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Ati Finals As Derived From Ati Text For Nursing Fundamentals, Part II

100 Questions
Nursing Quizzes & Trivia

Questions derived from Fundamentals for Nursing Edition 7. 0, application exercises. Chapter 35 through Chapter 57, pages 348 through 636. For any questions or suggestions, email at [email protected] Com

Questions and Answers
  • 1. 
    A nurse is teaching a group of young adults who are about to go for a marathon. Which of the following should she teach?
    • A. 

      Increase fluid intake in dry climates

    • B. 

      Decrease fluid intake in high altitudes

    • C. 

      Include caffeine as a regular beverage

    • D. 

      Decrease fluid intake after training

  • 2. 
    After an interview, a 90 year old patient told the nurse that he had diarrhea and vomiting for the past 2 days. Which of the following will indicate that the client might be suffering from hypovolemia? Select all that apply:
    • A. 

      Tachypnea

    • B. 

      Furrowed tongue

    • C. 

      Sunken eyeballs

    • D. 

      Bradycardia

    • E. 

      Hypertension

  • 3. 
    A patient has been admitted for peritonitis and has signs of dehydration. Which of the following laboratory findings would be expected for this patient. Select all that apply:
    • A. 

      Increased urine osmolality

    • B. 

      Decreased serum osmolality

    • C. 

      Decreased urine specific gravity

    • D. 

      Increased serum sodium

    • E. 

      Increased HCT

  • 4. 
    A nurse has been assigned 4 patients. Which of them is at risk for HYERVOLEMIA?
    • A. 

      A patient receiving loop diuretic

    • B. 

      A patient who lost 500 ml of blood during surgery

    • C. 

      A patient who had a myocardial infarction

    • D. 

      A patient who is 3 hours postoperative is and under an NG suction

  • 5. 
    After looking at the laboratory results for a group of patients, which of the following should be reported to the respective physician?
    • A. 

      Serum potassium 4 mEq/L

    • B. 

      Serum calcium 8.5 mg/dL

    • C. 

      Serum chloride 99 mEq/L

    • D. 

      Serum sodium 143 mEq/L

  • 6. 
    Which of the following should be a part of a care plan designed for a hypernatremic patient?
    • A. 

      Administer a loop diuretic

    • B. 

      Increase sodium intake

    • C. 

      Restrict oral intake of water

    • D. 

      Infuse hypotonic IV fluids

  • 7. 
    When an infant has a heart attack, which of the following pulses should be palpated to determine how the heart is working?
    • A. 

      Radial

    • B. 

      Pedal

    • C. 

      Carotid

    • D. 

      Brachial

  • 8. 
    • A. 

      Open the airway

    • B. 

      Initiate rescue breathing

    • C. 

      Deliver chest compressions

    • D. 

      Provide defibrillation

  • 9. 
    A nurse is treating a diabetic 15-year old patient two days after an appendectomy. The client can tolerate a regular diet quite well. He has walked around the unit with assistance and request pain medication every 6 to 8 hours at a 3 on a 0 to 10 pain scale. His wound is approximated, free of redness with slight serous drainage noted on the dressing. Which of the following risk factors for poor wound healing does this patient have? Select all that apply
    • A. 

      Extremes in age

    • B. 

      Impaired/suppressed immune system

    • C. 

      Impaired circulation

    • D. 

      Poor wound care such as breaches in aseptic technique

    • E. 

      Malnutrition

  • 10. 
    An entry in a patient chart indicates wound drainage is "sanguineous". What does this mean? 
    • A. 

      Foul-smelling

    • B. 

      Green-tinged or yellow

    • C. 

      Watery in appearance

    • D. 

      Bright red

  • 11. 
    • A. 

      An open burn area

    • B. 

      A bone fracture that is casted

    • C. 

      A sprained ankle

    • D. 

      A sutured surgical incision

  • 12. 
    A 70-year old female has had a bowel obstruction surgery six days ago. During the past day, she has complained of nausea, and she threw up small amounts of clear liquid in the last 7 hours. Her vital signs are stable. Currently, her incision is well approximated without redness, tenderness or swelling. Which of the following could indicate the possibility of a wound infection?  
    • A. 

