NUR304 - Adult Health - NCLEX Questions for Exam 1

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The nurse and a client are discussing possible behaviors that might be interfering with the client's ability to fall asleep. Which of the following assessment questions is most likely to identify possible problems with the client's sleep routine that possibly are contributing to the difficulty?
1. "When do you usually retire for the night?"
2. "What do you do to help yourself fall asleep?"
3. "How much time does it usually take for you to fall asleep?"
4. "Have you changed anything about your presleep ritual lately?"

2. "What do you do to help yourself fall asleep?"

As people try to fall asleep, they close their eyes and assume relaxed positions. Stimuli to the RAS decline. If the room is dark and quiet, activation of the RAS further declines. At some point the BSR takes over, causing sleep. If the client engages in activities such as reading or watching television as a means of falling asleep, this could be causing the problem. Although the other questions are not inappropriate, they are not as directed toward the cause of the problem.

The nurse is completing an assessment of the client's sleep patterns. A specific question that the nurse should ask to determine the potential presence of sleep apnea is:
1. "How easily do you fall asleep?"
2. "Do you have vivid, lifelike dreams?"
3. "Do you ever experience loss of muscle control or falling?"
4. "Do you snore loudly or experience headaches?"

4. "Do you snore loudly or experience headaches?"

To assess for sleep apnea (unlike assessing for narcolepsy or insomnia), the nurse may ask, "Do you snore loudly?" and "Do you experience headaches after awakening?" A positive response may indicate the client experiences sleep apnea.

The nurse knows that which of the following habits may interfere with a client's sleep?
1. Listening to classical music
2. Finishing office work
3. Reading novels
4. Drinking warm milk

2. Finishing office work

At home a client should not try to finish office work or resolve family problems before bedtime. Noise should be kept to a minimum. Soft music may be used to mask noise if necessary. Reading a light novel, watching an enjoyable television program, or listening to music helps a person to relax. Relaxation exercises can be useful at bedtime. A dairy product snack such as warm milk or cocoa that contains L-tryptophan may be helpful in promoting sleep.

Which of the following information provided by the client's bed partner is most associated with sleep apnea?
1. Restlessness
2. Talking during sleep
3. Somnambulism
4. Excessive snoring

4. Excessive snoring

Partners of clients with sleep apnea often complain that the client's snoring disturbs their sleep. Restlessness is not most associated with sleep apnea. Sleep talking is associated with sleep-wake transition disorders; somnambulism is associated with parasomnias (specifically, arousal disorders and sleep-wake transition disorders).

A 74-year-old client has been having sleeping difficulties. To have a better idea of the client's problem, the nurse should respond:
1. "What do you do just before going to bed?"
2. "Let's make sure that your bedroom is completely darkened at night."
3. "Why don't you try napping more during the daytime?"
4. "Do you eat a small snack before going to bed?"

1. "What do you do just before going to bed?"

To assess the client's sleeping problem, the nurse should inquire about predisposing factors, such as by asking "What do you do just before going to bed?" Assessment is aimed at understanding the characteristics of any sleep problem and the client's usual sleep habits so that ways for promoting sleep can be incorporated into nursing care. Older adults sleep best in softly lit rooms. Napping more during the daytime is often not the best solution. The nurse should first assess the client's sleeping problem. The client does not always have to eat something before going to bed.

Which of the following symptoms should the nurse assess with a client who is deprived of sleep?
1. Elevated blood pressure and confusion
2. Confusion and irritability
3. Inappropriateness and rapid respirations
4. Decreased temperature and talkativeness

2. Confusion and irritability

Psychological symptoms of sleep deprivation include confusion and irritability. Elevated blood pressure is not a symptom of sleep deprivation. Rapid respirations are not a symptom of sleep deprivation. There may be a decreased ability of reasoning and judgment that could lead to inappropriateness. Decreased temperature is not a symptom of sleep deprivation. The client with sleep deprivation is often withdrawn, not talkative.

When discussing the benefits of physical activity and exercise with a client, the nurse identifies which of the following as a positive outcome to the client? (Select all that apply.)
1. Stress management
2. Enhanced cardiac output
3. Improved bone integrity
4. Facilitation of weight control
5. Increased cognitive function
6. Increased musculoskeletal flexibility

1. Stress management
2. Enhanced cardiac output
3. Improved bone integrity
4. Facilitation of weight control
6. Increased musculoskeletal flexibility

Regular physical activity and exercise enhances functioning of all body systems, including cardiopulmonary functioning (endurance), musculoskeletal fitness (flexibility and bone integrity), weight control and maintenance (body image), and psychological well-being. Effects on cognitive function are not consistent.

Following an assessment of the client, the nurse identifies the nursing diagnosis activity intolerance related to increased weight gain and inactivity. An outcome identified by the nurse should be:
1. Resting heart rate will be 90 to 100 beats/minute
2. Blood pressure will be maintained between 140/80 and 160/90 mm Hg
3. Exercise will be performed 3 to 4 times over the next 2 weeks
4. Achievement of a rating of 3 for activity endurance

3. Exercise will be performed 3 to 4 times over the next 2 weeks

An appropriate outcome for activity intolerance related to increased weight gain and inactivity is that the client will perform exercise 3 to 4 times over the next 2 weeks. This outcome is realistic, measurable, and addresses the problem. A resting heart rate of 90-100 beats/minute is too high, and it does not address the need to increase activity. This outcome does not state whether this blood pressure is at rest or after exercising. It also does not address the need to increase activity. A more appropriate outcome is that the client will increase his or her activity (over the next 2 weeks).

Nurses need to implement appropriate body mechanics in order to prevent injury to themselves and their clients. Which principle of body mechanics should the nurse incorporate into client care?
1. Flex the knees and keep the feet wide apart.
2. Assume a position far enough away from the client.
3. Twist the body in the direction of movement.
4. Use the strong back muscles for lifting or moving.

1. Flex the knees and keep the feet wide apart.

The correct answer is to flex the knees and keep the feet wide apart. This will create a wide base of support, providing greater stability for the nurse and reducing the risk of back injury. The nurse should be positioned close to the client and use the arms and legs. Dividing balanced activity between arms and legs reduces the risk of back injury. Facing the direction of movement prevents abnormal twisting of the spine, also reducing the risk of back injury.

While ambulating in the hallway of a hospital, the client complains of extreme dizziness. The nurse, alert to a syncopal episode, should first:
1. Support the client and walk quickly back to the room
2. Lean the client against the wall until the episode passes
3. Lower the client gently to the floor
4. Go for help

3. Lower the client gently to the floor

If the client has a syncopal episode or begins to fall, the nurse should assume a wide base of support with one foot in front of the other, supporting the client's weight, and then extend the leg, allowing the client to slide against the leg while gently lowering the client to the floor and protecting the client's head. The nurse should not attempt to walk the client quickly back to the room. The nurse should not lean the client against a wall as the client may fall. The nurse should not leave the client alone and go for help.

The client needs to use crutches at home, and will have to manage going up and down a short flight of stairs. The nurse evaluates the use of an appropriate technique if the client:
1. Uses a banister or wall for support when descending
2. Uses one crutch for support while going up and down
3. Advances the crutches first to ascend the stairs
4. Advances the affected leg after moving the crutches to descend the stairs

4. Advances the affected leg after moving the crutches to descend the stairs

To descend stairs, the crutches are placed on the stairs and the client moves the affected leg, then the unaffected leg to the stairs with the crutches. The client should continue to use the crutches for support, not the banister or wall. The client should continue to use both crutches for support when going up or down stairs. When ascending stairs, the client moves the unaffected leg up the stair, then the crutches and affected leg.

