NURS 255 Final 2

Question 1

A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?

A. Monitoring evidence-based practice for clients who have a specific diagnosis

B. Ensuring that health care providers comply with regulations

C. Setting quality standards for accreditation of health care facilities

D. Determining whether medications are safe for administration to clients

Answer 1

B. Ensuring that health care providers comply with regulations

Question 2

A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply.)

A. Preferred provider organization (PPO)

B. Medicare

C. Long-term care insurance

D. Exclusive provider organization (EPO)

E. Medicaid

Answer 2

B. Medicare

E. Medicaid

Question 3

A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy?

A. Collaborating with providers to perform obesity screenings during routine office visits

B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity

C. Providing specialized intraoperative training in surgical treatments for obesity

D. Educating acute care nurses about postoperative complications related to obesity

Answer 3

A. Collaborating with providers to perform obesity screenings during routine office visits

Question 4

A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply.)
A. Intensive care unit
B. Oncology treatment center
C. Burn center
D. Cardiac rehabilitation
E. Home health care

Answer 4

A. Intensive care unit
B. Oncology treatment center
C. Burn center

Question 5

A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.)
A. Home health care
B. Rehabilitation facilities
C. Diagnostic centers
D. Skilled nursing facilities
E. Oncology centers

Answer 5

A. Home health care
B. Rehabilitation facilities

D. Skilled nursing facilities

Question 6

A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist

Answer 6

D. Occupational therapist

Question 7

A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication’s effects? (Select all that apply.)
A. Provider
B. Certified nursing assistant
C. Pharmacist
D. Registered nurse
E. Respiratory therapist

Answer 7

A. Provider
C. Pharmacist
D. Registered nurse

Question 8

A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.)
A. A client who has terminal cancer requests hospice care in the home.
B. A client asks about community resources available for older adults.
C. A client states, “I would like to have my child baptized before surgery.”
D. A client requests an electric wheelchair for use after discharge.
E. A client states, “I do not understand how to use a nebulizer.”

Answer 8

A. A client who has terminal cancer requests hospice care in the home.
B. A client asks about community resources available for older adults.
D. A client requests an electric wheelchair for use after discharge.

Question 9

A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? (Select all that apply.)
A. Social worker
B. Certified nursing assistant
C. Occupational therapist
D. Speech-language pathologist
E. Physical therapist

Answer 9

C. Occupational therapist
D. Speech-language pathologist

Question 10

A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAs) can perform, which of the following client activities should the nurse include? (Select all that apply.)
A. Bathing
B. Ambulating
C. Toileting
D. Determining pain level
E. Measuring vital signs

Answer 10

A. Bathing
B. Ambulating
C. Toileting
E. Measuring vital signs

Question 11

A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client’s choice is an example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence

Answer 11

B. Autonomy

Question 12

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Beneficence

Answer 12

D. Beneficence

Question 13

A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence

Answer 13

C. Justice

Question 14

A nurse questions a medication prescription as too extreme in light of the client’s advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence

Answer 14

D. Nonmaleficence

Question 15

A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma?
A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment.
B. A nurse overhears another nurse telling an older adult client that if he doesn’t stay in bed, she will have to apply restraints.
C. A family has conflicting feelings about the initiation of enteral tube feedings for their father who is terminally ill.
D. A client who is terminally ill hesitates to name their partner on their durable power of attorney form.

Answer 15

C. A family has conflicting feelings about the initiation of enteral tube feedings for their father who is terminally ill.

Question 16

A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.)
A. Right place
B. Right supervision and evaluation
C. Right direction and communication
D. Right documentation
E. Right circumstances

Answer 16

B. Right supervision and evaluation
C. Right direction and communication
E. Right circumstances

Question 17

A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members?
A. Nursing supervisor
B. Registered nurse (RN)
C. Practical nurse (PN)
D. Assistive personnel (AP)

Answer 17

B. Registered nurse (RN)

Question 18

A nurse is delegating the ambulation of a client who had a knee arthroplasty 2 days ago to an AP.
Which of the following information should the nurse share with the AP? (Select all that apply.)
A. The client’s roommate ambulates independently.
B. The client ambulates wearing slippers over antiembolic stockings.
C. The client uses a front-wheeled walker when ambulating.
D. The client had pain medication 30 min ago.
E. The client is allergic to codeine.
F. The client ate 50% of breakfast this morning.

