Adult Health Nursing Final Exam
Course Introduction
Adult Health Nursing focuses on the comprehensive care of adult patients across diverse health settings, emphasizing the physiological, psychological, and sociocultural aspects influencing health and wellness. The course covers the application of the nursing process in managing acute and chronic health conditions, health promotion, disease prevention, and rehabilitation. Students will develop critical thinking and clinical decision-making skills necessary for effective nursing interventions, therapeutic communication, and collaboration within interdisciplinary healthcare teams. Practical experiences and evidence-based approaches are integrated to prepare students for providing holistic, patient-centered care to adults throughout the lifespan.
Recommended Textbook
Nursing A Concept Based Approach to Learning Volume I.II and III 1st Edition by Pearson Services
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Chapter 1: Acid-Base Balance
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Sample Questions
Q1) The nurse is caring for a client who is being mechanically ventilated. The current ventilator settings are: respiratory rate, 25 breaths per minute; tidal volume, 600 mL; FiO<sub>2</sub>, 30%; humidification 30 mg H<sub>2</sub>O/L. After being ventilated for 2 hours, arterial blood gas analysis reveals a pH of 7.20 and a PaCO<sub>2</sub> of 49 mmHg. Which change in ventilator settings should the nurse anticipate?
A)Increase in humidification of inspired air
B)Decrease of FiO<sub>2</sub> from 30% to 25%
C)Increased respiratory rate to 30 breaths per minute
D)Decreased tidal volume of each breath
Answer: C
Q2) A client with severe metabolic alkalosis is admitted to the unit. Which is the priority for the client?
A)Administering medication for metabolic alkalosis
B)Monitoring oxygen saturation
C)Teaching the client the risk factors for metabolic alkalosis
D)Setting goals for the client with metabolic alkalosis
Answer: B
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Page 3
Chapter 2: Cellular Regulation
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Sample Questions
Q1) A client prescribed tamoxifen (Nolvadex)for breast cancer treatment asks the nurse how the medication works. What is the best response by the nurse?
A)"Tamoxifen works by inhibiting the cellular mitosis of breast cancer."
B)"Tamoxifen works by blocking estrogen receptors on breast tissue."
C)"Tamoxifen works by binding to the DNA of breast cancer cells."
D)"Tamoxifen works by inhibiting the metabolism of breast cancer cells."
Answer: B
Q2) The nurse is preparing to perform a health assessment on an adult client who has a family history of cancer. Which questions should the nurse ask the client to assess for the early warning signs of cancer? Select all that apply.
A)"Do you have a cough that is associated with seasonal allergies?"
B)"Have you noticed a change in your appetite?"
C)"Have you noticed any cuts that have not healed?"
D)"Have you had any changes in bowel or bladder habits?"
E)"Have you experienced any problems swallowing?"
Answer: C, D, E
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4
Chapter 3: Comfort
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Sample Questions
Q1) What word best describes the pain a client experiences at the end of life?
A)Unmanageable
B)Unpredictable
C)Inevitable
D)Acute
Answer: C
Q2) A client reports feeling tired and not refreshed after sleeping. The client also tells the nurse that family members have been making comments about the client's loud snoring at night. What should the nurse suspect as being the cause of this client's fatigue?
A)Insomnia
B)Depression
C)Thyroid disorder
D)Sleep apnea
Answer: D
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Chapter 4: Digestion
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Sample Questions
Q1) A home healthcare nurse is providing care to an older adult client who lives alone and has limited financial resources. The client has a history of celiac disease. When planning care for this client, which nursing diagnoses are appropriate? Select all that apply.
A)Risk for Constipation
B)Imbalanced Nutrition: Less than Body Requirements
C)Risk for Imbalanced Fluid Volume
D)Diarrhea
E)Chronic Pain
Q2) The nurse is providing care to a client diagnosed with celiac disease who experiences frequent diarrhea. Based on this data, the nurse anticipates the client may also experience which associated problems? Select all that apply.
A)Skin breakdown
B)Fluid and electrolyte imbalance
C)Hair loss
D)Lifestyle issues
E)Sexual dysfunction
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Chapter 5: Elimination
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Sample Questions
Q1) The nurse on the medical unit is admitting an older adult client whose primary symptoms include fatigue, pruritus, and pain in the right flank area. When conducting this client's assessment, which technique is the least appropriate?
A)Palpation over the costovertebral angles and flanks
B)Blunt percussion over the costovertebral angles and flanks
C)Palpation of the lower pole of both kidneys
D)Capturing of both kidneys
Q2) The nurse is caring for an older adult client. The client tells the nurse that he is constipated. What is the nurse's initial action?
A)Encourage the client to increase fluid intake and activity.
B)Assess the client's intake of fiber and fluids.
C)Determine what the client means by constipation.
D)Obtain an order for a laxative and an enema from the physician.
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Chapter 6: Fluids and Electrolytes
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Q1) The nurse is reviewing laboratory values for a female client suspected of having a fluid imbalance. Which laboratory value should indicate a diagnosis of dehydration to the nurse?
A)Serum osmolality 230 mOsm/kg
B)Hematocrit 30%
C)Hematocrit 53%
D)Serum potassium 3.8 mEq/L
Q2) An older adult client is brought to the emergency department. The client has been experiencing fever, nausea, and vomiting for the past 2 days. The client denies thirst.
Urine dipstick indicates a decreased urine specific gravity. Based on this data, which diagnosis should the nurse most anticipate for this client?
A)Congestive heart failure
B)Dehydration
C)Fluid overload
D)Normal changes of aging
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8
Chapter 7: Health Wellness and Illness
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Sample Questions
Q1) The nurse is assessing a 24-year-old woman who recently found out she is pregnant. Which factor would the nurse identify as the most likely source of a barrier to health promotion in this client?
A)Age of the client
B)Presence of the client's mother during the appointment
C)Pregnancy occurred as a result of rape
D)First pregnancy (primigravida)
Q2) A nurse is providing wellness teaching to a client who is interested in beginning an exercise program to reduce certain health risks. The nurse determines that the client understands the teaching when the client selects which health risks that can be reduced by regular exercise? Select all that apply.
A)Liver disease
B)Type 2 diabetes
C)Cardiovascular disease
D)Falling
E)Renal disease
Q3) A nurse is caring for a 50-year-old client performing aerobic exercise in the cardiac rehabilitation office. The nurse calculates the client's target heart rate as ________-________.
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Page 9
Chapter 8: Immunity
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Sample Questions
Q1) The nurse is collecting a health history for a client being seen in an outpatient clinic who complains of joint pain and swelling that have lasted for about 2 months. The client is diagnosed with rheumatoid arthritis (RA). Which of the following statements made by this client supports the nursing diagnosis of Activity Intolerance?
A)"I seem to get tired early in the day and require a nap."
B)"My joints are stiffest at night before I go to sleep."
C)"I find it difficult to move when I first get up in the morning."
D)"I take ibuprofen for the pain as needed."
