1.
The client's temp at 8:00 am, using an oral thermometer is 36.1° C (97.2° F). If the resp, pulse, and bp are WNL, what would the nurse do next?
Correct Answer
B. Check what the client's temperature was the last time
Explanation
Although the temp is slightly lower than expected, it would be best to determine the client's previous temp range next. This may be normal for the client.
2.
Which of the following clients meets the criteria for the selection of an apical site for assessment of the pulse rather than radial pulse?
Correct Answer
C. A client with an arrhythmia
Explanation
the apical pulse would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm.
3.
When the nurse enters the room to enter vital signs in preparing the client for a dx test, the client is on the phone. What technique should the nurse use to determine the respiration rate?
Correct Answer
D. Since there is no evidence of distress or urgency, defer the measurement
Explanation
Since the client's needs always come first, delay the measurement unless it looks urgent.
4.
For a client with a previous blood pressure of 138/74 and pulse of 64, approx. how long should the nurse take to release the bp cuff in order to obtain an accurate reading?
Correct Answer
B. 30-45 sec
Explanation
deflation should occur at 2-3 mm Hg per second, so previous start would have been 168 (30+138) and going down at a rate of 2-3 seconds.
5.
It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP?
Correct Answer
A. A client being prepared for elective facial surgery with a hx of stable hypertension
Explanation
Vital signs may be delegated if they are stable, the findings are expected or the technique requires no modification.
6.
An 85-year-old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing and is unable to move self or maintain position unaided. The nurse determines that which of the following sites is appropriate for taking temp
Correct Answer
C. Axillary, Typmpanic, Temporal
Explanation
Ok - oral + stroke + facial dropping = no. Rectal would work but that's wayyy to much extra work when you have other methods.
7.
The nurse reports that the client has dyspnea when ambulating. The nurse is most likely assessed which of the following?
Correct Answer
C. Shortness of breath
Explanation
Dyspnea is related to inadequate oxygenation, meaning the client will most likely experience shortness of breath. Shallow respirations are associated with tachypnea (rapid breathing). Wheezing may or may not occur with dyspnea. Hemoptysis is unrelated to dyspnea.
8.
It is important to remove gloves and gowns in the room if the client is under which of the following precautions?
Correct Answer
C. Contact
Explanation
see K+E pg. 689
9.
Place the following nurse priories in the correct sequence if a fire occurs in a health setting.
1. report the fire
2. extinguish the fire
3. protect the clients
4. contain the fire
Correct Answer
C. 3,2,4,1
Explanation
In the event of a fire in a health setting, the first priority should be to protect the clients by ensuring their safety and evacuating them if necessary. Once the clients are safe, the nurse should then report the fire to the appropriate authorities or fire department. After reporting the fire, the nurse should focus on containing the fire to prevent it from spreading further and causing more damage. Finally, if it is safe to do so, the nurse can attempt to extinguish the fire using appropriate fire-fighting equipment. Therefore, the correct sequence of nurse priorities in this situation is 3, 2, 4, 1.
10.
What is the leading cause of accidents in young and middle aged adults?
Correct Answer
A. Automobile crashes
Explanation
Automobile crashes are the leading cause of accidents in young and middle-aged adults. This is because young and middle-aged adults are more likely to be active drivers and spend a significant amount of time on the roads. Factors such as inexperience, distracted driving, speeding, and impaired driving contribute to a higher risk of accidents in this age group. Additionally, the use of mobile devices while driving has become increasingly common among young and middle-aged adults, further increasing the likelihood of automobile crashes.
11.
Because a hospitalized elderly female client, who ambulates with a walker, is receiving diuretics which result in frequent trips to the bathroom at night, the nurse should perform which of the following?
Correct Answer
C. Provide bedside commode
Explanation
12.
Which NADA nursing dx is most applicable for toddlers?
