NACE 1 PN-RN Exam New Latest Version with All Questions from Actual Past Exams, Exams of Nursing

Download NACE 1 PN-RN Exam New Latest Version with All Questions from Actual Past Exams and more Exams Nursing in PDF only on Docsity! NACE 1 PN-RN Exam New Latest Version with All Questions from Actual Past Exams and 100% Correct Answers To assess a person with dark skin for signs of cyanosis, a nurse should look at the client's -ankles. -conjunctiva. -wrists. -earlobes. ---------- Correct Answer ---------- conjunctiva While auscultating a client's lungs, a nurse hears a high-pitched musical sound over the bronchi on both inspiration and expiration, with the sound loudest on expiration. How should the nurse describe the auscultated sound? -Wheezing, pronounced on expiration. -Crackles bilaterally. -Bronchial rhonchi. -Inspiratory and expiratory rales. ---------- Correct Answer ---------- Wheezing, pronounced on expiration What are five components of sexual health? A.Gender identity, gender role behavior, Sexual self-concept, body image and sexual freedoms and responsibilities B.Gender identity, sexual preference, sexual self-concept, body image and sexual freedom's and responsibilities C.Gender role behavior, sexual preference, sexual Self-concept, body image and sexual freedom's and responsibilities. D.Gender role behavior, Gender specifics, sexual preference, body image and sexual freedom's and responsibilities. --------- Correct Answer ---------- A Which term is defined as successful adjustments and coping with the stressors of every day life in a manner that is acceptable to society and healthy for the client? A.Mental health promotion B.Mental illness Avoidance C.Impaired mental health D.Mental health --------- Correct Answer ---------- D Nosocomial infections are: A.Infections that a client gets chronically throughout their lives B.Infections that a client receives at home from a household cleaning agent C.Infections that a client does not have at admission, but gets while in a healthcare facility D.Infections that are only airborne and spread through respiration and an open wound -- ------- Correct Answer ---------- C Restraints are: A.A preferred method of treatment for the majority of mental health patients B.A preferred method of treatment for the majority of mental health and Alzheimer's patients C.Not a preferred method of treatment and should only be used as a last resort D.I preferred method of safety for any client who is in a coma --------- Correct Answer --- ------- C What types of clients should be screened for Falls? A.The elderly B. The Confused or elderly C. They confused, elderly and the mentally ill D.All clients --------- Correct Answer ---------- D Which of the following is an example of an internal disaster? A.A loss of electrical power B.A nearby plane crash C.A nuclear explosion D.Major school bus accident --------- Correct Answer ---------- A A verbal or nonverbal response that is sent from the receiver to the center after a message is called: A. Feedback. B.Request C. Verification D. Mode --------- Correct Answer ---------- A What is the cognitive process that the sender uses when contemplating how they will frame or formulate a message? A. Decoding B.Encoding C. Self coding D.Recoding --------- Correct Answer ---------- B What type of communication is internal self talk and reflective thought? A. Prayer B. Meditation C. Intrapersonal communication D. Interpersonal communication --------- Correct Answer ---------- C Which person zone ranges from 4 feet to 12 feet? A. The social zone B. The publics Zone Cholesterol 45 mg/dL. The above findings suggest an excess of which of these types of cholesterol? -HDL cholesterol. -Total cholesterol. -LDL cholesterol. -Triglycerides. ---------- Correct Answer ---------- LDL cholesterol Which of these dietary modifications should a nurse anticipate for a client who has a diagnosis of cirrhosis of the liver? -Restriction of carbohydrates. -Supplements of potassium. -Supplements of vitamin E. -Restriction of protein. ---------- Correct Answer ---------- Restriction of protein. Which of these dietary modifications should a nurse initiate to help increase the oral intake of a client who has dysphagia? -Low-residue foods. -Thickened liquids -Bland foods. -Clear liquids. ---------- Correct Answer ---------- thickened liquids Which of these food selections, if made by a client on a 500 mg-sodium diet, should indicate to a nurse the need for ADDITIONAL instruction? -One raw apple. -One tablespoon of corn oil. -One cup of milk. -One half cup of boiled rice. ---------- Correct Answer ---------- One cup of milk. Which of these laboratory findings should indicate to a nurse that a client who has been diagnosed with acquired immunodeficiency syndrome (AIDS) has a compromised nutritional status? -Decreased eosinophil count. -Elevated serum glutamic oxaloacetic transaminase. -Elevated blood urea nitrogen. -Decreased serum albumin. ---------- Correct Answer ---------- Decreased serum albumin. Which of these