NACE NURSING ACCELERATION CHALLENGE EXAM | NACE EXAM AND PRACTICE EXAM WITH 600+ QUESTIONS, Exams of Nursing

Download NACE NURSING ACCELERATION CHALLENGE EXAM | NACE EXAM AND PRACTICE EXAM WITH 600+ QUESTIONS and more Exams Nursing in PDF only on Docsity! NACE NURSING ACCELERATION CHALLENGE EXAM | NACE EXAM AND PRACTICE EXAM WITH 600+ PRACTICE TEST QUESTIONS AND A STUDY GUIDE AT THE END | ACCUERATE AND VERIFIED QUESTIONS WITH DETAILED ANSWERS | GUARANTEED PASS | GRADED A Which type of precautions is indicated for a patient with a surgical-site infection and purulent discharge? Contact and droplet Airborne Droplet Contact Contact Which of the following injection sites is the BEST choice for intramuscular (IM) administration of 3 mL of medication for a well-developed adult female of normal weight? Deltoid Vastus lateralis Dorsogluteal site Ventrogluteal site Ventrogluteal site The ventrogluteal site is the preferred IM injection site because there is little danger of injecting into fatty tissue, large nerves, or blood vessels. In a well-developed adult, up to 4 mL can be safely injected. The dorsogluteal site is the least preferred site because of its proximity to the sciatic nerve and large blood vessels and increased fat deposits. The vastus lateralis site is also good because it lacks large nerves or large blood vessels. The deltoid site is usually avoided because of the small muscle size and the proximity of the radial nerve and artery. Injections to the deltoid should be limited to 1 mL. A burn patient is upset and argues loudly with the nurse, refuses wound care, and states that the treatment is too painful. Which response is an example of therapeutic communication? "You should be happy that the burns are healing so well" "You should stop arguing with the nurses" "Everyone gets upset at times" "Let's talk about this and see if we can figure out a way to make the treatment more comfortable for you" "Let's talk about this and see if we can figure out a way to make the treatment more comfortable for you" Collaborating with the patient to find a solution to a problem is an example of therapeutic communication. The other responses are nontherapeutic and can block effective communication. Saying "Everyone gets upset at times" devalues the patient's feelings. "You should stop arguing with the nurses" is a negative judgment that may anger the patient more and does not deal with the real issue. Saying "You should be happy the wound is healing" provides unwanted advice and ignores the patient's concerns. According to Maslow's hierarchy of needs, which of the client's needs must be met FIRST? Belonging and self-esteem Physiological Safety and security Self-actualization Physiological Physiological needs must be met first. Abraham Maslow stated that human behavior is motivated by needs, and that there is a hierarchy of needs that begins with basic needs and progresses to personal needs. People may not progress in one direction from one need to another, but movement may be in multiple directions in a lifelong process of working toward self- actualization, which requires creativity and some degree of freedom. Failure to develop toward self-actualization may result in depression and feelings of failure. A bed-bound patient has a 1.5-inch foam overlay over her mattress. The nurse places her hand under the overlay and finds that the foam overlay has compressed to 0.75 inch. What does this indicate? Excess wear Adequate support Bottoming out Moisture retention Bottoming out Support surface material should provide at least one inch of support under areas to be protected when in use to prevent "bottoming out." (Check by placing a hand palm-side up under the overlay and below the pressure point.) Static support surfaces are appropriate for patients who can change position without increasing pressure to an ulcer. Dynamic support surfaces are needed for those who need assistance to move or when static pressure devices provide less than one inch of support. A patient who is a Jehovah's Witness needs a transfusion of packed red blood cells because of blood loss, but his religion prohibits blood transfusions. Which of the following is the correct action? Tell the patient that he may die without the transfusion Provide full information and the reasons for the transfusion Assume the patient will not accept a transfusion and report this to the physician Tell the patient that his health is more important than religious beliefs Provide full information and the reasons for the transfusion It's important to approach the patient/family with full information and reasons for the transfusion or