practical nursing final exam

Question 1

A nurse is helping another nurse fasten the knot of a cover gown before assisting a colleague with a dressing change. Which advantage does a cover gown offer?

Answer 1

Its snug-fitting wristbands avoid contamination of the forearms.

Question 1

A nursing is caring for an older adult client with an indwelling urinary catheter. Which measure is the priority for the nurse to take to prevent urinary tract infections (UTIs)?

Answer 1

placing catheter tubing lower than the client’s bladder

Question 1

The CDC has identified three new standard precautions for infection control. Which clinical situation is addressed by these new precautions?

Answer 1

A client is scheduled for a lumbar puncture to assess for meningitis.

Question 1

The nurse is preparing a client who is in droplet isolation for transport to radiology. What is the appropriate nursing intervention(s)? (Select all that apply.)

Answer 1

facilitating interdepartmental coordination about the transport
placing a clean sheet on the stretcher that the client will be transported upon ensuring that the client has a mask on
reminding transporter to utilize droplet precautions

Question 1

nurse needs to visit the intensive care unit to administer an enema to a client. Which step should the nurse take when using the sterile solution located at the entrance to the intensive care unit?

Answer 1

Pour and discard a small amount of the solution.

Question 1

A nurse is observing the housekeeping staff when they are cleaning a health care facility. Which principle should the housekeeping staff follow for medical asepsis?

Answer 1

Wet-mop floors to avoid distributing microorganisms.

Question 1

A labor and delivery nurse will be participating in a client’s emergency caesarean section and intends to apply the principles of surgical asepsis appropriately. Surgical asepsis is most clearly characterized by:

Answer 1

Steps are taken to render an item completely free of microorganisms.

Question 1

A nurse is caring for a client with acute influenza. The nurse has taken precautions to reduce pathogen transmission. Which method is the most likely way for the influenza virus to be transmitted from one host to another?

Answer 1

talking

Question 1

Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, “I don’t want to wear those. I can’t catch anything just by holding my loved one’s hand.” What is the best response to educate the family about infection transmission?

Answer 1

These barriers help prevent the transmission of infection to you or other people.”

Question 1

A nurse needs to check the vital signs of a client with an infectious disease who is receiving intravenous therapy through an IV pump. Before entering the client’s room, the nurse follows airborne and contact precautions. Which infectious disease does the client have?

Answer 1

SARS

Question 1

A nurse needs to fix a respirator mask on a client who was exposed to hazardous chemicals at a factory site. Which of the following respirator masks should the nurse carry in the ambulance to fix on the client?

Answer 1

powered air purifying respirator

Question 1

A client has been swabbed for an antibiotic-resistant microorganism upon admission to the hospital, and the results reveal that she has been colonized. What are the implications of this assessment finding?

Answer 1

The microorganism is present on the client but is not making her sick.

Question 1

The nurse is caring for four clients. Which client presents the most susceptibility for infection?

Answer 1

46-year old with a foley catheter following anesthesia

Question 1

The nurse is discussing antiviral medication with a client diagnosed with human immunodeficiency virus (HIV). Which client statement indicates a need for further teaching?

Answer 1

The antiviral medication will cure the virus from my body.”

Question 1

An older adult client from a long-term care facility is being admitted to the hospital with an infected wound on the left foot. What action should the nurse perform upon admission related to the client’s residential occupancy?

Answer 1

Perform a nasal swab to identify colonization with methicillin-resistant Staphylococcus aureus (MRSA).

Question 1

A nurse is transporting a client with pulmonary tuberculosis to the x-ray unit. Which precaution is the priority for the nurse to take to prevent the spread of pathogens?

Answer 1

Wear personal protective equipment when transporting the client.

Question 1

A client has been receiving care in an isolation room in the hospital for several days and is on contact and droplet precautions. How can the nurse best minimize the psychological effects of this client’s illness experience?

Answer 1

plan to have frequent interaction with the client

Question 1

When caring for a client with a bacterial respiratory infection and an active cough, what action should the nurse take in order to prevent becoming infected?

Answer 1

Wear a mask when caring for the client.

Question 1

A health care facility has experienced a recent outbreak of infection that is attributable to an antibiotic-resistant microorganism. Which type of client is most likely at increased risk for infection?

Answer 1

elderly

Question 1

The nurse is planning to provide teaching to a client who is recovering from abdominal surgery. When is the most appropriate time to teach the client?

Answer 1

As the client is sitting quietly, reading a book

Question 1

When providing care for a client at a healthcare facility, the nurse comes to realize that the client lacks the ability to read or write. Which teaching approach from the following options would be most beneficial for the client?