Q2) A nurse is caring for a client with systemic lupus erythematosus (SLE)who is prescribed immunosuppressive therapy. When providing teaching for this client, which statements are appropriate for the nurse to include? Select all that apply.
A)"Avoid large crowds and situations that increase your exposure to infection."
B)"Report any cough or difficulty breathing to the physician if you are taking cyclophosphamide."
C)"Use aspirin instead of acetaminophen if you develop a fever."
D)"Heavy menstrual bleeding may occur during therapy."
E)"Be sure to drink plenty of liquids."
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Chapter 9: Infection
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Sample Questions
Q1) Which agent can be used to destroy pathogens other than spores?
A)Antiseptic
B)Disinfectant
C)Sterilizing agent
D)Isolating agent
Q2) The nurse is teaching a class on infection control. Which nursing measure is most appropriate in breaking a link in the chain of infection?
A)Place contaminated linens in a paper bag.
B)Use personal protective equipment (PPE).
C)Cover one's cough by placing the mouth in the hand.
D)Wear sterile gloves for client care.
Q3) Which oral antiviral drug that is commonly prescribed for influenza A and B works by preventing the release of newly formed virus?
A)Rimantadine (Flumadine)
B)Zanamivir (Relenza)
C)Oseltamivir (Tamiflu)
D)Amantadine (Symmetrel)
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Chapter 10: Inflammation
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Sample Questions
Q1) A client is admitted to the hospital with an elevated temperature, nausea, and pain and tenderness in the lower right quadrant of the abdomen. After receiving pain medication, the client continues to complain of pain at a level of 8 on a 0-10 pain scale. The client is not scheduled to receive pain medications for at least another 2 hours. Given these circumstances, which statement by the nurse is most appropriate?
A)"I will inform the healthcare provider about your continued pain."
B)"I do not have any medications ordered for you at this time."
C)"Try to rest for a while longer until it is time to receive your medication"
D)"Let's try a heating pad or warm blanket to see if that helps with your discomfort."
Q2) A client with acute abdominal pain is scheduled for an appendectomy in 3 hours. While waiting for the surgery, the client reports that the pain has subsided. In this scenario, what is the priority action by the nurse?
A)Determine when the client can be medicated for pain.
B)Contact the surgery department.
C)Contact the healthcare provider.
D)Notify the nursing supervisor.
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Page 12
Chapter 11: Intracranial Regulation
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Sample Questions
Q1) An older adult client is experiencing a tonic-clonic (grand mal)seizure exceeding 10 minutes in length. Which medication should the nurse prepare to administer to this client?
A)Intramuscular injection of diazepam
B)Intramuscular injection of phenytoin
C)Intravenous diazepam slowly over several minutes
D)Oral administration of gabapentin
Q2) Which of the following is characteristic of triggers for seizures?
A)They are externalized.
B)They are generalized.
C)They are internalized.
D)They are variable.
Q3) The nurse is planning care for an older adult client with a head injury secondary to a motor vehicle crash. Which information should the nurse keep in mind when planning this client's care? Select all that apply.
A)Anxiety, illness, and pain can alter the ability to learn.
B)Baseline reflexes may be slower or diminished.
C)Impulse transmission and reactions to stimuli are slower.
D)Neurologic assessment should be completed in a single session.
E)Impairment in vision and hearing should be taken into consideration.
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Chapter 12: Metabolism
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Sample Questions
Q1) The nurse is caring for a client recovering from a liver transplant necessitated by cirrhosis of the liver. Which postoperative outcome would be a priority for this client?
A)Moist membranes of the mouth
B)Normal serum bilirubin levels
C)Ability to move the legs
D)Normal pupil reaction
Q2) The nurse is reviewing the laboratory test results for a client with an endocrine disorder. Which diagnostic tests would the nurse anticipate reviewing for this client? Select all that apply.
A)Prothrombin time
B)Serum albumin
C)Ammonia level
D)Liver enzymes
E)T<sub>3</sub> and T<sub>4</sub> levels
Q3) Which client is at the greatest risk for developing hypothyroidism?
A)A 21-year-old woman who has a mother with Graves disease
B)A 32-year-old man who has an uncle with type 1 diabetes mellitus
C)A 57-year-old woman whose aunt had systemic lupus erythematosus
D)A 72-year-old man whose father had cardiovascular disease
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Page 14
Chapter 13: Mobility
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Sample Questions
Q1) The first day after surgery to repair a fractured hip sustained from a fall, an older adult client refuses to ambulate but states, "I will consider it tomorrow." In this situation, which is the priority action by the nurse?
A)Coordinate personnel to assist with ambulation
B)Document the client's refusal
C)Assess why the client is refusing to ambulate
D)Notify the healthcare provider
Q2) A client who sustained a cervical neck injury 2 days ago is demonstrating an irregular respiratory pattern with a rate of 8-10 breaths per minute. Based on this data, which is the priority nursing diagnosis?
A)Impaired Physical Mobility
B)Autonomic Dysreflexia
C)Ineffective Breathing Pattern
D)Impaired Gas Exchange
Q3) The cells that produce the matrix for bone formation are known as
A)osteoclasts.
B)sarcomeres.
C)osteoblasts.
D)epiphyseal plates.
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Page 15
Chapter 14: Nutrition
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Sample Questions
Q1) The community health nurse reviews data collected during interviews with community members during a health fair and decides to create a brochure on how to improve iron intake. Which of the following action items might the nurse include that would help vegans and vegetarians increase their iron intake? Select all that apply.
A)Take calcium supplements.
B)Consume tofu.
C)Consume lentils.
D)Increase intake of vitamin C.
E)Consume Swiss chard.
Q2) The nurse is assessing the nutritional status of an older client. Which finding is most likely to suggest xerostomia?
A)The client refuses food because it is difficult to chew with missing teeth.
B)The client frequently becomes dehydrated due to failure to remember to drink water.
C)The client has a chronically dry mouth despite adequate intake of fluids.
D)The client does not enjoy foods due to diminished taste.
Q3) The nurse is performing a nutritional assessment of a client who weighs 185 lb and is 5 feet, 3 inches tall. This client's body mass index, rounded to the nearest hundredth, is
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Page 16
Chapter 15: Oxygenation
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Sample Questions
Q1) A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which intervention is appropriate to decrease an infant's risk for SIDS?
A)Using firm bedding
B)Ensuring the room temperature is at least 80°F at all times
C)Recommending bed sharing
D)Placing the infant in a prone position for sleeping
Q2) The nurse is caring for a woman who is 32 weeks pregnant and requires mechanical ventilation for ARDS. In addition to standard nursing interventions for adult clients with ARDS, what special interventions need to be implemented for this client?
A)Inducing labor
B)Administering nitric oxide and corticosteroids
C)Providing nutritional support
D)Fetal monitoring
Q3) The client with ARDS who is likely to have the poorest outcome is
A)a Hispanic male with pneumonia.
B)an African American male with sepsis.
C)a Caucasian female with sepsis.
D)an African American female with chest trauma.
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17
Chapter 16: Perfusion
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Sample Questions
Q1) Which nursing intervention related to perfusion can be performed independently?
