practice questions from Iggy

Question 1

When caring for clients using evidence-informed practice, which of the following does the
nurse use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the client outcomes are met

Answer 1

c

Question 2

The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the client’s left hip. Which of the following is the most
appropriate nursing diagnosis for this client?
a. Impaired physical mobility related to decrease in muscle control (left-sided
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
protecting tissue integrity
c. Impaired skin integrity related to pressure over bony prominence (impaired
circulation)
d. Ineffective peripheral tissue perfusion related to sedentary lifestyle

Answer 2

C

Question 3

The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
volume related to excessive fluid loss through normal route (diaphoresis). Which of the
following is an appropriate client outcome?
a. Client has a balanced intake and output.
b. Client’s bedding is changed when it becomes damp.
c. Client understands the need for increased fluid intake.
d. Client’s skin remains cool and dry throughout hospitalization.

Answer 3

A

Question 4

The nurse is caring for a terminally ill client who has 20-second periods of apnea followed
by periods of deep and rapid breathing. Which of the following terms should the nurse use
to document this finding?
a. Agonal breathing
b. Apneustic breathing
c. Death rattle respirations
d. Cheyne-Stokes respirations

Answer 4

D

Question 5

The nurse is caring for a young adult who is dying after an automobile accident. The
family members want to donate the client’s organs and ask the nurse how the decision
when death has occurred is made. Which of the following is the basis for the nurses’
response to the family in this situation?
a. The client is flaccid and unresponsive.
b. The client is experiencing respiratory acidosis and is on a ventilator.
c. The client is unconscious with no brain stem activity.
d. Respiratory efforts cease and no apical pulse is audible.

Answer 5

C

Question 6

The nurse is providing hospice care to a client who is manifesting a decrease in all body
system functions except for a heart rate of 124 and a respiratory rate of 28. Which of the
following is the basis for the nurses’ response about these symptoms?
a. They will continue to increase until death finally occurs.
b. They are a normal response before these functions decrease.
c. They indicate a reflex response to the slowing of other body systems.
d. They may be associated with an improvement in the client’s condition.

Answer 6

B

Question 7

The nurse is caring for a client who has been diagnosed with metastatic cancer and plans a
trip across the country “to settle some issues with my sisters and brothers.” Which of the
responses should the nurse recognize that the client is manifesting?
a. Restlessness
b. Yearning and protest
c. Anxiety about unfinished business
d. Fear of the meaninglessness of one’s life

Answer 7

C

Question 8

The spouse of a client with terminal lung cancer visits daily and cheerfully talks with the
client about vacation plans for the next year. When the nurse asks about any concerns, the
spouse says, “I’m busy at work, but otherwise things are fine.” Which of the following
nursing diagnoses is appropriate?
a. Ineffective denial related to threat of unpleasant reality
b. Anxiety related to threat to current status
c. Caregiver role strain related to inexperience with caregiving
d. Hopelessness related to chronic stress

Answer 8

A

Question 9

As the nurse admits a client with severe heart failure to the hospital, the client tells the
nurse, “If my heart or breathing stop, I do not want to be resuscitated.” Which of the
following actions should the nurse take?
a. Ask if these wishes have been discussed with the health care provider.

b. Place a “Do-Not-Resuscitate” (DNR) notation in the client’s care plan.
c. Inform the client that a notarized advance directive must be included in the record
or resuscitation must be performed.
d. Advise the client to designate a person to make health care decisions when the
client is not able to make them independently.

Answer 9

A

Question 10

A client who is very close to death is very restless and keeps repeating, “I am not ready to
die.” Which of the following actions should the nurse take?
a. Remind the client that no one feels ready for death.
b. Sit at the bedside and ask if there is anything the client needs.
c. Insist that family members remain at the bedside with the client.
d. Tell the client that everything possible is being done to delay death.

Answer 10

B

Question 10

The nurse is caring for a client in a hospice palliative care program who is experiencing
continuous, increasing amounts of pain. Which of the following time schedules should the
nurse implement for the administration of opioid pain medications?
a. Around-the-clock routine administration of analgesics.
b. PRN doses of medication whenever the client requests.
c. Enough pain medication to keep the client sedated and unaware of stimuli.
d. Analgesic doses that provide pain control without decreasing respiratory rate.

