NURS 100 Comprehensive Final

Question 1

A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes?

A. Droplet
B. Indirect contact
C. Airborne
D. Direct contact

Answer 1

A. Droplet

Client should be placed in a private room and the nurse should wear a surgical mask when caring for the client.

Question 2

A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection?

A. Reservoir
B. Susceptible host
C. Portal of entry
D. Portal of exit

Answer 2

B. Susceptible host

The susceptible host is the client who acquired the infection. The susceptible host becomes a reservoir for the infectious agent.

Question 3

A nurse is performing a throat culture on a client. Which of the following actions should the nurse take?

A. Swab the back of the client’s pharyngeal wall
B. Place the swab in a clean container after obtaining the culture
C. Insert the swab in the culture medium within 1 hr of obtaining the sample
D. Don sterile gloves to obtain the culture from the client

Answer 3

A. Swab the back of the client’s pharyngeal wall

The nurse should swab the client’s tonsils, the tonsillar pillars, or the back of the pharyngeal wall, to obtain an accurate culture.

Question 4

A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take?

A. Open the first flap on the sterile package away from their body
B. Place objects on the sterile field at least 1.3 cm (0.5 in) from the edge
C. Unwrap both sides of the sterile package at the same time
D. Set up the sterile field next to a wall in the client’s room

Answer 4

A. Open the first flap on the sterile package away from their body

Question 5

A nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the following links of the chain of infection does the faucet represent?

A. Reservoir
B. Susceptible host
C. Portal of entry
D. Portal of exit

Answer 5

A. Reservoir

The faucet is an example of a reservoir in the chain of infection. The reservoir is the location where the infectious agent lives, grows, reproduces itself, and waits to be transmitted to a susceptible host.

Question 6

A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests?

A. C-reactive protein
B. Troponin
C. Creatine kinase
D. Lactic acid

Answer 6

A. C-reactive protein

Nonspecific marker that can increase when inflammation is present

Question 7

A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make?

A. “You can wear artificial fingernails if they are kept short”
B. “Leave rings on your fingers when performing surgical hand asepsis”
C. “Keep your fingernails less than half an inch in length”
D. “Remove nail polish on your fingernails if it is chipped”

Answer 7

D. “Remove nail polish on your fingernails if it is chipped”

Question 8

A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include?

A. Use a brush to scrub the surface of the hands
B. Rinse antiseptic solution from the hands before it dries
C. Apply chlorhexidine and ethanol to the hands
D. Leave jewelry on the hands when cleansing

Answer 8

C. Apply chlorhexidine and ethanol to the hands

Question 9

A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission?

A. Direct contact
B. Droplet
C. Airborne
D. Indirect contact

Answer 9

B. Droplet

Question 10

A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include?

A. Gowns can be reused on the same client
B. Masks should be removed after leaving a client’s room
C. Gloves should be removed from the inside out
D. Eyeglasses can be used in place of goggles

Answer 10

C. Gloves should be removed from the inside out

Question 11

A nurse is planning to admit a client who has respiratory syncytial virus (RSV). Which of the following transmission-based precaution should the nurse plan to implement?

A. Protective
B. Contact
C. Standard
D. Airborne

Answer 11

C. Gloves should be removed from the inside out

Question 12

A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hr. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing?

A. Incubation
B. Convalescence
C. Acute illness
D. Prodromal

Answer 12

D. Prodromal

Question 13

A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include?

A. The door to the AIIR should remain closed
B. Clients who are on contact precautions require AIIR
C. An AIIR has at least 4 air exchanges every hr
D. A mask is not needed to care for clients who are in an AIIR

Answer 13

A. The door to the AIIR should remain closed

Question 14

A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

A. Washes their hands for 10 sec
B. Turns off the faucet with a towel
C. Uses hot water to wash their hands
D. Holds their hands above their elbows while rinsing off the soap

Answer 14

B. Turns off the faucet with a towel

Question 15

A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include?

A. Empty sharps containers when they become full
B. Report needlestick injuries to the nursing supervisor
C. Engage the safety device on a needle after documenting the medication administration
D. Recap needles after medication administration

Answer 15

B. Report needlestick injuries to the nursing supervisor

Question 16

A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger?

