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Comprehensive Final Exam (Practice
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Which actions are associated with a first-level need according to Maslow’s hierarchy of needs? Select all that apply o eating a sandwich for lunch o inviting friends over for a party o taking a nap after working out at the gym o getting a haircut before the holiday season o locking the car door when alone in the car o Taking a bottle of water along when going for a walk - 1,3, A nurse identifies a 1 cm superficial break in the skin over the right trochanter of a client during an admission assessment. What should the nurse do first? o initiate a turning schedule o complete a skin assessment form o inform the primary healthcare provider of the clients status o start wound care based on the agency’s pressure ulcer protocol - 2 Which situations may lead to a legal action for assault? Select all that apply. o A nurse threatens a client with inserting a tube to feed the client if the client does not eat all the food on their meal tray
o A nurse administers a medication that the client has refused by telling the client that it is different from the refused medication o A nurse uses a restraint when a client attempts to leave the hospital before the primary provider writes a discharge prescription o A nurse tells a client who has a prescription for bed rest that unless the client stays in bed the 4 side rails on the bed will have to be raised o A nurse is heard by a client's relative telling another nurse on an elevator that the client contracted hepatitis C from IV drug use when in fact, the client contracted the disease via a blood transfusion - 1, A nurse caring for a newly admitted client reviews the information on the client’s admission history and performs a chart review. The nurse should assess the client for which additional human response based on data collected? o Peripheral edema o burning on urination o suprapubic distension o decreased blood pressure - 3 A nurse assess four clients to determine their hygiene needs. The nurse should anticipate that the client with which problem would have the greatest difficulty having hygiene needs met by the nurse. o Pain o Dementia o Impaired vision o Limited mobility - 2 A client with the diagnosis of stage 4 pancreatic cancer is consulting with a discharge planner regarding the most appropriate level of care required after palliative surgery. The client is able to provide self-care but will need pain management. Which setting is most appropriate for this client? o Home hospice care
o Offer the client choices about care o Distract the client by discussing the news o Assist the client to recognize personal limitations o Have the client engage in activities that can be completed successfully - 2, 5 A client comes to the ED and reports pain to the hip. Which client assessments reflect chronic pain rather than acute pain? Select all that apply. o Variable breathing patterns o Decreased blood pressure o Slow monotonous speech o Increased heart rate o Pressured speech o Dilated pupils - 1,2, What action is unrelated to maintaining airborne precautions for a client with a diagnosis of suspected primary tuberculosis? o Donning a gown when entering a room o Wearing a respirator mask when in the room o Maintaining negative air pressure within the room o Having the client wear a surgical mask when transported outside of the room - 1 A nurse is to administer eardrops to an adult. The nurse verifies the original prescription, washes the hands, and collects the medication, following the 3 checks and the 10 rights associated with medication administration. The nurse then dons clean gloves. Place the following steps in the order in which they should be implemented. o Pull the auricle up and back o Apply slight pressure several times to the tragus of the ear o Instruct the pt. to remain in a side-lying position for 5- 10 mines o Position the client in a side-lying position with the affected ear facing up
o Hold the dropper a half in above the ear canal and instill the drops so that they fall on the side of the ear canal - 4,1,5,2, Before going to lunch, a nurse provides information to the nurse accepting responsibility for a client who returned 2 hours ago after a fiber optic colonoscopy. Which information is the most important for the covering nurse to know about this client? o Gag reflex is present o Reports mild abdominal pain o Passing flatus for the last hour o Dozing intermittently since the procedure - 2 Which nursing assessments indicate a period of exacerbation? Select all that apply o Clients symptoms have returned despite adhering to the medical regimen o The clients status is unchanged following a course of chemotherapy o Client reports long-standing joint pain from arthritis o Client had an allergic reaction to a prescribed medication o Client states that the back spasms are acting up again - 1, A client who misuses alcohol is admitted to the hospital for detoxification. The client is intoxicated and agitated. The clients agitation increases and the client becomes verbally abusive to the nurse. What should the nurse do next? o Obtain a prescription for a physical restraint for the client o Offer emotional support while touching the clients shoulder o Stand between the client and the exit to the room while talking with the client o Approach the clients bedside and state that using bad language is unacceptable - 3
