Examination 1 (NR224)

Questions

QUESTION 1
Which of the following is an example of a standards for critical thinking?
a) Professional standards
b) Non-intellectual standards
c) Competent standards
d) Basic standards

QUESTION 2
A nurse enters a client’s room to assess vital signs, and the client states, “I drank some hot tea about 5 minutes ago.” Which of the following actions should the nurse take?
a) Wait 10 seconds and return to assess the client’s oral temperature
b) Wait 30 minutes and return to assess the client’s oral temperature
c) Document that the client’s temperature was unable to be assessed
d) Assess the client’s rectal temperature and document findings

QUESTION 3
A nurse is instructing a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the instructions?
a) Look down at your feet while using the crutches
b) Place one crutch forward with the opposite foot, and then place the second crutch forward followed by the second foot
c) Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches
d) Support your body weight on the underarm crutch pads

QUESTION 4
A client on droplet isolation precautions verbalizes feeling uncomfortable when the nurse enters the room with personal protective equipment on. What is the most appropriate nursing action?
a) Request that the isolation precautions are discontinued
b) Reinforce education about the need for protective equipment
c) Limit interactions with the client
d) Wear personal protective equipment only when touching the client

QUESTION 5
The unlicensed assistive personal (UAP) tells the nurse that a client’s heart rate is abnormally high. Which action should the nurse take first?
a) Ask the UAP to recheck the heart rate
b) Assess the heart rate
c) Notify the health care provider
d) Document the heart rate reported by the UAP

QUESTION 6
A nurse needs to lift a box in the supply room. Which of the following actions should the nurse take to prevent an injury due to lifting?
a) Stand with feet shoulder-width apart when lifting
b) Turn to the side when setting the box to the side
c) Hold the box from the body while lifting
d) Bend at the waist when picking up the box

QUESTION 7
The nursing process is utilized when nurses care for clients. Which statements about the nursing process are accurate? Select all that apply.
a) Prescribe diagnostic tests based on objective data
b) Identify appropriate nursing interventions for client care
c) Plan care to achieve health-related goals
d) Use a medical diagnosis to state client problems
e) Utilize assessment data to determine client needs

QUESTION 8
A nurse is caring for a newly admitted client. The client complained of fever and chills. Which of the following is a priority nursing action?
a) Administer an antipyretic medication
b) Provide client with cold fluids to drink
c) Assess client’s temperature
d) Notify the physician

QUESTION 9
The nurse obtains the following data as part of the assessment phase of the nursing process. Which data represent subjective findings? Select all that apply.
a) Client states “I’m anxious”
b) Unsteady gait observed during ambulation
c) Pain reported 6 out of 10
d) Blood glucose 82mg/dl
e) Respirations:18 breaths per minute
f) Headache with vision changes

QUESTION 10
A client is admitted to the hospital for suspected active tuberculosis. What is the nurse’s highest priority when admitting this client to the nurse facility?
a) Hang a sign on the door to restrict visitors
b) Don a surgical mask immediately
c) Report the client’s infection to the center for disease control (CDC)
d) Place the client in a negative air flow room

QUESTION 11
A nurse auscultates an immobilized client’s lungs and notes crackles to the left upper lobe. The nurse should understand that this finding is most likely an indication of which of the following conditions?
a) Chest pain
b) Pulmonary edema
c) Pneumonia
d) Asthma exacerbation

QUESTION 13
A nurse is instructing unlicensed assistive personnel (UAP) about using personal protective equipment (PPE) while caring for clients. Which of the following statements should the nurse identify as an indication that the UAP understands the instructions?
a) I will wear gloves when measuring a client’s blood pressure
b) I will wear gloves to minimize the number of times I have to wash my hands
c) I will wear gloves whenever I am in contact with clients
d) I will wear gloves and gown when bathing a client with open skin lesions

QUESTION 14
While providing preoperative teaching for a client who undergo surgery, the nurse explains that the client will wear ant-embolism stockings during and after the procedure. When the client asks that the stockings do, which of the following responses should the nurse make?
a) They will help to maintain your body temperature
b) They will make it easier for you to range-of-motion exercises
c) They will protect your legs and heels from pressure ulcerations
d) They will improve blood flow in your legs

QUESTION 15
A nurse is instructing a client about the regulation of body movements during activity and exercise. Which of the following systems of the body should the nurse include in the instructions as the most important system of the body that regulate body movement?
a) Skeletal system
b) Gastrointestinal system
c) Integumentary system
d) Genitourinary system

