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4006 MIDTERM EXAM COMPREHENSIVE STUDY
GUIDE 2026
โ The nurse is auscultating the client's lungs and notes normal vesicular sounds as being which of the following? Select one: a. Medium-pitched blowing sounds with inspiration equalling expiration b. Loud, high-pitched, hollow sounds with expiration longer than inspiration c. Soft, breezy, low-pitched sounds with longer inspiration d. Sounds created by air moving through small airways. Answer: c. Soft, breezy, low-pitched sounds with longer inspiration โ During the physical examination, the nurse should use which part of the hand to assess characteristics such as consistency, contour, and texture in the client's glands? Select one: a. Dorsum of the hand b. Pads of the fingers c. Palmar surface of the hand d. Fingertip grasp of the tissue.
Answer: b. Pads of the fingers โ If a low-pitched murmur is suspected with prior assessment, which of the following is the best position for the client when the nurse auscultates the apical site? Select one: a. Sitting up b. Standing c. Lying on the left side d. Dorsal recumbent. Answer: c. Lying on the left side โ Which of the following positions maximizes the nurse's ability to assess the client's upper body for symmetry? Select one: a. Sitting b. Supine c. Prone d. Dorsal recumbent. Answer: a. Sitting
Select one: a. Put sterile gloves on before opening sterile packages. b. Check integrity of sterile packages prior to use. c. Place the cap of the sterile solution well within the sterile field. d. Place sterile items on the very edge of the sterile drape.. Answer: b. Check integrity of sterile packages prior to use. โ The nurse suspects that an older adult client may have pneumonia. Older adult clients may react differently to infectious processes, so the nurse is alert to atypical signs and symptoms, such as which one of the following? Select one: a. Hypotension b. Confusion c. Erythema d. Chills. Answer: b. Confusion โ The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent with sterile asepsis? Select one: a. Clean forceps may be used to move items on the sterile field.
b. Sterile fields may be prepared well in advance of the procedures. c. The first small amount of sterile solution should be poured and discarded. d. Wrapped sterile packages should be opened starting with the flap closest to the nurse.. Answer: c. The first small amount of sterile solution should be poured and discarded. โ The client has a 15-cm laceration on his right forearm and an infection develops. Which of the following is a sign of an acute inflammatory process? Select one: a. A blanching of the skin b. A decrease in temperature at the site c. A decrease in the number of white blood cells (WBCs) d. A release of histamine that adds to the pain response. Answer: d. A release of histamine that adds to the pain response โ The nurse works in a small rural hospital with a wide variety of clients. Of the clients admitted this afternoon, the nurse recognizes that the individual with which of the following conditions is most susceptible to infection? Select one: a. Burns
a. 9 or below b. 10 to 12 c. 13 to 14 d. 15 to 16. Answer: a. 9 or below โ Which of the following statements is true for wounds that heal by primary intention? Select one: a. They will likely have minimal scarring. b. They will likely contain infected tissue. c. They will likely present with ragged edges. d. They will likely have portions of missing tissue.. Answer: a. They will likely have minimal scarring. โ The nurse recognizes that skin integrity can be compromised when skin is exposed to body fluids. The greatest risk exists for the client who has exposure to which one of the following fluids? Select one: a. Urine b. Purulent exudates c. Pancreatic fluids
d. Serosanguineous drainage. Answer: c. Pancreatic fluids โ The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following interventions is the best one for this client's skin integrity? Select one: a. Having the client sit up in a chair for four-hour intervals b. Keeping the head of the bed in a high-Fowler's position to increase circulation c. Keeping a written schedule of turning and positioning d. Encouraging the client to perform pelvic muscle training exercises several times a day. Answer: c. Keeping a written schedule of turning and positioning โ Which of the following information about how smoking influences healing does the nurse include when planning a program on wound healing? Select one: a. Smoking suppresses protein synthesis. b. Smoking creates increased tissue fragility. c. Smoking depresses bone marrow function.
โ The nurse observes thin, watery fluid draining from the left ear of a client who has sustained a head injury. How is this drainage described? Select one: a. Serous b. Purulent c. Cerebrospinal fluid d. Serosanguineous. Answer: a. Serous โ The nurse notes that the client's skin is reddened, with a small intact serum-filled blister. How should the nurse classify this stage of ulcer formation? Select one: a. Stage I b. Stage II c. Stage III d. Stage IV. Answer: b. Stage II โ When turning a client, the nurse notices a reddened area on the coccyx. Which of the following skin care interventions should the nurse use on this area?
