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PN 4006 MIDTERM G2 Q BASED QUESTIONS AND
ANSWERS
The nurse is preparing to perform a physical examination on a client who has cardiopulmonary disease. Knowing this about the client, the nurse is alert for the presence of which of the following when checking the client's nails? Select one: a. Clubbing b. Bands in nailbeds c. Yellow discoloration d. Splinter hemorrhages - Answers :A- clubbing The nurse is auscultating the client's lungs and notes normal vesicular sounds as being which of the following? Select one: a. Medium-pitched blowing sounds with inspiration equalling expiration b. Loud, high-pitched, hollow sounds with expiration longer than inspiration c. Soft, breezy, low-pitched sounds with longer inspiration d. Sounds created by air moving through small airways - Answers :c. Soft, breezy, low- pitched sounds with longer inspiration During the physical examination, the nurse should use which part of the hand to assess characteristics such as consistency, contour, and texture in the client's glands? Select one: a. Dorsum of the hand b. Pads of the fingers c. Palmar surface of the hand d. Fingertip grasp of the tissue - Answers :b. Pads of the fingers If a low-pitched murmur is suspected with prior assessment, which of the following is the best position for the client when the nurse auscultates the apical site? Select one: a. Sitting up b. Standing c. Lying on the left side d. Dorsal recumbent - Answers :c. Lying on the left side Which of the following positions maximizes the nurse's ability to assess the client's upper body for symmetry? Select one: a. Sitting b. Supine c. Prone d. Dorsal recumbent - Answers :a. Sitting
The nurse is observing a new staff member work with the client. Of the following activities, which one has the greatest possibility of contributing to a nosocomial infection and requires correction? Select one: a. Washing hands before applying a dressing b. Taping a plastic bag to the bed rail for tissue disposal c. Placing a Foley catheter bag on the bed when transferring a client d. Using alcohol to cleanse the skin before starting an intravenous line - Answers :c. Placing a Foley catheter bag on the bed when transferring a client Which one of the following indicates that the nurse is using surgical aseptic technique? Select one: a. Inserting an intravenous catheter b. Placing soiled linen in moisture-resistant bags c. Disposing of syringes in puncture-proof containers d. Washing hands before changing a dressing - Answers :a. Inserting an intravenous catheter The client requires a sterile dressing change. Which of the following is an appropriate intervention for the nurse to implement in maintaining sterile asepsis? Select one: a. Put sterile gloves on before opening sterile packages. b. Check integrity of sterile packages prior to use. c. Place the cap of the sterile solution well within the sterile field. d. Place sterile items on the very edge of the sterile drape. - Answers :b. Check integrity of sterile packages prior to use. The nurse suspects that an older adult client may have pneumonia. Older adult clients may react differently to infectious processes, so the nurse is alert to atypical signs and symptoms, such as which one of the following? Select one: a. Hypotension b. Confusion c. Erythema d. Chills - Answers :b. Confusion The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent with sterile asepsis? Select one: a. Clean forceps may be used to move items on the sterile field. b. Sterile fields may be prepared well in advance of the procedures. c. The first small amount of sterile solution should be poured and discarded. d. Wrapped sterile packages should be opened starting with the flap closest to the nurse. - Answers :c. The first small amount of sterile solution should be poured and discarded.
The nurse recognizes that skin integrity can be compromised when skin is exposed to body fluids. The greatest risk exists for the client who has exposure to which one of the following fluids? Select one: a. Urine b. Purulent exudates c. Pancreatic fluids d. Serosanguineous drainage - Answers :c. Pancreatic fluids The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following interventions is the best one for this client's skin integrity? Select one: a. Having the client sit up in a chair for four-hour intervals b. Keeping the head of the bed in a high-Fowler's position to increase circulation c. Keeping a written schedule of turning and positioning d. Encouraging the client to perform pelvic muscle training exercises several times a day - Answers :c. Keeping a written schedule of turning and positioning Which of the following information about how smoking influences healing does the nurse include when planning a program on wound healing? Select one: a. Smoking suppresses protein synthesis. b. Smoking creates increased tissue fragility. c. Smoking depresses bone marrow function. d. Smoking reduces the amount of functional hemoglobin in the blood. - Answers :d. Smoking reduces the amount of functional hemoglobin in the blood. The client has a large, deep wound on the sacral region. The nurse correctly packs the wound by doing which one of the following? Select one: a. Filling two-thirds of the wound cavity b. Leaving saline-soaked folded gauze squares in place c. Putting the dressing in very tightly d. Extending only to the surface of the wound - Answers :d. Extending only to the surface of the wound How should the nurse clean a wound? Select one: a. Go over the wound twice and discard that swab. b. Move from the outer region of the wound toward the centre. c. Clean wound from least contaminated to most contaminated area. d. Use an antiseptic solution followed by a normal saline rinse. - Answers :c. Clean wound from least contaminated to most contaminated area.