Answer 10

A

Question 11

The nurse is caring for a client with lung cancer as part of a home hospice palliative
program. Which of the following interventions should the nurse implement?
a. Discuss cancer risk factors and appropriate lifestyle modifications.
b. Encourage the client to discuss past life events and their meaning.
c. Accomplish a thorough head-to-toe assessment once a week.
d. Educate the client about the purpose of chemotherapy and radiation.

Answer 11

B

Question 12

The nurse has been caring for a terminally ill client for the past 10 months. The nurse and
the family are present when the client dies and feels saddened and tearful as the family
members begin to cry. Which of the following actions should the nurse take at this time?
a. Contact a grief counsellor as soon as possible.
b. Cry along with the client’s family members.
c. Leave the home as quickly as possible to allow the family to grieve privately.
d. Consider whether working in hospice is desirable since client losses are common.

Answer 12

B

Question 13

A client who is in the clinic for an immunization tells the nurse, “My mother died 4
months ago, and I just can’t seem to get over it. I’m not sure it is normal to still think
about her every day.” Which of the following nursing diagnoses is most appropriate?
a. Ineffective role performance related to depression
b. Complicated grieving related to emotional disturbance (death of loved one)
c. Anxiety related to unmet needs (lack of knowledge about normal grieving)
d. Impaired mood regulation related to loneliness

Answer 13

C

Question 14

A terminally ill client is admitted to the hospital. Which of the following actions should
the nurse include in the initial plan of care?
a. Determine the client’s wishes regarding end-of-life care.
b. Emphasize the importance of addressing any family issues.
c. Discuss the normal grief process with the client and family.
d. Encourage the client to talk about any fears or unresolved issues.

Answer 14

A

Question 15

1. The nurse is assessing a client the morning of the first postoperative day and notes redness
   and warmth around the incision. Which of the following actions should the nurse
   implement?
   a. Obtain wound cultures.
   b. Document the assessment.
   c. Notify the health care provider.
   d. Assess the wound every 2 hours.

Answer 15

B

Question 16

A client with an open abdominal wound has a complete blood cell (CBC) count and
differential, which indicate an increase in white blood cells (WBCs) and a shift to the left.
Which of the following actions is priority as a result of this assessment data?
a. Obtain wound cultures.
b. Start antibiotic therapy.
c. Redress the wound with wet-to-dry dressings.
d. Continue to monitor the wound for purulent drainage.

Answer 16

A

Question 17

The nurse is caring for a client with a systemic bacterial infection that has “goose
pimples,” feels cold, and has a shaking chill. At this stage of the febrile response, which of
the following assessments should the nurse monitor?
a. Skin flushing
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure

Answer 17

C

Question 18

The nurse is caring for a young adult client who is receiving antibiotics for an infected leg
wound and has a temperature of 38.8°C (101.8°F). Which of the following actions by the
nurse is most appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Give the prescribed PRN Aspirin 650 mg.
d. Check the client’s oral temperature again in 4 hours.

Answer 18

D

Question 19

Which of the following nursing actions is most likely to detect early signs of infection in a
client who is taking immuno-suppressive medications?
a. Monitor white blood cell count.
b. Check the skin for areas of redness.
c. Check the temperature every 2 hours.
d. Ask about fatigue or feelings of malaise.

Answer 19

D

Question 20

A client who is confined to bed and who has a stage 2 pressure injury is being cared for in
the home by family members. To prevent further tissue damage, which of the following
actions should the nurse instruct the family members that it is most important?
a. Change the client’s bedding frequently.
b. Use a hydrocolloid dressing over the injury.
c. Record the size and appearance of the pressure injury weekly.
d. Change the client’s position every 2 hours.

Answer 20

D

Question 21

A client arrives in the emergency department with a swollen ankle after an injury incurred
while playing soccer. Which of the following actions by the nurse is most appropriate?
a. Elevate the ankle above heart level.
b. Remove the client’s shoe and sock.
c. Apply a warm moist pack to the ankle.
d. Assess the ankle’s range of motion (ROM).

Answer 21

A

Question 22

The nurse is admitting a client with stage 3 pressure injuries on both heels. Which of the
following information obtained by the nurse will have the most impact on wound healing?
a. The client states that the injuries are very painful.
b. The client has had the heel injuries for the last 6 months.
c. The client has several old incisions that have formed keloids.
d. The client takes corticosteroids daily for rheumatoid arthritis.