A)Administration of drug regimens
B)Insertion of device to measure central venous pressure (CVP)
C)Teaching relaxation techniques
D)Thoracentesis
Q2) The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse?
A)Blood pressure of 142/92 mmHg
B)Pulse of 92 beats per minute
C)Respiratory rate of 24 per minute
D)Weight gain of 16 oz per week
Q3) While completing a health history with an older adult client, the nurse learns that the client experienced a transient ischemic attack (TIA)several months ago. The nurse should recognize that:
A)the client is at risk for an ischemic thrombotic stroke.
B)the client will have minimal symptoms should a stroke occur.
C)the client will not experience a stroke in the future.
D)the client is at high risk for a hemorrhagic stroke.
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Chapter 17: Perioperative Care
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Sample Questions
Q1) While receiving report from the operating room, the nurse learns that a client's surgical wound after gallbladder removal is classified as III. What does this classification tell the nurse? Select all that apply.
A)The alimentary tract was not entered.
B)The wound is necrotic and infected.
C)Gallbladder contents spilled into the surgical site.
D)A break in sterility occurred during the surgery.
E)The alimentary, respiratory, genital, or urinary tract was entered.
Q2) The nurse is providing teaching to a client who is scheduled to undergo surgery in 2 weeks. Which topics should the nurse include that will prepare the client to help reduce complications during the postoperative phase? Select all that apply.
A)Maintaining a patent airway
B)Deep breathing and coughing
C)Caring for the surgical incision
D)Managing constipation
E)Managing pain
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Chapter 18: Sensory Perception
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Q1) The nurse is caring for a client who recently sustained a blow to the head. Which of the following assessment findings suggest that the client should be more closely evaluated for retinal detachment?
A)Eye pain and redness
B)Floaters in the visual field
C)Subconjunctival hemorrhage
D)Hyphema
Q2) The nurse is providing client teaching on Guillain-Barré syndrome. Which explanation for a client's false perception that socks are being worn is accurate?
A)Confusion is a part of this disorder, so the client is simply confused as to whether socks are being worn.
B)This disorder causes a change in sensation that makes the client feel as if socks are being worn.
C)The medications used to treat this disorder cause the client to feel as if socks are being worn.
D)Tactile hallucinations are part of this disorder, so the client is hallucinating that socks are present.
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Chapter 19: Sexuality
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Sample Questions
Q1) During a health history, the nurse learns that a male client has a recent onset of erectile dysfunction (ED). Which assessment question is likely to elicit the most useful information about factors that may be contributing to the client's ED?
A)"Does this occur often?"
B)"For what diseases and disorders have you been treated?"
C)"Are you on any medications?"
D)"How does your partner feel about this problem?"
Q2) A client who gave birth 10 weeks ago via cesarean section tells the nurse that she is having difficulty resuming sexual relations with her husband. She reports both reduced desire for sex and pain upon penetration. What is the nurse's best response to this client?
A)"Are you breastfeeding? If so, switching to formula will help resolve these issues."
B)"Most women don't report these sorts of problems unless they've delivered vaginally."
C)"These problems are common during the postpartum period and usually resolve with time."
D)"Based on the symptoms you're reporting, I'm concerned you might be experiencing a postpartum mood disorder."
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Chapter 20: Thermoregulation
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Sample Questions
Q1) During an assessment, the nurse notes that a client who was a victim of an industrial accident has a mildly elevated body temperature. When discussing the client's increased temperature, which will the nurse attribute it to?
A)Infection
B)Diet
C)Exercise
D)Stress
Q2) A nurse is caring for a client with hypothermia and frostbite of the nose and fingers. Which action by the nurse is inappropriate for this client?
A)Massage frostbite areas to rewarm them and increase circulation.
B)Rapidly rewarm affected areas in circulating warm water.
C)Keep the client on bedrest with the affected parts elevated.
D)Debride blisters.
Q3) Which hormone is responsible for epinephrine release and thus chemical thermogenesis?
A)Norepinephrine
B)Thyroxine
C)Progesterone
D)Aldosterone
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Chapter 21: Tissue Integrity
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Sample Questions
Q1) Softening of the skin as a result of prolonged wetting or soaking is also referred to as A)maceration.
B)debridement.
C)excoriation.
D)shearing.
Q2) The nurse is planning care for a client in the acute stage of a burn injury. Which aspects of care should the nurse identify as a priority? Select all that apply.
A)Nutrition
B)Psychosocial support
C)Pain management
D)Fluid resuscitation
E)Wound care
Q3) What impact might corticosteroids have on tissue integrity?
A)It may increase sensitivity to sunlight, leading to sunburns.
B)It may cause thinning of the skin, making skin more easily injured.
C)It may make skin appear shiny and lose its hair distribution.
D)It may cause the skin to become overly dry.
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23
Chapter 22: Addiction
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Q1) A pregnant client tells the nurse that she and her husband are going to a 50th wedding anniversary party for her grandparents this weekend. The client asks the nurse if it will be okay for her to have a few glasses of wine at the party. Which response by the nurse is appropriate?
A)"Drinking a few glasses of wine will not be a problem."
B)"Consuming alcohol during pregnancy can cause the baby to be born without limbs."
C)"Drinking any alcoholic beverages of any type during pregnancy puts your baby at risk for injury."
D)"Wine is acceptable but not hard liquor."
Q2) A client who is attending a Narcotics Anonymous (NA)program asks the nurse what the most important initial goal of attending the meetings is. How should the nurse respond?
A)"The most important initial goal is to admit that you have a problem."
B)"The most important initial goal is to learn problem-solving skills."
C)"The most important initial goal is to take a personal moral inventory."
D)"The most important initial goal is to make amends to people you have hurt."
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Chapter 23: Cognition
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Q1) The nurse is reviewing pharmacologic treatments with a caregiver of an individual with Alzheimer disease. Which statement indicates that teaching has been effective?
A)"There are effective drugs, but they cannot be used over a long period."
B)"There aren't any drugs that are effective in treating this disease."
C)"The earlier the drugs are started, the greater the likelihood they will have benefits."
D)"There are drugs that can control symptoms for many years."
Q2) Which is true regarding the aging process and cognition?
A)Generally, older adults' short-term memory changes significantly.
B)Generally, many older adults have increased difficulty finding and rapidly listing words.
C)The ability to use and understand word combinations declines steadily with age.
D)The ability to acquire practical information declines steadily with age.
Q3) Damage to which region of the brain may result in loss of recent memory?
A)Neuron
B)Hippocampus
C)Cerebrum
D)Neurotransmitter
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Chapter 24: Culture and Diversity
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Q1) The clinic nurse is caring for an infant during a routine wellness exam. The parents and infant immigrated to the United States 6 months ago. The mother explains that she believes that an herbal remedy is the best way to treat the infant's colic. Which action by the nurse is appropriate?
A)Ask the mother what the ingredients are in the remedy.
B)Give the mother an alternate remedy for colic.
C)Explain how herbal ingredients may be harmful to the infant.
