For the client with “hyperkalemia related to decreased renal excretion secondary to potassium-sparing diuretic therapy,” an appropriate goal would be: ECG will show no cardiac arrhythmia within 48 hours after removing high potassium foods from diet. Bowel motility will be restored within 24 hours after beginning supplemental potassium. ECG will show no cardiac arrhythmia within 24 hours after beginning supplemental potassium. Bowel motility will be restored within 24 hours after eliminating high potassium foods from diet. Question 2 1 / 1 pts A client is at risk for fluid volume excess. Which nursing interventions would ensure the most accurate monitoring of the client’s fluid status? Measuring intake and output and severity of edema Measuring intake and output and daily weights Assessing for skin tenting and crackles in the lungs Assess for skin tenting and adventitious lung sounds IncorrectQuestion 3 0 / 1 pts A client following a total hip replacement, asks a nurse why she is receiving enoxaparin (Lovenox) for prevention of deep vein thrombosis (DVT) when , with her last hip surgery, she received heparin subcutaneously. What is the nurse’s best response? “ Enoxaparin is less expensive and easier to administer than the heparin.” “There is less risk of bleeding with enoxaparin, and it does not affect your laboratory results.” “Enoxaparin is a low-molecular – weight heparin that lasts twice as long as regular heparin.” “Enoxaparin can be administered orally whereas heparin is only administered by injection.” IncorrectQuestion 4 0 / 1 pts When caring for a client with chronic pain disorder which intervention would best help that client cope with the disorder? A program of physical exercise. Music therapy for expression. Patient-controlled analgesia pump. Complete bedrest. Question 5 1 / 1 pts A client is admitted to the hospital with arterial blood gas results are pH 7.33, pCO2 45, HCO3 18. The main acid-base balance problem demonstrated by these results is: Respiratory acidosis. Respiratory alkalosis. Metabolic acidosis. Metabolic alkalosis. Question 6 1 / 1 pts Which action should you take to prevent hypoxia during nasotracheal suctioning? Measuring pulse oximetry throughout the procedure Inserting the suction catheter through the vocal cords when the client exhales Administering 100% oxygen by manual resuscitation bag before initiating suctioning Removing the suction tube from the nasopharynx as soon as the client begins to cough Question 7 1 / 1 pts Which nursing assessment is most accurate in determining the patency of a client’s newly placed left forearm internal arteriovenous (AV) fistula for hemodialysis? Feel for a bruit on the left forearm Palpate for a thrill over the fistula Aspirate blood from the fistula every 8 hours Checking the client’s distal pulses and circulation. Question 8 1 / 1 pts A nurse is talking about a client's grave condition while the nurse stands just outside the room of another client who has many visitors. This nurse is violating which of the following client rights? Advance directives Informed consent Do not resuscitate Confidentiality Question 9 1 / 1 pts A nurse is giving medications to a group of clients. He mixes up the medications of two of the clients and gives the wrong drugs. One of the clients has to have her stomach pumped after the incident and almost dies. The nurse could be guilty of: Attempted murder. Assault with a deadly drug. Malpractice Manslaughter. IncorrectQuestion 10 0 / 1 pts A client who underwent a surgical procedure the preceding day has a normal assessment with an oral temperature of 99.7F at 0800. The client is to be discharged later in the day if the client’s condition is stable. Based on the client’s current temperature, which action should be taken by the nurse? Inform the surgeon since the discharge should be canceled. Instruct the client to use incentive spirometer 10 times every hour and drink plenty of fluids and then recheck the temperature in 2 hours. Administer the dose of aspirin 81 mg earlier then the scheduled time. Realize that the temperature in only mildly elevated and was taken during the time of day when temperatures are highest according to normal diurnal deviations. Question 11 1 / 1 pts An operating room nurse is positioning a client on the operating room table so as to prevent the client’s extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to avoid: A drop in blood pressure Muscle fatigue in the extremities An increase in pulse Nerve and muscle damage Question 12 1 / 1 pts Your client is concerned about the side effects of an experimental drug the client is taking. You tell your client that you will contact the doctor about this concern. If you follow through on your commitment, you are supporting which ethical principle? Autonomy Beneficence Fidelity Nonmaleficence Question 13 1 / 1 pts