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WorksheetsN310 Final Exam Review
Total questions: 70
Worksheet time: 1hrs 10mins
Which is the correct term for this nursing action: A nurse falsely imprisons a patient by an unauthorized use of restraints.
Crime
Tort
Misdemeanor
Felony
An elderly person who is placed in a nursing home by his family is remorseful about the loss of his financial independence. What is the term for the type of loss he is experiencing?
Physical loss
Psychological loss
Actual loss
Perceived loss
Which defense mechanism is portrayed in the following scenario? After throwing his lunch tray on the floor, a patient complains to the nurse manager about the quality of the food he is being fed during his hospital stay.
Denial
Displacement
Rationalization
Reaction Formation
1.5 grams equals how many milligrams?
001.5 mg
15 mg
150 mg
1,500 mg
The nurse is caring for a client who has been taking antibiotics for a week and is now having watery diarrhea. Which intervention is most important when caring for this client?
Administer antidiarrheal medication
Add the antibiotic to the patient's allergy list
Change the antibiotic prescribed to the client
Wash hands with soap and water when caring for the client
Which early response indicates to the nurse that the client is experiencing hypoxia? Select all that apply.
Increased heart rate
Dyspnea
Restlessness
Bradypnea
Irritability
A client presents to the emergency department with shortness of breath and reports feeling dizzy when standing. On assessment, the nurse notes the following:
Blood pressure: 88/56 mmHg
Heart rate: 115 bpm
Respiratory rate: 24/min
Oxygen saturation: 95% on room air
Which assessment finding should the nurse prioritize?
Blood pressure of 88/56 mmHg
Heart rate of 115 bpm
Respiratory rate of 24/min
Oxygen saturation of 95%
A nurse gives a resident in a nursing home a choice about which color shirt to wear. According to Maslow's Hierarchy of Needs, which level of need has the nurse met?
Self-esteem
Love and Belonging
Safety and Security
Physiological
The nurse is caring for a post-operative client who reports incisional pain of 7/10 and is reluctant to ambulate. The nurse observes shallow breathing and diminished breath sounds in the lower lobes. Which nursing diagnosis should the nurse prioritize?
Acute Pain related to surgical incision
Impaired Physical Mobility related to pain
Risk for Infection related to surgical incision
Ineffective Airway Clearance related to shallow breathing
The nurse is caring for a client with a new diagnosis of diabetes mellitus who requires education on self-management. What action should the nurse take first?
Demonstrate how to check blood glucose levels.
Teach the client the importance of a balanced diet.
Assess the client’s readiness to learn and prior knowledge.
Provide written materials about diabetes management.
A client with COPD has the following arterial blood gas (ABG) results:
pH: 7.32
PaCO₂: 55 mmHg
HCO₃⁻: 24 mEq/L
How should the nurse interpret these results?
Metabolic acidosis
Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis
The nurse evaluates the effectiveness of interventions for a client with impaired skin integrity due to a pressure injury. Which finding indicates improvement?
Increased redness around the wound edges
Decrease in wound drainage over 48 hours
Purulent drainage noted during dressing changes
Client reports decreased pain at the wound site
A nurse is performing a safety assessment of an older adult client living at home. Which finding requires the most immediate intervention?
Scatter rugs in the living room
Medication bottles stored in a kitchen cabinet
Grab bars in the bathroom
Nightlights placed in the hallway
The nurse is caring for a client with new-onset blindness. Which intervention should the nurse implement first to support the client?
Encourage the client to explore the room using touch.
Orient the client to the environment using a consistent format.
Provide the client with resources for support groups.
Teach the client to use assistive devices for mobility.
A client reports leaking urine when sneezing, coughing, or laughing. Which type of urinary incontinence does this describe?
Urge incontinence
Overflow incontinence
Functional incontinence
Stress incontinence
According to Selye's General Adaptation Syndrome, which statement does the nurse know is most related to adaptation?
Adaptations depend on the nature of the stressor.
Adaptations can be conscious or unconscious.
Adaptations are maladaptive responses.
Adaptations become secondary stressors.
The nurse is orienting a newly admitted client to the hospital. Which is most important for the nurse to teach the client how to do?
Notify the nurse when help is needed.
