Final Rev.

Question 1

Equipment that the nurse will use to monitor a patient experiencing pyrexia.

Answer 1

thermometer

Question 2

Best route to assess the temperature of a client who is diaphoretic and unresponsive.

Answer 2

tympanic

Question 3

Pulse that the nurse will assess on an adult found to be unresponsive and not breathing.

Answer 3

carotid

Question 4

Physiological response of smoking and caffeine consumption causing an increase in blood pressure.

Answer 4

vasoconstriction

Question 5

Nurse’s best response when an order says not to give a medication if BP is less than 100 mm Hg systolic and
client’s systolic BP is less than 100.

Answer 5

hold the medication

Question 6

The next step a nurse should take after finding signs of infection in the wound of a stable client.

Answer 6

notify HCP

Question 7

Maximum number of side rails on a client’s hospital bed that can be raised legally, without a provider’s order.

Answer 7

3

Question 8

The nurse’s concern upon observing cyanosis in the foot of a client with ankle restraints.

Answer 8

blood flow/ circulation

Question 9

Risk for a client with indwelling urinary catheter if the drainage bag is allowed to touch the floor.

Answer 9

infection (urinary tract)

Question 10

Hand-washing method that must be performed to prevent the spread of C. diff.

Answer 10

soap and water

Question 11

Technique the nurse will implement to reduce effects of orthostatic hypotension before ambulating a client who has been in bed for several days.

Answer 11

dangling on the bedside

Question 12

Tool the nurse can use to assess a client’s risk for impaired skin integrity.

Answer 12

braden scale

Question 13

Technique used to keep a client’s spine stable while repositioning.

Answer 13

log rolling

Question 14

Tool the nurse can use to assess a client’s risk for falling.

Answer 14

morse scale

Question 15

Method for cleaning a contaminated body area to prevent spreading infection.

Answer 15

least to most contaminated

Question 16

Condition for which impaired sensory perception, impaired mobility, shear, friction, and moisture are risk factors.

Answer 16

pressure ulcer development/impaired skin integrity

Question 17

Abnormal elimination that places a client at risk for skin breakdown.

Answer 17

incontenence

Question 18

Stage of a shallow open reddish, pink ulcer without slough on the right ear of a client.

Answer 18

stage II

Question 19

Type of healing required for a Stage IV pressure ulcer.

Answer 19

secondary intention

Question 20

Type of wound drainage that indicates infection.

Answer 20

purulent

Question 21

Critical-thinking skill utilized when the nurse reviews the effectiveness of nursing actions.

Answer 21

evaluation

Question 22

Step of the Nursing Process necessary to develop a plan of care

Answer 22

assessment

Question 23

Question the nurse should ask when a client reports a medication allergy.

Answer 23

Ask the patient to describe the type of reaction

Question 24

ype of Nursing Diagnosis that indicates a potential patient response or reaction.

Answer 24

“risk for”

Question 25

Step of the Nursing Process in which the nurse provides wound care for a client

Answer 25

implement

Question 26

The best way to assess a client’s fluid-volume status.

Answer 26

daily weights

Question 27

0.9% sodium chloride (Normal Saline) is this type of intravenous fluid.

Answer 27

isotonic

Question 28

Condition that causes urinary leakage during coughing or sneezing.

Answer 28

stress UI

Question 29

Part of the colon affected by fecal impaction.

Answer 29

rectum

Question 30

Assessment finding the nurse will expect when auscultating the abdomen of a client who has not had a bowel
movement in 3 days.

Answer 30

hypoactive

Question 31

Least restrictive method of oxygenation therapy.

Answer 31

nasal canula

Question 32

Type of breathing exercise performed using an Incentive Spirometer.

Answer 32

deep breating exercise

Question 33

Occurs when muscles or structures of the oral cavity or throat relax during sleep, upper airway is blocked,
diminishing or stopping airflow for up to 30 seconds

Answer 33

obstructive sleep apnea

Question 34

Chronic difficulty falling asleep, frequent awakenings from sleep, and/or short sleep or nonrestorative sleep.

Answer 34

insomnia

Question 35

Type of assessment needed to determine effectiveness of a client’s sleep routine.

Answer 35

subjective

Question 36

Assessment required for a client experiencing pain.

Answer 36

subjective

Question 37

The reason unlicensed assistive personnel cannot ask a client to rate their severity of pain.

Answer 37

assessment

Question 38

Impaired hearing due to the aging process

Answer 38

presbycussis

Question 39

Condition in which the client has difficulty understanding the written and spoken word.

Answer 39

receptive aphasia

Question 40

The inability to name common objects or express simple ideas in words or writing.

Answer 40

expressive aphasia

Question 41

Intervention to best assist in educating clients with limited English proficiency about their disease process

Answer 41

trained medical interpreter

Question 42

Providing nursing care for the whole patient, considering the body, mind, and spirit.

Answer 42

holistic nursing care

Question 43

Having more roles or responsibilities within a role than are manageable

Answer 43

role over load

Question 44

How a person thinks about oneself.

Answer 44

self concept

Question 45

Erikson’s developmental stage at 12 to 20 years, that focuses on finding a sense of self

Answer 45

identity vs role confusion

Question 46

Recognizes the natural healing abilities of the body; incorporates complementary and alternative interventions.

Answer 46

holistic health model

Question 47

Involves minimizing the effects of long-term disease or disability through interventions directed at preventing
complications and deterioration.

Answer 47

tertiary prevention

Question 48

The only type of true prevention in patient care.

Answer 48

primary prevention

Question 49

The best way to evaluate if client teaching has been effective.

Answer 49

teach back/ return demonstration

Question 50

Type of learner who learns best with a hands-on approach

Answer 50

kinesthetic

Question 51

Primary goal is to help patients and families achieve the best quality of life.

Answer 51

palliativ care

Question 52

ype of losses that occur as part of normal life transitions across the life span.

Answer 52

maturational losses

Question 53

Kübler-Ross stage of dying in which the client would present as withdrawing from others.

Answer 53

depression

Question 54

Type of grief that involves a relationship that is not socially sanctioned.

Answer 54

disenfranchized

Question 55

Program that provides care for those expected to live less than 6 months.

Answer 55

hospice

Question 56

Angle at which the nurse will administer a tuberculin test.

Answer 56

5-15 degrees

Question 57

How insulin is measured.

Answer 57

units

Question 58

Purpose for having the client rinse their mouth with water after a corticosteroid inhaler treatment.

Answer 58

risk for fungal infection

Question 59

Number of times a nurse should read medication labels before administering to avoid med errors.

Answer 59

3

Question 60

Teaching that the nurse will provide to a post-surgical client to best minimize the risk of future infection.

Answer 60

hand washing/ hygiene