Exam 2: NUR170/ NUR 170 Concepts of Medical Surgical Nursing (Latest 2025/26) | Answered 50 out of 50 100% - Galen College of Nursing.

Exam 2: NUR170/ NUR 170 Concepts of Medical Surgical Nursing (Latest 2025/26) | Answered 50 out of 50 100% - Galen College of Nursing. Exam 2: 1. The nurse is teaching an adult female client about health promotion. Which of the following should the nurse recommend as a primary prevention intervention? a. Performing a breast self-examination (BSE). b. Having a yearly physical with labs. c. Receiving family planning services. d. Checking blood pressure every 3 months. 2. The nurse is caring for a client who has joint pain. The nurse incorporates the nutritional status, sleep patterns, energy level, and sense of well-bring into the plan of care. Which of the following concepts is the nurse practicing? a. Homeostasis b. Individuality c. Health promotion d. Holism 3. The community health nurse is preparing to provide education to an adolescent client regarding health promotion. Which of the following health promotion topics is most appropriate for this client? a. Dental checkups b. Preventive health screenings c. Weight control d. Peer group influences 4. The nurse is caring for a client who has a low serum albumin level. Which statement by the nurse indicates a correct understanding of albumin levels? a. “The client is experiencing a rapid breakdown of protein.” b. “This indicates a low level of iron circulating in the blood.” c. “The results indicate prolonged malnutrition.” d. “This indicates that the client has experienced blood loss.” 5. The nurse is preparing to discharge an elderly client who is at risk for aspiration. Which of the following should the nurse recommend? a. Prepare liquids at prescribed consistency b. Tilt the head back when swallowing c. Drink warm water instead of cold d. Use extra pillow when eating in bed 6. The nurse is administering an intermittent gastrointestinal (GT) feeding to a client. Which of the following actions is appropriate for the nurse to take? a. Aspiration and disposal of any residual prior to feeding delivery. b. Setting up feeding bag system to deliver the feeding at a fast rate c. Raising and lowering the syringe to adjust the flow rate of the feeding. d. Placing the head of the bed at 15 degrees with the client on their left side 7. The nurse is caring for a client who is receiving prescribed medication intravenously (IV). Upon assessment, the nurse notes the IV site is swollen and cool to the touch. Which of the following is most appropriate action for the nurse to take? a. Slow the rate of the infusion and provide a warm blanket b. Stop the infusion and start supportive treatmentc. Call the primary health care provider (PHCP) and get order for a new medication d. Monitor the client closely since they need the medication 8. The nurse is caring for a client who was admitted to the acute care unit with a decreased phosphorus level. Which of the following should the nurse recommend? a. Enforce strict isolation protocols b. Strain all urine c. Encourage consumption of a high- calorie carbohydrate diet d. Encourage consumption of milk and yogurt 9. The nurse is caring for a client who is 5-days postoperative and has been on bed rest. Which of the following interventions should the nurse implement to decrease the client’s possibility of developing hypercalcemia? a. Assist the client to turn, cough, and deep breath every 2 hours b. Measure vital signs every 4 hours c. Assist the client to ambulate around the room at least 3 times daily. d. Irrigate the client’s nasogastric (NG) tube every 2 hours. 10. The nurse is caring for a client who has had diarrhea for 48 hours abd has developed fatigue, restlessness, and disorientation. Which of the following laboratory results should the nurse correlate to these signs and symptoms? a. Calcium b. Sodium c. Phosphate d. Magnesium 11. The nurse is caring for a client who has hypokalemia. Which of the following signs and symptoms should the nurse expect to see? a. Headache b. Facial edema c. Muscle weakness d. Abdominal cramping 12. The nurse is caring for a client who is diagnosed with an elevated aldosterone level. The nurse should expect to find a. An increased urine output b. Urinary frequency c. A decreased urine output d. Urinary urgency 13. The nurse is caring for a client who has oliguria. The nurse recognized that the client is experiencing a. A urine output greater than 120 ml/hr b. Increased hesitancy with voiding c. A urine output less than 30 ml/hr d. A foul odor associated with urination 14. The nurse is assessing the following assigned older adult clients who have urinary catheters in place. Which client should the nurse recognizes as being at greatest risk for developing a urinary tract infection (UTI)? a. The 65- year- old client who has a condom catheterb. The 80-year-old male client who reports frequent urination at