A. Burn
B. Frostbite
C. Bacteria
D. Radiation

Answer 16

C. Bacteria

Question 17

A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take?

A. Wear an N95 respirator when caring for the client
B. Place the client in a private room
C. Place a mask on the client when they leave their room
D. Place the client in a negative airflow room

Answer 17

B. Place the client in a private room

Question 18

A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask?

A. Protective isolation
B. Contact
C. Droplet
D. Airborne

Answer 18

D. Airborne

Question 19

A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse include in the bundle?

A. Try to use alternatives before inserting indwelling urinary catheters
B. Use clean technique for insertion of indwelling urinary catheters
C. Check clients every 2 days to evaluate the need for indwelling urinary catheters
D. Disconnect the system to obtain urine samples from indwelling urinary catheters

Answer 19

A. Try to use alternatives before inserting indwelling urinary catheters

Question 20

A nurse is assisting with teaching a newly licensed nurse about removing PPE. Which of the following items should the nurse instruct to remove first?

A. Mask
B. Gloves
C. Goggles
D. Face shield

Answer 20

B. Gloves

Question 21

A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use?

A. Alcohol-based sanitizer
B. Soap and water
C. Iodine solution
D. Chlorhexidine solution

Answer 21

B. Soap and water

Question 22

A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes transmission?

A. Airborne
B. Droplet
C. Direct contact
D. Indirect contact

Answer 22

A. Airborne

Question 23

A nurse is caring for a client who states, “I am feeling so much better. My fever is gone, and I have a good appetite.” The nurse should identify the client is likely in which of the following stages of infection?

A. Incubation
B. Convalescence
C. Acute infection
D. Prodromal

Answer 23

B. Convalescence

Question 24

A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions?

A. Protective
B. Contact
C. Droplet
D. Airborne

Answer 24

B. Contact

Question 25

A nurse is observing an assistive personnel (AP) obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse?

A. The AP pulls the pinna up and back when obtaining a tympanic temperature
B. The AP informs the client when they are counting the respirations
C. The AP gently presses down with the pads of two to three fingers over the radial pulse site
D. The AP selects a blood pressure cuff width that is 40% the circumference of the client’s arm

Answer 25

B. The AP informs the client when they are counting the respirations

Question 26

A nurse is preparing an in-service about vital signs for a group of newly hired assistive personnel. Which of the following information should the nurse include about measuring body temperature?

A. Tympanic temperature can e affected by environmental temperature
B. Temporal temperature is inaccurate in children under 3 years of age
C. Axillary temperature reflects rapid changes in a client’s core body temperature
D. Oral temperature is easily accessible despite a client’s position

Answer 26

D. Oral temperature is easily accessible despite a client’s position

Question 27

A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect?

A. Increase in blood pressure
B. Increase in respiratory rate
C. Decrease in cardiac output
D. Decrease in preload

Answer 27

A. Increase in blood pressure

A client who has an increase in afterload increases the risk for hypertension. Afterload is the resistance of the ventricle to pump the heart muscle and eject blood into the client’s bloodstream during systole.

Question 28

A nurse is discussing the use of a client’s thigh for blood pressure measurements with an assistive personnel (AP). Which of the following information should the nurse include?

A. Select a blood pressure cuff that is 25% of the circumference of the client’s thigh
B. Palpate the femoral pulse when obtaining blood pressure in the thigh
C. Expect blood pressure in the thigh to be 10 to 15 mm Hg less than in the arm
D. Use the thigh to obtain blood pressure when a client has severe edema in their arms

Answer 28

D. Use the thigh to obtain blood pressure when a client has severe edema in their arms

Question 29

A charge nurse is discussing a client’s respiratory data with a newly licensed nurse. Which of the following statements should the nurse include?

A. “Clients will exhibit an increase in their respiratory rate after using a bronchodilator”
B. “Count the respiratory rate for 1 minute for clients who have a respiratory infection”
C. “Expect clients who had a brainstem injury to exhibit rapid respirations”
D. “Clients who are experiencing acute pain will have slow, deep respirations”

Answer 29

B. “Count the respiratory rate for 1 minute for clients who have a respiratory infection”

Question 30

A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include?

