NUR2115 Exam 1, 2, Final Exam & NUR2115 Exam 1, 2, Final E... - $70.45 Add To Cart
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NUR 2115 Exam 1 / NUR2115 Exam 1 (Latest, 2022)/ NUR 2115 Fundamentals of Professional Nursing Exam 1/ NUR2115 Fundamentals of Professional Nursing Exam 1:... [Show More] Rasmussen College Rasmussen College NUR2115 Exam 1 / NUR 2115 Exam 1 (Latest, 2022)/ NUR 2115 Fundamentals of Professional Nursing Exam 1/ NUR2115 Fundamentals of Professional Nursing Exam 1 NU211 Fundamentals of Professional Nursing Exam 1 NU 211 Exam 1 / NU211 Exam 1 (Latest): Fundamentals of Professional Nursing: Rasmussen College • Question 1 1 out of 1 points A nurse is planning care for a 17 year old following a motor vehicle accident. Which of Erickson's developmental stages should the nurse keep in mind in the planning? Identity vs. Role Confusion • Question 2 1 out of 1 points Before developing a procedure, a nurse reviews all current research-based literature on insertion of a nasogastric tube. What type of nursing will be practiced based on this review? evidence-based nursing • Question 3 1 out of 1 points A nurse is admitting a client to a geriatric medicine unit following the client's recent diagnosis of acute renal failure. Which of the following nursing actions is most likely to reduce the client's chance of experiencing a fall while on the unit? -Orient the patient to the room and environment thoroughly upon admission. • Question 4 1 out of 1 points What drawbacks does charting by exception (CBE) have? Vulnerability to legal liability since nurse’s safe, routing care is not recorded • Question 5 1 out of 1 points The student nurse knows mobility contributes to positive outcomes throughout the body. What is a positive effect of mobility on the respiratory system? Preventions of secretions pooling • Question 6 1 out of 1 points A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." What action should the nurse take? notify the surgeon that the client wishes to withdraw informed consent from procedure client has right to withdraw informed consent • Question 7 1 out of 1 points A nurse is documenting care given to a client with a new right leg amputation. The nurse accidently documents a dressing change was performed on the left leg. What would be the best action to correct this error? Draw a single line through the entry and rewrite it above or beside it. • Question 8 1 out of 1 points Identify the statement that is not therapeutic communication? Not using silence? • Question 9 1 out of 1 points A child is admitted to the emergency department with a fractured arm. During the admission interview, the nurse should implement what communication technique to elicit the most information from the parents? The use of clarifying questions • Question 10 1 out of 1 points A nurse is administering influenza immunizations at a local clinic. What level of disease prevention is the nurse demonstrating? Tertiary • Question 11 1 out of 1 points Nurses provide many interventions to prevent falls in health care settings. What would be an appropriate intervention to prevent falls? Lock wheels on beds and wheelchairs. • Question 12 1 out of 1 points What charting entry would be the most defensible in court? Notified Dr. Jones of BP of 90/40 • Question 13 1 out of 1 points The World Health Organization (WHO) defines health as which of the following? a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity. • Question 14 1 out of 1 points The student nurse knows lack of mobility contributes to negative outcomes throughout the body. What is a negative effect of immobility on the musculoskeletal system? 1)disuse osteoporosis 2)disuse atrophy 3)contractures 4)stiffness and pain in the joints • Question 15 1 out of 1 points The student nurse knows lack of mobility contributes to negative outcomes throughout the body. What is a negative effect of immobility on the cardiovascular system? 1)decreased efficiency of orthostatic neurovascular reflexes (orthostatic hypotension) 2)altered distribution of blood volume 3)venous vasodilation and stasis 4)dependent edema 5)increase use of valsalva maneuver 6)thrombus 7)diminished cardiac reserve • Question 16 0 out of 1 points Barriers to evidence-based practice (EBP) include which of the following? An organizational culture that does not support change • Question 17 1 out of 1 points When a labor and delivery nurse tells a coworker that an Asian client probably did not want any pain medication because "Asian women typically are stoic," the nurse is expressing what? Stereotyping • Question 18 1 out of 1 points What nursing statement may be seen as the first line in a SOAP note? Client complaining of abdominal pain rated 8/10 • Question 19 1 out of 1 points Examples of evidence-based practice (EBP) include which of the following? (Select all that apply) Catheter associated urinary tract infections practice alert Prevention of pressure ulcers Pain assessment as the fifth vital sign • Question 20 1 out of 1 points An elderly client has impaired sensation in her lower extremities. What educational statement would be necessary to reduce her risk of injury? Always test the temperature of bath water before stepping in • Question 21 1 out of 1 points Advantages of open-ended questions include what? (Select all that apply): The let the interviewee(client) do the talking They can provide information the interviewer did not ask for The interviewer is able to listen and observe • Question 22 1 out of 1 points The nurse is admitting a new client to the unit. The nurse notes that this client would need an alternate meal choice when the menu specified pork for a meal. What cultural group would require an alternative meal choice? Muslim • Question 23 1 out of 1 points When providing nursing care to an African American individual, which of the following cultural factors should the nurse consider? Values and beliefs are often present oriented • Question 24 1 out of 1 points When evaluating a resident for transition from a long-term care facility to a home environment, what may the nurse ask the resident to perform? ADLs • Question 25 1 out of 1 points All individuals, according to Maslow's Hierarchy of Needs, have which of the following? Basic human needs • Question 26 1 out of 1 points What is one of the most significant trends in health care today? Shift from hospitals to community-based care • • Question 27 1 out of 1 points A group of nurses are planning to investigate the effectiveness of turning immobilized stroke clients' more frequently in order to prevent skin breakdown. The team has begun by formulating a PICO question. Which of the following will the "O" in the team's PICO question refer to? "O" denotes the outcome of interest ex: Preventing skin breakdown. • Question 28 1 out of 1 points A staff development nurse is teaching proper body mechanics to newly hired nursing assistants at a long term care facility. What technique can be used to help prevent a back injury? Spreading feet shoulder-width apart to broaden the base of support Holding the object that you are lifting close to your body • Question 29 1 out of 1 points When caring for a client who is visually impaired, the nurse will do which of the following? Explain the reason for touching the client before doing so? • Question 30 1 out of 1 points The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education sessions. Which of the following topics for the all-staff education is most likely to benefit the greatest number of residents? Teaching nurses how to prevent falls • Question 31 1 out of 1 