Answer 22

D

Question 23

The nurse is caring for a client with diabetes who had abdominal surgery one week ago,
and obtains the following data. Which of these findings should be reported immediately to
the health care provider?
a. Blood glucose 7.6 mmol/L
b. Oral temperature 38.3°C (100.9°F)
c. Client has increased incisional pain
d. New 5-cm separation of the proximal wound edges

Answer 23

D

Question 24

A client who has an infected abdominal wound develops a temperature of 40°C (104°F).
All the following interventions are included in the client’s plan of care. In which order
should the nurse perform the following actions?
a. Sponge client with cool water.
b. Administer intravenous antibiotics.
c. Perform wet-to-dry dressing change.

d. Administer acetaminophen.

Answer 24

B,D,A,C

Question 25

1. The nurse is caring for a client with deficient fluid volume caused by a massive burn
   injury. Which of the following assessment data will be of greatest concern to the nurse?
   a. The blood pressure is 90/40 mm Hg.
   b. Urine output is 30 mL over the last hour.
   c. Oral fluid intake is 100 mL for the last 8 hours.
   d. There is prolonged skin tenting over the sternum.

Answer 25

A

Question 26

The nurse is caring for a client recently admitted with small cell carcinoma of the lung and
the syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following
assessments should the nurse carefully monitor?
a. Increased total urinary output
b. Elevation of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss

Answer 26

C

Question 27

The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated
with multiple draining wounds. Which of the following assessments is the most accurate to
evaluate volume status in this client?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output

Answer 27

B

Question 28

The nurse is caring for an alert and oriented older-adult client with a history of
dehydration. Which of the following information should the home health nurse teach the
client as to when to increase fluid intake?
a. In the late evening hours
b. If the oral mucosa feels dry
c. When the client feels thirsty
d. As soon as changes in level of consciousness (LOC) occur

Answer 28

B

Question 29

The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of
hypertension. Which of the following assessment data would the nurse include in the
teaching plan?
a. Personality changes
b. Frequent loose stools
c. Facial muscle spasms
d. Lower extremity weakness

Answer 29

D

Question 30

The nurse is teaching a client about spironolactone as a diuretic. Which statement by the
client indicates that the teaching about this medication has been effective?
a. “I will try to drink at least eight glasses of water every day.”
b. “I will use a salt substitute to decrease my sodium intake.”
c. “I will increase my intake of potassium-containing foods.”
d. “I will drink apple juice instead of orange juice for breakfast.”

Answer 30

D

Question 31

The nurse is caring for a client admitted with hyponatremia. Which of the following
actions should the nurse anticipate implementing?
a. Restrict client’s oral free water intake.
b. Avoid use of electrolyte-containing drinks.
c. Infuse a solution of 5% dextrose in 0.45% saline.
d. Administer vasopressin (antidiuretic hormone, [ADH]).

Answer 31

A

Question 32

The nurse is caring for a client with severe hypokalemia and is preparing to administer
intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider.
Which of the following actions should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 20 mEq/hour.
c. Give the KCl only through a central venous line.
d. Add no more than 40 mEq/L to a litre of IV fluid.

Answer 32

B

Question 33

The nurse is caring for a client with hyperkalemia and is interpreting the
electrocardiogram (ECG) report. Which of the following ECG changes would the nurse
expect to assess in this client?
a. Ventricular dysrhythmias
b. Bradycardia
c. Flatten T wave
d. Prolonged P-R interval

Answer 33

D

Question 34

10. The nurse is caring for a client who has required prolonged mechanical ventilation and has
    the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and
    HCO3 25 mmol/L. Which of the following interpretations would the nurse document?
    a. Metabolic acidosis
    b. Metabolic alkalosis
    c. Respiratory acidosis
    d. Respiratory alkalosis

Answer 34

D

Question 35

The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid,
deep respirations. Which of the following actions should the nurse implement?
a. Notify the client’s health care provider.
b. Give the prescribed PRN lorazepam.
c. Start the prescribed PRN oxygen at 2–4 L/minute.
d. Encourage the client to take deep, slow breaths.

