SOLVED1

101. After signing an informed consent form, a client tells the nurse, “T have changed my mind and do not want to have the procedure.” Which of the following actions should the nurse take? a. Remind the client that a signed informed consent form is a legally binding document. b. Notify the surgeon that the client wishes to withdraw informed consent for the procedure. c. Tell the client to discuss the matter with her family. d. Proceed with preparation of the client for the surgical procedure. 102. A nurse is caring for a client and using active listening skills. Which of the following actions should the nurse take? a. Sit side-by-side with the client. b. Have a pen and paper. c. Use intermittent eye contact. d. Lean back in the chair. 103. A nurse is orienting a new assistive personnel (AP) to the unit. Which of the following actions should the nurse identify as an indication that the AP needs further instruction? A.Wears a gown when entering the room of a client who requires contact precautions b. Dons gloves to empty a urinary drainage device c. Washes and rinses her hands for 10 seconds Ä‘.Wears a respirator mask when entering the room of a client who requires airborne precautions 104. A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions should the nurse take to help the client cope with his feelings of loss? a. Let the client know that this is a common problem of the aging population. b. Provide the client with the activities to perform so he wont have time to dwell on the past. C. Listen attentively when the client talks about the past. D. Tell the client about some of the younger clients in the hospital who have experienced loss. 105. A nurse is reinforcing dietary teaching with the client who is Asian-American and looks at the floor during the instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity? a. Check to see what is on the floor. b. Pause and wait until the client looks up. c. Move closer to the client. d. Continue the discussion while avoiding eye contact. 106. A nurse is reinforcing teaching with a client about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development? a. Generativity versus stagnation c. Intimacy versus isolation b. Identity versus role diffusion d. Trust versus mistrust 107. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage renal disease. At the first dialysis treatment, the client tells the nurse, “I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again.” The nurse should recognize the client is demonstrating which stage of Kübler-Ross’s stages of grieving? a. Bargaining b. Denial c. Depression d. Anger 108. A Spanish-speaking client arrives at the triage desk in the emergency department and nurse to take? states to the nurse, “No speak English, need interpreter.” Which is the best action for the a. Have one of the clients family members interpret b. Have the Spanish speaking triage receptionist interpret c. Seek an interpreter from the hospitals interpreter services d. Obtain a Spanish speaking dictionary and attempt to triage the client 109. A parent asks how long she should enforce a “time-out” for her 4-year-old, who frequently hits her younger brother and takes his toys. The nurse recommends: a. 2 minutes b. 3 minutes c. 4 minutes d. 5 minutes 110. The nurse can assess Cheyne-Stokes respiration by its characteristics of respirations that are: a, harsh and rattling b. wheezing and labored. c. shallow followed by periods of apnea. d. long periods of apnea followed by a hiccoughing breath. 111. A nurse says to a patient, “I am going to take your TPR, and then i’ll check to see whether you can have a PRN analgesic.” In considering factors that affect communication, the nurse has: a. used terminology to clearly inform the patient of what she is doing. b. given information that is unnecessary for the patient to know. c. used medical jargon, which might not be understood by the patient. d. taken into consideration the patient’s need to know what is happening. 112. A nurse is instructing the mother of a toddler who has iron-deficiency anemia to increase iron in the child’s diet in addition to the prescribed iron supplement. Which of the following foods should the nurse recommend? a. Skim milk b. Bananas C.Tuna fish d. Cucumbers 113. Therapeutic communication: a. facilitates the formation of a positive nurse-patient relationship. b. manipulates the patient. c. assigns the patient a passive role. d. requires the patient to accept what the nurse says. 114. When the nurse is assisting a male patient to shave his face, it is most important for her tO: a. practice on a male friend or relative before trying it on a patient. b. have the patient shave first before any other hygiene measures are performed. C. be sure the patient knows to draw the razor in the direction the hair grows. d. check whether a safety razor can be used or whether it is contraindicated. 