Preliminary Examination In Competency Appraisal
Aklan Polytechnic College College of Nursing 1st Semester A. Y. 2020-2021 PRELIMINARY EXAMINATION IN COMPETENCY APPRAISAL
- 1.A nurse is discussing hearing aids with a client who began wearing hearing aids 5 weeks earlier. Which statement demonstrates that the client is successfully adapting to the hearing aids?
- A.
“I just wear the hearing aids when I go out in public.”
- B.
“I take a cotton-tipped swab and clean out my ear canals before I insert the hearing aids.”
- C.
“I store the hearing aids in the protective box.”
- D.
“I use mild soap and water weekly to soak the plastic parts of the hearing aids after I remove the batteries.”
- 2.A nurse is caring for a client who is unable to perform oral hygiene. The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?
- A.
Don sterile gloves before removing the dentures.
- B.
Use a foam swab to pry the upper plate loose before removing it.
- C.
Loosen the upper plate by grasping it at the front teeth with a piece of gauze and moving the plate up and down to loosen it prior to removal.
- D.
Leave the dentures in the client’s mouth and use a toothbrush to brush the plates.
- 3.A client who underwent surgery for colon cancer 6 weeks earlier has an appointment with a wound care nurse. After correctly demonstrating the changing of the stoma pouch, the client asks the nurse for advice regarding how to deal with gas coming from the stoma. To respond to the client’s concern, the nurse should ask the client to do which of the following? SELECT ALL THAT APPLY.
- A.
Describe the usual dietary intake, including types of foods
- B.
Include cruciferous vegetables in the diet daily
- C.
Decrease fluid intake to 1,200 mL per 24 hours
- D.
Prick the colostomy stoma pouch with a pin
- E.
Limit intake of gas-producing beverages such as carbonated sodas
- F.
Go to the restroom to release the gas that collects in the colostomy stoma pouch by opening the pouch clamp
- 4.A male client undergoes surgery for a hernia repair. The client has orders to be discharged to home when stable. The client has tried several times to urinate into the urinal while in bed without success. Which interventions are appropriate to promote voiding for this client? SELECT ALL THAT APPLY.
- A.
Apply an external catheter
- B.
Assist the client to stand at the bedside to attempt to void
- C.
Assess the pain level of the client and administer medication appropriately if in pain
- D.
Assist the client to the bathroom and turn on running water within hearing distance of the client while the client attempts to void
- E.
Discuss relaxation techniques and ask the client to imagine being at home and voiding in his own home bathroom
- F.
Explain that the client should void within 8 hours of surgery or return to the hospital for catheterization.
- 5.A client who was treated for constipation 1 month earlier comes to a primary care provider’s office for an appointment. A nurse interviews the client and obtains information from the client about bowel function and the effectiveness of the prescribed treatments. The nurse determines that the client is no longer constipated based on which statement?
- A.
The client drinks 2,000 mL of fluids daily; including 4 ounces of prune juice.
- B.
The client has had a soft, formed bowel movement without straining every other day for the past 2 weeks.
- C.
The client self-administered one disposable enema the day of last month’s appointment.
- D.
The client has minor discomfort from hemorrhoids during bowel movements.
- 6.A client who is recovering from orthopedic surgery keeps an appointment at a clinic and uses a walker to ambulate with partial weight-bearing as instructed. Which observation should lead the nurse to conclude that the client is using the correct technique?
- A.
Has elbows bent at a 30-degree angle
- B.
Is bent over the walker
- C.
Lifts the walker while walking; holding it about 2 inches above the floor
- D.
Has a walker that has four wheels in place
- 7.A nurse reviews the record of a client who has been immobile because of a degenerative neurological condition. The nurse reads that the client has bilateral foot drop. Which finding during the nurse’s assessment supports the presence of foot drop?
- A.
The great toe is dorsiflexed and the other toes are fanned out.
- B.
The feet are unable to be maintained perpendicular to the legs.
- C.
The client is unable to move feet into a position of plantar flexion.
- D.
The client is only able to dorsiflex the feet bilaterally.
- 8.A home health nurse visits an 82-year-old client who has experienced multiple strokes and is unable to change position independently in bed. The nurse teaches family caregivers techniques to move and reposition the client, who is in a hospital bed. Which technique should be included in the teaching plan for this client?
- A.
Before moving the client, family caregivers should raise the hospital bed to the level of their waists. After completing the move, the bed must be returned to the lowest level.