D)Tell the mother not to use the remedy because there is no way to know what the ingredients' scientific effect may be.
Q2) The nurse is reviewing the discharge instructions for administration of home medications with an older adult client. In considering the normal changes experienced with aging when developing a teaching plan for this client, what type of bias should the nurse be careful to avoid?
A)Relativism
B)Fundamentalism
C)Ageism
D)Multiculturalism
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Chapter 25: Development
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Q1) A nurse is assessing a child who shows marked abnormalities in speech patterns. These includes using you in place of I, parroting words and phrases, and repeating questions rather than answering them. The nurse should recognize that these are characteristic of which condition?
A)Cerebral palsy
B)Autism spectrum disorder
C)Attention-deficit/hyperactivity disorder (ADHD)
D)Failure to thrive
Q2) The nurse is assessing a child who was last seen in the clinic 2 years earlier. Which of the following should the nurse anticipate as having remained relatively stable over time?
A)The child's behavior
B)The child's physical characteristics
C)The child's temperament
D)The child's home environment
Q3) What does a nonorganic cause of failure to thrive (FTT)mean?
A)The FTT is not the result of a disease process or medical condition.
B)The FTT is the result of inborn errors in metabolism.
C)The FTT is the result of congenital disease.
D)The FTT is the result of a congenital anomaly such as cleft palate.
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Page 27
Chapter 26: Family
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Q1) The nurse is caring for a client who was involved in a car accident. The client's spouse was killed in the accident. The couple has two teenage children. Which statement explains how this tragedy will be approached by the family?
A)The family feels that their place in the community has been eliminated.
B)Family members may become detached from extended family.
C)Family disorganization may occur.
D)The family may withdraw into seclusion during the grief process.
Q2) A cohesive nuclear family has one kindergarten-aged child. The mother works from home and is the primary caregiver for the child. The father is required to travel a lot for work. Currently, the father is on an out-of-town project that will last for 6 months. He is home on the weekends, but gone the rest of the week. The nurse understands that family cohesion in this family is likely to become:
A)disengaged triadic between all three members.
B)cohesive dyadic between the mother and father.
C)cohesive dyadic between the mother and child.
D)cohesive triadic between all three members.
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Chapter 27: Grief and Loss
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Q1) The nurse recognizes that the spouse of a terminally ill client has completed the grieving process, but the ill client is still alive. Because of this, the nurse may need to provide what interventions for the ill client?
A)Interventions to prevent physical and spiritual distress of the spouse
B)Interventions to prevent despair in other family members
C)Interventions to prevent guilt in the client
D)Interventions to prevent isolation and loneliness for the client
Q2) The nurse is planning care for a group of clients who are experiencing grief. Which principle from accepted grief models should the nurse use to guide care?
A)No clear timetables for grief exist, nor are there clear-cut stages of grief.
B)There is strong research evidence indicating that these models are not useful for many dying clients.
C)These models serve as clear and definitive predictors of grief behaviors.
D)The Kübler-Ross model is primarily used to describe anticipatory grief.
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Chapter 28: Mood and Effect
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Sample Questions
Q1) An adolescent client hospitalized with asphyxiation following a suicide attempt tells the nurse, "I know other kids have the same problems I do, but I just wanted to make it stop." Which action by the nurse is the most appropriate?
A)Discuss the client's attendance at school and what activities are enjoyed.
B)Suggest the client listen to music and read a light novel to reduce stress.
C)Ask if the client would like to talk about stressors and problems.
D)Ask what is so devastating that the client needed to commit suicide.
Q2) The nurse is caring for a client with bipolar disorder who has expressed the desire to harm self. What is the priority nursing diagnosis for this client?
A)Powerlessness
B)Impaired Social Interaction
C)Risk for Suicide
D)Social Isolation
Q3) Which intervention is a primary prevention strategy for depression?
A)Regular screening for depression
B)Provide education about stress management
C)Counseling clients about their risk for mood disorders
D)Developing community-based mental health programs
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Chapter 29: Self
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Sample Questions
Q1) A student nurse is asked to recall the questions included in the SCOFF questionnaire. Which questions identified by the student nurse are appropriate? Select all that apply.
A)Do you believe yourself to be fat when others say you are too thin?
B)Would you say that food dominates your life?
C)Do you worry you have lost control over how much you eat?
D)Do you make yourself sick because you feel uncomfortably full?
E)Have you recently lost more than 1 pound in a 3-month period?
Q2) A client tells the nurse that he feels pressure to spend every Sunday with his parents. However, the client's wife does not participate and stays at home waiting for the client to return. Which of the following elements is determining the client's self-concept?
A)Family and culture
B)History of successes and failures
C)Stressors
D)Resources
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Chapter 30: Spirituality
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Sample Questions
Q1) The nurse is caring for a devout Muslim client who is near death. The nurse should be prepared for which request from the client related to religious beliefs?
A)Turn the client's head or body toward Mecca.
B)Have a spiritual leader perform the Anointing of the Sick.
C)Read the client the Tibetan Book of the Dead.
D)Perform a ritualistic bath for cleansing the body.
Q2) The nurse is caring for a client who is actively engaged in an organized religion. Based on this statement, the nurse knows that which of the following statements is most likely true?
A)The client believes in the presence of only one god.
B)The client knows other individuals from the same religion who may be available to offer emotional and spiritual support.
C)The client lives by the moral code of the Ten Commandments.
D)The client will require time set aside for prayer several times each day, and the nurse will need to work around this schedule.
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Chapter 31: Stress and Coping
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Sample Questions
Q1) What important fact should the nurse relay to the young adult who was just diagnosed with obsessive-compulsive disorder?
A)Not acting on compulsions is the best cure.
B)Treatment is essential to remission.
C)Recognizing the obsessions as false will lessen their impact.
D)The disorder will gradually get better over time.
Q2) A client states to the nurse that learning how to use the blood glucose machine will have to wait until holiday events are planned. Which cognitive indication of stress is the client demonstrating?
A)Problem solving
B)Suppression
C)Self-control
D)Cognitive structuring
Q3) When caring for a client newly diagnosed with obsessive-compulsive disorder, which action by the nurse is appropriate?
A)Do not interrupt the ritual.
B)Interrupt the ritual.
C)Teach about antianxiety foods.
D)Teach ritual interruption skills.
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Chapter 32: Trauma
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Sample Questions
Q1) A client is admitted with injuries sustained from a domestic dispute. When planning care, the nurse will include which short-term interventions? Select all that apply.
A)Explore options for self-development.
B)Improve quality of life by increasing self-esteem.
C)Explore options for help.
D)Convey safety.
E)Determine immediacy of danger.
Q2) The nurse is planning care for a client with multiple lower extremity fractures sustained from a motor vehicle crash. Which is an appropriate client goal for the nurse to include in the plan of care?
A)The client will have adequate urine output.
B)The client will regain mobility.
C)The client will participate in self-care activities.
D)The client will be discharged to home.
Q3) Which individual has the highest risk of developing PTSD?
