Which characteristics of the stages of infection indicate the full stage of infection?
• Question 1 Which characteristics of the stages of infection indicate the full stage of infection?
a. It is the interval between the pathogen’s invasion of the body and the appearance of symptoms of infection.
b. Specific signs and symptoms are present.
c. The organisms are growing and multiplying.
d. Early signs and symptoms of disease are present, but these are often vague and nonspecific.
• Question 2 While assessing the client, the nurse hears diminished lung sounds on auscultation, counts a respiratory rate of 22 and regular, and obtains an oxygen saturation of 89% on room air. What nursing diagnosis is best supported by this assessment data?
a. Impaired gas exchange ??
b. Ineffective airway clearance ??
c. Anxiety
d. Tachypnea
• Question 3 A nurse accidentally sticks her hand with a needle after administering an injection to a client. What action should the nurse take first?
a. Report the incident to the charge nurse.
b. Wash the area of the puncture thoroughly with soap and warm water.
c. Complete an incident report.
d. Go to employee health services.
• Question 4 A client is having difficulty climbing stairs and reports shortness of breath. The nurse notes that the client is breathing heavy, having nasal flaring and mouth is wide open. How will the nurse document this client’s response to activity?
a. Wheezing with activity.
b. Tachypnea.
c. Dyspnea on exertion (DOE).
d. Apnea.
• Question 5 A home care client was recently prescribed continuous oxygen. What client statement indicates further education is needed?
a. I will be able to tell how much oxygen I’m getting by looking at the flowmeter.
b. I should call my doctor if I find it harder to concentrate.
c. I will make sure my visitors smoke outside.
d. I will wear synthetic clothing and woolen socks when using my oxygen
• Question 6 A nurse is interviewing a client who will undergo a cardiac coronary catheterization (angiography). The nurse inquires if the client has someone with her that will be able to drive her home after the procedure. What phase of the nursing process involves questioning and gathering data?
a. Planning
b. Evaluation
c. Assessment
d. Diagnosis
Question 7 Following shift-to-shift report, what nursing process activity is performed first?
a. Critically analyze assessment data to determine priorities.
b. Collect and organize client data through physical assessment.
c. Set client-centered, measurable and realistic goals.
d. Determine effectiveness of intervention.
• Question 8 A nurse working on an orthopedic unit is caring for four clients. What client is at greatest risk for skin breakdown?
a. An adolescent who has a cervical fracture and is in a halo brace.
b. A young adult who has a femur fracture and is in a cast.
c. A middle adult who has a fractured radius and an arm cast.
d. An older adult who has a hip fracture and is in an immobilizer
• Question 9 The nurse is assigned to care for a middle-ages adult woman who recently had abreast removed due to cancer. While preparing to clean the incision, the patient tells the nurse, “I just can’t look at myself like this.” What is the best therapeutic response?
a. It could be worse.
b. Let me finish preparing the supplies, then we can talk.
c. I see this is a difficult change for you. Tell me more about how you’re feeling.
d. Don’t worry, everything will be alright.
• Question 10 While performing an assessment, the nurse hears crackles in bilateral lower lung lobes. The nurse adds a nursing diagnosis of impaired gas exchange. What purpose does a nursing diagnoses serve? (Select all that apply.)
a. Nursing diagnoses allow for greater autonomy in the nursing field.
b. Nursing diagnoses allow for greater accountability to the nursing profession.
c. Nursing diagnoses provide clear identification of the body of nursing knowledge.
d. Nursing diagnoses identify problems other non-nursing team members are expected to resolve.
• Question 11 A nurse identifies a client as having a risk for impaired skin integrity. The clients position is changed every two hours as directed in the care plan interventions. How should the nurse evaluate the effectiveness of the intervention?
a. Examine the condition of the client’s skin using inspection and palpation.
b. Ask the unlicensed assistive personnel (UAP) if the patient’s position has been changed every two hours.
c. Ask the client how the interventions is working.
d. Delegate skin assessment to a licensed practical nurse.