points The documentations states, "patient is highly satisfied with her spiritual wellness." What would the supporting documentation show to support spiritual wellness? Having peace and harmony with your values and actions • Question 32 1 out of 1 points A nurse is collecting data from a client who has required strict bedrest for 1 week. What should the nurse identify as an indication that the client is ready to ambulate? Performs active ROM exercises of all extremities. • Question 33 1 out of 1 points There are four concepts common in all nursing theories. Which one of the four concepts is the focus of nursing? The person • Question 34 1 out of 1 points The student nurse knows mobility contributes to positive outcomes throughout the body. What is a positive effect of mobility on the urinary system? Prevents stasis of urine in the bladder • Question 35 1 out of 1 points What is the primary purpose of an incident report? Quality improvement • Question 36 1 out of 1 points A grade school nurse is addressing parents at a Parent Teacher Association (PTA) meeting regarding car safety. What is a recommended safety guideline for grade school children? Booster seats should be used for children until they are 4-feet 9-inches tall or at least 8 years of age. • Question 37 1 out of 1 points Nurses are responsible for making sure their educational background and clinical experience are adequate to fulfill the nursing responsibilities delineated by the job description. What is one way to violate this responsibility? Accepting assignments that the nurse feels are unsafe • Question 38 1 out of 1 points After reviewing several research articles, the clinical nurse specialist on a medical surgical unit rewrites the procedure on assessing placement of a nasogastric tube. What source of nursing knowledge did the nurse use in this situation? scientific knowledge • Question 39 1 out of 1 points What is the best explanation for the way evidence-based practice (EBP) has changed the way nursing care is delivered? nursing care now uses EBP as a means of ensuring quality care • Question 40 0 out of 1 points When assessing a client's blood pressure manually, the nurse can use which artery? (Select all that apply). Brachial artery, radial, popliteal • Question 41 1 out of 1 points The physician's admitting orders indicate that the client is to be placed in a Fowler's position. Upon positioning this client, how much will the nurse elevate the head of the bed? 45 to 60 degrees • Question 42 0 out of 1 points A nursing student is conducting a literature review to find evidence-based practice (EBP) standards for the nursing care of clients diagnosed with diabetes. The student nurse knows that the first step in this process is to locate reputable sources of information. Which sources below would not be appropriate for the nursing student to use for the literature review? Unreliable websites? Medline: an online database of health care related journals Diabetes Care: a peer reviewed journal published by the American Diabetes Association Cumulative Index to Nursing and Allied Health Literature • Question 43 1 out of 1 points The nurse is caring for a client diagnosed with late-stage Alzheimer's disease and he requires full assistance with transfers to and from the bed. What nursing actions is most likely to promote safe handling of this client? Provide to the client brief, clear instructions that are phrased positively. • Question 44 1 out of 1 points An adolescent has recently had a ring inserted into her navel. What is the greatest risk facing the adolescent as a result of this activity? An infection • Question 45 1 out of 1 points What is one of the most significant trends in health care today? Shift from hospitals to community-based care • Question 46 1 out of 1 points A registered nurse, by the name of Alicia Jones, is documenting assessments at the beginning of the shift. How should the nurse sign the entry? A. Jones, RN • Question 47 1 out of 1 points The nurse is planning health teaching for a client with advanced kidney failure. Which of the following tertiary health promotion activities would the nurse include? Medications, Medical therapy, Surgical treatment, Rehabilitation, Physical therapy, Occupational therapy, job training • Question 48 1 out of 1 points A charge nurse is implementing the ISBARR communication tool for nurses and physicians. How can the nurse help to reduce resistance to this change? explain the change by listing advantages to nurses, physicians and patients • Question 49 1 out of 1 points A nursing instructor has assigned a student to care for a client of Asian descent. The instructor reminds the student that personal space considerations vary among cultures. What personal space preferences are important for the student to consider when caring for this client? People of Asian descent prefer some distance between themselves and others. • Question 50 1 out of 1 points When evaluating a resident for transition from a long-term care facility to a home environment, what may the nurse ask the resident to perform? ADLs [Show Less]
NUR 2115 Exam 2 / NUR2115 Exam 2 (Latest, 2022)/ NUR 2115 Fundamentals of Professional Nursing Exam 2/ NUR2115 Fundamentals of Professional Nursing Exam 2:... [Show More] Rasmussen College Rasmussen College NUR2115 Exam 2 / NUR 2115 Exam 2 (Latest, 2022)/ NUR 2115 Fundamentals of Professional Nursing Exam 2/ NUR2115 Fundamentals of Professional Nursing Exam 2 NU211 Fundamentals of Professional Nursing Exam 2 NU211 Exam 2 / NU 211 Exam 2 (Latest): Fundamentals of Professional Nursing: Rasmussen College • Question 1 1 out of 1 points Which characteristics of the stages of infection indicate the full stage of infection? a. It is the interval between the pathogen’s invasion of the body and the appearance of symptoms of infection. b. Specific signs and symptoms are present. c. The organisms are growing and multiplying. d. Early signs and symptoms of disease are present, but these are often vague and nonspecific. • Question 2 1 out of 1 points While assessing the client, the nurse hears diminished lung sounds on auscultation, counts a respiratory rate of 22 and regular, and obtains an oxygen saturation of 89% on room air. What nursing diagnosis is best supported by this assessment data? a. Impaired gas exchange ?? b. Ineffective airway clearance ?? c. Anxiety d. Tachypnea • Question 3 1 out of 1 points A nurse accidentally sticks her hand with a needle after administering an injection to a client. What action should the nurse take first? a. Report the incident to the charge nurse. b. Wash the area of the puncture thoroughly with soap and warm water. c. Complete an incident report. d. Go to employee health services. • Question 4 1 out of 1 points A client is having difficulty climbing stairs and reports shortness of breath. The nurse notes that the client is breathing heavy, having nasal flaring and mouth is wide open. How will the nurse document this client's response to activity? a. Wheezing with activity. b. Tachypnea. c. Dyspnea on exertion (DOE). d. Apnea. • Question 5 1 out of 1 points A home care client was recently prescribed continuous oxygen. What client statement indicates further education is needed? a. I will be able to tell how much oxygen I’m getting by looking at the flowmeter. b. I should call my doctor if I find it harder to concentrate. c. I will make sure my visitors smoke outside. d. I will wear synthetic clothing and woolen socks when using my oxygen • Question 6 1 out of 1 points A nurse is interviewing a client who will undergo a cardiac coronary