A)Victim of assault
B)Natural disaster survivor
C)Motor vehicle crash survivor
D)Military veteran
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Page 34
Chapter 33: The Concept of Reproduction
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Sample Questions
Q1) A nurse is caring for the 1-hour-old newborn of a mother with diabetes mellitus. Which actions will the nurse include in the newborn's plan of care? Select all that apply.
A)Assess blood glucose frequently.
B)Assess for SGA.
C)Assess for hyperthyroidism.
D)Assess the newborn's temperature hourly.
E)Assess for hyperbilirubinemia.
Q2) The nurse is preparing to provide an enteral feeding to a preterm infant. Which is the priority nursing action prior to administering the feeding?
A)Weigh the current diaper.
B)Measure abdominal girth.
C)Weigh the baby.
D)Measure pulse oximetry.
Q3) During which phase of the ovulatory cycle does the ovum get fertilized?
A)Follicular phase
B)Luteal phase
C)Proliferative phase
D)Secretory phase
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Chapter 34: Assessment
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Sample Questions
Q1) An adult client and her spouse are seen in an urgent care clinic. The client presents with a temperature of 102°F, complains of nausea, and has experienced vomiting and diarrhea for 12 hours. The nurse notes that the client's mucous membranes are pale and dry and suspects that the client is dehydrated. Which action by the nurse is the most appropriate?
A)Ask the spouse for more information.
B)Assess for pedal edema.
C)Assess skin turgor.
D)Repeat the temperature measurement.
Q2) The nurse is assessing an older adult client during a routine health maintenance visit. To assess the client's range of motion of the knees, which action by the nurse is appropriate?
A)Seat the client and extend each knee until the client alerts the nurse of severe pain.
B)Seat the client and extend each knee until the client alerts the nurse of any pain whatsoever.
C)Place the client prone and gently lift the entire right leg, followed by the entire left leg.
D)Have the client stand and extend each knee as far as it will go.
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Chapter 35: Caring Interventions
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Sample Questions
Q1) In holistic nursing, the nurse should emphasize the client's personal responsibility in maintaining health. This idea is most closely related to which concept in caring interventions?
A)Nursing presence
B)Empowerment
C)Compassion
D)Competence
Q2) The family members of a recently deceased client wrote a letter to the unit manager, expressing their appreciation for the way the client was treated while dying in the hospital. The family mentioned characteristics that indicate the nurses were caring. What behaviors did the family most likely use to explain the caring actions of the nurses?
Select all that apply.
A)Delivered care with style
B)Treated the client as a human being
C)Respected the client
D)Maintained client confidentiality
E)Established limits with the client
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Chapter 36: Clinical Decision Making
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Sample Questions
Q1) The nurse is caring for an older school-age client who is sleeping when the menu choices for dinner are brought to the room. Which intervention should the nurse use to meet the dietary needs of this client?
A)Wake the child to choose a meal for dinner.
B)Order chicken nuggets because most children like this meal.
C)Ask the dietary worker to come back later.
D)Ask the parents to bring dinner from home for the client.
Q2) After receiving the morning report, the nurse prioritizes care needed by several clients. Which factors should the nurse keep in mind when creating this priority list?
Select all that apply.
A)Client condition
B)Safety
C)Time available
D)Client preferences
E)Nurse preferences
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Chapter 37: Collaboration
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Sample Questions
Q1) Which of the following individuals would be included on an interdisciplinary healthcare team but not on an interprofessional healthcare team?
A)Nurse practitioner
B)Laboratory technologist
C)Pharmacist
D)Physical therapist
Q2) A home healthcare nurse is planning care for an older adult client. Which interdisciplinary program would best support the needs of an older adult client within the community? Select all that apply.
A)Assertive community treatment (ACT)
B)YMCA
C)Programs of All-Inclusive Care for the Elderly (PACE)
D)Outpatient clinic
E)Meals on Wheels
Q3) Which of the following is an example of covert conflict?
A)Complaining to a friend about an assigned job task
B)Yelling at a coworker who has insulted another coworker
C)Telling a manager that you think she is being unnecessarily harsh
D)Warning a client that inappropriate contact and comments will not be tolerated
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Page 39
Chapter 38: Communication
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Sample Questions
Q1) The nurse is caring for a school-age client who is scheduled to have major heart surgery the next morning. The nurse enters the room to administer a medication and finds the client crying. Which response by the nurse is most therapeutic?
A)"Would you like some toys from the playroom?"
B)"I'm going to go get the doctor."
C)"You shouldn't cry. You are not in pain."
D)"It is okay to cry. I know this is scary."
Q2) Handoff communication, or the transfer of data during transitions in care, includes an opportunity to ask questions, clarify, and confirm the information being passed between sender and receiver. What is the main objective for ensuring effective communication during a client handoff?
A)To avoid lawsuits
B)To make sure all documentation is complete
C)To facilitate quality improvement
D)To ensure client safety
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Chapter 39: Managing Care
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Sample Questions
Q1) The nursing supervisor is asked to help manage the switch from paper to electronic records. Which standard managerial steps will the nursing supervisor take to initiate this process? Select all that apply.
A)Planning
B)Experimenting
C)Organizing
D)Criticizing
E)Synthesizing
Q2) The nurse is caring for several medical-surgical clients. The nurse has delegated skin care of an incontinent client to new unlicensed assistive personnel (UAP)on the unit. Which action by the nurse will improve effectiveness of the client care provided?
A)Ask the client if the care was appropriate.
B)Ask the UAP if the care was given.
C)Demonstrate the appropriate care needed and have the UAP give a return demonstration.
D)Closely observe the UAP each time the care is given.
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Chapter 40: Professional Behaviors
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Sample Questions
Q1) A nurse is always on time, neat in appearance, and caring toward clients. Which statement best characterizes this nurse's level of professional commitment?
A)The nurse is demonstrating a pattern of behaviors congruent with nursing's professional code of ethics.
B)The nurse is demonstrating a strong belief in and acceptance of the unit's goals, values, and morals.
C)The nurse is demonstrating a willingness to exert control over personal behaviors.
D)The nurse is demonstrating a strong desire to be part of a group.
Q2) A hospital's nursing staff is deciding whether to unionize. The hospital CFO tells a nurse supervisor to make sure all leaders of the unionization effort are scheduled for client care during union meetings. Which actions by the nurse supervisor are appropriate? Select all that apply.
A)Schedule the organizers for client care during union meeting times.
B)Schedule the organizers for client care according to clinical staffing needs.
C)Reprimand the staff nurses for their attempts to unionize.
D)Continue to implement the usual staffing procedures.
E)Discuss the need for professional nursing integrity with the CFO.
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Page 42
Chapter 41: Teaching and Learning
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Sample Questions
Q1) A nursing student has been assigned to present a teaching project to the class, using each of Bloom's taxonomy domains. The student has planned several activities to include when presenting the project to the class. Which activities are within the affective domain? Select all that apply.
A)Class members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class.
B)Class members must list the technical skills they have learned.
C)Class members must demonstrate a favorite nursing skill for the class.
