Exam 2 Study Guide

Question 1

What is the primary reason why the nurse should avoid glue-on artificial nails?
A) They could interfere with the dexterity of fingers
B) They could fall off in the client’s bed
C) They harbor microorganisms
D) They can scratch a client

Answer 1

they harbor microorganisms

Question 2

A nurse is caring for a group of clients with infections. Which infection is classified as a health care associated infection?
A) Respiratory infection contracted from a visitor
B) Vaginal infection in a postmenopausal woman
C) Urinary tract infection in a client who is sedentary
D) Wound infection caused by unwashed hands of a caregiver

Answer 2

wound infection caused by unwashed hands of a caregiver

Question 3

A client’s stool specimen is positive for Clostridium difficile. Which isolation precautions should the nurse institute for this client?
A) Surgical mask and gown when caring for client
B) Gloves and handwashing when caring for client
C) Gown and gloves when caring for client
D) N95 mask and negative flow room when caring for client

Answer 3

gown and gloves when caring for client

Question 4

A nurse plans to remove a client’s wound dressing. The nurse identifies the client, explains what is to be done, and why, washes their hands, collects equipment, provides privacy, and ensures the client’s comfort. Place the following steps in the order in which they should be
implemented when removing the soiled dressing.
- Don clean gloves
- Pull the tape away from the skin gently
- Assess the volume, color, and odor of exudate
- Place the soiled dressing and gloves in the biohazard receptacle
- Remove the dressing by lifting the edge of the dressing upward and toward the center of the
wound
- Loosen the edges of the tape around the dressing, starting from the outside and moving toward
the center of the dressing

Answer 4

1) don clean gloves
2) loosen the edges of the tape around the dressing, starting from the outside and moving toward the center of the dressing
3) pull the tape away from the skin gently
4) remove the dressing by lifting the edge of the dressing upward and toward the center of the wound
5) assess the volume, color, and odor of exudate
6) place the soiled dressing and gloves in the biohazard receptacle

Question 5

The nurse preparing to place an indwelling urinary catheter for a confused client. What is the highest priority when placing this catheter?
A) Donning (applying) sterile gloves before preparing sterile field
B) Ensuring that the client is comfortable
C) Culturing urine after placement of catheter
D) Explaining to the client the importance of not pulling on catheter

Answer 5

donning (applying) sterile gloves before preparing sterile field

Question 6

A client’s urine is cloudy, amber, and has an unpleasant odor. Which problem may this
information indicate that requires the nurse to make a focused assessment?
A) Urinary retention
B) Urinary tract infection
C) Urinary incontinence
D) Ketones in the urine

Answer 6

urinary tract infection

Question 7

A 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?
A) Anuria
B) Dysuria
C) Diuresis
D) Incontinence

Answer 7

anuria

Question 8

Which is an effective nursing intervention to prevent urinary tract infections?
A) Teach female clients to wipe from back to front after voiding
B) Advise clients to report burning on urination to health care provider
C) Instruct clients to use bath power to absorb perineal perspiration
D) Encourage clients to drink several quarts of fluid daily

Answer 8

encourage clients to drink several quarts of fluid daily

Question 9

A client has a urinary retention catheter (indwelling urinary catheter). Which is the most
important when the nurse cares for this client?
A) Ensuring the catheter remains connected to the collection bag
B) Label the tubing with date of insertion
C) Increasing fluid intake to 3000 ml daily
D) Applying an antimicrobial agent to the urinary meatus BID

Answer 9

ensuring the catheter remains connected to the collection bag

Question 10

Which should the nurse implement to facilitate bladder continence for a male client who is cognitively impaired? (Select all that apply)
A) Offer toileting every 2 hours
B) Apply a condom catheter in the morning
C) Provide clothing that is easy to manipulate
D) Place an indwelling urinary catheter
E) Explain the need to call for help with toileting every 2 hours

Answer 10

A) offer toileting every 2 hours
C) provide clothing that is easy to manipulate

Question 11

Which stage pressure ulcer requires the nurse to measure the extent of undermining or tunneling?
A) Stage 1
B) Stage II
C) Stage IV
D) Deep tissue injury

Answer 11

stage IV

Question 12

What strategies should be included in pressure ulcer prevention? (select all that apply)
A) Use moisture barrier ointment with incontinence
B) Reposition immobile patients every 4 hours
C) When patient is in the side lying position ensure HOB < 30 degrees
D) Place patient on pressure reducing support surface
E) Maintain bed at 45 degree angle
F) Massage reddened bony prominences
G) Oral nutrition supplement should be used when undernourished

Answer 12

A) use moisture barrier ointment with incontinence
C) when patient is in the side lying position ensure HOB < 30 degrees
D) place patient on pressure reducing support surface
G) oral nutrition supplement should be used when undernourished

Question 13

A nurse is caring for a client with hemiplegia (paralysis of one side of body) after a
stroke. Which complication of immobility would the nurse monitor for?
A) Dehydration
B) Hypertension
C) Diarrhea
D) Contractures

Answer 13

contractures

Question 13

A nurse is transferring a client from a bed to a chair. Which assessment should the nurse do to quickly determine this client’s tolerance to this activity?
A) Monitor for bradycardia
B) Allow the client time to adjust to the change in position
C) Obtain a blood pressure
D) Determine if the client feels dizzy

