A nurse manager has a staff nurse who observes certain religious holidays. The manager tries to make
sure that these observances can be met if possible.
... [Show More] Which value is the manager practicing?
1. Human dignity
2. Social justice
3. Autonomy
4. Altruism
Question 2
Parents of a terminally ill child have decided to remove their child from life support, a decision that has
met with little positive support. Which nursing action demonstrates autonomy regarding the parents’
decision?
1. Showing respect for the family
2. Respecting the parents’ decision
3. Referring the parents to social services
4. Asking to be assigned to a different client
Question 3
A client has chosen to discontinue hemodialysis. His family is not supportive of his decision. Which
statement should the nurse make that demonstrates the theory of principles-based reasoning?
1. “This client is of sound mind and is capable of making his own decisions regarding health care. It
really is his decision to make.”
2. “I need to try and help the family understand the client’s decision so they can work through this
situation together.”
3. “This client’s health is so deteriorated that the treatment is not saving his life. It is prolonging the
ultimate outcome, which is his death.”
4. “The client understands his decision and the advanced stage of his disease. If he quits treatment, he will
die.”
Question 4
A decision has been made for an older client to receive aggressive cancer therapy despite knowing
that the therapy will actually be more harmful than the disease and subject the client to harmful
chemicals. With which ethical principle is this nurse caring for this client struggling?
1. Autonomy
2. Justice
3. Beneficence
4. Nonmaleficence
Question 5
When completing a community assessment, the community health nurse will take several aspects into
account. What is the first stage of this assessment that the nurse will complete?
1. Learn about the people in the community.
2. Understand the major illnesses present in the community.
3. Identify the boundaries of the community.
4. Make sure resources are available in the community.
Question 6
A public health nurse is working with a group of home health nurses in an isolated, mountainous region
where access to smaller communities and individuals is quite difficult, especially in the winter and early
spring—seasons when the health needs of these individuals are quite high. The public health nurse has set
up video conferencing and video clinics for these home health nurses regarding various client teaching
and health promotion activities. What activity did the public health nurse conduct?
1. Community-based nursing
2. Parish nursing
3. Telenursing
4. Collaborative health care
Question 7
The nurse is providing care to a group of clients. For which situation would the nurse’s use of critical
thinking be a priority?
1. Administering IV push meds to critically ill clients
2. Educating a home health client about treatment options
3. Teaching new parents car seat safety
4. Assisting an orthopedic client with the proper use of crutches
Question 8
A client is experiencing a productive cough, audible coarse crackles, elevated temperature of 102.3°F,
chills, and body aches. What did the nurse use to determine that this patient is experiencing respiratory
compromise?
1. Deductive reasoning
2. Inductive reasoning
3. Socratic questioning
4. Critical analysis
Question 9
The nurse who just moved from an urban area to a sparsely populated rural area understands that certain
customs and practices the nurse follows may be quite foreign to the people in the new area. Which
attitude of critical thinking is the nurse demonstrating?
1. Fair-mindedness
2. Insight into egocentricity
3. Intellectual humility
4. Intellectual courage to challenge the status quo and rituals
Question 10
The nurse implements a quicker way to set up and initiate an intravenous infusion while still following
safe practice. Which attitude of critical thinking is this nurse practicing?
1. Independence
2. Intellectual courage to challenge the status quo or rituals
3. Integrity
4. Confidence
Question 11
The student is learning the steps of the nursing process. What is the first thing that the student should
realize about the purpose of this process?
1. Deliver care to a client in an organized way.
2. Implement a plan that is close to the medical model.
3. Identify client needs and deliver care to meet those needs.
4. Make sure that standardized care is available to clients.
Question 12
The nurse provides a back rub to a client after administering a pain medication with the hope that these
two actions will help decrease the client’s pain. Which phase of the nursing process is this nurse
implementing?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Question 13
The nurse is admitting an infant to the care area. The parents and grandmother are present. What should
the nurse use as the best source of data for this client?
1. Medical record from the child’s birth
2. Grandmother
3. Parents
4. Admitting physician
Question 14
The nurse documents: “Client avoids eye contact and gives only vague, nonspecific answers to direct
questioning by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures) in
conversation with spouse.” Which method of data collection does this documentation demonstrate?
1. Examining
2. Interviewing
3. Listening
4. Observing
Question 15
A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write
appropriately?