A nurse plans to provide foot care for an older adult. What actions should the nurse include in this procedure? Select all that apply. o Soak the feet for 30 mines o Push the cuticles back gently with a washcloth o Dry each foot thoroughly, especially between the toes o Clean under nails with an orangewood stick while the foot is in the water o Soak the feet one at a time in water that has temp of 115-120 degrees F - 2,3, A client who had a brain attack is experiencing hemiparesis and fatigue. The nurse plans to progress from passive range of motion to active range of motion exercises are prescribed. What should the nurse of to best facilitate teaching sessions with the client? o Plan teaching sessions after lunch o Have another nurse assist with teaching sessions o Conduct client teaching sessions that are 15 mines in length o Medicate the client for pain 30 mines before a teaching session - 3 A client is to receive a prescribed drug for the first time at 10 am. The lab report indicates a newly elevated creatinine level at 6 am. Which nursing action is most important when caring for this client? o Assess the client for clinical manifestations of drug toxicity o Call the pharmacist to ensure that it is safe to administer the medication o Withhold the medication until repeat test results are within normal range o Inform the MD of the clients impaired kidney function - 4 With which clients should a nurse protect oneself from potential exposure to HIV when providing direct physical care? Select all that apply.
o Client who is crying o Man who is diaphoretic o Woman who is menstruating o Client who is incontinent of feces o Client who requires the insertion of a IV catheter - 3, Which skill should the nurse implement first when assessing a client’s abdomen? o Palpation o Inspection o Percussion o Auscultation - 2 Which actions are associated with the analysis step of the nursing process? Select all that apply o A nurse takes the vitals when a client reports dizziness o A nurse groups collected information into related categories o A nurse determines that a client is at risk for a pressure ulcer because of immobility and edema o A nurse and client decide that within 2 days the client will learn how to transfer from a bed to chair safely o A nurse concludes that further intervention is needed when the client does not accurately prepare an insulin injection - 2, A nurse enters the room of a pt. who is scheduled to go into surgery within the hour. The nurse observes the client gazing out the window and that the pts eyes are filled with tears. The nurse asks, " Are you okay?" The client responds, "Don't worry. Ill be fine" What is the nurse's most appropriate response. o What are you thinking about o I’ll be here if you need to talk o Don’t you think everything will be all right? o When people cry, it usually means something is wrong - 1
o A client experiencing nausea and vomiting for several hours o A client asking for pain medication for incisional pain on a level 3 o A client reporting chest pain 3 days after admission for a fractured pelvis o A client requesting to see the surgeon before signing the consent form for morning surgery - 3 A nurse is preparing a medication to be administered to a client. The nurse identifies that the name of the medication on the unit dose package is not the same as the name on the medication administration record. What should the nurse do? o Give it if the dose on the drug is the same as what is indicated on the prescription o Call the MD and ask if the drug provided is the drug prescribed o Ask another nurse on the unit who is more familiar with drugs if it is equivalent to the prescription o Check a drug information resource to determine if the name on the unit dose package is a generic form of the drug - 4 Which nursing interventions are important when assisting a client to eat? Select all that apply. o Offer to toilet the client before the meal o Place the client in an upright position for the meal o Engage the client in conversation when feeding the client o Open containers, cut meat, and apply condiments to the clients food o Ask the clients preference regarding the order of foods and fluids to ingest o ensure the client has swallowed the previous bite before assisting with another bite - 1,2,5,
