Download NURS 200 TEST BANK 2024 FINAL EXAM WITH COMPREHENSIVE ANSWERS and more Exams Nursing in PDF only on Docsity! NURS 200 Final Exam Test Bank 2024 Chapter 11 Question 1 The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process? 1. Deliver care to a client in an organized way. 2. Implement a plan that is close to the medical model. 3. Identify client needs and deliver care to meet those needs. 4. Make sure that standardized care is available to clients. Question 2 While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Question 3 During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says leave me alone. Which subjective data should the nurse document? 1. Restlessness 2. Leave me alone 3. Not talkative 4. Pale and diaphoretic Question 4 Family of a client demonstrating confusion state that this is not the client’s usual behavior. How should the nurse document this data? 1. Inference 2. Subjective data By Hadassahkim 3. Objective data 4. Secondary subjective data Question 5 The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the client’s pain. Which phase of the nursing process is this nurse implementing? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Question 6 Which determinant of blood pressure would best explain a patient’s blood pressure reading of 120/100? 1. Blood viscosity 2. Blood volume 3. Pumping action of the heart 4. peripheral vascular resistance Question 7 The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse use as the best source of data for this client? 1. Medical record from the childbirth 2. Grandmother 3. Parents 4. Admitting physician Question 8 A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse respond to this client? 1. In order to make sure all of your information is complete; I need to ask these questions. 2. You’re right. Let me know if there’s anything you need right now. By Hadassahkim A client in the emergency department has a non-life-threatening wound. The unit is busy with other clients, families, and people in the waiting room. How should the nurse conduct an interview with this client? 1. Have the client wait until the department quiets down, as the wound is not too serious. 2. Tell the client to wait in the waiting room and fill out the paperwork. 3. Draw curtains around the client and nurse to provide as much privacy as possible. 4. Make sure the clients back are to the rest of the room so as not to be heard by passersby. Question 17 A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this client’s interview? 1. As soon as the client gets to the floor 2. After the client has settled in and been oriented to the room 3. When the family is available to help 4. After the client has been medicated Question 18 A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication with this client? 1. Have a member of the housekeeping staff who speaks the same language translate. 2. Use the translation services supplied by the hospital. 3. Make sure a family member who does speak English is available. 4. Conduct the interview using hand gestures. Question 19 The nurse is greeting a newly admitted client. What statement should the nurse make to establish rapport with this client? 1. Hello, I’m your nurse and I’ll be taking care of you today. 2. You’re lucky there are no students on the unit today. 3. Good morning, is there anything you need right now? 4. Hi. If you need anything, put on your call light. Correct Answer: 1 By Hadassahkim Question 20 The nurse has just completed an admission interview with a new client. Which nursing statement indicates that the interview is in the closing phase? 1. I’m going to set up your physical assessment now. Do you have any questions? 2. Tell me more about how you feel. 3. Could you give examples of what types of other treatments you’ve had? 4. Is there anything you’re worried about? Question 21 During an assessment interview, the client states that an elective surgical procedure will not be done because it does not fit into the client’s life goals. Into which of Gordons functional health patterns should the nurse identify this client’s comment? 1. Cognitive/perceptual pattern 2. Coping/stress-tolerance pattern 3. Health-perception/health-management pattern 4. Value/belief pattern Question 22 The nurse suspects that a client with a history of injuries is a victim of abuse. What did the nurse use to come to this conclusion? 1. Observation of cues 2. Validation 3. Inference 4. Judgment Question 23 The nurse is reviewing the nursing process with a first-year nursing student. What should the nurse explain as being the purpose of the diagnosis phase? Standard Text: Select all that apply. 1. Develop a list of problems. 2. Identify client strengths. 3. Develop a plan. By Hadassahkim 4. Specify goals and outcomes. 5. Identify problems that can be prevented. Correct Answer: 1, 2, 5 Question 24 The nurse decides to seek wound care alternatives for a client’s stasis ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning? 1. Diagnosis 2. Implementation 3. Evaluation 4. Assessment Question 25 While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time? 1. Initial assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed assessment Question 26 Unlicensed assistive personnel measure a newly admitted clients vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data? 1. Retake the vital signs. 2. Call the physician. 3. Continue with the physical assessment as soon as possible. 4. Report the findings to the charge nurse. Correct Answer: 1 Question 27 By Hadassahkim Standard Text: Select all that apply. 1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature. 2. Advocating for a client who is mentally incapable of expressing her needs. 3. Deciding to increase a clients nasal oxygen based on his current pulse oxygenation levels. 4. Documenting all clients pain level responses after the administration of pain medication. 5. Attending in-services on a new hydraulic lift to be used to support safe client care. Correct Answer: 1,2,3,4 Chap 12 Question 1 After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses? 1. The ones that the nurse is licensed to treat 2. The ones that address other health professionals’ interventions 3. The ones that focus on the client’s primary illness 4. The ones that have standardized care available Correct Answer: 1 Question 2 A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client? 1. Risk nursing diagnosis 2. Syndrome diagnosis 3. Wellness diagnosis 4. Actual diagnosis Correct Answer: 3 Question 3 A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client? 1. Syndrome diagnosis 2. Risk nursing diagnosis By Hadassahkim 3. Actual diagnosis 4. Wellness diagnosis Correct Answer: 1 Question 4 The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label? 1. Must contain three components 2. Describes the health problem for which nursing therapy is given 3. Helps define medical diagnoses for nursing 4. Promotes a taxonomy of nursing Correct Answer: 4 Question 5 An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new nursing diagnosis in these clients plan of care? 1. The clients’ eyes are closed. 2. The client’s skin is pale and mottled. 3. The client’s spouse is asleep in the chair next to the bed. 4. The television is on and the volume is turned up. Correct Answer: 2 Question 6 The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis? 1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends families. 2. The children attend Sunday school classes, one parent always attends services with the children, and the parents attempt interaction with congregational activities. 3. The grandparents go to weekly services and have formal interaction with clergy. By Hadassahkim 4. The children have attended private, religious schools, and the parents are involved in the schools’ activities. Correct Answer: 1 Question 7 The graduate nurse is struggling with identifying cues from clustered data. What should the nurse use to recognize data patterns and cues? 1. Depend on knowledge gained from peers’ experiences. 2. Work with seasoned and experienced nurses and learn from them. 3. Take assessment notes and utilize information from textbooks for comparison. 