• Question 12 The nurse is preparing to assess the cardiopulmonary system with inspection, palpation, percussion and auscultation. The patient complains of chest pain. What priority assessments are needed next?
Auscultation of the chest wall?
• Question 13What strategy is most effective in blocking the transmission of microbes from the infectious reservoir to susceptible hosts?
a. Sterilize the infectious human reservoir.
b. Block the portal of exit from the infectious reservoir.
c. Block the portal of entry into the host.
d. Decrease susceptibility of the host.
• Question 14 The student nurse is assessing breath sounds on a client with asthma and notes continuous musical sounds. What adventitious breath sound should the student document?
a. Wheezing.
b. Pleural friction rub.
c. Rhonchi.
d. Crackles.
• Question 15 The nurse is performing a comprehensive assessment and is completing the Braden scale. What is the Braden scale used to determine?
a. The level of physical mobility of a patient.
b. The risk of developing pneumonia
c. The risk of developing a pressure ulcer
d. To assess the level of swallowing.
• Question 16 What is the correct flow of blood from the inferior vena cava through the heart and lungs?
Right atrium>1
Right ventrical>2
Pulmonary artery>3
Plumonary vein>4
Left atrium5
• Question 17 When should a nurse wear eye protection?
a. While providing oral hygiene care to a client who is HIV positive.
b. While emptying a urinary drainage bag for a client who had pneumonia.
c. While irrigating a wound with saline.
d. While transporting cerebrospinal fluid specimen to the lab.
• Question 18 A nurse is caring for a comatose obese client. What intervention reduces friction and shear injury?
a. Delay bathing to avoid excess stress.
b. Elevate head of bed over 45 degrees and keep foot of bed flat.
c. Using 2 caregivers to boost the client up in bed with a lift sheet.
d. Using an electric ceiling lift to reposition client every 2 hours.
• Question 19 What statement should the nurse include in a lesson on proper hand hygiene?
a. You do not have to wash your hands if you were wearing gloves during care.
b. Rub all surfaces of your hands with an alcohol rub for at least 15-20 seconds or until dry.
c. Use an alcohol rub when your hands are visibly soiled.
d. Use hot water to kill the most germs.
• Question 20 The nurse is planning care for an adult client recovering from pneumonia. What is an expected outcome for the nursing diagnosis of impaired gas exchange?
a. The nurse will assess arterial blood gases.
b. Client will have oximetry results in the range of 80-85% on room air.
c. Client will demonstrate non-labored breathing at 12-20 breaths per minute within 48 hours
d. Client will tolerate oxygen wearing while maintaining oxygen saturations>100%
• Question 21 A nurse is telling a client with chronic obstructive pulmonary disease (COPD) to breathe out slowly and gently, like blowing out a candle to prolong exhalation. What technique is the nurse teaching the client?
Pursed lips breathing
• Question 22 Which of the following are interventions the nurse should expect in a plan of care for a hyperthermic client? (Select all that apply.)
a. Monitor intake and output
b. Encourage fluids with all interactions
c. Monitor vital signs
d. Apply additional blankets
• Question 23 The nurse uses critical thinking in the evaluation phase of the nursing process. What is an appropriate nursing intervention upon finding a pressure ulcer that is larger than the previous measurement? (Select all that apply.)
a. Evaluate client’s ability to reposition self in bed
b. Modify interventions using evidence-based practice
c. Change nothing about the care plan as all evidence-based interventions will eventually work
d. Collaborate with the inter-professional health care team to improve nutrition, hydration and skin care.
e. Explain to the patient that the previous interventions were poor
• Question 24
A client suddenly begins to have syncope and dyspnea upon exertion (DOE). What objective data may be found when the nurse performs the focused assessment?
a. Pulmonary embolism.
b. Tachypnea.
c. Patient states, “I can’t breathe.”
d. Laryngeal abscess.
• Question 25
The client’s white blood cell count (WBC) is 7,500/mm3. What interpretation of the laboratory values by the nurse is most accurate?
a. Client has a low value and is at risk for infection.
b. Client has a high value and most likely has an infection.
c. Client value is within normal range.