QUESTION16
A nurse is completing an initial assessment on a newly admitted client. Which objective information would the nurse expect to obtain? Select all that apply.
a) Observing the client’s use of accessory muscles
b) Noting the client’s level of consciousness
c) Discussing the client beliefs
d) Auscultating the client’s bowel sounds
e) Assessing the client’s gait during ambulation
f) Asking about the client’s family health history

QUESTION 17
What is the most common means of transmission of pathogens?
a) Gloves
b) Masks
c) Wounds
d) Hands

QUESTION 18
A mother is requesting access to the medical records of her 19 -year- old son. Which of the following statements by the nurse is appropriate?
a) I will have to ask my charge nurse first before I can allow you to view his records
b) I will review the information that you are requesting in just a moment
c) The patient will have to give permission for you to access the medical records
d) You will need to provide me with his full name and date of birth first

QUESTION 19
The nurse is caring for a client with radial pulse of 48 beats per minute. What is the nurse’s priority action for this client?
a) Auscultate the apical pulse rate
b) Palpate the brachial pulse
c) Document the radial pulse in the client’s chart
d) Inform the health care provider

QUESTION 20
A nurse in a clinic is assessing a client who will undergo diagnostic testing with injection contrast (dye). When should the nurse ask about the client’s potential allergies to contrast?
a) When the test is complete
b) Before the test begins
c) During the first 5 minutes of the test
d) One hour after the test

QUESTION 21
A nurse in a health care facility is helping an older client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. The nurse can best ensure proper use of the walker and the safety of the client by taking which of the following actions?
a) Have the client slide the walker forward while simultaneously moving one leg forward to take a step
b) Have the client lift the walker and place it in front of her with all four tips on the ground before taking a step
c) Make sure that the upper bar of the walker is level with the client’s waist
d) Walk in front of the client to assist in moving the walker

QUESTION 22
A unlicensed assistive personnel (UAP) reports a client’s vital signs to the nurse: temperature 37.1oc (98.8 o F), pulse 52/min, respiratory rate 18/min, and BP 118/78mmHg. Which of the following vital signs should the nurse re-measure?
a) Blood pressure
b) Respiratory rate
c) Temperature
d) Heart rate

QUESTION 23
A nurse is assisting an older adult client who requires minimal support to maintain balance while ambulating. Which of the following devices should the nurse use when helping the client ambulate?
a) Jacket harness
b) Gait belt
c) Four- wheel walker
d) Cane

QUESTION 24
A nurse has provided education to a client who received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
a) I will make sure that I have extra rubber crutch tips
b) Every day I will inspect my crutches for signs of water
c) I will place my body weight and lean on the crutches as needed
d) The crutches should not fit firmly under my axillae

QUESTION 25
The nurse is aware that an immobilized client is at risk for thrombus formation. Which interventions are associated with deep vein thrombosis prevention? Select all that apply.
a) Have the client wear elastic stocking
b) Administer antipyretic medication, as prescribed
c) Monitor temperature hourly
d) Encourage the client to perform ankle exercises
e) Apply sequential compression devices to the bilateral lower extremities

QUESTION 26
A nurse is preparing to assist a client who has been on bed rest for several days to ambulate for the first time. Which action should the nurse instruct the client to perform first?
a) Apply the gait belt around the client’s hips
b) Assist the client to a standing position slowly
c) Have the client look ahead while walking
d) Advise the client to sit on the side of the bed

QUESTION 27
A nurse is talking with a client who is beginning a range of motion exercise. The client asks the nurse why range of motion exercise are necessary. Which of the following responses should the nurse make?
a) Range of motion exercise increase joint mobility
b) Range of motion exercise reduced joint mobility
c) Range of motion exercise reduces circulation
d) Range of motion exercise causes disability

QUESTION 28
A nurse respects the right of others to have different opinions. The nurse is also tolerant of different views from the clients and peers. Which of the following concepts of a critical thicker does the nurse demonstrate?
a) Truth seeking
b) Analyticity
c) Open-mindedness
d) Self- confidence

QUESTION 29
A nurse is developing a plan of care for a new client. The nurse understands that which statement is correct regarding planning of safe, high-quality care in the nursing process?
a) Nursing practice is solely focused on the client satisfaction
b) Nursing practice is based upon scientific evidence
c) Nursing practice is founded on experience
d) Nursing practice is dependent upon standardized care plans