catheterization (angiography). The nurse inquires if the client has someone with her that will be able to drive her home after the procedure. What phase of the nursing process involves questioning and gathering data? a. Planning b. Evaluation c. Assessment d. Diagnosis • Question 7 1 out of 1 points Following shift-to-shift report, what nursing process activity is performed first? a. Critically analyze assessment data to determine priorities. b. Collect and organize client data through physical assessment. c. Set client-centered, measurable and realistic goals. d. Determine effectiveness of intervention. • Question 8 1 out of 1 points A nurse working on an orthopedic unit is caring for four clients. What client is at greatest risk for skin breakdown? a. An adolescent who has a cervical fracture and is in a halo brace. b. A young adult who has a femur fracture and is in a cast. c. A middle adult who has a fractured radius and an arm cast. d. An older adult who has a hip fracture and is in an immobilizer • Question 9 1 out of 1 points The nurse is assigned to care for a middle-ages adult woman who recently had abreast removed due to cancer. While preparing to clean the incision, the patient tells the nurse, "I just can't look at myself like this." What is the best therapeutic response? a. It could be worse. b. Let me finish preparing the supplies, then we can talk. c. I see this is a difficult change for you. Tell me more about how you’re feeling. d. Don’t worry, everything will be alright. • Question 10 1 out of 1 points While performing an assessment, the nurse hears crackles in bilateral lower lung lobes. The nurse adds a nursing diagnosis of impaired gas exchange. What purpose does a nursing diagnoses serve? (Select all that apply.) a. Nursing diagnoses allow for greater autonomy in the nursing field. b. Nursing diagnoses allow for greater accountability to the nursing profession. c. Nursing diagnoses provide clear identification of the body of nursing knowledge. d. Nursing diagnoses identify problems other non-nursing team members are expected to resolve. • Question 11 1 out of 1 points A nurse identifies a client as having a risk for impaired skin integrity. The clients position is changed every two hours as directed in the care plan interventions. How should the nurse evaluate the effectiveness of the intervention? a. Examine the condition of the client’s skin using inspection and palpation. b. Ask the unlicensed assistive personnel (UAP) if the patient’s position has been changed every two hours. c. Ask the client how the interventions is working. d. Delegate skin assessment to a licensed practical nurse. • Question 12 1 out of 1 points The nurse is preparing to assess the cardiopulmonary system with inspection, palpation, percussion and auscultation. The patient complains of chest pain. What priority assessments are needed next? Auscultation of the chest wall? • Question 13 1 out of 1 points What strategy is most effective in blocking the transmission of microbes from the infectious reservoir to susceptible hosts? a. Sterilize the infectious human reservoir. b. Block the portal of exit from the infectious reservoir. c. Block the portal of entry into the host. d. Decrease susceptibility of the host. • Question 14 1 out of 1 points The student nurse is assessing breath sounds on a client with asthma and notes continuous musical sounds. What adventitious breath sound should the student document? a. Wheezing. b. Pleural friction rub. c. Rhonchi. d. Crackles. • Question 15 1 out of 1 points The nurse is performing a comprehensive assessment and is completing the Braden scale. What is the Braden scale used to determine? a. The level of physical mobility of a patient. b. The risk of developing pneumonia c. The risk of developing a pressure ulcer d. To assess the level of swallowing. • Question 16 1 out of 1 points What is the correct flow of blood from the inferior vena cava through the heart and lungs? Right atrium>1 Right ventrical>2 Pulmonary artery>3 Plumonary vein>4 Left atrium5 • Question 17 1 out of 1 points When should a nurse wear eye protection? a. While providing oral hygiene care to a client who is HIV positive. b. While emptying a urinary drainage bag for a client who had pneumonia. c. While irrigating a wound with saline. d. While transporting cerebrospinal fluid specimen to the lab. • Question 18 1 out of 1 points A nurse is caring for a comatose obese client. What intervention reduces friction and shear injury? a. Delay bathing to avoid excess stress. b. Elevate head of bed over 45 degrees and keep foot of bed flat. c. Using 2 caregivers to boost the client up in bed with a lift sheet. d. Using an electric ceiling lift to reposition client every 2 hours. • Question 19 1 out of 1 points What statement should the nurse include in a lesson on proper hand hygiene? a. You do not have to wash your hands if you were wearing gloves during care. b. Rub all surfaces of your hands with an alcohol rub for at least 15-20 seconds or until dry. c. Use an alcohol rub when your hands are visibly soiled. d. Use hot water to kill the most germs. • Question 20 1 out of 1 points The nurse is planning care for an adult client recovering from pneumonia. What is an expected outcome for the nursing diagnosis of impaired gas exchange? a. The nurse will assess arterial blood gases. b. Client will have oximetry results in the range of 80-85% on room air. c. Client will demonstrate non-labored breathing at 12-20 breaths per minute within 48 hours d. Client will tolerate oxygen wearing while maintaining oxygen saturations>100% • Question 21 1 out of 1 points A nurse is telling a client with chronic obstructive pulmonary disease (COPD) to breathe out slowly and gently, like blowing out a candle to prolong exhalation. What technique is the nurse teaching the client? Pursed lips breathing • Question 22? 1 out of 1 points Which of the following are interventions the nurse should expect in a plan of care for a hyperthermic client? (Select all that apply.) a. Monitor intake and output b. Encourage fluids with all interactions c. Monitor vital signs d. Apply additional blankets • Question 23 1 out of 1 points The nurse uses critical thinking in the evaluation phase of the nursing process. What is an appropriate nursing intervention upon finding a pressure ulcer that is larger than the previous measurement? (Select all that apply.) a. Evaluate client’s ability to reposition self in bed b. Modify interventions using evidence-based practice c. Change nothing about the care plan as all evidence-based interventions will eventually work d. Collaborate with the inter-professional health care team to improve nutrition, hydration and skin care. e. Explain to the patient that the previous interventions were poor • Question 24 1 out of 1 points A client suddenly begins to have syncope and dyspnea upon exertion (DOE). What objective data may be found when the nurse performs the focused assessment? a. Pulmonary embolism. b. Tachypnea. c. Patient states, “I can’t breathe.” d. Laryngeal abscess. • Question 25 1 out of 1 points The client's white blood cell count (WBC) is 7,500/mm3. What interpretation of the laboratory values by the nurse is most accurate? a. Client has a low value and is at risk for infection. b. Client has a high value and most likely has an infection. c. Client value is within normal range. • Question 26 1 out of 1 points The body transfers heat to an ice pack, causing the ice pack to melt and the clients temperature to be reduced. The nurse knows the decrease in temperature is caused by which