The nurse observes thin, watery fluid draining from the left ear of a client who has sustained a head injury. How is this drainage described? Select one: a. Serous b. Purulent c. Cerebrospinal fluid d. Serosanguineous - Answers :a. Serous The nurse notes that the client's skin is reddened, with a small intact serum-filled blister. How should the nurse classify this stage of ulcer formation? Select one: a. Stage I b. Stage II c. Stage III d. Stage IV - Answers :b. Stage II When turning a client, the nurse notices a reddened area on the coccyx. Which of the following skin care interventions should the nurse use on this area? Select one: a. Clean the area, dry it, and add a protective moisturizer. b. Apply a diluted hydrogen peroxide and water mixture, and use a heat lamp on the area. c. Soak the area in normal saline solution. d. Wash the area with an astringent and paint it with povidone-iodine (Betadine). - Answers :a. Clean the area, dry it, and add a protective moisturizer. The client is scheduled for a dressing change. When removing the adhesive tape used to secure the dressing, the nurse should lift the edge and hold the tape in which manner? Select one: a. At a 45-degree angle to the skin surface while pulling away from the dressing b. At a right angle to the skin surface while pulling toward the dressing c. At a right angle to the skin surface while pulling away from the dressing d. Parallel to the skin surface while pulling toward the dressing - Answers :d. Parallel to the skin surface while pulling toward the dressing The nurse is concerned that the client's abdominal wound is at risk for dehiscence. Which of the following interventions is the best one to prevent this complication? Select one: a. Administering antibiotics to prevent infection b. Using appropriate sterile technique when changing the dressing c. Keeping sterile towels and extra dressing supplies near the client's bed d. Placing a pillow over the incision site when the client is deep breathing or coughing - Answers :d. Placing a pillow over the incision site when the client is deep breathing or coughing
b. The client's intake and output c. The client's serum electrolyte levels d. The client's daily body weight - Answers :d. The client's daily body weight The nurse anticipates that the client with a fluid volume excess will manifest which one of the following signs? Select one: a. Increased urine specific gravity b. Decreased body weight c. Increased blood pressure d. Decreased pulse strength - Answers :c. Increased blood pressure Out of all of the following clients, the nurse recognizes that which one is most at risk for a fluid volume deficit? Select one: a. A 6-month-old learning to drink from a cup b. A 1 2 - year-old who is moderately active in 27°C weather c. A 42-year-old with severe diarrhea d. A 90-year-old with frequent headaches - Answers :c. A 42-year-old with severe diarrhea A client complains of a headache and chills during a blood transfusion. Which one of the following actions should the nurse take immediately? Select one: a. Check the vital signs. b. Stop the blood transfusion. c. Slow the rate of blood flow. d. Notify the physician and blood bank personnel. - Answers :b. Stop the blood transfusion. A client experiences a loss of intracellular fluid. The nurse anticipates that which of the following IV therapies will be used to replace this type of fluid loss? Select one: a. 0.45% normal saline (NS) b. 10% dextrose c. 5% dextrose in lactated Ringer's d. Dextrose 5% in 1/2 NS - Answers :a. 0.45% normal saline (NS) The nurse will be starting a new intravenous (IV) infusion and needs to select the site for the insertion. In selecting a site, the nurse should do which of the following? Select one: a. Start with the most distal site. b. Look for hard, cord-like veins. c. Use the dominant arm. d. Vigorously rub and tap the chosen vein. - Answers :a. Start with the most distal site.