Answer 1

Use verbal and visual modes of communication.

Question 1

As the nurse provides care for a client, they notice that the client takes pleasure in reading books and magazines. Which learning domain encompasses the client’s preferred learning style?

Answer 1

Cognitive

Question 1

While conducting a health teaching session, the nurse observes that the client lacks attentiveness and easily loses concentration. Which technique from the following options would be most suitable for capturing the client’s attention during the education?

Answer 1

Involve the client in an active way.

Question 1

While providing care for a client, the nurse intends to deliver health education. What specific subject area should the nurse prioritize in their educational efforts?

Answer 1

self-administration of medications

Question 1

While providing care for a client, the nurse intends to deliver health education. What specific subject area should the nurse prioritize in their educational efforts?

Answer 1

nutrition and dietary instruction

Question 1

While providing care for a 45-year-old male client who has lost function in both of his legs due to an automobile accident, what initial action should the nurse take to customize the learning experience for the client?

Answer 1

Gather pertinent information from the client.

Question 1

While providing care for a 60-year-old client who has an inadequate bowel movement regimen, what is the most suitable approach for the nurse to utilize when teaching this client?

Answer 1

Begin the session with a reference to the client's actual experience.

Question 1

A client is being discharged to home and will be requiring a portable oxygen concentrator at home to facilitate comfort and recovery. Which member of the interdisciplinary team is most suitable for assisting the client in obtaining medical equipment?

Answer 1

Social worker

Question 1

A client is admitted to a skilled nursing facility after sustaining fractures from a fall incident. Which interdisciplinary team member is responsible for assessing and developing plans to restore clients' activities of daily living (ADL) skills, particularly focusing on the motor skills of the upper extremities?

Answer 1

occupational therapist

Question 1

The client has experienced an acute worsening of multiple sclerosis symptoms. What type of healthcare facility would offer the most suitable care for this client?

Answer 1

skilled

Question 1

The nurse recognizes that effective communication that is clear and accurate is crucial when clients are being transferred or referred. Which scenario best exemplifies a referral??

Answer 1

The nurse arranges for a client with a diabetic foot ulcer to see a podiatrist in a community.

Question 1

While temporarily taking over a colleague's lunch break, a nurse on an orthopedic unit responds to a client's call light and is asked to assist the client with transferring from the bed to the bathroom. Since the nurse has not previously cared for this client and is uncertain about their current activity orders, which written source would be the most convenient and reliable way to verify the client's current level of activity?

Answer 1

nursing Kardex

Question 1

When documenting information about a client's condition, a nurse mistakenly records the vital signs as 80/120 in the paper chart. What is the most appropriate approach for acknowledging and rectifying the documentation error?

Answer 1

Cross out 80/120 with a single line and place the nurse's initials above it.

Question 1

A newly graduated nurse understands that health care records serve as a legal document of evidence. What actions should the nurse take to ensure their charting is legally defensible?

Answer 1

Ensure that the client's name appears on all pages.

Question 2

In a problem-oriented medical record maintained by a nurse, which section of the record describes the client's responses to interventions and any modifications made to the initial plan?

Answer 2

progress notes

Question 3

The newly hired nursing staff in the medical-surgical unit are undergoing training to adapt to their new computer charting system. During training, the educator emphasized which of the following benefits of electronic health records (EHRs)?

Answer 3

The computer system reduces omissions by prompting the nurse to enter specific information.

Question 4

The facility has recently transitioned to electronic health records (EHR) for documenting patient information. During an in-service about the use of electronic health records (EHR), the educator emphasized which of the following disadvantages of EHR?

Answer 4

Acquiring proficiency in using the system requires significant time.

Question 5

A newly graduated nurse has recently started a job at a hospital. The facility has recently transitioned to electronic health records (EHR) for documenting patient information. Which of the following options represents a benefit of utilizing electronic health records (EHRs) in nursing practice?

Answer 5

Medical records can be accessed simultaneously by multiple healthcare providers from various workstations.

Question 6

A newly hired nurse in the skilled nursing facility is undergoing training to adapt to the facility’s computer charting system. During training, the educator emphasized which of the following limitations of electronic health records (EHRs)?

Answer 6

System upgrades and power or electronic failures can cause downtime, leading to interruptions and delays in documentation and access to the complete record.

Question 6

A nurse is caring for four clients. Which client has the highest risk of infection?

Answer 6

an older man with an enlarged prostate

Question 6

When caring for a newborn, the nurse understands that infants and older adults are susceptible to fluctuations in body temperature. What is the most likely cause of temperature fluctuations in the infant?