night. c. The 25-year-old female client who has low self-esteem d. The 78-year- old male client who has a patent indwelling urethral 15. The nurse is caring for the following assigned clients on a medical unit. Which client should the nurse recognize as being at greatest risk for experiencing difficulty with urinary elimination? a. The client who is complaining of leg pain b. The client who drinks coffee until noon each day c. The client who ambulates independently d. The client who has confusion and a mild fever 16. The nurse is caring for a female client with limited mobility who is having difficulty voiding. Which of the following actions should the nurse take first? a. Request a prescription for an indwelling urinary catheter b. Provide bed side commode c. Insert a straight catheter d. Assist the client into an upright position 17. The nurse is assessing a client who has steatorrhea. Which of the following finding is consistent with this condition? a. Liquid and clumps of stool b. Dark-red blood in the stool c. Fat, loose stool d. Frequent small hard stools Exam 3: 1. When changing the dressing on a clients partial-thickness wound, the nurse observes a beefyred translucent wound bed. Which of the following actions should the nurse take? a. Contact the primary health care provider (PCP) immediately. b. Document the findings as abnormal and continue to observe. c. Culture the wound and place the client in isolation. d. Discard the old dressing and cover the wound with a new dressing. 2. The nurse is teaching a newly hired nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? a. Altered mental status. b. Nutritional deficiencies c. Advanced age d. Immobility 3. The nurse is caring for a client who is being discharged home with surgical wound on the coccyx that is to heal by secondary intention. Which of the following complications should the nurse prioritize on the clients care plan? a. Contractures b. Increased tissue perfusion c. Self-care deficit d. Disturbed body image.4. The nurse is caring for a client who has a deep pressure ulcer (Stage 3) that is heavily draining. Which of the following dressing choices should the nurse choose to promote adequate healing? a. Transparent, adhesive, film cover b. Wet to dry gauze c. Dry cotton gauze d. Alginate packing, dry, gauze cover 5. The nurse is planning a staff development conference about the use of the hot and cold therapy. Which of the following statements, if made by a participant, indicates a correct understanding of the conference? a. “Cold therapy is for treatment of open wounds because it improves blood flow to the area.” b. “Heat therapy is not used in the first 24 hours after a traumatic injury because it may cause increased swelling and bleeding.” c. “Heat therapy is not the first 24 hours after injury because it may cause arterial spasm and delayed healing” d. “When using cold therapy, the temperature must be less than 32 degrees F to achieve the desired effects.” 6. The nurse is planning a staff development conference about the use of abdominal binders. Which of the following statements, if made by a participant, indicates a correct understanding of the conference? a. “If pins are used instead of Velcro, they should be placed vertically to keep the binder secure” b. “Padding should not be used under the binder because it can impair circulation to the area” c. “The binder should be placed over the waist with the upper edge over the bottom portion of the rib cage” d. “Skin and bony prominences should be assessed frequently for signs of impaired circulation.” 7. The nurse has attended a continuing education conference on the physiological effects of prolonged immobility. The nurse is correct to state that prolonged immobility can result in a. Vasoconstriction and venous stasis b. Hypertension and irregular heart rate c. Pooling of respiratory secretions and pneumonia d. Muscle atrophy and total paralysis 8. The nurse is caring for a client who is at risk of developing contractures. The nurse recognizes which of the following as intervention to prevent contractures? a. Turing the client every 2 hours which lying in bed, if awake. b. Have the client sit in a chair at least 4 hours every day. c. Have the client perform active range of motion exercises d. Have the client perform passive range of motion exercise 9. The nurse is caring for a client who is confined to the bed. While providing care, the nurse raises the height of the bed to a comfortable working position, The rationale for the nurse’s action is to a. Allow the nurse to stand with the feet closer together while working b. Narrow the nurses base of support making the nurse more stablec. Prevent a shift in the nurse's base of support making the nurse move stable d. Shift the nurses center of gravity away from the base of support 10. The nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to decrease the cardiovascular complications