A. “Cardiac output is the amount of blood flow through the heart in 1 minute”
B. “Cardiac output is the amount of blood ejected from the atria”
C. “Cardiac output is the ability of the muscle fibers in the ventricles to stretch”
D. “Cardiac output is the resistance of the ventricles to pump blood through the heart”

Answer 30

A. “Cardiac output is the amount of blood flow through the heart in 1 minute”

Question 31

A nurse is evaluating the effectiveness of interventions used to address clients’ vital signs that were outside of the expected reference ranges. Which of the following findings indicates the intervention was effective?

A. An older adult client who has pneumonia and a respiratory rate of 26/min after a position change
B. An adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid analgesic
C. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler
D. An older adult client who has an infection and a pulse rate of 110/min after using relaxation techniques

Answer 31

C. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler

Question 32

A nurse is assessing a client who has orthostatic hypotension. Which of the following actions should the nurse take?

A. Encourage the client to change positions slowly
B. Restrict the client’s oral intake of fluids
C. Encourage the client to take a short walk
D. Discontinue IV fluids

Answer 32

A. Encourage the client to change positions slowly

Question 33

A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering?

A. A nicotine product
B. An opioid antagonist
C. An antihypertensive
D. A bronchodilator

Answer 33

D. A bronchodilator

Question 34

A nurse is preparing an in-service for a group of newly hired assistive personnel (AP) about body temperature. Which of the following information should the nurse include?

A. Wait 5 min after a client has consumed a hot drink to obtain oral temperature
B. Place a tape or patch thermometer over a client’s scapula
C. A tympanic thermometer reflects a client’s body surface temperature
D. A temporal probe thermometer uses infrared scanning to determine a client’s temperature

Answer 34

D. A temporal probe thermometer uses infrared scanning to determine a client’s temperature

Question 35

A nurse is preparing an in-service about factors affecting respiratory rate for a group of assistive personnel. Which of the following information should the nurse include?

A. Anxiety can decrease a client’s respiratory rate
B. Opioid analgesic can increase a client’s respiratory rate
C. Pain can decrease a client’s respiratory rate
D. Fever can increase a client’s respiratory rate

Answer 35

D. Fever can increase a client’s respiratory rate

Question 36

A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include?

A. Oxygen saturation is determined by the amount of oxygen bound to white blood cells
B. Oxygen saturation reflects the amount of oxygen being delivered to body tissues
C. The expected reference range for oxygen saturation is 90%to 100%
D. A capillary refill of less than 5 seconds ensures a reliable oxygen saturation measurement

Answer 36

B. Oxygen saturation reflects the amount of oxygen being delivered to body tissues

Question 37

A nurse is caring for a client who has an increase in cardiac output. Which of the following findings should the nurse expect?

A. Increase in blood pressure
B. Decrease in respiratory rate
C. Decrease in heart rate
D. Increase in stroke volume

Answer 37

A. Increase in blood pressure

Question 38

A nurse is teaching a group of assistive personnel (AP) about techniques used to obtain BP. For which of the following clients should the nurse instruct the AP to obtain an electronic BP measurement?

A. A client who has a BP lower than the expected reference range
B. A school-age child
C. A client recovering from extensive abdominal surgery
D. A client who has stabilized BP measurements

Answer 38

D. A client who has stabilized BP measurements

Question 39

A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients’ vital signs indicate that interventions were effective?

1. A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min
2. An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min
3. A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/66 mm Hg
4. A toddler who was febrile 2 hr ago due to a viral infection and has a temporal temperature of 38.2 C (100.8 F)
5. An adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min

Answer 39

1, 2, 3

Question 40

A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take?

A. Instruct the client to bear down like they are having a bowel movement
B. Offer the client hot caffeinated tea to drink early in the morning
C. Hold the client’s thyroid medication
D. Encourage the client to take a warm shower

Answer 40

A. Instruct the client to bear down like they are having a bowel movement

The Valsalva maneuver can be used to regulate heart rate. To elicit this, the nurse should instruct the client to “bear down” like they are having a bowel movement. This action produces a vasovagal response in the client’s body which lowers the client’s heart rate.