Answer 18

B. The client ambulates wearing slippers over antiembolic stockings.
C. The client uses a front-wheeled walker when ambulating.
D. The client had pain medication 30 min ago.

Question 19

A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client’s record? (Select all that apply.)
A. Cover errors with correction fluid, and write in the correct information.
B. Put the date and time on all entries.
C. Document objective data, leaving out opinions.
D. Use as many abbreviations as possible.
E. Wait until the end of the shift to document.

Answer 19

B. Put the date and time on all entries.
C. Document objective data, leaving out opinions.

Question 20

A nurse is receiving a provider’s prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.)
A. Repeat the details of the prescription back to the provider.
B. Have another nurse listen to the telephone prescription.
C. Obtain the provider’s signature on the prescription within 24 hr.
D. Decline the verbal prescription because it is not an emergency situation.
E. Tell the charge nurse that the provider has prescribed morphine by telephone.

Answer 20

A. Repeat the details of the prescription back to the provider.
B. Have another nurse listen to the telephone prescription.
C. Obtain the provider’s signature on the prescription within 24 hr.

Question 21

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply).
A. Medication error
B. Needlesticks
C. Conflict with provider and nursing staff
D. Omission of prescription
E. Missed specimen collection of a prescribed laboratory test

Answer 21

A. Medication error
B. Needlesticks
D. Omission of prescription

Question 22

A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.)
A. A single electronic records password is provided for nurses on the same unit.
B. Family members should provide a code prior to receiving client health information.
C. Communication of client information can occur at the nurses’ station.
D. A client can request a copy of their medical record.
E. A nurse can photocopy a client’s medical record for transfer to another facility.

Answer 22

B. Family members should provide a code prior to receiving client health information.
C. Communication of client information can occur at the nurses’ station.
D. A client can request a copy of their medical record.
E. A nurse can photocopy a client’s medical record for transfer to another facility.

Question 23

A nurse is caring for a client who is two days postoperative and has not achieved satisfactory pain relief. According to the nursing process, which of the following actions should the nurse take first?
A. Check the client to determine the reason for inadequate pain relief.
B. Determine whether the change in plan reduces the client’s pain.
C. Change the plan of care to provide a different method of pain relief.
D. Educate the client about the plan of care for managing the pain.

Answer 23

A. Check the client to determine the reason for inadequate pain relief.

Question 24

A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply.)
A. Find a mentor.
B. Use a journal to write about the outcomes of clinical judgments.
C. Review articles about evidence-based practice.
D. Limit consultations with other professionals involved in a client’s care.
E. Make quick decisions when unsure about a client’s needs.
F. Organize client data using a concept map.

Answer 24

A. Find a mentor.
B. Use a journal to write about the outcomes of clinical judgments.
C. Review articles about evidence-based practice.
F. Organize client data using a concept map.

Question 25

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air-dry after washing

Answer 25

B. Wash the hands with soap and water for at least 15 seconds. D. Use a clean paper towel to turn off hand faucets.

Question 26

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

Answer 26

D. The flap farthest from the body

Question 27

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the fiel C. The inner wrapping of an item on the sterile field D. An irrigation syringe appropriately placed on the sterile field E. One gloved hand with the other gloved hand

Answer 27

C. The inner wrapping of an item on the sterile field D. An irrigation syringe appropriately placed on the sterile field E. One gloved hand with the other gloved hand

Question 28

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 ft away from the client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound. D. Keep a box of facial tissues nearby for the client to use during the dressing change.

Answer 28

C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound.

Question 29

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

Answer 29

B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse.

Question 30

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse suggest?? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions.

Answer 30

B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. E. Wear a gown when performing care that might result in contamination from secretions.

Question 31

The nurse is reviewing the use of transmission-based isolation precautions with a group of new nurses. Sort the following infectious diseases by the type of precautions required. (Contact, Droplet, Airborne) A. Tuberculosis B. SARS-CoV-2 (COVID-19) C. Influenza D. C. difficile E. MRSA

Answer 31

A. Tuberculosis AIRBORNE B. SARS-CoV-2 (COVID-19) AIRBORNE C. Influenza DROPLET D. C. difficile CONTACT E. MRSA CONTACT

Question 32

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when they are sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

Answer 32

C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment

Question 33

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession.

