NACE FINAL EXAM 2024-2025, Exams of Health sciences

Download NACE FINAL EXAM 2024-2025 and more Exams Health sciences in PDF only on Docsity! 1 | P a g e NACE FINAL EXAM 2024-2025 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+|BRAND NEW!!!|GUARANTEED PASS |LATEST UPDATE Which of these goals should a nurse include in the plan of care for a client who has a sensory alteration related to blindness? a. The client will demonstrate techniques that compensate for the visual change, by the time of discharge. b. The client will carry out more activities while in the hospital as evidenced by attending group counseling. c. The nurse will compensate for the client's visual deficit when performing activities of daily living. d. The nurse will get the client's approval of the nursing care plan. a. The client will demonstrate techniques that compensate for the visual change, by the time of discharge. By the time of discharge, the patient should demonstrate techniques that compensate for the visual change. Knowing how to compensate for their impairment will maintain the patient's safety. Obtaining approval for the plan of care is not specific to a visually-impaired patient. A nurse should not compensate for the patient's deficit, as the goal should be to increase the patient's independence. The patient may or may not be able to carry out more activities based on other issues and diagnoses. A client has a diagnosis of iron-deficiency anemia. Which of these foods should a nurse recommend the client eat to enhance iron absorption of a food? a. Corn. b. Celery. 2 | P a g e c. Green beans. d. Broccoli. d. Broccoli. Among the food choices, broccoli should be recommended to enhance iron absorption because broccoli contains the highest amount of vitamin C. Vitamin C-rich foods improve iron absorption. Green beans, corn, and celery are not rich in vitamin C. A client who has dumping syndrome should be instructed to limit intake of which of these food substances? a. Starch. b. Artificial sweeteners. c. Protein. d. Simple sugars. d. Simple sugars. Foods high in simple sugars should be avoided because they pass through your stomach quickly and may cause diarrhea and cramping. Starches, protein, and artificial sweeteners do not need to be limited. A client who is on warfarin (Coumadin) sodium therapy should be cautioned to AVOID overconsumption of which of these foods? a. Poultry. b. Green, leafy vegetables. c. Skim milk. d. Whole grain breads. b. Green, leafy vegetables. Excessive amounts of green, leafy vegetables should be avoided by a client on Coumadin because they are high in vitamin K, which counteracts the effects of Coumadin. Coumadin is prescribed to prevent blood clots and thins the blood to flow more easily through narrowed blood vessels. Skim milk, whole grain breads, and poultry do not contain high amounts of vitamin K. A nurse emphasizes to a client, who has a diagnosis of cirrhosis of the liver, the importance of refraining from alcohol. Which of these understandings should the nurse have about the physiological effects of alcohol? a. Alcohol depletes glucagon stored in the liver. b. Alcohol interferes with the liver's ability to synthesize high-density lipoprotein. c. Increased stress is placed on the liver in detoxifying alcohol. d. The production of the liver enzyme glucuronyl transferase is increased by alcohol. 5 | P a g e When planning care for a client, a nurse should recognize that which of these characteristics would distinguish a pureed soft diet from a mechanical soft diet or a regular soft diet? a. nutritive value. b. fiber content. c. cost. d. texture. d. texture. Texture is the characteristic that distinguishes the diets from each other. Pureed soft diet consists of pureed foods. A mechanical soft diet consists of regular table food that is soft, moist, or easy to swallow and chew. A regular soft diet consists of food that can easily be mashed with the back of a fork - requiring a small amount of chewing. When preparing a diet plan for diabetic client, a nurse should recognize that which of these foods would be found in the bread/starch exchange list? a. Broccoli. b. Beets. c. Avocado. d. Green peas. d. Green peas. Green peas are in the bread/starch exchange list. Green peas are part of the legume family, which also includes dried beans and lentils. Avocado, beets, and broccoli are vegetables. Which of these dietary modifications should a nurse anticipate for a client who has a diagnosis of cirrhosis of the liver? a. Restriction of carbohydrates. b. Restriction of protein. c. Supplements of potassium. d. Supplements of vitamin E. b. Restriction of protein. Protein causes toxins to form in the digestive tract, so eating less protein will help decrease the buildup of toxins in the blood and brain with clients who have a damaged liver, as in liver cirrhosis. A low-protein diet and agents such as lactulose may help hepatic encephalopathy. Supplements of vitamin E may not help. Carbohydrates should not be restricted. Supplements of potassium are not part of dietary modification. 