Correct Answer
C. Risk for poisoning
Explanation
The nursing diagnosis "Risk for poisoning" is the most applicable for toddlers because they are at a stage where they are curious and exploring their environment, which puts them at a higher risk for accidental ingestion of harmful substances. Toddlers have a tendency to put objects in their mouths, and they may not have developed the ability to differentiate between safe and dangerous substances. Therefore, the risk for poisoning is a significant concern for this age group.
13.
A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure?
Correct Answer
D. Use a bed exit safety monitoring device
Explanation
The most appropriate safety measure for a 75-year-old client who becomes disoriented and tries to get out of bed is to use a bed exit safety monitoring device. This device will help alert the healthcare team if the client attempts to leave the bed without assistance, allowing them to intervene and prevent falls or injuries. Restraints should be avoided whenever possible due to the risk of physical and psychological harm. Asking a family member to stay with the client may not be feasible or available at all times, and checking the client every 15 minutes may not provide immediate intervention if the client attempts to leave the bed.
14.
A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission?
1. Place a padded tongue depressor at the head of the bed
2. Pad the bed with blankets
3. Inform the client about the importance of a medical tag
4. Teach the client about epilepsy
5. Test oral suction equipment
Correct Answer
D. 2,5
15.
Which of the following nursing interventions is the highest in priority for a client at risk for falls in a hospital setting?
Correct Answer
D. Place the bed in the lowest position
Explanation
placing bed in the lowest position makes the fall shorter
16.
When planning to teach health care topics to a group of male adolescents, the nurse should consider which of the following topics take priority?
Correct Answer
C. Guns are the most frequently used weapon in adolescent suicide
Explanation
When planning to teach health care topics to a group of male adolescents, the nurse should consider that guns are the most frequently used weapon in adolescent suicide. This topic takes priority because it addresses a serious and immediate health concern for this specific population. By providing education and raising awareness about the dangers of guns and the risk of suicide, the nurse can potentially help prevent tragic outcomes and promote the overall well-being of these adolescents.
17.
A client can bathe independently except for the back and feet, walk to and from the bathroom and dress if the clothing is provided. What is the most appropriate functional level for this client?
Correct Answer
C. Semidependent (+2)
Explanation
The client is able to perform most activities of daily living independently, such as bathing, walking, and dressing. However, they require assistance with bathing their back and feet, indicating a level of dependency in those areas. Therefore, the most appropriate functional level for this client is semidependent (+2).
18.
A client with diabetes has very dry skin on her feet and lower extremities. To maintain intact skin the nurse teaches which of the following?
Correct Answer
B. Use of non-perfumed lotion
Explanation
Using a non-perfumed lotion is the correct answer because it helps to moisturize the skin and prevent dryness. Perfumed lotions may contain irritants that can further dry out the skin, so it is important to use a non-perfumed option. Soaking the feet frequently can actually worsen dryness by stripping away natural oils. Applying foot powder may help with odor, but it does not address the issue of dry skin. Avoiding knee high elastic stockings is not directly related to maintaining intact skin on the feet and lower extremities.
19.
The client wears an in-the-ear hearing aid and because of arthritis needs someone to insert the hearing aid. THe nurse teachers the UAP to do which of the following actions before inserting the client's hearing aid?
Correct Answer
A. Turn the hearing aid off
Explanation
Before inserting the client's hearing aid, it is important to turn the hearing aid off. This is necessary to prevent any discomfort or potential harm to the client's ear when the hearing aid is being inserted. Turning off the hearing aid ensures that it is not accidentally turned on during the insertion process, which could cause discomfort or loud noises for the client.
20.
The client is in surgery and will be returning to his bed via a stretcher. The nurse plan ahead by making which type of beds and placing the bed in which position?
Correct Answer
D. A surgical bed in high position
Explanation
The client is in surgery and will be returning to his bed via a stretcher. In order to accommodate the client's needs and ensure a smooth transition, the nurse plans ahead by making a surgical bed in high position. This allows for easy access and transfer of the client from the stretcher to the bed.