Answer 33

A. Complete a fall-risk assessment.

Question 34

A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on their side." B. "I will go to the nurses' station for assistance." C. "I will note the time that the seizure begins." D. "I will prepare to insert an airway."

Answer 34

B. "I will go to the nurses' station for assistance."

Question 35

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit.

Answer 35

C. Move clients who are nearby.

Question 36

A nurse educator is providing education on infant safety to a group of guardians. Which of the following statements by a guardian indicates an understanding of the teaching? A. "I should line the crib with bumper pads." B. "I will make sure the crib slats are no more than 3 inches apart." C. "I should place the baby on their back when sleeping." D. "I should place the baoy in a vehicle safety seat facing forward in the back seat of the car."

Answer 36

C. "I should place the baby on their back when sleeping."

Question 37

A home health nurse is assessing a client who experienced extreme exposure to heat and has a body temperature of 40°C (104°F). The nurse should anticipate that the client will display which of the following manifestations? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

Answer 37

A. Hypotension

Question 38

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identity as an indication that an attendee understands the teaching? (Select all that apply.) A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible." E. "When pulling an object, I should move my front foot forward."

Answer 38

B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible."

Question 39

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional staff to assist with the transfer. C. Use a transfer belt and assist the client back into bed. D. Determine the client's ability to help with the transfer.

Answer 39

D. Determine the client's ability to help with the transfer.

Question 40

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.) A. Request assistance when repositioning a client. B. Avoid twisting your spine or bending at the waist. C. Keep your knees slightly lower than your hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles.

Answer 40

A. Request assistance when repositioning a client. B. Avoid twisting your spine or bending at the waist. D. Use smooth movements when lifting and moving clients.

Question 41

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? A. Supine B. Semi-Fowler's C. Lateral Semi-prone Recumbent D. Trendelenburg

Answer 41

B. Semi-Fowler's

Question 42

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurse's priority? A. A client who has partial-thickness and full-thickness burns to the face, neck and chest. B. A client who received crush injuries to the chest and abdomen and is expected to die C. A client who has a 4-inch laceration to the head D. A client who has a fractured fibula and tibia

Answer 42

A. A client who has partial-thickness and full-thickness burns to the face, neck and chest.

Question 43

A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? A. "Lie on your back with your head and shoulders supported by a pillow." B. "Have your head turned to the side while you lie on your stomach." C. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table." D. "Lie on your side with your top arm resting on the bed and your weight on your hip."

Answer 43

C. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table."

Question 44

A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? (Select all that apply.) A. Open doors to client rooms. B. Place blankets over clients who are confined to beds. C. Move beds away from windows. D. Draw shades and close drapes. E. Instruct ambulatory clients in the hallways to return to their rooms.

Answer 44

B. Place blankets over clients who are confined to beds. C. Move beds away from windows. D. Draw shades and close drapes.

Question 45

An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water. B. Wash the affected area with antibacterial soap. C. Brush the chemical off the skin and clothing. D. Leave the clothing in place until emergency personnel arrive.

Answer 45

C. Brush the chemical off the skin and clothing.

Question 46

A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply.) A. A client who is dehydrated and receiving IV fluid and electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mm Hg E. A client who has acute appendicitis and is scheduled for an appendectomy

Answer 46

C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mm Hg

Question 47

A nurse educator is reviewing actions to take in the event of a bomb threat by phone to a group of new nurses. Which of the following statements by a nurse indicates understanding? A. "I will get the caller off the phone as soon as possible so I can alert the staff." B. "I will begin evacuating clients using the elevators." C. "I will not ask any questions and just let the caller talk." D. "I will listen for background noises."

Answer 47

D. "I will listen for background noises."

Question 48

The ostomy nurse is providing preoperative education for the client who is scheduled for a sigmoid colostomy. The nurse should identify that which of the following client statements is an indication that the client is ready to learn? A. "I will not look at my incision after the surgery." B. "Will you give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "I can't remember what my doctor told me about the surgery."

Answer 48

C. "Can you tell me about how long the surgery will take?"

Question 49

The ostomy nurse is educating the client about how to empty their ostomy pouch. Which of the tollowing actions by the client indicates that psychomotor learning has taken place? A. The client states how often the ostomy pouch should be emptied. B. The client demonstrates emptying the ostomy pouch. C. The client writes the steps of how to empty the ostomy pouch on a piece of paper. D. The client states they understand how to empty their ostomy pouch.