      Increased pain

    • B. 

      Decreased pulse rate

    • C. 

      Decrease WBC count

    • D. 

      Increased thirst

  • 13. 
    A surgical client acutely becomes agitated and pulls of her dressing. The nurse enters the room and finds out that the wound is separated with viscera protruding. Which of the following interventions are appropriate? Select all that apply
    • A. 

      Repack the wound

    • B. 

      Call for help

    • C. 

      Cover the wound with sterile dressing moistened with 0.9% sodium chloride

    • D. 

      Assist the client to a chair

    • E. 

      Stay with the client

  • 14. 
    An 85-year old diabetic patient must now use a wheelchair after a stroke 2 years ago that affected her right side. She feels no pain on this side. Although she has a good appetite, she needs help with eating. Which of the following factors could cause this patient to have pressure ulcers?
    • A. 

      Dehyrdation

    • B. 

      Limited mobility

    • C. 

      Nutritional impairment

    • D. 

      Incontinence

  • 15. 
    For a CVA patient who is wheel chair bound, which of the following can prevent skin breakdown?
    • A. 

      Massage bony prominences frequently

    • B. 

      Keep patient on high fowler's position while in bed

    • C. 

      Have the client sit on a donut shaped cushion

    • D. 

      Encourage repositioning every 15 minutes while the client is on a wheelchair.

  • 16. 
    Which of the following is a STAGE III DECUBITUS?
    • A. 

      Reddened skin and does not blanch with pressure

    • B. 

      Ulcer is an abrasion or a blister

    • C. 

      Bone is exposed at the center of the ulcer

    • D. 

      Ulcer extends past the subcutaneous tissue to the muscle

  • 17. 
    Which of the following formula contains a complete nutrition?
    • A. 

      Polymeric

    • B. 

      Modular

    • C. 

      Elemental

    • D. 

      Specialty

  • 18. 
    The enteral access tube best suited for short-term use (less than 4 weeks)
    • A. 

      Nasogastric tube

    • B. 

      Gastrostomy tube

    • C. 

      Jejunostomy tube

    • D. 

      PEG tube

  • 19. 
    After an enteral feeding is given, what is the purpose of flushing a tube?
    • A. 

      Provide sufficient fluid intake

    • B. 

      Dilute concentration of formula

    • C. 

      Clear the tubing to prevent clogging

    • D. 

      Ensure placement of tube is maintained

  • 20. 
    Before initiating an enteral feeding, what is the highest priority assessment that the nurse must do?
    • A. 

      Is the tube correctly placed?

    • B. 

      Is the client alert and oriented?

    • C. 

      How long has the feeding container been open?

    • D. 

      Does the client have diarrhea?

  • 21. 
    While assessing a patent with a continuous enteral feeding, nurse noticed aspiration if the tube feeding. What should she do next?  
    • A. 

      Auscultate breath sounds

    • B. 

      Stop the feeding

    • C. 

      Obtain a chest x-ray

    • D. 

      Provide oxygen

  • 22. 
    The proper way to secure a nasogastric tube.  
    • A. 

      Tape from the client's nose to the nasogastric tube

    • B. 

      A safety pin trough the nasogastric tube to the client's gown

    • C. 

      Tape to the client's cheek with a short length of tubing looped on the nose

    • D. 

      Tape around the connection of the nasogastric tube and the suction tubing

  • 23. 
    • A. nasal cannula
    • A.
    • B. simple face mask
    • B.
    • C. nonbreather mask
    • C.
    • D. venturi mask
    • D.
    • E. face tent
    • E.
  • 24. 
    Which of the following can cause a low pulse oximetry reading? Select all that apply:
    • A. 

      Nail polish

    • B. 

      Poor peripheral circulation

    • C. 

      Edema

    • D. 

      Hyperthermia

  • 25. 
    • A. 

      Pale skin and mucous membranes

    • B. 

      Elevated blood pressure

    • C. 

      Restlessness

    • D. 