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? 6 | P a g e a. Decreased eosinophil count. b. Elevated blood urea nitrogen. c. Elevated serum glutamic oxaloacetic transaminase. d. Decreased serum albumin. d. Decreased serum albumin. Serum albumin concentration is a common index of nutritional status, where decreased serum albumin indicates compromised nutritional status. Elevated blood urea nitrogen levels suggest impaired kidney function. A high level of serum glutamic oxaloacetic transaminase released into the blood may be a sign of liver or heart damage, cancer, or other diseases. Eosinophils are part of the white cell count differentials. Decreased eosinophil count may mean decreased ability to fight allergic reactions. Which of these laboratory values indicates a decreased risk of cardiovascular disease? a. A low ratio of cholesterol to lipoprotein. b. A high ratio of triglycerides to high-density lipoprotein. c. A high ratio of high-density lipoprotein to low-density lipoprotein. d. A low ratio of triglycerides to cholesterol. c. A high ratio of high-density lipoprotein to low-density lipoprotein. High-density lipoprotein is known as "good" cholesterol, as higher amounts of this cholesterol decrease the risk of cardiovascular disease. Low density lipoprotein is known as "bad" cholesterol, as high levels of this kind of cholesterol lead to cardiovascular disease. Laboratory values that show a high ratio of triglycerides to high density lipoproteins, a low ratio of cholesterol to lipoprotein, and a low ratio of triglycerides to cholesterol should not indicate to a nurse a decreased risk of cardiovascular disease. Which of these nutrients should a nurse recognize as the most difficult to digest by a child who has cystic fibrosis? a. Simple carbohydrates. b. Protein. c. Fat. d. Complex carbohydrates. c. Fat. A child with cystic fibrosis (CF) has the most difficulty digesting fat because they lack the enzyme in their pancreas to digest it. Since CF is a malabsorption syndrome, the child with CF will also have some difficulty digesting protein and carbohydrates, but not as much difficulty as with fat and fat soluble vitamins must be supplemented. A nurse is assisting an 80-year-old client in planning nutritious meals at a reasonable cost. Which of these statements regarding dietary guidelines should the nurse make? 7 | P a g e a. Include more meat and poultry in your diet and your food dollar will go farther. b. If you are not hungry, skip a meal and drink a nutritional shake instead. c. Eat plenty of foods that are high in carbohydrates because those food sources are especially affordable. d. Consume fewer calories and smaller portions than you did as a young adult. d. Consume fewer calories and smaller portions than you did as a young adult. An 80-year-old patient should consume fewer calories than he/she did as a young adult. In the elderly, fewer calories are required due to loss of lean body mass and a decrease in the basal metabolic rate. A nurse is caring for a client who has sustained serious head trauma. Which of these assessment findings should the nurse report immediately? a. Brisk pupil reaction to light. b. Serous discharge from the ear. c. Purposeful movement of the arms. d. Excessive tearing of both eyes. b. Serous discharge from the ear. Serous discharge from the ear is an indicator of a basilar skull fracture. Unequal or dilated pupils, not brisk pupillary reactions, are an indicator of a head injury. Purposeful movement of the arms is a normal finding. Excessive tearing of the eyes is not associated with head trauma. A nurse is caring for a client who is diagnosed with cancer and is receiving chemotherapy. The nurse should recognize that the client's family members are providing psychosocial support if they a. transport the client to scheduled treatments. b. ask the nurse how long the treatments will continue. c. talk with the client during treatments. d. tell the nurse that they feel overwhelmed. c. talk with the client during treatments. From the options given, talking with the client during treatments is the most direct observation of support. A nurse should expect to observe which of these symptoms in a client who has Cushing's syndrome? a. Pallor and weight loss. b. Increased thirst and dysphagia. c. Abnormal fat distribution and joint pains. d. Hair loss and blurred vision. c. Abnormal fat distribution and joint pains. 