A rapid infusion of blood has been given to the client. The nurse assesses the client for which one of the following? Select one: a. Diaphoresis b. Anxiety c. Hypertension and tachycardia d. Nausea and vomiting - Answers :c. Hypertension and tachycardia An IV of 125 mL is to be infused over a one-hour period. A microdrip infusion set will be used. Which of the following is the nurse's calculation of the infusion rate? Select one: a. 32 gtt/min b. 60 gtt/min c. 125 gtt/min d. 250 gtt/min - Answers :c. 125 gtt/min The client has severe anemia and will be receiving blood transfusions. The nurse prepares and begins the infusion. Ten minutes after the infusion has begun, the client develops tachycardia, chills, and low back pain. After stopping the transfusion, which of the following actions should the nurse take next? Select one: a. Administer an antipyretic. b. Begin an infusion of epinephrine. c. Run normal saline through the blood tubing. d. Obtain and send a urine specimen to the lab. - Answers :d. Obtain and send a urine specimen to the lab. Arterial blood gases are obtained for the client. The client's results (pH, 7.48; CO2, 42 mm Hg; HCO3, 32 mmol/L) indicate which one of the following acid-base imbalances? Select one: a. Metabolic acidosis b. Respiratory acidosis c. Respiratory alkalosis d. Metabolic alkalosis - Answers :d. Metabolic alkalosis Which of the following is an unexpected value that the nurse, in reviewing the results of the client's blood work, should report to the physician? Select one: a. Calcium, 1.9 mmol/L b. Sodium, 140 mmol/L c. Potassium, 3.5 mmol/L d. Magnesium, 1.8 mmol/L - Answers :a. Calcium, 1.9 mmol/L An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment, the nurse notes that the child is warm and flushed, is lethargic, has difficulty breathing, and has moist crackles. The nurse determines that the child has which one of the following?
c. pH, 7.35; PaCO2, 35 mm Hg; HCO3, 24 mmol/L d. pH, 7.52; PaCO2, 48 mm Hg; HCO3, 28 mmol/L - Answers :a. pH, 7.3; PaCO2, 38 mm Hg; HCO3, 19 mmol/L A client has intravenous (IV) therapy for the administration of antibiotics and is stating that the IV site "hurts and is swollen." Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to infiltration? Select one: a. Intensity of the pain b. Warmth of integument surrounding the IV site c. Amount of subcutaneous edema d. Skin discoloration of a bruised nature - Answers :b. Warmth of integument surrounding the IV site Acute renal failure and a resulting metabolic acidosis develop in a client. The nurse recognizes that the respiratory system compensates through which of the following processes? Select one: a. Hypoventilation and increase of bicarbonate in the bloodstream b. Alternating periods of deep versus shallow breaths to maintain homeostasis of the serum pH c. Hyperventilation to decrease the serum carbon dioxide and thereby increase the pH d. Expansion of the lung tissues to their fullest, which increases the inspiratory reserve volumes to provide more oxygen to the tissues - Answers :c. Hyperventilation to decrease the serum carbon dioxide and thereby increase the pH A client has pneumonia. Which of the following evaluations does the nurse make about the effectiveness of the client's cough? Select one: a. The client has a frequent, dry cough. b. The client has decreased adventitious sounds on auscultation. c. The client is breathing with deeper inhalation. d. The client's oxygen saturation is improved. - Answers :b. The client has decreased adventitious sounds on auscultation. It is suspected that the client's oxygenation status is deteriorating. The nurse is aware that which abnormal assessment finding represents the most serious indication of the client's decreased oxygenation? Select one: a. Poor skin turgor b. Clubbing of the nails c. Central cyanosis d. Pursed-lip breathing - Answers :c. Central cyanosis The nurse is checking the client's overall oxygenation. In assessment of the presence of central cyanosis, which of the following areas will the nurse inspect?