process? a. Radiation b. Convection c. Evaporation d. Conduction • Question 27 1 out of 1 points What statement identifies the purpose of nursing diagnostic statements? a. Nursing diagnoses identify the plan b. Nursing diagnoses link to the health care provider’s recommendations c. Nursing diagnoses identify actual problems and potential problems d. Nursing diagnoses gather clients’ data and analyze their health status • Question 28 1 out of 1 points A client is admitted for treatment of poorly healing infected leg ulcers. What is the importance of obtaining a client's nutritional history? a. Poor nutrition may cause an ulcer. b. Clients’ eating habits are usually unsatisfactory to sustain overall health. c. The client’s food intake will likely be decreased as a result of the illness. d. Nutrition directly affects wound healing and infection prevention. • Question 29 1 out of 1 points A nurse is admitting a client who has tuberculosis. What transmission-based precautions should the nurse initiate? Airborne • Question 30 1 out of 1 points A nurse is caring for a client who had vascular surgery on the left lower extremity. The client suddenly states, "I have tingling in my toes on the left foot." What is the first thing the nurse should assess? a. Vital signs. b. Assessment bilateral dorsalis pedis and posterior tibial artery pulses. c. Assess the bilateral femoral and axillary pulses. d. Abdominal shape and symmetry. • Question 31 1 out of 1 points A nurse is assessing for cyanosis in the client who has dark skin. What site should the nurse examine to identify cyanosis in this client? Oral and mucous membranes • Question 32 1 out of 1 points Respiratory rate is regulated by mechanisms of the cardiovascular system, neurological system and pulmonary system. As the oxygen in the blood diminishes, which initial physiological responses should the nurse expect to see on assessment? Increased heart rate and increased respiration rate. • Question 33 1 out of 1 points A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. What intervention should the nurse use to help maintain the integrity of the client's skin? a. Bend at the waist to physically lift the client up in bed. b. Apply cornstarch to keep sensitive skin areas dry. c. Allow skin to remain damp until the fever breaks. d. Elevate the head of the bed no more than 45 degrees. • Question 34 1 out of 1 points The nurse is assessing an ischial pressure ulcer on a client. Objective data reveals an ulcer that is 3 cm x 2 cm and involves the epidermis and partially into the dermis. The nurse also notes an area of redness around the pressure ulcer. What would the nurse document this wound as? a. A stage IV pressure ulcer with undermining. b. A stage II pressure ulcer with surrounding erythema. c. A stage III pressure ulcer with surrounding erythema. d. A stage I pressure ulcer with surrounding erythema • Question 35 1 out of 1 points A nurse is educating a married client on modifiable ways to lower the risk of infections. The nurse should include what behaviors? a. Abstinence b. Smoking cessation c. Slow the aging process d. Avoiding aggressive contact sports. • Question 36 1 out of 1 points What nursing intervention is best for patients with existing pressure ulcers on bilateral heels? a. Placing the patient in a whirlpool bath containing povidone-iodine solution. b. Applying an agent to increase moisture at the ulcer site. c. Reposition client every two hours??? d. Apply pressure-reducing boots to keep weight off affected area. • Question 37 1 out of 1 points Which of the following are true regarding the use of the incentive spirometer? Improves the patient breathing in their lungs especially in surgery or a long illness such as pneumonia. • Question 38 1 out of 1 points A nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure? a. Remove all metal necklaces. b. Take several shallow breaths during the procedure. c. Do not eat or drink anything the morning of the test. d. Expect minor discomfort after the procedure. • Question 39 1 out of 1 points A nurse is caring for a client on prolonged bedrest. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of what condition? Impairedgas exchange • Question 40 1 out of 1 points The nurse identifies alternate wound care interventions for a client with a venous stasis ulcer. The nurse was hopeful to see some improvement by this time, however the wound is not reducing in size or amount of drainage. What phase of the nursing process does the care plan revision fall into? a. Evaluation b. Assessment c. Diagnosis d. Implementation • Question 41 1 out of 1 points You are caring for a 20 year old client who has an abdominal incision. The surgical wound was closed with 10 sutures. This surgical wound is healing by what process? a. Binary intention. b. Secondary intention. c. Tertiary intention. d. Primary intention. • Question 42 1 out of 1 points Physiological changes associated with aging place the older adult client at risk for what nursing problem? a. Impaired skin integrity b. Risk for poisoning c. Ineffective coping d. Risk for suffocation • Question 43 1 out of 1 points What is the primary difference between acute and chronic wounds? a. Acute wounds are full-thickness. b. Acute wounds usually heal within days to weeks. c. Acute wounds exceed typical healing time. d. Acute wounds include pressure ulcers. • Question 44 1 out of 1 points A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse don? a. A gown. b. Sterile gloves. c. Clean gloves and gown. d. Protective eyewear. • Question 45 1 out of 1 points A client had to return to surgery for a retained foreign object and now has an open wound that will be closed at a later date. This wound is healing by what process? Tertiary intentions healing • Question 46 1 out of 1 points What desired outcome is most appropriate for a client with the nursing diagnosis of impaired gas exchange? a. Client will demonstrate unlabored respirations at 6 breaths a minute by tomorrow. b. Client’s blood CO2 will increase by 1200. c. Client will rest in the prone position for all meals. d. Client will have oxygen saturation greater than or equal to 95% before and after activity. • Question 47 1 out of 1 points A nurse is teaching a newly hired group of unlicensed assistive personnel (UAP) about infection-control measures on the unit. What is the most effective way to prevent the spread of pathogens during client care? a. Properly disposing of contaminated equipment. b. Discarding used syringes in appropriate containers. c. Changing soiled linens daily for clients who have draining wounds. d. Performing hand hygiene frequently and consistently. • Question 48 1 out of 1 points While performing a health history questionnaire, a patient confirms that he occasionally coughs up mucous. What additional question(s) will the nurse follow up with? (Select all that apply.) a. How much do you spit out? b. Move on with the assessment, there are no further questions needed. c. What color is the mucous and is it ever blood-tinged? d. Are there certain times of the day or environments where you cough up more mucous? e. Why don’t you just swallow the mucous? • Question 49 1 out of 1 points The nurse notices that there is a new area of skin breakdown. This would be an example of what phase of the nursing process? a. Assessment b. Diagnosis c. Implementation d. Planning • Question 50 1 out of 1 points A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. What order of intervention should the nurse use to help maintain the integrity of the client's skin after an episode of incontinence? (Choose the correct order) 1. Remove soiled clothing 2. Clean and dry client’s skin 3. Apply barrier cream if needed 4. Redress the client Extra questions from other exam: 1. A nurse is admitting a client who has pertussis. What transmission-based precautions should the nurse initiate? a. Airborne b. Contact c. Droplet d. Protective 2. What is a sign or symptom of late hypoxia? a. Elevated respiratory rate. b. Cyanosis. c. Restlessness. d. Elevated heart rate. 3. The nurse notices that there is a new area of skin breakdown. This would be an example of what phase of the nursing process? a. Assessment b. Diagnosis c. Implementation d. Planning 4. What body systems is not involved in the process of normal gas exchange? a. Cardiovascular system. b. Pulmonary system. c. Hepatic system. d. Neurologic system. 