A client with a fractured left femur has been using crutches for the past 4 weeks. The physician tells the client to begin putting a little weight on the left foot when walking. Which of the following gaits should the client be taught to use?
1. Two-point
2. Three-point
3. Four-point
4. Swing-through

1. Two-point

The two-point gait requires at least partial weight bearing on each foot. The client moves a crutch at the same time as the opposing leg, so that the crutch movements are similar to arm motion during normal walking. In a three-point gait, weight is borne on both crutches and then on the uninvolved leg. The four-point gait gives stability to the client but requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. This client is only supposed to use partial weight bearing, so this gait would not be appropriate. Paraplegics who wear weight-supporting braces on their legs use the swing-through gait. It would not be appropriate for this client.

The nurse is working with a client who has left-sided weakness. After instruction, the nurse observes the client ambulate in order to evaluate the use of the cane. Which action indicates that the client knows how to use the cane properly?
1. The client keeps the cane on the left side.
2. Two points of support are kept on the floor at all times.
3. There is a slight lean to the right when the client is walking.
4. After advancing the cane, the client moves the right leg forward.

2. Two points of support are kept on the floor at all times.

Two points of support, such as both feet or one foot and the cane, should be on the floor at all times. The cane should be kept on the stronger side, the client's right side. The client should keep his or her body upright and midline. Leaning can cause the client to lose his or her balance and fall. After advancing the cane, the client should move the weaker leg, the client's left leg, forward to the cane.

Which of the following statements by the nurse reflects a need for immediate follow-up regarding the physical effects of chronic pain on body function?
1. "His pulse and blood pressure are within his normal baseline limits, so I'm sure the pain medication is working."
2. "Please take his pulse and blood pressure, and let me know if they are elevated above his normal baselines."
3. "If his pulse and blood pressure are above his normal baseline, let me know, and I will medicate him for pain."
4. "Unmanaged pain usually manifests itself in both an elevated pulse and blood pressure."

1. "His pulse and blood pressure are within his normal baseline limits, so I'm sure the pain medication is working."

Except in cases of severe traumatic pain, which sends a person into shock, most people reach a level of adaptation in which physical signs return to normal. Thus clients in pain will not always have changes in their vital signs. Changes in vital signs are more often indicative of problems other than pain. Although the remaining options recognize the phenomena, they are not assuming that no elevation of vital signs means the absence of pain.

Which of the following symptoms would the nurse expect with a client who is experiencing acute pain?
1. Bradycardia
2. Bradypnea
3. Diaphoresis
4. Decreased muscle tension

3. Diaphoresis

An expected assessment finding of a client experiencing acute pain would be diaphoresis resulting from sympathetic nerve stimulation. Additional assessment findings of a client experiencing acute pain would be an increased heart rate, respiratory rate, and muscle tension.

When a client's husband questions how a patient-controlled analgesia (PCA) pump works, the nurse explains that the client:
1. Has control over the frequency of the intravenous (IV) analgesia
2. Can choose the dosage of the drug received
3. May request the type of medication received
4. Controls the route for administering the medication

1. Has control over the frequency of the intravenous (IV) analgesia

With a PCA system the client controls medication delivery. The PCA system is designed to deliver no more than a specified number of doses. The client does not choose the dosage. The health care provider prescribes the type of medication to be used. The advantage for the client is that he or she may self-administer opioids with minimal risk for overdose. The client does not control the route for administration. Systemic PCA typically involves IV drug administration but can also be given subcutaneously.

Which of the following is most appropriate when the nurse assesses the intensity of the client's pain?
1. Ask about what precipitates the pain.
2. Question the client about the location of the pain.
3. Offer the client a pain scale to objectify the information.
4. Use open-ended questions to find out about the sensation.

3. Offer the client a pain scale to objectify the information.

Descriptive scales are a more objective means of measuring pain intensity. Asking the client what precipitates the pain does not assess intensity, but rather it is an assessment of the pain pattern. Asking the client about the location of pain does not assess the intensity of the client's pain. To determine the quality of the client's pain, the nurse may ask open-ended questions to find out about the sensation experienced.

The nurse should describe pain that is causing the client a "burning sensation in the epigastric region" as:
1. Referred
2. Radiating
3. Deep or visceral
4. Superficial or cutaneous

3. Deep or visceral

Deep or visceral pain is diffuse and may radiate in several directions. Visceral pain may be described as a burning sensation. Referred pain is felt in a part of the body separate from the source of pain, such as with a myocardial infarction, in which pain may be referred to the jaw, left arm, and left shoulder. Radiating pain feels as though it travels down or along a body part, such as low back pain that is accompanied by pain radiating down the leg from sciatic nerve irritation. Superficial or cutaneous pain is of short duration and is localized as in a small cut.

A priority nursing intervention when caring for a client who is receiving an epidural infusion for pain relief is to:
1. Use aseptic technique
2. Label the port as an epidural catheter
3. Monitor vital signs every 15 minutes
4. Avoid supplemental doses of sedatives

3. Monitor vital signs every 15 minutes

When clients are receiving epidural analgesia, monitoring occurs as often as every 15 minutes, including assessment of respiratory rate, respiratory effort, and skin color. Complications of epidural opioid use include nausea and vomiting, urinary retention, constipation, respiratory depression, and pruritus. A common complication of epidural anesthesia is hypotension. Assessing vital signs is the priority nursing intervention. Because of the catheter location, strict surgical asepsis is needed to prevent a serious and potentially fatal infection. To reduce the risk for accidental epidural injection of drugs intended for IV use, the catheter should be clearly labeled "epidural catheter." Supplemental doses of opioids or sedative/hypnotics are avoided because of possible additive central nervous system adverse effects.

Which of the following statements made by a nurse discussing the effect of an antibiotic on the gastrointestinal system reflects the best understanding of the possible occurrence of diarrhea?
1. "The GI tract naturally rids itself of bacterial toxins by increasing peristalsis, and that causes diarrhea."
2. "The antibiotic is responsible for killing off the GI tract's normal bacterial, and diarrhea is the result."
3. "For some, antibiotics irritate the mucous lining of the intestines, causing decreased absorption and diarrhea."
4. "When you are taking an antibiotic, your body is fighting off an infection, and peristalsis is faster and so diarrhea occurs."

2. "The antibiotic is responsible for killing off the GI tract's normal bacterial, and diarrhea is the result."

A client who is 2 days' postoperative reports feeling "constipated" to the nurse. The client has good bowel sounds in all four quadrants and has tolerated liquids well. Her pain is being controlled with an opioid analgesic. Which of the following interventions should the nurse try initially?
1. "Let me get you some apple juice."
2. "Ambulating may get your bowels moving."
3. "I'll see about getting a different pain medication."
4. "Your health care provider might prescribe an enema if I call."

1. "Let me get you some apple juice."

An adult client reports to the nurse that she has been experiencing constipation recently and is interested in any suggestions regarding dietary changes she might make. Which of the following suggestions provided by the nurse is most likely to minimize the client's complaint?
1. "Have you tried foods like prunes and bran?"
2. "You might find the new flavored bulk laxatives helpful."
3. "What have you tried in the past that hasn't been helpful?"
4. "Increase your fluid intake; have some juice with breakfast."

4. "Increase your fluid intake; have some juice with breakfast."

Which of the following statements made by an older adult reflects the best understanding of the role of fiber regarding bowel patterns?
1. "The more fiber I eat, the fewer problems I have with my bowels."
2. "Whole grain cereal and toast for breakfast keeps my bowels moving regularly."
3. "My wife makes whole grain muffins; they are really good and good for me too."
4. "I use to have trouble with constipation until I started taking a fiber supplement."

2. "Whole grain cereal and toast for breakfast keeps my bowels moving regularly."