21.
The nurse observed the UAP performing perineal care for a client. WHich of the following actions indicates that further teaching is required?
Correct Answer
D. Did not retract foreskin
Explanation
The nurse observed the UAP performing perineal care for a client and noticed that they did not retract the foreskin. This indicates that further teaching is required because retracting the foreskin is an important step in perineal care for male clients. It allows for proper cleaning and inspection of the area, ensuring hygiene and identifying any potential issues or abnormalities. Therefore, the UAP should be educated on the importance of retracting the foreskin during perineal care.
22.
The nurse is discussing foot care with a client who was recently dx with diabetes. Which of the following statements indicates a need for further teaching?
Correct Answer
B. I enjoy walking barefoot around the house
Explanation
walking barefoot increases the chance for injury and infection
23.
The client is experiencing labored, shortness of breath has a respiratory rate of 28. The bed is currently in the flat position. The best nursing intervention includes putting the bed in which of the following positions?
Correct Answer
A. Fowler's
Explanation
The client is experiencing labored, shortness of breath and has a respiratory rate of 28. Placing the bed in Fowler's position would be the best nursing intervention. Fowler's position is a semi-sitting position with the head of the bed elevated between 45 and 60 degrees. This position helps to improve lung expansion and ease breathing by allowing the diaphragm to descend more easily. It also helps to prevent aspiration and promotes drainage in patients with conditions such as pneumonia or congestive heart failure.
24.
Which of the following nursing dx is most appropriate for a client with a BMI of 35 would likely have?
Correct Answer
B. Imbalanced nutrition: more than body requirements
Explanation
Imbalanced nutrition: more than body requirements is the most appropriate nursing diagnosis for a client with a BMI of 35. This diagnosis indicates that the client is consuming more calories than their body needs, leading to weight gain and an increased risk for obesity-related health problems. The client's high BMI suggests that they may be overeating or making poor food choices, contributing to the imbalance in their nutrition. By identifying this diagnosis, nurses can develop interventions to help the client make healthier dietary choices and manage their weight effectively.
25.
An adult reports eating, on average, the following each day: 3 cups dairy, 2 cups fruit, 5 ounces grain, and 5 ounces meat. The nurse counsel would be:
Correct Answer
D. Increase the number of servings of grains
Explanation
The adult's daily intake of dairy, fruit, and meat is within the recommended range. However, the intake of grains is below the recommended amount of 6 ounces per day. Therefore, the nurse would advise increasing the number of servings of grains to ensure a balanced diet.
26.
Which of the following is the best indication of proper placement of nasogastric tube in the stomach?
Correct Answer
C. pH of the aspirate is less than 5
Explanation
The pH of the aspirate being less than 5 is the best indication of proper placement of a nasogastric tube in the stomach. A pH of less than 5 indicates that the tube is in the acidic environment of the stomach, confirming correct placement. The other options, such as the client being unable to speak or gagging during insertion, are not reliable indicators of proper placement. Additionally, the ease of fluid instillation into the tube does not necessarily indicate correct placement.
27.
What is the proper technique with gravity tube feeding?
Correct Answer
A. Feeding bag is hung 1 ft higher than the tube's insertion point into the chest
Explanation
The proper technique with gravity tube feeding is to hang the feeding bag 1 ft higher than the tube's insertion point into the chest. This ensures a continuous flow of the feeding solution into the patient's stomach or intestines. Gravity helps in the proper flow of the feeding solution and prevents any backflow or blockage in the tube. Hanging the bag higher than the insertion point creates a pressure gradient that facilitates the flow of the solution.
28.