associated with limited mobility? a. Limit fluid to decrease workload on the heart b. Have the client do dorsiflexion of the feet and ankles c. Perform passive range of motion exercises once a day d. Place the client in a flat position to promote venous return 11. The home health nurse is assembling a puzzle with an elderly client and notices that the client is trying to connect 2 puzzle pieces by standing them up. Which of the following aspects of sensory deprivation should the nurse document as being MOST affected? a. Delirium b. Affective c. Social d. Perception 12. The nurse is caring for a client who has a gustatory impairment and is becoming malnourished because nothing tastes good. Which of the following should the nurse recommend? a. “Eat soft foods that will be easy to chew and swallow” b. “Stay away from spicy foods that could cause irritation” c. “Take sips of water between eating different foods” d. “Cleanse the mouth with glycerin swabs after each meal” 13. The nurse is teaching a client who has respiratory problems about the function of the alveoli. Which of the following information about the alveoli function should the nurse share with the client? a. Contain a thin mucus, which traps foreign substances to expel from the lungs b. Store excess oxygen, which is important when experiencing shortness of breath c. Carry out gas exchange between the heart and lungs d. Produce white blood cells, which are important for the immune system 14. The nurse is caring for a client who has hypoxia. Which of the following clinical Manifestations should the nurse expect to observe? a. General malaise and wheezing in the lungs b. Confusion and crackles in the lungs c. Pallor and weak peripheral pulses d. Rapid pulse and shallow respirations 15. The nurse is returning from an in-service regarding care of the client with dyspnea. It indicates a need for further education if the nurse is seen placing the client in a. Orthopneic position b. High-fowlers position c. Semi-fowlers position d. Prone position 16. The nurse is caring for a client who is in severe respiratory distress and has been prescribed high concentrations of oxygen (above 95%). Which of the following oxygen delivery systems should the nurse use for this client? a. Oxygen tentb. Partial rebreather mask c. Bilevel positive airway pressure (BiPAP) with oxygen d. Non rebreather mask 17. The nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is receiving 2 L/min of oxygen. Which of the following oxygen delivery devices is MOST appropriate for the nurse to administer the oxygen? a. Partial non rebreather mask b. Nasal Cannula c. Simple face mask d. Flow by oxygen delivery 18. The nurse preceptor is observing a newly hired nurse provide oxygen delivery to a client. The nurse preceptor should intervene if the newly hired nurse is observed a. Adding a humidifying bottle to prescribed oxygen delivery of 4 L or more b. Making sure the client removes the oxygen before smoking c. Ensuring the electrical oxygen equipment is properly grounded d. Providing the client with a water-based jelly in the nose become dry 19. The nurse is caring for a client who has a chronic lung disease. The primary health care provider has prescribed the use of an incentive spirometer every hour while the client is awake. The nurse should recognize that this treatment a. Is a method to loosen secretions and promote lung expansion b. Is performed by leaning forward and exhaling sharply c. Is performed by exhaling and holding the breath for three seconds d. Will promote bronchodilation of the airway 20. While caring for a client the nurse begins to suspect the client has increased afterload. Which of the following pieces of equipment should the nurse obtain to determine the presence of this condition? a. Nasal oxygen cannula b. Stethoscope c. Doppler d. Pulse oximeter 21. The nurse is conducting a comprehensive nursing history of an assigned client. Which of the following should the nurse recognize as a modifiable risk factor for cardiovascular disease? a. Family history b. Stress c. Gender d. Age 22. The nurse is teaching a client about promoting a healthy heart. Which of the following statements by the client requires follow up by the nurse? a. I will try to get at least 30 minutes of aerobic exercise three times per week b. I will eat a diet low in total fat saturated fat and cholesterol c. I will try to reduce the stress in my life by using effective coping mechanisms d. I will enroll in a smoking sensation program so that I can quit smoking cigarettes 23. The nurse is caring for a client recently diagnosed with pulmonary edema. which of the following findings should the nurse expect when performing an assessment?a. Cyanosis, nocturia b. Wheezing, nausea c. Chest pain, pedal edema d. Dyspnea, increased pulse rate 24. Earth has attended a continuing education conference about the normal physiologic changes in the