5. How should the nurse auscultate the lung lobes? a. Listen only to the posterior chest. b. Listen to the left upper lobe and left lower lobe, then precede to the right upper and right lower lobes. c. Listen to the top of the anterior chest and then the top of the posterior chest. d. Listen to the chest sounds proceeding from top to bottom and side to side. 6. A nurse is caring for a client who experienced a lacerated spleen with internal bleeding. She has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of what condition. a. An upper airway respiratory infection. b. Aspiration pneumonia c. atelectasis [Show Less]
NUR 2115 Final Exam / NUR2115 Final Exam (Latest, 2022)/ NUR 2115 Fundamentals of Professional Nursing Final Exam / NUR2115 Fundamentals of Professional Nu... [Show More] rsing Final Exam: Rasmussen College Rasmussen College NUR2115 Final Exam / NUR 2115 Final Exam (Latest, 2022)/ NUR 2115 Fundamentals of Professional Nursing Final Exam / NUR2115 Fundamentals of Professional Nursing Final Exam NU211 Fundamentals of Professional Nursing Final Exam NU 211 Final Exam / NU211 Final Exam (Latest): Fundamentals of Professional Nursing: Rasmussen College Question 1 1.5 out of 1.5 points When assessing a 2-3 year old child, what is important to consider? Answers: Assess least invasive to most invasive. Start with examining the ears and mouth. Make sure to examine the child lying on the exam table. It’s easier to examine the child if the parent is not in the room. Question 2 1.5 out of 1.5 points The nurse notes an audible, crunching/grating sound on the client’s knee while climbing the stairs. Choose the best term. Answers: Crepitus Bulge sign Ballottement Inversion Question 3 1.5 out of 1.5 points The nurse palpates the left upper quadrant of abdomen with the knowledge that which organs are located in that area? Answers: Liver and gallbladder. Pancreas and spleen Large intestine and liver Left ureter and gallbladder Question 4 1.5 out of 1.5 points Identify which reflex is being tested in this picture. Answers: Plantar Patellar Triceps Achille’s Question 5 1.5 out of 1.5 points The clinic nurse assesses the skin of a white client with a diagnosis of psoriasis. The nurse understands that which characteristic is associated with this skin disorder? Answers: Clear, thin nail beds Red-purple raised areas Oily skin and no episodes of pruritus Silvery-white scaly patches on the scalp, elbows, knees, and sacral regions Question 6 1.5 out of 1.5 points "When testing stool for occult blood, the nurse is aware that a false-positive result may occur with:" Answers: a large amount of red meat within the last 3 days. absent bile increased fat content increased ingestion of fruit Question 7 1.5 out of 1.5 points The nurse is preparing to complete a musculoskeletal examination on a client. Which two assessment techniques would the nurse plan to use during this exam? Answers: Inspection and percussion Percussion and palpation Auscultation and percussion Inspection and palpation Question 8 1.5 out of 1.5 points While assessing edema on a client’s lower leg, the nurse notices a deep imprint of his fingers where the leg was palpated which takes several minutes to resolve. How would the nurse document this finding? Answers: No edema 1+ edema 3+ edema 4+ edema Question 9 1.5 out of 1.5 points The nurse is performing an assessment on an older client having difficulty sleeping at night. Which statement indicates that teaching about improving sleep is necessary? Answers: "I drink hot chocolate before bed" "I swim three times a week" "I have stopped smoking cigars" "I read for 40 minutes before bed" Question 10 1.5 out of 1.5 points "After completing a comprehensive health assessment of a client, which of the following statement is subjective data?" Answers: The client complains of itching The client s skin feels warm to the touch The client is scratching his arm The client s temperature is 100°F Question 11 1.5 out of 1.5 points Which of the following statements is most appropriate when the nurse is obtaining a genitourinary history from an elderly man? Answers: Do you need to get up at night to urinate? " Do you experience nocturnal emissions, or wet dreams? " Do you know how to perform urinary self-examination? Has anyone ever touched your genitals and you did not want them to? Question 12 1.5 out of 1.5 points "During a breast health interview, a client states that she has noticed pain in her left breast. The nurse s most appropriate response to this would be:" Answers: I would like some more information about the pain in your left breast. Don t worry about the pain; breast cancer is not painful. I would like some more information about the pain in your right breast. Breast pain is almost always the result of benign breast disease and so let s just ignore it. Question 13 1.5 out of 1.5 points The Glasgow Coma Scale is used to grade neurological responses to which three parameters? Answers: Eye opening, verbal response, motor response Verbal response, pain response, reflexes Pupil response, motor response, reflexes Motor movement and strength, reflexes, pupillary size and reaction Question 14 1.5 out of 1.5 points If a nurse uses their hand to press down into the abdomen to assess for tenderness, the nurse is performing which technique? Answers: Palpation Inspection Auscultation Percussion Question 15 0 out of 1.5 points "While obtaining a history of a 3-month old infant from the mother, the nurse asks about the baby s ability to suck and grasp the mother s finger. What is the nurse assessing?" Answers: Reflexes Intelligence Cranial atrophy Thalmus function Question 16 1.5 out of 1.5 points An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: Answers: of the shortening of the vertebral column. long bones tend to shorten with age. there is a significant loss of subcutaneous fat. there is a thickening of the intervertebral discs. Question 17 1.5 out of 1.5 points A client asks, “Why is touching my toes necessary? This is a sports physical examination not an exercise class.” How would the nurse reply? Answers: “This is the best way to check for symmetry of your arms.” “I am looking at the stretch of your ham strings.” “This allows me to see how straight your spinal column is.” “It is considered abnormal if you can’t touch your toes from this position.” Question 18 1.5 out of 1.5 points Medication administration or procedural errors can be prevented by completing which task? Answers: Ensuring the room is temperature controlled Closing the door and curtain Washing your hands Asking the client to give their name and date of birth Question 19 1.5 out of 1.5 points The nurse is assessing an older adult’s functional ability. What is the definition of functional ability? Answers: The measure