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4006 MIDTERM G2 Q BASED REVISION QUESTIONS AND CORRECT DETAILED ANSWERS 100% VERIFIED, Exams of Nursing

Cheyney University of PennsylvaniaNursing

4006 MIDTERM G2 Q BASED REVISION QUESTIONS AND CORRECT DETAILED ANSWERS 100% VERIFIED

Typology: Exams

2024/2025

Available from 03/04/2025

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4006 MIDTERM G2 Q BASED REVISION QUESTIONS AND
CORRECT DETAILED ANSWERS 100% VERIFIED
1. The nurse is preparing to perform a physical examination on a client who has
cardiopulmonary disease. Knowing this about the client, the nurse is alert for the
presence of which of the following when checking the client's nails? Select one:
a. Clubbing
b. Bands in nailbeds
c.Yellow discoloration
d. Splinter hemorrhages: A- clubbing
2. 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: c. Soft, breezy, low-
pitched sounds with longer inspiration
3. 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: b. Pads of the fingers
4. 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:
pf3
pf4
pf5
pf8
pf9
pfa
pfd
pfe
pff
pf12
pf13
pf14
pf15
pf16
pf17
pf18
pf19
pf1a

Partial preview of the text

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4006 MIDTERM G2 Q BASED REVISION QUESTIONS AND

CORRECT DETAILED ANSWERS 100% VERIFIED

  1. The nurse is preparing to perform a physical examination on a client who has cardiopulmonary disease. Knowing this about the client, the nurse is alert for the presence of which of the following when checking the client's nails? Select one: a. Clubbing b. Bands in nailbeds c. Yellow discoloration d. Splinter hemorrhages: A- clubbing
  2. 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: c. Soft, breezy, low- pitched sounds with longer inspiration
  3. 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: b. Pads of the fingers
  4. 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: c. Lying on the left side

  1. 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: a. Sitting
  2. The nurse is observing a new staff member work with the client. Of the following activities, which one has the greatest possibility of contributing to a nosocomial infection and requires correction? Select one: a. Washing hands before applying a dressing b. Taping a plastic bag to the bed rail for tissue disposal c. Placing a Foley catheter bag on the bed when transferring a client d. Using alcohol to cleanse the skin before starting an intravenous line: c. Placing a Foley catheter bag on the bed when transferring a client
  3. Which one of the following indicates that the nurse is using surgical aseptic technique? Select one: a. Inserting an intravenous catheter b. Placing soiled linen in moisture-resistant bags c. Disposing of syringes in puncture-proof containers d. Washing hands before changing a dressing: a. Inserting an intravenous catheter
  4. The client requires a sterile dressing change. Which of the following is an appropriate intervention for the nurse to implement in maintaining sterile asepsis? Select one:
  1. 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 b. Diabetes c. Pulmonary emphysema d. Peripheral vascular disease: a. Burns
  2. The client has a large, deep abdominal incision that requires a dressing. The incision is packed with sterile 1.75-cm packing and covered with a dry, 10 × 10-cm gauze. When changing the dressing, the nurse accidentally drops the packing onto the client's abdomen. Which of the following actions should the nurse take? Select one: a. Add alcohol to the packing and insert it into the incision. b. Throw the packing away, and prepare a new one. c. Pick up the packing with sterile forceps, and gently place it into the incision. d. Rinse the packing with sterile water, and put the packing into the incision with sterile gloves.: b. Throw the packing away, and prepare a new one.
  3. The nurse uses the Braden Scale in the extended care facility to determine the client's risk for pressure ulcer development. Which score, based on this scale, places the client at the highest level of risk? Select one: a. 9 or below b. 10 to 12 c. 13 to 14 d. 15 to 16: a. 9 or below
  4. 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.: a. They will likely have minimal scarring.

  1. 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: c. Pancreatic fluids
  2. 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 circula- tion c. Keeping a written schedule of turning and positioning d. Encouraging the client to perform pelvic muscle training exercises several times a day: c. Keeping a written schedule of turning and positioning
  3. 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. d. Smoking reduces the amount of functional hemoglobin in the blood.: d. Smoking reduces the amount of functional hemoglobin in the blood.
  4. The client has a large, deep wound on the sacral region. The nurse correctly packs the wound by doing which one of the following? Select one: a. Filling two-thirds of the wound cavity

d. Wash the area with an astringent and paint it with povidone-iodine (Beta- dine).: a. Clean the area, dry it, and add a protective moisturizer.