      Cyanotic skin and mucous membranes

    • E. 

      Bradycardia

  • 26. 
    Which of the following are late signs of hypoxemia? Select all that apply: 
    • A. 

      Cyanotic skin and mucous membranes

    • B. 

      Hypotension

    • C. 

      Bradycardia

    • D. 

      Confusion and stupor

    • E. 

      Elevated blood pressure

  • 27. 
    A nurse is caring for a client who is dyspneic. What position should the client be in?
    • A. 

      Supine

    • B. 

      Dorsal Recumbent

    • C. 

      Fowler's

    • D. 

      Lateral

  • 28. 
    Which of the following oxygen delivery systems should be used when a precise amount of oxygen needs to be delivered?
    • A. 

      Venturi mask

    • B. 

      Nonbreather mask

    • C. 

      Nasal cannula

    • D. 

      Simple face mask

  • 29. 
    • A. Place the client in fowler's position
    • A.
    • B. Check for a provider's order
    • B.
    • C. Have the client rinse his mouth
    • C.
    • D. Obtain necessary equipment
    • D.
    • E. Perform hand hygiene, provide privacy, and explain procedure to patient
    • E.
  • 30. 
    Place the following steps for obtaining a sputum specimen in the correct order by matching them with an appropriate number
    • A. Assess client's ability to cough and expectorate
    • A.
    • B. Instruct the client to breathe deeply two to four times and then cough deeply to raise the sputum from the lung
    • B.
    • C. Maintaining sterility, place the lid on the specimen cup, label it, and place it in the biohazard bag
    • C.
    • D. Deliver the specimen to the laboratory within 30 minutes
    • D.
    • E. Have the client expectorate the sputum into a sterile cup without contamination.
    • E.
  • 31. 
    Which of the following directions should the nurse give to a client who is learning self-monitoring of blood glucose (SMBG)? Select all that apply:
    • A. 

      Warm the hand before puncturing the finger

    • B. 

      Perform SMBG once daily at bedtime

    • C. 

      Calibrate the glucose monitor each time a new bottle of strips is opened

    • D. 

      Wipe the hand with an alcohol swab

    • E. 

      Prick the outer edge of the fingertip for a blood sample

  • 32. 
    Which of the following can alter the results of blood glucose testing?
    • A. 

      Amoxicillin (Amoxil)

    • B. 

      Dexamethasone (Decadron)

    • C. 

      Morphine (Duramorph)

    • D. 

      Acetaminophen (Tylenol)

  • 33. 
    A client has an admission blood glucose reading of 350 mg/dL. The client has no history of elevated blood glucose, and there is an insulin order. Which of the following actions should the nurse take first?
    • A. 

      Check the client's level of awareness

    • B. 

      Check the client's dietary orders

    • C. 

      Review the client's recent nutritional intake

    • D. 

      Notify the provider

  • 34. 
    In order to promote adherence with medication administration, which of the following instructions should be included? Select all that apply: 
    • A. 

      Only take medications when not feeling well

    • B. 

      Place pill in daily pill holders

    • C. 

      Contact physician if side effects take place

    • D. 

      Ask a relative to assist once in a while

    • E. 

      Refill prescriptions when the current supply is completed

  • 35. 
    A patient claims that his pain medication is not working as it used to. The nurse should realize that the client is experiencing what?
    • A. 

      Placebo effect

    • B. 

      Tolerance

    • C. 

      Accumulation

    • D. 

      Dependence

  • 36. 
    A nurse is preparing medication for a pre-school child. Which of the following should the nurse recognize as a factor that would alter how a pre-school child is affected medication? Select all that apply: 
    • A. 

      Increased gastric acid production

    • B. 

      Lower blood pressure

    • C. 

      Increased first pass medication metabolism

    • D. 

      Higher body water content

    • E. 

      Increased absorption of topical medication

  • 37. 
    Upon looking at the MAR, a nurse observes that one of her clients is taking four new mediations. Which of the following should be a concern?
    • A. 

      The client is lactose intolerant

    • B. 

      Two of the medications cause drowsiness

    • C. 

