WorksheetsNCM103 Final Exam Set B
Total questions: 50
Worksheet time: 1hrs 20mins
Upon assessment, the nurse notes that a client has dyspnea, crackles in both lung bases, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details?
Ineffective Breathing Pattern
Anxiety
Ineffective Airway Clearance
Impaired Gas Exchange
The client is experiencing severe shortness of breath, but is not cyanotic. What laboratory value should the nurse review in an attempt to understand this phenomenon?
Blood sugar
Hemoglobin and hematocrit
Cardiac enzymes
Serum electrolytes
The client complains of difficulty breathing. Which assessment findings should the nurse associate with that complaint?
Use of accessory muscles
Increased respiratory depth
Increased respiratory rate
Decreased respiratory depth
Decreased respiratory rate
The staff development instructor planning self-concept development classes for staff nurses is going to include information to improve the nurses’ self-concept along with information to use with clients. Why is the information for nurses important?
he nurse's self-concept is more important than the client's.
Poor self-concept is the number-one reason for nursing burnout.
Nurses with positive self-concept are better able to help clients.
Nurses with poor self-concept are more likely to make errors.
Which statement, made by the client, would indicate a "me-centered" self-concept?
"I couldn't stand to disappoint my parents."
"My sister is so much smarter than I am."
"My future is based on the decisions I make today."
"The world has always been against people like me."
The nurse is admitting a client to the emergency department with complaints of severe abdominal pain. What is the nurse's FIRST action?
Administer IV pain medication as ordered.
Start an IV line of lactated Ringer's.
Assess pain using a scale of 1 to 10.
Place a Foley catheter to bedside drainage.
The nurse is providing discharge instructions to a client prescribed an opioid medication. What should the nurse suggest to decrease the risk of constipation with this medication?
Take an antihistamine three times per day.
Drink 6 to 8 glasses of water per day.
Assess respiratory rate before taking medication.
Assess heart rate before taking medication.
A client recovering from a left below-the-knee amputation is experiencing left foot pain. The nurse realizes the client is experiencing which type of pain?
Phantom limb pain
Acute pain
Chronic pain
Narcotic-induced pain
The nurse is assessing a client's urinary elimination. Which factor should the nurse keep in mind as influencing this elimination?
Age
Body image
Knowledge
Socioeconomic status
A client asks the nurse why expelled flatus is foul-smelling. What should the nurse respond?
The actions of microorganisms within the gastrointestinal tract are responsible for the odor.
The client's emotions are causing the gas formation.
The sensory nerves in the rectum are being stimulated.
The client has swallowed too much air while eating.
A client asks the RN why it is more difficult to use a bedpan for defecating than sitting on the toilet. Which would be the nurse’s best response?
The sitting position decreases the contractions of the muscles of the pelvic floor.
The sitting position increases the downward pressure on the rectum, making it easier to pass stool.
The sitting position increases the pressure within the abdomen.
The sitting position inhibits the urge to urinate, allowing one to defecate.
The client has complaints of being tired, listless, and unable to tolerate activity at usual levels. Which laboratory value should the nurse review first while assessing this complaint?
Blood urea nitrogen
Hemoglobin and hematocrit
Blood sugar
Serum potassium
A client has a heart rate of 170 beats per minute. For what will the nurse assess next in this client?
Increased cardiac output
Increased preload
Decreased afterload
Decreased cardiac output
The client has experienced a myocardial infarction with damage to the inferior portion of the heart. Due to this history, the nurse monitors the client for the development of rhythm disturbances that are most directly based upon which factor?
The resultant change in blood sugar
Electrolyte disturbances from tissue damage
The automaticity of cardiac cells
Decreased blood flow to the liver
After a cardiac catheterization, an infant is diagnosed with a malformation of the mitral valve. The nurse will monitor the client for the development of a problem associated with the delivery of
oxygenated blood to the body.
deoxygenated blood to the lung.
oxygenated blood to the right atrium.
deoxygenated blood to the left ventricle.
The nurse is counseling a family in which a member is terminally ill. The family has children of varying ages. Which of the following is a CORRECT statement about reactions of children to death?
Toddlers perceive death as irreversible and unnatural.
Preschool children view death as a spiritual release.
At about age 9, children begin to understand that death is inevitable.
Adolescents tend to have better outcomes than adults after a loss.
