Exam 2 (clinical Exam) NUR 100 Questions With Complete
Solutions
A client diagnosed with a broken bone is on what precautions?
Correct Answer Standard percautions
A client is diagnosed with adenovirus. What precautions should
the patient be placed on? Correct Answer Droplet precautions
A client is sneezing and is suspected to have seasonal influenza.
What precautions should the patient be placed on? Correct
Answer Droplet precautions
A client is suspected of having tuberculosis. What precautions
should the patient be placed on? Correct Answer Airbourne
Precautions
A client that needs to have vital signs taken are on what
precautions? Correct Answer standard percautions
A client who had hemopoietic stem cell transplant this week
should be placed on Correct Answer Isolation percautions
A common site of HAls is Correct Answer The urinary tract is
often caused by Escherichia coli, Staphylococcus aureus, and
enterococci.
- Other sites of HAls are surgical wounds, the respiratory tract,
and the bloodstream.
,A comprehensive nutritional assessment should be conducted
Correct Answer Upon the client's admission to the health care
facility and anytime the client's status changes significantly.
A mobility assessment should be performed prior to Correct
Answer Initially mobilizing a client and repeated every 24
hours. Additionally, it should be conducted following
procedures that may alter a client's mobility and need for
assistance. The assessment results should be recorded in the
medical record and verbally communicated with the health care
team members to ensure the safety of both the client and the
staff.
A nurse cares for a client requiring a mechanical lift to transfer
from the bed to a reclining chair. The nurse should follow the
recommendation of asking how many personnel to assist with
this task? Correct Answer 2 or more
A nurse is assessing a client's respiration. Which of the
following actions should the nurse take? Correct Answer
Elevate the head of the clients bed 45 degree to 60 degree.
A nurse is auscultating a client's apical pulse to listen to the S1
and 52 heart sounds. 52 heart sounds are heard when which of
the following occurs? Correct Answer When the semilunar
valves close
A nurse is caring for a client who can rise to a standing position
from a chair with the use of a cane. The nurse should assist the
client with ambulation using which of the following equipment?
Correct Answer gait belt
,A nurse is caring for a client with a large draining foot wound.
Which of the following PPE equipment should the nurse don
prior to entering the client's room? Correct Answer Non-sterile
gloves and gown
A nurse is collecting data about a client's respiratory condition.
Which of the following actions should the nurse take to
determine the depth of the client's respiration? Correct Answer
Observe the degree of chest-wall movement during inspiration
and expiration.
A nurse is establishing baseline for a client's respirations. Which
of the following actions should the nurse take? Correct Answer
Observe the clients chest movements while appearing to assess
their pulse.
A nurse is obtaining a client's blood pressure and notices the
pressure reading on the manometer when listening to the fourth
Korotkoff sound.
Which of the following factors does this pressure reading
correlate to? Correct Answer It might not follow with a fifth
Korotkoff sound
A nurse is obtaining a client's vital signs. The client has a new
onset of a temperature of 39° C (102° F). Which of the
following other vital signs should the nurse expect? Correct
Answer An elevated pulse rate
, A nurse is obtaining vital signs from a client. Which of the
following findings is the priority for the nurse to report to the
provider? Correct Answer Respirations 30/min
A nurse is planning care for a client who is experiencing
tachycardia. Which of the following interventions should the
nurse plan to include? Correct Answer Encourage the client to
practice relaxation techniques each day.
A nurse is preparing to auscultate a client's apical pulse at the
point of maximal impulse (PMI). In which of the following
locations should the nurse position the stethoscope? Correct
Answer Overt the fifth intercostal space at the left midclavicular
line
A nurse is preparing to measure a client's vital signs. The nurse
should identify that which of the following factors will affect the
methods that are used? (Select all that apply.) Correct Answer -
The client who has a BMI of 35
-The client is reporting a "stuffy" nose
-The client is taking digoxin for an irregular heart rate
-The client had a mastectomy 2 years ago
A nurse is preparing to obtain a client's blood pressure. Which
of the following actions should the nurse take to measure the
blood pressure accurately? Correct Answer Use a cuff of the
appropriate size for the client
A nurse is preparing to use a tympanic thermometer to acquire a
client's temperature. Which of the following actions should the
Solutions
A client diagnosed with a broken bone is on what precautions?