Answer 49

B. The client demonstrates emptying the ostomy pouch.

Question 50

The ostomy nurse is educating the client about diet. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions about their diet. B. Ask the client to list foods to include in their diet. C. Encourage the client to fill out an evaluation form about how the nurse presented the information about diet. D. Ask the client if they have additional resources for further instruction about their new diet:

Answer 50

B. Ask the client to list foods to include in their diet.

Question 51

A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply.) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity

Answer 51

B. Decreased height D. Nail thickening E. Decreased bladder capacity

Question 52

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my child to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have taken during the day.",

Answer 52

D. "I keep forgetting which medications I have taken during the day.",

Question 53

A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to include in the presentation? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test

Answer 53

B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test

Question 54

A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. "Eat three large meals a day." B. "Eat your meals in front of the television." C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite."

Answer 54

C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite."

Question 55

A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) A. Increase protein intake to increase muscle mass. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation.

Answer 55

A. Increase protein intake to increase muscle mass. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation.

Question 56

A nurse is examining the breast of a female young adult client. The nurse should determine that which of the following are expected findings? (Select all that apply) A. The client's nipples are inverted. B. The client has a dimple on the left breast. C. The client's left breast is smaller than the right breast. D. The client's areolae are oval shaped. E. The underlying veins in the breast are visible.

Answer 56

C. The client's left breast is smaller than the riaht breast. D. The client's areolae are oval shaped. E. The underlying veins in the breast are visible.

Question 57

A nurse is auscultating a client's lungs. Which of the following findings are expected? (Select all that apply). A. High pitched musical sounds B. Expiration is longer than inspiration over the trachea upon auscultation. C. Soft, breezy, low- pitched sounds D. Medium pitched blowing sounds

Answer 57

B. Expiration is longer than inspiration over the trachea upon auscultation. C. Soft, breezy, low- pitched sounds D. Medium pitched blowing sounds

Question 58

A nurse in a provider's office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion

Answer 58

A. Smaller nipples D. More pendulous E. Nipple inversion

Question 59

A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds

Answer 59

C. Resonance E. Bronchovesicular sounds

Question 60

During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias

Answer 60

C. Flatus

Question 61

During a cardiovascular examination, a nurse in à provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate? (Select all that apply.) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Apical heart rate E. Murmur

Answer 61

B. Closure of the mitral valve D. Apical heart rate

Question 62

A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Tympany B. High-pitched clicks C. Borborygmi D. Friction rubs E. Bruits

Answer 62

A. Tympany B. High-pitched clicks

Question 63

A nurse is performing an integumentary assessment for a group of clients. Which of the following findings is the nurse's priority? A. Pallor B. Jaundice C. Cyanosis D. Erythema

Answer 63

C. Cyanosis

Question 64

A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Capillary refill less than 3 seconds B. - 1+ pitting edema in both feet C. Pale nail beds in one hand D. Thick skin on the soles of the feet E. 2+ pulses on the client's lower extremities

Answer 64

A. Capillary refill less than 3 seconds D. Thick skin on the soles of the feet E. 2+ pulses on the client's lower extremities

Question 65

A nurse is caring for a client who is newly admitted to the unit. Which action should the nurse take to establish a helping relationship with the client? A. Make sure the communication is equally distributed between the nurse's and client's desires. B. Encourage the client to communicate their thoughts and feelings. C. Give the nurse-client communication no time limits. D. Allow communication to occur spontaneously throughout the nurse-client relationship.

Answer 65

B. Encourage the client to communicate their thoughts and feelings.

Question 66

Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (Select all that apply.) A. Use an open posture. B. Write down what the client says to avoid forgetting details. C. Establish and maintain eye contact. D. Nod in agreement with the client throughout the conversation. E. Sit facing the client.

Answer 66

A. Use an open posture. C. Establish and maintain eye contact. E. Sit facing the client.

Question 67

A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm. B. Sit at eye level with the child. C. Stand facing the child. D. Stand with a relaxed posture.

Answer 67

B. Sit at eye level with the child.

Question 68

A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.) A. "You will do great! You just have to get used it." B. "Why are you worried about going home?" C. "Your daily routines will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "It sounds like you are not sure how having a colostomy will affect swimming."