The nurse instructs the client that before the fecal occult blood test (FOBT) she may eat:
1. Whole wheat bread
2. A lean, T-bone steak
3. Veal
4. Salmon

1. Whole wheat bread

A nurse who is caring for postoperative clients on a surgical unit knows that for 24 to 48 hours postoperatively, clients who have undergone general anesthesia may experience:
1. Colitis
2. Stomatitis
3. Paralytic ileus
4. Gastrocolic reflex

3. Paralytic ileus

While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should:
1. Immediately stop the infusion
2. Lower the height of the enema container
3. Advance the enema tubing 2 to 3 inches
4. Clamp the tubing

2. Lower the height of the enema container

The nurse is discussing a middle-age adult male client's report of nocturia. The client has diabetes that is managed with diet and exercise as well as hypertension that is currently well-controlled with medication. The nurse should include which of the following as possible causes for his frequent urination at night? (Select all that apply.)
1. An enlarged prostate gland
2. Poorly controlled blood glucose
3. Drinking a cup of tea before bed
4. Possible side effect of his medication
5. Taking his diuretic too close to bedtime
6. Consuming too many liquids during the day

1. An enlarged prostate gland
2. Poorly controlled blood glucose
3. Drinking a cup of tea before bed
5. Taking his diuretic too close to bedtime

Which of the following symptomatology is reflective of a lower urinary tract infection? (Select all that apply.)
1. Chills and fever
2. Nausea and vomiting
3. Frequency or urgency
4. Cloudy or blood-tinged urine
5. Pelvic tenderness or flank pain
6. Burning or pain when voiding

1. Chills and fever
2. Nausea and vomiting
3. Frequency or urgency
4. Cloudy or blood-tinged urine
6. Burning or pain when voiding

Which of the following clients presents with an increased risk for urinary incontinence? (Select all that apply.)
1. The 74-year-old diagnosed with parkinsonism 5 years ago
2. The 25-year-old with Crohn's disease diagnosed 4 years ago
3. The 62-year-old Alzheimer's disease client diagnosed 8 years ago
4. The 34-year-old mother of two diagnosed with multiple sclerosis 8 years ago
5. The 73-year-old diagnosed with benign prostatic hyperplasia (BPH) 6 years ago
6. The 69-year-old client diagnosed with type 2 diabetes 9 years ago

1. The 74-year-old diagnosed with parkinsonism 5 years ago
3. The 62-year-old Alzheimer's disease client diagnosed 8 years ago
4. The 34-year-old mother of two diagnosed with multiple sclerosis 8 years ago
5. The 73-year-old diagnosed with benign prostatic hyperplasia (BPH) 6 years ago
6. The 69-year-old client diagnosed with type 2 diabetes 9 years ago

The nurse recognizes that a client recovering from anesthesia required for surgical repair of a fractured ulna is likely to experience difficulty urinating primarily because of:
1. The impaired cognitive state the client will experience as the effects of the anesthesia wear off
2. The decreased volume of orally ingested fluids before, during, and after the surgical procedure
3. The length of time the client was under the effects of general anesthesia required for the surgical procedure
4. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder

4. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder

A timed urine specimen collection is ordered. The test will need to be restarted if which of the following occurs?
1. The client voids in the toilet.
2. The urine specimen is kept cold .
3. The first voided urine is discarded.
4. The preservative is placed in the collection container.

1. The client voids in the toilet.

The unit manager is evaluating the care of a new nursing staff member. Which of the following is an appropriate technique for the nurse to implement in order to obtain a clean-voided urine specimen?
1. Apply sterile gloves for the procedure.
2. Restrict fluids before the specimen collection.
3. Place the specimen in a clean urinalysis container.
4. Collect the specimen after the initial stream of urine has passed.

4. Collect the specimen after the initial stream of urine has passed.

The nurse is visiting the client who has a nursing diagnosis of urinary retention. Upon assessment the nurse anticipates that this client will exhibit:
1. Severe flank pain and hematuria
2. Pain and burning on urination
3. A loss of the urge to void
4. A feeling of pressure and voiding of small amounts

4. A feeling of pressure and voiding of small amounts

When obtaining a sterile urine specimen from an indwelling urinary catheter the nurse should:
1. Disconnect the catheter from the drainage tubing
2. Withdraw urine from a urinometer
3. Open the drainage bag and removing urine
4. Use a needle to withdraw urine from the catheter port

4. Use a needle to withdraw urine from the catheter port

Which of the following statements should the nurse use to instruct the nursing assistant caring for a client with an indwelling urinary catheter?
1. Empty the drainage bag at least every 8 hours.
2. Clean up the length of the catheter to the perineum.
3. Use clean technique to obtain a specimen for culture and sensitivity.
4. Place the drainage bag on the client's lap while transporting the client to testing.

1. Empty the drainage bag at least every 8 hours.

The nurse determines that the nursing diagnosis stress urinary incontinence related to decreased pelvic muscle tone is the most appropriate for an oriented adult female client. A therapeutic nursing intervention based on this diagnosis is to:
1. Apply adult diapers
2. Catheterize the client
3. Administer Urecholine
4. Teach Kegel exercises

4. Teach Kegel exercises

The client has been on a low-protein diet. This will most likely affect which pharmacokinetic process?
a. Absorption
b. Excretion
c. Distribution
d. Metabolism

c. Distribution

A low-protein diet may lead to an inadequate level of plasma proteins, which will affect availability of "free" drug.

The primary provider has written a medication prescription. The nurse is having difficulty deciphering what has been written. The best strategy to clarify the information is
a. Ask the patient what medication the provider prescribed.
b. Call the pharmacist and ask her to read the prescription.
c. Ask the nurse who knows the provider's handwriting to read the prescription.
d. Call the provider and ask him to clarify the prescription.

d. Call the provider and ask him to clarify the prescription.

All other answers increase the risk of a medication error.

When administering a drug via a parenteral routes, the drug would be absorbed fastest if given per the IM route.
a. True
b. False

b. False

Absorption refers to the "movement" of the drug from the site of administration into the blood stream. Therefore, the intravenous, parenteral route leads to "instant" absorption.

It is most important for the nurse to understand the various ways in which pain is classified
a. so that he can document the client's pain using accurate terms
b. so that he can be clear in his communication with the physician
c. so that he can develop an effective pain management plan
d. so that he can educate the client thoroughly

c. so that he can develop an effective pain management plan

ANS: C
Different modalities are used in the treatment/ management of pain and are often based on how the pain is classified (e.g., acute vs. chronic).

The nurse is assessing the confused client. In trying to determine the client's level of pain, the nurse should
a. be aware that confused clients don't feel as much pain due to their confusion
b. observe the client carefully for changes in behavior or vital signs
c. ask the client's family how much pain the client normally has
d. use only pain scales that feature numbers or "faces" the client can point to

b. observe the client carefully for changes in behavior or vital signs

The nurse should observe the confused client for nonverbal cues to pain.

Mr. Zenobia's chronic cancer pain has recently increased, and he asks the home health nurse what can be done. In relationship to his long-acting morphine, which of the following is an appropriate response by the nurse?
a. "If you take more morphine, it will not change your pain relief."
b. "I'll call the physician and ask for an increased dose."
c. "The amount you are taking now is all I can give you."
d. "I'm worried if we increase your dose that you will stop breathing."

b. "I'll call the physician and ask for an increased dose."

There is no ceiling on the analgesic effect of opioid narcotics. Patients develop a tolerance to the effects, which often necessitates an increase in the dose.