nutrients should a nurse recognize as the most difficult to digest by a child who has cystic fibrosis? -Complex carbohydrates. -Protein. -Fat. -Simple carbohydrates. ---------- Correct Answer ---------- fat A nurse in an acute care setting finds a client who has a history of heart disease lying on the floor. The client does not respond to verbal stimuli. The next action that the nurse should take is to -establish an airway. -call the physician. -check the blood pressure. -begin external cardiac compression. ---------- Correct Answer ---------- establish an airway. A nurse is planning care for a client who is hospitalized for treatment of acute pulmonary edema. To which of these measures should the nurse assign priority? -Interpreting serum electrolyte levels. -Measuring urinary output. -Monitoring respiratory status. -Providing a low sodium diet. ---------- Correct Answer ---------- Monitoring respiratory status. A nurse should assess a client's apical pulse by placing the stethoscope in which of these positions? -Under the right breast at the level of the diaphragm. -On the left of the mediastinum. -On the right side under the second rib. -Under the left breast at the fifth intercostal space. ---------- Correct Answer ---------- Under the left breast at the fifth intercostal space. A nurse should encourage a client who has a postoperative wound infection to eat foods rich in which of these nutrients? -Carbohydrates and vitamin D. -Protein and vitamin C. -Fat and cholesterol. -Folic acid and minerals. ---------- Correct Answer ---------- Protein and vitamin C. A nurse should expect to observe which of these symptoms in a client who has Cushing's syndrome? -Pallor and weight loss. -Increased thirst and dysphagia. -Abnormal fat distribution and joint pains. -Hair loss and blurred vision. ---------- Correct Answer ---------- Abnormal fat distribution and joint pains. A nurse should expect to observe which of these symptoms in a client who is diagnosed with hyponatremia? -Lethargy. -Tinnitus. -Paralytic ileus. -Rubbery skin. ---------- Correct Answer ---------- Lethargy A nurse should recognize that a client who has acute renal failure is receiving hemodialysis for which of these purposes? -To improve kidney function. -To increase urinary output. -To remove nitrogenous waste. -To enhance glomerular filtration. ---------- Correct Answer ---------- To remove nitrogenous waste. 1. The World Health organizations definition of health is? A. The absence of all disease B. A complete, holistic state of wellbeing C. The absence of disease and risk factors D. Engaging in healthy Lifestyles and health promotion. --------- Correct Answer ---------- B 2. You are caring for a middle-age client who has cancer and is no longer able to work outside of the home. Although the client is doing relatively well in terms of his physical, psychological, and social condition, he is no longer able to work. What fact about this client is accurate? A.This client is not considered healthy, according to a functional model of wellness, because the client is unable to be employed any longer. B.This client is considered healthy, according to the health illness continuum, Because a client expresses physical, psychological and social well-being. C.This client is considered healthy, according to a functional model of wellness, because the client expresses physical, psychological and social well-being. D.This client is not considered healthy, according to the optimal wellness theory, because the client is an able to be employed any longer --------- Correct Answer ---------- A 3. Which model of health and illness is most closely aligned with Hans Seyle theory of stress? A.The health illness continuum B.The dimensions model C.The agent - host - environment model D.The adaptation model --------- Correct Answer ---------- D 4. Select the health and wellness Theory that is correctly paired with its description. A.High- level wellness model: The components of wellness are the physical, social, emotional, intellectual, spiritual, occupational environmental components of health. B.Seven components of wellness - high-level wellness and a very favorable environment, emergent high-level wellness in an unfavorable environment, protected poor health in a favorable environment, And poor health in an unfavorable environment. C.Health - illness continuum: Disease occurs as a result of the interrelationships among the agent, the host and the environment D. Health belief model:This model Can predict whether or not a person will engage in screening tests --------- Correct Answer ---------- D 5.Which theorists developed the high-level wellness theory? B. Health promotion nursing diagnosis C. A potential nursing diagnosis D. A syndrome nursing diagnosis --------- Correct Answer ---------- B 19. All nursing diagnosis is must minimally contain: A. The problem and etiology B. The problem and expected outcome C. The etiology and defining characteristics D. The etiology and the expected outcome --------- Correct Answer ---------- A 20. Which words in the nursing diagnosis, " impaired mobility related to a neuromuscular dysfunction as evidenced by an unsteady gait" is considered a qualifier? A. Mobility B. Related to neuromuscular functioning C. Evidence by an unsteady gait D. Impaired --------- Correct Answer ---------- D 21. The major difference between a source oriented and problem oriented medical record system? A. The source oriented medical system has interdisciplinary progress notes in one section and the problem oriented medical record system has progress notes from each profession spread out B. The problem oriented medical system uses narrative progress Notes and the source oriented medical record system does not C. The problem oriented medical system has interdisciplinary progress notes in one section and the source oriented medical record system has progress notes was from each profession spread out D. The source oriented medical system uses charting by exception and the source oriented medical record system does not --------- Correct Answer ---------- C 22.A SOAP note is written: A.On a daily basis by the physician B. Every shift for every problem. C. According to the problem list in the back of the medical record. D. Separately for each identified problem. --------- Correct Answer ---------- D 23. SOAP is the acronym for: A.Subjective data, Objective data, assessment and priorities. B.Subjective data, Objective data, assessment and planning C.Subjective data, observations, analysis and planning D.Subjective data, observations, analysis and priorities --------- Correct Answer ---------- B 24. --------- Correct Answer ---------- C 25. --------- Correct Answer ---------- A 26. --------- Correct Answer ---------- D 27. --------- Correct Answer ---------- D 28. --------- Correct Answer ---------- B 29. --------- Correct Answer ---------- A 30. --------- Correct Answer ---------- A 31. --------- Correct Answer ---------- C 32. --------- Correct Answer ---------- A 33. --------- Correct Answer ---------- D 34. --------- Correct Answer ---------- C 35. --------- Correct Answer ---------- B 36. --------- Correct Answer ---------- A 37. --------- Correct Answer ---------- A 38. --------- Correct Answer ---------- A 39. --------- Correct Answer ---------- B 40. --------- Correct Answer ---------- D 41. --------- Correct Answer ---------- C 42. --------- Correct Answer ---------- B 43. --------- Correct Answer ---------- D 44. --------- Correct Answer ---------- A 45. --------- Correct Answer ---------- C 46. --------- Correct Answer ---------- B 47. --------- Correct Answer ---------- D 48. --------- Correct Answer ---------- C 49. --------- Correct Answer ---------- B 50. --------- Correct Answer ---------- A 51. --------- Correct Answer ---------- D 52. --------- Correct Answer ---------- C 53. --------- Correct Answer ---------- D 54. --------- Correct Answer ---------- B 55. --------- Correct Answer ---------- C 56. --------- Correct Answer ---------- A 57. --------- Correct Answer ---------- D 58. --------- Correct Answer ---------- D 59. --------- Correct Answer ---------- B 60. --------- Correct Answer ---------- A 61. --------- Correct Answer ---------- A 62. --------- Correct Answer ---------- D 63. --------- Correct Answer ---------- B 64. --------- Correct Answer ---------- D 65. --------- Correct Answer ---------- D 66. --------- Correct Answer ---------- A 105. accurate identification is necessary during all aspects of nursing care, especially during medication administration. What is the minimum number of unique identifiers, other than room number that can be used? A. 2 B. 3 C. 4 D. 5 --------- Correct Answer ---------- A A nurse is caring for a client who has not voided for several hours. When percussing the client's bladder to assess for distention, the nurse should expect to hear which of these sounds? -Tympany -Hyperresonance -Dullness -Resonance. ---------- Correct Answer ---------- dullness A nurse is preparing to change a client's sterile dressing. Which actions by the nurse, if observed, would contaminate the sterile field? -The nurse opens the sterile dressing tray without touching the inner surface of the wrapper -The nurse removes the indicator tape from a package of sterile 4x4's and opens the first flap with a motion away from the nurse's body -The nurse spills sterile saline on the sterile field -The nurse handles the inside of the sterile gown when putting it on. ---------- Correct Answer ---------- The nurse spills sterile saline on the sterile field. A nurse removes an indwelling urethral (Foley) catheter from a client. Six hours later, the nurse notes that the client has not voided. Which of these actions should the nurse take? -Apply pressure to the client's suprapubic area -Obtain an order to recatheterize the client -Run the tap water while the client is on the toilet -Tell the client to call whenever there is the urge to void. ---------- Correct Answer --------- - Run the tap water while the client is on the toilet. A client who is