1. Client will ambulate without a walker by 6 weeks.
2. Client will ambulate freely in house.
3. Client will not fall.
4. Client will have freer movement in daily activities.
Question 16
The nurse is reviewing interventions written for a client’s plan of care. Which intervention should the
nurse recognize as being dependent?
1. Repositioning the client every 2 hours
2. Assisting the client with transfers to the bathroom
3. Providing ongoing physical assessment, especially of the incisional sites
4. Administering medications for pain
Question 17
The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client
who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a
rationale?
1. Have suction equipment available at all times.
2. Clear secretions from oral/nasal passageways as needed.
3. Keep client in low-Fowler’s position to prevent reflux.
4. Provide frequent assessment for presence of obstructive material in mouth and throat.
Question 18
A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart
with him, as it’s his record. How should the nurse respond to this client’s request?
1. “You’ll have to ask your doctor for permission to do that.”
2. “Actually, the original record is the property of the hospital, but you are welcome to copies of your
records.”
3. “We’ll make sure that all of your records are sent ahead to the rehab hospital, so you don’t really have
to worry about those details.”
4. “There’s a new law that protects your records, so you’re not going to be able to have access to them.”
Question 19
After classroom discussion regarding confidentiality policies and laws protecting client records, a student
asks why it’s permissible for them to review and have access to client records in the clinical area. How
should the nursing instructor respond?
1. “Confidentiality and privacy laws don’t apply to students.”
2. “Most students review so many records and charts that they could not possibly remember details from
any one of them.”
3. “Records are used in educational settings and for learning purposes, but the student is bound to hold all
information in strict confidence.”
4. “As long as the clinical instructor is in the area, accessing client records is part of the education
process.”
Question 20
The client states: “I really don’t want anyone to visit me who has not been cleared by me first.” If
utilizing SOAP format, in which category should the nurse document this statement?
1. Subjective data
2. Objective data
3. Assessment
4. Planning
Question 21
A client did not meet the goal of walking unassisted, without assistive devices, by discharge from
rehabilitation. The case manager using a critical pathway should identify this outcome as being which of
the following?
1. An unattainable goal
2. A variance
3. An error in care planning
4. An error in intervention implementation
Question 22
When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the
legs. Which chart entry should the nurse document for this finding?
1. Client fell out of bed, but did push the call button for assistance.
2. Client became tangled in the bed linens, then called for assistance after falling out of bed.
3. Recorder responded to client’s call light, upon entering the room, found client on floor.
4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.
Question 23
A nurse is working in a rehabilitation center with a client who had a serious injury. Part of the client’s care
plan includes working on coping with her current limitations since the injury. This nurse is working
within which model of health?
1. Role performance
2. Adaptive
3. Eudemonistic
4. Clinical
Question 24
During a home visit with a new community member, the nurse suspects that a client has a chronic illness.
What did the nurse assess to make this clinical decision? Select all that apply.
1. Experienced symptoms for 8 months
2. Has periods where the symptoms disappear
3. Altered activities of daily living because of the illness
4. Problem disappeared with over-the-counter medication
5. Symptoms appeared abruptly and disappeared after treatment
Question 25
A community health nurse is learning about the REACH initiative and has decided to implement
community education on this approach. What topics should the nurse include in this
education? Select all that apply.
1. Child and adult immunizations
2. Cardiovascular disease
3. Chronic lower respiratory disease
4. Stroke
5. Infant mortality
Question 26
A client is the child of an African American father and Asian American mother. The client has been
exposed to cultural foods, traditions, and customs from both parents throughout life. What term should
the nurse use to describe this client’s cultural development?
1. Diversity
2. Subculture
3. Multicultural
4. Cultural sensitivity
Question 27
A client has requested that she have a special item present in her room and explains that it gives her a
feeling of comfort and a sense of organization. On which psychosocial component is this client focusing?
1. Culture
2. Religion
3. Ethnicity
4. Socialization
Question 28
A client makes the following statement: “I must be paying for all the wrongs I did in my life, to have such
a diagnosis as this.” The nurse suspects that this client views health from which type of belief?
1. Magico-religious belief
2. Holistic health belief
3. Biomedical health belief
4. Folk medicine
Question 29
The school nurse is conducting head lice screenings. Before checking the head of an Asian child, the
nurse should first take which action?