4. Know that this will take time, and experience is the best teacher. Correct Answer: 3 Question 8 The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In looking at the clients coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. Why should the nurse utilize this information? 1. Strengths can be an aid to mobilizing health and the healing process. 2. The client will be more active in the plan. 3. It will be easier for the nurse to educate the client about other interventions. 4. The nurse won’t have to spend time going over the pathology of the clients disease. Correct Answer: 1 Question 9 A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client? 1. Pain due to unknown factors 2. Pain related to unknown etiology 3. Pain caused by psychosomatic condition 4. Pain manifested by clients’ report Correct Answer: 2 Question 10 By Hadassahkim Question 17 A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. What is the etiology of this diagnosis? 1. Unfamiliarity of disease process 2. Anxiety 3. Restlessness 4. Tachycardia Correct Answer: 1 Question 18 The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction. Which collaborative action would be appropriate for this client? 1. Provide a calm, quiet atmosphere in the clients room. 2. Administer pain medication. 3. Educate the client and family regarding treatment and therapies. 4. Monitor for changes in the clients condition. Correct Answer: 2 Question 19 The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions for a client. Which data did the nurse use to support this diagnosis? Standard Text: Select all that apply. 1. The client has dry, cracked skin. 2. The client has one large and several smaller open, ulcerated areas on his right leg. 3. The client does not drive. 4. The client states that he does not use alcohol or drugs. 5. The clients clothes are soiled. 6. The client has obvious body odor. Correct Answer: 1, 2, 5, 6 By Hadassahkim Question 20 The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems? 1. Mental status of the client 2. Chronic nature of the illness 3. Nursing care focus 4. Prognosis Correct Answer: 3 Question 21 The nurse is using the Taxonomy II nursing diagnoses system. What axes should the nurse realize are coded within this system? Standard Text: Select all that apply. 1. Gordons health pattern groupings 2. Age 3. Time 4. Health status 5. Gender 6. Location Correct Answer: 2, 3, 4, 6 Question 22 The nurse is reviewing assessment data collected for a clients care plan. What criteria should the nurse use when formulating this clients nursing diagnoses? Standard Text: Select all that apply. 1. Nonjudgmental statements 2. Stated in terms of a need 3. Must be legally advisable 4. Cause/effect correctly stated 5. Medical terminology used to describe the cause 6. Diagnosis worded specifically and precisely By Hadassahkim Correct Answer: 1,3,4,6 Question 23 The nurse wants to propose a new nursing diagnosis. What action should the nurse take first? 1. Using the proposed nursing diagnosis when constructing client care plans 2. Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility 3. Submitting the diagnosis to NANDAs Diagnostic Review Committee 4. Presenting the proposed nursing diagnosis at the local AMA (American Medical Association) meeting. Correct Answer: 3 Question 24 The nurse is providing care to a client. Which nursing diagnoses can the nurse apply when providing client care? Standard Text: Select all that apply. 1. Ineffective Breathing Pattern 2. Risk of Infection 3. Readiness for Enhanced Nutrition 4. Readiness for Enhanced Family Coping 5. Anxiety Correct Answer: 1,5 Question 25 A nursing diagnosis that was written according to the PES format model would include: Select all that apply. 1. Ineffective coping related to depression as evidenced by suicide attempt 2. Noncompliance (DASH diet) related to denial of having disease 3. Risk for infection related to recent surgery 4. Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds 5. Ineffective Breathing Pattern as evidenced by cyanotic lips Correct Answer: 1,4 By Hadassahkim 3. Tell the client that this therapy will be impossible to receive. 4. Make arrangements to have the client moved to a long-term care facility. Correct Answer: 2 Question 8 A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately? 1. Client will ambulate without a walker by 6 weeks. 2. Client will ambulate freely in house. 3. Client will not fall. 4. Client will have freer movement in daily activities. Correct Answer: 1 Question 9 The nurse identifies for a client the nursing diagnosis Fluid volume deficit, related to active fluid loss, secondary to diarrhea. What would be and appropriate goal statement for this diagnosis? 1. Client will drink more fluids by tomorrow. 2. Client will have good skin turgor. 3. Client will have moist mucous membranes. 4. Client will have intake of at least 1000 mL within 24 hours. Correct Answer: 4 Question 10 The nurse is reviewing the Nursing Outcomes Classification (NOC) taxonomy system. To what can the nurse compare this taxonomy? 1. Nursing diagnosis statement 2. Planning portion of the care plan 3. Goal statement of the traditional care plan 4. Implementation phase of the care plan Correct Answer: 3 Question 11 By Hadassahkim The nurse is caring for a client with Parkinsons disease who desires to improve fine motor skills. Which statement should the nurse identify as an appropriate collaborative intervention for this client? 1. Provide assistance as needed with dressing and grooming. 2. Provide assistive devices and educate client to use grab bar and large handled utensils. 3. Make sure lighting and space are adequate for client. 4. Administer medications to improve muscle tone. Correct Answer: 2 Question 12 The nurse is reviewing interventions written for a clients plan of care. Which intervention should the nurse recognize as being dependent? 1. Repositioning the client every 2 hours 2. Assisting the client with transfers to the bathroom 3. Providing ongoing physical assessment, especially of the incisional sites 4. Administering medications for pain Correct Answer: 4 Question 13 One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention? 1. 60 to 90 degrees during feeding times 2. Position in chair 3. Upright in a chair 4. Impaired swallowing Correct Answer: 1 Question 14 A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Which should the nurse identify as an observation intervention? 1. Turn and reposition client every 2 hours. By Hadassahkim 2. Cushion bony prominences with soft foam while in bed. 3. Provide ongoing assessment for skin breakdown every shift. 4. Apply lotion to dry skin twice daily. Correct Answer: 3 Question 15 The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention? 1. Assist client with ambulation. 2. Ambulate with client, using a gait belt, twice daily for 15 minutes. 3. Make sure client understands the rationale for using the gait belt. 4. Client will ambulate in hallway twice daily. Correct Answer: 2 Question 16 A hospital is implementing the use of the NIC (Nursing Interventions Classification) taxonomy. What purpose will the implementation of this taxonomy serve? 1. Help the nurse with documentation of the care plan 2. Require that the nurse use sound judgment and knowledge of the client 3. Match nursing diagnoses to exact interventions 4. Help the nurse choose activities that are individualized to the client Correct Answer: 2 Question 17 The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale? 1. Have suction equipment available at all times. 2. Clear secretions from oral/nasal passageways as needed. 3. Keep client in low-Fowlers position to prevent reflux. By Hadassahkim The nurse is collecting information to plan care for a client with a heart problem. Which information indicates that planning for this clients discharge was started by the nurse? Standard Text: Select all that apply. 1. The client is scheduled for cardiac catheterization and echocardiogram. 2. Recent laboratory data indicates the development of heart failure. 3. The client does not have a scale to perform daily weights at home. 4. The clients spouse has care needs that the client will not be able to complete going forward. 5. The client is pleasant and eager to learn how to control newly diagnosed health problem. Correct Answer: 3, 4 After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? 