 4. Delegate the collection of the specimen to unlicensed assistive personnel. Question 22 An older client is having difficulty handling the specimen cup for a clean catch urine specimen. What can the nurse do to help this client? 1. Provide a clean funnel to pour the urine into the specimen cup. 2. Document that the specimen could not be obtained. 3. Catheterize the client for the specimen. 4. Ask the physician to obtain the specimen. Question 23 A client is scheduled for a nuclear imaging test. What should the nurse instruct the client about this test? 1. It is the use of a magnetic field to produce an image of a body part or organ. 2. A radioisotope will be injected to determine organ functioning as being either hot or cold. 3. It produces a three-dimensional image of an organ. 4. It is more sensitive than an x-ray image. Question 24 The nurse is instructing a female client on how to cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity. What should the nurse instruct this client to do? Standard Text: Select all that apply. 1. Clean the perineal area using a circular motion. 2. Use all towelettes provided. 3. Use each towelette once, and discard. 4. Clean the perineal area from back to front. 5. Clean the perineal area from front to back. , 3, 5 Question 25 Unlicensed assistive personnel (UAP) will be conducting a test on a clients urine. What should the nurse instruct the UAP about the test? Standard Text: Select all that apply. 1. Nothing, because the UAP can perform urine testing. 2. Remind the UAP to tell the client the results of the test. 3. Notify the physician with the results of the test. 4. Report the results of the test to the nurse. 5. Save the urine, in case the nurse wants to repeat the test. , 5 Question 26 A client is having a timed urine collection done. The unlicensed assistive personnel does not save one specimen. What should the nurse do? 1. Continue with the test, and document that one specimen is missing. 2. End the test immediately, and send what is collected to the laboratory. 3. Document that the test cannot be completed. 4. Start the test over. Question 27 The nurse is caring for a client who has just had a lumbar puncture. What should the nurse document about this clients procedure? Standard Text: Select all that apply. 1. Date and time performed 2. The physicians name 3. The clients ability to void after the procedure 4. The color, character, and amount of cerebrospinal fluid withdrawn 5. The clients status after the procedure , 2, 4, 5 Question 28 A client has just completed a bone marrow biopsy. What should the nurse document about the client at this time? Standard Text: Select all that apply. 1. Clients tolerance of the procedure 2. Bowel sounds 3. The site for bleeding 4. Status of deep tendon reflexes 5. Presence of pain and any pain medication received , 3, 5 Question 29 A client is scheduled for a bronchoscopy. What should the nurse instruct the client about this procedure? Standard Text: Select all that apply. 1. Tissue samples may be taken for biopsy. 2. Eating will not be permitted for 12 hours. 3. A local anesthetic is sprayed on the throat. 4. Bed rest for 8 hours is necessary after the test. 5. Informed consent is required for this procedure. , 3, 5 Question 30 The nurse needs to obtain a urine specimen from a client with an indwelling urinary catheter. What should the nurse do when collecting this specimen? Standard Text: Select all that apply. 1. Withdraw 30 mL of urine for a routine urinalysis. 2. Perform catheter care before obtaining the specimen. 3. Apply sterile gloves before retrieving the urine specimen. 4. Send the specimen immediately or refrigerate it for later pickup. 5. Clamp the drainage tubing for 30 minutes if there is no urine in the catheter. , 4, 5 Chap 44 Question 1 The nurse is assisting in logrolling a client recovering from spinal surgery. Why should the nurse place a pillow between the clients legs when turning? Standard Text: Select all that apply. 1. Stabilizes the spine 2. Prevents hip contractures 3. Supports the upper leg 4. Keeps the legs parallel and aligned 5. Prevents adduction of the upper leg , 4, 5 Question 2 During a prenatal visit, the nurse is instructing a newly pregnant client in regard to exercise. What advice is best for the nurse to give this client? 1. Pregnant clients can exercise if exercise was a part of their life prior to pregnancy. 2. Due to the stress of a growing fetus, exercise should be limited to no more than 10 minutes per day. 3. Healthy pregnant women should exercise at least 30 minutes on most if not all days. 4. The pregnant womans exercise should actually increase above normal recommended levels to prevent water weight gain. Question 3 The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client? 1. Institute an exercise plan that includes weight-bearing activities. 2. Increase the amount of calcium in the clients diet. 3. Protect the clients bones with strict bed rest. 4. Provide the client with assisted range-of-motion exercising twice daily. Question 4 The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this clients plan of care? 1. Frequent position changes to reverse the contractures 2. Exercises to strengthen flexor muscles 3. Range-of-motion exercises to prevent worsening of contractures 4. Weight-bearing activities to stimulate joint relaxation Question 5 The nurse has documented that the client has orthostatic hypotension. Which assessment finding would support this assessment? 