Answer 6

great surface area relative to mass and very high metabolic rate

Question 7

At the start of the shift, a nurse measures a client's blood pressure and records a systolic reading of 130 mmHg and a diastolic reading of 70 mmHg. What does the systolic blood pressure represent?

Answer 7

represents peak pressure in the client's arteries.

Question 7

A parent of a 9-year-old child informs the nurse, "I haven't noticed any fever yet, but my child describes feeling achy and unwell." During which phase of the fever does the nurse recognize that the child may be experiencing these symptoms?

Answer 7

prodromal

Question 8

While assessing a client's vital signs at a healthcare facility, the nurse notes that the client is experiencing excessive sweating. Which region of the brain is responsible for triggering sweating in clients?

Answer 8

hypothalamus

Question 9

A client who has been admitted with dehydration complains of dizziness when walking. What teaching should the nurse give to the client?

Answer 9

"Dizziness when you change position can occur when fluid volume in the body is decreased."

Question 10

A nurse is caring for a client who has a lack of appetite. What is most likely to influence a client's core body temperature?

Answer 10

proteins

Question 11

The nurse is performing client education with a 63-year-old client who is being treated for hypertension. What lifestyle modification should the nurse recommend in order to help the client control their blood pressure?

Answer 11

reduce sodium intake

Question 12

The nurse is providing care for a client with a subnormal temperature. What interventions should the nurse implement to facilitate warming of the client's internal organs?

Answer 12

provide warm fluids

Question 13

When caring for a client with low body temperature, which thermometer should the nurse prioritize for measuring the client's body temperature?

Answer 13

tympanic

Question 14

When assessing the apical heart rate of a healthy individual, where should the nurse position the stethoscope to hear the heartbeats?

Answer 14

slightly below the left nipple

Question 15

A nurse is providing care for a client who has a fever. The nurse is evaluating the client's core body temperature. Which of the following locations closely reflects the client's core body temperature?

Answer 15

ear

Question 16

A student nurse needs to count a client's heart rate. What is the rationale for a student nurse to prioritize obtaining the apical pulse over the radial pulse during a client assessment?

Answer 16

The radial pulse is difficult to obtain.

Question 17

A 41-year-old client visits the clinic for a routine check-up. What is the expected range for the client's blood pressure?

Answer 17

120/80 mmHg

Question 18

What education should the nurse provide to a young adult training for a triathlon competition who has a pulse rate of 49 beats/min?

Answer 18

The heart rate is within normal limits due to the exercise regimen the client is following.

Question 19

A 6-month-old client is seeing a physician for a well-child visit. What is the expected range for the client's heart rate?

Answer 19

80-140 beats per minute

Question 20

A 32-year-old client visits the clinic for a routine check-up. What is the expected range for the client's heart rate?

Answer 20

60-100 beats per minute

Question 21

The nurse is teaching a client about proper use of a glucometer. What instructions will the nurse give during the teaching session?

Answer 21

Blood glucose levels are obtained 30 minutes before eating, and before bedtime.

Question 22

A client informs the nurse about feeling "different" compared to earlier in the day. In response, when should the nurse expect to perform a vital signs assessment?

Answer 22

immediately

Question 23

When evaluating a client's pulse, the nurse detects a palpable pulse for a period of time before it becomes impalpable with slightly increased pressure. The pulse rate is measured at 70 beats per minute. How should the nurse document the quality of the client's pulse?

Answer 23

thready pulse

Question 24

After answering a client's call light, the nurse discovered the client gasping and expressing difficulty breathing, stating, "I can't get my breath." The nurse promptly administered supplemental oxygen and adjusted the client's position, resulting in the alleviation of symptoms. When documenting this incident, how should the nurse describe the client's condition?

Answer 24

dyspnea

Question 25

A public health nurse has been asked to engage in an initiative with the purpose of advocating for the adoption of ergonomics. What is the most likely goal of this initiative?

Answer 25

to promote comfort and health in workplace settings

Question 26

Among the group of unlicensed assistive personnel (UAP) who have received education on proper body mechanics, which statement made by a UAP necessitates the nurse's intervention?

Answer 26

"It is easier to twist my back when moving objects from side to side."

Question 27

When working at a computer and needing to document client data in a healthcare facility, which ergonomic guideline should the nurse adhere to?

Answer 27

Keep the elbows flexed no more than 100 degrees to 110 degrees.

Question 28

A nurse is providing care for a client who is experiencing significant back pain and has remained in a supine position in bed for an extended duration. Which specific body position poses the greatest risk for inducing foot drop?

Answer 28

supine

Question 29

When assigning the task of positioning inactive clients to an unlicensed assistive personnel (UAP), what specific instructions will the nurse provide?