      There are no generic forms available

    • D. 

      The client has difficulty swallowing four pills at one one time

  • 38. 
    A nurse tells a patient that a prescribed medication may have side effects. Which of the following instructions should the nurse give if anticholinergic effects are among the potential side effects? Select all that apply:
    • A. 

      Keep a bottle of water available

    • B. 

      Use a soft toothbrush when brushing teeth

    • C. 

      Wear sun glasses when exposed to sunlight

    • D. 

      Try to void before taking medication

    • E. 

      Take medication with an antacid

  • 39. 
    A patient is suffering from renal damages as a result of glomerulonephritis. Which of the following needs to be monitored when administering  patient's medication?
    • A. 

      Decreased efficacy of medication

    • B. 

      Delayed clearance of medications from the blood

    • C. 

      Increased risk of analphylaxis

    • D. 

      Delayed clearance of medication from the blood

  • 40. 
    A patient with chronic high blood pressure has been prescribed with an antihypertensive drug. Which of the following should the nurse teach to this patient with regards to over the counter (OTC) medications? 
    • A. 

      Continue taking OTC drugs with antihypertensive medication

    • B. 

      Consult physician before taking an OTC drug

    • C. 

      Stop taking antihypertensive drugs while taking OTC drugs

    • D. 

      Take only one half the recommended dose of OTC medications.

  • 41. 
    When assessing an IV site for infiltration, the following are indications that infiltration might have occurred. Select all that apply:
    • A. 

      A drop in temperature around the site

    • B. 

      An increased rate of infusion

    • C. 

      Local swelling at the site

    • D. 

      Reddened skin

    • E. 

      A damp dressing

  • 42. 
    The following should be included when documenting the insertion of an IV catheter. Select all that apply
    • A. 

      Date and time of insertion; catheter size

    • B. 

      Type of dressing (name and brand if available)

    • C. 

      IV fluid and rate (if applicable)

    • D. 

      Number, location, and conditions of site attempted cannulations

    • E. 

      Insertion site and appearance

  • 43. 
    • A. 16 - gauge
    • A.
    • B. 18 - gauge
    • B.
    • C. 22 to 24 gauge
    • C.
  • 44. 
    A patient is receiving dextrose 5% in water IV. When monitoring for fluid overload, which of the following should be observed? Select all that apply:
    • A. 

      Decreased blood pressure

    • B. 

      Tachycardia

    • C. 

      Flattened neck veins

    • D. 

      Shortness of breath

    • E. 

      Crackles heard in the lungs

  • 45. 
     A nurse is setting up an injection of morphine (Duramorph) to a patient who complains of pain. Before this however, another client in another room called and requested for a bedpan.  This nurse then asked for a second nurse to give the injection so that she can help the client needing a bedpan. Which of the following actions should the second nurse take?  
    • A. 

      Give the injection prepared by the other nurse

    • B. 

      Offer to assist the client needing a bedpan

    • C. 

      Prepare another syringe and give the injection

    • D. 

      Tell the client needing a bedpan that she will have to wait for her own nurse.

  • 46. 
    According to the MAR, a medication was ordered for 9:00 in the morning. Which of the following are acceptable times? Select all that apply:
    • A. 

      0905

    • B. 

      0825

    • C. 

      1000

    • D. 

      0850

    • E. 

      0935

  • 47. 
    Which of the following prevents medication error?
    • A. 

      Taking all medications out of the unit-dose wrappers before entering the bedside

    • B. 

      Giving up the prescribed medication and then looking up the dosage range

    • C. 

      Relying on another nurse to clarify a medication prescription

    • D. 

      Checking with the physician when a single dose indicates an administration of multiple tablets

  • 48. 
    When implementing medication therapy, the nurse's responsibilities include which of the following? Select all that apply:
    • A. 

      Observe patient for drug side effects

    • B. 

      Monitor for therapeutic effects

    • C. 

      Prescribing an appropriate dose

    • D. 

      Maintain a current knowledge base

    • E. 