1. Ask permission.
2. Make sure the child understands the reason for the contact.
3. Put gloves on.
4. Ask the child to wait until last, to avoid embarrassing the child.
Question 30
The nurse is teaching a client from a culture that is “present oriented” about a dressing change that should
be performed twice a day. How should the nurse address the cultural issue?
1. Allow the client to select the times the dressing will be changed.
2. Instruct the client to change the dressing after breakfast and before going to bed.
3. Explain that the client should complete the dressing change at 10 AM and 4 PM.
4. Suggest that the dressing change can be performed whenever the client chooses, as long as it gets done
twice daily.
Question 31
The nurse is planning care for an older adult client. On what should the nurse focus if following
the Functional Consequences Theory on aging?
Standard Text: Select all that apply.
1. Promote safety.
2. Promote mental health.
3. Improve quality of life.
4. Promote spiritual health.
5. Promote growth and development.
Question 32
A group of elderly women come to the community center for exercise classes taught by the community
health nurse. This activity will help lead to which outcome for these clients?
1. Reverse the effects of aging and cure pain.
2. Slow bone density loss and decrease muscle atrophy.
3. Eliminate the risk for osteoporosis.
4. Prevent pathologic fractures.
Question 33
A nurse explains to a client that he will need to have a bowel prep before going to his
esophagogastroscopy. On what should the nurse focus to improve communication skills?
1. Pace
2. Intonation
3. Simplicity
4. Clarity
Question 34
The nurse enters a client’s room and finds that the telephone is lying in the client’s lap, tissues are wadded
up on the bed, and the client’s eyes are red and watery. What is the best response by the nurse?
1. “Can I hang that phone up for you?”
2. “Well, it’s a beautiful day outside. Let’s open the blinds.”
3. “Has your doctor been in to talk to you yet?”
4. “You look upset. Is there anything you’d like to talk about?”
Question 35
A nurse is working in a pediatric clinic and has to explain a nebulizer treatment to a child.
Which approach should the nurse use?
1. Give the child’s parent a full explanation, but make sure the child hears what is said.
2. Let the child handle the equipment first, then demonstrate on the child’s doll.
3. Start the treatment, but make sure that the parent is there to comfort the child if she becomes afraid.
4. Make sure that the physician is available for questions.
Question 36
A nurse enters a client’s room and asks about his level of pain. The client, grimacing, says “It’s fine.”
Which communication factor is the client struggling with?
1. Territoriality
2. Environment
3. Congruence
4. Attitude
Question 37
The nurse is conducting an admission interview. Which response indicates that the nurse is attentively
listening to the client’s explanations?
1. “Can you explain what your symptoms are like?”
2. “When was the last time you saw a doctor for this?”
3. “Uh-huh,” while nodding the head
4. “I’m sorry, say that again?”
Question 38
The nurse is identifying communication strategies for a client unable to speak. What would be appropriate
for the client in this situation?
1. Using a picture board to facilitate communication
2. Facing the client when speaking
3. Employing an interpreter
4. Making sure that the language spoken is the client’s dominant language
Question 39
The nurse wants to gain information about a client’s situation. Which question should the nurse use to
maximize communication with this patient?
1. “What brings you to the hospital?”
2. “Are you having pain?”
3. “Does your pain feel better or worse today?”
4. “Is there anything I can do for you?”
Question 40
The nurse is preparing to perform a health assessment of the abdomen. In which order should the nurse
perform the assessment?
1. Auscultate, percuss, palpate, inspect
2. Inspect, auscultate, palpate, percuss
3. Inspect, auscultate, percuss, palpate
4. Palpate, percuss, auscultate, inspect
Question 41
The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse
should document this as being
1. cyanosis.
2. jaundice.
3. pallor.
4. erythema.
Question 42
While performing an assessment of the integument system, the nurse notes the client’s eyeballs are
protruding and the upper eyelids are elevated. What term should the nurse use to document this finding?
1. Erythema
2. Cyanosis
3. Exophthalmos
4. Normocephalic
Question 43
The nurse is performing a lung assessment on a client with suspected pneumonia. Which finding should
the nurse report to the physician immediately?
1. Chest symmetrical
2. Breath sounds equal bilaterally
3. Asymmetrical chest expansion
4. Bilateral symmetric vocal fremitus
Question 44
The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to
comprehend what is being said to him; however, he is unable to respond by speech or writing. What type
of aphasia should the nurse realize this patient is demonstrating?