- B.
The pillow should be removed from under the client’s head when positioned in a dorsal recumbent position.
- C.
Family members should tighten their abdominal muscles and buttocks while keeping their feet about 12 inches apart when using a lift sheet to pull the client up in bed.
- D.
The client’s heels should rest on the bed surface and feet kept in a position perpendicular to the legs when the client is lying on the back.
- 9.A hospitalized client, identified to be at risk for thromboembolic disease, has anti-embolism hose ordered. A nurse discusses the correct use of the stockings. Which direction should the nurse include in teaching this client?
- A.
If ambulating 10 times daily for 5 minutes at a time, wearing the hose is unnecessary.
- B.
The most appropriate time to apply the hose is before standing to get out of bed in the morning.
- C.
If the hose becomes painful to the skin underneath, notify the nurse and request pain medication.
- D.
Only cross the legs while wearing the antiembolism hose; otherwise keep the legs uncrossed.
- 10.A client reports pain at an intravenous infusion site that has infiltrated. When a nurse applies a warm, moist compress to the site, the client asks how the treatment will help the condition. The nurse answers the client based on the understanding that the application of moist heat will:
- A.
Alter tissue sensitivity by producing numbness.
- B.
Decrease the metabolic needs of the involved tissues.
- C.
Stop the local release of histamine in the tissues.
- D.
Increase blood flow and improve capillary permeability.
- 11.A nurse is caring for a client who has experienced a first-degree sprain of the ankle. A primary care provider writes a prescription for an analgesic medication. Which intervention, beside the analgesic, should the nurse advise the client to utilize for the first 24 hours after the injury?
- A.
Applying ice directly to the ankle
- B.
Soaking the foot in warm water for 20 minutes, three times per day
- C.
Applying ice continuously to the ankle
- D.
Resting and elevating the limb as much as possible
- 12.An elderly client residing in a nursing home has bilaterally weak handgrips and has difficulty with self-feeding. Which nursing interventions should be implemented to promote independence for this client? SELECT ALL THAT APPLY.
- A.
Ask the client for permission to open all containers, remove lids from items on the food tray, and cut up meats
- B.
Obtain built-up silverware for the client to use
- C.
Observe the client but do not provide assistance if the client is having difficulty
- D.
Feed the client if the client is eating too slowly
- E.
Ensure that the client is wearing prescribed dentures, eye glasses, or hearing aids before starting to eat
- 13.A dietitian, who is consulted to see a hospitalized client because of nutritional concerns, orders a calorie count. The nurse should participate in this intervention by:
- A.
Asking the client to recall the food and beverages consumed on a normal day.
- B.
Asking the client to recall the food and beverages consumed on the day the calorie count is initiated.
- C.
Informing the client that a record is being maintained of food and beverages consumed.
- D.
Asking the client to approximate how many times per week certain food groups, such as cereals and breads, are eaten.
- 14.A hospitalized client has daily weights ordered. The client is able to stand, and the nursing unit has an electronic digital scale to use for client weights. Which intervention best ensures that the client’s daily weight is accurate?
- A.
Asking the client to wear supportive shoes before stepping on the scale
- B.
Ensuring that the scale is calibrated and “zeroed” before a weight is obtained
- C.
Weighing the client by moving the sliding indicator until the scale balances
- D.
Weighing the client at different times of the day
- 15.A nurse plans guidelines to assist nursing personnel in meeting the hygiene needs of adult clients with dementia. Which guidelines are appropriate for the nurse to include? SELECT ALL THAT APPLY.
- A.
Utilizing two staff members to bathe the client quickly while limiting the client’s ability to physically resist
- B.
Creating a calm environment during a bed bath by including music and dimmed lighting
- C.
Allowing clients, who are willing and able, to participate in some of the hygiene activities
- D.
Assessing and treating clients for pain before initiating hygiene activities
- E.
Washing the hair and body separately if either activity causes distress or is overwhelming to the client
- F.
Keeping the temperature of the bathing area warm and limiting body exposure of clients during bathing
- 16.A nurse should inform a nursing assistant to avoid taking a rectal temperature for which client?
- A.
The adult client who underwent ileostomy surgery because of a perforated bowel
- B.
The adult client who has a frequent, productive cough and is receiving oxygen by nasal cannula
- C.
The adult client who developed thrombocytopenia after receiving chemotherapy
- D.