QUESTION 30
A violet client is placed on a physical restraint, how often should the nurse monitor the client?
a) Every thirty minutes
b) Every one hour
c) Every two hours
d) Every fifteen minutes

QUESTION 31
A client admitted to the hospital has developed a vancomycin-resistant enterococcus (VRE) infection. Which type of isolation precautions should the client use when caring for this client?
a) Contact
b) Airborne
c) Droplet
d) Standard

QUESTION 32
A nurse is caring for a client that is 1-day postoperative following gynecologic surgery. The client reports incisional pain. Which of the following actions should the nurse take first?
a) Determine the time the client last received pain medication
b) Ask the client to rate the pain on a scale from 0 to 10
c) Reposition the client and offer a back tub
d) Measure the client’s vital signs, including temperature

QUESTION 33
A client who has mobility restrictions receives home health care and spends most of the day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse anticipate?
a) Decrease in urinary stasis
b) Decrease in renal calculi
c) Increase in urine output
d) Increase in urinary tract infection

QUESTION 34
A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. Which of the following actions should the nurse plan to take?
a) Place the chair on the client’s right side
b) Instruct the client to place his hands around the nurse’s neck during the transfer
c) Raise the client’s bed to the nurse’s waist level
d) Use a gait belt when standing and pivoting the client

QUESTION 35
A visitor arrives to the nurse’s station with flowers and asks for an update about an immobile client’s condition. The visitor is worried about complications of immobility in the client. Which of the following responses should the nurse provide?
a) She got up to the bathroom three times yesterday
b) She is much better and should be discharged tomorrow
c) She is able to turn and reposition self in bed
d) I am not able to provide you with that information

QUESTION 36
Which of the following include physical hazards in the environment that threatens a client’s safety? (Select all that apply)
a) Poison
b) Fires
c) Poor nutrition
d) Falls
e) Disasters

QUESTION 37
A nurse is assessing a client who has a femur fracture. Which of the following changes in vital signs indicates that the client may be developing a serious complication?
a) Increase heart rate from 78 to 108 beat per minutes
b) Increase blood pressure from 112/68 to 118/76 mmHg
c) Increased oral temperature from 98.6 degrees F.
d) Increased respiratory rate from 16 to 20 breaths per minutes

QUESTION 38
A nurse uses different approaches to administer nursing care to a client. The nurse makes adjustments and tries new interventions when current interventions are not working. Which critical thinking attitude is demonstrated by the nurse?
a) Creativity
b) Integrity
c) Fairness
d) Authority

QUESTION 39
A client is admitted to the rehabilitation unit after having a stroke and is unable to move the right arm and leg. Which statement is true regarding range of motion exercises for this client?
a) Passive range -of-motion exercises should be implemented to maintain mobility of minor joints
b) Passive range-of -motion exercises should be initiated once the client is able to ambulate independently
c) Active range-of-motion exercises should not be performed if a client has had a stroke
d) Active range-of-motion exercises should only be performed on major joints

QUESTION 40
The nurse checks the peripheral pulses at the lower extremities prior to applying a sequential compression device to the client’s bilaterally lower extremities. Which step of the nursing process does the nurse demonstrate when checking the peripheral pulses of the client?
a) Implementation
b) Assessment
c) Planning
d) Evaluation

QUESTION 41
A nurse manager is educating a new graduate nurse about when to measure a client’s vital signs. When is it appropriate for the new graduate nurse to assess clients’ vital signs? (Select all that apply).

a) When a client is admitted to the healthcare facility
b) When a client reports symptoms of distress
c) Before, during, and after nursing interventions that influence vital signs
d) During every interaction with a client
e) Before, during, and after administration of medication that can affect a client’s cardiovascular function

QUESTION 42
A nurse is caring for a client who had an appendectomy 3 days ago. Which objective assessment data would most likely indicate the client may be developing an infection?
a) Moderate incisional pain
b) Heart rate 96 beats per minute
c) An increase in temperature
d) Active bowels sound

QUESTION 43
A nurse is assisting a client during ambulation When the client begins to fall. Which of the following actions should the nurse take?
a) Call the emergency response team
b) Support the client’s center of gravity
c) Encircle the circle the client underneath the arms
d) Lower the client to the floor

QUESTION 44
Which of the following interviewing techniques prompts the client to describe a situation with more than one or two words and allows the client to actively describe their health status?
a) Probing
b) Open ended questions
c) Back channeling
d) Closed ended questions