During assessment, the client says that it has been "a long time" since she has thought very much about religion. The nurse caring for this client has a strong belief in God and the healing power of prayer. What action should be taken by the nurse?
Mention the nurse's belief and offer to pray with the client for forgiveness.
Tell the client that the nurse will pray for her often.
Ask the client if there are any spiritual needs with which the staff can assist.
Refer the client for spiritual counseling.
The nurse has identified that many of the clients in the long-term care facility have spiritual concerns and distress. What is the nurse's first step in becoming a competent provider for these clients?
The nurse must possess a healthy spiritual self-awareness.
The nurse must learn about diverse spiritual beliefs and practices.
The nurse should start going to church more often.
The nurse should establish regular religious services in the facility.
As a part of care planning, the nurse considers the client's spiritual needs. What is the rationale for this concern?
Nurses are the only health professionals who provide this type of holistic care.
Meeting the client's spiritual needs can decrease suffering.
Until spiritual needs are met, physical needs cannot be healed.
It is important that the nurse's idea of spirituality matches the client's ideas.
A client is experiencing changes in taste. What can the nurse do to improve this client’s gustatory sense? Select all that apply.
Suggest eating each food separately.
Offer foods with a variety of flavors.
Recommend eating foods that are cold.
Promote sips of water between eating different foods.
Encourage the client to consume foods of different textures.
The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement?
Use short phrases.
Overarticulate words.
Vary the volume of the voice.
Face the client during conversation.
A client can be aroused only with extreme or repeated stimuli. How should the nurse document this client’s behavior?
Somnolent
Disoriented
Comatose
Semicomatose
An older client has become very confused since being hospitalized earlier in the week. Prior to this illness, the client exhibited clear thought processing and was able to maintain an independent lifestyle. How should the nurse document this mental state?
As reversible confusion
As sundown syndrome
As delirium
As dementia
The nurse is assisting a visually impaired client with ambulation. How should the nurse proceed with this intervention?
Walk slightly behind the client.
Walk 1 foot in front of the client.
Walk on the right side of the client.
Walk on the left side of the client.
The odor from a hospitalized client's draining wound permeates the room and is very overwhelming and distracting to the client and the staff. What intervention would be most helpful?
Spray the room routinely with a floral room spray.
Instill a vinegar solution into the wound.
Keep the wound dressing dry and clean.
Burn a candle in the room.
During review of admission data, the nurse learns that the new client has impairment of kinesthetic sensation. Which nursing intervention should be planned for this client?
Use the clock face as a format for describing the position of food on meal trays.
Provide all teaching materials in very large font.
Ensure that the client has assistance when ambulating.
Use only nonirritating soaps for bathing.
A client is prescribed steroid medication. When preparing discharge instructions, the nurse should include information about infection control because steroids cause
decreased oxygen supply to tissues.
suppression of the inflammatory process necessary for healing.
a decrease in the amount of nutrients such as glucose in the blood.
blood vessel constriction, which impairs waste product removal.
Multiple severely injured clients have arrived in the emergency department. On rapid assessment, the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage. The client is otherwise stable. What action should the nurse take?
Place a tourniquet above the wound.
Remove the dressing and place direct pressure on the wound.
Add an additional dressing to the wound without removing the original.
Remove the dressing and replace it with a new sterile dressing.
A client sustained a significant loss of blood after a motor vehicle accident. The nurse notes that the client’s urine output has decreased and suspects that which hormones have influenced this client’s fluid balance? Select all that apply.
Aldosterone
Angiotensin
Antidiuretic hormone
Estrogen
Progesterone
An older client receiving intravenous fluids at 175 ml/hr is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as being which complication of intravenous fluid therapy?
An allergic reaction to the antibiotics in the fluid
Fluid volume excess
Pulmonary embolism
Speed shock
The nurse is caring for a client who is being mechanically ventilated. Arterial blood gas analysis reveals respiratory acidosis. Which change in ventilator settings should the nurse anticipate?
Decrease in oxygen delivery
Decreased tidal volume of each breath
Increased respiratory rate
Increase in humidification of inspired air
The nurse wants to assess a client for orthostatic hypotension. What action should the nurse take?
Assess the client for dependent edema and then raise the legs to the level of the heart and reassess for edema.
Measure the client's heart rate and blood pressure in both the sitting and standing position.
Measure the client's blood pressure before, during, and after administration of a normal saline fluid challenge.