A 55-year-old female is about 20 lb over her desired weight. She has been on a low calroies diet with no improvement. Which of the following statements reflects a health approach to the desired weight loss? "I need to:"
Correct Answer
A. Increase my exercise at least 30 min each day
Explanation
Increasing exercise by at least 30 minutes each day is a healthy approach to desired weight loss. Exercise helps to burn calories and increase metabolism, which can aid in weight loss. It also has numerous other health benefits, such as improving cardiovascular health, increasing muscle strength, and boosting mood. Switching to a low carb diet may be effective for weight loss in some cases, but it is not specified if the individual's current diet is high in carbs. Keeping a list of forbidden foods may lead to a restrictive mindset and potential disordered eating patterns. Buying more organic and less processed foods can be a healthy choice, but it alone may not lead to significant weight loss.
29.
An elderly asian client has mild dysphagia from a recent stroke. The nurse plans the clien's meal based on the need to:
Correct Answer
C. Include as many of the client's favorite foods as possible
Explanation
The nurse plans the client's meal based on the need to include as many of the client's favorite foods as possible. This is because the client has mild dysphagia from a recent stroke, which may make swallowing difficult. By including the client's favorite foods, the nurse can ensure that the client enjoys their meal and is more likely to eat an adequate amount. This is important for maintaining proper nutrition and preventing malnourishment in elderly clients.
30.
Which of the following meals would the nurse recommend to a client as the highest in calcium, iron and fiber
Correct Answer
D. 3 ounces tuna, +1 ounce cheese sandwich on whole wheat bread plus a pear
Explanation
The meal consisting of 3 ounces of tuna, a 1 ounce cheese sandwich on whole wheat bread, and a pear would be recommended by the nurse as the highest in calcium, iron, and fiber. Tuna is a good source of both calcium and iron, while the cheese sandwich on whole wheat bread provides additional calcium and fiber. The pear adds more fiber to the meal, making it the best choice for all three nutrients. The other meal options do not contain as much calcium, iron, and fiber as this choice.
31.
The nurse recognizes that urinary elimination changes may occur even in health elders because
Correct Answer
D. The amount of urine retained after voiding increases
Explanation
As people age, their bladder muscles may weaken, leading to incomplete emptying of the bladder. This can cause a larger amount of urine to be retained after voiding. This is why the nurse recognizes that urinary elimination changes may occur even in healthy elders. The other options are not relevant in explaining this phenomenon.
32.
During assessment of the client with urinary incontinence, the nurse is most likely to assess which of the following? 1. Perineal skin irritation2. Fluid intake < 1,500 ml day3. Hx of Antihistamine intake4. Hx of frequent urinary tract infections
Correct Answer
C. 1,2,4
Explanation
Antihistamines can increase urine output
33.
Which of the following represents the appropriate nursing managemnt of a client wearing a condom catheter?
Correct Answer
B. Check the penis for adequate circulation after 30 min
Explanation
The appropriate nursing management of a client wearing a condom catheter includes checking the penis for adequate circulation after 30 minutes. This is important to ensure that the condom catheter is not causing any restriction in blood flow to the penis, which could lead to complications such as tissue damage or necrosis. Regular checks for circulation help to prevent these complications and ensure the client's safety and well-being.
34.
During the straight catheterization of a female client, if the catheter slips into the vagina, the nurse should
Correct Answer
A. Leave the catheter in place and get a new sterile catheter
Explanation
the catheter can not be reused. Leaving the old on in place will help differentiate vaginal opening from the urinary meatus
35.
Which of the following statements indicates the need for further teaching of home care client with a long-term indwelling catheter?
Correct Answer
C. Soaking in a warm tub bath may decrease irritation associated with the catheter
Explanation
Soaking increases the possible spreading of infection
36.
The nurse will need to assess the client's performance of client intermittent self-catherization (CISC) for a client with which of the following?
Correct Answer
B. Kock pouch
Explanation
A Kock (pronounced coke) pouch creates a conduit to the bladder using a portion of the ileum to form a reservoir for urine. Client needs to place catheter @ home. CISC requires medical aspesis.