blood components without being judgmental, allowing them to express their feelings. One considering the route of administration, absorption, dosage, frequency of administration, distribution, and serum levels achieved over time. The half-time is the time needed to reduce plasma concentrations to 50% during elimination. Usually the equivalent of five half-times is needed to completely eliminate a drug or achieve steady-state plasma concentrations if giving doses intermittently. The effect-site equilibrium is the time between administration of a drug and the clinical effect. When determining the burden of proof for acts of negligence, how would risk management classify willfully providing inadequate care while disregarding the safety and security of another? Comparative negligence Gross negligence Negligent conduct Contributory negligence Gross negligence Gross negligence. Negligence indicates that proper care has not been provided, based on established standards. Reasonable care uses a rationale for decision making in relation to providing care. Types of negligence include the following: Negligent conduct indicates that an individual failed to provide reasonable care or to protect/assist another, based on standards and expertise. Gross negligence is willfully providing inadequate care while disregarding the safety and security of another. Contributory negligence involves the injured party contributing to his/her own harm. Comparative negligence attempts to determine what percentage of negligence is attributed to each individual involved. Which of the following is a legal document that specifically designates someone to make decisions regarding medical and end-of-life care if a patient is mentally incompetent? Do-not-resuscitate order General power of attorney Advance directive Durable power of attorney Durable power of attorney The legal document that designates someone to make decisions regarding medical and end-of- life care if a patient is mentally incompetent is a durable power of attorney. This is a type of advance directive, which can include living wills or specific requests of the patient regarding treatment. A do-not-resuscitate order indicates that the patient does not want resuscitative treatment for terminal illnesses or conditions. A general power of attorney allows a designated person to make decisions for a person over broader areas, including financial. Which of the following is advised to promote phase delay in a patient with circadian rhythm sleep disorder? Avoid early morning light, and seek bright light in the evening Exposure to light after the time of minimum body temperature (about 3 a.m.) Walk outside in sunlight after awakening Avoid bright light in the evening Circadian rhythm sleep disorder (CRSD) is characterized by advanced phase sleep disorder (APSD), delayed phase sleep disorder (DPSD), free-running disorder, shift-work disorder, and other irregular patterns. To promote phase delay:• Expose to light immediately before time of minimum body temperature (about 3 a.m.).• Avoid early morning light and/or wear sunglasses and seek bright light in the evening. To promote phase advance:• Expose to light after the time of minimum body temperature (about 3 a.m.).• Walk outside in sunlight after awakening, and avoid bright light in the evening.• Take a melatonin supplement in the evening. 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. 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. 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. 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. 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. 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. 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 -Folacin. -Iron vitamin b12 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. 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 -2.0 mL -3.5 mL 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 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 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. -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. 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. -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. 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." -"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. 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. 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. 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. -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. -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 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. -Having the client drink a carbonated beverage. -Instructing the client to bear down. -Inserting a lubricated rectal tube into the client's rectum. 