When should the nurse assess pain?
1) Whenever a full set of vital signs is taken
2) During the admission interview
3) Every 4 hours for the first 2 days after surgery
4) Only when the patient complains of pain

1) Whenever a full set of vital signs is taken

The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan?
1) Place the cold pack directly on the skin over the ankle.
2) Apply the cold pack to the ankle for 30 minutes at a time.
3) Check the skin frequently for extreme redness.
4) Keep the cold pack in place for at least 24 hours.

3) Check the skin frequently for extreme redness.

Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia?
1) The patient will verbalize a reduction in pain after receiving pain medication and repositioning.
2) The patient will rest quietly when undisturbed.
3) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation.
4) The patient will receive pain medication every 2 hours as prescribed.

3) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation.

A patient with a history of mitral valve replacement, hypertension, and type 2 diabetes mellitus undergoes emergency surgery to remove an embolus in her right leg. Which factor contraindicates the use of epidural analgesia in this patient?
1) Anticoagulant therapy
2) Diabetes mellitus
3) Hypertension
4) Embolectomy

1) Anticoagulant therapy

After undergoing dural puncture while receiving epidural pain medication, a patient complains of a headache. Which action can help alleviate the patient's pain?
1) Encourage the client to ambulate to promote flow of spinal fluid.
2) Offer caffeinated beverages to constrict blood vessels in his head.
3) Encourage coughing and deep breathing to increase CSF pressure.
4) Restrict oral fluid intake to prevent excess spinal pressure.

2) Offer caffeinated beverages to constrict blood vessels in his head.

An older adult receiving hospice care has dementia as a result of metastasis to the brain. His bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed? The client:
1) Experiences less pain than in earlier stages of cancer.
2) Cannot communicate the character of his pain effectively.
3) Recalls pain at a later time than when it occurs.
4) Relies on caregiver to provide pain relief without asking.

2) Cannot communicate the character of his pain effectively.

What is typically the most reliable indicator of pain?
1) Patient's self-report
2) Past medical history
3) Description by caregiver(s)
4) Behavioral cues

1) Patient's self-report

Which of the following actions violates a principle that is key to proper hand washing at the bedside?
a. Washing your hands for 1 minute
b. Shaking your hands dry over the sink
c. Using warm, not very hot water
d. Using the soap provided by the agency

b. Shaking your hands dry over the sink

Shaking your hands will not completely remove the excess moisture, allowing for the reacquisition of bacteria on the area.

The client has a draining abdominal wound that has become infected. In caring for the client, the nurse will implement
a. contact precautions
b. droplet precautions
c. no precautions
d. airborne precautions

a. contact precautions

Contact precautions are used when "contact" with the infected drainage could lead to transmission of the infection.

In a small rural hospital they work with a wide variety of clients. Of this afternoon client's admitted, the nurse acknowledges the client with the highest susceptibility to infection is the individual with:
1) Burns
2) Diabetes
3) Pulmonary emphysema
4) Peripheral vascular disease

1) Burns

In preventing and controlling the transmission of infections, the single most important technique is:
1) Hand hygiene
2) The use of disposable gloves
3) The use of isolation precautions
4) Sterilization of equipment

1) Hand hygiene

Which of the following nursing activities is of highest priority for maintaining medical asepsis?
1) Washing hands
2) Donning gloves
3) Applying sterile drapes
4) Wearing a gown

1) Washing hands

The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique?
1) Closing the patient's door to limit room traffic while preparing the sterile field
2) Using clean procedure gloves to handle sterile equipment
3) Placing the nonsterile syringes containing flush solution on the sterile field
4) Remaining 6 inches away from the sterile field during the procedure

4) Remaining 6 inches away from the sterile field during the procedure

How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation?
1) Place the tray in a specially marked trash can inside the patient's room.
2) Place the tray in a special isolation bag held by a second healthcare worker at the patient's door.
3) Return the tray with a note to dietary services so it can be cleaned and reused for the next meal.
4) Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose of it there.

1) Place the tray in a specially marked trash can inside the patient's room.

The nurse is removing personal protective equipment (PPE). Which item should be removed first?
1) Gown
2) Gloves
3) Face shield
4) Hair covering

4) Hair covering

In which situation would using standard precautions be adequate? (Select all that apply.)
1) While interviewing a client with a productive cough
2) While helping a client to perform his own hygiene care
3) While aiding a client to ambulate after surgery
4) While inserting a peripheral intravenous catheter

2) While helping a client to perform his own hygiene care
3) While aiding a client to ambulate after surgery
4) While inserting a peripheral intravenous catheter

A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? (Select all that apply.)
1) Question the order because the patient must remain in isolation.
2) Place an N-95 respirator mask on the patient and transport him to the test.
3) Place a surgical mask on the patient and transport him to CT lab.
4) Notify the computed tomography department about precautions prior to transport.

3) Place a surgical mask on the patient and transport him to CT lab.
4) Notify the computed tomography department about precautions prior to transport.

A client has severe right-sided weakness and is unable to complete bathing and grooming independently. Based on this observation, the nurse identifies a nursing diagnosis of:
1) Powerlessness
2) Self-care deficit
3) Tissue integrity impairment
4) Knowledge deficit of hygiene practices

2) Self-care deficit

The client who is unable to complete bathing and grooming independently has a nursing diagnosis of self-care deficit. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of powerlessness. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of tissue integrity impairment. There is no indication this client has a knowledge deficit of hygiene practices.

Which of the following statements made by a nurse reflects the best understanding of the role of the bath in the nursing assessment process?
1. "I work with my ancillary staff to be able to determine what is abnormal."
2. "The skin is easy to observe for abnormalities when you are giving the bath."
3. "I use the time to really look at my clients and determine what's normal and what's not."
4. "Bath time is an excellent time to get to know your clients and form that nurse-client relationship."

3. "I use the time to really look at my clients and determine what's normal and what's not."

Take this time to identify abnormalities and initiate appropriate actions to prevent further injury to sensitive tissues. It also provides an opportunity to assess other systems (e.g., circulatory, respiratory) and client behaviors as well. While the nurse is responsible for determining abnormalities, the ancillary staff should be instructed to report any suspicious factors they note. Answer 3 is the most thorough statement regarding the question.

The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patient's care plan? "Teach the patient to:
1) use an electric razor for shaving."
2) apply skin moisturizer."
3) use less soap when bathing."
4) floss teeth daily."

1) use an electric razor for shaving."

The nurse should instruct the patient prescribed an anticoagulant to use an electric razor instead of a double-edge razor for shaving to prevent the risk of excess bleeding. Older adults should be encouraged to use skin moisturizers and use less soap while bathing to combat excess drying of the skin that occurs as a result of aging. However, even if this patient is an older adult, a risk for bleeding takes priority over a risk for dry skin. Everyone should be encouraged to floss their teeth daily; however, some patients with severe bleeding risk may be told not to floss.

For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated.
1) 32-year-old admitted with a closed head injury
2) 76-year-old admitted with septic shock
3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago
4) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion

3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago

Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. The patient who sustained a closed head injury may develop increased intracranial pressure during care. Therefore, he requires the critical thinking skills of a registered nurse to perform his morning care safely. The patient admitted with septic shock may easily become unstable with care; therefore, a registered nurse is required to provide his morning care safely. The patient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical thinking skills of a registered nurse to detect respiratory compromise quickly.

A patient with diarrhea is incontinent of liquid stool. The nurse documents that he now has excoriated skin on his buttocks. Which finding by the nurse led to this documentation?
1) Skin was softened from prolonged exposure to moisture.
2) Superficial layers of skin were absent.
3) Epidermal layer of skin was rubbed away.
4) Lesion caused by tissue compression was present.

2) Superficial layers of skin were absent.

Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. Maceration is the softening of skin from exposure to moisture. Abrasion, a rubbing away of the epidermal layer of the skin, especially over bony areas, is often caused by friction or searing forces that occur when a patient moves in bed. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion that are a result of immobility.