The client, a Jehovah's Witness scheduled for surgery, has expressed concern that she might receive blood products, an act condemned by her religion. What is your best response? "You should allow the health care professionals to do whatever is needed to save your life." "If you are worried about contamination, the blood supply in this country is the safest in the world." "I will have the hospital chaplain come and interpret the Bible for you to show you that there really is nothing unacceptable in a blood transfusion." "Transfusions are not routine and now there are good alternatives to transfusions if you should lose an excessive amount of blood." IncorrectQuestion 14 0 / 1 pts A Saudi Arabian woman had just given birth. Her husband moved into the hospital room with his wife immediately after she gave birth. He kept the door to the room shut, and questioned everyone who entered, including the nurses. As a nurse, how do you interpret his behavior? The husband was afraid that his newborn baby would be stolen by a stranger. The husband tried to control the wife and might indicate the sign of spouse abuse. The husband believed that his wife is sacred and revered and needs to be protected. The wife actually told the husband that she needed some privacy and no disturbance. Question 15 1 / 1 pts A Mexican-American client has just delivered her first baby. Based on her past experience with a Mexican-American family, her Anglo-American nurse assumes that family members will assist with the client’s care. This is an example of: Discrimination. Ethnocentrism. Stereotyping Racism. Question 16 1 / 1 pts The first generation of a Chinese family used herbal remedies to treat their illnesses. However, members of the third North American generation no longer do so. They obtain their health care from a medical doctor, the same as most North Americans. This is an example of: Acculturation to assimilation. Ethnocentrism. Culture shock. Cultural competence. Question 17 1 / 1 pts A Jewish client asks the nurse, “Why am I sick? I haven’t committed any sins.” This statement is a belief that illness is: Something that cannot be prevented Disharmony with the forces of nature An imbalance in life forces A punishment from God. Question 18 1 / 1 pts A female just gave birth for the first time via C-section. She emigrated from China to U.S. around 1 year ago. When the nurse is assessing her culture, which of the following behaviors is least likely to be seen? The client asks for pain medication around the clock to stop the pain from Csection. The client refuses to drink any cold liquids and not bathe after delivery. The client tries to close all windows and wrapping herself with many clothes. The client believes that giving birth causes a loss of yang, which must be restored. Question 19 1 / 1 pts One of the nurses in the community health clinic has noticed that many Latin American and African clients arrive as much as one or two hours late for their appointments. What cultural interpretation would explain this pattern? Rejection of the Protestant work ethic Relaxed orientation to time Low value on health maintenance Resistance to community health care Question 20 1 / 1 pts Upon admission to the post anesthesia care unit at 0920, the client has a temperature of 97.2° F, a pulse of 68, respirations of 12 and a blood pressure of 120/73. You take vital signs every 10 minutes. Which of the following readings obtained at 1010 would you report to the physician? Blood pressure of 90/48 Respirations of 14 Pulse of 86 Temperature of 98.1° F Question 21 1 / 1 pts A Hispanic patient who speaks very little English is scheduled for surgery tomorrow. The nurse is concerned that the informed consent signed by the patient on admission may not be valid for which of the following reasons? The surgical consent was form was not notarized. The patient may not understand the document he signed, which outlines treatments and risks. It was witnessed by unlicensed personnel. The patient may be an undocumented immigrant. Question 22 1 / 1 pts The nurse encourages a client to deep breath after surgery. The client states, “It hurts too much.” Which of the following nurse actions would be most appropriate? Assess the client’s need for pain medication prior to performing breathing exercises. Encourage the client to deep breathe anyway because it is the best for her health and to prevent complications. Tell the client that she does not need to deep breathe. Tell the client you will report her lack of compliance to her physician. Question 23 1 / 1 pts A client diagnosed with cardiomyopathy is hyponatremic as a result of fluid volume overload. A fluid restriction of 800 mL /24 hours is ordered by a physician. What action by the nurse is most appropriate? Provide ice chips and refill the glass every 4 hours. Encourage the client to perform