1. Decrease in blood pressure when moving from supine to standing 2. Decrease in heart rate when moving from supine to sitting 3. Pale color in the legs when lying in bed 4. Complaints of dizziness when first sitting up Question 6 The clients chief complaint is, I just cant get around like I used to. I have to stop halfway up the stairs to the bedroom, and just walking to the bathroom makes me so tired. Which nursing diagnosis is most likely appropriate for this client? Activity Intolerance: 1. Level 1. 2. Level 2. 3. Level 3. 4. Level 4. Question 7 The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should take which action? 1. Include what mobility is impaired. 2. Use Level 1, 2, 3, or 4 to describe immobility. 3. Describe what happens when the client attempts mobility. 4. Add strength assessment data. Question 8 The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? 1. Nurses must wear back belts when lifting clients. 2. All nursing personnel must attend annual body mechanics education. 3. In order to prevent injury, nurses must strive to become physically fit. 4. No solo lifting of clients is permitted in the facility. Question 9 The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. Which technique should the nurse use to protect the back? 1. Place the feet together to provide a strong base of support. 2. Flex the knees to lower the center of gravity. 3. Face the box, pick it up, and rotate the upper body toward the table. 4. Hold the box as close to the body as possible. Question 10 The nurse is caring for a client experiencing dyspnea. In which position should the nurse place this client? 1. High Fowlers position with two pillows behind the head 2. Orthopneic position across the overbed table 3. Prone position with knees flexed and arms extended 4. Sims position with both legs flexed Question 11 While assisting the client with a bath, the nurse encourages full range of motion in all the clients joints. Which activity would best support range of motion in the hand and arm? 1. Give the client a washcloth to wash the face. 2. Move the wash basin farther toward the foot of the bed so the client must reach for it. 3. Have the client brush the hair and teeth. 4. Move each of the clients hand and arm joints through passive range of motion. Question 12 The bed-bound client complains of pain and burning in the right calf area. What action should be taken by the nurse? 1. Deeply palpate the area for rebound tenderness. 2. Percuss over the area for change in tone. 3. Measure the calf and compare to the opposite calf. 4. Medicate the client for pain and reassess in 30 minutes. Question 13 The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse? 1. Percuss for flatness over the liver. 2. Palpate for bladder fullness. 3. Use the p.r.n. order to medicate the client with an antacid. 4. Inspect the sacral area for edema. Question 14 The client who is unconscious is developing foot drop. What nursing action is indicated? 1. Place high-topped shoes on the client while in bed. 2. Keep the linens on the end of the bed turned back to expose the feet. 3. Use only the prone and Sims positions for client positioning. 4. Use a device to elevate the linens off the feet. Question 15 The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? Standard Text: Select all that apply. 1. Place a turn sheet on the bed. 2. Always use two personnel to move the client. 3. Stand at the head of the bed to pull the client up. 4. Slide the client toward the head of the bed. 5. Encourage the client to assist as possible. , 2, 5 Question 16 The nurse is preparing to assist a client to a lateral position to position a bedpan. What action should the nurse take first? 1. Perform hand hygiene. 2. Move the client to the side of the bed. 3. Place the clients arm over the chest. 4. Raise the opposite side rail. Question 17 When planning care, the nurse should identify which client as needing logrolling for position changes? 1. A client with documented pneumonia 2. The client who has had abdominal surgery 3. The client who fell from a house, sustaining a fractured tibia 4. A client who has a severe headache from hypertensive crisis Question 18 The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? 1. Toward the nearest corner of the head of the bed 2. Toward the side of the bed 3. Toward the far corner of the foot of the bed 4. Directly toward the client Question 19 What is the priority action of the nurse prior to transferring a client from bed to wheelchair? 1. Place the bed in its lowest position. 2. Place the wheelchair parallel to the bed. 3. Lock the brakes on the bed. 4. Place a transfer belt on the client. Question 20 The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed is parallel to the stretcher and 1. slightly higher. 2. slightly lower. 3. at the same height. 4. at least 2 inches lower. Question 21 The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? 