Select one: a. The client's palms and soles of the feet b. The client's nail beds c. The client's earlobes d. The client's tongue - Answers :d. The client's tongue The client is experiencing a sinus dysrhythmia with a pulse rate of 82 beats per minute. On entering the client's room, which of the following does the nurse expect to find? Select one: a. The client is extremely fatigued. b. The client is complaining of chest pain. c. The client is experiencing a "fluttering" sensation in the chest. d. The client is not experiencing any clinical symptoms based on the assessment. - Answers :d. The client is not experiencing any clinical symptoms based on the assessment. A 64-year-old client is seen in the emergency department for palpitations and mild shortness of breath. The ECG reveals a normal P wave, P-R interval, and QRS complex with a regular rhythm and a rate of 108 beats per minute. The nurse should recognize this as which type of cardiac dysrhythmia? Select one: a. Sinus dysrhythmia b. Sinus tachycardia c. Supraventricular tachycardia d. Ventricular tachycardia - Answers :b. Sinus tachycardia The nurse is reviewing the results of the client's diagnostic testing for respiratory function. Of the following results, which finding falls within expected or normal limits? Select one: a. SaO2 88% b. pH 7. c. PaCO2 40 mm Hg d. PaO2 79 mm Hg - Answers :c. PaCO2 40 mm Hg The nurse knows that a pacemaker may be required for which of the following conditions? Select one: a. Sinus tachycardia b. Sinus bradycardia c. Ventricular fibrillation d. Heart failure - Answers :b. Sinus bradycardia The client is admitted to the emergency department with a pneumothorax. Which of the following does the nurse anticipate the client will be experiencing? Select one: a. Dyspnea
Select one: a. Assess nares for skin breakdown every six hours. b. Check patency of the cannula every two hours. c. Inspect the mouth every six hours. d. Check oxygen flow every 24 hours. - Answers :a. Assess nares for skin breakdown every six hours. The nurse is preparing to remove the skin staples from an older adult's incision. Which action should the nurse take to prevent a complication as a result of age and its effect on healing? Select one: a. Be prepared to use skin glue on the edges of the wound. b. Have Steri-Strips ready to use after the staples are removed. c. Increase the amount of protein in the patient's diet. d. Assess the skin edges before the patient is discharged. - Answers :b. Have Steri- Strips ready to use after the staples are removed. The nurse prepares to change the patient's dressing using sterile technique. Which does the nurse implement to promote infection control? Select one: a. Scrubs the drain insertion site in a back-and-forth manner b. Cleans the incision from wound edges toward the center c. Removes the old dressing with clean gloves; inspects the wound d. Dons sterile gloves, removes the dressing, and opens sterile supplies - Answers :c. Removes the old dressing with clean gloves; inspects the wound The nurse prepares to remove the patient's sutures and staples. Which step should the nurse implement before proceeding with the removal? Select one: a. Assess the type of suture material used. b. Snip off both ends of the suture material. c. Cleanse crusting with hydrogen peroxide. d. Plan staple removal for postoperative day 5. - Answers :a. Assess the type of suture material used. The nurse is performing a wound assessment after removing the soiled dressing. What finding would indicate a problem requiring additional assessment? Select one: a. An incisional ridge continues to be present. b. The patient experiences less discomfort. c. There is a lack of new drainage. d. The patient states, "My wound feels warm." - Answers :d. The patient states, "My wound feels warm." The nurse needs to apply a dry sterile dressing. Which should the nurse implement first?
Select one: a. Inspect the appearance of the wound. b. Remove excess moisture from the wound. c. Cleanse with sterile saline solution. d. Prepare the sterile field for supplies. - Answers :a. Inspect the appearance of the wound. The nurse teaches a patient about Steri-Strips after suture removal. What information does the nurse include in patient teaching? Select one: a. They provide a skin barrier. b. They provide gentle support. c. They prevent scarring of the wound. d. They collect additional drainage. - Answers :b. They provide gentle support. The nurse applies Steri-Strips to the patient's surgical site after suture removal. During patient teaching, what does the nurse instruct the patient to avoid doing? Select one: a. Limit heavy lifting activities. b. Ambulate several times a day. c. Soak in the bathtub for relaxation. d. Use a pillow to support incision. - Answers :c. Soak in the bathtub for relaxation. The nurse prepares to apply a dressing for a patient who has a full-thickness wound with moderate exudate and necrosis. Which is the best nursing intervention to help the patient achieve an expected long-term outcome for this wound? Select one: a. Assess the wound for sinus tracts and tunneling. b. Maintain oxygenation with supplemental oxygen. c. Pack the wound lightly with a wet-to-dry dressing. d. Provide a well-balanced diet with high-quality protein. - Answers :d. Provide a well- balanced diet with high-quality protein. The nurse assesses a patient with a surgical incision. What is an expected patient outcome on the fourth postoperative day? Select one: a. The tympanic temperature is 39.5° C at 8 AM and noon. b. The incision is slightly reddened and swollen without drainage. c. The skin is spongy and warm around the incision. d. The patient's pain has been increasing gradually. - Answers :b. The incision is slightly reddened and swollen without drainage. The nurse is preparing to initiate a blood transfusion. Which step of the procedure should the nurse implement first? Select one: a. Begin the infusion at 2 mL/min.