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. 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. -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. 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 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. 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. To remove nitrogenous waste. Which of these instructions should a nurse include when teaching a client who has mild heart failure? -Limit your fluid intake to 2,000 mL per day. -Balance activity and rest periods. -Eat three large meals a day. -Get at least 10 hours of sleep every night. Balance activity and rest periods. Proper PPE for contact precaution [c.diff, wounds, etc] - CORRECT ANSWER Gown and gloves Proper PPE for droplet precaution - CORRECT ANSWER Surgical mask within 3 ft of pt Proper PPE for airborne precaution [TB] - CORRECT ANSWER respirator (N95) and negative pressure room Illnesses requiring droplet precautions - CORRECT ANSWER Pertussis, influenza, diphtheria, pneumonia, bacterial meningitis Illnesses requiring airborne precautions - CORRECT ANSWER Measles, Severe Acute Respiratory Syndrome (SARS), Varicella (chickenpox), and Mycobacterium tuberculosis How to remove a wound dressing? - CORRECT ANSWER From clean area to contaminated area How to draw up urine sample from catheter? - CORRECT ANSWER swab collection port of catheter with antiseptic swab. Insert needle and aspirate urine in syringe. Which insulin can be given IV: - CORRECT ANSWER Humulin R Enoxaparin - CORRECT ANSWER (Lovenox)- anticoagulant Gas forming foods - CORRECT ANSWER legumes Cleansing an ulcer - CORRECT ANSWER Cleanse from the innermost point then outwards What should the nurse do if they give the wrong medication to a pt? - CORRECT ANSWER Notify PCP Trough - CORRECT ANSWER the lowest level of a drug in the blood Medication is given once a day, when should the nurse check trough levels? - CORRECT ANSWER just before the next she gives the next dose Pt refused medication what should the nurse do first? - CORRECT ANSWER listen to why the patient refuses the medicine. [one quizlet said document, that was not an option] What should the nurse do if their pt has trouble falling asleep? - CORRECT ANSWER -warm bath -routine schedule Exercise before bed Clinical manifestations for sleep apnea - CORRECT ANSWER snore loudly with apneic periods up to 60 sec, occurring at least 30 times a night, day time somnolence, headache, depression, increase weight. Where is the apical pulse located? - CORRECT ANSWER 5th intercostal space, left mid- clavicular line Where to palpate the brachial pulse? - CORRECT ANSWER Just below the bend of the elbow (AC), medial aspect. Where is the vastus lateralis located? - CORRECT ANSWER Anterior thigh, lateral aspect PC vs AC - CORRECT ANSWER PC: after meals AC: before meals OD vs OS - CORRECT ANSWER OD: oculus dexter- right eye OS: oculus sinister- left eye How to check NG placement - CORRECT ANSWER fluoroscopy IM needle -gauge -length -max dose - CORRECT ANSWER 18-25 gauge 1''-3'' inches 2mL Subcu needle -gauge -length -max dose - CORRECT ANSWER 25-27 1/4''-5/8'' 1mL Older adults are at risk of toxic effects of medications because: - CORRECT ANSWER decrease renal function The pt is diaphoretic and tachycardic when walking. What other symptoms would you expect? - CORRECT ANSWER orthostatic hypotension noted with dangling Low pitch rattles, lessen with cough: - CORRECT ANSWER rhonchi Symptoms of COPD: - CORRECT ANSWER -clubbing in upper digits -AP chest diameter of 1:1 -tripod positioning Albumin - CORRECT ANSWER 3.5-5 [answer says 2.8 g/dl] symptoms of cataracts - CORRECT ANSWER blurred or cloudy vision how to check fluid status - CORRECT ANSWER -inspect lips and mucus membranes -pinch the skin on back of hands -measure BP and pulse -obtain daily weight Unable to see close up: - CORRECT ANSWER presbyopia I wake up to urinate once each night and I often wake up feeling tired in the morning are symptoms of: - CORRECT ANSWER sleep disturbances Joint stiffness in the morning is a symptoms of: - CORRECT ANSWER osteoarthritis Which pt should the nurse see first: - CORRECT ANSWER ABCs A client with expiratory wheezing after an albuterol treatment Pt comes in the the ED, what question should the nurse ask? [??] - CORRECT ANSWER Ask if the patient has started any new prescription or OTC medication. [answer] Ineffective protection r/t chemotherapy side effects is: - CORRECT ANSWER