1. The UAP 2. A licensed practical (vocational) nurse 3. A registered nurse 4. It makes no difference Question 22 The nurse is assisting a newly delivered mother in ambulating to the nursery to see the baby. The client complains of light-headedness and begins to faint. What is the nurses most important action? 1. Ensure the clients modesty as she falls. 2. Be certain the client does not hit the head on anything. 3. Call for immediate assistance. 4. Check the vital signs and for excessive vaginal bleeding. Question 23 The nurse is providing range-of-motion exercising to the clients elbow when the client complains of pain. What action should the nurse take? 1. Stop immediately and report the pain to the clients physician. 2. Discontinue the treatment and document the results in the medical record. 3. Reduce the movement of the joint just until the point of slight resistance. 4. Continue to exercise the joint as before to loosen the stiffness. Question 24 The client has a history of postural hypotension. Which activities should the nurse advise this client as likely to cause postural hypotension? Standard Text: Select all that apply. 1. Hot baths 2. Heavy meals 3. Use of a rocking chair 4. Moving in bed 5. Bending down to the floor , 2, 5 Question 25 The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching? Standard Text: Select all that apply. 1. Hold the cane on the weaker side of the body. 2. Move the cane forward while the body weight is between both legs. 3. The length of the cane should permit the elbow to be fully extended. 4. Move the weaker leg forward while the weight is between the cane and the stronger leg. 5. Move the stronger leg forward while the weight is between the cane and the weaker leg. , 4, 5 Chap 47 Question 8 The nurse has instructed an overweight client to follow a 2,000-calorie diet by substituting foods considered low in calories for those higher in calories. How should the client interpret the food label to decide if a food is low in calories? 1. The product label will state lighter or reduced calories. 2. The Nutrition Facts label will have the letter L located in the lower right corner. 3. Nutritional labeling on the product will indicate less than 40 calories per serving. 4. The product will contain no more than 11% fat. Question 9 Type: MCSA Nitrogen balance testing is planned for a client. What instruction to the staff caring for this client is essential? 1. Remove the clients oxygen cannula 10 minutes prior to the test. 2. Accurate measurement of food intake is very important. 3. All urine output should be collected for 48 hours. 4. Keep the client NPO beginning at midnight before the test. Chap 50 Question 1 Type: MCSA The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the client? 1. The ability to cough 2. Filtration and humidification of inspired air 3. The sneeze reflex initiated by irritants in the nasal passages 4. Decrease in oxygen-carrying capacity of the trachea Question 2 When planning care, for which client should the nurse include close observation for a decreased or absent cough reflex? 1. The client with a nasal fracture 2. The client with impairment of vagus nerve conduction 3. The client with a sinus infection 4. The client with reduction in respiratory membrane conduction Question 3 The client complains of difficulty breathing. Which assessment findings should the nurse associate with that complaint? 1. Use of accessory muscles 2. Increased respiratory depth 3. Increased respiratory rate 4. Decreased respiratory depth 5. Decreased respiratory rate , 2, 3, 4 Question 4 The client has been admitted with complaints of shortness of breath of 2 weeks duration and has received the nursing diagnosis Impaired Gas Exchange. Which admission laboratory result would support the choice of this diagnosis? 1. Increased hematocrit 2. Decreased BUN 3. Increased blood sugar 4. Increased sedimentation rate Question 5 A client diagnosed with chronic obstructive lung disease who is receiving oxygen at 1.5 liters per minute via nasal cannula is complaining of shortness of breath. What action should the nurse take? 1. Increase the oxygen to 3 liters per minute via nasal cannula. 2. Lower the head of the clients bed to the semi-Fowlers position. 3. Have the client breathe through pursed lips. 4. Encourage the client to breathe more rapidly. Question 6 After learning of a terminal illness and life expectancy, the client begins to hyperventilate and complains of being light-headed with the fingers, toes, and mouth tingling. What action should be taken by the nurse? 1. Prepare to resuscitate the client. 2. Have the client concentrate on slowing down respirations. 3. Place the client in Trendelenburgs position and ask him to cough forcefully. 4. Administer 25 mg of meperidine (Demerol) according to the prn pain order. Question 7 Type: MCSA The client is experiencing severe shortness of breath, but is not cyanotic. What laboratory value should the nurse review in an attempt to understand this phenomenon? 1. Blood sugar 2. Hemoglobin and hematocrit 3. Cardiac enzymes 4. Serum electrolytes Question 8 A client has a medical condition that often results in the development of metabolic acidosis. The nurse should observe this client for the development of which breathing pattern as a result of this condition? 