jaundiced reports itching. To relieve the itching, which of these measures would be most helpful? -Having the client wear clothing made from synthetic fibers -Giving the client sponge baths with tepid water several times a day -Rubbing the client's skin with diluted alcohol -Exposing the client to the direct rays of the sun. ---------- Correct Answer ---------- Giving the client sponge baths with tepid water several times a day. A nurse is assigned to care for a client who has pulmonary tuberculosis and is coughing. Which of these protective devices should the nurse put on before entering the client's room to give an oral medication? -Mask -Gloves -Gown -Eye shield. ---------- Correct Answer ---------- mask A nurse is instructing a client on how to limit saturated fat intake and increase intake of foods high in polyunsaturated fat. Which of these fats is highest in polyunsaturated fatty acids? -Corn oil -Vegetable shortening -Olive oil -Butter. ---------- Correct Answer ---------- corn oil A nurse obtains a tympanic electronic thermometer reading of 97F (36.1C) on a client who is flushed and warm to touch. Which of these actions should the nurse take next? -Return the electronic unit and connect it to the source to recharge the batteries -Report the reading to the nurse-in-charge -Recheck the temperature with another thermometer -Recheck the temperature in a half-hour. ---------- Correct Answer ---------- Recheck the temperature with another thermometer A nurse who is caring for a client with a nursing diagnosis of impaired physical mobility repositions the client every two hours. Which of these steps of the nursing process does the nurse demonstrate? -Planning -Assessing -Analyzing -Implementing. ---------- Correct Answer ---------- implementing Before nurses obtain information about a client's sexual health status as part of the admission assessment, it would be most important for nurses to assess their own -interviewing techniques -gender role identity -knowledge of sexual reproduction -personal attitudes about sexuality. ---------- Correct Answer ---------- personal attitudes about sexuality A nurse is caring for a client whose laboratory reports indicate hypernatremia. Which of these measures should be included in this client's plan of care? -Inserting an indwelling catheter -Increasing fluid intake -Elevating the lower extremities -Monitoring respiratory rate. ---------- Correct Answer ---------- increasing fluid intake A nurse is teaching a client how to maintain a low-fat diet when dining out in restaurants. During the interview, the client gazes out the window without comment or question. The nurse should take which of these actions? -Say nothing more until the client makes a verbal response -Use visual aids to get the client's attention -Say, "You don't seem very interested in this discussion -"Ask, "Why are you behaving in this hostile manner?" ---------- Correct Answer ---------- Say nothing more until the client makes a verbal response A nurse prepares to teach a client how to self-administer injections. The nurse has planned to teach the client about the medication during this session. The client says repeatedly, "You mean I have to stick myself with a needle?" Which of these responses would be most supportive of the learning process? -I see that you're upset, but let's start by discussing what the drug can do for you -Many people have this same concern, but it won't be as hard as you expect -You're bothered by the thought of injecting yourself -I wonder if you're reacting to the feelings that people have about illegal drug use. -------- -- Correct Answer ---------- You're bothered by the thought of injecting yourself A client has an order for psyllium hydrophilic mucilloid (Metamucil) 1 packet po qd. Which of these actions is essential when a nurse is preparing to administer this medication? -Prepare the medication with four ounces of juice -Provide special mouth care after medication administration. -Administer the medication after it stops effervescing. -Monitor bowel sounds before administration. ---------- Correct Answer ---------- Monitor bowel sounds before administration. A client who is three days postoperative is refusing to deep breathe and cough because of incisional discomfort. Which of these nursing diagnoses should receive priority in this client's care plan? -Noncompliance -Impaired gas exchange. -Impaired physical mobility. -Pain. ---------- Correct Answer ---------- pain While preparing a client for surgery, a nurse discovers that the client does not understand the surgical procedure. A signed surgical consent is on the chart. Which of these actions should the nurse take? -Reassure the client. -Send the client to surgery. -Explain the operative procedure. -Notify the physician ---------- Correct Answer ---------- notify the physician -painful joints. -tetany. -toothaches. ---------- Correct Answer ---------- tetany A nurse should expect that a client who has open-angle glaucoma will report -difficulty seeing distant