• Question 26
The body transfers heat to an ice pack, causing the ice pack to melt and the clients temperature to be reduced. The nurse knows the decrease in temperature is caused by which process?
a. Radiation
b. Convection
c. Evaporation
d. Conduction
• Question 27
What statement identifies the purpose of nursing diagnostic statements?
a. Nursing diagnoses identify the plan
b. Nursing diagnoses link to the health care provider’s recommendations
c. Nursing diagnoses identify actual problems and potential problems
d. Nursing diagnoses gather clients’ data and analyze their health status
• Question 28
A client is admitted for treatment of poorly healing infected leg ulcers. What is the importance of obtaining a client’s nutritional history?
a. Poor nutrition may cause an ulcer.
b. Clients’ eating habits are usually unsatisfactory to sustain overall health.
c. The client’s food intake will likely be decreased as a result of the illness.
d. Nutrition directly affects wound healing and infection prevention.
• Question 29
A nurse is admitting a client who has tuberculosis. What transmission-based precautions should the nurse initiate?
Airborne
• Question 30
A nurse is caring for a client who had vascular surgery on the left lower extremity. The client suddenly states, “I have tingling in my toes on the left foot.” What is the first thing the nurse should assess?
a. Vital signs.
b. Assessment bilateral dorsalis pedis and posterior tibial artery pulses.
c. Assess the bilateral femoral and axillary pulses.
d. Abdominal shape and symmetry.
• Question 31 A nurse is assessing for cyanosis in the client who has dark skin. What site should the nurse examine to identify cyanosis in this client?
Oral and mucous membranes
• Question 32 Respiratory rate is regulated by mechanisms of the cardiovascular system, neurological system and pulmonary system. As the oxygen in the blood diminishes, which initial physiological responses should the nurse expect to see on assessment?
Increased heart rate and increased respiration rate.
• Question 33 A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. What intervention should the nurse use to help maintain the integrity of the client’s skin?
a. Bend at the waist to physically lift the client up in bed.
b. Apply cornstarch to keep sensitive skin areas dry.
c. Allow skin to remain damp until the fever breaks.
d. Elevate the head of the bed no more than 45 degrees.
• Question 34 The nurse is assessing an ischial pressure ulcer on a client. Objective data reveals an ulcer that is 3 cm x 2 cm and involves the epidermis and partially into the dermis. The nurse also notes an area of redness around the pressure ulcer. What would the nurse document this wound as?
a. A stage IV pressure ulcer with undermining.
b. A stage II pressure ulcer with surrounding erythema.
c. A stage III pressure ulcer with surrounding erythema.
d. A stage I pressure ulcer with surrounding erythema
• Question 35 A nurse is educating a married client on modifiable ways to lower the risk of infections. The nurse should include what behaviors?
a. Abstinence
b. Smoking cessation
c. Slow the aging process
d. Avoiding aggressive contact sports.
• Question 36 What nursing intervention is best for patients with existing pressure ulcers on bilateral heels?
a. Placing the patient in a whirlpool bath containing povidone-iodine solution.
b. Applying an agent to increase moisture at the ulcer site.
c. Reposition client every two hours???
d. Apply pressure-reducing boots to keep weight off affected area.
• Question 37 Which of the following are true regarding the use of the incentive spirometer?
Improves the patient breathing in their lungs especially in surgery or a long illness such as pneumonia.
• Question 38 A nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?
a. Remove all metal necklaces.
b. Take several shallow breaths during the procedure.
c. Do not eat or drink anything the morning of the test.
d. Expect minor discomfort after the procedure.
• Question 39 A nurse is caring for a client on prolonged bedrest. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of what condition?