mouth care when feeling thirsty. Offer sugary lozenges for the client to hold in the mouth. Replenish the client’s water every 2 hours and have the client take small sips. Question 24 1 / 1 pts A client has an incision with a penrose drain. What should the nurse do when changing the dressing? Clean the incision site, and then clean around the drain. Place most of the dressings above the drain site to absorb the drainage. Use one swab to clean all around the drain and one inch below it. Remove the old dressing with a sterile glove. Question 25 1 / 1 pts Your client is complaining of stiffness and muscle tension in his back. You suggest a back rub, but the client declines the offer. What action should you take? Insist on giving the back rub, saying how much it will relax the back muscles. Document that the client is noncompliant with the nursing plan of care. Accept his refusal but tell the client to call you if he changes his mind. Instruct the UAP to rub the client’s back while assisting him to change into a clean gown. Question 26 1 / 1 pts Which statement indicates the client's friend understands the home care instructions for wound care? "If the wound is painful, I will give pain medication one hour before starting to change it." "It is okay if his cat keeps him company while I change the dressing." "I will report any increase in redness or swelling of the wound." "It is okay to use adhesive tape since the skin is intact." Question 27 1 / 1 pts During morning care the nurse begins to talk with a client about attending church the previous evening. The client is quiet and does not respond to the nurse's dialogue. What should the nurse do in this situation? Analyze this client's silence as spiritual distress. Realize the conversation is making the client uncomfortable and stop talking about it. Keep talking about it, asking the client questions about going to church. Contact the hospital chaplain and explain the client's need for spiritual counseling. IncorrectQuestion 28 0 / 1 pts After assessing a client, the nurse concludes the client does not have a strong sense of spiritual well-being. What client behaviors did this nurse assess? Sense of inner peace Contempt for others Gratitude Humor Question 29 1 / 1 pts To help alleviate spiritual distress effectively, the nurse must Learn as much as possible about the practices of the client's religious group. Offer to pray with the client. Recognize that "No religious affiliation" on the client's record indicates that the client is an agnostic and has no spiritual needs. Find out what the client perceives his/her spiritual needs to be. Question 30 1 / 1 pts Which dietary adjustment would support a hospitalized Muslim’s spiritual wellness during Ramadan? Arranging for only one large meal to be served in the middle of the day. Including whole grain foods and fresh fruit with each meal. Requesting that meals be served before dawn and after sunset. Providing herbal teas and unleavened bread before each meal IncorrectQuestion 31 0 / 1 pts Physiological changes during sleep include increased: Pulse rate. Basal metabolic rate. Activity of the gastrointestinal tract. Tonus of the skeletal muscles. Question 32 1 / 1 pts A client is being admitted to the medical unit with a diagnosis of upper gastrointestinal bleeding due to a painful gastric ulcer. During her admission nursing history she tells the nurse she hasn't been getting any sleep at night and she is so tired. Based on her history, what should the nurse investigate? Her diet, with particular attention to the evening meal If pain is the reason she is waking up Her environment Her history of urinary tract infections Question 33 1 / 1 pts Since being in the hospital, a client has taken her baths in the morning according to hospital routine; however, at home, she always took a warm bath just before going to bed. Now she has developed difficulty sleeping. What should the nurse do to help the client sleep better? Rub her back for 15 minutes before she retires. Offer her warm milk and crackers at 9:00 PM. Allow her to take her bath in the evening. Ask her physician for a PM sleeping medication. IncorrectQuestion 34 0 / 1 pts The home health nurse instructs the client about use of an antihypertensive medication. The client plans to take an over the counter medication for his cold. The nurse should instruct the client to avoid which of the following over the counter products while taking an antihypertensive? Acetaminophen Aspirin Pseudoephedrine Steroid cream IncorrectQuestion 35 0 / 1 pts When you check a client for pain relief 1 hour after the client was given 15 mg of morphine IM, the client is sleeping and has a respiratory rate of 8 breaths per minute. What is your best first action? Attempt to arouse the client by calling his or her name and shaking the client's arm. Administer oxygen by