Answer 68

C. "Your daily routines will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "It sounds like you are not sure how having a colostomy will affect swimming."

Question 69

A nurse is providing information about age-related physical changes to the family member of an older adult. Which of the following information should the nurse include? A. Older adults have oilier skin than younger persons. B. Dry mouth is common for older adults. C. It is common for older adults to have increased perspiration. D. Hair in the eyebrows decreases.

Answer 69

B. Dry mouth is common for older adults.

Question 70

A nurse is providing instructions about foot care to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) A. Wear wool socks. B. Apply lotion between the toes. C. Wash the feet daily, using warm water. D. Warm the feet using a heating pad. E. Smooth the edges of the toenails with an emery board.

Answer 70

C. Wash the feet daily, using warm water. E. Smooth the edges of the toenails with an emery board.

Question 71

A nurse is providing denture care for a client. Which of the following actions should the nurse take? A. Using a gauze pad to grasp and pull forward and downward to remove the upper denture B. Storing the dentures overnight in a labeled denture cup filled with a solution of water and mouth wash C. After brushing the dentures, rinsing them in hot water D. Donning sterile gloves prior to performing denture care

Answer 71

A. Using a gauze pad to grasp and pull forward and downward to remove the upper denture

Question 72

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side. B. Place two fingers in the client's mouth to open it. C. Brush the client's teeth once per day. D. Inject a mouth rinse into the center of the client's mouth.

Answer 72

A. Turn the client's head to the side.

Question 73

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. The nurse should include that which of the following provides the body with the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates

Answer 73

D. Carbohydrates

Question 74

A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) A. Older adults are more prone to dehydration than younger adults. B. The recommended intake of daily fiber decreases in older adults. C. Many older adults need calcium supplementation. D. Older adults need more calories than they did when they were younger. E. Older adults should consume a diet low in carbohydrates.

Answer 74

A. Older adults are more prone to dehydration than younger adults. B. The recommended intake of daily fiber decreases in older adults. C. Many older adults need calcium supplementation.

Question 75

A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Giving the client thin liquids B. Instructing the client to tuck their chin when swallowing C. Having the client use a straw D. Encouraging the client to lie down and rest after meals

Answer 75

B. Instructing the client to tuck their chin when swallowing

Question 76

A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup

Answer 76

C. Vanilla custard

Question 77

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction

Answer 77

C. Pressure injury

Question 78

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) A. Instruct the client not to perform the Valsalva maneuver. B. Apply elastic stockings. C. Review laboratory values for total protein level. D. Place pillows under the client's knees and lower extremities. E. Assist the client to change positions often.

Answer 78

B. Apply elastic stockings. E. Assist the client to change positions often.

Question 79

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Place the cane 38 cm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane.

Answer 79

A. Hold the cane on the right side. B. Keep two points of support on the floor. D. After advancing the cane, move the weaker leg forward.

Question 80

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hr. B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake. D. Reposition the client every 4 hr.

Answer 80

A. Encourage the client to perform antiembolic exercises every 2 hr.

Question 81

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain. B. A client who has incisional pain 72 hr following pacemaker insertion. C. A client who has food poisoning and reports abdominal cramping. D. A client who has episodic back pain following a fall 2 years ago.

Answer 81

D. A client who has episodic back pain following a fall 2 years ago.

Question 82

A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply.) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

Answer 82

C. Bradypnea D. Orthostatic hypotension E. Nausea

Question 83

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button too much so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop while I am using this device." D. "I will ask my adult child to push the dose button when I am sleeping."

Answer 83

C. "I should tell the nurse if the pain doesn't stop while I am using this device."

Question 84

A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors

Answer 84

A. Presence of associated manifestations

Question 85

A nurse is assessing a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. Ask the client what precipitates the pain. B. Question the client about the location of the pain. C. Offer the client a pain scale to measure their pain. D. Use open-ended questions to identify the client's pain sensations.

Answer 85

C. Offer the client a pain scale to measure their pain.

Question 86

A nurse is teaching a client about performing a fecal occult blood test at home. Which of the following information should the nurse include? A. Do not eat red meat within one day of the test. B. One stool specimen is sufficient for testing. C. A red color change indicates a positive test. D. Ensure the specimen does not include urine.