nursing diagnosis for cancer pt TMS (transcranial magnetic stimulation) - CORRECT ANSWER a procedure that uses magnetic pulses to stimulate nerve cells in the brain. -muscles relaxants are given before treatment Where to check the client for melanoma: - CORRECT ANSWER palms, soles, and nails Pt has a penicillin allergy, which med can they take? - CORRECT ANSWER -levofloxacin Clozaril (Clozapine) - CORRECT ANSWER Antipsychotic. -available OTC and generic [WRONG] symptoms of hypothyroidism - CORRECT ANSWER weight gain, fatigue, slow heart rate and respiration rate, cold intolerance Which drink is best for a burn patient to promote recovery? - CORRECT ANSWER -protein shake Pt has gastric ulcers. Which response by the pt requires a need for more teaching? - CORRECT ANSWER "I can drink coffee with meals and between meals" The nurse is which link on the chain of infection? - CORRECT ANSWER mode of transmission The pt is 24 hours post procedure and the nurse notices some redness and mild swelling of the incision? What should the nurse do? - CORRECT ANSWER Document and continue monitoring the wound Pt has pneumonia. Which order should the nurse do first? - CORRECT ANSWER Encourage deep breathing and cough Pt is having a procedure in the morning. What should the night shift nurse report to the surgeon? - CORRECT ANSWER allergy to shellfish Pt comes in having a MI. Complains of mid sternal chest pain, diaphoretic, shaky. What should the nurse addess first? - CORRECT ANSWER acute pain How to document drainage from a wound? - CORRECT ANSWER -two 4x4 saturated When to take alendronate? - CORRECT ANSWER before eating. What traits to observe for when a person has addictive behaviors? - CORRECT ANSWER - antisocial post prandial blood sugar - CORRECT ANSWER test for glucose in blood, two hours after a meal Pt on digitalis k value 3.0 what food? - CORRECT ANSWER Asparagus Weak rapid pulse - CORRECT ANSWER Give iv fluids OSA -sleep apnea - CORRECT ANSWER Spo2 90% Pt refused meds nurse understands this shows what - CORRECT ANSWER Fidelity C.The agent - host - environment model D.The adaptation model 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 D 5.Which theorists developed the high-level wellness theory? A. Clark and Leavell B. Halbert Dunn C. Anspaugh, Hamrick and Rosato D. Rosenstock and Becker B 6. The clients level of motivation and commitment is impacted by many factors including emotions, affect, behavior specific cognition, the clients prior experiences, personal characteristics, feelings of self efficacy and the support of others according to which model of health and wellness? A. Seven components of wellness B. The dimensions model C. Penders Health promotion model D. The agent - host - environment model C 7.The goal of nursing, according to which theory is to Facilitate protections against "penetration" and to facilitate "reconstitution "? A. The systems Model B. Orems self care theory C. The 21 nursing problems D. Interpersonal relations model A 8. Madeleine Leininger Support which of the following nursing modes of intervention? A. Cultural practices and cultural respect B. Self care agency C. Cultural care restructuring and repatterning D.Universality C 9.Which nursing theory is the most abstract? A. Leiningers Self care agency B. Rogers science of unitary human beings C.Neumans nature of nursing D. Hendersons goal attainment theory B 10. Select the nursing theory that is accurately paired with the theorist that developed it. A. Neumans: Science of unitary beings B. Rogers - the nature of nursing C. Henderson - goal attainment theory D. King - goal attainment theory D 11.Which of the following is not one of the four modes of adaptation according to Roy's adaptation model? A. Independence B. Person C. Health D. Nursing A 12. Which theorist is credited with the theory of transcultural nursing? A. Sister Callista Roy B. Dorothea Orem C. Madeleine Leininger D. Martha Rogers C 13. Which personality trait fosters critical thinking? A. The ability to memorize facts B. Respectfulness C. Open mindedness D. The ability to establish priorities C 14. Which phase of the decision-making process is most prone to errors? A. Ranking and weighing criteria B. Problem definition C. Deciding on the best alternative D. Implementing the course of action B 15. During which phase of the nursing process does the data get organized and validated with the client by the nurse? A. Assessment B. Analysis C. Evaluation D. Planning A 16. You are determining the outcome to patient care for your client. Which phase of the nursing process are you using? A. Evaluation B. Diagnosis C. Planning A 17. The