cardiovascular system that occur with aging. which of the following statements by the nurse indicates a correct understanding of the conference? a. heart valves become increasingly stiff in older adults b. cardiac output is not affected by age c. the heart of older adults is more responsive to stress d. blood vessels become more elastic in older adults 25. The nurse is caring for a client who is connected to a cardiac monitor. the monitor alarms and indicates that the client has developed an abnormal rhythm pattern. which of the following actions is priority for the nurse to take? a. assess the client's level of consciousness and pulse b. replace the clients' electrodes and wires c. alert the Primary Health care provider immediately d. call the rapid response team for help 26. The nurse is caring for a hospitalized client who is recovering from a severe illness and wants to change their living will, which was signed nine months ago. which of the following responses by the nurse is most appropriate? a. I'm sure that can be done but is someone pressuring you to make changes at this time b. we can assist but only if you have a copy of your current living will. did you bring it with you? c. you will need to have your power of attorney present since you have a living will d. I will be happy to get someone who can assist you with your desired changes 27. The nurse preceptor is reviewing appropriate tasks to delegate to unlicensed assistive personnel with a newly hired nurse. which of the following tasks listed by the newly hired nurse requires a follow up by the nurse preceptor? a. postmortem care b. simple dressing change c. teaching d. measuring intake and output 28. When professionals work together to solve ethical dilemmas nurses must also examine their own values. which of the following is the best rationale for this step? a. letting perspectives white in the decision-making process according to the majority culture b. ensuring that the facts stay separated from opinion so biases are avoided, and perspectives are respected c. Letting judgmental attitudes be duly provoked for a spirited debate and unanimous decision d. identifying and using the one correct solution so that they will be satisfied with the outcome29. While driving home an obstetric nurse witnesses a motor vehicle crash. the driver seems to have crushed upper airway. The nurse makes a cut in the trachea and inserts a straw from the purse to provide an airway. The client survives but has permanent damage to the vocal cords. making it difficult to talk. which of the following statements is correct regarding the nurses actions? a. the nurse stayed within the guidelines of the Good Samaritan law b. the nurse took actions beyond those that were standard and appropriate c. the nurse acted appropriately and save the clients life d. the nurse should have just stayed with the client and waited for help 30. The nurse is caring for a 50-year-old client who was admitted with nonspecific symptoms and passed away 36 hours later. a full code was conducted without success. the client had multiple lines and drains. which of the following questions is the priority for the nurse to ask the family before moving the body to the morgue? a. are you aware that an autopsy will be required to be performed on your loved one at this time? b. will you be requesting an autopsy on your loved one to determine the cause of death? c. would you like all the lines and tubes removed before seeing your loved one? 31. Observed that client who was upset about not being permitted to smoke throw a breakfast tray on the floor out of frustration. which of the following responses by the nurse regarding the client's behavior is appropriate initially? a. call security to assist with restraining the client and to stay with the client b. tell the client that these actions are childish and not the way to get special privileges c. acknowledged the clients' feelings but reinforced that the rules must be followed d. leave the room immediately to notify the Primary Health provider 32. The nurse is caring for a client who has expressed anxiety about starting a new job. the client states, “I can't help from yelling at my family for no apparent reason.” the nurse should recognize this behavior as consistent with which of the following defense mechanisms? a. Displacement b. Sublimation c. Repression d. Regression 33. The nurse working in emergency department is caring for a client who was in a motor vehicle crash. the client states, “I did not run the red light.” despite very clear evidence on the street surveillance tape. which of the following defense mechanisms is the client using? a. Dissociation b. Reaction formation c. Projection d. Denial 34. The nurse is caring for a client who states, “if I didn't have to work, I would take better care of myself.” the nurse should recognize that the client is using which of the following defense mechanisms? a. Identification b. Introjection c. Projection d. Rationalization35. The nurse is assessing a clients use of coping skills in response to stressful situations. Which of the following questions should the nurse ask? a. “How have you managed stressful situations in the past?” b. “Does stress cause you to experience muscle tension or headaches?” c. “What causes you to have stress?” d. “Do you have someone to talk to when you are stressed?” 