10 | P a g e d. Using oxygen at six liters per minute Clients who have COPD should maintain low-flow oxygen rates. These clients have hypoxia and hypercarbia. Increasing their oxygen levels can cause a loss of the respiratory drive and lead to respiratory arrest. Having plants in the room, wearing clothing made of 100% cotton, or using humidified oxygen would not be safety hazards to a client who has COPD. A client who is on bed rest with an indwelling urinary catheter has had no urinary drainage for the past four hours. Which of these actions should a nurse take first? a. Force fluids. b. Elevate the client's legs. c. Palpate the client's suprapubic area. d. Ensure the drainage bag is below the level of the bed. d. Ensure the drainage bag is below the level of the bed. Urine from a Foley catheter drains by gravity, and thus the drainage bag needs to be below the level of the bed. Forcing fluids, elevating the client's legs, and palpating the client's suprapubic area are not the first actions a nurse should take for this client. A nurse should recognize that an elderly client who has a history of osteoporosis is at greatest risk for developing which of these complications? a. Bone cancer. b. Impotence. c. Sciatica. d. Stress fractures. d. Stress fractures. Elderly clients with osteoporosis often develop stress fractures. An elderly client with a history of osteoporosis is not at an increased risk for bone cancer, impotence or sciatica. When a client is hospitalized for pneumonia, a nurse should plan to increase fluid intake for which of these primary purposes? a. Maintain renal function. b. Improve cardiac output. c. Promote bowel function. d. Improve airway clearance. d. Improve airway clearance. The primary purpose of increasing fluid intake for a client hospitalized for pneumonia is to improve airway clearance by liquefying secretions so the client can cough and expectorate. A client's renal function, cardiac output, and bowel function are not affected by pneumonia. 11 | P a g e 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? a. Give the client a bed bath. b. Sit and talk with the client for ten minutes. c. Walk with the client around the unit. d. Encourage the client to socialize with the roommate. c. Walk with the client around the unit. After being confined to a geriatric chair for two hours, the nurse should walk around the unit with the client. This will reduce pressure on the client's skin and promote circulation and lung expansion. Giving the client a bed bath, sitting and talking with the client or encouraging the client to socialize with the roommate would not promote the client's circulation. It is more important to move the client. A client in a long-term care facility is learning to use a walker. Which of these instructions should a nurse reinforce to the client? a. "Use the walker as needed for balance." b. "Step and move the walker simultaneously." c. "Move the walker and then step into it." d. "Glide the walker along the floor with each step." c. "Move the walker and then step into it." The client should be instructed to move the walker and step into it for safety and balance. The walker should be used each time the client ambulates. Stepping and moving the walker simultaneously, or gliding the walker along the floor with each step, may lead to falls. For which of these reasons should a nurse administer a diuretic to a client early in the morning? a. Any toxic effects of the drug will be readily recognized. b. The peak action of the drug will occur while the client is awake. c. Mobility during the day will increase the volume of urine produced. d. The client will require additional fluid intake at night. b. The peak action of the drug will occur while the client is awake. A diuretic should be administered to a client in the morning so the peak action of the drug (diuresis and increased urine output) will occur while the client is awake. Toxic effects, the client's mobility, and required fluid intake are not affected by what time the drug is taken. A nurse is caring for a client with a self-care deficit related to toileting. Which of these nursing orders would serve as the best guide when providing care to this client? a. Reposition the client frequently to improve renal perfusion. b. Ambulate client to toilet every four hours while the client is awake. 