The nurse is making an occupied bed. Arrange the following steps in the order the nurse should perform them.
A. Position the patient laterally near the side rail farthest from you (that side rail is up); roll the soiled linens under him.
B. Lower the side rail on the side of the bed you are working on.
C. Raise the side rail on the side of the bed you are working on.
D. After placing clean linens and tucking them under the soiled linens, roll the patient over the "hump" and position him facing you on the near side of the bed.

B. Lower the side rail on the side of the bed you are working on.
A. Position the patient laterally near the side rail farthest from you (that side rail is up); roll the soiled linens under him.
D. After placing clean linens and tucking them under the soiled linens, roll the patient over the "hump" and position him facing you on the near side of the bed.
C. Raise the side rail on the side of the bed you are working on.

First lower the side rail on your side of the bed. This allows you to maintain good body mechanics while positioning the patient (in step 1). Position patient laterally near far side rail, and roll soiled linens under him. Then place clean linens on the side nearest you, and tuck them under soiled linens. Next, roll the patient over the "hump," and position him on his other side, facing you. Do this before raising the near side rail so you do not have to reach across the side rail to help the patient roll and turn to his other side.

A client's vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats per minute, respiratory rate 14 breaths per minute, and blood pressure 118/76. Four hours later the client's oral temperature is 102.2°F (39°C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats per minute? Why?

ANS: 111 BPM.

∆ 1 °F = 10 BPM
102.2 °F - 99.3 °F = 2.9 °F * (10 BPM / 1 °F) = ∆ 29 BPM + 82 BPM = 111 BPM

The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider?
1) Decreased blood pressure (BP) after standing up
2) Decreased temperature after a period of diaphoresis
3) Increased heart rate after walking down the hall
4) Increased respiratory rate when the heart rate increases

1) Decreased blood pressure (BP) after standing up

Orthostatic Hypotension

Which one of the following clients would probably have a higher than normal respiratory rate? A client who has:
1) Had surgery and is receiving a narcotic analgesic.
2) Had surgery and lost a unit of blood intraoperatively.
3) Lived at a high altitude and then moved to sea level.
4) Been exposed to the cold and is now hypothermic.

2) Had surgery and lost a unit of blood intraoperatively.

Hypovolemia / shock. BP decreases, respiratory rate increases

A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." The nurse's best response would be:
1) "Your vital signs confirm that your infection is resolved; how do you feel?"
2) "I'll let your health care provider know so you can be discharged."
3) "Your vital signs are stable, but there are other things to assess."
4) "We still need to keep monitoring your temperature for a while."

3) "Your vital signs are stable, but there are other things to assess."

A client's axillary temperature is 100.8°F. The nurse realizes this is outside normal range for this client, and that axillary temperatures do not reflect core temperature. What should the nurse do to obtain a good estimate of the core temperature?
1) Add 1°F to 100.8°F to obtain an oral equivalent.
2) Add 2°F to 100.8°F to obtain a rectal equivalent.
3) Obtain a rectal temperature reading.
4) Obtain a tympanic membrane reading.

3) Obtain a rectal temperature reading.

At last measurement, the client's vital signs were as follows: oral temperature 98°F (36.7°C), heart rate 76, respiratory rate 16, and blood pressure (BP) 118/60. Four hours later, the vital signs are as follows: oral temperature 103.2°F (38.5°C), heart rate 76 beats/minute, respiratory rate 14 breaths/minute, and blood pressure 120/66. Which should the nurse's first intervention be at this time?
1) Ask the client if he has had a warm drink in the last 30 minutes.
2) Notify the primary care provider of the client's temperature.
3) Ask the client if he is feeling chilled.
4) Take the temperature by a different route.

1) Ask the client if he has had a warm drink in the last 30 minutes.

Comparing the changes in vital signs as a person ages, which statement(s) is/are correct? (Select all that apply.)
1) Blood pressure decreases less than heart rate and respiratory rate.
2) Respiratory rate remains fairly stable throughout a person's life.
3) Blood pressure increases; heart rate and respiratory rate decline.
4) Men have higher blood pressure than women until after menopause.

3) Blood pressure increases; heart rate and respiratory rate decline.
4) Men have higher blood pressure than women until after menopause.

Match the breath sound with the appropriate description.
1) High-pitched sound heard on inspiration in infants
2) High-pitched, continuous musical sound
3) High-pitched popping or low-pitched bubbling sounds
4) Low-pitched continuous sounds that clear with coughing
5) Labored, snoring sound

a. Crackles
b. Rhonchi
c. Stridor
d. Wheezes
e. Stertor

1. c. High-pitched sound heard on inspiration in infants: Stridor
2. d. High-pitched, continuous musical sound: Wheezes
3. a. High-pitched popping or low-pitched bubbling sounds: Crackles
4. b. Low-pitched continuous sounds that clear with coughing: Rhonchi
5. e. Labored, snoring sound: Stertor

How do the following impact blood pressure?
A. Blood pressure cuff too narrow
B. Blood pressure cuff too wide
C. Assessing immediately after smoking
D. Assessing immediately after eating
E. Assessing when the client is in mild-to-moderate pain
F. Assessing when the client experiences severe pain
G. Assessing immediately after exercise

How do the following impact blood pressure?
A. Blood pressure cuff too narrow: False Increase
B. Blood pressure cuff too wide: False Decrease
C. Assessing immediately after smoking: Increase
D. Assessing immediately after eating: Increase
E. Assessing when the client is in mild-to-moderate pain: Increase
F. Assessing when the client experiences severe pain: Increase. Eventually chronic pain modulates to decrease.
G. Assessing immediately after exercise: Immediately upon stopping it is increased, but within 5 minutes decreases.

An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is:
1. Confusion
2. Impaired judgment
3. Sensory deficits
4. History of falls

4. History of falls

According to the falls assessment tool, the greatest indicator of risk is a history of falls. According to the falls assessment tool, the second leading risk factor for falls is confusion. According to the falls assessment tool, impaired judgment is the fourth leading risk factor for falls. According to the falls assessment tool, sensory deficit is the fifth leading risk factor for falls.

The nurse recognizes that the leading cause of death for the otherwise healthy 1-year-old is:
1. Physical abuse
2. Accidental injury
3. Contagious diseases
4. Stranger abduction

2. Accidental injury

Injuries are the leading cause of death in children older than 1 year of age and cause more deaths and disabilities than do all diseases combined.

Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis?
1) Risk for Falls
2) Risk for Ineffective Airway Clearance (choking)
3) Risk for Poisoning
4) Risk for Suffocation (drowning)

1) Risk for Falls

Risk for Falls due to loss of muscle strength and joint mobility

The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best?
1) Continue to monitor the pump to see if the crack worsens.
2) Place the pump back on the utility room shelf.
3) A small crack poses no danger so continue using the pump.
4) Clearly label the pump and send it for repair.

4) Clearly label the pump and send it for repair.

Label it and take it out of service - all organizations have labels which indicate the equipment is not working. Evaluate the policy to determine if Clinical engineering or biomed needs to be contacted.

A nurse is teaching a group of mothers about first aid. Should poison come in contact with their child's clothing and skin, which action should the nurse instruct the mothers to take first?
1) Remove the contaminated clothing immediately.
2) Flood the contaminated area with lukewarm water.
3) Wash the contaminated area with soap and water and rinse.
4) Call the nearest poison control center immediately.

1) Remove the contaminated clothing immediately.

Remove contaminated clothing immediately - then wash with water - irrigate it and contact poison control.