36. The nurse is caring for assigned clients. The nurse should recognize that the client at greatest risk for sensory overload is the client who is A. Recovering from surgery to the left eye B. Had a stroke and has left side weakness C. Being placed in isolation D. Being monitored in the ICU 37. The nurse is assessing a client who has developed a decreased ability to focus and disorientation over the last 12 hours. The nurse should recognize this as a. Delirium b. Depression c. Sensory Overload d. Dementia 38. The nurse is caring for a client who has been severely visually impaired since birth. Which of the following action should the nurse take in teaching the client to call for nursing assistance? a. Place a raised braille sticker on the call button for easy identification Exam 4: 1.) The nurse had just finished preparing a pain medication injection for an assigned client when a code blue is called for another assigned client. The nurse asks a newly hired nurse on the floor to give the pain medication to the client. Which of the following actions by the newly hired nurse is appropriate? a. Do not give the medication as prepared. Check the medication administration record (MAR) and prepare new medication to be administered. b. Administer the medication if the client is rating pain at an 8 or above on the 0 (no pain) to 10 (severe pain) pain scale. c. Hold on to the medication until the experienced nurse is finished running the code blue. d. Administer the medication since the experienced nurse had just prepared it for the client. 2.) The nurse has administered an intramuscular (IM) medication to a client. Approximately 15 minutes after administration, the client develops an itchy rash all over and reports feeling very “uneasy” to the nurse. Which of the following actions should the nurse take first? a. Obtain an order for hydrocortisone cream to relive the itching. b. Document the reaction in the client’s chart as a side effect. c. Determine if the client is having any difficulty breathing.d. Report the findings to the primary health care provider (PHCP) and the pharmacist. 3.) The nurse has been assigned a group of 8 clients on a very busy medical-surgical unit. While passing medications, the nurse realizes a medication error has been made. Which of the following actions should the nurse take first? a. Document the medication given, how the client responded, and reassess 1 hour later. b. Prepare an incident report so that the facility can determine the cause of the error. c. Assess the client for any adverse reactions and notify the primary health care provider (PHCP). d. Find the nurse manager, explain the medication error, and prepare to leave for the day. 4.) The nurse is caring for a client who has a prescription for acetaminophen 325 mg 2 tablets by mouth (PO) every 4 hours as needed for temperature over 101° F. The client requests something for a headache. Which of the following actions by the nurse is appropriate? a. Explain to the client that the only thing they have prescribed is for a fever. b. Check the last set of vital signs to see if the client was running a temperature. c. Administer the acetaminophen since it can be used for fever and headache. d. Contact the primary health care provider (PHCP) to get an order for pain control. 5) The nurse is caring for a client who takes 6 tablets of methotrexate once every week on Fridays. How many mg of methotrexate does the client take per dose according to the exhibit below? a. 2.5 mg. b. 15 mg. c. 2.4 mg. d. 6 mg. 6) The nurse is preparing to administer a medication from a vial. In which order should the nurse perform the steps in the exhibit below, starting with the first step? 1. Invert the vial. 2. Fill the syringe with medication. 3. Inject air into the airspace of the vial. 4. Clean with alcohol swab and allow to dry. 5. Pull back on the plunger the amount to be drawn up. 6. Tap the side of the syringe barrel to remove air bubbles. Group of answer choices a. 4, 1, 5, 3, 6, 2. b. 4, 5, 3, 1, 2, 6. c. 1, 4, 5, 3, 2, 6. d. 1, 4, 5, 3, 6, 2. 7) The nurse is preparing to administer the client’s prescribed narcotic analgesic. The nurse should first assess the client’sa. blood pressure. b. heart rate. c. respiratory rate. d. morning laboratory results. 