1. Cheyne-Stokes 2. Biots 3. Cluster 4. Kussmauls Question 9 Upon assessment, the nurse notes that a client has dyspnea, crackles in both lung bases, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details? 1. Ineffective Breathing Pattern 2. Anxiety 3. Ineffective Airway Clearance 4. Impaired Gas Exchange Question 10 The nurse encourages the client to expectorate sputum rather than swallowing it. What is the rationale for this direction? 1. Sputum contains bacteria that should be expectorated. 2. Swallowing sputum is dangerous to the system. 3. The nurse should view the sputum for quality and quantity. 4. The client is likely to aspirate the sputum while attempting to swallow it. Question 11 The nurse is planning a time schedule for a clients twice-daily postural drainage. Which time schedule would be best? 1. 0800 and 1100 2. 1200 and 1800 3. 0700 and 2000 4. 0900 and 2100 Question 12 A client is receiving oxygen by nonrebreather mask, but the bag is deflating on inspiration. What action should be taken by the nurse? 1. Turn the client to the left side. 2. Increase the percentage of oxygen being delivered. 3. Check for an airtight seal between the clients face and the mask. 4. Increase the liter flow of oxygen being delivered. Question 13 The nurse has placed an oropharyngeal airway in a client. What action should the nurse take at this time? 1. Tape the airway in place. 2. Suction the client. 3. Turn the clients head to the side. 4. Insert a nasal trumpet. Question 14 A client has a newly created tracheostomy for mechanical ventilation after a surgical procedure. What action should the nurse plan for this client? 1. Deflate the cuff of the tracheostomy tube every 2 hours for 5 minutes. 2. Remove the tracheostomy ties and replace them with an elastic bandage. 3. Remove the tracheostomy inner cannula. 4. Tape the tracheostomy obturator to the head of the bed. Question 15 The nurse needs to hyperinflate a client prior to suctioning. How should the nurse proceed with this requirement? 1. Turn the suction level up to 60 cm prior to inserting the catheter. 2. Increase the oxygen flow to the client by 20% prior to suctioning. 3. Provide 2 to 3 breaths at 1.5 times the tidal volume prior to suction. 4. Instruct the client to cough forcefully from the abdomen prior to suction. Question 16 The nurse who is assessing a clients chest tube insertion site notices a fine crackling sound and feeling upon palpating the area. What action should the nurse take? 1. Discontinue the chest tube suction. 2. Collaborate with the clients physician. 3. Mark the area involved and remove the tube. 4. Reinforce the chest tube dressing. Question 17 The nurse is preparing to assist with the removal of a chest tube that is a simple insertion without a purse-string suture. What materials should the nurse gather for this procedure? 1. An occlusive dressing 2. A 4 4 gauze 3. An adhesive gauze pad dressing 4. A non-adherent gauze dressing Question 18 The nurse has completed discharge teaching for a client who will be going home on oxygen therapy. What statement made by the client would indicate that this client needs further instruction? 1. I will replace my cotton blankets with polyester ones. 2. My son will not be able to smoke when I am around. 3. I will have my electrical appliance checked for grounding. 4. I will buy a fire extinguisher for my bedroom. Question 19 A client with a nasotracheal tube in place has been restless and pulling at the tube. How should the nurse assess if the tube is still in place? 1. Count the clients respirations. 2. Assess the depth of the clients respirations. 3. Auscultate for bilateral breath sounds. 4. Deflate the cuff and listen for minimal leak. Question 20 The nurse has just initiated oxygen by nasal cannula for a client with the medical diagnosis of chronic obstructive pulmonary disease. What is the nurses next action? 1. Fill the humidifier with normal saline. 2. Pad the tubing where it contacts the clients ears. 3. Set the oxygen delivery to 5 liters. 4. Secure the cannula with ties around the clients head. Question 21 The nurse who is performing care for a client with a new tracheostomy needs to change the ties. What is the best method for changing these ties? 1. Remove the old ties, clean the area well, and then put on new ties. 2. Attach the new tape and tie with a square knot behind the clients neck. 3. Have an assistant hold the tracheostomy tube in place, remove the soiled ties, and replace the ties. 4. Remove the outer cannula, replace the soiled ties, and reinsert. Question 22 The nurse is planning the care of a client who has need for frequent suctioning. What should the nurse delegate to the UAP? 1. Both oral and tracheal suctioning 2. Only oral suctioning 3. Only tracheal suctioning 4. Neither oral nor tracheal suctioning Question 23 During tracheal suctioning, the nurse notes that the client heart rate has increased from 80 to 100 bpm. Based upon this assessment, what action should the nurse take? 1. Immediately discontinue suctioning. 2. Prepare to resuscitate the client. 3. Continue to suction until the airway is clear. 