Impairedgas exchange
• Question 40The nurse identifies alternate wound care interventions for a client with a venous stasis ulcer. The nurse was hopeful to see some improvement by this time, however the wound is not reducing in size or amount of drainage. What phase of the nursing process does the care plan revision fall into?
a. Evaluation
b. Assessment
c. Diagnosis
d. Implementation
• Question 41 You are caring for a 20 year old client who has an abdominal incision. The surgical wound was closed with 10 sutures. This surgical wound is healing by what process?
a. Binary intention.
b. Secondary intention.
c. Tertiary intention.
d. Primary intention.
• Question 42 Physiological changes associated with aging place the older adult client at risk for what nursing problem?
a. Impaired skin integrity
b. Risk for poisoning
c. Ineffective coping
d. Risk for suffocation
• Question 43 What is the primary difference between acute and chronic wounds?
a. Acute wounds are full-thickness.
b. Acute wounds usually heal within days to weeks.
c. Acute wounds exceed typical healing time.
d. Acute wounds include pressure ulcers.
• Question 44 A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client’s pulse. What personal protective equipment (PPE) should the nurse don?
a. A gown.
b. Sterile gloves.
c. Clean gloves and gown.
d. Protective eyewear.
• Question 45 A client had to return to surgery for a retained foreign object and now has an open wound that will be closed at a later date. This wound is healing by what process?
Tertiary intentions healing
• Question 46 What desired outcome is most appropriate for a client with the nursing diagnosis of impaired gas exchange?
a. Client will demonstrate unlabored respirations at 6 breaths a minute by tomorrow.
b. Client’s blood CO2 will increase by 1200.
c. Client will rest in the prone position for all meals.
d. Client will have oxygen saturation greater than or equal to 95% before and after activity.
• Question 47 A nurse is teaching a newly hired group of unlicensed assistive personnel (UAP) about infection-control measures on the unit. What is the most effective way to prevent the spread of pathogens during client care?
a. Properly disposing of contaminated equipment.
b. Discarding used syringes in appropriate containers.
c. Changing soiled linens daily for clients who have draining wounds.
d. Performing hand hygiene frequently and consistently.
• Question 48 While performing a health history questionnaire, a patient confirms that he occasionally coughs up mucous. What additional question(s) will the nurse follow up with? (Select all that apply.)
a. How much do you spit out?
b. Move on with the assessment, there are no further questions needed.
c. What color is the mucous and is it ever blood-tinged?
d. Are there certain times of the day or environments where you cough up more mucous?
e. Why don’t you just swallow the mucous?
• Question 49 The nurse notices that there is a new area of skin breakdown. This would be an example of what phase of the nursing process?
a. Assessment
b. Diagnosis
c. Implementation
d. Planning
• Question 50 A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. What order of intervention should the nurse use to help maintain the integrity of the client’s skin after an episode of incontinence? (Choose the correct order)
1. Remove soiled clothing
2. Clean and dry client’s skin
3. Apply barrier cream if needed
4. Redress the client
Extra questions from other exam:
1. A nurse is admitting a client who has pertussis. What transmission-based precautions should the nurse initiate?
a. Airborne
b. Contact
c. Droplet
d. Protective
2. What is a sign or symptom of late hypoxia?
a. Elevated respiratory rate.
b. Cyanosis.
c. Restlessness.
d. Elevated heart rate.
3. The nurse notices that there is a new area of skin breakdown. This would be an example of what phase of the nursing process?
a. Assessment
b. Diagnosis
c. Implementation
d. Planning
4. What body systems is not involved in the process of normal gas exchange?
a. Cardiovascular system.
b. Pulmonary system.
c. Hepatic system.
d. Neurologic system.
5. How should the nurse auscultate the lung lobes?
a. Listen only to the posterior chest.
b. Listen to the left upper lobe and left lower lobe, then precede to the right upper and right lower lobes.
c. Listen to the top of the anterior chest and then the top of the posterior chest.
d. Listen to the chest sounds proceeding from top to bottom and side to side.
6. A nurse is caring for a client who experienced a lacerated spleen with internal bleeding. She has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of what condition.
a. An upper airway respiratory infection.
b. Aspiration pneumonia
c. atelectasis
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