A nurse is assessing the heart sounds of a client who has developed chest
pain that 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 ...
A nurse is assessing the heart sounds of a client who has developed chest
pain that 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 Ans - 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 presure 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 Ans - D) place the bladder of the cuff over the posterior aspect of
the thigh
A charge nurse is teaching adult cardiopulmonary resusciation (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 assisstance
B. Begin Chest compressions
C. Confirm unresponsiveness.
D. Give rescue breaths. Correct Ans - 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 Ans - 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
Ans - 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 Ans -
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 trachesotomy care.
B. Obtainging cotton balls for the tracheostomy care.
C. Obtaining sterile gloves for the tracheostomy care.
D. Obtaining a sterile brush for the tracheostomy care. Correct Ans - 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 Ans - 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 explannation of the procedure.
B. The client has been informed about the risks and benefits of the
procedure.
C. The nurse witnessed the provider's explanantion of the procedure.
D. The signature on the preoperative consent form is the client's. Correct
Ans - 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 Ans - 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 Ans - 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 Ans - C) I keep having
nightmares about my upcoming surgery
A nurse on a medical-surgical unit is caring for a client.
Which of the following actions should the nurse take first when using the
nursing process?
A. Identify goals for client care.
B. Obtain client information.
C. Document nursing care needs.
D. Evaluate the effectivness of nurse care. Correct Ans - B) Obtain client
information
A nurse is caring for an older adult client who is violent and attempting to
disconnect her IV lines. The provider prescribes soft wrist restraints.
Which of the following actions should the nurse take while the client is in
restraints?
A. Tie the restraints to the side rails.
B. Perform range-of-motion exercises to the wrists every 3 hrs.
C. Remove the restraints one at a time.
D. Obtain a PRN prescription for the restraints. Correct Ans - C) Remove
the restraints one at a time
A nurse is planning care for a client who reports abdominal pain.
, An assessment by the nurse reveals the client has a temperature of 39.2
(102.6 F), heart rate of 105/min, a soft nontender abdomen, and menses
overdue by 2 days.
Which of the following findings should be the nurse's priority.
A. Heart rate 105/min
B. soft, nontender abdomen
C. temperature
D. overdue menses Correct Ans - C) Temperature
A nurse is inserting an IV catheter for a client that results in a blood spill on
her gloved hand.
The client has no documented bloodstream infection.
Which of the following actions should the nurse take?
A. Wash the gloved hands and then throw the gloves away.
B. Prepare an incident report to document the event.
C. Carfefully remove the gloves and follow with hand hygiene.
D. Ask the provider to order a blood culture to determine the risk of infection.
Correct Ans - C) Carefully remove the gloves and follow with hand hygiene
A nurse is caring for a client who is postoperative and has parlytic ileus.
Which of the following abdominal assessments should the nurse expect?
A. Frequent bowel sounds with flatus.
B. Absent bowel sounds with distention
C. Hyperactive bowel sounds with diarrhea.
D. Normal bowel sounds with increased peristalsis. Correct Ans - B)
Absent Val sounds with distention
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant
to learning self-injection of insulin.
Which of the following statements should the nurse make?
A. "Tell me what I can do to help you overcome your fear of giving yourself
injections."
B. "I am sure your provider will not be pleased that you refuse to give
yourself insulin injections."
C. "It's okay. I am sure your partner will be able to learn how to give you the
insulin injections."
D. "You won't be able to go home unless you learn to give yourself insulin
injections." Correct Ans - A) Tell me what I can do to help you overcome
your fear of giving yourself injections
A nurse is recieving a client from the PACU who is postoperative following
abdominal surgery.
Which of the following actions should the nurse make to transfer the client
from the stretcher to the bed?
A. Lock the wheels on the bed and stretcher.
B. Instruct the client to raise his arms above his head.
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