Which is the most commonly reported "incident" in hospitals?
1) Equipment malfunction
2) Patient falls
3) Laboratory specimen errors
4) Treatment delays

2) Patient falls

Patient falls, usually in an attempt to go to the bathroom

A patient in the emergency department is angry, yelling, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse are advisable?
1) Reassure the patient by entering the room alone.
2) Ask the patient if he is carrying any weapons.
3) Stay between the patient and the door; keep the door open.
4) Make eye contact while stating firmly "I will not tolerate cursing and threats."

3) Stay between the patient and the door; keep the door open.

Make sure you do not get trapped. You should never enter the room alone if someone is threatening, the nurse must be calm and reassuring. Asking about weapons and setting limits may escalate the situation.

When the nurse walks into the patient's room, she notices fire coming from the patient's trash can. Rank the following actions in the order they should be performed by the nurse.
A. Activate the fire alarm.
B. Move the patient out of the room.
C. Close all doors and windows.
D. Put out the fire using the proper extinguisher.

B. Move the patient out of the room.
A. Activate the fire alarm.
C. Close all doors and windows.
D. Put out the fire using the proper extinguisher.

R.A.C.E. - rescue, alarm, contain, and exstinquish or evacuate

The nurse knows that the results of a fecal occult blood test can be inaccurate if
a. the client has had an excessive intake of red meat
b. the female client is menstruating
c. the client takes high doses of vitamin C
d. all of the above

d. all of the above

Mrs. Addie is 70 years old. While the nurse is gathering admission assessment data, the patient states, "I've taken a tablespoon of Milk of Magnesia every day for 3 years." Which nursing diagnosis is most appropriate for the nurse to use in her plan of care?
a. Diarrhea
b. Constipation
c. Risk for Ineffective Therapeutic Regimen
d. Perceived Constipation

d. Perceived Constipation

Daily laxative use by the patient might suggest that she perceives she is constipated, and the nurse would gather further assessment data related to the client's bowel pattern. There is not enough data to infer actual constipation.

The nurse is assisting the client in caring for her ostomy. The client states, "Oh, this is so disgusting. I'll never be able to touch this thing." The nurse's best response is
a. "I'm sure you will get used to taking care of it eventually."
b. "Yes, it is pretty messy, so I'll take care of it for you today."
c. "It sounds like you are really upset."
d. "You sound very angry. Should I call the chaplain for you?"

c. "It sounds like you are really upset."

This statement reflects the principles of therapeutic communication.

When changing a diaper, the nurse observes that a 2-day-old infant has had a green black, tarry stool. What should the nurse do?
1) Notify the physician.
2) Do nothing; this is normal.
3) Give the baby sterile water until the mother's milk comes in.
4) Apply a skin barrier cream to the buttocks to prevent irritation.

2) Do nothing; this is normal.

During the first few days of life, a term newborn passes green black, tarry stools known as meconium. Stools transition to a yellow green color over the next few days. After that, the appearance of stools depends upon the feedings the newborn receives. Sterile water does nothing to alter this progression. Meconium stools are more irritating to the buttocks than other stools because they are so sticky and the skin usually must be rubbed to cleanse it.

Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of:
1) Milk and cheese.
2) Bread and pasta.
3) Fruits and vegetables.
4) Lean meats.

3) Fruits and vegetables.

The nurse should encourage the patient to increase his intake of foods rich in fiber because they promote peristalsis and defecation, thereby relieving constipation. Low-fiber foods, such as bread, pasta, and other simple carbohydrates, as well as milk, cheese, and lean meat, slow peristalsis.

A nurse is teaching wellness to a women's group. The nurse should explain the importance of consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce glasses)?
1) 2 to 4 glasses a day
2) 4 to 6 glasses a day
3) 6 to 8 glasses a day
4) 8 to 10 glasses a day

3) 6 to 8 glasses a day

A minimum of 6 to 8 glasses of fluid should be consumed each day to promote healthy bowel function.

The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis?
1) Prepare the patient for an abdominal flat plate.
2) Collect a stool specimen that contains 20 to 30 ml of liquid stool.
3) Administer a laxative to prepare the patient for a colonoscopy.
4) Test the patient's stool using a fecal occult test.

2) Collect a stool specimen that contains 20 to 30 ml of liquid stool.

To confirm the diagnosis of an infection, the nurse should collect a liquid stool specimen that contains 20 to 30 ml of liquid stool. An abdominal flat plate and a fecal occult blood test cannot confirm the diagnosis. Colonoscopy is not necessary to obtain a specimen to confirm the diagnosis.

A patient with a colostomy complains to the nurse, "I am having really bad odors coming from my pouch." To help control odor, which foods should the nurse advise him to consume?
1) White rice and toast
2) Tomatoes and dried fruit
3) Asparagus and melons
4) Yogurt and parsley

4) Yogurt and parsley

Yogurt, cranberry juice, parsley, and buttermilk may help control odor. White rice and toast (also bananas and applesauce) help control diarrhea. Asparagus, peas, melons, and fish are known to cause odor. Tomatoes, pears, and dried fruit are high-fiber foods that might cause blockage in a patient with an ostomy.

A patient with severe hemorrhoids is incontinent of liquid stool. Which of the following interventions is contraindicated?
1) Apply an indwelling fecal drainage device.
2) Apply an external fecal collection device.
3) Place an incontinence garment on the patient.
4) Place a waterproof pad under the patient's buttocks.

1) Apply an indwelling fecal drainage device.

An indwelling fecal drainage device is contraindicated for children; for more than 30 consecutive days of use; and for patients who have severe hemorrhoids, recent bowel, rectal, or anal surgery or injury; rectal or anal tumors; or stricture or stenosis. External devices are not typically used for patients who are ambulatory, agitated, or active in bed because the device may be dislodged, causing skin breakdown. External devices cannot be used effectively when the patient has Impaired Skin Integrity because they will not seal tightly. Absorbent products are not contraindicated for this patient unless Impaired Skin Integrity occurs. Even with absorbent products or an external collection device, the nurse should place a waterproof pad under the patient to protect the bed linens.

The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patient's rectum? Choose all that apply.
1) 2 inches
2) 3 inches
3) 4 inches
4) 5 inches

2) 3 inches
3) 4 inches

When administering an enema, the nurse should insert the tubing about 3 to 4 inches into the patient's rectum. Two inches would not be effective because it would not place the fluid high enough in the rectum. Five inches is too much.

When administering an enema, list the following steps in the order in which they should be performed. Label the steps from 1 to 6, with 1 being the first step to perform.
A. Document the results of the procedure.
B. Assess the patient for cramping.
C. Insert the tubing about 3 to 4 inches into the rectum.
D. Lubricate the tip of the enema tubing generously.
E. Raise the container to the correct height and instill the solution at a slow rate.
F. Encourage the patient to hold the solution for 3 to 15 minutes, depending on the type of enema.

D. Lubricate the tip of the enema tubing generously.
C. Insert the tubing about 3 to 4 inches into the rectum.
E. Raise the container to the correct height and instill the solution at a slow rate.
B. Assess the patient for cramping.
F. Encourage the patient to hold the solution for 3 to 15 minutes, depending on the type of enema.
A. Document the results of the procedure.

You must lubricate the tip before inserting the tubing. You would then begin instilling the solution before assessing for cramping that the instillation might produce. Only after the solution is instilled would you ask the patient to hold the solution. The last action is to document the results of the procedure, after the procedure is finished.

Light sleep and slowing brain and body processes are associated with which stage of NREM sleep?
a. I
b. II
c. III
d. IV

b. II

These are characteristics of a person in Stage II of NREM sleep.

The nurse is caring for a hospitalized client who normally works the night shift at his job. The client states, "I don't know what is wrong with me. I have been napping all day and can't seem to think clearly." The nurse's best response is
1) "You are sleep deprived, but that will resolve in a few days."
2) "You are experiencing hypersomnia, so it will be important for you to walk in the hall more often."
3) "There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?"
4) "I will notify the doctor and ask him to prescribe a hypnotic medication to help you sleep."