D)Class members must reflect on how they felt the first time they provided direct client care.
E)Class members must identify two attitudinal changes that have occurred in their lives since beginning their nursing education.
Q2) Which theory of learning holds that knowledge acquisition is the ongoing assimilation and accommodation of new experiences and interpretations?
A)Constructivist
B)Behaviorist
C)Social learning
D)Cognitive
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Chapter 42: Accountability
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Sample Questions
Q1) A nurse obtains certification to provide direct client care, educate others, consult, conduct research, and manage oncology care. Which expanded nursing role best describes this nurse's career position?
A)Nurse anesthetist
B)Clinical nurse specialist
C)Nurse educator
D)Nurse researcher
Q2) A nurse educator is teaching a group of students about professionalism. The educator informs the students that a profession is distinguished from other kinds of occupations by a number of characteristics. Which of the following are among those characteristics? Select all that apply.
A)The members of a profession are financially liable for their actions.
B)The members of a profession participate in ongoing research.
C)The members of a profession must acquire specialized education.
D)The members of a profession possess autonomy.
E)The members of a profession regularly socialize with one another.
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Chapter 43: Advocacy
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Sample Questions
Q1) The nurse notices that there is broken equipment on the playground in a neighborhood where care is provided to low-income residents. The nurse tries unsuccessfully to get the owner to address this safety issue. Which additional action is most consistent with the role of the nurse as a public advocate?
A)Write an article in the local newspaper to gain public attention.
B)No action is required; this is a civil problem beyond the realm of the nurse.
C)Call the police to report the owner's neglect.
D)Tell the parents they should not pay their rent until the playground is fixed.
Q2) An older adult client with metastasized breast cancer informs the nurse that her doctor is insisting that she participate in a course of chemotherapy, even though the client does not want to have any further treatment. Which actions by the nurse exemplify advocacy for this client? Select all that apply.
A)Tell the client that it is in her best interest to follow the doctor's advice.
B)Inform the doctor about the client's clear wishes not to have further chemotherapy.
C)Ascertain whether or not the client has an advance care directive and, if not, assist her in creating one.
D)Discuss the implications of various choices with the client.
E)Avoid interfering in the doctor-client relationship.
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Chapter 44: Ethics
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Sample Questions
Q1) The nurse performing an admission assessment on a client must inform the client of client rights and responsibilities. Which client rights are considered standard by many healthcare agencies? Select all that apply.
A)You have a right to be informed about the care you receive.
B)You have the right to safe care.
C)You have the right to be treated with courtesy and respect.
D)You have the right to be listened to.
E)You have the right to be appointed a personal advocate by the healthcare provider.
Q2) The nurse is talking with a parent who decides to decline treatment for a 3-year-old client whose cancer has metastasized. There is a conflict between the parents and the rest of the family regarding the withdrawal of care from the child. Which should the nurse consider when determining the appropriate action for this client?
A)The beliefs of the child
B)The values of the parents
C)The age of the child
D)The values of the rest of the family
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Chapter 45: Evidence-Based Practice
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Sample Questions
Q1) A nurse is preparing to conduct a research study and wants to do a literature search for relevant articles. Which of the following sections should the nurse expect to find in each search result? Select all that apply.
A)Abstract
B)Methods
C)Funding
D)Results
E)References
Q2) A nurse educator is interacting with a group of nurses who are working toward their graduate degrees. The members of the group are interested in replication studies. Which of the following replication studies would be most appropriate given the changing demographics in the United States?
A)A study examining the ability of families to adapt to acute health problems
B)A study examining how effective use of supplies affects the cost of care
C)A study examining the ability of an aging population to care for itself
D)A study examining how new technology affects client care
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Chapter 46: Healthcare Systems
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Sample Questions
Q1) A nurse is planning a community health fair at a local community center. Which goals regarding health promotion does the nurse plan to highlight at the event? Select all that apply.
A)The ability to change and modify goals as health needs change
B)The ability for clients to be able to assess and evaluate their health needs
C)The ability for the client to promote health in other individuals
D)The ability to promote cost-saving techniques to healthcare providers
E)The ability to prevent disease by imitating nursing techniques
Q2) The nurse educator is teaching a group of nursing students about the methods that are used by insurance companies to ration healthcare resources. Which method does the educator include in the teaching session regarding this topic?
A)Denying coverage for services not supported by research
B)Covering clients for preexisting conditions only
C)Providing health savings accounts for covered individuals
D)Covering organ donations
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Chapter 47: Health Policy
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Sample Questions
Q1) When a law related to public health policy is passed, what type of agency of the federal or state government is responsible for administering it?
A)A local branch agency
B)A legislative branch agency
C)An executive branch agency
D)A judicial branch agency
Q2) Which type of health insurance plan requires the participant to select a primary care provider?
A)Health maintenance organization (HMO)
B)Preferred-provider organization (PPO)
C)Point-of-service (POS)
D)Indemnity
Q3) What action can a nursing student take to comply with nurse practice acts and remain accountable for knowing the legal nursing scope of practice in their state?
A)Become engaged in organizational quality improvement projects.
B)Obtain current licensure.
C)Join the American Nurses Association (ANA).
D)Become accredited.
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Chapter 48: Informatics
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Sample Questions
Q1) What is the primary advantage of electronic reminders in the electronic health record?
A)They help nurses decrease the length of stay.
B)They help nurses increase client safety.
C)They help nurses document assessments.
D)They help nurses track quality metrics.
Q2) Which factor increases nurses' use of clinical decision support systems (CDSS)?
A)Out-of-the-way workstations
B)Nursing experience
C)Caring for a new client
D)Reminder pop-ups
Q3) The nurse is preparing discharge instructions for a client with a foot wound. How will the clinical information system support this client's learning needs?
A)Improves documentation about the client's status
B)Summarizes the list of charges that will appear on the client's bill
C)Provides a record of all medications received while hospitalized
D)Prints discharge instructions to use for teaching
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Chapter 49: Legal Issues
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Sample Questions
Q1) A nurse educator is planning a class for a group of nursing students regarding risk management. Which information should the educator include in this presentation? Select all that apply.
A)Risk management seeks to prevent harm.
B)Risk management empowers clients.
C)Risk management controls the cost of supplies.
D)Risk management examines past mistakes and identifies potential hazards.
E)Risk management ensures that nurses are truthful.
Q2) The nurse observes a healthcare provider discussing an operative procedure with a client and determines that informed consent was achieved. Which information was included in the informed consent process? Select all that apply.
A)The provider's disapproval if the surgery is not performed
B)The health problem that requires surgery
C)The purpose of the surgery
D)The expectations of the surgery
E)Outcome if surgery is not performed
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Chapter 50: Quality Improvement
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Sample Questions
Q1) Which statements best describe how a quality improvement process can contain healthcare costs? Select all that apply.
A)"Promoting safety increases the cost of care."
B)"Medication errors decrease the cost of care."
C)"High nurse-to-client ratios result in decreased readmission rates."