1.Initial 2.Ongoing 3.Discharge 4.Strategic Correct Answer: 4 The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following? 1.Hospital policies 2.Standardized care plans 3.Orthopedic protocols 4.Standards of care Correct Answer: 1 By Hadassahkim The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The cli-ent’s pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but skin is very dry. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan? 1.Pain 2.Nausea 3.Constipation 4.Potential for wound infection Correct Answer: 2 The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated goal/outcome? The client will 1.Turn in bed q2h. 2.Report the importance of applying lotion to skin daily. 3.Have intact skin during hospitalization. 4.Use a pressure-reducing mattress. Correct Answer: 3 The care plan includes a nursing intervention “4/2/15 Measure client’s fluid intake and output. F. Jenkins, RN.” What element of a proper nursing intervention has been omitted? 1.Action verb 2.Content 3.Time 4.None Correct Answer: 3 The nurse recognizes which of the following as a benefit of using a standardized care plan? 1.No individualization is needed. 2.The nurse chooses from a list of interventions. 3.They are much shorter than nurse-authored care plans. By Hadassahkim 4.They have been approved by accrediting agencies Correct Answer: 2 Which of the following is likely to occur if a goal statement is poorly written? 1.There is no standard against which to compare outcomes. 2.The nursing diagnoses cannot be prioritized. 3.Only dependent nursing interventions can be used. 4.It is difficult to determine which nursing interventions can be delegated Correct Answer: 1 When written properly, NOC outcomes and indicators 1. Do not require customization. 2. Address several nursing diagnoses. 3. Are broad statements of desired end points. 4. Reflect both the nurse’s and the client’s value Correct Answer: 4 Which of the following principles does the nurse use in selecting interventions for the care plan? 1. Actions should address the etiology of the nursing diagnosis. 2. Always select independent interventions when possible. 3. There is one best intervention for each goal/outcome. 4. Interventions should be “doing,” not just “monitoring Correct Answer: 1 Chap 14 Question 1 By Hadassahkim Correct Answer: 4 Question 8 On one of the first days working alone, the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse. What action should the nurse take? 1. Ask the nurse mentor to assist with the teaching after reviewing the procedure. 2. Read the policy and procedure manual before the teaching session. 3. Do the best the nurse can by remembering what was taught in nursing school. 4. Ask for a different assignment until the nurse feels comfortable with this one. Correct Answer: 1 Question 9 A client is prescribed a medication that the nurse has never administered and information about the medication is not in the drug reference manual. What should the nurse do? 1. Follow the physicians orders as written and give the medication. 2. Call the pharmacy and do further investigating before administering the medication. 3. Ask the client about this medication. 4. Call the physician and ask what the medication is and what it is for. Correct Answer: 2 Question 10 The nurse is providing care to an assigned client. Which action indicates that the nurse supports the clients respect for dignity? 1. Allowing the client to complete hygienic care when possible 2. Providing all care to the client whenever possible 3. Telling the other staff that the client is demanding, so they are able to meet the clients needs 4. Presenting information to the clients family about the clients condition Correct Answer: 1 Question 11 The nurse provides routine morning care to a client, including all the medications and scheduled treatments. What action should the nurse make next? 1. Move on to the next assignment to increase the nurses efficiency. By Hadassahkim 2. Report this to the charge nurse. 3. Document all care in the progress notes. 4. Get supplies organized for the next clients medications and treatments. Correct Answer: 3 Question 12 The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process? 1. Assessment is done at the beginning of the process. 2. Evaluation is completed at the end of the process. 3. They are the same and there is no need to differentiate. 4. The difference is in how the data are used. Correct Answer: 4 Question 13 The nurse notes that a client has the outcome goal Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic. Which client statement should the nurse use to evaluate this goal? 1. Im getting really sleepy from that medication. I think Ill take a nap. 2. My pain is a 4. 3. I still have some pain. 4. Will the pain ever go away? Correct Answer: 2 Question 14 A client has the goal statement Client will be able to state two positive aspects of rehab therapy by the end of the week. What statement demonstrates that the nurse appropriately evaluated this goal? 1. Goal not met, client able to state one positive aspect by the end of the week. 2. Goal met, client able to state one positive aspect by the end of the week. 3. Goal met, client able to state two positive aspects of therapy by weeks end. 4. Goal incomplete, client not able to positively state anything about rehab. By Hadassahkim Correct Answer: 3 Question 15 A client has the goal statement Client will have clear lung sounds bilaterally within 3 days. One intervention to meet this goal is for the nurse to teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the clients lungs are indeed clear. What should the nurse do to relate the intervention to the outcome? 1. Ask how many times per day the client practiced the coughing and deep breathing exercises. 2. Tell the client that the lungs are clear. 3. Document the assessment findings to show the effectiveness of the intervention. 4. Write this evaluation statement: Goal met, lung sounds clear by third day. Correct Answer: 1 Question 16 A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the clients symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. What should the nurse do? 1. Keep the problem on the care plan, in case the symptoms return. 2. Document that the problem has been resolved and discontinue the care for the problem. 3. Assume that whatever the cause was, the symptoms may return, but document that the goal was met. 4. Document that the potential problem is being prevented because the symptoms have stopped. Correct Answer: 2 Question 17 A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: Client will be free of pain within 48 hours. As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan? 1. The goal statement is written inaccurately. 2. The interventions are dependent of nursing. By Hadassahkim The nurse reviews clients records and the care they received while in the hospital for an insurance company. Part of the job description requires the nurse to make sure that the client and insurance company were billed for services and treatment/therapies rendered and that there were no errors in billing. Which type of audit is the nurse completing? 1. Concurrent 2. Peer review 3. Nursing audit 4. Retrospective Correct Answer: 4 Question 25 The nurse assigns unlicensed assistive personnel to measure vital signs for several clients. The task is completed and documented correctly; however, one of the clients had a blood pressure reading of 180/110. The nurse learns this information at the end of the shift. Which responsibility of delegation did the nurse fail to carry out? 1. Delegating to the appropriate staff 2. Delegating the appropriate task 3. Selecting the appropriate client 4. Appropriately supervising care Correct Answer: 4 Question 26 The nurse is implementing care and treatments for assigned clients. What actions should the nurse prepare to complete during this phase of the nursing process? Standard Text: Select all that apply. 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing intervention Correct Answer: 2, 4, 5 Question 27 By Hadassahkim After implementing interventions and reassessing the client’s response, the nurse completes the process by evaluating. What attributes of evaluation should the nurse include when completing this step of the nursing process? Standard Text: Select all that apply. 