4. Complete the suction episode as quickly as possible. Question 24 A client who is being mechanically ventilated has copious amounts of secretions ranging from thick and tenacious to frothy. In preparing to suction this client, the nurse should take which action? 1. Hyperventilate the client using the settings on the mechanical ventilator. 2. Hyperventilate the client using a manual resuscitator. 3. Avoid hyperventilation, but instill normal saline into the endotracheal tube. 4. Avoid hyperventilation and increase the oxygen to 100% for several breaths. Question 25 A client has been prescribed both a bronchodilator and a steroid medication that is delivered by inhaler. What information is essential to teach this client in regard to these medications? 1. The medications cannot be used on the same day. 2. The steroid inhaler should be used when immediate effects are necessary. 3. The bronchodilator should be used only when absolutely necessary and only after the steroid inhaler. 4. Both medications have the possible side effect of increased heart rate. Question 26 A client complains of difficulty breathing. What will the nurse most likely assess in this client? Standard Text: Select all that apply. 1. Use of accessory muscles 2. Increased respiratory depth 3. Increased respiratory rate 4. Decreased respiratory depth 5. Decreased respiratory rate , 2, 3, 4 Question 27 A client who was a victim of a house fire is coughing. The nurse realizes that the purpose of the cough is to 1. improve oxygenation. 2. remove irritants from the nasal passages. 3. remove irritants from the trachea or bronchi. 4. close the glottis. Question 28 A client is experiencing atelectasis. The nurse anticipates that this client will have an alteration in 1. Ventilation. 2. Alveolar gas exchange. 3. Transportation of oxygen and carbon dioxide. 4. Systemic diffusion. Question 29 A client is demonstrating signs of hypoxia. What laboratory value will help the nurse determine the clients degree of effective gas exchange? 1. Blood glucose 2. Serum potassium 3. Serum sodium 4. Arterial blood gas Question 30 The nurse is determining a clients ability to transport oxygen from the lungs to body tissues. What factors will influence this ability? Standard Text: Select all that apply. 1. Cardiac output 2. Exercise 3. Diet 4. Erythrocyte count 5. Hematocrit , 2, 4, 5 Question 31 A clients blood gas analysis results show an increase in carbon dioxide level. What will the nurse most likely assess in this client? 1. Decreased respiration rate 2. Increased respiration rate 3. Increased blood pressure 4. Decreased bowel sounds Question 32 A clients blood gas results reveal a low oxygen level. The nurse realizes that which area of the body will respond to this level and influence respirations? 1. Alveoli 2. Trachea 3. Bronchioles 4. Carotid bodies Question 33 An older client is prescribed diazepam (Valium). What should the nurse monitor in this client? 1. Respirations 2. Urine output 3. Muscle tone 4. Appetite Question 34 The nurse is assessing an older client. What effects of aging should the nurse keep in mind during this assessment? Standard Text: Select all that apply. 1. Decreased cough reflex 2. Stiffening of blood vessels 3. Alteration in protein synthesis 4. Dry mucous membranes 5. Increased risk of aspiration , 4, 5 Question 35 A client is diagnosed with congestive heart failure. The nurse should assess the client for which conditions that can alter this clients respiratory function? 1. Conditions that affect the airway. 2. Conditions that affect transport. 3. Conditions that affect the movement of air. 4. Conditions that affect diffusion. Question 36 The nurse is conducting a health history for a client with a respiratory disorder. What should the nurse include in this assessment? Standard Text: Select all that apply. 1. Lifestyle 2. Presence of cough 3. Sputum production 4. Pain 5. Diet , 2, 3, 4 Question 37 A client is concerned about maintaining a healthy respiratory system. What should the nurse instruct the client to do to promote a healthy respiratory status? Standard Text: Select all that apply. 1. Use pursed-lip breathing. 2. Exercise regularly. 3. Do not smoke. 4. Breathe through the nose. 5. Breathe through the mouth. , 3, 4 Question 38 Which client statement indicates to the nurse that instruction about the use of a humidifier has been effective? 1. A humidifier takes moisture out of the air. 2. A humidifier tightens secretions. 3. A humidifier prevents my lungs from getting too dry. 4. A humidifier replaces the use of oxygen. Question 39 The nurse documents that a prescribed expectorant has been effective for a client. What did the nurse evaluate in this client? 1. Respiratory rate 24 and labored 2. Audible wheeze upon auscultation 3. High-pitched cough present 4. Presence of a productive cough Question 40 The nurse is performing nasotracheal suctioning of a client. What should the nurse do when suctioning this client? 1. Apply suction for 510 seconds. 2. Plan to suction for 10 minutes. 3. Apply suction while inserting the catheter. 4. Apply suction for 2030 seconds. Question 41 The nurse wants to delegate the Yankauer suctioning of a client to UAP. What will the nurse ensure that UAP know before delegating this activity? 