Get out of the bed to use the bathroom.
Raise and lower the head and foot of the bed.
Use the telephone system to call family members.
The nurse administers an incorrect dose of medication to a client. Which is the primary purpose of documenting this event in an Incident Report?
To record the event for future litigation
To provide a basis for designing new policies
To ensure accountability for the cause of the accident
To prevent similar situations from happening again
When preparing to administer a medication to a client, the nurse identifies that the dose ordered by the primary health-care provider is more than the manufacturer's recommended dose. Which should the nurse do?
Inform the supervisor.
Verify the prescription with the primary health-care provider.
Give the average dose of the medication.
Give the drug as prescribed.
When the nurse attempts to administer medication to a client, the client refuses to take the medication because it causes diarrhea. The nurse provides teaching about the medication, but the client continues to refuse the medication adamantly. Which should the nurse do first?
Discuss with a family member the need for the client to take the medication.
Explain again to the client the consequences of refusing to take the medication.
Document in the client's clinical record the client's refusal to take the medication.
Notify the primary health-care provider of the client's refusal to take the medication.
A client with a terminal illness tells the nurse, "I have lived a long life. I am ready to go." Which is the nurse's best response?
Offer the client a back rub.
Discuss with the client how dying is part of the life cycle.
Tell the family about the client's statement.
Sit quietly by the client's bedside.
A man with a heart condition continues to perform strenuous sports against medical advice. Which defense mechanism does the nurse identify that the client is using?
Denial
Repression
Introjection
Dissociation
Which should the nurse do during the evaluation step of the nursing process?
Set the time frames for goals.
Revise a plan of care.
Establish outcomes.
Determine priorities.
A client is admitted to a postoperative surgical unit after abdominal surgery. During which step of the nursing process does the nurse determine which actions are required to meet the needs of this client?
Implementation
Assessment
Planning
Analysis
Which is the primary goal of the assessment phase of the nursing process?
Build trust
Validate the medical diagnosis
Establish goals
Collect data
The nurse collects information about a client. Based on the clinical judgement measurement model, which should the nurse do next?
Plan nursing interventions.
Determine the significance of the data.
Formulate nursing diagnosis.
Write client-centered goals.
Which route is associated with the administration of a suppository? Select all that apply.
Ear
Nose
Mouth
Vagina
Rectum
A client with terminal cancer is willing to try new therapies. Which stage of the Kübler-Ross Stages of Grieving does the nurse identify that the client is experiencing?
Denial
Depression
Bargaining
Acceptance
Which is the primary reason why a nurse performs a physical assessment of a newly admitted client?
To identify if the client is at risk for falls
To establish a therapeutic relationship with the client
To identify important information about the client
To ensure that the client's skin is totally intact
The nurse is caring for a group of hospitalized clients. Which should the nurse do first to prevent client infections?
Provide small bedside bags to dispose of used tissues.
Identify clients at risk.
Encourage staff to avoid coughing near clients.
Administer antibiotics as prescribed.
The nurse assesses a client's wound and determines the exudate to be purulent. Which of the following actions should the nurse take to interrupt the portal-of-exit link in the chain of infection?
Wash the hands before providing care to a client.
Position a commode next to a client's bed.
Provide education about a balanced diet.
Change the dressing when it is soiled.
The nurse is preparing a bed to receive a newly admitted client to the hospital. Which action is most important?
Placing the client's name on the end of the bed
Ensuring that the bed wheels are locked
Positioning the call bell in reach
Raising one side rail
How often should "docusate sodium 100 mg PO BID" be given?
Three times a day
Two times a day
Every other day
At bedtime
The primary health-care provider prescribes a medication that must be administered via the intramuscular route. Which site should the nurse eliminate from consideration because it has the highest potential for injury when administering an intramuscular injection?
Vastus lateralis
Rectus femoris
Ventrogluteal
Dorsogluteal
Which information about a parenteral medication indicates that the nurse should use a filtered needle when preparing the medication?
Has to be reconstituted
Is supplied in an ampule
Appears cloudy in the vial
Is to be mixed with another medication
The primary health-care provider prescribes 500 mL of D5W with 10 mEq of KCI to be administered over 10 hours. The IV tubing states that each mL delivers 60 gtts. To what rate per minute (mL/min) should the nurse adjust the flow rate of the intravenous solution? Record your answer using a whole number.