3) "There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?"

The data suggests that the patient is used to being awake at night and sleeping during the day. The hospital routine has disrupted this normal pattern.

For which sleep disorder would the nurse most likely need to include safety measures in the client's plan of care?
a. Snoring
b. Enuresis
c. Narcolepsy
d. Hypersomnia

c. Narcolepsy

Narcolepsy can occur suddenly during the daytime hours when a person is involved in any type of activity. This could put the person at risk for harm depending on the activity in which he is engaged.

Which of the following factors has the greatest positive effect on sleep quality?
1) Sleeping hours in synchrony with the person's circadian rhythm
2) Sleeping in a quiet environment
3) Spending additional time in stage IV of the sleep cycle
4) Napping on and off during the daytime

1) Sleeping hours in synchrony with the person's circadian rhythm

Which is a major factor regulating sleep?
1) Electrical impulses transmitted to the cerebellum
2) Level of sympathetic nervous system stimulation
3) Amount of sleep a person has become accustomed
4) Amount of light received through the eyes

3) Amount of sleep a person has become accustomed to

A patient tells you that she has trouble falling asleep at night, even though she is very tired. A review of symptoms reveals no physical problems and she takes no medication. She has recently quit smoking, is trying to eat healthier foods, and has started a moderate-intensity exercise program. Her sleep history reveals no changes in bedtime routine, stress level, or environment. Based on this information, the most appropriate nursing diagnosis would be Disturbed Sleep Pattern related to:
1) Increased exercise.
2) Nicotine withdrawal.
3) Caffeine intake.
4) Environmental changes.

1) Increased exercise.

Which patient teaching would be most therapeutic for someone with sleep disturbance?
1) Give yourself at least 60 minutes to fall asleep.
2) Avoid eating carbohydrates before going to sleep.
3) Catch up on sleep by napping or sleeping in when possible.
4) Do not go to bed feeling upset about a conflict.

4) Do not go to bed feeling upset about a conflict.

From what stage of sleep are people typically most difficult to arouse?
1) NREM, alpha waves
2) NREM, sleep spindles
3) NREM, delta waves
4) REM

3) NREM, delta waves

The patient is diagnosed with obstructive sleep apnea. Identify the symptoms you would expect the client to exhibit. Choose all that apply.
1) Bruxism
2) Enuresis
3) Daytime fatigue
4) Snoring

3) Daytime fatigue
4) Snoring

The female client states to the nurse, "I'm so distressed. It seems like every time I laugh hard, I wet myself." The nurse knows that this condition is known as
a. stress incontinence
b. urge incontinence
c. functional incontinence
d. unconscious incontinence

a. stress incontinence

Stress incontinence results from increased pressure within the abdominal cavity.

Four nurses are inserting catheters in their clients. Which nurse's statement, related to this intervention, is incorrect?
I am inserting this catheter to
a. empty your bladder prior to your procedure
b. treat your problem of leaking urine
c. obtain a sterile urine specimen
d. measure the amount of urine left after you emptied your bladder

b. treat your problem of leaking urine

Insertion of a urinary catheter is not a "treatment" for incontinence. "Never event" by CMS - CAUTI

There is a 24-hour urine collection in process for a client. The NAP inadvertently empties one specimen into the toilet instead of the collection "hat." The nurse should
a. Continue with the collection of urine until the 24-hour time period is finished.
b. Make a note to the lab to inform them that one specimen was missed during the collection.
c. Begin filling a new collection container and take both containers to the lab at the end of the collection period.
d. Dispose of the urine already collected and begin an entirely new 24-hour collection.

d. Dispose of the urine already collected and begin an entirely new 24-hour collection.

Once one specimen is "missed" during a 24-hour urine collection, the results of the lab test will be inaccurate and the collection must be restarted.

While performing a physical assessment, the student nurse tells her instructor that she cannot palpate her patient's bladder. Which statement by the instructor is best? "You should:
1) Try to palpate it again; it takes practice but you will locate it."
2) Palpate the patient's bladder only when it is distended by urine."
3) Document this abnormal finding on the patient's chart."
4) Immediately notify the nurse assigned to your patient."

2) Palpate the patient's bladder only when it is distended by urine."

The bladder is not palpable unless it is distended by urine. It is not difficult to palpate the bladder when distended. The nurse should document her finding, but it is not an abnormal finding. It is not necessary to notify the nurse assigned to the patient.

Which urine specific gravity would be expected in a patient admitted with dehydration?
1) 1.002
2) 1.010
3) 1.025
4) 1.030

4) 1.030

Normal urine specific gravity ranges from 1.010 to 1.025. Specific gravity less than 1.010 indicates fluid volume excess, such as when the patient has fluid overload (too much IV fluid) or when the kidneys fail to concentrate urine. Specific gravity greater than 1.025 is a sign of deficient fluid volume that occurs, for example, as a result of blood loss or dehydration.

The nurse is caring for a patient who underwent a bowel resection 2 hours ago. His urine output for the past 2 hours totals 50 mL. Which action should the nurse take?
1) Do nothing; this is normal postoperative urine output.
2) Increase the infusion rate of the patient's IV fluids.
3) Notify the provider about the patient's oliguria.
4) Administer the patient's routine diuretic dose early.

3) Notify the provider about the patient's oliguria.

50 mL in two hours is not normal output. The kidneys typically produce 60 ml of urine per hour. Therefore, the nurse should notify the provider when the patient shows diminished urine output (oliguria). Patients who undergo abdominal surgery commonly require increased infusions of IV fluid during the immediate postoperative period. The nurse cannot provide increased IV fluids without a provider's order. The nurse should not administer any medications before the scheduled time without a prescription. The provider may hold the patient's scheduled dose of diuretic if he determines that the patient is experiencing deficient fluid volume.

The nurse measures the urine output of a patient who requires a bedpan to void. Which action should the nurse take first? Put on gloves and:
1) Have the patient void directly into the bedpan.
2) Pour the urine into a graduated container.
3) Read the volume with the bedpan on a flat surface at eye level.
4) Observe color and clarity of the urine in the bedpan.

1) Have the patient void directly into the bedpan.

First, the nurse should put on gloves and have the patient void directly into the bedpan. Next, she should pour the urine into a graduated container, place the measuring device on a flat surface, and read the amount at eye level. She should observe the urine for color, clarity, and odor. Then, if no specimen is required, she should discard the urine in the toilet and clean the container and bedpan. Finally, she should record the amount of urine voided on the patient's intake and output record.

The nurse instructs a woman about providing a clean catch urine specimen. Which of the following statements indicates that the patient correctly understands the procedure?
1) "I will be sure to urinate into the 'hat' you placed on the toilet seat."
2) "I will cleanse my genital area from front to back before I collect the specimen midstream."
3) "I will need to lie still while you put in a urinary catheter to obtain the specimen."
4) "I will collect my urine each time I urinate for the next 24 hours."

2) "I will cleanse my genital area from front to back before I collect the specimen midstream."

To obtain a clean catch urine specimen, the nurse should instruct the patient to cleanse the genital area from front to back and collect the specimen midstream. This follows the principle of going from "clean" to "dirty." The nurse should have the ambulatory patient void into a "hat" (container for collecting the urine of an ambulatory patient) when monitoring urinary output, but not when obtaining a clean catch urine specimen. A urinary catheter is required for a sterile urine specimen, not a clean catch specimen. A 24-hour urine collection may be necessary to evaluate some disorders but a clean catch specimen is a one-time collection.