Question 41

A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct?

A. Pulse 52/min
B. Respiratory rate 24
C. SaO2 97% right index finger, room air
D. Blood pressure 132/86 mm Hg

Answer 41

C. SaO2 97% right index finger, room air

Question 42

A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature?

A. A toddler who has diarrhea
B. A client who is 1 day postoperative following a hemorrhoidectomy and receiving pain medications via PCA pump
C. An infant who is receiving intravenous fluids
D. A client who is diaphoretic and frequently chewing ice to relieve dry mouth

Answer 42

D. A client who is diaphoretic and frequently chewing ice to relieve dry mouth

Oral temperatures should not be obtained in clients who have consumed food or liquids or smoked tobacco products within the previous 30 min. The client’s diaphoresis will make it difficult to obtain an accurate temperature via the tympanic membrane or temporal artery. Therefore, the nurse should direct the AP to obtain this client’s temperature rectally.

Question 43

A nurse is observing an AP who is obtaining a blood pressure reading from a client. Which of the following actions by the AP requires follow up by the nurse?

A. The AP uses a cuff width that is 40% of the circumference of the client’s arm
B. The AP provides support for the client’s arm while taking the BP
C. The AP waits to take the client’s BP 45 min after the client ambulates in the hallway
D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second

Answer 43

D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second

The recommended rate is 2 mm Hg per second.

Question 44

A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?

A. “The body increases body temperature through the process known as vasodilation”
B. “The body loses heat through shivering”
C. “The body lowers body temperature through sweating”
D. “The body generates heat through evaporation”

Answer 44

C. “The body lowers body temperature through sweating”

Question 45

A nurse on the pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range and requires intervention?

A. A 1-month-old infant who has a respiratory rate of 58/min
B. A 3-year-old preschooler who has an apical pulse rate of 144/min
C. An 8-year-old child who has a respiratory rate of 25/min
D. An 18-month-old toddler who has an apical pulse rate of 120/min

Answer 45

B. A 3-year-old preschooler who has an apical pulse rate of 144/min

Question 46

A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include?

A. “Convection is the loss of body heat when a client is in contact with a cooler surface”
B. “Conduction is the loss of body heat when sweat dries from a client’s skin”
C. “Evaporation is the loss of body heat when a client is near a current of cool air”
D. “Radiation is the loss of body heat when a client is in close proximity to a cooler surface”

Answer 46

D. “Radiation is the loss of body heat when a client is in close proximity to a cooler surface”

Question 47

A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their respiratory rate that requires intervention?

A. An adolescent who has a respiratory rate of 20/min
B. An older adult who has a respiratory rate of 16/min
C. An infant who has a respiratory rate of 52/min
D. A school-age child who has a respiratory rate of 14/min

Answer 47

D. A school-age child who has a respiratory rate of 14/min

Question 48

A charge nurse is reviewing the expected reference range of blood pressure in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include?

A. “Hypertension is diagnosed with two elevated measurements on two separate occasions”
B. “Successive blood pressure measurements of 126 over 78 is classified as stage I hypertension”
C. “Stage II hypertension is diagnosed when the blood pressure measurement is 132 over 86”
D. “A blood pressure measurement of 176 over 102 is classified as a hypertensive crisis”

Answer 48

A. “Hypertension is diagnosed with two elevated measurements on two separate occasions”

Question 49

A nurse is discussing the physiology of blood pressure with a group of AP. Which of the following information should the nurse include?

A. Diastolic blood pressure is the minimum amount of pressure exerted when the heart is relaxed
B. Blood pressure is measured and documented in millimeters of mercury
C. Blood pressure decreases when the blood viscosity increased
D. Systolic blood pressure reflects the pressure when the heart is relaxed

Answer 49

B. Blood pressure is measured and documented in millimeters of mercury

Diastolic blood pressure is the minimum amount of pressure exerted when the heart is relaxed

Systolic blood pressure is the maximum amount of pressure exerted when the heart contracts and forces blood into the aorta

Question 50

A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart?