12 | P a g e c. Teach coping strategies for dealing with incontinence based on client readiness. d. Provide emotional support and reassurance for voiding accidents. b. Ambulate client to toilet every four hours while the client is awake. Offering a bedpan every four hours while the client is awake is the best intervention for self-care deficit related to toileting, as it provides a regular schedule for bladder retraining. Repositioning the client frequently, teaching coping strategies based on client readiness, and providing emotional support are not the best guides when providing care for self-care deficit related to toileting. Which of these nursing measures is appropriate during an asthmatic attack? a. Minimizing environmental stress. b. Teaching the client to deep breathe and cough. c. Having the client use a pillow to splint the chest. d. Maintaining the client in a semi-Fowler's position. a. Minimizing environmental stress. During an asthmatic attack, a nurse should minimize environmental stress. Environmental stress will increase dyspnea. Teaching the client to deep breathe and cough, or using a pillow to splint the client's chest are not effective nursing methods during an asthmatic attack. Allow client to assume position of comfort & don't insist on semi-Fowler's position. An elderly client fell and sustained head trauma. A nurse is monitoring this client for signs of increased intracranial pressure. Which of these signs would provide the earliest indication that the client's intracranial pressure has increased? a. Change in the level of consciousness. b. Drop in blood pressure. c. Decrease in temperature. d. Difficulty breathing. a. Change in the level of consciousness. One of the earliest signs of increased intracranial pressure following head trauma is a change in the level of consciousness. Clients with increasing intracranial pressure will experience an increase in blood pressure. A decrease in temperature and difficulty breathing are not early signs of increased intracranial pressure. 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? a. "Do you experience heartburn after a large meal?" b. "Do you experience loose stools after eating?" c. "Do you have gastric pain before meals?" d. "Do you have difficulty swallowing when eating?" 15 | P a g e An 83-year-old client who was recently admitted to a nursing care facility frequently looks vacantly at family members and says, "I don't know where I am." A nurse notes that the client also has a history of getting up several times at night and falling. Based on the information the nurse should give priority to which of these measures? a. Placing a call light within the client's reach. b. Having the client void before they go to bed. c. Reminding the client that this is their new home now. d. Maintaining the bed in a low position. d. Maintaining the bed in a low position. Maintaining the bed in the lowest position and even placing the mattress on the floor will reduce the risk of injury if the patient does fall, and should be a priority measure in the patient's evening care. The other options are applicable but are not the priority. A client has an abdominal wound drainage tube attached to wall suction. Which of these nursing diagnoses should be included in the client's care plan? a. Imbalanced body temperature. b. Altered gastrointestinal tissue perfusion. c. Fluid volume deficit. d. Chronic pain. c. Fluid volume deficit. The suction will affect the amount of fluid removed from the patient's body. It will not alter the patient's temperature or tissue perfusion. The drain is temporary, and therefore the patient may be experiencing acute, not chronic, pain. A client has an intravenous infusion in the left forearm. A nurse finds that the solution is infusing at a much slower rate than was established earlier. After verifying that the infusion has NOT infiltrated, the nurse should take which of these actions next? a. Agitate the infusion container. b. Reposition the client's left arm. c. Check the intravenous fluid for sedimentation. d. Have the client open and close the left fist. b. Reposition the client's left arm. Repositioning the patient's arm can often change the position of the catheter enough to regain proper flow. The other measures can be assessed for, and/or tried, but are not the first actions that the nurse should consider. 16 | P a g e A client has an order for a transdermal nitroglycerin (Nitro-Dur) patch q 6h. Which of these actions should a nurse include when applying a new patch? a. Rotate the application site. b. Locate the point of maximal impulse. c. Count the pulse for a full minute. d. Leave the previous patches in place. a. Rotate the application site. The patch should be placed in a different position after the old one is removed. The medication can be absorbed through the skin at any location. A one minute pulse would be obtained prior to administering digoxin (Lanoxin). A client has received instructions from a nurse about physical preparation for surgery. The teaching has been effective if the client can identify that the purpose of having nothing by mouth for six to eight hours prior to surgery is to a. enhance the administration of anesthesia preoperatively. b. regulate intraoperative fluid status. c. reduce the risk of intraoperative vomiting. d. decrease