1. How to apply suction during the insertion of the catheter 2. Not to apply suction during the insertion of the catheter 3. How to maintain sterile technique 4. How to listen for lung sounds Question 42 The nurse has completed nasopharyngeal suctioning of a client. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Amount, consistency, color, and odor of sputum 2. Amount of sterile solution used to flush the catheter 3. Lung sounds before the procedure 4. Lung sounds after the procedure 5. Oxygen saturation after the procedure , 3, 4, 5 Question 43 The nurse is documenting the completion of tracheostomy suctioning and tracheostomy care in a clients medical record. What should this documentation include? Standard Text: Select all that apply. 1. Lung sounds before and after suctioning 2. Characteristics of suctioned sputum 3. Integrity of the skin around the stoma 4. Side on which the tracheostomy tie knot is located 5. Flow rate of oxygen , 2, 3, 5 Question 44 The nurse is planning care for a client who was admitted after having a myocardial infarction. Based upon this history, the nurses greatest concern is that this client might develop which health problem? 1. Chronic renal failure 2. A gastric ulcer 3. Hypoxemia 4. A cerebral vascular accident Question 45 Before administering the prescribed medication propranolol (Inderal) to a client, the nurse contacts the health care provider to question the order. What health problems did the client have that caused the nurse to question the medication order? Standard Text: Select all that apply. 1. COPD 2. Asthma 3. Arthritis 4. Gastritis 5. Heart failure , 2 Question 46 The nurse is planning care for a client with an oral endotracheal tube. Which interventions should be included in this clients plan of care? Standard Text: Select all that apply. 1. Insert an oropharyngeal airway. 2. Provide nasal care every 2 to 4 hours. 3. Provide oral hygiene every 2 to 4 hours. 4. Adjust non-humidified airflow as prescribed. 5. Move the tube to opposite sides of the mouth every 8 hours. , 2, 3, 5 Chap 51 • The nurse is planning teaching for a client that focuses on Healthy People 2020 objectives for cardiovascular health. Which modifiable risk factors should the nurse include in this teaching? Standard Text: Select all that apply. 1. Age 2. Gender 3. Obesity 4. Smoking 5. Hypertension , 4, 5 • What dietary teaching should the nurse provide to the client who has homocysteine elevation? 1. Reduce salt intake. 2. Take a B-complex vitamin supplement daily. 3. Increase fluid intake to 2,000 mL per day. 4. Avoid alcohol intake. • The client has a history of recurrent transient ischemic attack (TIA). Based upon this history the nurse should be most concerned about the clients potential to develop 1. renal failure. 2. gangrene. 3. myocardial infarction. 4. stroke. • The nurse is assessing a newly admitted client for the presence of impaired peripheral arterial circulation. Which finding would be significant to this condition? 1. Ruddy skin color over legs 2. Bounding pedal pulses 3. Hot spots on the feet and legs 4. Decreased hair on the legs • The client is admitted with a possible deep vein thrombosis. Nursing interventions should be designed to prevent which complication? 1. Myocardial infarction 2. Renal failure 3. Pulmonary embolism 4. Pneumonia • A client is diagnosed with anemia. What will the nurse most likely assess in this client as evidence of an alteration in cardiovascular functioning? Standard Text: Select all that apply. 1. Chronic fatigue 2. Lower-extremity edema 3. Pallor 4. Shortness of breath 5. Hypotension , 3, 4, 5 Chap 52 Question 1 Type: MCSA The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have not yet been successful and should continue? 1. 35 mL per hour 2. 80 mL per hour 3. 50 mL per hour 4. 30 mL per hour Question 2 Type: MCSA The nurse suspects that a clients body is attempting to correct an acidbase imbalance. How will this imbalance be corrected? 1. Slow but efficient respiratory regulation will occur. 2. Primary regulation is through GI system losses. 3. Kidney regulation is powerfully effective. 4. The cardiovascular system is the major buffer. Question 3 Type: MCSA The nurse is caring for a client who is recovering from surgery. Which intervention should the nurse implement to decrease the clients possibility of developing hypercalcemia? 1. Measure vital signs every 4 hours. 2. Assist the client to turn, cough, and deep breathe every 2 hours. 3. Assist the client to ambulate around the room at least three times daily. 4. Irrigate the clients nasogastric tube every 2 hours. Question 4 Type: MCSA The client is admitted to the acute care unit with a phosphorus level of 2.3 mg/dL. Which nursing intervention would support this clients homeostasis? 1. Encourage consumption of milk and yogurt. 2. Enforce strict isolation protocols. 3. Encourage consumption of a high-calorie carbohydrate diet. 4. Strain all urine. Question 5 Type: MCSA The mother of a 1-month-old infant is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infants mother? 1. Have the infant be seen by a physician 2. Give the infant at least 2 ounces of juice every 2 hours. 3. Measure the infants urine output for 24 hours. 