Category 1
Which of the following is the best way to assess generalized edema in a client with congestive heart failure?
a. Obtain weight daily
b. Auscultate lung sounds every shift
c. a. Measure the circumference of the ankles daily
d. .Press fingers into the tissue over the tibia, just above the ankle
a. Obtain weight daily
While caring for a client who has just been diagnosed with a terminal illness. Which of the following is the traditional first stage of grief that the nurse expects to see?
a. Depression
b. Bargaining
c. Anger
d. Denial
d. Denial
While collecting a 24 hours urine specimen, it is important to do which of the following?
a. Add the voiding at the end of the test to the container
b. Limit fluids to less than 1000mL/day
c. Force fluids to at least 3000 mL/day
d. Start the test with an empty bladder
d. Start the test with an empty bladder
A nurse caring for a client on bed rest with a history of respiratory health problems should perform which of the following actions?
a. Monitor peripheral pulses once a shift and as needed
b. Auscultate for bowel sounds once a shift and as needed
c. Monitor for skin turgor every shift and as needed
d. Auscultate breath sounds at the beginning of shift and as needed
d. Auscultate breath sounds at the beginning of shift and as needed
Which of the following factors makes dementia different from confusion and delirium?
a. It is not easily treated
b. It is progressive and permanent
c. It is caused by depression.
d. . It takes much longer to cure
b. It is progressive and permanent
When can a nurse record absence of bowel sounds in a client?
a. After auscultating all four quadrants for 1 minute each
b. After auscultating the two upper quadrants for 5 minutes
c. After auscultating all quadrants for 5 minutes each
d. After auscultating the two lower quadrants for 2 minutes each
c. After auscultating all quadrants for 5 minutes each
Which of the following are included in Kubler-Ross’s stages of dying? Select all that apply.
a. Acceptance
b. Bargaining
c. Depression
d. Denial
e. Anger
a. Acceptance
b. Bargaining
c. Depression
d. Denial
e. Anger
When giving a medicine through a nasogastric (NG) tube, what is the first action by the nurse?
a. Ask the client if the tube is painful
b. Flush the tube with 30 mL of water
c. Check placement of the tube
d. Take the vital signs
c. Check placement of the tube
The nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further teaching about its use if the client makes which statement?
a. "I need to place my lips completely over the mouthpiece."
b. I will inhale slowly, maintaining a constant flow."
c. "I need to sit upright when using the device."
d. "After maximal inspiration, I will hold my breath for 10 seconds and then exhale."
d. "After maximal inspiration, I will hold my breath for 10 seconds and then exhale."
A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel?
a. Starting peripheral intravenous therapy
b. Changing a peripheral intravenous dressing
c. Regulating intravenous flow rate
d. Recording intake and output
d. Recording intake and output
To correctly determine the strength of a client’s upper extremities during a neurologic examination, the nurse has the client perform which action?
a. Wiggle the toes of both feet at the same time.
b. Push against his hand with the sole of one foot and then the other
c. Grip the nurse’s fingers with the client’s hands
d. Stand up independently.
c. Grip the nurse’s fingers with the client’s hands
When working with a client with aphasia, the nurse may attempt to enhance communication by use of which of the following?
a. Using open-ended questions
b. Using gestures
c. Speaking loudly
d. Communicating through a physical therapist
b. Using gestures
A client complains of leaking urine whenever she sneezes, coughs, or laughs. The nurse recognizes that this report is consistent with which type of incontinence?
a. Reflex
b. Stress
c. Urge
d. Functional
b. Stress
The nurse is told that the blood gas results indicate a pH of 7.50 and a PaCo2 of 32 mm Hg. The nurse determines that these results are indicative of which acid-base disturbance?
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory acidosis
d. Respiratory alkalosis
d. Respiratory alkalosis
The nurse reviews a client's serum sodium level and notes that the level is 150 mEq/L. The health care provider prescribes dietary instructions for the client based on the sodium level. Which food item should the nurse instruct the client to avoid?
a. Molasses
b. Spinach
c. Processed oat cereals
d. Squash
c. Processed oat cereals
The nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit which of the following?
a. A brisk response
b. A consensual response
c. Accommodation
d. A dilation response
b. A consensual response
What is considered a normal change in the skin associated with aging?
a. . Nail growth increases
b. . Sebaceous gland activity increases
c. Adipose tissue decreases
d. Hair follicles increases
c. Adipose tissue decreases
One action that may assist the female patient to regain bladder control is to do which of the following?
a. Restrict fluid to 1000 mL/day
b. Use absorbent panty liners
c. Teach her Kegel exercises
d. Ambulate her regularly
c. Teach her Kegel exercises
The nurse is preparing to suction an adult client through the client's tracheostomy tube.
Which interventions should the nurse perform for this procedure? Select all that apply.
a. Hyper-oxygenate the client before suctioning.
b. Apply suction for up to 10 seconds.
c. Apply intermittent suction while rotating and withdrawing the catheter.
d. Apply suction while gently inserting the catheter.
e. Set the wall suction unit pressure at 160 mm Hg.
a. Hyper-oxygenate the client before suctioning.
b. Apply suction for up to 10 seconds.
c. Apply intermittent suction while rotating and withdrawing the catheter.
The patient is started on IV therapy. A sign that he is receiving too much or too rapid IV fluid would be which of the following?
a. Sudden vomiting
b. Slow, bounding pulse
c. Very rapid pulse rate
d. Decreasing urine output
b. Slow, bounding pulse
Which of the following is the correct way for a nurse to auscultate the breath sounds of a client?
a. Percuss the chest by quickly tapping on the chest wall surface to produce sounds
b. Inspect the chest wall for characteristics of movements and respirations
c. Touch the chest wall and note the texture, temperature, and moisture of the skin
d. Use a stethoscope and properly position the earpieces and diaphragm
d. Use a stethoscope and properly position the earpieces and diaphragm
Dehydration may occur more quickly for a 76-year-old than for a younger person due which of the following reasons?
a. More ADH is produced in the older adult
b. There is a decrease in the urine concentrating ability of the kidney in the older adult
c. There is less subcutaneous fat in the older adult
d. The thirst mechanism is more active in the older adult
b. There is a decrease in the urine concentrating ability of the kidney in the older adult
The nurse is reviewing the health care records of assigned clients. Which client is at risk for excess fluid volume?
a. The client on gastrointestinal (GI) suctioning
b. The client with an ileostomy
c. The client with renal failure
d. The client on diuretics
c. The client with renal failure
A client has a prescription for continuous monitoring of oxygen saturation by pulse
oximetry. The nurse performs which best action to ensure accurate readings on the oximeter?
a. Ask the client to limit motion in the hand attached to the pulse oximeter.
b. Place the sensor distal to an intravenous (IV) site with a continuous IV infusion.
c. Apply the sensor to a finger with very dark nail polish.
d. Apply the sensor to a finger that is cool to the touch.
a. Ask the client to limit motion in the hand attached to the pulse oximeter.
A nurse knows that there is a risk for cerebral edema, increased intracranial pressure, rupture of brain cells, and death if there is an infusion of an excessive volume of:
a. Hypertonic solution.
b. Hypotonic solution.
c. Any of the above.
d. Isotonic solution.
b. Hypotonic solution.