postoperative peristalsis. c. reduce the risk of intraoperative vomiting. Maintaining an NPO status preoperatively is recommended so that the stomach is empty and the risk of vomiting is reduced. Other measures would be taken for enhancing administration of anesthesia, regulating fluids, or decreasing postoperative peristalsis for abdominal surgeries. A client who appears cachectic is scheduled for emergency surgery. A preoperative nutritional assessment should be performed by a nurse for which of these reasons? a. A malnourished client is prone to postoperative infection. b. Poor nutrition predisposes a client to respiratory complications. c. Poor nutrition increases the risk of postoperative hemorrhage in a client. d. A malnourished client has increased metabolic needs. a. A malnourished client is prone to postoperative infection. All the answers could be potential risks for a patient who is malnourished, but the most probable and problematic is infection. After discussing a client's weight-reduction dietary plan, a nurse finds the client eating candy that a visitor brought. Which of these approaches should the nurse take? a. Tell the client's visitors not to bring candy. b. Remove the candy because it is not allowed on the client's diet. 17 | P a g e c. Remind the client that as an adult, he/she should demonstrate the self-control necessary to improve health. d. Recognize that the client is ultimately responsible for making their own decisions. d. Recognize that the client is ultimately responsible for making their own decisions. The nurse can provide education on a healthy lifestyle and nutrition, but a competent adult is responsible for his/her own actions. Telling visitors not to bring the candy, or removing the candy, takes care of only the immediate situation. The patient is likely to be confronted with other similar situations in which they need to make a choice. 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. 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. 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. Run the tap water while the client is on the toilet. 20 | P a g e 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 notify the physician A 31-year-old client is receiving medical treatment for ulcerative colitis. The treatment includes antibiotics and prednisone. A nurse should plan to monitor the client for which of these nutritional consequences of this treatment? -Hypercalcemia. -Hyperglycemia. -Hyponatremia. -Hypolipidemia. hyperglycemia After ten months on dialysis, a client undergoes a renal transplant and is receiving immunosuppressive therapy. Which of these nutritional consequences should a nurse anticipate? -A decreased synthesis of bile acids will occur. -An increased intake of simple carbohydrates will be necessary. -The client's protein requirements will be significantly higher. -The client's need for fat-soluble vitamins will be greater. The client's protein requirements will be significantly higher. Assuming that all of these foods are available, which sandwich selection would be appropriate for a client who is on a bland diet of 50 grams of fat? -Peanut butter and jelly on whole wheat bread. -Creamy chicken salad and tomato on rye bread. -Flaked white tuna and lettuce on white bread. -Bologna and American cheese with maynonnaise on white bread. Flaked white tuna and lettuce on white bread Following a partial gastrectomy, a client loses the ability to synthesize intrinsic factor. As a result, a nurse should expect that the patient will be unable to absorb which of these nutrients? -Vitamin B12. -Copper. -Folacin. -Iron vitamin b12 21 | P a g e When preparing a diet plan for diabetic client, a nurse should recognize that which of these foods would be found in the bread/starch exchange list? -Green peas. -Avocado. -Broccoli. -Beets. green peas Which if these diet orders should a nurse give initially to a client who has acute pancreatitis? -Hydrolyzed protein formula. -Nothing by mouth. -Pureed soft diet. -Two grams of sodium, 30 grams of fat. nothing by mouth Which of these is a major disadvantage of a clear liquid diet? -Fluids allowed are not palatable. -High caloric content results in hyperglycemia. -High fluid intake leads to diarrhea. -Diet is nutritionally inadequate. Diet is nutritionally inadequate. Which of these diets should a nurse implement for a woman who is recovering from hyperemesis of pregnancy? -High-protein liquids every two hours. -Foods that are high in soluble fiber divided equally throughout the day. -Frequent meals of soft, bland foods. -Frequent small, dry meals, with clear liquids in between. Frequent small, dry meals, with clear liquids in between. Which of these factors should a nurse investigate as the most likely etiology of altered nutrition in a client who is receiving radiation therapy for endometrial cancer? -Malabsorption. -Absence of essential enzymes. -Dysphagia. -Loss of appetite loss of appetite A nurse is reinforcing instructions about breast self-examination with a premenopausal woman. Which of these statements, if made by the client, would indicate that she needs FURTHER instructions? -I will use a circular pattern when feeling for abnormalities of my breasts. -I will examine both of my breasts weekly while showering. -I will look in a mirror for changes in contour of my breasts. -I will gently compress the nipple of my breasts to check for discharge. 