1. Purposeful activity 2. Nursing accountability 3. Continuous 4. Judgments 5. Opinion Correct Answer: 1, 2, 3, 4 Question 28 The nurse is preparing to evaluate care provided to a client. What behaviors should the nurse demonstrate that show an understanding of the relationship of evaluation to the other phases of the nursing process? Standard Text: Select all that apply. 1. Effectively assessing the client’s needs 2. Selecting the appropriate nursing diagnosis related to the client’s needs 3. Collecting client-focused data with a specific need in mind 4. Evaluating by using assessment data to determine effective achievement of goals and outcomes 5. Basing evaluation on assessment data collected during the admission phase Correct Answer: 1, 2, 3, 4 Question 29 The nurse notes that assessment data indicate a change in a client’s condition. What should the nurse ask before changing this clients plan of care? Standard Text: Select all that apply. 1. How difficult will it be to change the care plan? 2. Are the new data complete? 3. Are the new data accurate? 4. Do the new data require a change in the care plan? By Hadassahkim 5. Will the primary medical provider agree with the need to alter the care plan? Correct Answer: 2, 3, 4 Question 30 The nurse is evaluating care provided to a client. Which nursing actions indicate that the phases of evaluation were completed by the nurse appropriately? Standard Text: Select all that apply. 1. Client problems updated 2. Data linked to NOC indicators 3. Data compared to desired outcomes 4. Interventions changed on the care plan 5. Physician notified of changes in the care plan Correct Answer: 1, 2, 3, 4 Question 31 A client recovering from total knee replacement surgery falls out of bed on the night shift and dies. Which quality improvement actions should the nurse manager expect to complete for this client occurrence? Standard Text: Select all that apply. 1. A root cause analysis 2. Paperwork about a sentinel event 3. Analysis of the nurse assigned to the client 4. Number of times the client was observed on the night shift 5. Number of hours since the client last received pain medication Correct Answer: 1, 2 Chap 15 Question 1 A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him, as it’s his record. How should the nurse respond to this clients’ request? 1. You’ll have to ask your doctor for permission to do that. By Hadassahkim 3. Plan of care 4. Progress notes Correct Answer: 3 Question 8 A client has specific cultural needs that affect the plan of care. In which part of the client’s problem-oriented medical record should the nurse document this information? 1. Database 2. Problem list 3. Plan of care 4. Progress notes Correct Answer: 2 Question 9 The client states: I really don’t want anyone to visit me who has not been cleared by me first. If utilizing SOAP format, in which category should the nurse document this statement? 1. Subjective data 2. Objective data 3. Assessment 4. Planning Correct Answer: 1 Question 10 The nurse administered analgesic medications to an assigned client via central line. In which section of PIE charting should the nurse document this information? 1. Plan 2. Intervention 3. Evaluation 4. Progress notes Correct Answer: 2 Question 11 The nurse is documenting client care on flow sheets that identify abnormal assessment findings. Which type of documentation system is the nurse using? By Hadassahkim 1. Computerized documentation 2. Focus charting 3. SOAP charting 4. Charting by exception Correct Answer: 4 Question 12 The nurse working in a hospital that utilizes a charting by exception (CBE) documentation system notes that a client did not require care in all of the areas identified on a flow sheet. What action should the nurse take? 1. Leave the areas blank. 2. Leave the areas blank, but then add an extensive explanation in the progress notes section of the chart. 3. Write N/A on the flow sheet in the areas that are not applicable to that client. 4. Make sure this information gets passed along in the shift report. Correct Answer: 3 Question 13 A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager using a critical pathway should identify this outcome as being which of the following? 1. An unattainable goal 2. A variance 3. An error in care planning 4. An error in intervention implementation Correct Answer: 2 Question 14 A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. Which type of form is this hospital utilizing? 1. Standardized care plans By Hadassahkim 2. Traditional care plans 3. Critical pathways 4. Kardex Correct Answer: 1 Question 15 Before providing care, the nurse reviews the client’s pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information. Which form should the nurse review to learn all of this information? 1. The client’s medical record 2. The MAR (medication administration record) 3. The written care plan 4. The Kardex Correct Answer: 4 Question 16 The nurse is teaching medication administration to a client being discharged. Which instruction should the nurse rewrite for this client? 1. Lasix, 20 mg, po bid 2. Lasix, 20 mg tablet, twice daily 3. Lasix, 20 mg by mouth, two times a day a day 4. Lasix, 20 mg by mouth 8 AM and 2 PM Correct Answer: 1 Question 17 A client in long-term care is scheduled for a review of the assessment and care screening process. Where should the nurse document this information? 1. MDS 2. OBRA 3. CBE 4. Kardex Correct Answer: 1 Question 18 By Hadassahkim Correct Answer: 1,2,5 Chap 26 Question 1 A nurse explains to a client that he will need to have a bowel prep before going to his esophagogastroscopy. On what should the nurse focus to improve communication skills? 1. Pace 2. Intonation 3. Simplicity 4. Clarity Correct Answer: 3 Question 2 The nurse observes during a dressing change that the clients wound has become infected. When asked by the client how the wound looks, the nurse says it looks fine but the nurse’s facial expression doesn’t support the response. Which aspect of communication should this nurse improve? 1. Adaptability 2. Credibility 3. Timing and relevance 4. Clarity and brevity Correct Answer: 1 Question 3 A nurse is working on a telemetry unit when one of the clients has a cardiac arrest. The client’s spouse is in the room when the code team arrives. Which statement by the nurse to the spouse is the best in this situation? 1. I know you’re worried about your loved one. I’m sure this is a difficult situation for you. Do you have any questions right now? 2. Your spouse’s heart stopped. All these people are here to help get it started. 3. Your spouse’s physician will be here shortly and explain all of the medication and treatment that your spouse is receiving right now. 4. Is there someone you would like to call? I’m sure this is a scary situation and you may feel more comfortable if someone were with you during this time. By Hadassahkim Correct Answer: 2 Question 4 The nurse enters a client’s room and finds that the telephone is lying in the client’s lap, tissues are wadded up on the bed, and the clients’ eyes are red and watery. What is the best response by the nurse? 1. Can I hang that phone up for you? 2. Well, it’s a beautiful day outside. Let’s open the blinds. 3. Has your doctor been in to talk to you yet? 4. You look upset. Is there anything you’d like to talk about? Correct Answer: 4 Question 5 A client has been sullen and withdrawn since receiving the news of her cancer diagnosis. As the nurse enters the room, the client asks for assistance with a shower. Which comment by the nurse is the most appropriate? 1. If you look better, you might feel better. 2. Taking a shower might wash away some of that gloom and doom. 3. This is a positive sign. I’ll be right back with your supplies. 4. Your spouse will be glad to see that you’re feeling better. Correct Answer: 3 Question 6 A nurse is working in a pediatric clinic and has to explain a nebulizer treatment to a child. Which approach should the nurse use? 1. Give the Childs parent a full explanation, but make sure the child hears what is said. 2. Let the child handle the equipment first, then demonstrate on the child’s doll. 3. Start the treatment, but make sure that the parent is there to comfort the child if she becomes afraid. 