of the expected changes of aging that one is experiencing The individual’s motivation to live independently The level of cognition present in an older person One’s ability to perform activities necessary to live in modern society Question 20 0 out of 1.5 points A client s respirations are 44. These respirations are considered to be which of the following? Answers: Tachypneic Apneic Eupneic Bradypneic Question 21 1.5 out of 1.5 points The client complains of ringing, crackling or buzzing in the ear. Choose the best term. Answers: Tinnitus Tympanic Otitis media Pinna Question 22 1.5 out of 1.5 points Which data do nurses document under the category of Family Health History? Answers: Present illness Allergies to medications Maternal Diseases Name and date of birth Question 23 1.5 out of 1.5 points The client has stiffness and fixation of a joint. Choose the correct term for this. Answers: Contracture Ankylosis Dislocation Subluxation Question 24 1.5 out of 1.5 points The most important technique when progressing from one auscultatory site on the thorax to another is: Answers: side-to-side comparison. top-to-bottom comparison. posterior-to-anterior comparison. interspace-by-interspace comparison. Question 25 1.5 out of 1.5 points The nurse notes fanning of the toes when the sole of the foot of an adult client is stimulated during assessment of the plantar reflex. How would the nurse chart this correctly? Answers: Babinski response Brudzinski sign Nuchal rigidity Hyperreflexia Question 26 1.5 out of 1.5 points The nurse should use which location for eliciting a deep tendon reflex? Answers: Achilles Femoral Scapula Abdomen Question 27 1.5 out of 1.5 points What would the nurse ask in order to gain insight into a disabled client’s functional ability? Answers: “When did the disability first begin?” “How has your disability affected your daily life?” “Why did you come to the clinic today?” “How do you feel about your disability?” Question 28 1.5 out of 1.5 points What is an example of objective data? Answers: A client receiving chemotherapy complains of nausea. A client states that they are feeling very anxious about their tests A client with an inner ear infection complains of dizziness The skin of a client who has liver failure has a yellowish tint. Question 29 1.5 out of 1.5 points The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the clients peripheral response to pain? Answers: Nail bed pressure Sternal rub Pressure on the orbital rim Squeezing of the sternocleidomastoid muscle Question 30 1.5 out of 1.5 points "When assessing a client s lungs, the nurse recalls that the left lung:" Answers: consists of two lobes is divided by the horizontal fissure. consists primarily of an upper lobe on the posterior chest. is shorter than the right lung because of the underlying stomach. Question 31 1.5 out of 1.5 points A client has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: Answers: peritonitis. diarrhea. laxative use. gastroenteritis. Question 32 1.5 out of 1.5 points What activity would the nurse perform first when assessing a client’s urinary elimination status? Answers: Obtain a nursing history Interpret results of diagnostic tests Perform a physical examination Goal setting with the client. Question 33 1.5 out of 1.5 points An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is his primary caregiver. The nurse should assess for signs of caregiver burnout. What is a sign of this burnout? Answers: Anxiety or depression Weight gain Hypertension Respiratory status Question 34 1.5 out of 1.5 points When assessing the range of motion of the client’s knee, the nurse expects the client to be able to perform which movement? Answers: Flexion and extension Circumduction and external rotation Adduction and rotation Flexion and supination Question 35 1.5 out of 1.5 points What is the correct term for when the client’s muscle is relaxed and the nurse moves a body part? Answers: Active ROM (range of motion) Myalgia Passive ROM (range of motion) Atrophy Question 36 1.5 out of 1.5 points The nurse is comparing the right and left legs of a client and notices that they are asymmetric in size. What additional data might the nurse collect at this time? Answers: Passively move each leg through range of motion and compare findings Observe the client’s gait and legs as they walk across the room Measure the circumference of each leg and compare the findings Palpating the joints and muscles of each leg and compare the findings Question 37 1.5 out of 1.5 points The sac that surrounds and protects the heart is called the: Answers: Pericardium Myocardium Endocardium Pleural space Question 38 1.5 out of 1.5 points What does thoracic expansion assess? Answers: Vibrations Voice sounds Breath sounds Chest movement Question 39 1.5 out of 1.5 points The nurse asks the client to puff out their cheeks and lift their eyebrows. Which cranial nerve is the nurse assessing? Answers: Optic nerve, cranial nerve II Facial nerve, cranial nerve VII Trigeminalnerve, cranial nerve V Abducens nerve, cranial nerve VI Question 40 1.5 out of 1.5 points What is the meaning of the term PERRLA? Answers: Pupils equal, round, reaction to light and accommodation Pupils equate to roundness and reactiveness always. Pupils equally react with roundness and light accommodation Pupils equal and reactive to light assessment Question 41 1.5 out of 1.5 points The nurse is explaining to a client that there are shock absorbers in his back to cushion the spine and to help it move. The nurse is referring to his: Answers: Intervertebral discs Costal Facets Nucleus Pulposus Vertebral foramen Question 42 1.5 out of 1.5 points The nurse auscultates a blowing, swooshing sound of an area of abnormal blood flow. Choose the best term. Answers: Dysphagia Macro cephalic Kinesthesia Bruit Question 43 1.5 out of 1.5 points The nurse has determined that the client’s bowel sounds are normal. What sounds did the nurse hear? Answers: Loud, high pitched, rushing, and tinkling sounds Like two pieces of leather being rubbed together Rare bubbly or blowing sound High pitched, irregular gurgling sounds Question 44 1.5 out of 1.5 points A client is seen in the clinic for a routine blood pressure assessment and states they have been experiencing the normal pain associated with aging. Which statement by the nurse is most therapeutic? Answers: “You must have osteoarthritis.” “Do you take medications for the discomforts you are experiencing?” “Normal aging can be quite painful.” “Tell me more about your pain and discomfort.” Question 45 1.5 out of 1.5 points A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: Answers: aphasia dysplasia dysphagia myophagia Question 46 1.5 out of 1.5 points A 4-year-old client is brought to the emergency department a parent. The parent states that the child points to their stomach and says “It hurts so bad”. Which pain assessment tool would be the best choice when assessing this child’s pain? Answers: Descriptor scale Numeric rating scale Brief pain inventory Faces pain scale Question 47 1.5 out of 1.5 points "The nurse notes that a client has had a black, tarry stool and recalls that a possible cause would be:" Answers: gastrointestinal bleeding gallbladder disease overuse of laxatives localized bleeding around the anus Question 48 1.5 out of 1.5 points Which of the following statements is true regarding the internal structures of the breast? Answers: "The breast is composed of fibrous, glandular, and adipose tissue." "The breast is mainly muscle, with very little fibrous tissue." "The breast is composed mostly of milk ducts, known