Correct Answer Standard percautions
A client is diagnosed with adenovirus. What precautions should
the patient be placed on? Correct Answer Droplet precautions
A client is sneezing and is suspected to have seasonal influenza.
What precautions should the patient be placed on? Correct
Answer Droplet precautions
A client is suspected of having tuberculosis. What precautions
should the patient be placed on? Correct Answer Airbourne
Precautions
A client that needs to have vital signs taken are on what
precautions? Correct Answer standard percautions
A client who had hemopoietic stem cell transplant this week
should be placed on Correct Answer Isolation percautions
A common site of HAls is Correct Answer The urinary tract is
often caused by Escherichia coli, Staphylococcus aureus, and
enterococci.
- Other sites of HAls are surgical wounds, the respiratory tract,
and the bloodstream.
,A comprehensive nutritional assessment should be conducted
Correct Answer Upon the client's admission to the health care
facility and anytime the client's status changes significantly.
A mobility assessment should be performed prior to Correct
Answer Initially mobilizing a client and repeated every 24
hours. Additionally, it should be conducted following
procedures that may alter a client's mobility and need for
assistance. The assessment results should be recorded in the
medical record and verbally communicated with the health care
team members to ensure the safety of both the client and the
staff.
A nurse cares for a client requiring a mechanical lift to transfer
from the bed to a reclining chair. The nurse should follow the
recommendation of asking how many personnel to assist with
this task? Correct Answer 2 or more
A nurse is assessing a client's respiration. Which of the
following actions should the nurse take? Correct Answer
Elevate the head of the clients bed 45 degree to 60 degree.
A nurse is auscultating a client's apical pulse to listen to the S1
and 52 heart sounds. 52 heart sounds are heard when which of
the following occurs? Correct Answer When the semilunar
valves close
A nurse is caring for a client who can rise to a standing position
from a chair with the use of a cane. The nurse should assist the
client with ambulation using which of the following equipment?
Correct Answer gait belt
,A nurse is caring for a client with a large draining foot wound.
Which of the following PPE equipment should the nurse don
prior to entering the client's room? Correct Answer Non-sterile
gloves and gown
A nurse is collecting data about a client's respiratory condition.
Which of the following actions should the nurse take to
determine the depth of the client's respiration? Correct Answer
Observe the degree of chest-wall movement during inspiration
and expiration.
A nurse is establishing baseline for a client's respirations. Which
of the following actions should the nurse take? Correct Answer
Observe the clients chest movements while appearing to assess
their pulse.
A nurse is obtaining a client's blood pressure and notices the
pressure reading on the manometer when listening to the fourth
Korotkoff sound.
Which of the following factors does this pressure reading
correlate to? Correct Answer It might not follow with a fifth
Korotkoff sound
A nurse is obtaining a client's vital signs. The client has a new
onset of a temperature of 39° C (102° F). Which of the
following other vital signs should the nurse expect? Correct
Answer An elevated pulse rate
, A nurse is obtaining vital signs from a client. Which of the
following findings is the priority for the nurse to report to the
provider? Correct Answer Respirations 30/min
A nurse is planning care for a client who is experiencing
tachycardia. Which of the following interventions should the
nurse plan to include? Correct Answer Encourage the client to
practice relaxation techniques each day.
A nurse is preparing to auscultate a client's apical pulse at the
point of maximal impulse (PMI). In which of the following
locations should the nurse position the stethoscope? Correct
Answer Overt the fifth intercostal space at the left midclavicular
line
A nurse is preparing to measure a client's vital signs. The nurse
should identify that which of the following factors will affect the
methods that are used? (Select all that apply.) Correct Answer -
The client who has a BMI of 35
-The client is reporting a "stuffy" nose
-The client is taking digoxin for an irregular heart rate
-The client had a mastectomy 2 years ago
A nurse is preparing to obtain a client's blood pressure. Which
of the following actions should the nurse take to measure the
blood pressure accurately? Correct Answer Use a cuff of the
appropriate size for the client
A nurse is preparing to use a tympanic thermometer to acquire a
client's temperature. Which of the following actions should the