Answer 13

determine if the client feels dizzy

Question 13

A nurse is assessing a client who is being admitted to the hospital. Which is the most important information that indicates whether the client is at risk for physical injury and falls?
A) Weakness experienced prior to admission
B) Two recent falls that occurred at home
C) The need for corrective eyeglasses
D) Use of a cane at home

Answer 13

two recent falls that occurred at home

Question 14

A nurse is planning care for a client who requires bilateral arm restraints because the client is delirious and attempting to pull out a urinary retention catheter. Which information is important to consider when planning care for this client? (Select all that
apply)
A) Use of restraints adequately prevents any injuries from occurring
B) Reasons for restraints must be clearly documented
C) Most clients recognize that restraints contribute to their safety
D) Restraints need a health care provider’s prescription (order) before application
E) Laws permit the use of restraints when specific guidelines are followed

Answer 14

B) reasons for restraints must be clearly documented
E) laws permit the use of restraints when specific guidelines are followed

Question 14

A nurse is applying wrist restraints for a client. Which should the nurse do first when applying the restraint?
A) Perform an inspection of the skin where the restraint is to be placed
B) Secure the restraints to the bed frame
C) Ensure two fingers of space between client’s wrist and restraint
D) Assess the client 15 minutes after applying restraint

Answer 14

perform an inspection of the skin where the restraint is to be placed

Question 14

Which of the following actions should the nurse implement to best prevent falls for an alert and oriented client with weakness following a knee replacement?
A) Place fall mats at the side of the bed
B) Complete fall risk assessment tool
C) Assist client with ambulation using gait belt
D) Apply self-releasing security belt when in chair

Answer 14

assist client with ambulation using gait belt

Question 15

A nurse teaches a client how to use the incentive spirometer. Which projected client
outcome supports the conclusion that the use of the incentive spirometer was effective?
A) Expiratory volume will be decreased
B) Inspiratory volume will be increased
C) Sputum will be expectorated
D) Coughing will be stimulated

Answer 15

inspiratory volume will be increased

Question 16

A client is admitted with the diagnosis of lower extremity arterial disease with decreased perfusion. Which is a specific, desirable outcome for a client with this
diagnosis?
A) Respirations within normal limits
B) Oriented to the environment
C) Palpable peripheral pulses
D) Prolonged capillary refill

Answer 16

palpable peripheral pulses

Question 17

Which action should the nurse implement to increase both the respiratory and the
circulatory functions of a client in a coma?
A) Encourage the client to cough
B) Massage the client’s bony prominences
C) Assist the client with breathing exercises
D) Change the client’s position frequently

Answer 17

change the client’s position frequently

Question 18

A nurse is assessing a client with a respiratory problem. Which clinical manifestation is reflective of an early response to hypoxia? (Select all that apply)
A) Dysrhythmias
B) Restlessness
C) Irritability
D) Cyanosis
E) Apnea

Answer 18

B) restlessness
C) irritability

Question 19

A prescription for oxygen reads, “6 liters of oxygen via face mask”. The client is
extremely confused being in an unfamiliar environment in the hospital. They become
agitated and repeatedly pulls off the mask. Which action should the nurse implement?
A) Tighten the strap around the head
B) Reapply the mask every time the client pulls it off
C) Provide an explanation of why the oxygen is necessary
D) Request that the prescription for oxygen be changed to a nasal cannula

Answer 19

request that the prescription for oxygen be changed to a nasal cannula

Question 20

Which assessment data documented in the medical record of an adult client would be most concerning for the nurse?
A) Pulse 110 beats per minute
B) WBC 12,000 cells/mcL (range 4,000-11,000 cells/mcL)
C) Oxygen saturation 85%
D) Respiratory rate 22

Answer 20

oxygen saturation 85%

Question 21

Which concept should the nurse consider when assessing a client’s pain?
A) The expression of pain is not always congruent with the pain experienced
B) Pain medication can significantly increase a client’s pain tolerance
C) The majority of cultures value the concept of suffering in silence
D) Most people experience approximately the same pain tolerance

Answer 21

the expression of pain is not always congruent with the pain experienced

Question 22

Which is most important for nurses to understand when caring for clients in pain?
A) Clients who are in pain will request pain medication
B) Client’s usually are able to describe the characteristics of their pain
C) Clients need to know that the nurse believes what they say about their pain
D) Clients will demonstrate vital signs that are congruent with the intensity of their pain

Answer 22

clients need to know that the nurse believes what they say about their pain

Question 23

A nurse is assessing a client experiencing chronic pain. Which characteristic(s) are
more common with chronic versus acute pain? (Select all that apply)
A) Gradual onset
B) Long duration
C) Anticipated end
D) Psychologically depleting
E) Responds to conventional interventions

Answer 23

A) gradual onset
B) long duration
D) psychologically depleting

Question 23

A nurse is helping a client who is experiencing mild pain to get ready for bed. Which nursing action is most effective to help limit the client’s pain?
A) Assisting with relaxing imagery
B) Obtaining a prescription for an opioid
C) Encouraging the client to take a warm shower
D) Recommending that the client be more active during the day

Answer 23

assisting with relaxing imagery