as lactiferous ducts." The breast is composed of only glandular tissue. Question 49 1.5 out of 1.5 points Which term is used to denote the movement of a limb towards the body? Answers: Adduction Abduction Annulus Anthropometrics Question 50 1.5 out of 1.5 points The part of the cardiac cycle in which the ventricles are relaxed and filling with blood is called which of the following? Answers: Diastole Systole Hypotension Symptom Question 51 1.5 out of 1.5 points A 46-year-old man requires assessment of his sigmoid colon. Which of the following is most appropriate for this examination? Answers: Colonoscopy Proctoscope Ultrasound A rectal exam with an examining finger Question 52 1.5 out of 1.5 points "During a health history of a patient who complains of chronic constipation, she asks the nurse about high-fiber foods. The nurse relates that an example of a high-fiber food would be:" Answers: broccoli hamburger french fries white dinner roles Question 53 1.5 out of 1.5 points Which pulse site is typically used to obtain a pulse rate from a client? Answers: Radial Temporal Posterior tibial Femoral Question 54 1.5 out of 1.5 points Chose the best term for the sound will the nurse will hear at the left midclavicular, fifth intercostal space? Answers: Thrill Heave Apical Pulse Murmur Question 55 1.5 out of 1.5 points Which is an example of objective data a nurse would collect during a physical examination? Answers: The client s radial and pedal pulses The client s stated concern about lack of money for prescriptions The client s complaints of tingling sensations in the feet The client s mother s statements that the client has been very nervous lately Question 56 1.5 out of 1.5 points The client has continuous tonic spasm of a muscle. Choose the correct term Answers: Tetany Tremor Atrophy Myalgia Question 57 1.5 out of 1.5 points The client complains of a sense that the room is spinning around. Choose the best term. Answers: Disequilibrium Vertigo Presyncope Fixation Question 58 1.5 out of 1.5 points In which situation should the nurse screen for intimate partner violence (IPV)? Answers: When IPV is suspected When a woman has an unexplained injury As a routine part of each health care encounter When a history of abuse in the family is known Question 59 1.5 out of 1.5 points What would the nurse expect to note when assessing a lesion diagnosed as malignant melanoma? Answers: An asymmetric black lesion A small papule with a dry, rough scale A firm nodular lesion topped with crust. A pearly papule with a central crater and a waxy border. Question 60 1.5 out of 1.5 points The nurse knows that the incidence of osteoporosis is greatest in which group? Answers: White women Black Men Black Women American Indian men Question 61 1.5 out of 1.5 points What is a term for a nutritional abnormality represented by recurrent binge and purge eating cycle? Answers: Bulimia Anorexia Binge eating Nervosa eating Question 62 1.5 out of 1.5 points A patient states, “Whenever I open my mouth real wide, I feel this popping sensation in front of my ears.” How would the nurse further examine this complaint? Answers: Place the stethoscope over the temporomandibular joint, and listen for bruits. Place the hands over the client’s ears, and ask the client to open their mouth “really wide. ” Place one hand on the client’s forehead and the other on their jaw, and ask the client to try to open their mouth. Place a finger over each of the client’s temporomandibular joints, and ask the client to open and close their mouth. Question 63 1.5 out of 1.5 points A client has a normal pupillary light reflex. The nurse recognizes that this indicates that: Answers: constriction of both pupils occurs in response to bright light the eyes converge to focus on the light light is reflected at the same spot in both eyes they focuses the image in the center of the pupil. Question 64 0 out of 1.5 points Which assessments would be appropriate for evaluating cerebellar function? (Select all that apply) Answers: Heel to shin test Finger to nose test Rapid alternating fingers Weber test Stereognosis Question 65 1.5 out of 1.5 points A patient has been diagnosed with venous stasis. Which of the following would the nurse most likely observe? Answers: A brownish discoloration to the skin of the lower leg A unilateral cool foot "Thin, shiny, atrophic skin" Pallor of the toes and cyanosis of the nailbeds Question 66 1,5 out of 1.5 points "When the nurse asks a 68-year-old client to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet further apart. The nurse would document this finding as a:" Answers: Positive Romberg's sign Lack of time and space. Pataxia Negative Homan's sign Question 67 1.5 out of 1.5 points A client tells the nurse, “I have to sleep propped up with 3 pillows so I can breathe at night.” How would the nurse document this? Answers: Orthopnea. Acute Emphysema. Paroxysmal Nocturnal Dyspnea. Acute Shortness of Breath Episode. Question 68 1.5 out of 1.5 points "During an annual physical exam, a 43-year-old client states that she doesn t perform monthly breast self-examinations. She tells the nurse that she believes that mammograms do a much better job than I ever could to find a lump. The nurse should explain to her that:" Answers: mammography may not detect all palpable lumps. breast self-examination is unnecessary until the age of 50 years. "she is correct, mammography is a good replacement for breast self-examination." she doesn t need to perform breast self-examination as long as a physician checks her breasts yearly. Question 69 1.5 out of 1.5 points The nurse is performing an assessment on a preschool aged client. Which method will aid in the ability to gather needed data? Answers: Allow the child to touch or try equipment before the exam Explain all the abnormalities you might find Ask the mother to leave the room Tell the child they must cooperate Question 70 1.5 out of 1.5 points On auscultating lung sounds in the adult client, the nurse documents which finding as normal? Answers: Bronchial sounds heard over the trachea and larynx Bronchovesicular sounds heard over the majority of the lung fields posteriorly Vesicular sounds near the sternal border bilaterally Tracheal sounds over the periphery of the lung fields Question 71 1.5 out of 1.5 points A nurse is inspecting the ear canal of an adult client. Which is the best method to move the pinna in order to straighten the ear canal to better visualize the area? Answers: There is no need to move the pinna Gently pull the pinna up and back Gently pull the pinna down and back Pull the pinna horizontal to the side of the head Question 72 1.5 out of 1.5 points What area would the nurse listen to if wishing to listen to the tricuspid valve area? Answers: Area 1 Area 2 Area 3 Area 4 Area 5 Question 73 1.5 out of 1.5 points The nurse noted a protrusion of the sternum and adjacent costal cartilage. Choose the correct term. Answers: Pectus carinatum Barrel Chest Pectus excavatum Kyphosis Question 74 1.5 out of 1.5 points A client’s respirations are 8. How could these respirations be documented? Answers: Apneic Eupneic Tachypneic Bradypneic Question 75 1.5 out of 1.5 points The nurses assesses the posterior tibial pulse by lightly palpating in which location? Answers: Behind the knee in the popliteal fossa The inner aspect of the ankle below and slightly behind the medial malleolus Over the dorsum of the foot between the extensor tendon of the 1st and 2nd toe The outer aspect of the ankle below and slightly behind the lateral malleolus Question 76 1.5 out of 1.5 points What risk