A. Atrioventricular (AV) node
B. Left ventricle
C. Sinoatrial (SA) node
D. Right ventricle

Answer 50

C. Sinoatrial (SA) node

The SA node is the pacemaker of the heart. It consists of a small group of special cells in the right atrium which initiates electrical impulses that travel to the AV node and sets the rate of the contraction of the ventricles.

Question 51

A nurse is caring for a client who has hypotension. Which of the following factors should the nurse identify as a contributing factor to the client’s condition?

A. Decrease in contractility
B. Increase in blood viscosity
C. Decrease in respiratory rate
D. Increase in preload

Answer 51

A. Decrease in contractility

The nurse should identify that a decrease in contractility of the client’s heart is a contributing factor to hypotension. Contractility is the ability of the heart muscle to contract effectively.

Respiratory rate does not directly affect the client’s BP.

Increase in preload causes an increase in BP

Question 52

A charge nurse is evaluating a newly licensed nurse’s documentation of vital signs for several clients. Which of the following documentation should the charge nurse identify as being incomplete?

A. Radial pulse regular at 84/min
B. Respirations observed as even, nonlabored at 20/min with client in supine position
C. BP 124/82 mm Hg, lying in bed
D. Temporal temperature 36.9 C (98.4 F)

Answer 52

C. BP 124/82 mm Hg, lying in bed

Question 53

A nurse is reviewing blood flow through the heart with a group of AP. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle?

A. Tricuspid valve
B. Pulmonary artery
C. Right atrium
D. Vena cava

Answer 53

B. Pulmonary artery

As the right ventricle contracts, blood is forced into the pulmonary artery, where it enters the lungs to become oxygenated. Once oxygenated, the blood is returned to the heart via the pulmonic vein, where it enters the left atrium. It then passes through the mitral valve into the left ventricle. As the ventricle contracts, the blood is forced into the aorta and systemic circulation.

Question 54

A nurse is caring for an older adult client who has a cognitive impairment and is postoperative. Which of the following actions should the nurse take?

A. Use the Crying, Requires Oxygen, Increases Vital Signs, Expression, Sleeplessness (CRIES) pain scale
B. Reassure family members that older adult clients have a decreased ability to sense pain
C. Evaluate the client for pain by observing their behavior
D. Assign a pain scale number based on the FACES pain scale

Answer 54

C. Evaluate the client for pain by observing their behavior

Question 55

A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort?

1. Grimacing
2. Restlessness
3. Elevated temperature
4. Increased diaphoresis
5. Bradycardia

Answer 55

1, 2, 4

Question 56

A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of-life pain management?

1. Fear of addition
2. Belief that pain is an expected part of their illness
3. Inability to sleep
4. Lack of support
5. Inadequate pain assessment

Answer 56

1, 2, 5

Question 57

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?

A. Muscles store calcium and magnesium
B. Muscles produce red blood cells and platelets
C. Muscles assist with thermoregulation in the body
D. Muscles provide protection of internal organs

Answer 57

C. Muscles assist with thermoregulation in the body

Question 58

A nurse is discussing climacteric changes that occur during middle adulthood with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the concept?

1. Both males and females experience a change of life referred to as climacteric
2. Climacteric in females is referred to as menopause
3. Climacteric in males means they are no longer able to fertilize a female egg
4. Climacteric changes in males occur gradually, over a number of years
5. Climacteric in females can manifest as heart palpitations

Answer 58

1, 2, 4, 5

Question 59

A nurse is teaching a newly licensed nurse about the development of dreams. The nurse should include that which of the following areas of the brain transmits the sensory data that is used to develop dreams?

A. Hypothalamus
B. Thalamus
C. Cerebral cortex
D. Pineal gland

Answer 59

B. Thalamus

The nurse should include that the thalamus transmits images, sounds, and sensations to the cerebral cortex, which are used to develop dreams during rapid eye movement (REM) sleep.

Question 60

A nurse is caring for a client who has a history of migraines. The client tells the nurse, “I have not been sleeping well. My migraine headaches have returned after not having one for over a year.” The nurse should identify that which of the following are potential contributing factors to the client’s migraines?

1. Sleep-wake homeostasis
2. Sensory overload
3. Sleep deprivation
4. Increased melatonin
5. Decreased hypocretin levels

Answer 60

2, 3

Hypocretin is a hormone responsible for maintaining alertness that is produced in the hypothalamus.