Answer 86

D. Ensure the specimen does not include urine.

Question 87

A nurse is teaching a client who has recurrent UTis. Which of the following instructions should the nurse include? (Select all that apply.) A. Urinate after sexual intercourse. B. Drink at least 1L of fluid each day. C. Clean perineum from the front to back. D. Wear nylon undergarments. E. Avoid bubble baths.

Answer 87

A. Urinate after sexual intercourse. C. Clean perineum from the front to back. E. Avoid bubble baths.

Question 88

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? (Select all that apply.) A. Empty the client's urinary drainage bag when it is ¾ full. B. Keep the urinary drainage bag below the level of the client's bladder. C. Assess the client's need for the indwelling urinary catheter daily. D. Rest the urinary collection bag on the floor when the client is sitting in a chair. E. Maintain a closed system of the client's urinary catheter.

Answer 88

B. Keep the urinary drainage bag below the level of the client's bladder. C. Assess the client's need for the indwelling urinary catheter daily. E. Maintain a closed system of the client's urinary catheter.

Question 89

A nurse is preparing to initiate a bladder-retraining program for a client who has urge incontinence. Which of the following actions should the nurse take? (Select all that apply.) A. Restrict the client's intake of fluids during the daytime. B. Have the client record urination times. C. Gradually increase the time of the client's urination intervals. D. Remind the client to try to hold urine until the next scheduled urination time. E. Restrict the client's coffee intake to 2 servings each day.

Answer 89

B. Have the client record urination times. C. Gradually increase the time of the client's urination intervals. D. Remind the client to try to hold urine until the next scheduled urination time.

Question 90

A nurse is caring for a client who had a stroke and has aphasia. Which of the following actions should the nurse take to promote communication? (Select all that apply.) A. Make sure one person speaks to the client at a time. B. Let the client know if they are not understood. C. Allow time for the client to respond. D. Use long sentences when talking to the client. E. Speak loudly to the client.

Answer 90

A. Make sure one person speaks to the client at a time. B. Let the client know if they are not understood. C. Allow time for the client to respond.

Question 91

A nurse is reviewing instructions with a client who has a new prescription for hearing aids. Which of the following client statements indicates an understanding of the instructions? A. "I will clean the ear molds of my hearing aids with rubbing alcohol each day." B. "I will use hairspray to keep my hair away from my hearing aids." C. "I will take the batteries out of my hearing aids when I take them off at night." D. "I will soak my hearing aids in warm water once each week."

Answer 91

C. "I will take the batteries out of my hearing aids when I take them off at night."

Question 92

A nurse is teaching a client how to self-administer ear drops. Which of the following client statements indicates an understanding of the teaching? A. "I will pull my ear down and back before I insert the drops." B."I will gently apply pressure with my finger to the front part of my ear after putting in the drops." C. "I will chill my ear drops before I use them." D. "I will place a cotton ball into my inner ear canal after the drops are in."

Answer 92

B."I will gently apply pressure with my finger to the front part of my ear after putting in the drops."

Question 93

A nurse is teaching a newly licensed nurse who is caring for a client who is receiving enteral feedings, how to administer medications through a jejunostomy tube. Which of the following instructions should the nurse include? A. "Flush the tube before and after each medication." B. "Mix the medications with the enteral feeding." C. "Use a parenteral syringe to administer the medications." D. "Combine multiple medications together to administer at the same time."

Answer 93

B. "Mix the medications with the enteral feeding."

Question 94

A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? A. Use a 22-gauge needle. B. Select a site on the client's abdomen. C. Use the Z-track technique to displace the skin on the injection site. D. Observe for bleb formation to confirm proper placement.

Answer 94

B. Select a site on the client's abdomen.

Question 95

The nurse is reviewing the client's medical administration record and notes a prescription for docusate 100 mg PO once every day. The nurse should identify this as which of the following types of prescription? A. Single B. Stat C. Routine D. Now

Answer 95

C. Routine

Question 96

The nurse administers the wrong medication to the client. Which of the following actions should the nurse take first? A. Report the error to the facility's risk manager. B. Notify the provider. C. Complete an incident report. D. Check the client's vital signs.

Answer 96

D. Check the client's vital signs.

Question 97

A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication's anticholinergic effects. Which of the following instructions should the nurse include? (Select all that apply.) A. Take sips of water frequently. B. Wear sunglasses when outdoors in sunlight. C. Use a soft toothbrush when brushing teeth. D. Take the medication with an antacid. E. Urinate prior to taking the medication.