4. Make sure that the physician is available for questions. Correct Answer: 2 Question 7 By Hadassahkim A nurse is giving a demonstration of new equipment to the rest of the nursing unit. Which level of proxemics should the nurse use? 1. Intimate 2. Personal 3. Social 4. Public Correct Answer: 3 Question 8 A nurse must perform a catheterization on a male client. Which zone of proximity should the nurse use for this intervention? 1. Personal distance 2. Intimate distance 3. Social distance 4. Public distance Correct Answer: 2 Question 9 A nurse enters a client’s room and asks about his level of pain. The client, grimacing, says Its fine. Which communication factor is the client struggling with? 1. Territoriality 2. Environment 3. Congruence 4. Attitude Correct Answer: 3 Question 10 A nurse is working with an elderly male client on a medical unit. Which statement demonstrates elderspeak by the nurse? 1. It’s time for us to go to physical therapy. 2. I think it would be better if you were planning to go to a nursing home after discharge. 3. Your children must really love their dad. 4. Your wife must be having trouble adjusting to your illness. By Hadassahkim 4. Verbal communication Correct Answer: 2 Question 18 During a health history, a client admits to taking nutritional supplements instead of prescribed medication. Which responses by the nurse indicate effective communication? Standard Text: Select all that apply. 1. What you did was wrong. 2. Who do you think you are? 3. You shouldn’t have done that. 4. Tell me more about the supplements. 5. Explain the reasoning behind your decision. Correct Answer: 4, 5 Question 19 The nurse needs to communicate information about a client’s status to a physician. Which approach demonstrates assertive communication by the nurse? 1. You need to check the laboratory results of the client in room 423. 2. You should visit with the client’s family about the upcoming procedure. 3. We need to be more aware of the situation among the client and the client’s family. 4. I am concerned that the client does not have adequate pain management. Correct Answer: 4 Question 20 The nurse wants to gain information about a client’s situation. Which question should the nurse use to maximize communication with this patient? 1. What brings you to the hospital? 2. Are you having pain? 3. Does your pain feel better or worse today? 4. Is there anything I can do for you? Correct Answer: 1 Question 21 By Hadassahkim The nurse is communicating with an older client. Which actions demonstrate that the nurse understands the best approaches to communicate with this client? Standard Text: Select all that apply. 1. Asking, what can I do to make you feel safe? 2. Observed intently listening to the client describe how being alone makes her feel 3. Offering to take the client out for a walk 4. Consistently arranging for the client to have her hair done 5. Managing to get a copy of the client’s favorite magazine Correct Answer: 1, 2, 5 Question 22 The nurse is beginning a helping relationship with a newly admitted client. Which behaviors should the nurse demonstrate that support this type of relationship? Standard Text: Select all that apply. 1. Becoming familiar with the client’s social history by reading the admission interview 2. Orienting the client to the physical layout of the facility as well as to the facility’s policies 3. Gaining the clients trust by consistently keeping promises to return and visit 4. Respecting the clients wish to be alone after hearing about the loss of a family friend 5. Asking to remain with the client when he is experiencing symptoms of the flu Correct Answer: 1, 3, 4, 5 Question 23 The graduate nurse is thinking about leaving a new job because of actions demonstrated by the nurse manager. Which actions should the graduate nurse identify as bullying? Standard Text: Select all that apply. 1. Pairing the graduate with a seasoned nurse to assist with learning new skills 2. Asking the graduate to participate in client rounds with the new interns on the care area 3. Confronting the graduate by stating that refusing an assignment is grounds for dismissal 4. Stating that requests for vacation time will be denied because the nurse asks too many questions By Hadassahkim 5. Assigning the graduate nurse a complicated client with needs that the graduate is not comfortable performing Correct Answer: 3, 4, 5 Chap 27 Question 1 The nurse has completed client teaching regarding medication administration. Which client statement best illustrates compliance? 1. I’m glad to know about my medications. It makes taking them a lot easier. 2. I already knew most of what you told me. 3. I think you should have waited until I was ready to go home. Maybe Id remember better. 4. If I take my medications as prescribed, I’ll feel better. Correct Answer: 1 Question 2 A nurse is planning a community health education project that deals with organ donation, and the target audience is a group of adults. When following andragogy concepts, the nurse should make sure that the teaching includes which information? 1. Past statistics about organ donors 2. Written pamphlets 3. Directions about how to become an organ donor 4. Information on how this group can influence their children Correct Answer: 3 Question 3 The nurse is instructing a client on self-administration of a subcutaneous injection. The nurse is using which theoretical construct of learning? 1. Thorndikes behaviorism 2. Skinners positive reinforcement 3. Pavlovs conditioning response 4. Banduras imitation By Hadassahkim exposed to yet. What should the instructor respond to the staff nurse that supports timing and learning environment? 1. It will take me a moment to explain the procedure to the students because weve not practiced this, but Ill find somebody to administer it. 2. Would it be OK if the students observed today? Then, well do it next time were here. 3. Were leaving now, but thanks for asking. 4. Ill check with the students and see if one of them would like to volunteer. Correct Answer: 2 Question 11 A client with an incision necessitating a complex dressing change is being discharged and will require continued dressings at home. Which statement by the client indicates a need to postpone teaching? 1. Its going to take time for me to understand this whole thing. 2. Lets make sure my spouse is around before you start explaining. 3. I wish my doctor would have explained this more in depth. 4. Im feeling nauseous, but go ahead and start anyway. Correct Answer: 4 Question 12 A nurse is working with the family of a child who is hospitalized with asthma. The family members speak little English, and the child is being sent home on nebulizer treatments as well as an inhaler. In addition to enlisting an interpreter to help with the language barrier, the nurse should 1. provide written instructions before discharge. 2. address any healing beliefs the family has. 3. make sure the child comes back for the follow-up appointment. 4. make sure the parents can set up the treatments for their child. Correct Answer: 2 Question 13 A client who is legally blind requires vitamin B12 injections every 2 weeks and insists on selfadministration. What is the best way for the nurse to assist this client? By Hadassahkim 1. Teach the spouse to draw up the medication, then the client can give the injection. 2. Make sure that the injection is scheduled during a visit, so the nurse can supervise. 3. Prefill syringes with the correct dose, so the client can use them for self-administration. 4. Schedule the clients clinic appointments in accordance with the dosing schedule, then give the injection when the client is at the clinic. Correct Answer: 3 Question 14 A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the clients motivation to learn? 1. Demonstrating the finger stick on the nurse 2. Offering to do the procedure for the client each time it is scheduled 3. Teaching the clients support system how to perform the procedure 4. Encouraging the clients participation each time the procedure is performed Correct Answer: 4 Question 15 The nurse is working with a group of older clients through a community senior citizens center. Utilizing an understanding of health literacy, the nurse will make sure that 1. information given to this group is written at a third-grade level. 2. teaching includes a variety of approaches. 3. information includes pictures. 