Select one: a. Clean the area, dry it, and add a protective moisturizer. b. Apply a diluted hydrogen peroxide and water mixture, and use a heat lamp on the area. c. Soak the area in normal saline solution. d. Wash the area with an astringent and paint it with povidone- iodine (Betadine).. Answer: a. Clean the area, dry it, and add a protective moisturizer. โ The client is scheduled for a dressing change. When removing the adhesive tape used to secure the dressing, the nurse should lift the edge and hold the tape in which manner? Select one: a. At a 45-degree angle to the skin surface while pulling away from the dressing b. At a right angle to the skin surface while pulling toward the dressing c. At a right angle to the skin surface while pulling away from the dressing d. Parallel to the skin surface while pulling toward the dressing. Answer: d. Parallel to the skin surface while pulling toward the dressing
โ A client requires wound debridement. The nurse is aware that which of the following statements is correct regarding this procedure? Select one: a. This procedure involves flushing debris from wounds. b. This procedure involves the removal of nonviable necrotic tissue. c. Mechanical methods involve direct surgical removal of the eschar layer of the wound. d. Enzymatic debridement may be implemented independently by the nurse whenever it is required.. Answer: a. This procedure involves flushing debris from wounds. โ The nurse prepares to irrigate the client's wound. What is the primary purpose of this procedure? Select one: a. To decrease scar formation b. To cleanse the wound and remove bacteria c. To improve circulation from the wound d. To decrease irritation from wound drainage. Answer: b. To cleanse the wound and remove bacteria โ Which of the following nursing entries is most complete in describing a client's wound?
Select one: a. "Wound appears to be healing well. Dressing dry and intact." b. "Wound well approximated with minimal drainage." c. "Drainage size of quarter; wound pink, 4 ร 4s applied." d. "Incisional edges approximated without redness or drainage; two 4 ร 4s applied.". Answer: d. "Incisional edges approximated without redness or drainage; two 4 ร 4s applied." โ Which of the following is the most common electrolyte imbalance? Select one: a. Hypokalemia b. Hyperkalemia c. Hyponatremia d. Hypernatremia. Answer: a. Hypokalemia โ The single best indicator of a client's fluid status is the nurse's assessment of which one of the following? Select one: a. The client's skin turgor b. The client's intake and output
โ A client complains of a headache and chills during a blood transfusion. Which one of the following actions should the nurse take immediately? Select one: a. Check the vital signs. b. Stop the blood transfusion. c. Slow the rate of blood flow. d. Notify the physician and blood bank personnel.. Answer: b. Stop the blood transfusion. โ A client experiences a loss of intracellular fluid. The nurse anticipates that which of the following IV therapies will be used to replace this type of fluid loss? Select one: a. 0.45% normal saline (NS) b. 10% dextrose c. 5% dextrose in lactated Ringer's d. Dextrose 5% in 1/2 NS. Answer: a. 0.45% normal saline (NS) โ The nurse will be starting a new intravenous (IV) infusion and needs to select the site for the insertion. In selecting a site, the nurse should do which of the following?
Select one: a. Start with the most distal site. b. Look for hard, cord-like veins. c. Use the dominant arm. d. Vigorously rub and tap the chosen vein.. Answer: a. Start with the most distal site. โ A rapid infusion of blood has been given to the client. The nurse assesses the client for which one of the following? Select one: a. Diaphoresis b. Anxiety c. Hypertension and tachycardia d. Nausea and vomiting. Answer: c. Hypertension and tachycardia โ An IV of 125 mL is to be infused over a one-hour period. A microdrip infusion set will be used. Which of the following is the nurse's calculation of the infusion rate? Select one: a. 32 gtt/min b. 60 gtt/min
d. Metabolic alkalosis. Answer: d. Metabolic alkalosis โ Which of the following is an unexpected value that the nurse, in reviewing the results of the client's blood work, should report to the physician? Select one: a. Calcium, 1.9 mmol/L b. Sodium, 140 mmol/L c. Potassium, 3.5 mmol/L d. Magnesium, 1.8 mmol/L. Answer: a. Calcium, 1.9 mmol/L โ An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment, the nurse notes that the child is warm and flushed, is lethargic, has difficulty breathing, and has moist crackles. The nurse determines that the child has which one of the following? Select one: a. Metabolic acidosis b. Respiratory acidosis c. Respiratory alkalosis d. Metabolic alkalosis. Answer: b. Respiratory acidosis
โ A child having an asthma attack has presented to the emergency department. He is breathing rapidly and has a blood pH of 7.47, signs and symptoms that the nurse suspects are consistent with which of the following conditions? Select one: a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis. Answer: d. Respiratory alkalosis โ When a deficit of body fluid exists in the intravascular compartment, which of the following signs can be expected? Select one: a. Crackles b. Hypertension c. Neck vein distension d. An elevated hematocrit level. Answer: d. An elevated hematocrit level