QUESTION 45
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information so the nurse relies on as a primary source of data?
a) Client
b) Client’s best friend
c) Client’s family
d) Client’s medical record

QUESTION 46
A nurse is removing personal protective equipment (PPE) after giving direct care to a client on isolation. Which of the following PPE items should the nurse remove first?
a) Gloves
b) Mask
c) Face shield
d) Gown

QUESTION 47
A nurse has collected subjective and objective data from a client. What is the next step in the nursing assessment process?
a) Interpret and validate the data
b) Identify an appropriately stated client-centered outcome
c) Plan nursing actions that will address the client’s problem
d) Implement all planned nursing interventions

QUESTION 48
A nurse is caring for client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client’s infection?
a) Performing hand hygiene before, during, and after contact with the client
b) Changing the client’s bed linens each day
c) Encouraging the client to consume a high-protein diet
d) Placing the client in a room with positive-pressure airflow

QUESTION 49
A nurse provides a client with education on the physiological effects of exercise on the body system. Which of the following is the most appropriate information to provide to the client as an effect of exercise on the body systems?
a) Exercise decreases muscle
b) Exercise decreases respiratory rate
c) Exercise increases joint immobility
d) Exercise increases cardiac output

QUESTION 50
A nurse is providing home safety information to an older adult client that uses a cane. Which of the following statements should the nurse include in the instructions?
a) You should hold the cane in your weak hand ambulating
b) The cane’s height should be the same as the distance from the floor to your waist
c) You should advance your weak leg to the cane, then move your strong leg
d) You should advance the cane 12 to 14 inches before taking a step

QUESTION 51
A nurse is obtaining the health history from a client, the client appears angry and upset. Which of the following statements should the nurse make?
a) You appear upset. I will give you some time alone to think about why
b) I noticed you are upset. Tell me about how you are feeling right now
c) I see you are upset. Hospitals can be scary
d) Have you ever been in the hospital before?

QUESTION 52
Which of the following documentation notes by the nurse is correct?
a) “The patient appears to be feeling better after receiving medications”
b) “The physician made an error so I called and asked her to correct it.”
c) “The patient fell in the bathroom and there was an incident report filed.”
d) “The patient is sleeping and respirations are even and unlabored.”

QUESTION 53
A nurse is orienting a newly licensed nurse about documenting a client’s information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?
a) Documentation allows nurse managers to monitor nurse’s activities
b) Documentation is a method of communication among the interprofessional healthcare team
c) Documentation provides information to the client financial charges for care provided
d) Documentation provides information used during chart audits

QUESTION 54
A nurse is preparing to fax client information to another healthcare facility. What is the appropriate nursing action?
a) Use any fax machine available to send protected health information (PHI)
b) Send faxes containing protected health information (PHI) promptly
c) Adjust fax machine settings to save faxes that are sent and received
d) Dial frequently used tax recipient by hand instead of using speed-dial

QUESTION 55
Which of the following development stage carries the highest risk of an injury from fall?
a) Adult hood
b) School age
c) Older adulthood
d) Preschool

QUESTION 56
A nurse is caring for a client who is immobile and has a prescription for range of motion exercises. Which of the following action should be a priority nursing action?
a) Ask the family member to perform the range of motion exercise
b) Assess the client for activity tolerance
c) Perform the range of motion per prescription
d) Provide the client with instructions on how to perform range of motion exercises

QUESTION 57
A nurse is assessing a client who has an oral temperature of 39 C (102.2 F). Which vital sign changes does the nurse anticipate for a client experiencing a fever? (Select all that apply).
a) Hypertension
b) Hypotension
c) Tachypnea
d) Bradypnea
e) Tachycardia
f) Bradycardia

QUESTION 58
While assessing a client who presents to the emergency room with flu-like symptoms, the nurse dons a mask. Which component of the chain of infection is the nurse breaking to prevent the spread of microorganisms?
a) Portal of exit
b) Infectious agent
c) Portal of entry
d) Reservoir

QUESTION 59
A nurse is caring for a client who received a stem cell transplant. Which of the following types of transmission-based precautions should the nurse have in place for the client?
a) Droplet precaution
b) Contact precaution
c) Standard precaution
d) Protective environment precaution

QUESTION 60
A nurse is obtaining admission data from a client. Which of the following is considered subjective assessment data?
a) Patient has a heart rate of 60 beats per minute
b) Patient’s skin is warm to touch
c) Patient walks with an unsteady gait
d) Patient states “I am dizzy