objects. -photophobia. -severe eye pain. -loss of peripheral vision. ---------- Correct Answer ---------- loss of peripheral vision A nurse should recognize that a client who has a perineal prostatectomy rather than a transurethral prostatectomy is more likely to develop which of these complications? -Ureteral stenosis. -Impotence. -Renal calculi. -Glomerulonephritis. ---------- Correct Answer ---------- impotence (ED) A nurse should teach a client who has diabetes mellitus & their family and friends to recognize early signs of a hypoglycemic reaction, which include -irritability. -fruity breath. -double vision. -hot, dry skin. ---------- Correct Answer ---------- irritability A client has an order for 1 gm of medication to be administered intramuscularly. The medication available is labeled 500 mg/mL. How many milliliters should a nurse administer? -0.5 mL -1.0 mL -2.0 mL -3.5 mL ---------- Correct Answer ---------- 2 mL. If 500 mg equals 1 mL, 1000 mg equals 2 mL A client who is receiving continuous bladder irrigation has an intake of 800 mL of intravenous fluid and 2,000 mL of irrigating solution. The urinary drainage bag contains 3,800 mL. The charted output should be -800 mL. -1,000 mL. -1,800 mL. -3,800 mL ---------- Correct Answer ---------- 1,800 mL A vial of medication contains 150 mg/2 mL. If a client is to receive 25 mg of the medication intramuscularly, how many milliliters should a nurse administer to them? -0.2 mL -0.3 mL -0.6 mL -1.0 mL ---------- Correct Answer ---------- 0.3 mL If 150 mg equals 2 mL, then 75 mg equals 1 mL, so 25 mg would equal 0.3 mL. When caring for a client during the immediate postoperative period after a sub-total thyroidectomy, it is important for a nurse to -ensure that the client remains in a supine position. -encourage the client to speak frequently. -provide the client with oral fluids. -monitor the client's respiratory status. ---------- Correct Answer ---------- -monitor the client's respiratory status Which of these actions by a nurse would be best when communicating with a client who has expressive aphasia? -Encourage the client to verbalize thoughts. -Involve the client's family in interpreting the patient's needs. -Ask questions of the client that require an affirmative or negative response. -Attempt to read the client's lip movements. ---------- Correct Answer ---------- Ask questions of the client that require an affirmative or negative response. A client who has been on nothing by mouth may now have fluids. Which of these beverages should be offered first? -Skim milk. -Eggnog. -Cream of chicken soup. -Apple juice. ---------- Correct Answer ---------- Apple juice A nurse should include which of these measures when caring for a client who has returned from hemodialysis? -Obtaining a post-procedure urine sample from the client. -Increasing the client's intake of fluids. -Placing the client in protective isolation. -Observing the client for signs of shock. ---------- Correct Answer ---------- Observing the client for signs of shock A client is receiving intermittent nasogastric tube feedings. A nurse should aspirate the residual stomach contents prior to administering a scheduled feeding for which of these purposes? -To check the pH of the gastrointestinal fluids. -To evaluate the osmolarity of the stomach contents. -To determine absorption of formula in the stomach. -To obtain a specimen of gastric secretion. ---------- Correct Answer ---------- To determine absorption of formula in the stomach. Which of the following endocrine system glands is primarily responsible for regulating an individual's metabolism and energy? ---------- Correct Answer ---------- thyroid gland The force of gravity on a person or object on the surface of a planet is known as which of the following? ---------- Correct Answer ---------- weight The parathyroid gland is an endocrine system gland located behind the thyroid gland. What does the parathyroid gland help the body control? ---------- Correct Answer ---------- calcium and phosphorus levels A nurse is counting a client's radial pulse and notes that the pulse is irregular in rate and rhythm. Which of these actions should the nurse take next? -Have the client rest quietly for 10 minutes, and then take the carotid pulse. -Monitor the client's radial pulse while another person takes the pulse at another site. -Lower the client's wrist and then take the radial pulse on both arms. -Measure the client's apical heart rate for one full minute. ---------- Correct Answer -------- -- Measure the client's apical heart rate for one full minute. A client develops a neurogenic bladder as a result of a spinal cord injury. To initiate a bladder training program for the client a nurse should plan which of these actions? -Restrict fluids throughout the day. -Compress the abdomen before each voiding. -Pour water over the perineum. -Observe for patterns of incontinence. ---------- Correct Answer ---------- Observe for patterns of incontinence. A client reports pain at the needle insertion site of an