8) The nurse is preparing to administer oral (by mouth, PO) medications to a client. The nurse is performing the first medication check at the medication dispensing cart. Which of the following actions indicates the need for follow up? a. Document administration of the medication in the MAR. b. Perform a math calculation if the ordered dose does not match the label dose. c. Compare the medication label to the medication order in the MAR. d. Verify the client’s name and room number against the medication administration record (MAR). 9) The nurse is preparing to administer oral (by mouth, PO) medications to a client who is diagnosed with dementia. The nurse enters the room and finds the family at the bedside and the client is sleeping. Which action should the nurse take next? a. Inform the family that the nurse will return once the client wakes up. b. Wake the client and administer the PO medication with sips of water. c. Return the medication to the medication cart and check on the client in one hour. d. Ask the family to call the nurse when the client wakes up. 10) The nurse is administering a proton pump inhibitor (PPI) through a nasogastric (NG) tube that is on low intermittent suction to a client. Which of the following actions is the most important for the nurse to take to ensure effective absorption? a. Prepare the medication by thoroughly shaking prior to administration. b. Flush NG tube with only 10-15 mL of water after all medications have been administered. c. Position the client in the supine position for 30 minutes to 1 hour after administration. d. Clamp the NG tube for 30 minutes to 1 hour after medication administration. 11) The nurse is reviewing a hand-written order for a client of phenytoin (a medication for seizures) 500 mg IM q3-4h PRN for pain. The nurse believes that the primary health care provider (PHCP) may have meant to write hydromorphone (an opioid). Which of the following actions should the nurse take next? a. Administer the medication and ask the PHCP for an additional order for the pain medication. b. Give the hydromorphone and have the charge nurse sign off on the change order as it is clearly an error.c. Hold the medication and call the PHCP to verify even though the client is currently in pain. d. Refuse to give the medication and notify the nurse manager so they can question the PHCP. 12) The nurse is caring for a client who has been prescribed a medication to be administered intradermally. It requires follow up if the nurse a. uses a 1-mL syringe with a 25-gauge, 1/4-inch needle. b. creates a bleb or wheal after injecting the medication. c. ensures that the volume to be injected is no more than 0.1 mL. d. injects the medication using a 30-degree angle. 13) While giving a client an intramuscular (IM) injection of a corticosteroid medication, the nurse aspirates by pulling back slightly on the plunger of the syringe. The rationale behind aspiration with an IM injection is to a. make sure the needle is in a muscle. b. reduce the discomfort of the injection. c. decrease the force of the injection. d. reduce the chance of a hematoma. 14) The nurse is giving an intramuscular (IM) injection of methylprednisolone to a client. Upon aspiration, the nurse notices blood return in the syringe. Which of the following actions should the nurse take next? a. Withdraw the needle, discard it, and start from the beginning. b. There is no longer a need to aspirate any IM injections. c. Pull the needle back slightly and inject the medication. d. Withdraw the needle and select a different injection site 15) The nurse is preparing to give an intramuscular (IM) antibiotic injection to a 72-year-old client. Which of the following is the preferred site for the injection? a. Dorsal gluteal. b. Vastus lateralis. c. Deltoid. d. Ventrogluteal. 16) The nurse is caring for a client who has been prescribed an oral antibiotic tablet that has been dispensed in a single (unit) dose package. Which of the following indicates the correct technique when administering a medication in tablet form? a. Cutting the tablet along the scored area with a pill cutter if needed.b. Placing the opened tablet in a medication cup prior to entering the room. c. Assessing blood pressure (BP) prior to administration. d. Positioning the client supine during medication administration. 17) The nurse is preparing to administer a rectal medication to a client. Which of the following indicates correct administration technique? a. Lubricating the flat end of the suppository. b. Having the client bear down during suppository insertion. c. Inserting the suppository beyond the rectal sphincter. d. Placing the client in a prone position. 18) The nurse is caring for a client who is prescribed a vaginal suppository. Which of the following demonstrates proper administration technique? a. Asking the client to remain in the supine position for 5-10 minutes after insertion. b. Removing the applicator after use and placing it on a towel. c. Placing the client on a bedpan prior to insertion of the suppository. d. Quickly pushing the plunger of the applicator until the applicator is empty. 