A nurse responds to a call light of a client who had a colon resection 2 days ago for the removal of a cancerous tumor. The client states; "It feels very wet and funny under my dressing." Which additional information collected by the nurse supports the conclusion that the pt may be experiencing dehiscence? Select all that apply o Client described throbbing pain at the site of incision o Client stated, "I just felt a popping sensation at my incision" o Client informed the nurse of voiding excessively during the night o Client stated, "My stomach feels better when I keep my knees bent." o Client reported just having had an intense episode of coughing that brought up phlegm." - 2, An 84-year-old man we admitted to a long-term care facility because his daughter can no longer care for him. The nurse reviews the clients family history and, when the the client is brought to the unit, interviews the client and performs a physical assessment. Which nursing intervention addresses this client’s most important need? o Use a product to thicken liquids before giving them to the client o Maintain splints and braces on extremities at all times o Apply an external urinary drainage device at night o Encourage the client to explore feelings - 4 A nurse and a nursing assistant are working together caring for a group of clients in a district. Which activities are appropriate for the nurse to assign to the nursing assistant? Select all that apply o Turning and repositioning a client who had spinal surgery o Giving a bath and oral care to a client receiving contact precautions o Providing range of motion exercises while administering a bed bath
pump and how basal and bolus doses of the analgesic help relieve pain. Later when the child is sleeping, the nurse observes one of the parents pushing the trigger to deliver a bolus dose of medication. What should the nurse do first? o Review with the parents that the child is still receiving medication even if not pushing the trigger o Tell the parents to stop pushing the trigger when the child is sleeping o Notify the primary healthcare provider of the parents' behavior o Increase the dosage of the basal dose - 1 A nurse is caring for a client who is receiving an anticoagulant. When assisting the client with hygiene, the client expresses a desire to shave himself. Which is the most important for the nurse to teach the client to do? o Use a safety razor when shaving o Use an electric razor when shaving o Apply some aftershave lotion on the skin after shaving 4)) Wrap the face with a hot towel for a few mines before shaving - 2 A nurse is admitting a client to an acute care facility. The nurse should explain to the client that the most important member of the healthcare team is which person? o Client o Nurse (primary) o Nurse manager o nurse practitioner - 1 A bladder-retraining program is prescribed for a client who is incontinent of urine after therapy for bladder cancer. Which nursing interventions when implemented effectively promote a successful bladder-retraining program? Select all that apply o Teach relaxation techniques o Follow the scheduled program o Place a commode at the bedside
o Wash the perineal area every shift o Maintain a strict record of fluid balance - 1, A nurse is designing a teaching plan for a client who speaks in a different language. What is a reliable way for the nurse to facilitate client understanding of the information? o Arrange a telephone translation service to be used during the teaching session o Have a staff member who is from the same country act as an interpreter o Provide a pamphlet with pictures to reinforce what is being taught o Use a translation book that will aid in the conversation of words - 1 A nurse is caring for a client who tends to become confused. Which information communicated to the client is the best intervention to prevent falls in a hospital setting. o I am going to care for you today and I will be here whenever you call me for help o When you finish in the bathroom, activate the call light and I will help you back to your bed o When you decide you want to talk around the unit, I would appreciate it if you would use that walker o I am going to transfer you to your wheelchair now and move you to an area near the nurses' station - 4 A nurse is assessing the physical status of several clients. Which client problem should be the nurse’s greatest concern? o Tenting of the skin o Difficulty breathing o Erythema over the greater trochanter o Body weight inadequate in relation to height - 2 A nurse is caring for an obese client with an abdominal surgical incision that has a separation of wound edges with a large amount of exudate. The primary MD prescribes a wet