intravenous infusion. A nurse observes that the area is red. Which of these actions should the nurse take? -Elevate the solution container and regulate the flow rate. -Remove the tape and reposition the needle in the vein. -Stop the infusion and remove the catheter or needle. -Reduce the flow rate of the fluid and elevate the extremity. ---------- Correct Answer ----- ----- Stop the infusion and remove the catheter or needle. A client is to receive 200 mL of three-quarter-strength tube feeding. Which of these proportions should a nurse administer? -100 mL of feeding and 100 mL of water. -125 mL of feeding and 75 mL of water. -150 mL of feeding and 50 mL of water. -175 mL of feeding and 25 mL of water. ---------- Correct Answer ---------- 150 mL of feeding and 50 mL of water. A nursing home client has been confined to a geriatric chair for two hours. Which of these measures should a nurse take at this time? -Give the client a bed bath. -Sit and talk with the client for ten minutes. -Walk with the client around the unit. -Encourage the client to socialize with the roommate. ---------- Correct Answer ---------- Walk with the client around the unit. -Offering reassurance to the client. -Validating information with the client. ---------- Correct Answer ---------- Validating information with the client. Which of these nursing actions would be most effective in gaining the confidence of an adult client who is anxious? -Show interest in the client's point of view. -Relate experiences similar to those of the client. -Demonstrate a clear understanding of what the client can do to relieve the problem. -Tell the client about resources that are available. ---------- Correct Answer ---------- Show interest in the client's point of view A client who is terminally ill with cirrhosis says to a nurse, "I'm angry at God because he won't give me a new liver." Which of these responses would be most helpful? -"You're angry at God." -"I understand your anger toward God." -"I don't blame you for being angry at God. -"You really need to control your anger toward God. ---------- Correct Answer ---------- you're angry at god After preparing a liquid cough medication for a client, a nurse asks another nurse to administer the medication. Which of these actions should the second nurse take? -Administer the medication as requested. -Pour a new dose of the medication. -Chart the medication as a missed dose. -Question the medication order. ---------- Correct Answer ---------- pour a new dose of the medication It is now eight hours since a male client had minor surgery. He expresses a desire to void but is unable to do so. To assist him in passing urine, which of these actions should a nurse take first? -Apply gentle pressure over the bladder region. -Assist the client to a standing position at the bedside. -Insert a straight catheter into the bladder. -Increase the client's fluid intake. ---------- Correct Answer ---------- Assist the client to a standing position at the bedside. The evening before surgery, a client asks a nurse, "Could you pray with me?" The nurse's reply should be based on which of these understandings about the nurse's role in the client's care? -Meeting the client's need is within the nurse's province if the nurse's faith is the same as the client's. -The nurse should request the chaplain of the client's faith to visit. -Prayer is not a nursing function; the nurse should institute such measures as distraction and relaxation. -The nurse has a responsibility to see that the client's need is met ---------- Correct Answer ---------- Meeting the client's need is within the nurse's province if the nurse's faith is the same as the client's. When a client has a nasogastric drainage tube connected to suction, a nurse should monitor the client for symptoms of which of these imbalances? -Metabolic alkalosis. -Respiratory alkalosis. -Metabolic acidosis. -Respiratory acidosis. ---------- Correct Answer ---------- Metabolic alkalosis. When assessing a client's lungs, a nurse should auscultate the lungs by using which of these techniques? -Listen during the inspiratory phase at alternating sites. -Listen to the entire right side before listening to the left side. -Listen to the chest while the patient is supine. -Listen for a full respiratory cycle at each site. ---------- Correct Answer ---------- Listen for a full respiratory cycle at each site. A 42-year-old client is admitted to a medical unit in acute renal failure. The client is given protein food with a high biological value. A nurse should recognize that the rationale for this diet prescription is to -minimize the amount of nitrogen that must be excreted. -increase the amount of urine produced. -reduce the total amount of caloric intake. -provide maximum vitamins and minerals per gram of protein. ---------- Correct Answer -- -------- minimize the amount of nitrogen that must be excreted. A community-based nurse is conducting nutrition education classes at a senior center. The nurse should instruct the clients to consume a