(a)
A client's stool specimen is positive for Clostridium difficile. Which isolation precautions should the nurse institute for this client?
Droplet
Contact
Reverse
Airborne
A client with impaired mobility is to be discharged from the hospital within a week. Which is an example of a discharge goal for this client?
The client will understand range-of-motion exercises before they are initiated.
The client will be taught range-of-motion exercises after they are prescribed.
The client will transfer independently to a chair by discharge.
The client will be kept clean and dry at all times.
A client is diagnosed with a stage IV pressure ulcer with eschar. Which medical treatment should the nurse anticipate the primary health-care provider will prescribe for this client?
Heat lamp treatment three times a day
Application of a topical antibiotic
Cleansing irrigations twice daily
Débridement of the wound
The nurse is caring for a 46-year-old quadriplegic male who develops a pressure injury on his sacrum. The nurse documents that the injury has full-thickness skin loss, and adipose tissue is visible. Which stage of pressure injury should the nurse document based on this assessment?
Stage I
Stage II
Stage Ill
Stage IV
The nurse places a client in the orthopneic position. Which is the primary reason for the use of this position?
Facilitates breathing
Supports hip extension
Prevents pressure ulcers
Promotes urinary elimination
An immobilized client is placed on a 2-hour turning and positioning program. Which should the nurse explain to the client is the primary reason why this program is important?
Supports comfort
Facilitates respiratory function
Promotes elimination
Maintains skin integrity
Which should a nurse do to encourage a confused client to drink more fluid?
Serve fluid at a tepid temperature.
Explain the reason for the desired intake.
Offer the client something to drink every hour.
Leave a pitcher of water at the client's bedside.
A client is anorexic because of stomatitis related to chemotherapy. Which of the following should the nurse be most concerned about when planning care for this client?
Aspiration
Dehydration
Constipation
Malnutrition
The nurse is performing passive range-of-motion exercises for a client who is in the supine position. Which motion occurs when the nurse bends the client's ankle so that the toes are pointed toward the ceiling?
Adduction
Supination
Dorsal flexion
Plantar extension
A client has thick, tenacious respiratory secretions. Which should the nurse do to liquefy the client's respiratory secretions?
Chance the client's position every to hours.
Get a prescription for an antitussive agent.
Teach effective deep breathing.
Encourage the client to drink more fluid.
The nurse teaches a client how to use an incentive spirometer. Which client outcome supports the conclusion that the use of the incentive spirometer is effective?
Expiratory volume will be decreased.
Inspiratory volume will be increased.
Coughing will be stimulated.
Sputum will be expected.
A client's hemoglobin saturation via pulse oximetry indicates inadequate oxygenation. Which should the nurse do first?
Notify the primary health-care provider.
Encourage breathing deeply.
Raise the head of the bed.
Administer oxygen.
A client with a history of anxiety and panic attacks presents to the emergency department with rapid breathing. Laboratory results revealed a low level of dissolved CO, but normal blood O, levels. Which term best describes what the client is experiencing?
Hypoxia
Hypoxemia
Hypocarbia (hypocapnia)
Hypercarbia (hypercapnia)
The nurse is counseling a client with the diagnosis of osteoporosis. In addition to calcium, which vitamin supplement should the nurse anticipate that the primary health-care provider will prescribe for this client?
Vitamin B
Vitamin K
Vitamin D
Vitamin E
A client reports burning on urination. Which question should the nurse ask to best obtain information about the client's dysuria?
"Can you tell me about the problems you are having with urination?"
"What are your usual bowel habits?"
"How would you describe your experience with incontinence?"
"What color is your urine?"
A primary health-care provider prescribes a urine specimen for culture and sensitivity via a straight catheter for a client. Which should the nurse do when collecting this urine specimen?
Use a sterile specimen container.
Collect urine from the catheter port.
Inflate the balloon with sterile water.
Have the client void before collecting the specimen.
The nurse is caring for a group of clients with a variety of urinary problems. Which physical response identified by the nurse should cause the most concern?