D)"Increased nursing staff has been linked to decreased infection rates."
E)"Use of computers increases the number of lawsuits."
Q2) Which statement correctly describes quality management?
A)Quality management compares nursing processes to accepted standards to prevent errors in treatment.
B)Quality management refers to systematic actions that lead to improvements in healthcare services.
C)Quality management is the degree to which health services increase the likelihood of desired health outcomes.
D)Quality management provides clients with appropriate service in a technically competent manner.
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Chapter 51: Safety
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Sample Questions
Q1) Which practices support promotion of health safety? Select all that apply.
A)Exercise every day
B)Avoid driving when sleepy or tired
C)Eliminate all foods containing fat
D)Wear seat belts
E)Only see healthcare providers when sick
Q2) A client asks the nurse if the staff members make many mistakes because there are so many posters and signs about safety on the walls. Which response by the nurse is best?
A)"The nurses here are safe. The posters are directed at certain members of the healthcare team who have been making more mistakes than usual."
B)"You don't need to worry about posters on the wall. Our primary concern is getting you well."
C)"We never make mistakes here. We want the public to know that we have client safety goals here."
D)"There is a potential for errors in all healthcare settings. The posters remind the staff and the clients of the need to work together to prevent them."
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Chapter 52: Assessment
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Sample Questions
Q1) The nurse is completing an assessment on a client who just received morphine. Which is the nurse's highest priority?
A)Pain level
B)Respirations
C)Temperature
D)Blood pressure
Q2) A client's daughter mentions to the nurse that her mom seems to have a decline in mental status and seems to be forgetting many things in their conversation since this hospitalization. Which is the best response by the nurse?
A)"Give your mom time, because it will take her a little longer when answering questions."
B)"Let me check the cranial nerve function to see if there is a defect in her mental status."
C)"You do not need to worry. This decline is part of the normal process of aging."
D)"If you bring some things from her home, it might reduce the confusion."
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Chapter 53: Caring Interventions
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Sample Questions
Q1) The nurse performs a skin assessment while bathing an older adult client. Which lifespan considerations regarding skin characteristics are more common in the older adult? Select all that apply.
A)Dry skin
B)Itchy skin
C)Poor healing
D)Increased risk of water retention
E)Increased risk of trauma
Q2) The nurse is making an occupied bed. In which order should the nurse perform when removing the top linens and adding the bath blanket?
A)Spread the bath blanket over the top sheet.
B)Remove the spread and the blanket.
C)Reach under the bath blanket, grasp top edge of sheet.
D)Ask the client to hold the top edge of the bath blanket.
E)Pull the sheet from under the bath blanket.
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55
Chapter 54: Comfort
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Sample Questions
Q1) The nurse is caring for a client with acute pain and uses the FLACC pain assessment. Which clinical scenario does the nurse recognize as least appropriate for use of the FLACC pain assessment?
A)Situations where clients self-report pain.
B)Situations requiring rapid pain assessment.
C)Clients who are asleep.
D)Clients who are children.
Q2) The nurse cares for a neonate who appears in pain. The neonate has tight facial muscles, loud and shrill cry, rapid breathing, tense extremities and is thrashing about.
Using the NIPS pain scale, which number will the nurse give the neonate?
A)5
B)6
C)7
D)8
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Chapter 55: Elimination
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Sample Questions
Q1) A nurse prepares to administer a warm water enema to a client. Place the steps of the procedure in correct order.
A)Raise the solution container.
B)Open the clamp.
C)Encourage the client to retain the solution.
D)Lift the upper buttock, insert the tube slowly.
E) Assist the client to the left lateral position with right leg flexed.
F)Allow the solution to run through the tubing to remove air.
Q2) The nurse cares for a client who requires hemodialysis and has an arteriovenous fistula. Which statements will the nurse include when teaching the client safety precautions for the AV fistula? Select all that apply.
A)"Keep the AV fistula dry and avoid washing with soap."
B)"Do not wear constrictive clothing or jewelry."
C)"Avoid lifting heaving objects with the extremity that has the AV fistula."
D)"Avoid lying on the extremity with the AV fistula."
E)"Immediately report swelling or discoloration."
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Chapter 56: Fluids and Electrolytes
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Source URL: https://quizplus.com/quiz/45824
Sample Questions
Q1) The nurse cares for a client with traumatic injuries due to a motor vehicle accident. The nurse wants to increase the intravenous flow rate of intravenous fluids infusing. Which actions will the nurse take? Select all that apply.
A)Insert a large bore IV catheter.
B)Warm the IV fluid prior to infusing.
C)Cool the IV fluid prior to infusing.
D)Insert a long IV catheter.
E)Use a macrodrip IV tubing set.
Q2) A nurse attempts to flush the lumen of a triple lumen central catheter and notes severe resistance to flushing. Which diagnostic procedure does the nurse anticipate when assessing the correct placement of the central line?
A)Chest CT
B)Fluoroscopy
C)Chest X-ray
D)Endoscopy
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Chapter 57: Infection
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Sample Questions
Q1) The nurse must remove soiled equipment from a client's isolation room. Place the steps in correct order of how the nurse will remove the equipment.
A)Place equipment in an isolation bag.
B)Wash equipment with an antimicrobial agent.
C)Perform hand hygiene and don gloves.
D)Remove the isolation bag.
Q2) The nurse is caring for a client with cancer who is neutropenic. Which guidelines will the nurse follow regarding neutropenic precautions? Select all that apply.
A)Ensure the client does not receive any visitors.
B)Do not allow the client to receive fresh flowers.
C)Inspect the client's food trays to ensure no fresh vegetables are given.
D)Keep the client's door closed.
E)Ensure the client wears an N95 mask when outside of the room.
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Chapter 58: Intracranial Regulation
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Sample Questions
Q1) The nurse instructs the UAP to hold the infant in a side-lying position in preparation for a lumbar puncture. The nurse shows the UAP how to flex the infant so that the spine is exposed and curved. Which explanation is the BEST to help the UAP understand why this position must be maintained?
A)"This position decreases pain for the infant while this procedure is performed."
B)"This position must be maintained because it gives the healthcare provider the best access to the infant's spinal column."
C)"This is the position in which the healthcare provider requested that the infant be placed."
D)"This position prevents contamination of the lumbar puncture site if the infant urinates or defecates during the procedure."
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Chapter 59: Metabolism
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Source URL: https://quizplus.com/quiz/45830
Sample Questions
Q1) A nurse is shopping and notes an individual who is acting oddly. The nurse notes that the person is sweating and appears confused. The nurse approaches the individual, helps him find a seat, and takes the pulse, which is increased. The person complains of a headache. Which is this nurse's first action in assisting this individual?
A)Ask for someone in the store to call for emergency assistance.
B)Ask the individual if he has any hard candy in his pocket.
C)Lie the individual on the floor and raise the individual's feet above the heart.
D)Determine if the store has an automated external defibrillator (AED).
Q2) The client calls the clinic complaining of an unusual problem. Which client statement to the nurse is most suggestive of a subjective symptom related to an endocrine problem?