37.
Because the client has flaccid bladder, the nurse is most likely to teach which of the following?
Correct Answer
C. Credes Maneuver: apply gentle manual pressure to the lower abdomen
Explanation
The client with a flaccid bladder is likely to have difficulty emptying their bladder completely. The Credes Maneuver involves applying gentle manual pressure to the lower abdomen to help promote bladder emptying by manually compressing the bladder. This technique can be taught by the nurse to help the client effectively empty their bladder and prevent complications such as urinary retention or urinary tract infections. Habit training, bladder training, and Kegel exercises may not be as effective in this situation as they do not directly address the issue of bladder emptying.
38.
Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in
Correct Answer
A. Constipation
Explanation
Repeatedly ignoring the sensation of needing to defecate can lead to constipation. When individuals consistently ignore the urge to have a bowel movement, the stool can become dry and hard, making it difficult to pass. This can result in infrequent or incomplete bowel movements, causing discomfort and bloating. Therefore, it is important for clients to be aware of the importance of responding to the body's natural signals and not ignoring the need to defecate.
39.
Which of the following statements provide evidence that an older adult who is prone to constipation needs more education?
Correct Answer
B. I need to take a laxative such as milk of magnesia if I don't have a BM each day.
Explanation
The statement "I need to take a laxative such as milk of magnesia if I don't have a BM each day" provides evidence that the older adult may need more education on managing constipation. This statement suggests that the individual believes that taking a laxative is necessary for daily bowel movements, which may indicate a lack of understanding about natural bowel patterns and the importance of dietary and lifestyle changes in promoting regular bowel movements.
40.
Because a client is scheduled for a colonscopy, the nurse will instruct the client to perform which of the following?
Correct Answer
D. Low, small volume enema
Explanation
high volume enema could result in electrolyte imbalance that makes it less than ideal.
41.
The nurse is most likely to report which of the following findings to the PCP for a client who has an established colostomy?
Correct Answer
C. The stoma color is deep purple
Explanation
The nurse is most likely to report that the stoma color is deep purple because this could indicate a lack of blood supply to the stoma, which is a serious concern. A healthy stoma should be pink or red, so a deep purple color suggests ischemia or necrosis. This finding should be reported to the primary care physician immediately for further evaluation and intervention.
42.
A client with a new stoma who has not had a bowl movement since surgery last week reports feeling nauseous. What is the appropriate action?
Correct Answer
B. After assessing the stoma and surrounding skin, call the surgeon.
Explanation
Don't give meds or interventions without an order. Right?
43.
The nurse assess a client's abdomen several days after abdominal surgery. It is firm, distended and painful to palpate. The client reports feeling bloated. The nurses consults with the surgeon who orders an enema. The nurse prepares to give what kind of enema?
Correct Answer
C. Return flow enema
Explanation
The given answer, "return flow enema," is correct because the client's symptoms of a firm, distended abdomen, pain on palpation, and feeling bloated indicate the presence of gas or fecal impaction. A return flow enema is designed to help relieve these symptoms by introducing fluid into the rectum and then allowing it to flow back out, carrying any gas or fecal matter with it. This type of enema helps to relieve discomfort and promote bowel movement.
44.
Which of the following is most likely to validate that a client is experiencing intestinal bleeding?
Correct Answer
C. Semisoft tar-colored stools
Explanation
Semisoft tar-colored stools are most likely to validate that a client is experiencing intestinal bleeding. Intestinal bleeding can cause the stool to appear black and tarry, indicating the presence of digested blood. This stool color is often associated with bleeding in the upper gastrointestinal tract, such as the stomach or small intestine. It is important to note that the other options do not typically indicate intestinal bleeding. Large quantities of fat mixed with pale yellow liquid stool may suggest malabsorption or pancreatic issues, brown, formed stools are considered normal, and narrow, pencil-shaped stools may indicate a potential obstruction in the colon.