      Changing the dose if side effects take place

  • 49. 
    The nursing process is a principle applied in medication administration. Match the process on the left with an action on the right.
    • A. Assessment/Data collection
    • A.
    • B. Planning
    • B.
    • C. Evaluation
    • C.
    • D. Implementation
    • D.
  • 50. 
    When medications act on receptors, what do they do? Select all that apply
    • A. 

      Mimic the action of the body's own hormones

    • B. 

      Change the enzymes made by the target cell

    • C. 

      Block the action of the body's own compounds

    • D. 

      Make the receptors respond in new ways

    • E. 

      Change the receptors molecular structure

  • 51. 
    After a PO medication has been absorbed, most of the medication is inactivated as the blood initially passes through the liver, producing an insignificant therapeutic effect. What do you call this? 
    • A. 

      Tolerance

    • B. 

      Antagonism

    • C. 

      Synergism

    • D. 

      First pass effect

  • 52. 
     Intravenous administration for a medication eliminates the need for ......
    • A. 

      Distribution

    • B. 

      Absorption

    • C. 

      Metabolism

    • D. 

      Excretion

  • 53. 
    Identify the correct client position for each of the following routes of administration.
    • A. Oral
    • A.
    • B. Otic
    • B.
    • C. Vaginal
    • C.
    • D. Rectal
    • D.
  • 54. 
    • A. intradermal
    • A.
    • B. subcutaneous
    • B.
    • C. intramuscular
    • C.
    • D. intravenous
    • D.
  • 55. 
    Nitroglycerin (Nitrogard) tablets, often prescribed for patients with cardiovascular disorders, are given sublingually. What does this mean?
    • A. 

      Crushed and ingested with a small amount of food

    • B. 

      Held under the tongue until dissolved

    • C. 

      Taken by mouth with a small amount of water

    • D. 

      Placed between the cheek and gums

  • 56. 
    A nurse is taking care of a CVA patient with aphasia. Which of the following interventions promote communication?
    • A. 

      Write down what the patient does not understand

    • B. 

      Speak fast and loud

    • C. 

      Allow plenty of time for the patient to respond

    • D. 

      Reduce background noise

    • E. 

      Use short sentences with simple words

  • 57. 
    A patient who recently overdosed on amphetamines is experiencing sensory overload. Which of the following should be implemented?
    • A. 

      Complete a thorough assessment ASAP

    • B. 

      Transfer the client to a room with another hearing impaired client

    • C. 

      Provide a private room and limit stimulation

    • D. 

      Talk loudly to the patient and encourage ambulation.

  • 58. 
    Match the sentence with blanks on the left with an appropriate word on the right.
    • A. A form of nonverbal communication that helps clarify verbal communication to clients is called ________
    • A.
    • B. _______means the client cannot speak or comprehend spoken language
    • B.
    • C. A client whose sensory input is reduced may experience sensory ___________
    • C.
  • 59. 
    A client with an indwelling catheter expresses the need to void. Which of the following is appropriate?
    • A. 

      Check to see if the catheter is patent

    • B. 

      Reassure the client that it is not possible for her to urinate

    • C. 

      Recatheterize the client with a larger-gauge catheter

    • D. 

      Notify the provider

  • 60. 
    When performing a 24-hour urine specimen test, which of the following interventions is correct? 
    • A. 

      Keep all voidings in a container at room temperature for 24 hours.

    • B. 

      Discard the first voiding

    • C. 

      Ask patient to urinate into the toilet, stop midstream, and finish urinating into the specimen container.

    • D. 

      Ask patient to urinate and pour the urine into a specimen container

  • 61. 
    Which of the following positions promotes a patient's normal elimination?
    • A. 

      Left lateral Sim's

    • B. 

      Supine

    • C. 

      Right side-lying

    • D. 

      Sitting

  • 62. 
    Which of the following interventions is expected when performing catherization on a female patient? Select all that apply: 
    • A. 

      Maintain surgical asepsis throughout the procedure

    • B. 

      Provide privacy

    • C. 

      Darken the room

    • D. 

      Ask the client not to talk during the procedure

    • E. 