high-fiber diet in order to prevent which of these conditions? -Acute irritable bowel syndrome. -Duodenal ulcer. -Gastritis. -Diverticulosis. ---------- Correct Answer ---------- Diverticulosis. A nurse is making a home visit to a mother of a 2-month-old baby. The baby has shown signs of failure to thrive. Which of these assessments by the nurse would provide the most useful data? -Ask the mother about her weight gain during pregnancy. -Inquire about the family's eating habits. -Obtain information about the route of the baby's delivery. -Observe the mother feeding the infant. ---------- Correct Answer ---------- Observe the mother feeding the infant. A nurse is providing dietary instruction to the mother of a child who has a diagnosis of phenylketonuria. Which of these foods should be eliminated from the child's diet? -Foods seasoned with monosodium glutamate. -Foods containing artificial colors. -Foods high in tyramine. -Foods sweetened with aspartame. ---------- Correct Answer ---------- Foods sweetened with aspartame. An 18-year-old college freshman who has had diabetes mellitus (Type I) for nine years takes isophane (NPH) and insulin injections (regular insulin) in the morning and late afternoon. This client reports not having enough time to get to the cafeteria to eat before the first class. Which of these suggestions should a nurse give the patient? -Delay taking your morning insulin until you have had breakfast. -Keep some hard candy available if you need it during class. -Store food in your room that can be used in your meal plan. -Eat a larger bedtime snack the night before. ---------- Correct Answer ---------- Store food in your room that can be used in your meal plan. An 82-year-old client is bedridden in a nursing home. As a result of the client's immobility, a nurse should anticipate that they will experience a loss of -calcium. -insulin receptivity. -iron-binding capacity. -body fat. ---------- Correct Answer ---------- calcium Before being diagnosed with acquired immunodeficiency syndrome (AIDS), a client's usual weight was 140 lb (54.43 kg). In the four weeks prior to admission, the patient lost 18 lb (8.16 kg). Based on the data, which of these assessments should a nurse make? -The client's previous use of drugs has interfered with nutrient absorption. -The weight loss increases the risk of complications. -The weight loss is primarily from a loss of fluid. -The initial loss of weight in AIDS patients is followed by stabilization. ---------- Correct Answer ---------- The weight loss increases the risk of complications. In evaluating the recovery of a client following a partial gastrectomy for cancer, which of these findings should a nurse interpret as indicating appropriate nutritional rehabilitation? -A weight gain of one-half to one pound per week. -A serum glucose of 80 to 100 mg/dL. -A blood urea nitrogen level less than 8 mg/100 dL. -A weight gain of two or more pounds per week. ---------- Correct Answer ---------- A weight gain of one-half to one pound per week. To evaluate how well a client who is on hemodialysis has adhered to the dietary regimen, a nurse should take which of these actions prior to each treatment? -Review the client's food intake since the last treatment. -Ensuring gravity drainage with level of cannister below patient waist. -Pinning the tubing to the bed. ---------- Correct Answer ---------- Emptying the device at least q 8h. Which of these nursing interventions is appropriate for a client during the immediate period following a cardiac catheterization? -Keep the head of the bed in high-Fowler's position for six hours. -Monitor insertion site for bleeding and hematoma. -Perform range-of-motion exercises every hour. -Maintain NPO status until bowel sounds return. ---------- Correct Answer ---------- Monitor insertion site for bleeding and hematoma. On the third postoperative day, a client who had a colon resection reports gas pain. Which of these measures would be most effective in relieving this discomfort? -Placing the client in a prone position. -Having the client drink a carbonated beverage. -Instructing the client to bear down. -Inserting a lubricated rectal tube into the client's rectum. ---------- Correct Answer -------- -- Inserting a lubricated rectal tube into the client's rectum. An elderly client falls and sustains a left hip fracture. The client is initially placed in skin traction (Buck's extension) for which of these purposes? -To reduce the fracture. -To approximate the edges of the fracture. -To prevent edema around the fracture. -To immobilize the fractured extremity. ---------- Correct Answer ---------- To immobilize the fractured extremity. When a client is hospitalized for pneumonia, a nurse should plan to increase fluid intake for which of these primary purposes? -Maintain renal function. -Improve cardiac output. -Promote bowel function. -Improve airway clearance. ---------- Correct Answer ---------- Improve airway clearance. Which of these problems should a nurse monitor for in a client who is