The adult client with hypothermia
- 17.A nursing assistant (NA), who is taking routine vital signs, tells a nurse that the small adult cuff is nowhere to be found and that a client’s arm is too small to use an adult-size cuff. In response to the NA’s report, which direction should the nurse give to the NA?
- A.
Document the other vital signs and note that proper blood pressure (BP) equipment is not available
- B.
Contact the nursing supervisor, obtain a small, adult BP cuff, and take the client’s BP with the small, adult-size cuff
- C.
Use the adult size BP cuff to obtain the blood pressure, add 10 to both the diastolic and systolic readings, and document on the client’s record the BP was obtained with an adult cuff
- D.
Take the client’s BP using any available cuff
- 18.A nurse takes a client’s blood pressure with an automatic blood pressure machine. The blood pressure is 86/56 mm Hg with a pulse rate of 64 beats per minute. Which action should the nurse do first?
- A.
Assess the client for dizziness and assess the skin on the extremities for warmth
- B.
Obtain a manual blood pressure cuff and retake the client’s blood pressure
- C.
Elevate the head of the client’s bed
- D.
Read the client’s medical record and determine the client’s normal range of blood pressure
- 19.A nurse is using a tympanic thermometer to measure a client’s temperature. When using a tympanic thermometer, the nurse should:
- A.
Check the setting to know the type of measurement reading, such as oral or core temperature.
- B.
Irrigate the ear canal with sterile saline 6 hours before obtaining the temperature.
- C.
Pull downward on the pinna in an adult when inserting the thermometer.
- D.
Hold the thermometer loosely in the ear until the thermometer sounds that the reading is finished.
- 20.A client who underwent a surgical procedure the preceding day has a normal assessment with an oral temperature of 99.7°F (37.6°C) at 0800 hours. The client is to be discharged later in the day if the client’s condition is stable. Based on the client’s current temperature, which action should be taken by the nurse?
- A.
Inform the surgeon since the discharge should be cancelled.
- B.
Instruct the client to use the incentive spirometer 10 times every hour and drink plenty of fluids and then recheck the temperature in 2 hours
- C.
Administer the dose of aspirin 81 mg earlier than the scheduled time
- D.
Realize that the temperature is only mildly elevated and was taken during the time of day when temperatures are highest according to normal diurnal deviations
- 21.A nurse is preparing to provide phototherapy to a 4-day-old newborn who was admitted with hyperbilirubinemia. The nurse instructs the parents on how to care for their baby while receiving phototherapy in the hospital. The nurse’s teaching should include:
- A.
Keeping the baby fully clothed to prevent hypothermia.
- B.
Covering the baby’s eyes with eye shields to prevent retinal damage.
- C.
Decreasing the number of feedings for their baby to reduce the number of soiled diapers.
- D.
Discontinuing the phototherapy if a mild skin rash develops.
- 22.When using a hypothermia blanket for a febrile client, which findings should lead the nurse to suspect hypothermia? SELECT ALL THAT APPLY.
- A.
Increased urine output
- B.
Drowsiness
- C.
Decreased heart rate (HR)
- D.
Decreased blood pressure (BP)
- E.
Increased BP
- F.
Increased HR
- 23.Which signs should indicate to a nurse that a client is experiencing a surgical site infection? SELECT ALL THAT APPLY.
- A.
Temperature of 100.4°F (38°C)
- B.
Localized pain and tenderness
- C.
Well-approximated wound edges
- D.
Redness or warmth at the affected site
- E.
Purulent drainage at the incision site
- F.
Thick, white drainage in the Jackson-Pratt (JP) tubing
- 24.A nurse is assessing a wound while completing a dressing change. The nurse documents the pressure ulcer as stage III. Which is the best description of the stage III pressure ulcer?
- A.
Partial-thickness skin loss involving the epidermis, dermis, or both
- B.
Full-thickness skin loss involving damage to subcutaneous tissue
- C.
Redness with intact skin that client reports as “itchy”
- D.
Full-thickness skin loss with undermining and sinus tracks
- 25.Which actions should a nurse plan when caring for a client with a stage III pressure ulcer to the right lower-extremity heel? SELECT ALL THAT APPLY.
- A.
Monitor the client’s nutritional intake
- B.
Assess for pain and premedicate prior to dressing changes
- C.
Monitor pedal pulses and capillary refill of affected extremity
- D.
Use hydrogen peroxide for cleaning of ulcer wound
- E.
Turn and reposition client every 1 to 2 hours
- F.
Elevate the extremity on pillows
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