4. Provide the infant with 50 mL of glucose water. Question 6 Type: MCSA A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this clients care? 1. Presence of bibasilar crackles 2. Tachycardia 3. Decreased pedal pulses 4. Headache Question 7 Type: MCSA The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic controller. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of drops per milliliter of fluid the tubing delivers. Where should the nurse look for this information? 1. On the packaging of the tubing 2. In the charting from the nurse who started the infusion 3. In the drug reference book 4. On the roller clamp of the tubing Question 8 Type: FIB The physician has ordered 50 mL of an IV solution to infuse over the next 20 minutes. In order to accurately infuse this solution, the nurse should set the electronic controller to deliver how many mL/hr? Standard Text: Record your answer, rounding to the nearest whole number. 50 mL/hr Question 9 Type: FIB The nurse is to administer 75 mL of an antibiotic solution by IV over the next 30 minutes. The tubing has a drop factor of 20. How many drops per minute should the nurse set the controller to deliver? Standard Text: Record your answer, rounding to the nearest whole number. Correct Answer: 50 drops per minute Question 10 Type: MCSA The nurse is caring for a client who is receiving IV therapy at a rate of 10 mL/hour. The 500-mL IV bottle was hung at 0900 Monday morning when the IV catheter was initiated. It is now 0900 on Tuesday morning. What nursing action should be taken? 1. Refigure the rate of the IV. 2. Infuse the remaining IV fluid before hanging a new bag. 3. Discard the remaining IV fluid and hang a new bag. 4. Discontinue the IV site and restart an IV in the opposite hand. Question 11 Type: MCSA A client tells the nurse about passing out after following a fasting diet for 5 days. Which acidbase imbalance should the nurse expect to assess in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis Question 12 Type: MCSA A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results should the nurse expect to find in this client? 1. pH 7.30; PaCO2 50; HCO3 27 2. pH 7.47; PaCO2 43; HCO3 28 3. pH 7.43; PaCO2 50; HCO3 28 4. pH 7.47; PaCO2 30; HCO3 23 Question 13 Type: MCSA The clients arterial blood gas report reveals a pH of 6.58. How does the nurse evaluate this value? 1. There is a slight elevation. 2. This value is incompatible with life. 3. This is a low normal value. 4. This value is extremely elevated. Question 14 Type: MCSA A client has experienced a narcotic overdose. What acidbase imbalance should the nurse expect to observe in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis Question 15 Type: MCSA Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority? 1. Notify the clients physician. 2. Discontinue the transfusion. 3. Slow the rate of the transfusion. 4. Prepare to resuscitate the client. Question 16 Type: MCSA A client on diuretic therapy has a serum potassium level of 3.4 mg/dL. Which food should the nurse encourage this client to choose from the dinner menu? 1. Baked chicken 2. Green beans 3. Cantaloupe 4. Iced tea Question 17 Type: MCSA A client has orders for the administration of IV fluid at a keep vein open rate in preparation for administration of IV antibiotics starting at noon. When the nurse goes to the room to start the IV, the UAP is preparing to bathe the client. What should the nurse do? 1. Instruct the UAP to wait until the IV is started to bathe the client. 2. Let the UAP start the bath on the opposite side of where the nurse will be starting the IV. 3. Tell the UAP to notify the nurse as soon as the bath is completed. 4. Give the UAP permission to skip the clients bath for today. Question 18 Type: MCSA The nurse is preparing to start an IV in the hand of a client who has very small veins. Which actions would be useful in dilating the veins? 1. Position the hand at heart level. 2. Stroke the vein. 3. Have the client clench and unclench the fist. 4. Slap the back of the clients hand. 5. Massage the vein. , 3, 5 Question 19 Type: MCSA The client complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly reddened, but not warmer than the surrounding skin, and without swelling. What action should be taken by the nurse? 1. Slow the IV infusion and reassess the area in 15 minutes. 2. Apply ice over the IV site and vein. 3. Discontinue the IV and place a warm pack on the area. 4. Call the physician for direction. Question 20 Type: MCSA The client who has an IV with an intermittent infusion lock in place wishes to shower. What action should be taken by the nurse? 1. Have the UAP discontinue the lock. 2. Cover the lock with an occlusive dressing. 3. Place a piece of cloth tape under the lock, wrapping the top in a U shape. 4. Tell the client that a bed bath is necessary until the IV is discontinued. Question 21 Type: MCSA The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV fluid should be used to initiate the IV for this transfusion? 1. 1,000 mL of lactated Ringers solution 2. 250 mL of normal saline 3. 500 mL of 5% dextrose and water 4. 100 mL of 5% dextrose and 1/2 normal saline Question 22 Type: MCSA After obtaining a unit of packed red blood cells for a client, the nurse learns the client needed to leave the care area for an emergency x-ray. What action should the nurse take? 1. Set up the blood with the IV fluid and y-tubing and place it on the IV stand in the clients room to initiate immediately after the client returns. 