22 | P a g e I will examine both of my breasts weekly while showering. A nurse is reinforcing teaching with a client who is diagnosed with non-insulin-dependent diabetes mellitus. Which of these topics is most important for the nurse to emphasize? -Individualized prescription of diet, exercise, and medication. -Clinical manifestations of non-insulin-dependent diabetes. -Lifestyle modifications to reduce stress. -Personal hygiene measures. Individualized prescription of diet, exercise, and medication. A nurse should assess a client who has a thyroidectomy for signs of hypocalcemia, which include -gingival hypertrophy. -painful joints. -tetany. -toothaches. 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. 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. 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. 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 25 | P a g e 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. 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. 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. Walk with the client around the unit. Which of these measures should a nurse include in the care plan of a client who has renal calculi? -Restricting fluid intake. -Straining all urine. -Maintaining bed rest. -Limiting potassium intake. straining all urine A nurse is reinforcing discharge instructions with a client who is on warfarin sodium (Coumadin) therapy. Which of these instructions should be emphasized? -Brush your teeth after meals with a firm toothbrush. -Use an electric razor for shaving. -Take aspirin (ASA) or other NSAID for all minor aches and pains. -Include plenty of green, leafy vegetables in your diet. Use an electric razor for shaving. Which of these measures should a nurse emphasize when feeding a client with left-sided facial paralysis who has difficulty swallowing? -Placing the food on the back of the client's tongue. -Placing the food in the unaffected side of the client's mouth. 26 | P a g e -Removing the client's dentures before feeding. -Mashing the food before feeding the client. Placing the food in the unaffected side of the client's mouth. Which of these actions should a nurse take to prevent the development of thrombophlebitis in a postoperative client? -Raise the knee gatch on the client's bed. -Ambulate the client. -Encourage the client to increase fluid intake. -Massage the client's legs. ambulate the client A client who is terminally ill with acquired immunodeficiency syndrome (AIDS) is admitted to the hospital. Which of these precautions should be included in the client's plan of care? -Standard precautions. -Respiratory precautions. -Strict isolation. -Enteric precautions. standard precautions A nurse is caring for a client who had a right lower lobectomy and has a closed (water-sealed) chest drainage system in place. Which of these actions should a nurse include in the plan of care? -Keep the system below the level of the client's waist. -Change the system every 72 hours. -Empty the system every 4 hours. -Clamp the system when ambulating the client. Keep the system below the level of the client's waist. A nurse identifies all of these nursing diagnoses for a client. Which diagnosis should the nurse give the highest priority? -Altered comfort: pain. -Altered nutrition: less than body requirements. -Impaired skin integrity. -Impaired tissue perfusion. Impaired tissue perfusion. A nurse is helping an elderly client who has been on prolonged bed rest to get out of bed for the first time. The client should be encouraged to move slowly in order to prevent -sudden perfusion of the kidneys. -engorgement of the femoral veins. -postural hypotension. -increased cardiac output postural hypotension. 