mask and apply an apnea monitor. Document the finding as the only action. Notify the physician Question 36 1 / 1 pts Which statement regarding chronic pain is true? Physiologic adaptation occurs so that manifestations of tachycardia and elevated blood pressure are not present. The person with chronic pain experiences local nerve adaptation so that the intensity of chronic pain diminishes over time. Chronic pain allows for better psychosocial adaptation over time, and the client has a reduction in the perception of pain. Morphine and morphine agonists are not effective for chronic pain because the cells involved in neuromodulation are no longer responsive. Question 37 1 / 1 pts Your patient has a long history of hypertension and has developed heart failure. You would anticipate giving medications to do which of the following? Increase preload Decrease afterload Decrease contractility Decrease cardiac output Question 38 1 / 1 pts Which of the following client statements indicates a need for further teaching regarding treatment for hypokalemia? “I will use avocado in my salads.” “I will be sure to check my heart rate before I take my digoxin.” “I will take my potassium in the morning after eating breakfast.” “I will stop using my salt substitute.” Question 39 1 / 1 pts Which of the following clients is most likely to experience poor cardiac output? A client who has recently completed exercising. A client who has a heart rate of 70 beats / minute. A client with a sustained heart rate of 30 beats/ minute. A client who receives a positive inotropic medication. Question 40 1 / 1 pts A patient is recovering from abdominal surgery. Which finding indicates that the patient is ready to have the NG tube removed? The patient no longer complains of nausea The patient burps after taking a sip of clear fluids Drainage from the patient’s stomach has diminished in volume The patient has been passing flatus Question 41 1 / 1 pts The nurse is using meditation with a client to help him decrease pain. Which factor is important to consider when using this type of therapy? The type of meditation is best determined by the nurse. The client’s condition will influence the use of meditation. Meditation is best taught when the client is in an outpatient setting. A certified professional should teach the client how to perform meditation. Question 42 1 / 1 pts The nurse suggests to a patient with osteoarthritis to participate in Pilates. What are the benefits of Pilates for this patient? It will give the patient an activity to perform to avoid boredom. It encourages spiritual connection. It may improve flexibility and joint health, and relieve sore muscles. It cleanses the colon and promotes flatus. Question 43 1 / 1 pts An alert competent patient refuses to take her daily antihypertensive medication. The nurse explains the importance of the medication. The patient still refuses even knowing that her BP is high at 170/100. Which of the following is the best nursing action? Administer the medication anyway because it is important. Inform the patient that the medication must be taken until the nurse gets and order to discontinue it. Withhold the medication and complete an incident report. Withhold the medication and report it to the physician Question 44 1 / 1 pts A nurse is helping a patient who is experiencing mild pain to get ready for bed. Which nursing action is most effective? Assisting with relaxing imagery. Obtaining a prescription for an opioid. Encouraging the patient to take a warm shower. Recommending that the patient be more active during the day. Question 45 1 / 1 pts During chest tube assessment, the nurse notes the presence of continuous bubbling in the water seal chamber of the closed chest drainage system. The nurse suspects that which of the following has most likely occurred? The client has developed a sudden new pneumothorax There is an air leak in the system. The wall suction unit has been set to intermediate or high level instead of low level suction. The connections have been taped too tightly. IncorrectQuestion 46 0 / 1 pts A client tells the nurse,” Since I have been taking that medicine, I feel so tired.” She is being treated with atenolol (Tenormin) for hypertension. The client’s statement is reflective of which nursing diagnosis? Risk for activity intolerance Cardiac Output, Decreased Health maintenance, altered Self-care deficit Question 47 1 / 1 pts The client presents to the emergency department complaining of “palpitations”. The nurse connects the client to the monitor. The heart rate is 180 bpm and the blood pressure is 108/50. The nurse would expect his pulse to be: Full and bounding Weak and thready Weak and bounding Full and thready IncorrectQuestion 48 0 / 1 pts The nurse is auscultating the chest of a thin, elderly client. Which technique is most appropriate for the nurse