1. Auditory aphasia
2. Acoustic aphasia
3. Sensory aphasia
4. Expressive aphasia
Question 45
The nurse is preparing the morning assignments. Which assessment could the nurse delegate to
unlicensed assistive personnel?
1. Neurological assessment
2. Musculoskeletal assessment
3. Vital signs assessment
4. Female genital assessment
Question 46
The nurse is preparing to administer a cardiotonic drug to a client. Which assessment should the nurse
perform before administering the medication?
1. Respiratory rate
2. Apical pulse
3. Popliteal pulse
4. Capillary blanch test
Question 47
The nurse is preparing to assess a client with the Glasgow Coma Scale. Which areas is the nurse assessing
in this patient? Select all that apply.
1. Eye response
2. Motor response
3. Verbal response
4. Orientation
5. Musculoskeletal response
Question 48
The nurse is concerned that an older client has nutritional deficiencies. What did the nurse find when
assessing this client’s nails to make this clinical decision? Select all that apply.
1. White spots
2. Curved nails
3. Deep purple areas
4. Spoon-shaped nails
5. Bands across the nails
Question 49
The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis?
1. Disinfecting an item before adding it to a sterile field
2. Allowing sterile gloved hands to fall below the waist
3. Suctioning the oral cavity of an unconscious client
4. Touching only the inside surface of the first glove while pulling it onto the hand
Question 50
A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client?
1. Edema, rubor, heat, and pain
2. Fever, malaise, anorexia, nausea, and vomiting
3. Palpitations, irritability, and heat intolerance
4. Tingling, numbness, and cramping of the extremities
Question 51
The nurse is reviewing collected data from a client. Which information should the nurse identify as a
physiological barrier to defend the client’s body from microorganisms?
1. Heavy smoking
2. Moisturizing the skin
3. Breakdown of skin
4. Voiding quantity sufficient
Question 52
The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper
hand-washing technique with this client?
1. Allow the water to splatter forcibly when it is turned on.
2. Clean the faucet after use.
3. Hold the hands upward under the faucet.
4. Use approximately a teaspoon of soap.
Question 53
A client needs to be placed in contact isolation. What items should the nurse ensure are included in this
client’s room?
1. Cabinet stocked with gloves and gowns
2. Cards and records
3. Paper towels, sink, and blood pressure cuff
4. Sign on the door
Question 54
A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the
transmission of the disease?
1. Have the client wear a mask when coming from admission.
2. Stock the supply cart at the beginning of each shift.
3. Wash the hands only after leaving the room.
4. Wear a mask when exiting the room.
Question 55
A client diagnosed with an infectious disease asks the nurse how the infection “got inside” her body.
Which responses would be appropriate for the nurse to make? Select all that apply.
1. “It depends on the number of organisms present to cause a disease.”
2. “It depends on how aggressive the organisms are to cause a disease.”
3. “It depends upon how the organisms get inside the body to cause a disease.”
4. “It depends upon where the person is at the time the disease is present.”
5. “It depends upon where the person works.”
Question 56
A client tells the nurse that the newly diagnosed communicable disease is negatively impacting
employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority
for this client?
1. Anxiety
2. Acute Pain
3. Social Isolation
4. Low Self-Esteem
Question 57
While irrigating a client’s abdominal wound, the irrigate splashes into the nurse’s nose and eyes. What
should the nurse do?
1. Flush the nose and eyes for 5 to 10 minutes with water or normal saline.
2. Begin HIV high-risk exposure prophylaxis within 24 hours.
3. Wash the areas with soap and water.
4. Have blood drawn for hepatitis B antibodies.
Question 58
The nurse documents in a client’s medical record: “The client is a drug addict and is always asking for
more medication than what is necessary.” With what might the nurse be charged?
1. Defamation
2. Slander
3. Libel
4. Incompetence
Question 59
The nurse is reviewing the Good Samaritan acts. For which situation should the nurse realize
that these laws apply?
1. Giving CPR to a client brought to the emergency department, when the client later is found to have a
“Do Not Resuscitate” order
2. Giving first aid to a child injured in a sporting event
3. Permitting a nursing student to try to insert an airway in an unconscious client
4. Leaving the scene of an emergency to call for help
5. Helping deliver the baby of a neighbor during a snowstorm
Question 60
The nurse needs to apply personal protective equipment before entering a client’s room. In which order
should the nurse perform the following actions?