4. there is ample time for teaching. Correct Answer: 4 Question 16 A client being discharged after a myocardial infarction has been prescribed several new medications and a low-fat diet. The client states: Im never going to understand what to do, when to do it, and why I should be doing all these things. Which nursing diagnosis should the nurse formulate for this client? 1. Health-Seeking Behavior related to desire to prevent heart problems By Hadassahkim 2. Deficient Knowledge (diet and medication regimen) related to inexperience 3. Noncompliance related to situational factors 4. Risk for Myocardial Infarction related to deficient knowledge Correct Answer: 2 Question 17 The nursing diagnosis Readiness for Enhanced Knowledge (Nutrition) related to desire to improve nutritional intake has been formulated for a client who has decided to change his eating habits to be more nutritionally sound. What would be an appropriate outcome for this client? 1. Client will understand the importance of eating healthy. 2. Client will be able to lose weight. 3. Client will list foods that are nutritionally sound, low fat, and high fiber. 4. Client will appreciate the value of using the Food Guide Pyramid. Correct Answer: 3 Question 18 A home health nurse is working with a client who has pulmonary fibrosis. Of the following teaching priorities, which will take the highest priority? 1. Client will be able to set up and administer a nebulizer treatment by the end of the day. 2. Client will have increased activity level by the end of the week. 3. Client will be able to do activities of daily living (ADLs) without shortness of breath in 3 days. 4. Client will have a positive attitude about the diagnosis by the end of the month. Correct Answer: 1 Question 19 A school nurse is putting together a program for adolescents about positive lifestyle choices. What should the nurse keep in mind when preparing content to present to this age group? Standard Text: Select all that apply. 1. Based on learning outcomes 2. Current 3. Adjusted to the adolescent client By Hadassahkim 2. Clients age 3. Clients understanding of health problem 4. Sensory acuity 5. Learning style Correct Answer: 2, 3, 4, 5 Question 26 A school nurse is planning a program for adolescents about positive lifestyle choices. The nurse should keep in mind that content presented to this age group must be Standard Text: Select all that apply. 1. based on learning outcomes. 2. current. 3. adjusted to the adolescent client. 4. based on sources available within the school system. 5. accurate. Correct Answer: 1, 2, 3, 5 Question 27 A client is being discharged after a 23-hour stay for a surgical procedure. When preparing the instructions for this client, what does the nurse need to do? Standard Text: Select all that apply. 1. Ensure the clients safe transition to home. 2. Include information about what the client has been taught. 3. Include what the client still needs to learn when discharged. 4. Check the clients insurance for hospitalization coverage. 5. Call the clients prescriptions in to the clients local pharmacy. Correct Answer: 1, 2, 3 Question 28 The nurse serves as an educator of other health care personnel. In what capacity will this nurse participate in education? Standard Text: Select all that apply. By Hadassahkim 1. Preceptor of new graduate nurses 2. Instructing a part of the critical care course 3. Clinical instruction of nursing students 4. One-to-one teaching of clients 5. Teaching grandparents how to care for children Correct Answer: 1, 2, 3 Question 29 The nurse planning an educational session for adult clients should include which andragogy concepts? Standard Text: Select all that apply. 1. People move from dependence to independence with maturity. 2. Previous experiences can be used as a resource for learning. 3. Learning is related to an immediate need or problem. 4. Learning is reinforced by prompt feedback. 5. Adults are oriented to learning when the material is useful sometime in the future. Correct Answer: 1, 2, 3, 4 Question 30 The nurse is utilizing humanistic theory when instructing a client. What will the nurse demonstrate when utilizing this theory? Standard Text: Select all that apply. 1. Empathy 2. Encouraging the client to establish goals 3. Encouraging the client to participate in self-directed learning 4. Multisensory teaching strategies 5. Providing a physical environment conducive to learning Correct Answer: 1, 2, 3 Question 31 A client tells the nurse that he has no questions about his illness, as he did a search for information on the Internet. What should the nurse do? By Hadassahkim 1. Ask the client to share the information obtained from the Internet search. 2. Document that the client has received instruction. 3. Tell the client that the Internet is a form of entertainment, not instruction. 4. Document that the client refused instruction. Correct Answer: 1 Question 32 The nurse instructs the older client to access the Internet to complete a post-hospitalization survey and update health information. The client tells the nurse that he does not have a computer and would not know how to use one. What should the nurse do? Standard Text: Select all that apply. 1. Suggest the client learn how to use a computer through classes held at a local library. 2. Provide times for the client to attend basic computer use classes through the community learning center. 3. Document that the client is resistant to instruction. 4. Notify the physician that the client will not be adhering to medical instruction as planned. 5. Identify the client as being noncompliant with instruction. Correct Answer: 1, 2 Question 33 The nurse suspects a client has low literacy. What did the nurse assess to come to this conclusion? Standard Text: Select all that apply. 1. Incorrect completion of previous hospitalizations form 2. Client refusing to sign forms because eyeglasses are at home 3. Client saying he forgot to report for laboratory testing 4. Score of 6 on the Newest Vital Sign assessment tool 5. Questioning the dosage pattern on a newly prescribed medication Correct Answer: 1, 2, 3 Question 34 By Hadassahkim Chap 29 Question 1 An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this clients low temperature could be due to which observation? 1. The anxiety level of the client has increased. 2. Hormones have fluctuated in this client. 3. Muscle activity has increased during the clients therapy session. 4. Loss of subcutaneous fat is noted. Correct Answer: 4 Question 2 The nurse is preparing to measure a clients temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading? 1. Assess that the equipment used is working properly. 2. Place the client in a position that is most comfortable for the health care provider. 3. Take the temperature with a chemical disposable thermometer when the client is perspiring. 4. Wait at least 10 minutes before taking the temperature after a client has been smoking. Correct Answer: 1 Question 3 The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use? 1. Axilla 2. Oral 3. Popliteal 4. Rectal Correct Answer: 2 Question 4 While waiting for the physician to respond regarding a clients elevated temperature, what can the nurse do to assist the client? 1. Bathe the client with ice water. 2. Give the client an antipyretic. By Hadassahkim 3. Increase fluid intake. 4. Lower the room temperature. Correct Answer: 3 Question 5 While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. How would the nurse explain these findings? 1. A change in the clients health status has occurred. 2. The client has thrown a blood clot in that extremity. 3. The RNs watch has stopped working. 4. Too much pressure was applied over the pulse site. Correct Answer: 4 Question 6 The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use? 1. Ask another nurse to assess the pulses. 2. Document the findings. 3. Obtain a Doppler ultrasound stethoscope. 4. Wait and try again later. Correct Answer: 3 Question 7 When assessing a clients peripheral pulse, the health care provider is also assessing which of the following? 1. Depth 2. Rhythm 3. Sound 4. Stress Correct Answer: 2 Question 8 By Hadassahkim The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN use to make this decision? 1. A forceful radial pulse is much too difficult to count correctly. 2. Both arteriole and venous sounds were heard simultaneously. 