Answer 29

change the inactive client’s position at least every 2 hours.

Question 30

When caring for a client who is experiencing cardiac dyspnea, the nurse aids the client in assuming the Fowler position. What benefit does Fowler's position provide to a client with dyspnea?

Answer 30

It relieves pressure on the diaphragm, allowing easy breathing.

Question 31

During rounds, a nurse discovers a fire outbreak in a client's room within a healthcare facility, which intervention is the priority?

Answer 31

Evacuate the client.

Question 32

While attending to four clients, which client does the nurse anticipate might have a sensitivity to latex?

Answer 32

21-year-old who cannot eat bananas

Question 33

When providing care for a client who is known to have a latex sensitivity, what is the easiest and most suitable method to prevent exposing the client to latex?

Answer 33

Use nonlatex gloves for the client.

Question 34

A nurse has been tasked with ensuring that the policies and procedures align with the requirements of the Nursing Home Reform Law. What trend initially prompted the enactment of this legislation?

Answer 34

the widespread use of physical restraints in long-term care facilities

Question 35

A nurse is caring for an older adult client who has Alzheimer’s disease. The client has a stable and steady gait. However, the client is still at risk of injury due to confusion. Which method of restraining should the nurse use?

Answer 35

bed alarm

Question 36

Which of the following nursing actions are appropriate when caring for a client who has been placed in physical restraints? (Select all that apply.)

Answer 36

Communicate with the family regarding the need for restraints. Offer opportunities for toileting frequently and regularly. Check circulation and skin condition frequently and regularly.

Question 37

An elderly client who has been diagnosed with osteoporosis and early-stage Alzheimer's disease needs to utilize an assistive device that will optimize stability while walking. Which assistive device will best meet this client's needs?

Answer 37

walker

Question 38

An elderly client is being seen at the clinic after experiencing a fall inside his home. He appears to have suffered no ill effects of the fall, but his wife has asked the nurse if he might benefit from the use of a cane. The nurse should be aware of what criterion for the safe use of a cane?

Answer 38

The client's weakness must be primarily limited to one side of his body.

Question 39

A nurse working at a healthcare facility is providing care for clients who rely on crutches for their mobility while ambulating. Which client would the nurse observe utilizing a four-point walking gait?

Answer 39

clients with disabilities such as arthritis or cerebral palsy

Question 40

The nurse is providing care for a client who has lower extremity paralysis and has been fitted with bilateral leg braces. Which crutch-walking gait will the nurse instruct to the client?

Answer 40

swing-through

Question 41

The client's care plan specifies that the client will be required to be in a high Fowler position. To adhere to this guideline, the nurse would raise the client's head at:

Answer 41

60 degrees to 90 degrees

Question 42

A nurse is tasked with transferring a client to the x-ray unit who has polio but possesses strong strength in their arms and upper body muscles. Which transfer device will be the most suitable for the client?

Answer 42

transfer board

Question 43

A nurse is providing care for a client who is recovering from acute back pain. The nurse noted that the client possesses upper body strength. Which device will allow the bedridden client to maintain as much independence as possible?

Answer 43

trapeze

Question 44

A nurse is attending to a client who has experienced a stroke. The client is currently lying in a supine position and is unable to reach the footboard. What action should the nurse take to minimize the risk of foot drop in the client?

Answer 44

use a foot splint

Question 45

A nurse is conducting a mental status assessment for a client admitted to a health care facility following a motor vehicle accident. Under which conditions would the nurse need to collect more objective assessment data?

Answer 45

when the client has taken an overdose of drugs

Question 46

A nurse is caring for a client reporting lower back pain. The nurse uses the body systems approach to assess the client. What are the advantages of using this approach for data collection?

Answer 46

It makes problems more easily identifiable, as findings tend to be clustered.

Question 47

A nurse is completing vital signs on a client who was brought into the emergency department by ambulance. Which assessment findings require immediate attention? (Select all that apply.)

Answer 47

Temperature is 101.4oF (38.6oC.). Oxygen saturation is 90%. Heart rate is 130 beats per minute. Pain is 8 on scale of 1 to 10.

Question 48

A nurse is performing a physical assessment for a client using the palpation technique. What is one of the purposes of using this technique?

Answer 48

to check the skin temperature and moisture

Question 49

A nurse is completing an assessment on a client with no history of nutrition-related problems. Which activity should the nurse complete as part of an initial nutritional screening?

Answer 49

height and weight

Question 50

A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30 or 6/9. The client asks the nurse, "What does that mean?" How should the nurse respond?