5. Perform hand hygiene
3. Apply the gown.
4. Apply the face mask.
2. Apply eyewear.
1. Apply gloves.
Question 61
The nurse is preparing to provide morning care to a client. What should the nurse explain to the client as
the reason for a daily bath?
1. Assess skin integrity
2. Develop a nurse–client relationship
3. Moisturize the skin
4. Stimulate circulation
Question 62
The nurse is reviewing assigned clients for morning care needs. Which situation could pose a threat to one
client’s personal hygiene?
1. A client has a newly formed ileostomy.
2. A client performs meticulous foot care.
3. A German client refuses to bathe everyday.
4. The room temperature is set at 72°F.
Question 63
A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing
intervention should be identified for this client’s problem?
1. Encourage the client to eat at least 40% of meals.
2. Keep linens dry and wrinkle-free.
3. Restrict fluid intake.
4. Turn client every 3 hours.
Question 64
A client tells the nurse that bathing is done at the sink in the bathroom at home because it is difficult to
physically lift the legs to get into the shower. The nurse identifies which factor as influencing this client’s
hygienic practice?
1. Religion
2. Personal preference
3. Culture
4. Health and energy
Question 65
During the morning bath of a client, the nurse identifies areas of erythema below the client’s breasts.
What should the nurse do to enhance comfort and healing for the client?
1. Wash the skin carefully.
2. Apply alcohol-free lotion.
3. Wash the area without soap.
4. Remove hair in the area.
Question 66
The nurse is preparing to administer a medication that the agency designates as “high alert.” What action
should the nurse take?
1. Ask another registered nurse to verify the medication.
2. Call the pharmacist to check the efficacy of the medication.
3. Decline to administer the medication unless there is a physician present.
4. Request that the nursing supervisor administer the medication.
Question 67
The hospitalized client has an order for Tylenol 325 mg 2 tablets every 4 hours prn temperature over
101°F. The client complains of a headache. Can the nurse legally administer Tylenol to treat the
headache?
1. Yes, as Tylenol is used both for fever and headache.
2. No, not unless the client also has a temperature over 101°F.
3. Yes, but the nurse should document the reason why the medication was administered as a temperature
elevation.
4. Yes, because the medication is available over the counter, an order is not required.
Question 68
During the process of administering medications, the nurse checks the name band for the client’s name.
What should be this nurse’s next action?
1. Administer the medication as ordered.
2. Initial the MAR that the medication will be given.
3. Double check the client’s identification using a second method.
4. Educate the client regarding the medication to be given.
Question 69
The nurse is caring for a team of four clients who are seriously ill. One of the clients has just received a
new cardiac medication. How should the nurse instruct the unlicensed assistive personnel (UAP) who is
also caring for this client?
1. Have the UAP assess for any unexpected effects from the medication.
2. Tell the UAP to teach the client’s family what to expect from the medication.
3. Have the UAP look the medication up in a drug reference book to read about drug actions and possible
side effects.
4. Give the UAP specific instructions regarding what drug actions or side effects to report to the nurse.
Question 70
During administration of an intradermal injection, the nurse notices that the outline of the needle bevel is
visible under the client’s skin. How should the nurse proceed?
1. Recognize that this is an expected finding in a properly administered intradermal injection.
2. Withdraw the needle, prepare a new injection, and start again.
3. Insert the needle further into the skin at a deeper angle.
4. Turn the needle so that the bevel is down and inject the medication slowly, looking for development of
a bleb.
Question 71
A client diagnosed with diabetes asks the nurse about reusing insulin syringes. Assessment reveals that
the client has poor personal hygiene and difficulty with fine motor skills. The nurse also knows the client
has financial difficulties. What instruction should the nurse give this client?
1. “The American Diabetes Association advises that syringes are for single use only.”
2. “In order to save money, I advise you to reuse syringes up to three times or until the needle feels dull.”
3. “Only people who practice good personal hygiene can reuse syringes.”
4. “All clients are different, but I advise you to use a new syringe for each injection.”
Question 72
The nurse is providing discharge teaching for a client who is being dismissed with prescriptions for a
bronchodilator inhaler and a corticosteroid inhaler. What information should the nurse provide regarding
the dosage schedule for these two medications?
1. Always use the corticosteroid inhaler first.
2. Use the bronchodilator first.
3. It makes no difference which inhaler is used first.
4. Use the inhalers on alternate days, not on the same day.
Question 73
A client is prescribed an oral medication. When reviewing this medication, the nurse realizes it might not
be the route of choice for this client because the client is experiencing? Select all that apply.