      Position patient with knees bent and apart

  • 63. 
    A home-bound patient needs to perform a fecal occult blood testing at home. Which of the following should be included when explaining the procedure to the patient? 
    • A. 

      Eat more protein before testing

    • B. 

      One stool specimen is enough for the test

    • C. 

      The specimen cannot be contaminated with urine

    • D. 

      A red color change indicates a positive test

  • 64. 
    An intervention order indicates that a patient needs a tap water enema done and repeated until the return is clear. Which of these should be  done first?  
    • A. 

      Explain procedure to the client

    • B. 

      Clarify the order with the provider

    • C. 

      Be sure that the tap water is not too hot

    • D. 

      Keep amount per enema to less than 1,000 ml

  • 65. 
    Which of the following can be recommended to a patient suffering from constipation?
    • A. 

      Fresh fruits and whole wheat toast

    • B. 

      Noodles with beef tips

    • C. 

      Mashed potatoes with gravy

    • D. 

      Macaroni and cheese

  • 66. 
    A patient has been suffering diarrhea for the past 4 days. When assessing the patient, which of the following are expected findings?
    • A. 

      Peripheral edema

    • B. 

      Hypotension

    • C. 

      Fever

    • D. 

      Bradycardia

    • E. 

      Poor skin turgor

    • F. 

      Abdominal cramping

  • 67. 
      A male patient was admitted for abdominal surgery. Client's initial vital signs are temperature at 37 C (98.6 F), pulse 98 / min, respirations 20 / min and blood pressure at 148 / 88 mm Hg. The client states, :I am really worried. This is the first surgery I ever had." Which of the following is an appropriate use of a complementary alternative intervention?
    • A. 

      Call provider and get permission to use relaxation techniques with the patient.

    • B. 

      Offer information and ask the client if he is interested in trying a relaxation technique

    • C. 

      Provide client with reassurance and information about the procedure

    • D. 

      Give client a therapeutic back massage and tell him to try to relax

  • 68. 
    A nurse is taking care of a patient with back pains. This patient tells the nurse that a friend recommended him to see a chiropractor. She asks the nurse what a chiropractor does to relieve back pain. Which of the following responses by the nurse would be correct?
    • A. 

      Chiropractors insert needles or put pressure along meridians in the back

    • B. 

      Chiropractors use their hands to balance the energy fields in the back

    • C. 

      Chiropractor use herbal remedies to treat back pain

    • D. 

      Chiropractors use their hands to manipulate the spine to treat back pain

  • 69. 
    Massage therapy is an example of which category of alternative therapy?
    • A. 

      Alternative medical philosophy

    • B. 

      Biological therapy

    • C. 

      Body manipulation

    • D. 

      Mind-body therapy

  • 70. 
    Which of the following complementary or alternative therapies can be part of a nursing intervention? Select all that apply
    • A. 

      Relaxation techniques

    • B. 

      Acupuncture

    • C. 

      Humor

    • D. 

      Therapeutic communication

  • 71. 
    • A. 

      Therapeutic touch

    • B. 

      Humor

    • C. 

      Chiropractic techniques

    • D. 

      Acupuncture

  • 72. 
    A nurse is assessing the pain level of a client admitted to the ER with severe abdominal pain. The nurse asks the client if he has nausea and vomiting. What is being assessed?
    • A. 

      Location of the pain

    • B. 

      Pain quality

    • C. 

      Associated symptoms

    • D. 

      Aggravating and relieving factors

  • 73. 
    Frequent pain assessment includes quantifying the intensity of pain. What is the best way to assess this? 
    • A. 

      Ask what precipitates the pain

    • B. 

      Question client about pain location

    • C. 

      Offer client a pain scale to measure his pain

    • D. 

      Use open ended questions to identify the sensation

  • 74. 
    Which of the following are true about pain?
    • A. 

      All cultures have the same attitude regarding pain

    • B. 

      Pain can cause anger and guilt

    • C. 

      In may be tough to assess pain properly in a client who is cognitively impaired.

    • D. 

      A client who is sleeping could not be experiencing pain

    • E. 