3. The pulse was bounding and easily obliterated. 4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site. Correct Answer: 4 Question 9 A client is unconscious and in respiratory distress after being in a motor vehicle crash. Which should the nurse realize as being a factor that caused a change in this clients respiratory rate? 1. Exercise 2. Increased intracranial pressure 3. Increased environmental temperature 4. Stress Correct Answer: 2 Question 10 The nurse needs to assess a clients respiratory status. Which client position would be the best for this assessment? 1. Prone 2. Semi-Fowlers 3. Side-lying 4. Supine Correct Answer: 2 Question 11 A client is being treated for congestive heart failure. Which physical finding would lead the RN to believe the clients condition has not improved? 1. Temperature of 98.6F (37C) 2. Moderate amount of clear thin mucus 3. Pulse oximetry reading of 96% By Hadassahkim Question 19 The RN needs vital signs assessed for four clients. Which client should the nurse address and not assign to the UAP? 1. Cardiac catheterization client returning to the nursing unit 2. COPD client on 2 Lpm oxygen via nasal cannula 3. Pneumonia client nearing discharge 4. Post-op client of 2 days from gallbladder surgery Correct Answer: 1 Question 20 Prior to assessing a clients blood pressure, the nurse reviews factors that could affect the reading. Which factors could impact blood pressure? Standard Text: Select all that apply. 1. Stress 2. Race 3. Obesity 4. Medications 5. Employment Correct Answer: 1, 2, 3, 4 Question 21 The nurse is planning to assess a clients pulse. What characteristics should the nurse include in this assessment? Standard Text: Select all that apply. 1. Rate 2. Rhythm 3. Volume 4. Tone 5. Viscosity Correct Answer: 1, 2, 3 By Hadassahkim Question 22 When assessing a clients respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in which factors? Standard Text: Select all that apply. 1. Oxygen concentration 2. Carbon dioxide concentration 3. Hydrogen ions 4. Potassium level 5. Serum calcium level Correct Answer: 1, 2, 3 Question 23 Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments independently in which situations? Standard Text: Select all that apply. 1. Client who complains of chest pain 2. Client returning from surgery 3. Prior to administering a medication that affects blood pressure 4. Client who complains of dizziness after ambulating. 5. Client being admitted to the care area Correct Answer: 1, 2, 3, 4 Question 24 When documenting a clients axillary temperature on the graphic sheet, how should the nurse identify the method of assessing the temperature? 1. AX 2. O 3. R 4. SL Correct Answer: 1 Question 25 By Hadassahkim The nurse assesses phase 1 Korotkoffs sound occurring at 136 and phase 5 Korotkoffs sound occurring at 72. How should the nurse document this clients blood pressure reading? 1. 136/72 2. 72/136 3. 136 72 4. 72 136 Correct Answer: 1 Question 26 A client comes to the emergency department with a temperature of 104F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke? Standard Text: Select all that apply. 1. Delirious 2. Pale and dizzy 3. Skin warm and flushed 4. No evidence of sweating 5. Had been playing tennis in the sun Correct Answer: 1, 3, 4, 5 Question 27 The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision? Standard Text: Select all that apply. 1. The valve on the bulb was closed. 2. The client was sitting with the legs crossed. 3. The arm was below the level of the heart. 4. The UAP waited 2 minutes before re-measuring. 5. The cuff bladder was placed over the brachial artery. Correct Answer: 2, 3 Chap 30 Question 1 By Hadassahkim 1. Pulses equal bilaterally 2. Full pulsations 3. Thready pulses 4. Pulses present bilaterally Correct Answer: 3 Question 8 During the assessment of a clients breasts, the nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What should the nurse do next? 1. Notify the charge nurse. 2. Notify the physician. 3. Document the findings in the nurses notes as normal. 4. Document the findings in the nurses notes as abnormal. Correct Answer: 3 Question 9 The nurse is preparing a client for an abdominal examination. What should the nurse done before beginning the examination? 1. Ask the client to urinate. 2. Ask the client to drink 8 ounces of water. 3. Assess vital signs. 4. Assess heart rate. Correct Answer: 1 Question 10 By Hadassahkim The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When testing for muscle grip strength, the nurse should ask the client to perform which action? 1. Grasp the nurses index and middle fingers while the nurse tries to pull the fingers out. 2. Hold an arm up and resist while the nurse tries to push it down. 3. Flex each arm and then try to extend it against the nurses attempt to keep the arm in flexion. 4. Shrug the shoulders against the resistance of the nurses hands. Correct Answer: 1 Question 11 The nurse is preparing to conduct a mental status assessment. What should the nurse include in this assessment? 1. Cognitive and affective functions 2. Cognitive and effective functions 3. Affective and memory functions 4. Affective and knowledge functions Correct Answer: 1 Question 12 The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to comprehend what is being said to him; however, he is unable to respond by speech or writing. What type of aphasia should the nurse realize this patient is demonstrating? 1. Auditory aphasia 2. Acoustic aphasia 3. Sensory aphasia 4. Expressive aphasia Correct Answer: 4 By Hadassahkim Question 13 The nurse is preparing to assess a clients reflexes. What equipment should the nurse gather before entering the room? 1. Sterile gloves 2. Clean gloves 3. Percussion hammer 4. Penlight Correct Answer: 3 Question 14 The nurse is assisting the physician who is preparing to test a sexually active female client for cervical cancer. What should the nurse expect the health care provider to perform? 1. Pap test 2. Breast exam 3. Rectal exam 4. Abdominal exam Correct Answer: 1 Question 15 The nurse is preparing the morning assignments. Which assessment could the nurse delegate to unlicensed assistive personnel? 1. Neurological assessment 2. Musculoskeletal assessment 3. Vital signs assessment 4. Female genital assessment Correct Answer: 3 Question 16 By Hadassahkim The nurse is assessing the nose and sinuses of a client. Which findings should the nurse identify as being within normal limits? Standard Text: Select all that apply. 1. Nose straight 2. Nares symmetrical 3. No tenderness over the bridge 4. Air movement restricted in one nare 5. Clear drainage from one nare Correct Answer: 1, 2, 3 Question 22 The nurse is planning a physical examination of a client following a head-to-toe format. In which order should the nurse conduct this assessment? 1. Head, upper extremities, abdomen, lower extremities 2. Neck, head, vital signs, chest and back 3. Lower extremities, abdomen, upper extremities, chest and back 4. Head, neck, lower extremities, abdomen Correct Answer: 1 Question 23 The nurse is assessing the peripheral vascular status of an older client. Which finding should the nurse consider as being normal for this client? 1. Easy to palpate upper extremity arteries 2. Easy to palpate lower extremity arteries 3. Reduction in the number of varicosities 4. Increase in diastolic blood pressure Correct Answer: 1 By Hadassahkim Question 24 The nurse is preparing to perform an eye assessment. What equipment should the nurse have available to complete this assessment? Standard Text: Select all that apply. 1. Penlight 2. Snellens chart 3. Sterile gloves 4. Gauze square 5. Millimeter ruler Correct Answer: 1, 2, 4, 5 Question 25 The nurse is preparing to conduct an assessment of the heart. Where should the nurse place the stethoscope to auscultate heart sounds? Standard Text: Select all that apply. 1. Aortic region 2. Pulmonic region 3. Tricuspid valve region 4. Abdomen 5. Mitral valve region Correct Answer: 1, 2, 3, 5 Question 26 The nurse is preparing to assess a client with the Glasgow Coma Scale. Which areas is the nurse assessing in this patient? Standard Text: Select all that apply. By Hadassahkim 1. Eye response 2. Motor response 3. Verbal response 4. Orientation 5. Musculoskeletal response Correct Answer: 1, 2, 3 Question 27 A client is experiencing abdominal pain. What assessments should the nurse perform to assess this complaint? Standard Text: Select all that apply. 