Question 61

A nurse is reviewing the concepts of central sleep apnea with a colleague. Which of the following statements by the colleague indicates an understanding of central sleep apnea?

A. “Common causes of central sleep apnea are opioid overdose and congestive heart failure”
B. “Central sleep apnea is caused by obesity and an inactive tongue”
C. “Central sleep apnea is easily diagnosed using polysomnography”
D. “Central sleep apnea is related to the recurrent episodes of upper airway collapse and obstruction”

Answer 61

A. “Common causes of central sleep apnea are opioid overdose and congestive heart failure”

Central sleep apnea (CSA) is the result of reduction of the brain’s transmission of signals to the respiratory muscles. This results in the cessation of breathing and is commonly caused by opioid overdose and heart failure.

Question 62

A nurse is caring for a client who works overnight shifts. The nurse should identify that individuals who perform shift work are at an increased risk for developing which of the following conditions?

A. Diabetes mellitus
B. Central sleep apnea
C. Hypersomnia
D. Restless leg syndrome (RLS)

Answer 62

A. Diabetes mellitus

Individuals who perform shift work are at an increased risk for developing health conditions, including diabetes mellitus, obesity, and cardiovascular disease

Question 63

A nurse is caring for a client who takes an over-the-counter sleep aid medication every evening. Which of the following findings should the nurse identify as a potential adverse effect of OTC sleep aid medications?

A. Hyperactivity
B. Diarrhea
C. Excessive salivation
D. Urinary retention

Answer 63

D. Urinary retention

The nurse should identify that OTC sleep aid medications can cause urinary retention, as well as daytime drowsiness, dry mouth, visual disturbances, and constipation.

Question 64

A nurse is reviewing the plan of care for a client who was admitted with insomnia and recent weight gain. Which of the following is a benefit of increased sleep that could help prevent further weight gain for the client?

A. Increased ghrelin production
B. Increased leptin production
C. Decreased hypocretin levels
D. Decreased melatonin levels

Answer 64

B. Increased leptin production

Sleep helps to prevent weight gain by increasing the production of leptin, the hunger-reducing hormone.

Question 65

A. Return the blood unit as it is nor compatible with the client’s blood type
B. Stay with the client for 15 min prior to starting the blood transfusion
C. Verify the unit of blood with another nurse
D. Prime the blood tubing with 0.45% sodium chloride

Answer 65

C. Verify the unit of blood with another nurse

Blood must be verified by two nurses before initiating the transfusion

Question 66

A nurse is preparing to start an IV for a client who has a high risk for bleeding. Which of the following actions should the nurse take?

A. Apply a cold compress to the selected IV site
B. Ask the client to hold the extremity up prior to searching for an IV site
C. Ask the client to spread the fingers of the selected extremity
D. Apply a blood pressure cuff set to 30 mmHg

Answer 66

D. Apply a blood pressure cuff set to 30 mmHg

Instead of using a tourniquet, the nurse should apply a blood pressure cuff set to 30 mmHg prior to starting an IV for this client. This will help protect the client’s extremity from bruising or bleeding

Question 67

A nurse is caring for a client who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first?

A. Initiate continuous cardiac monitoring
B. Elevate the head of the client’s bed
C. Instruct the client to deep breathe and cough
D. Initiate continuous SpO2 monitoring

Answer 67

B. Elevate the head of the client’s bed

Question 68

A nurse is reviewing a client’s laboratory results. Which of the following should the nurse report to the provider?

A. Potassium 4.5 mEq/L
B. Sodium 138 mEq/L
C. Magnesium 3 mEq/L
D. Calcium 10 mg/dL

Answer 68

C. Magnesium 3 mEq/L

Expected reference of magnesium: 1.3 to 2.1 mEq/L

Expected reference of potassium is 3.5 to 5 mEq/L

Expected reference of sodium is 135 to 145 mEq/L

Expected reference of calcium is 9 to 10.5 mg/dL

Question 69

A nurse is calculating a client’s intake and output for the last 4 hr. The client consumed 480 mL of water and 240 mL of coffee. The client has also received IV fluids for 4 hr infusing at 100 mL/hr. Which of the following represents the client’s intake over the last 4 hr?