primary difference between registered nurse licensure and a nursing certificate in an area of practice is that nursing licensure is: A. Required by the American nurses Association, and a nursing certification is not required. B. Mandated by the state board of nursing, and a nursing certification is not required. C. Nursing licensure ensures that the nurse is competent, while a nursing Certification does not D. Renewed every two years, and a nursing certification is not renewed. B 18. A clinical judgment about a persons, family, our communities motivation and desire to increase well-being and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used and any health state, Describes which type of nursing diagnosis? A. An actual nursing diagnosis B. Health promotion nursing diagnosis C. A potential nursing diagnosis D. A syndrome nursing diagnosis 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 37. A 38. A 39. B 40. D 41. C 42. B 43. D 44. A 45. C 46. B 47. D 48. C 49. B 50. A 51. D 52. C 53. D 54. B 55. C 56. A 57. D 58. D 59. B 60. A 61. A 62. D 63. B 64. D 65. D 66. A 67. C 68. B 69. D 70. B 71. A 72. C 73. D 74. A 75. C 76. B 77. D 78. A C. Intrapersonal communication D. Interpersonal communication C 93. Which person zone ranges from 4 feet to 12 feet? A. The social zone B. The publics Zone C. The personal zone D. The intimate zone A 94. What therapeutic communication skill is most similar to clarification in terms of it's purpose? A. Offering of self B. Paraphrasing C. Perception validation D. Providing leads C 95. What statement accurately describes drug distribution? A. The components of the medication that moves in the bloodstream to the intended target B. The breakdown of a drug, or medication, in the liver C. The buildup of the medication in the clients system as a result of impaired excretion or metabolism of the drug, which can lead to toxic effects D. An antigen-antibody immunologic response to a medication A 96. What is another term for drug metabolism? A. Biolistic B. Biointeraction C. Biotransformation D. Biotransmission C 97. A nursing saying to a client "Don't worry, you will be just fine", is an example of•. A.False reassurance. B. Incompliant reassurance C. Leading Reassurance. D. Deductive reassurance. A 98. Probing is invasive and it: A.Is an important technique in nursing. B. Violates the client's right to privacy. C.Is the most effective way to get complete information. D. Forces the client to lie. B 99. "Do you think that I am taking good care of you today?" is an example of-. A. A therapeutic positive open-ended question. B. A nontherapeutic testing statement. C. A standard open-ended question. D. Giving the client the ability to talk freely. B 100. What blocks open therapeutic communication? A. Open-ended questions B. Disagreeing, while agreeing allows for open therapeutic communication C. Agreeing, while disagreeing allows for open therapeutic communication D. Agreeing and disagreeing D 101. Most documentation errors are errors of omission A. Omission. B. Commission. C. Remission. D. Submission. A 102. The deltoid and the Gluteus maximus muscles are contraindicated for IM injections among: A. Toddlers who have been walking for only 18 months B. Preschool age C. Infants D. Adolescents C 103. Which type of oxygen therapy system is considered a high flow system? A. Nasal cannula B. Face tent C. Reservoir nasal cannula D. Venturi mask D 104. What populations are at the greatest risk for med errors? A. Clients who do not speak English B. Infants, children and the elderly C. Clients who have cognitive impairment D. Infants, children and psychiatric clients B 106. Controlled substances must be recorded and documented on the narc record immediately upon: A. Their removal from a secure and double locked cabinet B. Administering the medication C. The client accepting the medication D. Getting approval from their physician A 107. Which measurement system uses drops, teaspoons, oz, cups and pints? A. The apothecary system B. The metric system C. The conversion system D. The household system D 108. What is the oldest form of measurement? A. The household system B. The apothecary system C. The metric system D. The conversion system B 109. How many drops per min would you infuse when the doctor orders 80CC/hr and you are using IV tubing that administered 15 drops in 1 CC? A.10 B.15 C.20 D.40 C 110. The doctor has ordered 5mg/KG/day 4 divided doses per day for your pediatric client. The label reads that there are 25/mg/5ml of this medication. How many drops should you administer to a baby who weighs 4.5 KG? A. 17 drops B. 16 drops C. 22 drops D.23 drops A