115. When the clinic nurse speaks to the 3-year-old child and says, “You can get dressed now and put your shirt and pants back on,” she is promoting his sense of A. Autonomy B. Industry C. Initiative D. Trust 116. To best method in counting regular respirations; the nurse a. informs the patient that she is counting his respirations and asks him to breathe normally. b. counts each inhalation and expiration for 1 full minute. C. watches the patient’s chest rise and fall from a distance so that the patient is unaware of what she is doing. d. continues holding the parish’s radial pulse as if she was sill counting it, and she counts the respirations for 30 seconds and multiplies by 2. 117. A patient asks the nurse, What would you do?” The reply that can best help the patient is: a. “If I were you, I would…” b. “What solutions have you considered?” c. “I would talk it over with my friends and do what the majority thought.” d. “I don’t know. I’m glad it isn’t my decision.” 118. When the nurse is making an occupied bed, back safety indicates that he should first a. raise the bed to the proper working height before starting. b. encourage the patient to use the side rail to help turn side to side. c. maintain the bed in low position to prevent the patient from falling. d. complete the linen change on one side before moving to the other side. 119. When a physical examination is being performed on a patient, which item is detectable using the skill of inspection? c. Skin tone a. Apical pulse rate b. Cardiac enlargement d. Skin turgor 120. You have an order to administer a subcutaneous injection to a patient. The best angle to insert the needle before administration is at a. 45 to 90 degrees c. 15 to 30 degrees b. 30 to 45 degrees d. 5 to 15 degrees 121. Standard Precautions as outlined by the Centers for Disease Control and Prevention (CDC) are a. used whenever there is a suspicion of infection or risk of infection. b. used to prevent transmission of respiratory and wound infections. c. indicated for patients who have wounds or are draining body fluids than can transmit disease. d. used in the care of all patients. 122. A hospitalized patient who develops a nosocomial infection is most likely to a. have a viral infection rather than a bacterial infection: b. have had the infection before the hospital admission in which it becomes apparent. c. be a surgical patient with an intravenous (IV) line or a urinary catheter. d. be discharged early to prevent spreading the infection further in the hospital. 123, In measuring the apical pulse of your patient, you first a. expose the left chest. b. count the beats for a minute. c. wash your hands and ensure privacy. d. warm the diaphragm of the stethoscope. 124. Your assigned patient states that she feels nausead and dizzy. What information is this? a. Objective b. Unreliable c. Subjective d. Historic 125. Which is the proper procedure for measuring a patient’s oxygen saturation oximeter? a. Draw blood from an artery. b. Count an apical-radial pulse. c. Attach a toe or finger clip probe. d. Count the pulse before and after exercise. 126. A nurse is using personal protective equipment (PPE) before entering the room of the patient who is being treated for an intestinal infection with diarrhea and vomiting nurse most likely needs to use which combination of PPE? a. Gown, gloves, and mask b. Gown, gloves, and goggles (or glasses) c. Shoe covers, gown, and gloves d. Reusable gown and mask 127. A patient who has inflammation of a joint tells the nurse he experiences the foll symptoms caused by the inflammation: a. fever of 104° F (40° C). c. nausea and loss of appetite b. rash and hives d. warmth and swelling 128. Your patient has damage to the hypothalamus after suffering a head injury from a fall, You would anticipate for the patient to exhibit: a. a blood pressure of 130/80 mm Hg. b. an oral temperature of 106.8° F. c. a pulse rate of 98 beats/min. d. respirations of 20 breaths/min. 129. When monitoring vital signs, it is important to a. document your findings by the end of the shift. b. report and document any abnormal findings. C. document your findings in the nurses’ notes only. d. document your abnormal findings in the graphic sheet only. 130. A patient who has a temperature of 104° F (40° C) is described as A. Febrile B. Afebrile C. Hyperdermic D. Hypothermic 131.A nurse is caring for a patient who was exposed to Bacillus anthracis. The nurse should wash her hands with: a. soap and water. b. alcohol wipes. C. chlorhexidine. d. an antiseptic. 132. The abbreviation AC in a prescription means that the medication is to be taken: a. Daily b. After meals C. As needed d. Before meals. 