1. nausea.
2. anxiety.
3. vomiting.
4. pain from cuts and abrasions.
5. irritated gastric mucosa.
Question 74
A client has a new order for a medication that does not have a termination date. The nurse would place
this medication order under which classification on the client’s medication administration record?
1. Standing
2. PRN
3. STAT
4. Single
Question 75
A client is brought to the emergency department after being involved in a motor vehicle crash. Although
the client is conscious, her condition is critical and will require emergency surgery. The client does not
speak English. Which action should the nurse take?
1. Read the consent form and have the client sign it anyway.
2. Explain the form to the best of the nurse’s ability using pictures and gestures.
3. Have the hospital interpreter explain the procedure.
4. Proceed with surgery, as implied consent would be the case in this situation.
Question 76
A nurse is caring for a client in the emergency department (ED) who was brought in by her adult child for
vague, flu-like symptoms. While helping the client to change into a gown, the nurse notices numerous
bruises on the client’s back and arms. When questioned, the client
is distracted and ambiguous with her answers. Which action should the nurse take?
1. Report the situation to law enforcement.
2. Report the situation to social services.
3. Question the adult child who brought the client to the ED.
4. File a written report in the client’s chart.
Question 77
A client scheduled for surgery has signed the consent form but refuses to have a Foley catheter placed,
saying “That’s not part of the surgery.” What should the nurse do?
1. Explain that this is part of the surgical prep and continue with the procedure.
2. Explain that the client has already signed the consent, and place the catheter.
3. Respect the client’s wishes and document accordingly.
4. Offer to call the physician.
Question 78
While hospitalized, a client was receiving 15 ml of an oral medication three times a day. When providing
discharge instructions, the nurse should teach the client to take how much of this medication at home?
1. 2 teaspoons
2. 1 teaspoon
3. 2 tablespoons
4. 1 tablespoon
Question 79
The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds.
Which operative wound would be excluded from this study?
1. Gastric resection
2. Uncomplicated abdominal hysterectomy
3. Breast biopsy
4. Lung resection
Question 80
The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage
into the abdominal cavity during the client’s bowel resection. For which category of wound should the
receiving nurse plan care for this client?
1. Clean-contaminated
2. Contaminated
3. Dirty
4. Infected
Question 81
The nurse assesses an open area over a client’s greater trochanter that is approximately 10 cm in diameter.
The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the
center. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?
1. There is undermining of adjacent tissues.
2. The crater extends into the subcutaneous tissue.
3. The joint capsule of the hip is visible.
4. The ulcer has thick dark eschar over the top.
Question 82
The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to
assess all new admissions. Before using this scale the nurse
1. should receive specific training.
2. must be certified.
3. is required to ask the client’s permission.
4. has to obtain special assessment equipment.
Question 83
A client is prescribed steroid medication. When preparing discharge instructions, the nurse should include
information about infection control because steroids cause
1. decreased oxygen supply to tissues.
2. suppression of the inflammatory process necessary for healing.
3. a decrease in the amount of nutrients such as glucose in the blood.
4. blood vessel constriction, which impairs waste product removal.
Question 84
On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that
“something popped” in the abdominal incision. Upon inspection, the nurse finds that evisceration has
occurred. What nursing action should be taken first?
1. Notify the client’s surgeon.
2. Cover the area with a large saline-soaked dressing.
3. Position the client in bed with knees bent.
4. Pack the wound with nonadherent gauze.
Question 85
The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis
problem statement is most appropriate for use with this client?
1. Altered Tissue Perfusion
2. Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Injury
Question 86
Upon assessing a pressure ulcer, the nurse notes the presence of red, yellow, and black tissue. Using the
RYB color code, which wound care should the nurse plan?
1. Red
2. Yellow
3. Black
4. A combination of all three
Question 87
The nurse documents that a client’s postoperative wound is purosanguinous. What did the nurse assess in
this client’s wound?
1. Water and red blood cells
2. Pus and red blood cells
3. Watery drainage
4. Pus
Question 88
The nurse assesses that a client is experiencing spiritual distress. What should be the nurse’s primary
intervention?
1. Establish a trusting nurse–client relationship.
2. Have the client describe the basic problem.
3. Ask the client what religion is practiced in the home.
4. Identify the client’s belief in a Supreme Being [Show Less]