1. Inspect the abdomen. 2. Auscultate the abdomen. 3. Palpate the abdomen. 4. Assess vital signs. 5. Assess peripheral pulses. Correct Answer: 1, 2, 3, 4 Question 28 The nurse is assessing the musculoskeletal status of a 4-year-old child. What findings should the nurse consider as being expected in this client? Standard Text: Select all that apply. 1. Lordosis 2. Genu valgus 3. Genu varum By Hadassahkim A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client? 1. Edema, rubor, heat, and pain 2. Fever, malaise, anorexia, nausea, and vomiting 3. Palpitations, irritability, and heat intolerance 4. Tingling, numbness, and cramping of the extremities Correct Answer: 2 Question 6 An older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client? 1. Active bowel sounds 2. Dry intact skin 3. Intact mucous membranes 4. Susceptibility of the client Correct Answer: 4 Question 7 The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the clients body from microorganisms? 1. Heavy smoking 2. Moisturizing the skin 3. Breakdown of skin 4. Voiding quantity sufficient Correct Answer: 4 Question 8 By Hadassahkim The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity? 1. Becoming ill with tetanus and receiving tetanus toxoid 2. Having chickenpox 3. Receiving a rabies shot after being bitten by a rabid dog 4. Receiving an injection of gamma globulin Correct Answer: 2 Question 9 A client was bitten by a rabid raccoon. What care should the nurse prepare to provide to this client? 1. A tetanus toxoid injection 2. An immunization for rabies 3. An injection of immunoglobulin 4. Mothers breast milk with antibodies in it Correct Answer: 2 Question 10 The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection? 1. Assess vital signs only once daily. 2. Raise the temperature in the clients room. 3. Wash hands. 4. Wear a mask for all client care. Correct Answer: 3 Question 11 By Hadassahkim The nurse wants to protect a client from developing an infection. Which action should the nurse take to break a link in the chain of infection? 1. Cover the mouth and nose when sneezing. 2. Place contaminated linens in a paper bag. 3. Use personal protective equipment (PPE) sparingly. 4. Wear gloves at all times. Correct Answer: 1 Question 12 The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper hand-washing technique with this client? 1. Allow the water to splatter forcibly when it is turned on. 2. Clean the faucet after use. 3. Hold the hands upward under the faucet. 4. Use approximately a teaspoon of soap. Correct Answer: 4 Question 13 The nurse is removing personal protective equipment. Which nursing action demonstrates the appropriate technique for removing a mask? 1. Bend the strip at the top of the mask. 2. Loop the ties over the ears. 3. Tie the strings in a bow. 4. Touch the mask by the strings only. Correct Answer: 4 Question 14 By Hadassahkim A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease? 1. Have the client wear a mask when coming from admission. 2. Stock the supply cart at the beginning of each shift. 3. Wash the hands only after leaving the room. 4. Wear a mask when exiting the room. Correct Answer: 1 Question 21 The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Client is receiving intravenous fluids. 2. Client has an indwelling urinary catheter. 3. Client is recovering from surgery. 4. Client is receiving pain medication. 5. Client is ambulating twice a day with assistance. Correct Answer: 1, 2, 3 Question 22 A client diagnosed with an infectious disease asks the nurse how the infection got inside her body. Which responses would be appropriate for the nurse to make? Standard Text: Select all that apply. 1. It depends on the number of organisms present to cause a disease. 2. It depends on how aggressive the organisms are to cause a disease. 3. It depends upon how the organisms get inside the body to cause a disease. By Hadassahkim 4. It depends upon where the person is at the time the disease is present. 5. It depends upon where the person works. Correct Answer: 1, 2, 3, 4 Question 23 The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client? Standard Text: Select all that apply. 1. Intact and dry skin 2. Intact oral mucous membranes 3. Bowel sounds present in all four quadrants 4. Nasal congestion 5. Urinary retention Correct Answer: 1, 2, 3 Question 24 A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client? 1. Social Isolation 2. Anxiety 3. Acute Pain 4. Imbalanced Nutrition: Less Than Body Requirements Correct Answer: 1 Question 25 By Hadassahkim A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client? 1. Anxiety 2. Acute Pain 3. Social Isolation 4. Low Self-Esteem Correct Answer: 1 Question 26 A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the risk of infection? Standard Text: Select all that apply. 1. Hand-washing technique 2. The importance of adequate nutrition 3. Covering the mouth and nose when coughing or sneezing 4. Increasing contact with others 5. Restricting rest period Correct Answer: 1, 2, 3 Question 27 A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed assistive personnel do? 1. Assist the client with hand washing. 2. Assist the client back to bed. 3. Change the clients bed. By Hadassahkim Correct Answer: 4 Question 3 The nurse is reviewing safety hazards with a pregnant client. What should the nurse include when instructing this client about safety and the developing fetus? 1. Banging into objects 2. Bicycle rides 3. Recreational activities 4. X-rays Correct Answer: 4 Question 4 The nurse would like to improve communication among caregivers. How should the nurse use the Joint Commission 2013 National Patient Safety Goals to achieve this objective? 1. Review a list of look-alike/sound-alike drugs used in the organization. 2. Use a verification process to confirm the correct procedure. 3. Report critical results of tests and diagnostic procedures on a timely basis.. 4. Use the clients room number as an identifier. Correct Answer: 3 Question 5 The nurse is planning care for a client who is prone to falling. Which nursing diagnoses should the nurse use for this client? 1. Deficient Knowledge 2. Risk for Injury 3. Risk for Disuse Syndrome 4. Risk for Suffocation By Hadassahkim Correct Answer: 2 Question 6 The nurse is identifying care goals for a client who is prone to getting hurt. Which care goal should the nurse select for this client? 1. Assess the clients mental status. 2. Keep the client dependent on the staff for all care. 3. Make all choices for the client. 4. Remain free from injury. Correct Answer: 4 Question 7 As a member of the safety committee, the nurses task is to identify actions to prevent falls within the organization. Which intervention should the nurse emphasize as important to prevent falls? 1. Display the phone number to the nurses station. 2. Keep electrical cords under the bed. 3. Keep the environment tidy. 4. Read label directions. Correct Answer: 3 Question 8 The home care nurse wants to ensure the safety of an older client who lives at home alone. Which intervention should the nurse identify as a way to prevent this client from falling? 1. Check vision every 5 years. 2. Exercise regularly. 3. Place socks on feet. By Hadassahkim 4. Turn the light on after getting out of bed. Correct Answer: 2 Question 9 The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. What should the nurse advise the mother to do? 1. Omit the afternoon nap. 2. Place a crib net over the top of the crib. 3. Remove all objects from around the crib. 4. Restrain the child if he gets up more than once. Correct Answer: 2 Question 10 While the nurse is performing morning care, a client begins to have a seizure. What should the nurse do to help this client? 1. Insert a tongue blade into the clients mouth. 2. Loosen any clothing around the neck and chest. 3. Restrain the client. 4. Turn the client to the supine position if possible. Correct Answer: 2 Question 11 The nurse is considering the use of restraints for a client. In which situation can the nurse apply restraints to a client? 1. Client wanders around the care area. 2. Client is picking at the access site for intravenous infusion of chemotherapy. By Hadassahkim