19) The nurse is caring for a client diagnosed with contact dermatitis. The primary health care provider (PHCP) has prescribed a topical ointment for pruritus. Which of the following indicates correct technique for administration of the medication? a. Remove any dry, flaky skin prior to administration. b. Remove extra hair from the area using an electric razor. c. Cleanse the area with soap and water, and pat dry prior to administration. d. Apply in a circumference around the affected skin but not directly over it. 20) The nurse is teaching a client about using transdermal patches at home. Which of the following client statements indicates a correct understanding of the teaching? a. “I will press the patch securely in place on my forearm.” b. “I will clean and dry the same area before applying the patch.” c. “I can use lotion to soothe irritated skin before applying a new patch.” d. “I will remove the old patch and apply a new one in a different location.” 21) The nurse is administering prescribed ophthalmic drops to a client who has glaucoma. Which of the following indicates a correct technique for administration? a. Apply the second drop of medication from the bottle into the eye.b. Instruct the client to squeeze the eyes shut after administration. c. Lift the upper lid and apply the drops over the iris. d. Place the drop of medication into the lower lid. 22) The nurse is preparing to administer prescribed otic (ear) drops to a 12-year-old child. Which of the following indicates correct technique for administering this medication? a. Place the tip of the dropper into the ear canal to administer the drops. b. Warm the medication container by rolling it in the palms of the hands. c. Instruct the child to stay in a side-lying position for 20 minutes after administration. d. Pull the pinna downward and backward for administration. 23) The nurse is teaching a postoperative client who is being discharged home. It demonstrates attainment of a cognitive skill if the client a. gets dressed independently after eating breakfast in the morning. b. explains that prescribed medications should be taken with food. c. demonstrates how to care for the surgical incision. d. uses crutches appropriately to move up and down stairs. 24) The nurse is preparing to teach a client who has recently been diagnosed with diabetes mellitus. Which of the following should the nurse consider when teaching a client? a. The availability of a support system. b. The findings from the physical assessment. c. The literacy level of the client. d. The client’s home environment. 25) The nurse is caring for a client who has been diagnosed with diabetes mellitus and must learn how to do a finger stick to check blood glucose levels. The client has been discouraged and withdrawn since receiving the diagnosis. Which of the following actions should the nurse take to assist in increasing the client's motivation to learn? a. Tell the client that it is normal to feel fearful about sticking themselves. b. Encourage the client to participate each time the finger-stick is performed. c. Continue performing the finger-stick until the client is ready to learn. d. Demonstrate the finger-stick on a family member to prove it is basically painless. 26) The nurse is caring for a client who has arthritis and experiences chronic pain daily. Which of the following findings should the nurse expect to observe?a. Constricted pupils. b. Diaphoresis. c. Anxiety and restless. d. Normal vital signs. 27) The nurse has attended an educational conference on non-pharmacological pain relief. Which of the following statements indicates the need for additional teaching? a. “A transcutaneous electrical nerve stimulation (TENS) unit is a common therapy.” b. “I can use non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief.” c. “Prayer is sometimes used to help alleviate pain.” d. “Guided imagery can be taught for pain relief.” 28) The nurse is caring for a 4-day postoperative client who is reporting incisional pain of 6 on a pain scale of 0(no pain) to 10 (severe pain). The nurse should prepare to administer which of the following prescribed medications first? a. Hydrocodone 10 mg PO (by mouth). b. Aspirin 650 mg PO. c. Acetaminophen 500 mg PO. d. Ibuprofen 200 mg PO. 29) The nurse is caring for an older adult who is unable to speak due to a stroke. Which of the following pain assessment tools should the nurse use for this client? a. Wong-Baker FACES scale. b. Pain awareness scale. c. Numeric rating scale. d. FLACC scale. 