27 | P a g e A nurse obtains all of these laboratory results for a client prior to surgery. Which one should the nurse report to the physician? -Hemoglobin level of 11.5 gm/dL. -Prothrombin time of 32 seconds. -Platelet count of 250,000/mm. -White blood cell count of 9,000 cells/mm. Prothrombin time of 32 seconds. The results of a client's diagnostic tests show a high total cholesterol level. The client asks a nurse, "What should I do to reduce my cholesterol level?" The nurse should suggest that the client decrease the intake of which of these nutrients? -Vegetable fats. -Complex carbohydrates. -Simple sugars. -Animal fats. animal fats When cleaning a client's dentures, which of these measures should a nurse implement while wearing gloves? -Brushing the dentures in an emesis basin with tepid water. -Soaking the dentures for 20 minutes in a peroxide solution. -Applying an abrasive dentifrice to the dentures with a stiff brush. -Rinsing the dentures in the sink using hot tap water. Brushing the dentures in an emesis basin with tepid water. Which of these communication techniques should a nurse use with a client who frequently misinterprets the nurse's instructions? -Conveying acceptance of the client. -Listening attentively to the client. -Offering reassurance to the client. -Validating information with the client. 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. 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." 30 | P a g e -calcium. -insulin receptivity. -iron-binding capacity. -body fat. 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. 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. 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. -Ask the client about fluid intake during the 24 hours prior to treatment. -Determine the client's blood glucose level. -Compare the client's present weight to the weight after the last treatment. Compare the client's present weight to the weight after the last treatment. When an elderly client is having difficulty eating because of poorly fitting dentures, which of these diets should that client have? -Full liquid. -Bland. -Mechanical soft. -Pureed. mechanical soft When comparing a pre-term infant to a full-term infant, a nurse should recognize that the pre-term infant has which of these needs per kilogram of body weight? -Less fat and cholesterol. -More kilocalories and protein. 31 | P a g e -More sodium and potassium. -Less fluid and water-soluble vitamins. More kilocalories and protein. When discussing dietary modifications for a client who was recently diagnosed with a duodenal ulcer, a nurse should make which of these recommendations? -Eat a high-protein diet. -Drink whole milk at each meal. -Eliminate uncooked vegetables. -Eliminate the consumption of alcohol. Eliminate the consumption of alcohol. Which of these nutritional goals should a nurse plan for a client who has been diagnosed with nephrotic syndrome? -To prevent protein malnutrition. -To replace serum electrolytes. -To prevent loss of fatty tissue. -To provide adequate carbohydrates. To prevent protein malnutrition. A nurse is planning age-appropriate health promotion classes for a community. The nurse should recognize that Erikson's stages of growth and development designate that the task of middle age is -identity vs. role confusion. -intimacy vs. isolation. -generativity vs. stagnation. -integrity vs. despair. generativity vs. stagnation. A nurse is working with a postoperative client after throat surgery who has been reluctant to drink fluids due to pain. Which of these findings should the nurse recognize as the best indication that the client's hydration status has improved? -The patient's urine specific gravity is 1.025. -The patient's skin appears shinier. -The patient no longer reports feelings of thirst. -The patient no longer reports episodes of pain. The patient's urine specific gravity is 1.025. A nurse should observe a client who is in sickle cell crisis for which of these symptoms? -Nausea and vomiting. -Fatigue and pain not relieved by rest. -Bleeding and dizziness. -Immobility and bruising, especially over the lower extremities. fatigue and pain 32 | P a g e A nurse teaches a client who has been newly diagnosed with insulin-dependent diabetes mellitus about blood glucose monitoring. Which of these statements would indicate to the nurse that the client has a correct understanding of the teaching? -I will check my blood sugar if I feel lightheaded. -I will check my blood sugar after I exercise. -I will check my blood sugar only when I am unable to eat. -I will check my blood sugar before each meal and at bedtime. I will check my blood sugar before each meal and at bedtime. (typically check blood sugar 4 times a day) A client who is taking furosemide (Lasix) complains of feeling weak and tired and having no appetite. A nurse should recognize that these symptoms are most likely related to which of these conditions? -Hypocalcemia. -Hypernatremia. -Hypokalemia. -Hyperchloremia. Hypokalemia. Which of these actions should a nurse take first while a person is having a tonic-clonic seizure in the hallway? -Call a code. -Check the person's pupillary response. -Position the person on their left side. -Protecting the person's head. Protecting the person's head. Which of these measures should be included in the care plan for a postoperative client who has a Hemovac (low pressure suction system) in place? -Irrigating the tubing q 4h. -Emptying the device at least q 8h. -Ensuring gravity drainage with level of cannister below patient waist. -Pinning the tubing to the bed. 