Answer 97

A. Take sips of water frequently. B. Wear sunglasses when outdoors in sunlight. E. Urinate prior to taking the medication.

Question 98

A nurse is preparing to administer diazepam to a client. Prior to administering the medication, which of the following actions is the nurse's priority? A. Teach the client about the purpose of the medication. B. Give the medication at the prescribed administration time. C. Identify the client's medication allergies. D. Document the client's anxiety level.

Answer 98

C. Identify the client's medication allergies.

Question 99

A nurse is teaching an older adult client about medication self-administration. Which of the following instructions should the nurse include? (Select all that apply.) A. Adjust doses to daily weight. B. Place pills in daily pill holders. C. Set up a daily calendar with medication reminders. D. Ask a relative to assist as needed. E. Request child-resistant caps on medication containers.

Answer 99

B. Place pills in daily pill holders. C. Set up a daily calendar with medication reminders. D. Ask a relative to assist as needed.

Question 100

A nurse is teaching a client who is lactating about taking medications. Which of the following instructions should the nurse include? A. Drink 8 oz of milk with each dose of medication. B. Use sustained-release medications. C. Take medications right after breastfeeding. D. Pump breast milk and freeze it prior to feeding.

Answer 100

C. Take medications right after breastfeeding.

Question 101

A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Hypertension

Answer 101

A. Restlessness B. Tachypnea D. Confusion E. Hypertension

Question 102

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares. B. Remove the nasal cannula during mealtimes. C. Check the position of the cannula frequently. D. Report any nausea or difficulty breathing. E. Post "No Smoking" signs in prominent locations.

Answer 102

C. Check the position of the cannula frequently. D. Report any nausea or difficulty breathing. E. Post "No Smoking" signs in prominent locations.

Question 103

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow. B. Assist the client to Fowler's position. C. Promote removal of pulmonary secretions. D. Obtain a specimen for arterial blood gases.

Answer 103

B. Assist the client to Fowler's position.

Question 104

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take wh providing tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpO decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer cannula surfaces in a circular motion from the stoma site outward D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder.

Answer 104

A. Apply the oxygen source loosely if the SpO decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer cannula surfaces in a circular motion from the stoma site outward

Question 105

The nurse is preparing to insert an NG tube on a client for stomach decompression. When determining the length of the tube to be inserted, what anatomical locations should the nurse use for measurement? (Select all that apply.) A. Tip of nose B. Abdomen C. Clavicle D. Earlobe E. Xyphoid process

Answer 105

A. Tip of nose D. Earlobe E. Xyphoid process

Question 106

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated."

Answer 106

B. "Flushing helps make sure the tube stays in place."

Question 107

A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been open. B. Verify the placement of the NG tube. C. Confirm that the client does not have diarrhea. D. Make sure the client is alert and oriented.

Answer 107

B. Verify the placement of the NG tube.

Question 108

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.) A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temperature. E. Discard any residual gastric contents.

Answer 108

A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate.

Question 109

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply.) A. Review a signal the client can use if feeling any distress. B. Lay a towel across the client's chest. C. Administer oral pain medication. D. Obtain a Dobhoff tube for insertion. E. Have a petroleum-based lubricant available.

Answer 109

A. Review a signal the client can use if feeling any distress. B. Lay a towel across the client's chest.

Question 110

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds. B. Stop the feeding. C. Obtain a chest x-ray. D. Initiate oxygen therapy.

Answer 110

B. Stop the feeding.

Question 111

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply.) A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with the hips and knees bent. E. Offer the client a warm beverage (herbal tea).

Answer 111

D. Position the client supine with the hips and knees bent.

Question 112

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply.) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst

Answer 112

A. Increase in incisional pain B. Fever and chills C. Reddened wound edges

Question 113

A nurse is caring for a 45-year-old client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply.) A. Age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound care

Answer 113

B. Chronic illness C. Low hemoglobin D. Malnutrition

Question 114

A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A. Keep the head of the bed elevated 30°. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client every 3 hr while in bed

Answer 114

A. Keep the head of the bed elevated 30°. D. Have the client sit on a gel cushion when in a chair.

Question 115

A nurse is reviewing the wound healing process with a group of newly licensed nurses. The nurse should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) A. Stage 3 pressure injury B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area

Answer 115

A. Stage 3 pressure injury E. Open burn area