Raise the client's legs above heart level and measure the blood pressure.
The nurse is caring for an 80-year-old client with the medical diagnosis of heart failure. The client has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client?
Heart Failure related to edema, as evidenced by confusion
Fluid Volume Deficit related to loss of fluids, as evidenced by edema
Excess Fluid Volume related to retention of fluids, as evidenced by edema and orthopnea
Excess Fluid Volume related to congestive heart failure, as evidenced by edema and confusion
The nurse is providing discharge instructions to a client who has been started on diuretic medication furosemide (Lasix) once daily. What information is essential to include in this information?
Take the medication at bedtime.
Avoid high-potassium foods.
Stand up slowly from a sitting position.
Do not take this medication on the days you take digitalis (Lanoxin).
A client on diuretic therapy has a serum potassium level of 3.4 mg/dL. Which food should the nurse encourage this client to choose from the dinner menu?
Baked chicken
Green beans
Sweet potato
Iced tea
The client's arterial blood gas report reveals a pH of 6.58. How does the nurse evaluate this value?
There is a slight elevation.
This value is incompatible with life.
This is a low normal value.
This value is extremely elevated.
A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results should the nurse expect to find in this client?
pH 7.30; PaCO2 50; HCO3 27
pH 7.47; PaCO2 43; HCO3 28
pH 7.43; PaCO2 50; HCO3 28
pH 7.47; PaCO2 30; HCO3 23
A client tells the nurse about passing out after following a fasting diet for 5 days. Which acid–base imbalance should the nurse expect to assess in this client?
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have not yet been successful and should continue?
35 mL per hour
80 mL per hour
50 mL per hour
30 mL per hour
The nurse is creating goals for a client’s plan of care. For what reasons should the nurse expect to use these goals? Select all that apply.
Serve as criteria to evaluate the client’s progress
Determine when the problem has been resolved
Motivate the client to provide a sense of achievement
Use as a measuring stick to limit the use of hospital resources
Provide direction when planning the client’s nursing interventions
The nurse manager is implementing computerized care plans for the care area. Which guidelines should the manager emphasize when the staff is writing care plans? Select all that apply.
Plans must be dated and signed.
Categories must have headings.
Plans must be specific.
Plans must include preventive care and health maintenance.
Plans are standardized and generalized for all clients.
The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale?
Have suction equipment available at all times.
Clear secretions from oral/nasal passageways as needed.
Keep client in low-Fowler's position to prevent reflux.
Provide frequent assessment for presence of obstructive material in mouth and throat.
The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention?
Assist client with ambulation.
Ambulate with client, using a gait belt, twice daily for 15 minutes.
Make sure client understands the rationale for using the gait belt.
Client will ambulate in hallway twice daily.
A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Which should the nurse identify as an observation intervention?
Turn and reposition client every 2 hours.
Cushion bony prominences with soft foam while in bed.
Provide ongoing assessment for skin breakdown every shift.
Apply lotion to dry skin twice daily.
One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention?
60 to 90 degrees during feeding times
Position in chair
Upright in a chair
Impaired swallowing
The nurse is reviewing interventions written for a client’s plan of care. Which intervention should the nurse recognize as being dependent?
repositioning the client every 2 hours
Assisting the client with transfers to the bathroom
Providing ongoing physical assessment, especially of the incisional sites
Administering medications for pain
The nurse is caring for a client with Parkinson’s disease who desires to improve fine motor skills. Which statement should the nurse identify as an appropriate collaborative intervention for this client?
Provide assistance as needed with dressing and grooming.
Provide assistive devices and educate client to use grab bar and large handled utensils.
Make sure lighting and space are adequate for client.
Administer medications to improve muscle tone.
The nurse identifies for a client the nursing diagnosis “Fluid volume deficit, related to active fluid loss, secondary to diarrhea.” What would be and appropriate goal statement for this diagnosis?
Client will drink more fluids by tomorrow.
Client will have good skin turgor.
Client will have moist mucous membranes.
Client will have intake of at least 1000 mL within 24 hours.
A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately?
Client will ambulate without a walker by 6 weeks.
Client will ambulate freely in house.
Client will not fall.
Client will have freer movement in daily activities.
A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client?
Syndrome diagnosis
Risk nursing diagnosis
Actual diagnosis
Wellness diagnosis