A. 1,120 mL
B. 720 mL
C. 480 mL
D. 580 mL

Answer 69

A. 1,120 mL

Question 70

A nurse is receiving report on four clients. The nurse should identify that which of the following clients might be experiencing hypomagnesemia?

A. A client who has vomited four times during the last 8 hr
B. A client who requested an extra breakfast tray to eat
C. A client who can ambulate without assistance
D. A client who reports extreme thirst

Answer 70

A. A client who has vomited four times during the last 8 hr

Nausea and vomiting are early manifestations of hypomagnesemia

Question 71

A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following actions should be the goal of treatment for the client?

A. Increase the carbon dioxide level
B. Increase the respiratory rate
C. Increase the bicarbonate level
D. Increase the pH level

Answer 71

A. Increase the carbon dioxide level

A state of respiratory alkalosis indicates that the client’s carbon dioxide level is currently below the expected reference range. The goal of treatment should be to raise the level of carbon dioxide level back to within the expected reference range for PaCO2 of 35 to 45 mm Hg.

Question 72

A nurse is caring for a client who has the following ABG values: pH 7.44, PaCO2 37 mmHg, and HCO3- 24 mEq/L. The nurse should identify that these values are an indication of which of the following?

A. Metabolic acidosis
B. Respiratory acidosis
C. Acid-base balance
D. Respiratory alkalosis

Answer 72

C. Acid-base balance

The nurse should identify that this client’s ABG values are within the expected reference ranges. The expected reference ranges are: pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, and HCO3- 21 to 28 mEq/L.

Question 73

A nurse is reviewing laboratory results for a client and notes the following ABG values: pH 7.31, PaCO2 49 mmHg, and HCO3- 25 mEq/L. The nurse should interpret these findings as an indication of which of the following acid-base imbalances?

A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis

Answer 73

B. Respiratory acidosis

This client’s ABG values indicate respiratory acidosis. Respiratory acidosis is indicated by a pH value below the expected reference range of 7.35 to 7.45 and a PaCO2 value above the expected reference range of 35 to 45 mm Hg.

Question 74

A nurse is reviewing a client’s latest ABG report. Which of the following values should the nurse identify as the priority to report to the provider?

A. pH 7.37
B. PaCO2 43 mmHg
C. HCO3- 27 mEq/L
D. PaO2 76 mmHg

Answer 74

D. PaO2 76 mmHg

Expected reference range of PaO2 is 80-100 mmHg

Question 75

A nurse is assessing a client who has been receiving IV therapy for several days and notes that the client’s daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following IV-related complications?

A. Phlebitis
B. Extravasation
C. Air embolism
D. Circulatory overload

Answer 75

D. Circulatory overload

The nurse should identify that a client who has been receiving IV therapy and whose daily weight has increased is at risk for circulatory overload. The nurse should assess the client for other indications of circulatory overload, including tachycardia, increased blood pressure, edema, cough, and tachypnea. The nurse should also inform the provider of the client’s increased weight.

Question 76

A nurse is reviewing the ABG values for a client and notes the following results: pH 7.49, PaCO2 39 mmHg, and HCO3- 35 mEq/L. The nurse should interpret this ABG reading as an indication of which of the following acid-base imbalances?

A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis

Answer 76

C. Metabolic alkalosis

This client’s ABG values indicate metabolic alkalosis. Metabolic alkalosis is indicated by a pH value above the expected reference range of 7.35 to 7.45, an HCO3- value above the expected reference range of 21 to 28 mEq/L, and a PaCO2 level within the expected reference range of 35 to 45 mm Hg.

Question 77

A charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

A. The nurse selects 0.45% sodium chloride to use to prime the tubing
B. The nurse asks another nurse to check the blood unit label and client identification prior to beginning the transfusion
C. The nurse uses tubing with a filter for the blood transfusion
D. The nurse discards the tubing after the first unit of blood is completed

Answer 77

A. The nurse selects 0.45% sodium chloride to use to prime the tubing

The charge nurse should intervene if the newly licensed nurse selects 0.45% sodium chloride to prime the tubing. The nurse should identify that 0.9% sodium chloride is the only IV solution that should be used to prime the tubing for blood administration

Question 78

A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client’s low potassium level?