      It is best to wait until pain worsens before administering analgesics

  • 75. 
    A nurse should know that pain is.........
    • A. 

      Most clients exaggerate their pain level

    • B. 

      Pain must have an identified source before using opioids

    • C. 

      Pain is whatever the client says

    • D. 

      Objective data are essential in assessing pain

  • 76. 
    • A. phantom limb pain, burning, "pins and needles" pain
    • A.
    • B. referred pain
    • B.
    • C. fractur pain, sharp, aching pain
    • C.
  • 77. 
    A patient had surgery 3 hours ago. He is reporting an incisional pain of 7 out of 10. His pulse, respirations, and blood pressure are all elevated. His pupils are dilated.  Which of the following statements explain these findings in relation to pain? Select all that apply: 
    • A. 

      Pain elicits a response from the sympathetic nervous system

    • B. 

      Pain elicits a response from the parasympathetic nervous system

    • C. 

      The client can experience tachycardia, hypertension, anxiety, diaphoresis, muscle tension, pallor and dilated pupils

    • D. 

      The client can experience hypotension, drowsiness, muscle relation and bradycardia

  • 78. 
    A nurse is assessing a client with pneumonia with a long history of osteoarthritis on her knees. Although she has a pain of 6 out of 10, her vitals indicate a normal range, and she does not show any muscle tension. Why? 
    • A. 

      The client must have had a larger dose of analgesics.

    • B. 

      What she has is a cultural expression of pain.

    • C. 

      As pain continues, the body is not able to sustain the level of sympathetic response, and the parasympathetic nervous system takes over. The client can still be in pain without a physiological manifestation.

    • D. 

      It is most probable that the patient is malingering.

  • 79. 
    A patient has been sitting on a chair for 3 hours. Which of the following could this patient be at risk for?
    • A. 

      Stasis of secretions

    • B. 

      Muscle atrophy

    • C. 

      Pressure ulcer

    • D. 

      Fecal impaction

  • 80. 
    Which of the following nursing interventions should be implemented to maintain a patent airway in a client on bed rest?
    • A. 

      Isometric exercises

    • B. 

      Suction every 8 hours

    • C. 

      Administer low dose of heparin as prescribed

    • D. 

      Teach the use of an incentive spirometer while awake

  • 81. 
     Which of the following interventions reduce the risk of thrombus development? Select all that apply:
    • A. 

      Teach the client not to use 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 client to change position frequently

  • 82. 
    Which of the following clients could benefit from the benefits of a cold compress? Select all that apply:
    • A. 

      A client who sprained an ankle

    • B. 

      A client who has Raynaud's phenomenon

    • C. 

      A client who just had knee arthoplasty

    • D. 

      A client who has a toothache

    • E. 

      A client who has a nose bleed

  • 83. 
    What is the main function of a sequential compression device (SCD)?
    • A. 

      Promote venous return

    • B. 

      Prevent pressure ulcers

    • C. 

      Prevent muscular atrophy

    • D. 

      Increase joint mobility

  • 84. 
    Identify the order in which the following steps of elastic stocking application should be completed.  
    • A. perform hand hygiene
    • A.
    • B. smooth any creases or wrinkles
    • B.
    • C. pull the remainder of the stocking over the client's heels and up on his leg
    • C.
    • D. turn the stockings inside to the heel
    • D.
    • E. assess the condition of the client's skin and the circulation of his legs
    • E.
    • F. put the stockings on the client's foot
    • F.
    • G. measure the client's calf and/or thigh circumference and length of the leg, and select the correct size stocking
    • G.
  • 85. 
    A nurse is assigned to a patient with a high risk for aspiration. Which of the following is an appropriate intervention?
    • A. 

      Give the patient thin liquids

    • B. 

      Instruct the client to tuck her chin when swallowing

    • C. 

      Have the client use a straw

    • D. 

      Encourage the client to lie down and rest after meals

  • 86. 
    Which of the following is the body's preferred energy source? 
    • A. 

      Fat

    • B. 

      Protein

    • C. 

      Vitamins

    • D. 

