TEST 2025 UPDATED EXAM
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EXAMS
, Which nonverbal behavior observed by the nurse indicates the client may be experiencing
acute pain
- grunting with movement
- clenched teeth
- grimacing
- wrinkled forehead
- restlessness
- grabbing abdomen
- tightly closed eyes and mouth
- reduced attention span
Which 3 observations does the nurse address immediately
- client crying and states "it hurts to take a deep breath or cough"
- client states need to wait for pain med until after dressing change
- spouse concerned client will become addicted to pain med
The nurse will _____. It is a priority for the nurse to assess ____. The nurse will ask the client
to ______.
- determine the client's tolerable pain level using a standard pain scale.
- the location, severity, and quality of pain
- describe conditions that make pain better or worse
The client's pain will be controlled during the dressing change
- position the client in low fowler's position with knees slightly bent.
- administer pain medication 15-30 mins prior to dressing change
the surgical incision is healing without further infection
- monitor client's vital signs and lab results daily
- report any increase in redness or drainage to physician
the client will demonstrate use of non-pharmologic pain relief techniques
-teach client to splint incision with rolled blanket or pillow
- educate client about meditation during procedures
Client sitting on side of bed, using pillow to splint incision while coughing
Improved
Client requests hydrocodone 5 mg (2 tablets) 30 minutes prior to dressing change
, Improved
Client asks family to leave during dressing change to allow client to rest
improved
foul odor detected from client's dressing
declined
client smiling and talking with nurse during dressing change
improved
the nurse explains to the nursing student that a client has a new diagnosis of psoriasis. Which
best describes psoriasis
chronic autoimmune reaction
the nurse prepares for a urinary catheterization procedure for a client. which action by the
nurse is most important
keeps the field holding the supplies in front of the nurse
A liver scan is prescribed for a client prior to surgery. which description best describes this
procedure
the client will be asked to lie still while a scanning probe is passed back and forth over the
body
the nurse prepares a client for discharge. the client tells another staff member "that nurse
really doesn't care about me and i don't want to talk anymore"
common response to the end of the nurse-client relationship
the nurse provides care a client beginning intermittent heparin therapy. the nurse knows
which lab test is used to monitor the effectiveness of heparin
activated partial thromboplastin time
which nursing action is best to identify and manage a client's valuable items during
hospitalization
document the disposition of the client's valuable items in the medical record
the nurse provides care for a client with an abdominal wound. the nurse notes there is a
purulent drainage from the wound. which action does the nurse take first
places the client on contact precautions
a nurse provides teaching on modifiable risk factors related to the CV system. Which factors
does the nurse include in the teaching.
, - high cholesterol levels
- elevated blood pressure
- cigarettes
- diet higher in sugar and fats
On the morning before surgery a client signs an operative consent form. soon afterward, the
client call the nurse and states, "I do not want the surgery." which action does the nurse take
first.
encourages the client to discuss the reasons for cancelling the surgery
the nurse identifies which change in the genitourinary system is usually associated with client
aging
increased frequency
A client is experiencing an episode of acute pain. Which physiological change should the
nurse expect to occur with acute pain
decreased skin temp
the nurse evaluates the lab results of several clients. for which client would the nurse expect a
decreased serum albumin
client with severe liver disease
the nurse identifies a staff member is using standard precautions appropriately when
the staff member places contaminated linens in a leak-proof bag
following a total hip arthroplasty, the older adult client is prescribed to start ambulation using
a walker. Which statement by the nurse regarding ambulation is best
advance the walker first, then carefully walk forward
the clinic nurse interviews a middle-age adult client who comes to the clinic reporting
difficulty sleeping and ongoing fatigue. the nurse learns the client works as a security guard
and frequently works the night shift. Which is the best initial statement
tell me about your usual sleeping habits
which nursing action does the nurse have to establish first when caring for a client in pain
establish a trusting relationship with the client
The nurse evaluates the laboratory results of several clients. For which client would the nurse
expect a decreased serum albumin?