QUESTION 61
Before the administration of cardiac medication, Lanoxin, the nurse auscultates the client’s apical pulse. Which phase of the nursing process is the nurse utilizing?
a) Evaluation
b) Planning
c) Assessment
d) Implementation

QUESTION 62
The nurse is caring for a client scheduled to have a mastectomy. Which type of preparation should equipment undergo prior to the procedure?
a) Disinfected
b) Cleaned
c) Sterilized
d) Aseptic

QUESTION 63
A nurse is planning care for a client that requires airborne precautions. Which of the following actions should the nurse take?
a) Wear an N95 respirator mask
b) Allow the client to ambulate in the hall
c) Stand 1.8 m (6ft) away from the client
d) Provide a positive-pressure airflow room
QUESTION 64
A nurse assesses vital signs for a client who has developed bronchitis: heart rate of 78 beats per minute, blood pressure of 136/90 mmHg, temperature 98.4 F, respiratory rate of 12 breaths pe minute, oxygen saturation 88%. Which of the following vital signs would the nurse document as abnormal?
a) The heart rate
b) The oxygen saturation
c) The respiration
d) The blood pressure

QUESTION 65
The nurse is reviewing isolation precaution guidelines. Which nursing intervention is highest priority for the client prescribed contact isolation precautions?
a) Collect a wound sample for culture
b) Confirm the need for isolation precaution
c) Instruct the client not to leave the room
d) Administer antibiotic therapy

QUESTION 66
A nurse is developing an exercise regimen with a sedentary older adult client. Which of the following activities should the nurse advise the client to avoid initially?
a) Running
b) Yoga
c) Swimming
d) Walking

QUESTION 67
A nurse is evaluating a client’s ability to use a cane. Which observation made by the nurse indicates that the client is using the cane correctly?
a) Client moves the cane first, then the unaffected leg
b) Client holds the cane with the hand on the unaffected side
c) Client leans toward the unaffected side while ambulating
d) Client moves the cane and affected leg at the same time

QUESTION 68
A nurse is caring for a client with a medical diagnosis of acute asthma exacerbation. The client is demonstrating clinical manifestations respiratory distress which includes shortness of breath, difficulty with breathing, pain, and oxygen saturation of 88% on room air. Which of the following assessment data would the nurse document as objective data?
a) Difficulty with breathing
b) Pain
c) Oxygen saturation 88% on room air
d) Shortness of breath

QUESTION 69
A nurse is admitting a client that requires droplet precautions due to strep pharyngitis. Which of the following actions should the nurse take?
a) Place the client in a room with negative airflow
b) Ensure the client’s room has HEPA filtration
c) Wear a mask when providing care to the client
d) Wear gown when providing care to the client

QUESTION 70
The nurse is planning care for a client that is prescribed bed rest. Which potential health issues resulting from prolonged bedrest could the patient experience?
(Select all that apply.)
a) Decreased muscle mass
b) Diarrhea
c) Atelectasis
d) Pressure ulceration
e) Thrombus formation

QUESTION 71
A nurse continuously reflects on past experiences when providing nursing care to clients. Which critical thinking and clinical judgement skills does the nurse demonstrate?
a) Interpretation
b) Self-evaluation
c) Evaluation
d) Inference

QUESTION 72
A nurse in an emergency department is assessing a new client. Which of the following manifestations is the highest priority for the nurse to address?
a) The client has generalized diaphoresis
b) The client has a blood pressure of 110/68mm.Hg
c) The client has cyanosis to the skin and mucous membranes
d) The client rates pain scale 9/10, with 10 being the worst

QUESTION 73
A nurse is caring for a client that reports acute pain, pain is 8/10 on a pain scale of 0 to 10. Which of the following vital signs changes will the nurse anticipate?
a) Decreased body temperature
b) Increased blood pressure
c) Decreased respiratory rate
d) Decreased heart rate
QUESTION 74
A new graduate nurse understands the highest risk of spreading infections within the hospital is from which source of transmission?
a) Injection needles
b) Client’s visitors
c) Hospital equipment
d) Healthcare providers

QUESTION 75
A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?
a) The presence of a bed alarm could have prevented the client from falling
b) The client was restless and trying to get out of bed all evening
c) The client attempted to climb over the side rails and fell
d) The client was lying on the floor next to his bed.

Answers

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