2. Place the blood in the unit refrigerator until the client returns. 3. Return the blood to the laboratory blood bank until the client returns. 4. Set up the blood with the IV fluid and y-tubing and place it in the unit medication room to initiate immediately after the client returns. Question 23 Type: MCSA The nurse initiates a blood transfusion for a client. What action should the nurse take next? 1. Stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. 2. Assign the UAP to sit with the client for 15 minutes. 3. Advise the client to notify the nurse if he experiences any chilling, nausea, flushing, or rapid heart rate. 4. Return to the room and take a set of vital signs in 15 minutes. Question 24 Type: MCSA The nurse is providing discharge instructions to a client who has been started on furosemide (Lasix) once daily. What information is essential to include in this information? 1. Take the medication at bedtime. 2. Avoid high-potassium foods. 3. Stand up slowly from a sitting position. 4. Do not take this medication on the days you take digitalis (Lanoxin). Question 25 Type: MCSA The nurse is reviewing orders for parenteral potassium. Which order is safe for the nurse to implement? 1. Add 20 mEq of KCL to 1,000 mL of IV fluid 2. 10 mEq KCL IV over 12 minutes 3. Dilute 20 mEq KCL in 3 mL of NS and give IV push 4. 10 mEq KCL SQ Question 26 Type: MCSA The client has been placed on a 1200-mL oral fluid restriction. How should the nurse plan for this restriction? 1. Allow 600 mL from 73, 400 mL from 311, and 200 mL from 117. 2. Instruct the client that the 1200 mL of fluid placed in the bedside pitcher must last until tomorrow. 3. Offer the client softer, cold foods such as sherbet and custard. 4. Remove fluids from diet trays and offer them only between meals. Question 27 Type: MCSA The nurse is caring for an 80-year-old client with the medical diagnosis of heart failure. The client has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client? 1. Heart Failure related to edema, as evidenced by confusion 2. Fluid Volume Deficit related to loss of fluids, as evidenced by edema 3. Excess Fluid Volume related to retention of fluids, as evidenced by edema and orthopnea 4. Excess Fluid Volume related to congestive heart failure, as evidenced by edema and confusion Question 28 Type: MCSA The nurse wants to assess a client for orthostatic hypotension. What action should the nurse take? 1. Assess the client for dependent edema and then raise the legs to the level of the heart and reassess for edema. 2. Measure the clients heart rate and blood pressure in both the sitting and standing position. 3. Measure the clients blood pressure before, during, and after administration of a normal saline fluid challenge. 4. Raise the clients legs above heart level and measure the blood pressure. Question 29 Type: MCSA The nurse is caring for a client who is being mechanically ventilated. Arterial blood gas analysis reveals respiratory acidosis. Which change in ventilator settings should the nurse anticipate? 1. Decrease in oxygen delivery 2. Decreased tidal volume of each breath 3. Increased respiratory rate 4. Increase in humidification of inspired air Question 30 Type: MCSA An older client receiving intravenous fluids at 175 ml/hr is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as being which complication of intravenous fluid therapy? 1. An allergic reaction to the antibiotics in the fluid 2. Fluid volume excess 3. Pulmonary embolism 4. Speed shock Question 31 Type: MCMA A client sustained a significant loss of blood after a motor vehicle accident. The nurse notes that the clients urine output has decreased and suspects that which hormones have influenced this clients fluid balance? Standard Text: Select all that apply. 1. Aldosterone 2. Angiotensin 3. Antidiuretic hormone 4. Estrogen 5. Progesterone Question 32 Type: MCMA A client tells the nurse about rarely feeling thirsty. The nurse realizes that further assessment is needed to evaluate Standard Text: Select all that apply. 1. status of osmotic pressure. 2. vascular volume. 3. presence of angiotensin. 4. urine output. 5. body weight. Question 33 Type: MCMA The nurse is preparing to discontinue a clients intravenous infusion. Which actions should the nurse take when removing the catheter from the vein? Standard Text: Select all that apply. 1. Pull the catheter out in line with the vein 2. Apply pressure to the site while removing the catheter. 3. Pull the catheter out at an angle perpendicular to the vein. 4. Bend the clients elbow if bleeding at the site persists after removal. 5. Apply pressure to the site after the catheter is removed for 2 to 3 minutes. Question 34 Type: MCMA A client is receiving a continuous intravenous infusion. What should the nurse document in the medical record about this infusion? Standard Text: Select all that apply. 1. Latest body temperature 2. Type of solution and flow rate 3. Total intravenous intake for the shift 4. Status of the intravenous catheter site 5. Results of blood pressure measurement