Answer 35

A

Question 36

The home health nurse is visiting an older-adult client who has a low serum protein level.
Which of the following assessment areas should the nurse assess?
a. Pallor
b. Edema
c. Confusion
d. Restlessness

Answer 36

B

Question 37

The nurse is caring for a client who is receiving 3% NaCl solution for correction of
hyponatremia. During administration of the solution, which of the following assessments
is a priority for the nurse to monitor?
a. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema

Answer 37

A

Question 38

The nurse is caring for a client who has a low serum total protein level and is taking
protein supplements. Which of the following data indicate that the client’s condition has
improved?
a. Hematocrit 28%
b. Good skin turgor
c. Absence of peripheral edema
d. Blood pressure 110/72 mm Hg

Answer 38

C

Question 39

The nurse is caring for a client who has the following arterial blood gas (ABG) results: pH
7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mmol/L. Which of the following
interpretations would the nurse document?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

Answer 39

A

Question 40

16. The nurse is caring for a client who has been receiving diuretic therapy and is admitted to
    the emergency department with a serum potassium level of 3.1 mmol/L. Of the following
    medications that the client has been taking at home, which of the following would be of
    most concern to the nurse?
    a. Oral digoxin 0.25 mg daily
    b. Ibuprofen 400 mg every 6 hours
    c. Metoprolol 12.5 mg orally daily
    d. Lantus insulin 24 U subcutaneously every evening

Answer 40

A

Question 41

Which of the following actions should the scrub nurse use to maintain aseptic technique
during surgery?
a. Use waterproof shoe covers.
b. Wear personal protective equipment.
c. Insist that all operating room (OR) staff perform a surgical scrub.
d. Change gloves after touching the thigh of a surgeon’s sterile gown.

Answer 41

D

Question 42

After orienting a new staff member to the scrub nurse role, the nurse preceptor will know
that the teaching was effective if the new staff member implements which of the following
actions?
a. Documents all client care accurately.
b. Labels all specimens to send to the laboratory.
c. Keeps both hands above the operating table level.
d. Takes the client to the postanaesthesia recovery area.

Answer 42

C

Question 43

Data that were obtained during the perioperative nurse is assessing a client in the
preoperative holding area. Which of the following findings would indicate a need for
special protection techniques during surgery?
a. A stated allergy to cats and dogs
b. A history of spinal and hip arthritis
c. Verbalization of anxiety by the client
d. Having a sip of water 2 hours previously

Answer 43

B

Question 44

The nurse is caring for a preoperative adult client who is scheduled for a routine surgery
and is in the holding area. The client asks the nurse, “Will the doctor put me to sleep with
a mask over my face?” Which of the following responses is most appropriate?
a. “A drug will be given to you through your IV line, which will cause you to go to
sleep almost immediately.”
b. “Only your surgeon can tell you for sure what method of anaesthesia will be used.
Should I ask your surgeon?”
c. “General anaesthesia is now given by injecting medication into your veins, so you
will not need a mask over your face.”
d. “Masks are not used anymore for anaesthesia. A tube will be inserted into your
throat to deliver a gas that will put you to sleep.”

Answer 44

A

Question 45

A client’s family history reveals that the client may be at risk for malignant hyperthermia
(MH) during anaesthesia. Which of the following information should the nurse include
when providing preoperative client teaching?
a. Anaesthesia can be administered with minimal risks with the use of appropriate
precautions and medications.
b. As long as succinylcholine is not administered as a muscle relaxant, the reaction
should not occur.
c. Surgery must be performed under local anaesthetic to prevent development of a
sudden, extreme increase in body temperature.
d. Surgery will be delayed until the client is genetically tested to determine
susceptibility to malignant hyperthermia.

Answer 45

ANS: A
General anaesthesia can be administered to clients with MH as long as precautions to
avoid MH are taken and preparations are made to treat MH if it does occur. Other factors
besides succinylcholine administration are associated with MH. Predictions about whether
MH will occur based on family history are inconsistent, and it may not be possible to
delay surgery.

Question 46

15. Which of the following actions by a member of the surgical team requires rapid
    intervention by the charge nurse?
    a. Wearing street clothes into the nursing station
    b. Wearing a surgical mask into the holding room
    c. Walking into the hallway outside an operating room without the hair covered
    d. Putting on a surgical mask, cap, and scrubs before entering the operating room

Answer 46

C