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A nurse is assessing the heart sounds of a client who has developed
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A nurse is assessing the heart sounds of a client who has developed
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A nurse is assessing the heart sounds of a client who has developed chest painthat becomes worse with inspiration.
The nurse auscultates a high-pitched scratching sound during both systole and
diastole with the diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document?
A. Audible Click
B. Murmur
C. Third heart sound
D. Pericardial friction rub -Correct Answer= D) Pericardial friction rub
A nurse is obtaining the blood pressure in a client's lower extremity.
Which of the following action should the nurse take?
A. Auscultate for the blood pressure at the dorsalis pedis artery.
B. Measure the blood pressure with the client sitting on the side of the bed.
C. Place the cuff 7.6cm (3in) above the popliteal artery.
D. Place the bladder of the cuff over the posterior aspect of the thigh. -Correct
Answer= D) place the bladder of the cuff over the posterior aspect of the thigh
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of
newly licensed nurses.
Which of the following actions should the charge nurse teach as the first response in
CPR?
A. Call for assistance
B. Begin Chest compressions
C. Confirm unresponsiveness.
D. Give rescue breaths. -Correct Answer= C) Confirm unresponsiveness
,A nurse is caring for a client who requires a chest x-ray.
Prior to the client being transported for the procedure, which of the following
actions should the nurse take first?
A. Explain the x-ray procedure to the client.
B. Help the client into a wheelchair before the transporter arrives.
C. Ask if the client has any questions.
D. Identify the client using two identifiers. -Correct Answer= D) Identify the client
using to identifiers
A nurse is caring for a child who is postoperative following a tonsillectomy.
Which of the following actions should the nurse take?
A. Encourage the child to cough frequently to clear congestion from anesthesia.
B. Place a heating pad at the child's neck for comfort.
C. Administer analgesics to the child on a routine schedule throughout the day
and night.
D. Provide the child with ice cream when oral intake is initiated. -Correct Answer= C)
Administer analgesics to the child on a routine schedule throughout the day and
night
A nurse is providing teaching to a client who has heart failure about how to reduce
his daily intake of sodium.
Which of the following factors is the most important in determining the client's
ability to learn new dietary habits?
A. The involvement of the client in planning the change.
B. The emphasis the provider places on the dietary changes.
C. The learning theory the nurse uses to teach the dietary changes.
D. The extent of the dietary changes planned for the client. -Correct Answer= A)
The involvement of the client in planning the change
,A charge nurse is observing a newly licensed nurse perform tracheostomy care for
a client.
Which of the following actions by the newly licensed nurse requires intervention?
A. Obtaining hydrogen peroxide for the tracheostomy care.
B. Obtaining cotton balls for the tracheostomy care.
C. Obtaining sterile gloves for the tracheostomy care.
D. Obtaining a sterile brush for the tracheostomy care. -Correct Answer= B)
Obtaining cotton balls for the tracheostomy
A nurse is preparing to perform mouth care for an unresponsive client.
Which of the following actions should the nurse plan to take?
A. Place the client supine.
B. Keep both side rails up.
C. Raise the level of the bed.
D. Inspect the client's mouth using a finger sweep. -Correct Answer= C) Raise the
level of the bed
A nurse is witnessing a client sign an informed consent form for surgery.
Which of the following describes what the nurse is affirming by this action?
A. The client fully understands the provider's explanation of the procedure.
B. The client has been informed about the risks and benefits of the procedure.
C. The nurse witnessed the provider's explanation of the procedure.
D. The signature on the preoperative consent form is the client's. -Correct Answer=
D) The signature on the pre-operative consent form is the clients
, A nurse is preparing to provide tracheostomy care for a client.
Which of the following actions should the nurse take first?
A. Open all sterile supplies and solutions.
B. Stabilize the tracheostomy tube.
C. Don sterile gloves
D. Perform hand hygiene -Correct Answer= D) Perform hand hygiene
A nurse is caring for an older adult client who becomes agitated when the nurse
requests that the client's dentures be removed prior to surgery. Which of the
following responses should the nurse .make?
A. It's for your safety. Dentures can slip and block your airway during surgery.
B. You wouldn't want your teeth to be lost or broken during surgery, would you?
C. The anesthesiologist requires everyone to remove their dentures.
D. What worries you about being without your teeth? -Correct Answer= D)
What worries you about being without your teeth?
A nurse in an oncology clinic is assessing a client who is undergoing treatment for
ovarian cancer. Which of the following statements by the client indicates she is
experiencing psychological distress?
A. My parents are retired, and they have come to help out with our children.
B. I am going to ask my husband to go to counseling with me.
C. I keep having nightmares about my upcoming surgery.
D. My girlfriends bought me a nice wig. -Correct Answer= C) I keep
having nightmares about my upcoming surgery
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