while evaluating the quality of a murmur? Use a stethoscope with tubing that measures 22 inches. Obtain a Doppler device to aid in auscultation. Place the bell of the stethoscope lightly on the chest Place the diaphragm of the stethoscope firmly on the chest. Question 49 1 / 1 pts An Asian client presents to the emergency department with a report of recurrent body aches. Upon assessment, the nurse identifies numerous circular, flat, ecchymotic burns. The burns appear to be approximately two inches in diameter, and are symmetrical. What is the likely cause of the condition? Abuse Cigarette burns Clapping Cupping Question 50 1 / 1 pts A home health nurse is assigned to an Asian American client who refuses to take the blood pressure medication prescribed by his physician. The client is using acupuncture treatments and does not believe in taking pills. How can the nurse best help this client? Notify the physician of the client’s health practices, and monitor the client for an impending crisis. Ask the nursing supervisor to transfer the client to an Asian American primary nurse. Advocate for client’s decision, and explain that pills may not help based on his beliefs. Discharge the client and advise him to call if he wants to obtain home care services at a later date. Question 51 1 / 1 pts The nurse is caring for a client on the third postoperative day after heart surgery. Because an important nursing diagnosis for post heart surgery clients is Ineffective Breathing Pattern, what is the best plan by the nurse? Ensure that the client performs deep breathing and vigorous coughing every 4 hours. Ensure the client uses the incentive spirometer every 2 hours while awake. Premedicate the client before ambulation Auscultate the lungs once a shift Question 52 1 / 1 pts A client has returned to the nursing unit following a tracheostomy. The nurse would place highest priority on assessing which of the following? Respiratory rate and breath sounds Amount of oxygen to be delivered How long ago the client received any pain medication Status of tracheostomy dressing Question 53 1 / 1 pts 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. IncorrectQuestion 54 0 / 1 pts The nurse decides to teach a client with hypertension the progressive relaxation response. Which instructions should the nurse give to the client when using this relaxation method? Sit in an upright position with legs crossed. Place sensors on the forehead to monitor physiological activity. Contract and then relax all your muscles sequentially from head to feet. Repeat a word or phrase forcefully with your breathing. Question 55 1 / 1 pts When using humor therapy with a client, the nurse should do which of the following? Use a humorous intervention within the first 20 minutes of meeting a client to establish the connection of shared laughter. Keep trying a different joke or prop until the nurse gets a laugh. Use humorous interventions after the nurse attended to the physical or emotional pain that the client might be experiencing. Try different jokes. If the client does not respond with observable laughter, he is unable to appreciate the humor the nurse shared. IncorrectQuestion 56 0 / 1 pts Nurses assist in performing relaxation, biofeedback, and imagery techniques with a client. These techniques share which of the following processes? Physical resting and rhythmic breathing. Therapeutic touch and meditation Physical activity and therapeutic touch Physical resting and reflexology Question 57 1 / 1 pts In evaluating the effectiveness of guided imagery for a client with preoperative anxiety, which data indicates that this therapy is successful? “I hope that I don’t have dreams like that tonight.” “I couldn’t concentrate very much with all I have to do today.” “I’ll practice what I learned next week.” “I feel less anxious about the upcoming surgery.” Question 58 1 / 1 pts The nurse taught the client about meditation. Which statement by the client demonstrates a correct understanding? “Meditation is a technique used to quiet the mind and focus on the future.” “Meditation involves a religious conviction.” “There is only one way to mediate.” “Meditation involves both relaxation and focus of attention.” Question 59 1 / 1 pts A patient is receiving an IV of D5and ½ NS IV. The physician’s orders one unit of packed RBCs to be transfused. The nurse primes the blood tubing with which solution prior to starting the blood? D5W Lactated Ringers NS D5 and ½ NS Question 60 1 / 1 pts An adult has received one unit of packed red blood cells after sustaining severe trauma to his legs with profuse bleeding. To evaluate whether the transfusion has been effective the nurse should Take his blood pressure. Auscultate lung sounds. Check hemoglobin and hematocrit results. Take his temperature. Question 61 1 / 1 pts A 70 year old client with terminal