What position should the patient assume before the nurse inserts an indwelling urinary catheter?
1) Modified Trendelenburg
2) Prone
3) Dorsal recumbent
4) Semi-Fowler's

3) Dorsal recumbent

The nurse should have the patient lie supine with knees flexed, feet flat on the bed (dorsal recumbent position). If the patient is unable to assume this position, the nurse should help the patient to a side-lying position. Modified Trendelenburg position is used for central venous catheter insertion. Prone position is sometimes used to improve oxygenation in patients with adult respiratory distress syndrome. Semi-Fowler's position is used to prevent aspiration in those receiving enteral feedings.

The surgeon orders hourly urine output measurement for a patient after abdominal surgery. The patient's urine output has been greater than 60 ml/hour for the past 2 hours. Suddenly the patient's urine output drops to almost nothing. What should the nurse do first?
1) Irrigate the catheter with 30 ml of sterile solution.
2) Replace the patient's indwelling urinary catheter.
3) Infuse 500 ml of normal saline solution IV over 1 hour.
4) Notify the surgeon immediately.

1) Irrigate the catheter with 30 ml of sterile solution.

If the patient's urinary output suddenly ceases, the nurse should irrigate the urinary catheter to assess whether the catheter is blocked. If no blockage is detected, the nurse should notify the surgeon. The surgeon may request that the catheter be changed if irrigation does not help or if the tubing is not kinked. However, the nurse should not change a catheter in the immediate postoperative period without consulting with the surgeon. The surgeon may prescribe an IV fluid bolus if the patient is suspected to have a deficient fluid volume.

Which diagnostic test/exam would best measure a client's level of hypoxemia?
a. chest x-ray
b. pulse oximeter reading
c. ABG
d. peak expiratory flow rate

c. ABG

The term "hypoxemia" means low blood oxygen level. Arterial blood gas sampling is the most direct way in which the level of oxygen in the blood can be measured.

The term "Kussmaul" refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the larynx.
a. true
b. false

b. false

The term for this sound of respiratory distress is "stridor."

In caring for a client with a tracheostomy, the nurse would give priority to the nursing diagnosis of
a. Risk for ineffective airway clearance
b. Anxiety related to suctioning
c. Social isolation related to altered body image
d. Impaired tissue integrity

a. Risk for ineffective airway clearance

While other diagnoses may be applicable, maintaining a patent airway by tending to excessive secretions is a priority.

Of the following factors, which would put a client at greatest risk for impaired skin integrity?
a. the medication digoxin
b. moisture
c. decreased sensation
d. dehydration

c. decreased sensation

Decreased sensation would greatly increase the risk for injury with a tear or break in the skin. This could lead to a delay in seeking treatment due to lack of awareness.

The client calls the nurse to the room and states, "Look, my incision is popping open where they did my hip surgery!" The nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. The nurse's best action is to
a. Notify the surgeon STAT.
b. Place a clean, sterile 4 x 4 over the incision and monitor the drainage.
c. Wrap an ace bandage firmly around the area and have the client maintain bedrest.
d. Immediately cover the wound with sterile towels soaked in normal saline and call the surgeon.

b. Place a clean, sterile 4 x 4 over the incision and monitor the drainage.

A 1 cm separation of wound edges only in the center of a surgical incision on the hip is too small to truly be termed dehiscence. Even if there were a large separation, there are no "internal viscera" to protrude.

The nurse is completing a head-to-toe assessment on her client at the beginning of the shift for the hospital unit. This would be considered a/an
a. Focused assessment
b. Initial assessment
c. Ongoing assessment
d. Special needs assessment

c. Ongoing assessment

This type of assessment can be completed at any time after the initial assessment. Gathering data at the beginning of a shift will enable the nurse to more effectively evaluate how to proceed with the plan of care for the shift.

When gathering admission assessment data the nurse obtains a weight of 200 pounds. The client states, "I've never weighed that much!" The nurse should
a. Explain to the client how weight gain occurs
b. Check the calibration and re-weigh the client
c. Document the weight as 200 pounds
d. Instruct the UAP to re-weigh the client in 2 hours

b. Check the calibration and re-weigh the client

It is important to FIRST validate data when there is a mismatch between what the client states as history and the data obtained. Validating data often includes ensuring that equipment is functioning properly first.

To maintain proper posture, it is important to
a. sleep on the softest mattress possible
b. avoid arching shoulders forward when sitting
c. keep your knees locked when standing upright
d. keep your stomach muscles relaxed to prevent back spasms

b. avoid arching shoulders forward when sitting

Arching shoulders forward when sitting alters the curvature of the spine and contributes to poor body alignment.

Of the following interventions for the client who is immobile, the nurse will give priority to
a. encouraging a diet high in fiber and extra fluids
b. administering the PRN medication for sleep
c. having the client use his incentive spirometer q2hrs
d. massaging the client's legs every hour

c. having the client use his incentive spirometer q2hrs

Use of the incentive spirometer helps to prevent atelectasis, which improves oxygenation - a priority need.

Identify the true statement about devices used when assisting clients to ambulate.
a. The client should stand a foot back from the back legs of a walker.
b. A cane should be used by the client to support the weakest side of the body.
c. A transfer belt should be placed around the client's chest for maximum " lift."
d. Each crutch-walking "gait" begins with the client in the tripod position.

*d. Each crutch-walking "gait" begins with the client in the

The tripod position is the basic crutch standing position from which the client then moves forward.

During the communication process, "decoding" is
a. The selection of words by the sender
b. The interpretation of the message by the receiver
c. The method by which the message is given
d. The way in which feedback is interpreted

b. The interpretation of the message by the receiver

The nurse is teaching the client about his upcoming procedure and the client is very stressed. It would be most important for the nurse to
a. Use humor first to decrease the client's stress level
b. Determine if the teaching should take place at a different time
c. Introduce himself as the RN to give credibility to his message
d. Speak to the client when family members are there so they can teach the client

b. Determine if the teaching should take place at a different time

Clients who are stressed may be unable to listen fully and will not receive/understand the intended message.

Use of the statements "Tell me more about..." or "I see" encourage clients to continue talking and expressing themselves. This is called:
a. Summarizing
b. Open-ended questions
c. Focusing
d. Encouraging elaboration

d. Encouraging elaboration

Communication involves both active listening and body language working together. The nurse actively listens to the client and:
1. Sits facing the client
2. Keeps the arms and legs crossed
3. Leans back in the chair away from the client
4. Avoids eye contact as much as is physically possible

1. Sits facing the client

Active listening means to be attentive to what the client is saying both verbally and nonverbally. A nonverbal skill to facilitate attentive listening is to sit facing the client. This posture gives the message that the nurse is there to listen and is interested in what the client is saying. For active listening, the arms and legs should be uncrossed. This posture suggests that the nurse is "open" to what the client says. For active listening, the nurse should lean toward the client. This posture conveys that the nurse is involved and interested in the interaction. For active listening, the nurse should establish and maintain intermittent eye contact. This conveys the nurse's involvement in and willingness to listen to what the client is saying.

Discussing the client's follow-up dietary needs immediately after the surgery when the client is experiencing discomfort is an error in:
1. Pacing
2. Intonation
3. Timing and relevance
4. Denotative meaning

3. Timing and relevance

Discussing follow-up dietary needs immediately after surgery when the client is experiencing discomfort is an error in timing and relevance. The client is less likely to be able to pay attention and comprehend instruction when in pain, and immediately after surgery, discussing follow-up dietary needs would seem irrelevant. Pacing has to do with the speed of conversation. This is not an example of an error in pacing. Intonation is the tone of voice used. This is not an example of an error in intonation. Denotative meaning is when a single word can have several meanings. This is not an example of an error in denotative meaning.

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