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. 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. 35 | P a g e -Observing for pallor. -Preventing bacterial infection. -Observing for edema. -Preventing physical trauma. 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. 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. 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. 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. Compression of the popliteal vessels can promote thrombus formation. A client who appears cachectic is scheduled for emergency surgery. A preoperative nutritional assessment should be performed by a nurse for which of these reasons? -A malnourished client is prone to postoperative infection. -Poor nutrition predisposes a client to respiratory complications. 36 | P a g e -Poor nutrition increases the risk of postoperative hemorrhage in a client. -A malnourished client has increased metabolic needs. A malnourished client is prone to postoperative infection. A client's medication order reads: "Aspirin 650 mg po pc." A nurse should give the aspirin to the client at which of these times? -Before meals. -Between meals. -With meals. -After meals. after meals After discussing a client's weight-reduction dietary plan, a nurse finds the client eating candy that a visitor brought. Which of these approaches should the nurse take? -Tell the client's visitors not to bring candy. -Remove the candy because it is not allowed on the client's diet. -Remind the client that as an adult, he/she should demonstrate the self-control necessary to improve health. -Recognize that the client is ultimately responsible for making their own decisions. Recognize that the client is ultimately responsible for making their own decisions. An 84-year-old client is admitted to the hospital with a temperature of 100.8 F (38.2 C), dry oral mucous membranes, and urine specific gravity of 1.035. Which of these nursing diagnoses should be given priority? -Urinary retention. -Ineffective thermoregulation. -Fluid volume deficit. -Impaired skin integrity. fluid volume deficit To assess a person with dark skin for signs of cyanosis, a nurse should look at the client's -ankles. -conjunctiva. -wrists. -earlobes. 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. 37 | P a g e Wheezing, pronounced on expiration A nurse is instructing a client who has been diagnosed with diabetes mellitus about food exchanges. The client says that she is unable to eat "the greasy meat" served in the cafeteria. Which of these foods, assuming that they are available, would be an acceptable substitute for her meat exchange? -Bagels and cream cheese. -Baked potato and sour cream. -Macaroni and cheese. -Spaghetti and tomato sauce. mac n cheese A nurse should monitor a client who is receiving long-term antibiotic therapy for which of these nutritional consequences? -Inhibition of intestinal synthesis of vitamin K. -Acceleration of the excretion of niacin. -Binding of ascorbic acid. -Reduction of the absorption of folacin. Inhibition of intestinal synthesis of vitamin K. A nurse should monitor the blood glucose levels of a client who is receiving total parenteral nutrition for which of these reasons? -The increased blood volume leads to a drop in serum glucose. -The glucose content of the solution may lead to hyperglycemia. -The pancreas fails to function adequately in the absence of gastric stimulation. -The peripheral tissues develop an increased resistance to insulin. The glucose content of the solution may lead to hyperglycemia. The assessment of a client who has a diagnosis of stomach cancer reveals protein and calorie malnutrition. Considering the diagnosis and nutritional status, a nurse should plan to use which of these nutritional interventions to improve the client's nutritional status after surgery? -Total parenteral nutrition via a central line. -High-density formula via gastrostomy feedings. -Vitamin-enriched, high-protein liquid via oral feeding. -Elemental formula via nasogastric tube. Total parenteral nutrition via a central line. The laboratory test results of a 30-year-old client reveal the following values: Total cholesterol 200 mg/dL Triglycerides 85 mg/dL; LDL Cholesterol 185 mg/dL; HDL Cholesterol 45 mg/dL. The above findings suggest an excess of which of these types of cholesterol? -HDL cholesterol. -Total cholesterol. -LDL cholesterol. -Triglycerides. LDL cholesterol