A. Furosemide
B. Nitroglycerin
C. Metoprolol
D. Spironolactone

Answer 78

A. Furosemide

Furosemide is a loop (high-ceiling) diuretic that inhibits the reabsorption of sodium and chloride and results in diuresis, which decreases potassium through excretion in the distal nephrons. Hypokalemia is an adverse effect of furosemide.

Question 79

A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment has corrected the fluid imbalance?

A. 0.5 mL/kg/hr
B. 2 mL/kg/hr
C. 7.5 mL/kg/hr
D. 15 mL/kg/hr

Answer 79

B. 2 mL/kg/hr

The expected urinary output for infants up to the age of 1 year is 2 mL/kg/hr. An infant who is not dehydrated should produce this amount of urine.

The expected urinary output for adults is 15 mL/kg/hr

Question 80

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

A. The client who has a tracheostomy tube attached to humidified oxygen
B. The client who has an indwelling urinary catheter to gravity drainage
C. The client who has a chest tube to water seal
D. The client who has a nasogastric (NG) tube to suction

Answer 80

D. The client who has a nasogastric (NG) tube to suction

Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach. When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes, especially potassium, and this loss places the client at risk for hypokalemia.

Question 81

A nurse is caring for a client who reports having daily constipation. Which of the following information should the nurse provide to the client regarding fiber intake?

1. Increasing daily fiber intake can help alleviate the issue of constipation
2. Eating more whole grains can promote regular bowel movements
3. Consume 10 g of fiber per day
4. Foods such as white rice increase fiber intake
5. Decreasing daily fiber intake can help alleviate digestive discomfort

Answer 81

1, 2

daily fiber recommendation is 25g for women and 38g for men

white rice does not increase fiber intake (brown rice does)

Question 82

A nurse is caring for a client who has renal disease and must limit potassium intake. Which of the following foods should the nurse instruct the client to avoid because they are high in potassium?

1. Apples
2. Bananas
3. Dried beans
4. Spinach
5. Tomatoes

Answer 82

2, 3, 4, 5

Question 83

A nurse is caring for a client who is receiving tube feedings via PEG. Which of the following actions should the nurse implement in order to help prevent the client from aspirating?

A. Keep the client’s head elevated to to at least 30 degrees for a minimum of 1 hr after a feeding
B. Verify the initial tube placement with an x-ray after the first feeding
C. Check the client’s tube feeding tolerance every 12 hr
D. Check the pH of the gastric contents each day

Answer 83

A

B is wrong; prior
C and D are wrong; every 4 hours

Question 84

A nurse is caring for a client who has a high phosphorus level. Which of the following instructions regarding food should the nurse provide?

A. You should eat white bread
B. You can drink 2 cups of milk per day
C. You should limit broccoli to 3 cups per week
D. You can have four servings of oatmeal per week

Answer 84

A; whole grains are high in phosphorus

B; 1 cup per day
C; 1 cup per week
D; one serving per week

Question 85

A nurse is assessing a client’s hair and notes that it is brittle. Which of the following should the nurse determine about the client’s nutritional intake?

A. The client is not getting enough vitamin A
B. The client has insufficient protein in their diet
C. The client needs more vitamin D from sun exposure
D. The client needs to eat five servings of fruit and vegetables daily

Answer 85

B. The client has insufficient protein in their diet

Question 86

A nurse is assessing a client who has been receiving IV therapy for several days and notes that the client’s daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following Iv-related complications?

A. Phlebitis
B. Extravasation
C. Air embolism
D. Circulatory overload

Answer 86

D. Circulatory overload

Question 87

A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

A. NPO until dysphagia subsides
B. Supplements via nasogastric tube
C. Initiation of total parenteral nutrition
D. Soft residue diet

Answer 87

B. Supplements via nasogastric tube

Supplements via nasogastric tube provide enteral nutrition for clients who are at risk for aspiration caused by a diminished gag reflex or difficulty swallowing. This nutritional therapy will likely be prescribed.