A)"I don't have as much energy as I used to. I get out of breath going up stairs."
B)"Recently I have noticed little purple spots on my legs."
C)"All I want to eat are salty things and I'm adding salt to everything I eat."
D)"My belly seems to be growing bigger every day and it's hard to breathe."
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Chapter 60: Mobility
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Sample Questions
Q1) The nurse is caring for a client who was placed in skeletal traction 48 hours ago for treatment of a serious femur fracture. The nurse will check the client's neurovascular status of the client's affected foot how often?
A)Every 30 minutes
B)Every 1 hour
C)Every 4 hours
D)Every 24 hours
Q2) The UAP is caring for a 79-year-old client who is immobilized and is preparing to complete range-of-motion (ROM)exercises. The nurse cautions the UAP to avoid which motion in an elderly client?
A)Flexion
B)Extension
C)Hyperextension
D)Abduction
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Chapter 61: Nutrition
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Sample Questions
Q1) The nurse has just begun a new enteral feeding on a client using a closed system of formula. The nurse labels the bag with the time and date it was begun (1300 hours on 12/6)knowing that this will mean the feeding tubing set will need to be changed at which time and date?
A)1300 hours on 12/7
B)0100 hours on 12/7
C)1300 hours on 12/8
D)1300 hours on 12/9
Q2) The nurse is caring for a client receiving enteral nutrition through a syringe. Midway through the feeding, the client complains of gas pains. Which is the nurse's best action at this time?
A)Contact the healthcare provider.
B)Clamp the tubing going to the client for a short time to see if symptoms are relieved.
C)Stop the feeding and remove the nasogastric tube.
D)Continue the feeding while reassuring the client that this is a common issue related to enteral feedings.
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Chapter 62: Oxygenation
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Sample Questions
Q1) The nurse is preparing to provide tracheostomy care to a 6-month-old infant and should know that which takes priority when performing this procedure?
A)Teaching the parents how to perform the procedure
B)Ensuring that a second person is available to assist with the procedure
C)Completing the procedure while the infant is asleep to minimize traumatizing the infant
D)Use clean rather than sterile procedure because the infant will be going home with the tracheostomy
Q2) The nurse is preparing to perform tracheostomy care on an alert, cooperative adult client and should request an assistant prior to which step?
A)An assistant is not required when performing tracheostomy care in a cooperative, alert adult client.
B)The assistant is required prior to pouring liquids into the sterile container.
C)The assistant is required prior to removing the inner cannula.
D)The assistant is required prior to removing and placing new tracheostomy ties.
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Chapter 63: Perfusion
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Sample Questions
Q1) How will the nurse know that the electrodes have been placed properly?
A)Lights on the box come on when electrodes are placed properly.
B)Follow the picture on the box for proper placement of electrodes.
C)Call the base station to run an ECG strip to check the signal of transmission.
D)Electrodes are placed correctly unless notified by the monitoring station.
Q2) Before removing a unit of blood from the blood bank, what should the nurse ask first?
A)Verify the client's name, date of birth, and blood type.
B)Review the signed consent form in the client's EMR.
C)Ask if any family members had a reaction to a blood transfusion.
D)Administer prescribed premedications before starting the blood transfusion.
Q3) How should the nurse calculate the heart rate from a rhythm strip?
A)Count the number of R waves in 30 large blocks and multiply by 10.
B)Count the number of small squares in a 3-second period and multiply by 0.20.
C)Count the number of large squares and multiply by 3.
D)Count the number of P waves in a 0.04 second and multiply by 5.
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Chapter 64: Perioperative Care
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Sample Questions
Q1) The nurse is preparing four older adult patients for surgery and knows that which client is at highest risk for postoperative pressure wound development?
A)The client who regularly attends the local senior center for socialization and meals and takes diphenhydramine (Benadryl)at night for sleep
B)The client who walks one mile every other day and takes ibuprofen twice a day for arthritis in his knees
C)The client who babysits every day and takes prednisone daily for allergies
D)The client who drives a bus every week and takes fluoxetine (Prozac)for anxiety
Q2) The nurse is preparing to change the dressing of a surgical client and will be alert for which signs or symptoms of a wound infection? Select all that apply.
A)Cool to the touch
B)Redness
C)Serosanguinous drainage
D)Client temperature of 101 degrees F
E)Pain rating of 2 out of 10
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Chapter 65: Reproduction
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Sample Questions
Q1) The nurse is admitting a client at full term to the labor and delivery unit. Using Leopold's maneuvers, the nurse determines that the fetus is in the left sacroanterior position (LSA)position and will obtain the fetal heart rate (FHR)at which site on the client's abdomen?
A)Midline, directly above the symphysis pubis
B)To the right of the client's umbilicus
C)To the left of the client's umbilicus
D)To the left, below the umbilicus
Q2) The nurse is assessing a pregnant client who is at 29 weeks gestation. The nurse notes that the client's blood pressure is 160/90 and documents that the clonus was noted after assessing the patellar reflex. Which assessment findings led the nurse to document this finding?
A)There was no response when the area directly above the knee was struck with the percussion hammer.
B)The nurse noted an extension of the leg when the percussion hammer touched the area above the knee.
C)The client complained of pain when the foot was dorsiflexed.
D)The client's foot tapped against the nurse's hand when it was dorsiflexed.
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Chapter 66: Safety
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Sample Questions
Q1) The nurse is caring for a client who becomes occasionally confused. When the client has a period of confusion, he attempts to pull out his Foley catheter. When the client is oriented, he likes to do crossword puzzles. After receiving an order for restraints, which would be the best place(s)to place the restraint in this client?
A)Around the client's elbows
B)Around the client's wrists
C)Around the client's fingers (using a mitt restraint)
D)Around the client's torso (using a vest-type restraint)
Q2) The nurse has completed an assessment of an older adult client who lives with her son and his wife. The nurse observed some bruising on the client but no other signs of abuse. Which question by the nurse to the client would be most helpful in determining if abuse is occurring?
A)"Who manages your money?"
B)"How did the bruises I noted on your wrists occur?"
C)"Are you happy with where you live?"
D)"How often do you see the doctor?"
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Chapter 67: Tissue Integrity
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Sample Questions
Q1) The nurse is preparing to remove staples from a woman who had a cesarean section 6 days ago and will use which forms of personal protective equipment when performing this task?
A)Sterile gloves, face shield
B)Face shield, gown, clean gloves
C)Gown, sterile gloves, shoe covers
D)Clean gloves
Q2) The nurse is preparing to change the dressing of a client who had abdominal surgery 3 days ago. The nurse notes that the incision has purulent drainage and appears very puffy. The client states that the pain level has increased from a 3 to a 7 in the last 24 hours. Which is the nurse's next action in regard to this client's wound?
A)Clean the wound, place a new dressing, and plan to recheck the incision in 4 hours.
B)Contact the client's surgeon after obtaining the client's vital signs.
C)Recognize that this is an expected outcome for a client on the third day after surgery.
D)Culture the wound drainage and redress the wound.
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