b. Assessing patient baseline vital signs before the transfusion c. Confirming the rate of the blood infusion with the health care provider d. Identifying patient blood type, cross-match, and blood product - Answers :d. Identifying patient blood type, cross-match, and blood product The prescription for the patient's intravenous (IV) infusion reads, "100 mL/hr." The nurse observes that the patient's IV line infused 125 mL in addition to the ordered volume after 2 hours. Which is the most important intervention for the nurse to implement? Select one: a. Compare weight to baseline data. b. Replace the infusion pump batteries. c. Assess the patient for respiratory distress. d. Reduce the infusion rate below 75 mL/hr. - Answers :c. Assess the patient for respiratory distress. The order calls for the patient to receive 500 mL of intravenous (IV) fluid over 4 hours, and the nurse uses IV tubing with a drop factor at 10 gtts/mL. Which rate should the nurse use on an electronic infusion pump for IV fluids to administer this prescription? Select one: a. 125 mL/hr b. 500 mL/hr c. 21 gtts/min d. 32 gtts/min - Answers :a. 125 mL/hr The nurse observes bleeding on the dressing of an intravenous (IV) insertion site. Which action should the nurse take first? Select one: a. Examine the insertion site. b. Reinforce the dressing. c. Apply a warm compress. d. Remove the IV line quickly. - Answers :a. Examine the insertion site. The nurse assesses the patient's intravenous (IV) infusion. Which clinical indicator cues the nurse to take special precautions while infusing IV fluids? Select one: a. Poor skin turgor b. Bilateral crackles c. Mild hypotension d. High serum sodium - Answers :b. Bilateral crackles The nurse feels resistance while trying to flush the intravenous (IV) line with a 5-mL syringe of normal saline solution before administering a medication by IV bolus. Which should the nurse implement next? Select one: a. Use a 3-mL syringe to flush. b. Aspirate the IV line for a blood return.
c. Check for causes of resistance. d. Inject the IV medication slowly. - Answers :c. Check for causes of resistance. The nurse is setting up to administer a unit of blood. Which is the most important nursing intervention during preparation for this procedure? Select one: a. Prepare a normal saline solution. b. Obtain a Y-tubing for administration. c. Provide the patient with information. d. Identify the blood product and patient. - Answers :d. Identify the blood product and patient. The nurse assesses the patient and determines that he may be at risk for altered peripheral tissue perfusion. Which activity should the nurse include in patient teaching to prevent decreased perfusion to his extremities while he is on bed rest? Select one: a. Avoid any fluids by mouth until the patient begins passing gas. b. Flex and rotate the ankles several times every hour while awake. c. Rest quietly to allow the maximum action of the opioid analgesics. d. Stay positioned on either side with pillows between the legs. - Answers :b. Flex and rotate the ankles several times every hour while awake. The nurse instructs the patient about postoperative coughing and deep-breathing exercises. Which technique should the nurse use to engage the patient in prevention of pneumonia and atelectasis? Select one: a. Begin coughing and deep breathing when the patient is ready. b. Take a deep breath, hold it for 10 seconds, and exhale slowly. c. Support the incision when doing these exercises. d. Begin coughing and deep breathing when the patient is wide awake - Answers :c. Support the incision when doing these exercises. The nurse administers blood to the patient and observes that the patient has tachycardia, chills, and lower back pain. Which should the nurse implement first? Select one: a. Notify the health care provider. b. Notify the blood bank. c. Complete the vital signs. d. Remove the intravenous (IV) tubing. - Answers :d. Remove the intravenous (IV) tubing. The nurse infuses a unit of blood, but after 4 hours the blood infusion is not complete. Which action should the nurse implement? Select one: a. Check the intravenous (IV) access for patency. b. Increase the infusion rate of the blood.