      Carbohydrates

  • 87. 
    If not supervised, school-age children tend to have dietary deficiencies in which of the following?
    • A. 

      Carbohydrates

    • B. 

      Fats

    • C. 

      Minerals

    • D. 

      Vitamins

  • 88. 
    Which of the following is appropriate for a nurse to give a client who is on a low-residue diet? 
    • A. 

      Whole grains

    • B. 

      Fruits and vegetables

    • C. 

      Dairy products

    • D. 

      Nuts and legumes

  • 89. 
    A nurse is caring for a client who weighs 80 kg (176 lbs) and is 1.6 m ( 5 ft 3 in) tall. Calculate her body mass index (BMI) and determine whether or not client is obese on her BMI  
  • 90. 
    Which of the following recommendations should a nurse give to a client to promote sleep and rest? Select all that apply:
    • A. 

      Avoid all caffeinated beverages

    • B. 

      Participate in regular exercise each morning

    • C. 

      Take an afternoon nap

    • D. 

      Practice relaxation exercises before bedtime

    • E. 

      Limit fluid intake at least 2 hours before bedtime

  • 91. 
    An older adult has been taking a bath in the morning following a facility's routine. At home, however, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. Which of the following interventions should the nurse take first?   
    • A. 

      Rub her back for 15 minutes before bedtime

    • B. 

      Offer her warm milk and crackers at 2100

    • C. 

      Allow her to take a bath in the evening

    • D. 

      Ask her provider for a sleeping medication

  • 92. 
    An 81-year old patient has been transferred from a long term care facility to an acute care setting. An indwelling urinary catheter was inserted just before her transfer. Which of the following may help prevent the development of nosocomial infection?
    • A. 

      Assess the patient's ability to void independently

    • B. 

      Place an absorbent pad under the patient to protect the bed in case of incontinence

    • C. 

      Frequently clean the patient's perineal area and properly care for her catheter

    • D. 

      Give the client a diet high in fiber to prevent constipation.

  • 93. 
    Which of the following are appropriate teaching measures related to care of the feet for a client who has diabetes mellitus? 
    • A. 

      Inspect the feet daily

    • B. 

      Use moisturizing lotions on the feet

    • C. 

      Wash the feet with warm water and let them air dry

    • D. 

      Use over-the-counter products to treat abrasions

    • E. 

      Check shoes for any foreign objects

  • 94. 
    A client experiences dyspnea and reports feeling tired after completing her morning care. Which of the following should the nurse include in the client's plan of care for the next day?  
    • A. 

      Plan several rest periods during morning care

    • B. 

      Do not offer any morning care

    • C. 

      Perform all of the client's care as quickly as possible

    • D. 

      Ask a family member to come in to give the client a bath.

  • 95. 
    In which stage of grief is a client who is terminally ill displaying when she states that she is going to a clinic for acupuncture? 
    • A. 

      Anger

    • B. 

      Depression

    • C. 

      Bargaining

    • D. 

      Acceptance

  • 96. 
    Which of the following is a sign of impending death?
    • A. 

      Elevated blood pressure

    • B. 

      Warm extremities

    • C. 

      Tense muscles

    • D. 

      Labored breathing

  • 97. 
    • A. culturally competent
    • A.
    • B. culturally congruent
    • B.
    • C. culturally sensitive
    • C.
    • D. culturally appropriate
    • D.
  • 98. 
    The belief that one's culture is superior to others is called 
    • A. 

      Ethnocentrism

    • B. 

      Socialization

    • C. 

      Repatterning

    • D. 

      Acculturation

  • 99. 
    Match the following terms with the descriptions. 
    • A. Hope
    • A.
    • B. Spiritual distress
    • B.
    • C. Spirituality
    • C.
    • D. Religion
    • D.
  • 100. 
    A client is observed crying as he reads from his devotional book. What intervention is appropriate? 
    • A. 

      Contact the hospital's spiritual services

    • B. 

      Ask him what is making him cry

    • C. 

      Provide quiet times for these moments

    • D. 

      Turn on the television for a distraction