lung cancer tells the nurse, "I am dying because I sinned by smoking cigarettes." What is the nurse's best response to this dying client? "You are correct, but it is too late to do anything about it now." "When you started smoking cigarettes we didn't know about the problems they cause. It is not your fault." "Why don't we call the hospital chaplain and you can pray about your sins." "Smoking cigarettes isn't a sin. There are many worse habits you could have.” Question 62 1 / 1 pts The emergency department nurse contacts the admissions office to request a bed for a bed-bound client who is a practicing Muslim. In acting as an advocate for the client, what request should the nurse make of the admission clerk? Please try to find a private room. A bed that faces east will be best. Have the bed stripped, as the client will provide special sheets. If the only available room is semi-private, the other client should be Muslim. Question 63 1 / 1 pts The nurse needs to collect a sputum specimen from a client for acid-fast bacillus. The best time to collect this specimen is: After breakfast in which the client has had milk. In the afternoon. At bedtime. In the morning after the client awakens. Question 64 1 / 1 pts The nurse should explain to a client who takes Lasix and has a potassium level of 3.2 mEq/L that he should Avoid apple juice, orange juice, and instant coffee. Eat three servings daily of fruits and meat or fish. Maintain a fluid intake of 2 L/day. Avoid driving or operating electrical equipment. IncorrectQuestion 65 0 / 1 pts What is the first step in developing cultural competence? Create opportunities to interact with a variety of cultural groups. Exam the nurse’s own cultural background, values, and beliefs about health and health care. Learn about a multitude of folk medicines and herbal substances that different cultures use for self-care. Learn assessment skills for different cultural groups, including cultural beliefs and practices and physical assessment. Question 66 1 / 1 pts When communicating with a patient who speaks a language that the nurse does not understand, it is important to first attempt to: Have a family member translate. Use a trained medical interpreter. Use specific medical terminology so there will be no mistakes. Focus on the translation rather than nonverbal communication Question 67 1 / 1 pts An example of distraction to provide pain relief is TENS. Exercise. Music. Biofeedback. Question 68 1 / 1 pts While caring for a patient with a history of narcolepsy with cataplexy, the nurse can delegate which activity to the unlicensed assistive personnel (UAP)? Teaching about the timing of medications Walking the patient to and from the bathroom. Developing a plan of care with a family member Planning an appropriate diet that avoids caffeine-containing food. Question 69 1 / 1 pts After admission of the postoperative patient to the med-surg unit which assessment data requires the most immediate attention? Oxygen saturation 86% Respiratory rate 13/min Temperature of 100.4 ₒ F Blood pressure of 90/60 IncorrectQuestion 70 0 / 1 pts To detect early signs or symptoms of inadequate oxygenation, the nurse would exam the patient for Dyspnea and hypotension Apprehension and restlessness Cyanosis and cool, clammy skin Increased urine output and diaphoresis Question 71 1 / 1 pts The nurse is assessing a client following hemodialysis. Which of the following findings indicates the treatment was effective? Fluid volume decrease. Cardiac dysrhythmias Hyperkalemia Hypertension. Question 72 1 / 1 pts During the admission interview, the client tells the nurse she is afraid she will not wake up after the surgery. A possible nursing diagnosis is: Anxiety related to perceived inability to deal with possible pain. Knowledge deficit related to coping with postoperative pain. Fear related to unknown outcome of surgery. Ineffective individual coping related to surgery Question 73 1 / 1 pts A client requires intravenous vancomycin for antibiotic- resistant pneumonia. The order calls for 500 mg to be administered, and the medication is supplied in a 100 mL piggyback that contains 5 mg per 1 ml to run over 1 hour. In order to administer the correct dose, a nurse should set the infusion pump to run at a rate of ----------------- mL/hour. 100 Question 74 1 / 1 pts Hand Hygiene is? Primary Intervention Secondary Intervention Recommended Intervention Tertiary Intervention Question 75 1 / 1 pts List all the steps in correct sequence of applying and removing PPE. Your Answer: Applying PPE: 1.Perform hand hygiene; 2. Apply gown; 3.Apply mask; 4.Apply eyewear or goggle; 5.Apply gloves; Removing PPE: 1. Remove gloves; Undo the tie if the tie is in the front of the gown before removing gloves. 2.Perform hand hygiene; 3.Remove google or eyewear; 4.Remove gown; 5.Remove mask; 6.Perform hand hygiene.