factors for osteoporosis? Answers: Smoking Steroid use Heavy bone structure Being Caucasian Male gender Question 77 1.5 out of 1.5 points The nurse is assessing an adult who has a pulse rate of 180 beats/minute. Which condition would the nurse document? Answers: Tachycardia Pulse amplitude Bradycardia Arrythmia Question 78 1.5 out of 1.5 points A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: Answers: Lordosis Scoliosis Ankylosis Kyphosis Question 79 1.5 out of 1.5 points The nurse is aware that a change that may occur in the gastrointestinal system of an aging adult is: Answers: decreased gastric acid secretion increased salivation megacolon increased esophageal emptying Question 80 1.5 out of 1.5 points What is the purpose of the side to side pattern used during respiratory assessment? Answers: Prevent fatiguing the client Tightly organize the assessment Allow comparison of like areas of the lungs Conserve time Question 81 1.5 out of 1.5 points "A nurse notes that a client has ascites, which indicates that which of the following is present?" Answers: Fluid Feces Flatus Fibroid tumors Question 82 1.5 out of 1.5 points What should the nurse do when there is difficulty eliciting a patellar reflex? Answers: Strike the knee harder Have the client use the reflex hammer on themselves Have the client lock their fingers together and try to pull them apart Keep trying to use the hammer in slightly different areas of the knee Question 83 1.5 out of 1.5 points The nurse documents that a client’s accommodation is normal when which situation occurs? Answers: The client has peripheral vision of 90 degrees The client’s eyes move up and down, side to side, and obliquely The right pupil constricts when a light is shown in the left eye The client’s pupils constrict when looking at a close object Question 84 1.5 out of 1.5 points "In assessing a patient s major risk factors for heart disease, which would the nurse want to include when taking a history?" Answers: "Smoking, hypertension, obesity, diabetes, high cholesterol" "Work history, hypertension, stress, age" "Personality type, high cholesterol, diabetes, intense exercise" "Sugar consumption, anorexia, diabetes, stress, high cholesterol" Question 85 1.5 out of 1.5 points The nurse is performing an abdominal assessment and inspects the skin on the abdomen. The nurse performs which assessment technique next? Answers: Palpates the abdomen for size Palpates the liver at the right rib margin Listens to bowel sounds in all four quadrants Percusses the right lower abdominal quadrant Question 86 1.5 out of 1.5 points A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would the nurse be concerned about with these findings? Answers: Cerebellum Thalamus Brainstem Extrapyramidal tract Question 87 1.5 out of 1.5 points What is the part of the cardiac cycle in which the ventricles are contracting and pushing blood out of the chambers? Answers: Systole Diastole Hypotension Symptom Question 88 1.5 out of 1.5 points During an interview, the client answers questions quietly and appears sad. While answering questions about her marriage, she begins to cry. Which is the nurse’s appropriate response? Answers: “Don’t cry. I’ll come back when you’ve settled down.” “I only have a few more questions to go, then I’ll leave you alone for a while. ” “Everyone has ups and downs in their marriage. What problems are you having?” “I see that you are upset. Is there something you’d like to discuss? Question 89 1.5 out of 1.5 points "During report, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to a/an:" Answers: enlarged liver. enlarged stomach distended bowels excessive diarrhea Question 90 1.5 out of 1.5 points On performing a spinal assessment on your client, it is noted that the left shoulder is higher than the right and the right hip is higher than the left. What might this be related to? Answers: Kyphosis Lordosis Scoliosis Spondylosis Question 91 1.5 out of 1.5 points A client being assessed has been diagnosed with pneumonia. The nurse assesses for abnormal voice sounds and can clearly hear an “a” sound over the left lower lobe of the lung when the client says “e, e, e”. This is an example of an abnormal finding for which test? Answers: Whispered pectoriloquy Egophony Bronchophony Stridor Question 92 1.5 out of 1.5 points The nurse is performing the Romberg test. The nurse notes the findings are abnormal. Which client response occurred in this situation? Answers: Client had minimal swaying Client demonstrates lack of arm swing Client moved his feet apart to steady himself Client opened their eyes Question 93 1.5 out of 1.5 points What is a common change seen in geriatric clients? Answers: Heart beat usually slows with age. Skin thickens due to long term exposure to environment Blood pressure increases due to decreased vessel elasticity Depression Question 94 1.5 out of 1.5 points How will the nurse accurately palpate the carotid pulse? Answers: Place two fingers of each hand firmly over the right and left temple at the same time Place the fingers gently in the space between the triceps and biceps muscles, first one then the other Palpate in the groove between the trachea and the right and left sternocleidomastoid muscles one at a time Palpate firmly with two fingers in the inguinal area between the navel and the symphysis pubis Question 95 1.5 out of 1.5 points "To assess the dorsalis pedis artery, the nurse would palpate:" Answers: lateral to the extensor tendon of the great toe. behind the knee. over the lateral malleolus. in the groove behind the medial malleolus. Question 96 1.5 out of 1.5 points The nurse asks the client to bend the ankle so the toes aim towards the nose. The nurse is assessing the client’s ability to perform what action? Answers: Inversion Dorsiflexion Plantar flexion Eversion Question 97 1.5 out of 1.5 points A nurse is conducting health screening for osteoporosis. Which of the following clients is at greatest risk for developing this disorder? Answers: A sedentary 65 year old woman who smokes cigarettes. A 25 year old woman who jogs a 36 year old man who has asthma A 70 year old man who consumes excess alcohol Question 98 1.5 out of 1.5 points "During an assessment, the nurse notes that a patient s left arm is swollen from the shoulder down to the fingers, with nonpitting edema. The right arm is normal. The patient had a mastectomy 1 year ago. The nurse suspects which problem?" Answers: Lymphedema Venous stasis Arteriosclerosis Deep vein thrombosis Question 99 1.5 out of 1.5 points What would be the best approach for the nurse to use when performing a functional assessment of an older client? Answers: Observe the client’s ability to perform the tasks Ask the client’s wife how they do when performing tasks Review the medical record for information of the client’s abilities Ask the client’s physician for information on the client’s abilities Question 100 0 out of 1.5 points A nurse is interviewing a client who was diagnosed with type 2 diabetes mellitus 6 months ago however the client has gained more weight and the blood glucose levels remain high. The nurse suspects that the client is non-compliant with their diet. Which response by the nurse would enhance data collection in this situation? Answers: “Tell me, how have you managed with your diet for these past few months?” “You do want to learn how to reduce your blood sugar levels, don’t you? “You need to follow what the doctor has prescribed for you in order to get better.” “Don’t you know anything about diabetes?” [Show Less]
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