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PN 4006 Midterm (G2 quizzes 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 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 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 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 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 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 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:
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. c. The first small amount of sterile solution should be poured and discarded. The client has a 15-cm laceration on his right forearm and an infection develops. Which of the following is a sign of an acute inflammatory process? Select one: a. A blanching of the skin b. A decrease in temperature at the site c. A decrease in the number of white blood cells (WBCs) d. A release of histamine that adds to the pain response d. A release of histamine that adds to the pain response The nurse works in a small rural hospital with a wide variety of clients. Of the clients admitted this afternoon, the nurse recognizes that the individual with which of the following conditions is most susceptible to infection? Select one: a. Burns b. Diabetes c. Pulmonary emphysema d. Peripheral vascular disease a. Burns The client has a large, deep abdominal incision that requires a dressing. The incision is packed with sterile 1.75-cm packing and covered with a dry, 10 × 10-cm gauze. When changing the dressing, the nurse accidentally drops the packing onto the client's abdomen. Which of the following actions should the nurse take? Select one: a. Add alcohol to the packing and insert it into the incision. b. Throw the packing away, and prepare a new one.
c. Pick up the packing with sterile forceps, and gently place it into the incision. d. Rinse the packing with sterile water, and put the packing into the incision with sterile gloves. b. Throw the packing away, and prepare a new one. The nurse uses the Braden Scale in the extended care facility to determine the client's risk for pressure ulcer development. Which score, based on this scale, places the client at the highest level of risk? Select one: a. 9 or below b. 10 to 12 c. 13 to 14 d. 15 to 16 a. 9 or below Which of the following statements is true for wounds that heal by primary intention? Select one: a. They will likely have minimal scarring. b. They will likely contain infected tissue. c. They will likely present with ragged edges. d. They will likely have portions of missing tissue. a. They will likely have minimal scarring. 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
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. 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 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 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). 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 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 d. Placing a pillow over the incision site when the client is deep breathing or coughing A client has a healing abdominal wound. The wound has minimal exudate and collagen formation. The wound is identified by the nurse as being in which phase of healing? Select one: a. Primary intention b. Inflammatory phase
Which of the following is the most common electrolyte imbalance? Select one: a. Hypokalemia b. Hyperkalemia c. Hyponatremia d. Hypernatremia a. Hypokalemia The single best indicator of a client's fluid status is the nurse's assessment of which one of the following? Select one: a. The client's skin turgor b. The client's intake and output c. The client's serum electrolyte levels d. The client's daily body weight 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 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 12-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 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. 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 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.
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 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 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? Select one: a. Metabolic acidosis b. Respiratory acidosis c. Respiratory alkalosis d. Metabolic alkalosis b. Respiratory acidosis A child having an asthma attack has presented to the emergency department. He is breathing rapidly and has a blood pH of 7.47, signs and symptoms that the nurse suspects are consistent
with which of the following conditions? Select one: a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis d. Respiratory alkalosis When a deficit of body fluid exists in the intravascular compartment, which of the following signs can be expected? Select one: a. Crackles b. Hypertension c. Neck vein distension d. An elevated hematocrit level d. An elevated hematocrit level The physician orders 1000 mL of D5RL with 20 mmol KCl to run for eight hours. With an infusion set with a drop factor of 15 gtt/mL, which of the following will the nurse calculate the flow rate to be? Select one: a. 12 drops per minute b. 22 drops per minute c. 32 drops per minute d. 42 drops per minute c. 32 drops per minute Which of the following is of great importance for the nurse to check before administering an IV solution with potassium that is prescribed for the client? Select one:
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 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. 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 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 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. 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 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.
The electrical activity of the client's heart is being continuously monitored while he is on the coronary care unit. Suddenly, the nurse finds that the client is experiencing ventricular fibrillation. Which of the following actions should the nurse prepare to take? Select one: a. Administer atropine. b. Prepare for CPR and defibrillation. c. Prepare the client for surgical placement of a pacemaker. d. Instruct the client to perform the Valsalva manoeuvre. b. Prepare for CPR and defibrillation. The nurse has reviewed information about the cardiovascular system before caring for a client with heart disease. The nurse knows that which of the following statements is true concerning the physiology of the cardiovascular system? Select one: a. Stimulating the parasympathetic system would cause the heart rate to increase. b. When a person has heart muscle disease, the heart muscles stretch as far as is necessary to maintain function. c. The QRS interval on the electrocardiogram represents the electrical impulses passing through the ventricles. d. When stroke volume decreases, a resultant decrease in heart rate occurs. c. The QRS interval on the electrocardiogram represents the electrical impulses passing through the ventricles. On admitting a client, the nurse finds a history of myocardial ischemia. What is the most disconcerting dysrhythmia that electrocardiography can reveal for this client? Select one: a. Sinus bradycardia b. Sinus dysrhythmia c. Ventricular tachycardia d. Atrial fibrillation
c. Ventricular tachycardia The client with a chronic obstructive respiratory disease is receiving oxygen via a nasal cannula. The nurse plans to include which of the following interventions in the client's care? 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. 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. 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 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?