o Remain seated in the chair for several minutes o Leave the room so that the client has privacy - 3 A nurse is purchasing toys for children in the child life center. Identify the toys that the nurse purchased that are appropriate for the ages of children progressing from infants to adolescents. o Chess set o Plastic rattles o Deck of cards o Pounding board o Construction set - 2,4,5,3, A nurse is assessing a postoperative client incision. Which clinical manifestations support the conclusion that the client has a wound infection versus an expected local response to the stress of surgery? Select all that apply o Redness o Swelling o Warm to touch o Purulent drainage o Elevated temperature - 4, A nurse is performing a range of motion exercises for a client who had a brain attack to prevent contractures. How should the nurse move the client is hip when performing internal rotation? o Position the leg behind the body o Move the leg laterally across the midline of the body o Turn the leg and foot pointing away from the other leg o Rotate the leg and foot pointing inward toward the other leg - 4 A resident in the nursing home wanders during the night and scares other residents by going into their rooms. What is the most effective intervention that the nurse should implement to address this situation? o Explain to others that the resident means no harm
o Position a bed alarm on the wandering residents bed o Close the doors of the other resident' rooms during the night o Place bolsters against four side rails of the wandering residents bed - 2 A nurse manager allows the staff to self-arrange days off on a monthly calendar. One nurse tells the nurse manager that no one wants to complain but that one of the nurses attempts to take off all of their holidays and most of the weekends off. What is the nurse managers best response o Why didn’t you meet with the nurse and attempt to work it out? o Will the other nurses be willing to confront the nurse if you all approach the nurse together? o I guess I will have to change the system of selecting days off because this system is not working o I will arrange a meeting so that we can meet together to fix the process so that it is fair to everyone - 4 A nurse teaches a client who is lactose intolerant about foods to avoid. Which foods eliminated from the diet by the client indicate an understanding about foods that contain lactose? Select all that apply o Soy milk o Fruit cocktail o Creamed soup o Cottage cheese o Vegetable juice - 3, A nurse must administer a medication through a nasogastric tube that is being used for gastric decompression. What is the most important intervention by the nurse? o Instill an ounce of water before instilling the medication o Use a high pressure via a piston syringe to instill the medication o Shut off the negative pressure after the medication is administered
A hospitalized client reports an inability to urinate. What should the nurse do to obtain more information about this problem? Select all that apply o Perform a straight cath o Initiate intake and output monitoring o Assess the clients lower abdomen for bladder distension o Implement a bladder ultrasound scan according to protocol o Ask the client about the time and amount of the last voiding o Obtain the clients weight to compare to the weight on admission to the hospital - 3,4, A female client on bedrest asks the nurse what she can do to prevent her hair from becoming tangled and matted. What should the nurse encourage the client to avoid? o Conditioning the hair after shampooing o Washing the hair with soap o Placing the hair in braids o Brushing the hair daily - 2 A client is taking furosemide daily because of hypertension. Which foods should the nurse teach the client to consume on a regular basis? Select all that apply o 10 grapes o 5 dried figs o 1 baked potato o Half a grapefruit o 1 cup cooked spinach - 2,3, A person calls the nursing unit of a hospital saying, "I am a lawyer and must speak with a client on the unit because there is a family emergency." What is the nurse’s most appropriate intervention? o Bring the client to the phone to talk o Refuse to discuss anything regarding the client with the lawyer
o Inform the lawyer that the presence of a client cannot be confirmed or denied o Take the lawyers phone number and give it to the client without revealing that the client is on the unit - 4 A nurse is caring for a client who was admitted to the hospital because of a fecal impaction. The nurse identified inadequate fiber, fluid, and activity contributed to this client’s problem. In addition, which medication that the client is taking may have contributed to the fecal impaction? o Warfarin o Metronidazole o Ferrous sulfate o Magnesium/aluminum hydroxide - 3 A nurse is caring for an older adult who had a brain attack and has a residual problem with chewing and swallowing. What is the greatest risk considering the client's physical status? o aspiration o constipation o fluid volume deficit o inadequate nutrition - 1 A nurse is assessing a pt. with the medical diagnosis of dehydration. Which assessments should the nurse document on the clients record to support this diagnosis? Select all that apply o Low urine specific gravity o Bounding radial pulse o Straw-colored urine o Sunken eyeballs o Flat neck veins o Tenting of skin - 4,5, A client who is a Christian Scientist is admitted to the hospital for medical management and dialysis for renal