Anuria
Enuresis
Diuresis
Dysuria
The nurse is performing a physical assessment on a newly admitted client experiencing urinary incontinence. Which problem identified by the nurse is often is associated with this problem?
Chronic pain
Reduced fluid intake
Disturbed self-esteem
Insufficient knowledge
The nurse is caring for two clients. One client has reflex incontinence, and the other has total incontinence. Which characteristic is common to both reflex incontinence and total incontinence?
Small loss of urine after an increase in intra-abdominal pressure
Loss of urine without awareness of bladder fullness
Retention of urine with intermittent urine overflow
Strong, sudden desire to pass urine
The nurse is caring for a critically ill client with a urinary retention catheter. Which hourly urine output should first alert the nurse that the primary health-care provider should be notified?
20 mL
30 mL
60 mL
100 mL
The nurse is planning to teach one client pursed-lip breathing and another client diaphragmatic breathing. Which technique associated with diaphragmatic breathing is different from pursed-lip breathing and should be included by the nurse in the teaching plan?
Inhale through the mouth.
Exhale through pursed lips.
Tighten the abdominal muscles while exhaling.
Raise both shoulders while inhaling deeply.
The nurse is caring for a client in respiratory distress. Which arterial blood gas (ABG) value would indicate that the client is in respiratory acidosis?
pH 7.55
pH 7.50
pH 7.30
pH 7.40
A client is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals profuse diaphoresis, dry, sticky mucous membranes; weakness; disorientation: and a decreasing level of consciousness. The data suggests which of the following electrolyte imbalances?
Hyperkalemia
Hypercalcemia
Hypernatremia
Hypermagnesemia
Which assessment is most important when caring for an adult client experiencing vomiting?
Electrolyte values
Bowel function
Body weight
Oral mucosa
The nurse suspects that an older adult may have a fluid and electrolyte imbalance. Which assessment best reflects fluid and electrolyte balance in an older adult?
Serum laboratory values
Intake and output results
Condition of the skin
Presence of tenting
Which is the best choice for an appetizer when teaching a client about a 2-g sodium diet?
Pigs in a blanket
Stuffed mushrooms
Cheese and crackers
Fresh vegetable sticks
Which client statement supports the nurse's conclusion that a client understands the need to reestablish bowel flora after a week of diarrhea?
"I must wean myself off of the antibiotics one day after my temperature is normal"
"I should eat a container of yogurt every day for a few days."
"I have to add rice to my diet in one meal each day."
"I ought to drink eight glasses of water a day."
The nurse is caring for a client with an intestinal stoma. Which intervention is most important?
Cleansing the stoma with cool water
Spraying an air-freshening deodorant in the room
Wearing sterile, nonlatex gloves when caring for the stoma
Selecting a bag with an appropriate-size stoma opening
A client requests pain medication for severe pain. Which should the nurse do first when responding to this client's request?
Use distraction to minimize the client's perception of pain.
Place the client in the most comfortable position possible.
Administer pain medication to the client quickly.
Assess the various aspects of the client's pain.
Which client statement indicates that the client is experiencing neuropathic pain?
"My lower back has been hurting for months after the accident."
"I stubbed my toe yesterday and it hurts really bad."
"I have bad migraines and I can't get relief."
"I have burning and tingling in my feet."
The nurse is teaching a client with a history of constipation about the excessive use of laxatives. Which effect of laxatives should the nurse include as the primary reason why their use should be avoided?
Weakens the natural response to defecation
Results in distention of the intestines
Precipitates incontinence
Causes abdominal discomfort
Which concept should the nurse consider when assessing a client's pain?
The expression of pain is not always congruent with the pain experienced.
Pain medication can significantly increase a client's pain tolerance.
The majority of cultures value the concept of suffering in silence.
Most people experience approximately the same pain tolerance.
The nurse is assessing a 4-year-old child during a sickle cell crisis. Which nursing action is appropriate in assessing the child's pain level?
The Wong-Baker FACES Pain Rating Scale
The numerical rating scale
The visual analog scale
The simple descriptor scale
A client has been in the intensive care unit (ICU) for 3 days. For which common adaptation indicating ICU psychosis associated with sleep deprivation should the nurse assess the client?
Hypoxia
Delirium
Lethargy
Dementia