133. The nurse will be injecting a drug into the fatty tissue of the patient’s abdomen. Which route does this describe? a. Intradermal b. Subcutaneous c. Intramuscular d. Transdermal 134. A gown should be removed by: a. Touching the outside of the gown only. b. Removing the gown outside the patient’s room. c. Allowing another individual to remove it for you. d. Touching the inside of the gown only. 135. A nurse is caring for a client who practices Islam. Which of the following food should the nurse notify the dietary department to eliminate from the client’s menu plan? a. Pork c. Bread b. Shellfish d. Lamb 136. A nurse steps into an outdoor employee dining area and overhears 2 staff members talking about a client having an upsetting visit with his partner earlier in the day. Which of the following actions should the nurse take? a. Tell the staff members that she will report the situation to their supervisor immediately. b. Ask the staff members to lower the volume of their voices. c. Remind the staff members that discussing a client where others can overhear them is a HIPAA violation. d. Avoid taking action unless she observes others listening to the staff members” conversation. 137. A nurse is documenting information about a client at a computer terminal in the nurses station when she has to leave the area to respond to a client call light. Which of the following action should the nurse take? A. Ask the unit clerk to make sure no one else uses the computer b. Turn the computer monitor so that it is not visible to anyone else. C. Turn the monitor off so the computer will log out automatically. d. Log out of the computer before leaving the area. 138. A nurse in a full personal protective equipment is preparing to leave the room of a client Who is in isolation. Which the following PE should the nurse remove first a. Face shield b. Gloves C. Gown d. Mask 139. Nurse is assisting with preparing an educational program for a group of staff nurses about transmission precautions. Which of the following instruction should the nurse include? a. A nurse should use airborne precautions when caring for a client who has tuberculosis b. A nurse should use contact precautions when caring for a client following stem cell transplantation. c. A nurse should use a protective environment when caring for a client who has streptococcal pharyngitis d. Inertia to use droplet precautions when caring for a client who has herpes Simplex virus. 140. A nurse is preparing to exit the isolation room of a client who is disseminated Varicella zoster virus which requires airborne isolation precautions which of the following actions should the nurse take? a. Keep the client door open to prevent a feeling of loneliness. b. Remove the first club by grasping the lower portion of the glove with the opposite hand and pulling it off inside out. c. Remove the mask by holding the front of the mask with one hand while untying the top and bottom ties with other hand. d. Fold decontaminated side outward while removing the gown 141. A nurse is preparing to auscultate a client a apical pulse at the point of Maximal impulse: Which of the following location should the nurse position the stethoscope? a. Over the right midclavicular line b. Over the angle of Louis C. Over the fifth intercostal space at the left midclavicular line d. Over the suprasternal notch 142 A nurse is obtaining a client vital sign. The client has new onset of a Temp 102 F. which of the following other vital signs should the nurse expect? a. An elevated pulse rate b. A decreased blood pressure c. An elevated blood pressure d. A decreased pulse rate 143. A nurse is preparing to record the difference between a client’s systolic and diastolic BP. Which of the following terms defines this information when documenting? a. Auscultatory gap b. Pulse pressure c. Orthostatic hypotension d. Pulse deficit. 144. A nurse is taking an adult clients temp rectally/ which of the following actions should the nurse take? a. Rotate the probe if any resistance is met as the thermometer is inserted. b. Insert the probe to aim at the client’s pelvic area. c. Dip the probe about 0.58 cm (2 in) into a tube of lubricant. d. Insert the probe about 2.5 cm (1 in) into the client’s anus. 145. A nurse is preparing to conduct a Romberg test on a client. The nurse should explain to the client that Romberg test is used to assess which of the following characteristics a. Gait b. Hearing c. Vision d. Balance 146. A nurse is performing a physical examination of the spine for an older adult client. The client should identify that which of the following findings is a common with aging? a. Lordosis b. Kyphosis c. Ankylosis d. Scoliosis 147. A nurse is preparing to use a Tympanic thermometer to acquire a Adult client’s temperature. Which of the following action should the nurse take to ensure an accurate reading? a. Attach the disposable probe cover. b. Assess the external ear for redness. c. Pull the pinna back and upward gently. d. Replace the thermometer in its charger.
SCIENCE
HEALTH SCIENCE
NURSING
NUR FUNDAMENTA

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