  1. The client is scheduled for a dressing change. When removing the adhe- sive 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: d. Parallel to the skin surface while pulling toward the dressing
  2. The nurse is concerned that the client's abdominal wound is at risk for dehiscence. Which of the following interventions is the best one to prevent this complication? Select one: a. Administering antibiotics to prevent infection b. Using appropriate sterile technique when changing the dressing c. Keeping sterile towels and extra dressing supplies near the client's bed d. Placing a pillow over the incision site when the client is deep breathing or coughing: d. Placing a pillow over the incision site when the client is deep breathing or coughing
  3. A client has a healing abdominal wound. The wound has minimal exudate and collagen formation. The wound is identified by the nurse as being in which phase of healing? Select one: a. Primary intention b. Inflammatory phase c. Proliferative phase d. Secondary intention: c. Proliferative phase
  4. 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.: a. This procedure involves flushing debris from wounds.

  1. 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. Decreased pulse strength: c. Increased blood pressure

  1. Out of all of the following clients, the nurse recognizes that which one is most at risk for a fluid volume deficit? Select one: a. A 6-month-old learning to drink from a cup b. A 12-year-old who is moderately active in 27°C weather c. A 42-year-old with severe diarrhea d. A 90-year-old with frequent headaches: c. A 42-year-old with severe diarrhea
  2. 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.: b. Stop the blood transfusion.
  3. 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: a. 0.45% normal saline (NS)
  4. 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.: a. Start with the most distal site.
  5. 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: c. Hypertension and tachycardia

  1. 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 c. 125 gtt/min d. 250 gtt/min: c. 125 gtt/min
  2. The client has severe anemia and will be receiving blood transfusions. The nurse prepares and begins the infusion. Ten minutes after the infusion has begun, the client develops tachycardia, chills, and low back pain. After stopping the transfusion, which of the following actions should the nurse take next? Select one: a. Administer an antipyretic. b. Begin an infusion of epinephrine. c. Run normal saline through the blood tubing. d. Obtain and send a urine specimen to the lab.: d. Obtain and send a urine specimen to the lab.
  3. Arterial blood gases are obtained for the client. The client's results (pH, 7.48; CO2, 42 mm Hg; HCO3, 32 mmol/L) indicate which one of the following acid-base imbalances? Select one: a. Metabolic acidosis b. Respiratory acidosis c. Respiratory alkalosis d. Metabolic alkalosis: d. Metabolic alkalosis
  4. 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. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis: d. Respiratory alkalosis

  1. 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: d. An elevated hematocrit level
  2. The physician orders 1000 mL of D5RL with 20 mmol KCl to run for eight hours. With an infusion set with a drop factor of 15 gtt/mL, which of the following will the nurse calculate the flow rate to be? Select one: a. 12 drops per minute b. 22 drops per minute c. 32 drops per minute d. 42 drops per minute: c. 32 drops per minute
  3. Which of the following is of great importance for the nurse to check before administering an IV solution with potassium that is prescribed for the client? Select one: a. Check for weakness. b. Assess renal function. c. Evaluate deep tendon reflexes. d. Initiate seizure precautions.: b. Assess renal function.
  4. A homeless client is brought into the emergency department with indi- cations of extremely poor nutrition. Arterial blood gases are assessed and the nurse anticipates that this client will demonstrate which of the following results?

Select one: a. pH, 7.3; PaCO2, 38 mm Hg; HCO3, 19 mmol/L b. pH, 7.5; PaCO2, 34 mm Hg; HCO3, 20 mmol/L c. pH, 7.35; PaCO2, 35 mm Hg; HCO3, 24 mmol/L d. pH, 7.52; PaCO2, 48 mm Hg; HCO3, 28 mmol/L: a. pH, 7.3; PaCO2, 38 mm Hg; HCO3, 19 mmol/L

  1. A client has intravenous (IV) therapy for the administration of antibiotics and is stating that the IV site "hurts and is swollen." Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to infiltration? Select one: a. Intensity of the pain b. Warmth of integument surrounding the IV site c. Amount of subcutaneous edema d. Skin discoloration of a bruised nature: b. Warmth of integument surrounding the IV site
  2. Acute renal failure and a resulting metabolic acidosis develop in a client. The nurse recognizes that the respiratory system compensates through which of the following processes? Select one: a. Hypoventilation and increase of bicarbonate in the bloodstream b. Alternating periods of deep versus shallow breaths to maintain homeosta- sis of the serum pH c. Hyperventilation to decrease the serum carbon dioxide and thereby in- crease the pH d. Expansion of the lung tissues to their fullest, which increases the inspirato- ry reserve volumes to provide more oxygen to the tissues: c. Hyperventilation to decrease the serum carbon dioxide and thereby increase the pH
  3. A client has pneumonia. Which of the following evaluations does the nurse make about the effectiveness of the client's cough? Select one:
  1. A 64-year-old client is seen in the emergency department for palpitations and mild shortness of breath. The ECG reveals a normal P wave, P-R interval, and QRS complex with a regular rhythm and a rate of 108 beats per minute. The nurse should recognize this as which type of cardiac dysrhythmia? Select one: a. Sinus dysrhythmia b. Sinus tachycardia c. Supraventricular tachycardia d. Ventricular tachycardia: b. Sinus tachycardia
  2. The nurse is reviewing the results of the client's diagnostic testing for res- piratory function. Of the following results, which finding falls within expected or normal limits? Select one: a. SaO2 88% b. pH 7. c. PaCO2 40 mm Hg d. PaO2 79 mm Hg: c. PaCO2 40 mm Hg
  3. The nurse knows that a pacemaker may be required for which of the following conditions? Select one: a. Sinus tachycardia b. Sinus bradycardia c. Ventricular fibrillation d. Heart failure: b. Sinus bradycardia
  4. The client is admitted to the emergency department with a pneumothorax. Which of the following does the nurse anticipate the client will be experienc- ing? Select one: a. Dyspnea b. Eupnea c. Fremitus d. Orthopnea: a. Dyspnea
  5. The client has pneumonia in the left lobe. The nurse should encourage him to lie in which of the following positions? Select one:

