A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration.
The nurse auscultates a high- pitched scratching sound during both systole and diastole with the
diap
...
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration.
The nurse auscultates a high- pitched scratching sound during both systole and diastole with the
diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document?
A. Audible Click
B. Murmur
C. Third heart sound
D. Pericardial friction rub
A nurse is obtaining the blood pressure in a client's lower extremity.
Which of the following action should the nurse take?
A. Auscultate for the blood presure at the dorsalis pedis artery.
B. Measure the blood pressure with the client sitting on the side of the bed.
C. Place the cuff 7.6cm (3in) above the popliteal artery.
D) place the bladder of the cuff over the posterior aspect of the thigh
A charge nurse is teaching adult cardiopulmonary resusciation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
A. Call for assisstance
B. Begin Chest compressions
C. Confirm unresponsiveness.
D. Give rescue breaths.
C) Confirm unresponsiveness
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported
for the procedure, which of the following actions should the nurse take first?
A. Explain the x-ray procedure to the client.
B. Help the client into a wheelchair before the transporter arrives.
C. Ask if the client has any questions.
D) Identify the client using to identifiers
A nurse is caring for a child who is postoperative following a tonsillectomy.
Which of the following actions should the nurse take?
A. Encourage the child to cough frequently to clear congestion from anesthesia.
B. Place a heating pad at the child's neck for comfort.
C. Administer analgesics to the child on a routine schedule throughout the day and night.
D. Provide the child with ice cream when oral intake is initiated.
A nurse is providing teaching to a client who has heart failure about how to reduce his daily
intake of sodium.
Which of the following factors is the most important in determining the client's ability to learn
new dietary habits?
A. The involvement of the client in planning the change.
B. The emphasis the provider places on the dietary changes.
C. The learning theory the nurse uses to teach the dietary changes.
D. The extent of the dietary changes planned for the client.
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.
Which of the following actions by the newly licensed nurse requires intervention?
A. Obtaining hydrogen peroxide for the trachesotomy care.
B. Obtainging cotton balls for the tracheostomy care.
C. Obtaining sterile gloves for the tracheostomy care.
D. Obtaining a sterile brush for the tracheostomy care.
A nurse is preparing to perform mouth care for an unresponsive client.
Which of the following actions should the nurse plan to take?
A. Place the client supine.
B. Keep both side rails up.
C. Raise the level of the bed.
D. Inspect the client's mouth using a finger sweep.
A nurse is witnessing a client sign an informed consent form for surgery.
Which of the following describes what the nurse is affirming by this action?
A. The client fully understands the provider's explannation of the procedure.
B. The client has been informed about the risks and benefits of the procedure.
C. The nurse witnessed the provider's explanantion of the procedure.
D. The signature on the preoperative consent form is the client's.
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first?
A. Open all sterile supplies and solutions.
B. Stabilize the tracheostomy tube.
C. Don sterile gloves
D. Perform hand hygiene
A nurse is caring for an older adult client who becomes agitated when the nurse requests that
the client's dentures be removed prior to surgery. Which of the following responses should the
nurse .make?
A. It's for your safety. Dentures can slip and block your airway during surgery.
B. You wouldn't want your teeth to be lost or broken during surgery, would you?
C. The anesthesiologist requires everyone to remove their dentures.
D. What worries you about being without your teeth?
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian
cancer. Which of the following statements by the client indicates she is experiencing
psychological distress?
A. My parents are retired, and they have come to help out with our children.
B. I am going to ask my husband to go to counseling with me.
C. I keep having nightmares about my upcoming surgery.
D. My girlfriends bought me a nice wig.
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should
the nurse take first when using the nursing process?
A. Identify goals for client care.
B. Obtain client information.
C. Document nursing care needs.
D. Evaluate the effectiveness of nurse care.
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV
lines. The provider prescribes soft wrist restraints. Which of the following actions should the
nurse take while the client is in restraints?
A. Tie the restraints to the side rails.
B. Perform range-of-motion exercises to the wrists every 3 hrs.
C. Remove the restraints one at a time.
D. Obtain a PRN prescription for the restraints.
A nurse is planning care for a client who reports abdominal pain.
An assessment by the nurse reveals the client has a temperature of 39.2 (102.6 F), heart rate of
105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following
findings should be the nurse's priority.
A. Heart rate 105/min
B. soft, nontender abdomen
C. temperature
D. overdue menses
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand.
The client has no documented bloodstream infection.
Which of the following actions should the nurse take?
A. Wash the gloved hands and then throw the gloves away.
B. Prepare an incident report to document the event.
C. Carefully remove the gloves and follow with hand hygiene.
D. Ask the provider to order a blood culture to determine the risk of infection
[Show More]