Answer 50

"You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)."

Question 51

A nurse greets a new client and asks the client to accompany the nurse to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client's:

Answer 51

level of consciousness.

Question 52

A nurse greets a new client and asks the client to accompany the nurse to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client's:

Answer 52

level of consciousness.

Question 53

A nurse is assessing a client who seems to have developed a hearing impairment after working at a construction site for a few months. The nurse is using the Weber test to assess the client's hearing acuity. What is the purpose of the Weber test?

Answer 53

It determines the equality or disparity of bone-conducted sound.

Question 54

A nurse is performing the diagnostic positions test to observe extraocular movements on a client during a routine eye exam. Which of the findings would the nurse expect to observe?

Answer 54

coordinated movement of both eyes

Question 55

When assessing the sensory skin perception of an older adult client, the nurse strokes the skin with a cotton ball at various places on both sides of the body. What information does the nurse obtain from this assessment?

Answer 55

ability to identify fine touch

Question 56

A nurse is teaching a client how to perform a self breast exam. Place the following examination techniques in the order they should be performed. i) place a pillow under the shoulder on the side where the first breast will be examined. ii) feel upward towards the axilla of each arm to determine if there are any lumps or hard or thickened areas. iii) stand in front of a mirror, look at both breasts with the arms relaxed at the side, with the hands pressing on the hips, and with the hands elevated above the head looking for dimpling in the skin or retraction of either nipple. iv) use the flat surface of the fingers in an up-and-down pattern from the underarm and across the breast from the clavicle to the base of the ribs to feel for changes in any area of the breast. v) squeeze the nipple gently between the thumb and index finger to determine if there is any clear or bloody discharge.

Answer 56

iii, i, iv, ii, v

Question 57

A nurse is examining a client with cirrhosis of the liver for edema. The nurse notes that the indentation remains for several seconds, and the skin swelling is obvious on inspection. How should the nurse quantify the severity of the finding?

Answer 57

3+ pitting edema

Question 58

During the physical assessment of a client, the nurse observes flat, round, colored, nonpalpable areas on the face. How should the nurse document this finding?

Answer 58

macules

Question 59

A nurse is assessing the skin of a client who had been on a hiking trip and developed a number of inflamed red patches on his hands and face as an allergic reaction. How should the nurse document this finding?

Answer 59

erythema

Question 60

During assessment, the nurse observes that the client has a yellow discoloration on the skin. What is the nurse's appropriate action?

Answer 60

Inspect the sclera and mucous membranes.

Question 61

Which anatomical structure is NOT part of the breast?

Answer 61

Diaphragm

Question 62

Which anatomical structure is NOT part of the genitourinary system?

Answer 62

Liver

Question 63

Which anatomical structure is NOT part of the thorax?

Answer 63

Liver

Question 64

Which assessment technique is used to evaluate the range of motion of joints?

Answer 64

Passive range of motion

Question 65

Which assessment technique is typically used to evaluate muscle strength?

Answer 65

Manual muscle testing

Question 66

Which technique is commonly used to assess for bowel sounds in the abdomen?

Answer 66

Auscultation

Question 67

What is the primary purpose of assessing Romberg's sign?

Answer 67

Assessing vestibular function

Question 68

What is the primary purpose of assessing the Babinski reflex?

Answer 68

Detecting upper motor neuron dysfunction

Question 69

Which technique is used to assess for tenderness over the kidneys?

Answer 69

Palpation

Question 70

Which assessment technique is used to evaluate tactile fremitus in the lungs?

Answer 70

Palpation

Question 71

Which technique is used to assess for bruits in the carotid arteries?

Answer 71

Auscultation

Question 72

What is the primary purpose of assessing capillary refill time?

Answer 72

Evaluating peripheral circulation

Question 73

Which technique is commonly used to assess for crepitus in the musculoskeletal system?

Answer 73

Palpation

Question 74

Which technique is used to assess for jugular venous distention in the neck?

Answer 74

Inspection

Question 75

Which condition may present with rebound tenderness in the abdomen?

Answer 75

Appendicitis

Question 76

Which condition may present with pitting edema in the lower extremities?

Answer 76

Heart failure

Question 77

Which condition may present with rigidity and guarding upon abdominal palpation?

Answer 77

Peritonitis

Question 78

Which of the following is an example of an abnormal finding related to the musculoskeletal system during a physical assessment?

Answer 78

Bilateral pedal edema

Question 79

Which condition may present with hematuria during a genitourinary assessment?

Answer 79

Urinary tract infection

Question 80

Which condition may present with a positive Murphy's sign during physical examination?

Answer 80

Cholecystitis