Comprehensive Final Exam (Practice Book Questions)

Which actions are associated with a first-level need according to Maslow's hierarchy of needs? Select all that apply 1) eating a sandwich for lunch 2) inviting friends over for a party 3) taking a nap after working out at the gym 4) getting a haircut before the holiday season 5) locking the car door when alone in the car 6) Taking a bottle of water along when going for a walk - ANS 1,3,6 A nurse identifies a 1 cm superficial break in the skin over the right trochanter of a client during an admission assessment. What should the nurse do first? 1) initiate a turning schedule 2) complete a skin assessment form 3) inform the primary healthcare provider of the clients status 4) start wound care based on the agency's pressure ulcer protocol - ANS 2 Which situations may lead to a legal action for assault? Select all that apply. 1) A nurse threatens a client with inserting a tube to feed the client if the client does not eat all the food on their meal tray 2) A nurse administers a medication that the client has refused by telling the client that it is different from the refused medication 3) A nurse uses a restraint when a client attempts to leave the hospital before the primary provider writes a discharge prescription 4) A nurse tells a client who has a prescription for bed rest that unless the client stays in bed the 4 side rails on the bed will have to be raised 5) A nurse is heard by a client's relative telling another nurse on an elevator that the client contracted hepatitis C from IV drug use when in fact, the client contracted the disease via a blood transfusion - ANS 1,4 A nurse caring for a newly admitted client reviews the information on the clients admission history and performs a chart review. The nurse should assess the client for which additional human response based on data collected? 1) Peripheral edema 2) burning on urination 3) suprapubic distention 4) decreased blood pressure - ANS 3 A nurse assesses four clients to determine their hygiene needs. The nurse should anticipate that the client with which problem will have the greatest difficulty having hygiene needs met by the nurse? 1) Pain 2) Dementia 3) Impaired vision 4) Limited mobility - ANS 2 A client with the diagnosis of stage 4 pancreatic cancer is consulting with a discharge planner regarding the most appropriate level of care required after palliative surgery. The client is able to provide self-care but will need pain management. Which setting is most appropriate for this client? 1) Home hospice care 2) Rehab facility 3) Skilled nursing facility 4) Assisted living apartment - ANS 1 A client comes to the emergency department reporting a sore throat and earaches. The client has a hx of diverticulitis and emphysema with shortness of breath. Which routes can the nurse use to obtain the client's temperature safely? Select all that apply 1) Oral 2) Skin 3) Rectal 4) Axillary 5) Temporal 6) Tympanic - ANS 2,4,5 A nurse is teaching a group of clients about diabetes mellitus. Which participant should the nurse anticipate will have the most difficulty following a medical regimen associated with chronic health problems? 1) adolescent 2) older adult 3) young adult 4) Middle aged adult - ANS 1 A nurse is caring for an older client who is hearing impaired. What should the nurse do to facilitate communication? Select all that apply 1) Talk at a slow rate 2) Use shorter phrases 3) Speak in a low tone of voice 4) Over articulate when speaking 5) Stand so that the nurses face can be seen easily - ANS 3,5 A client is frustrated about not being able to perform ADLs without help. What should the nurse do to reduce the client's frustration? Select all that apply 1) Disregard the client's behavior 2) Offer the client choices about care 3) Distract the client by discussing the news 4) Assist the client to recognize personal limitations 5) Have the client engage in activities that can be completed successfully - ANS 2, 5 A client comes to the ED and reports pain to the hip. Which client assessments reflect chronic pain rather than acute pain? Select all that apply. 1) Variable breathing patterns 2) Decreased blood pressure 3) Slow monotonous speech 4) Increased heart rate 5) Pressured speech 6) Dilated pupils - ANS 1,2,3 What action is unrelated to maintaining airborne precautions for a client with a diagnosis of suspected primary tuberculosis? 1) Donning a gown when entering a room 2) Wearing a respirator mask when in the room 3) Maintaining negative air pressure within the room 4) Having the client wear a surgical mask when transported outside of the room - ANS 1 A nurse is to administer eardrops to an adult. The nurse verifies the original prescription, washes the hands, and collects the medication, following the 3 checks and the 10 rights associated with medication administration. The nurse then dons clean gloves. Place the following steps in the order in which they should be implemented. 1) Pull the auricle up and back 2) Apply slight pressure several times to the tragus of the ear 3) Instruct the pt to remain in a side-lying position for 5-10 mins 4) Position the client in a side-lying position with the affected ear facing up 5) Hold the dropper a half in above the ear canal and instill the drops so that they fall on the side of the ear canal - ANS 4,1,5,2,3 Before going to lunch, a nurse provides information to the nurse accepting responsibility for a client who returned 2 hours ago after a fiberoptic colonoscopy. Which information is the most important for the covering nurse to know about this client? 1) Gag reflex is present 2) Reports mild abdominal pain 3) Passing flatus for the last hour 4) Dozing intermittently since the procedure - ANS 2