diagnosed with Parkinson's disease and has difficulty swallowing? -Gastritis. -Gingivitis. -Aspiration. -Sore throat. ---------- Correct Answer ---------- aspiration A client asks a nurse how a decubitus ulcer will heal. The nurse's response should include an explanation of which of these physiological factors? -Negative nitrogen balance. -Adequate tissue perfusion. -Aerobic metabolism. -Vitamin E absorption. ---------- Correct Answer ---------- Adequate tissue perfusion A nurse is monitoring an immediate postoperative client for bleeding. Which of these findings would indicate that the client is in the early stage of hypovolemic shock? -The client has a large urinary output. -The client has a rapid pulse rate. -The client has slow, labored breathing. -The client has an elevated temperature. ---------- Correct Answer ---------- The client has a rapid pulse rate. A client who is suspected of having a hiatal hernia is admitted to the hospital. It is important for a nurse to ask the client which of these questions? -"Do you experience heartburn after a large meal?" -"Do you experience loose stools after eating?" -"Do you have gastric pain before meals?" -"Do you have difficulty swallowing when eating?" ---------- Correct Answer ---------- "Do you experience heartburn after a large meal?" A nurse has instructed a client about how to perform a sterile dressing change. The client would demonstrate understanding of asepsis by taking which of these actions first? -Putting on a mask. -Donning sterile gloves. -Applying sterile dressings. -Washing their hands. ---------- Correct Answer ---------- washing their hands A nurse is about to give a cleansing enema to a client. The rectal tube has been lubricated. Before inserting the tube into the rectum, the nurse should -place the client on a bedpan. -ask the client to tighten the abdominal muscles. -run a little solution through it. -have the solution container below the level of the rectum. ---------- Correct Answer ------- --- run a little solution through it A young client who is admitted to the hospital says to a nurse, "This is such a dismal place." Which of these responses by the nurse would be most empathetic? -Do you find it dreary? -Do you think it could use a new coat of paint? -Luckily, you won't have to stay long. -There's a nice view from the window. ---------- Correct Answer ---------- do you find it dreary? Ferrous sulfate 323 mg b.i.d. is ordered for a client who has iron-deficiency anemia. Which of these fluids should the client be instructed to administer with the iron to enhance absorption? -Water. -Orange juice. -Milk. -Carbonated beverages. ---------- Correct Answer ---------- OJ If a client's platelet count is below the normal range, a nurse should pay particular attention to which of these measures in the client's plan of care? -Observing for pallor. -Preventing bacterial infection. -Observing for edema. -Preventing physical trauma. ---------- Correct Answer ---------- Preventing physical trauma. In which of these situations could a nurse be held negligent? -The nurse records a client's toxic reaction to a drug but fails to report it to the physician. -The nurse allows a newly admitted client to give any valuables to the person who accompanied the patient to the hospital. -The nurse removes the water pitcher of a client who is scheduled to have fasting blood work, and the client falls when getting out of bed to get a drink. -The nurse delays giving a medication pending clarification of the order with the physician. ---------- Correct Answer ---------- The nurse records a client's toxic reaction to a drug but fails to report it to the physician. A nurse has instructed a client who is taking a loop diuretic about eating foods high in potassium. Which of these fruits, if chosen by the client, would indicate that they require FURTHER teaching? -Banana. -Orange. -Apple. -Cantaloupe. ---------- Correct Answer ---------- apple A nurse is teaching a client in the use of incentive spirometry. Which of these observations would indicate that the client understood the instructions? -The client takes a deep breath through the mouthpiece before exhaling. -The client sustains forceful exhalation into the device for two to three seconds. -The client inhales and exhales with equal volume through the mouthpiece. -The client breathes rapidly into the device for one full minute. ---------- Correct Answer - --------- The client takes a deep breath through the mouthpiece before exhaling. A nurse observes a client with impaired peripheral circulation sitting with crossed legs. The client should be encouraged to avoid this practice for which of these reasons? -Pressure from the patella may cause skin breakdown. -Obliteration of the pedal pulses may impede venous return. -Adduction of the lower extremity will contribute to development of vasospasm. -Compression of the popliteal vessels can promote thrombus formation. ---------- Correct Answer ---------- Compression of the popliteal vessels can promote thrombus formation.