a. On the affected side b. With the unaffected lung down c. On either side d. Supine: b. With the unaffected lung down

  1. The electrical activity of the client's heart is being continuously monitored while he is on the coronary care unit. Suddenly, the nurse finds that the client is experiencing ventricular fibrillation. Which of the following actions should the nurse prepare to take? Select one: a. Administer atropine. b. Prepare for CPR and defibrillation. c. Prepare the client for surgical placement of a pacemaker. d. Instruct the client to perform the Valsalva manoeuvre.: b. Prepare for CPR and defibrillation.
  2. The nurse has reviewed information about the cardiovascular system be- fore caring for a client with heart disease. The nurse knows that which of the following statements is true concerning the physiology of the cardiovascular system? Select one: a. Stimulating the parasympathetic system would cause the heart rate to increase. b. When a person has heart muscle disease, the heart muscles stretch as far as is necessary to maintain function. c. The QRS interval on the electrocardiogram represents the electrical impuls- es passing through the ventricles. d. When stroke volume decreases, a resultant decrease in heart rate occurs.- : c. The QRS interval on the electrocardiogram represents the electrical impulses passing through the ventricles.
  3. On admitting a client, the nurse finds a history of myocardial ischemia. What is the most disconcerting dysrhythmia that electrocardiography can reveal for this client? Select one: a. Sinus bradycardia b. Sinus dysrhythmia

d. Plan staple removal for postoperative day 5.: a. Assess the type of suture material used.

  1. The nurse is performing a wound assessment after removing the soiled dressing. What finding would indicate a problem requiring additional assess- ment? Select one: a. An incisional ridge continues to be present. b. The patient experiences less discomfort. c. There is a lack of new drainage. d. The patient states, "My wound feels warm.": d. The patient states, "My wound feels warm."
  2. The nurse needs to apply a dry sterile dressing. Which should the nurse implement first? Select one: a. Inspect the appearance of the wound. b. Remove excess moisture from the wound. c. Cleanse with sterile saline solution. d. Prepare the sterile field for supplies.: a. Inspect the appearance of the wound.
  3. The nurse teaches a patient about Steri-Strips after suture removal. What information does the nurse include in patient teaching? Select one: a. They provide a skin barrier. b. They provide gentle support. c. They prevent scarring of the wound. d. They collect additional drainage.: b. They provide gentle support.
  4. The nurse applies Steri-Strips to the patient's surgical site after suture removal. During patient teaching, what does the nurse instruct the patient to avoid doing? Select one: a. Limit heavy lifting activities. b. Ambulate several times a day. c. Soak in the bathtub for relaxation. d. Use a pillow to support incision.: c. Soak in the bathtub for relaxation.
  1. The nurse prepares to apply a dressing for a patient who has a full-thick- ness wound with moderate exudate and necrosis. Which is the best nursing intervention to help the patient achieve an expected long-term outcome for this wound? Select one: a. Assess the wound for sinus tracts and tunneling. b. Maintain oxygenation with supplemental oxygen. c. Pack the wound lightly with a wet-to-dry dressing. d. Provide a well-balanced diet with high-quality protein.: d. Provide a well-bal- anced diet with high-quality protein.
  2. The nurse assesses a patient with a surgical incision. What is an expected patient outcome on the fourth postoperative day? Select one: a. The tympanic temperature is 39.5° C at 8 AM and noon. b. The incision is slightly reddened and swollen without drainage. c. The skin is spongy and warm around the incision. d. The patient's pain has been increasing gradually.: b. The incision is slightly reddened and swollen without drainage.
  3. The nurse is preparing to initiate a blood transfusion. Which step of the procedure should the nurse implement first? Select one: a. Begin the infusion at 2 mL/min. b. Establish a single-line infusion. c. Check vital signs in 30 minutes. d. Shake the blood gently to mix the preservative.: a. Begin the infusion at 2 mL/min.
  4. After inserting a peripheral intravenous (IV) line into the patient, the nurse provides patient teaching about the IV insertion site. What information should the nurse give to the patient? Select one: a. Expect minor pain at the insertion site.