30) The nurse is caring for a client who is hospitalized and from another country and is continually being cared for by family members. The constant presence of family members at the bedside has presented a problem with the delivery of care. Which of the following actions by the nurse addresses this concern in a culturally sensitive manner? a. Ask the charge nurse for a change in client care assignment. b. Evaluate the benefits of having the family participate in the care. c. Explain to the client and family that visitors need to be limited. d. Ask the primary health care provider (PHCP) to write a prescription limiting visitors.31) The nurse has recently attended a conference regarding how to provide culturally competent health care. Which of the following actions should the nurse take initially to begin providing this type of care? a. Determine if the client's belief system has been included in the delivery of care. b. Learn about the world view of others. c. Assess personal assumptions, biases, and attitudes. d. Ask the client about alternative approaches to healing. 32) The nurse is preparing to assess a female client who is from a culture that dictates what forms of touching are considered appropriate. Before beginning the assessment, which of the following actions should the nurse take? a. Inform the client of what needs to be done and ask for permission to be touched. b. Make sure the client has a female nurse assigned at all times. c. Ask the client to talk about their cultural beliefs and practices. d. Document that the assessment is limited due to cultural restrictions. 33) The hospice nurse is visiting a family who lost a child last year. The parents are talking about the upcoming anniversary of the child’s death. The nurse spends time with them discussing their child’s life and death. Which of the following nursing principles does the nurse's action demonstrate? a. Palliative care. b. Loss validation assessment. c. Encouragement of normal grieving. d. Grief assessment. 34) The nurse is called into the supervisor's office regarding deteriorating work performance since the loss of a spouse 2 years ago. The nurse begins sobbing and says things at home are falling apart as well. Which of the following types of grief is the nurse experiencing? a. Unresolved grief. b. Disenfranchised grief. c. Expected grief. d. Anticipatory grief. 35) The nurse is assessing a client for factors that may interfere with adherence to the prescribed medical treatment. Which of the following questions should the nurse ask when attempting to determine risk factors? a. “Has anyone in your family ever received similar medical treatment?” b. “How much physical activity do you perform in a weeks’ time?”c. “Have you had any recent changes with your weight?” d. “How much does your medical treatment interfere with your daily lifestyle?” 36) The nurse is reviewing the vital signs of assigned clients. Which of the following results requires immediate follow-up? a. An oral temperature of 100.4° F. b. A blood pressure of 158/110 mm Hg. c. An apical pulse of 110. d. A respiratory rate of 22. 37) The nurse is caring for a client who has developed pain in the left calf. Which of the following actions by the nurse reflects clinical reasoning? a. Notify the primary health care provider (PHCP). b. Check color, temperature, and pulses distally. c. Request that an ultrasound of the calf be performed. d. Administer a prescribed analgesic. 38) The nurse is caring for a client who has a fractured leg. The nurse is auscultating the breath sounds over the peripheral lung fields. Which of the following sounds is an expected finding? a. Rhonchi. b. Vesicular. c. Bronchial. d. Broncho-vesicular. 39) The nurse is caring for a client who has been prescribed the diuretic furosemide. The client is reporting muscle weakness and heart palpitations. Which of the following laboratory results is essential for the nurse to monitor? a. Sodium. b. Calcium. c. Potassium. d. Magnesium. 40) The nurse is caring for a client who has a potassium level of 2.9 mEq/L. The nurse should assess the client for a. hyperactive deep tendon reflexes. b. muscle twitching.c. cardiac dysrhythmias. d. numbness in the extremities. 41) The charge nurse is observing a newly hired nurse insert a urinary catheter into a female client. It indicates correct technique if the newly hired nurse is observed a. reinserting the catheter after it was misplaced in the vagina. b. keeping both hands sterile throughout the procedure. c. advancing the catheter to the “Y” split of the catheter. d. using the last cotton ball to cleanse directly over the meatus. 42) The nurse is planning a staff development conference about the use of hot and cold therapy. Which of the following statements by a participant indicates a correct understanding of the conference? a. “Heat therapy is not used in the first 24 hours after a traumatic injury because it may cause increased swelling and bleeding.” b. “Heat therapy is not used in the first 24 hours after injury because it may cause arterial spasm and delay healing.” c. “When using cold therapy, the temperature must be less than 32° F to achieve the desired effects.” d. “Cold therapy is indicated for treatment of open wounds because it improves blood flow to the area and reduces pain.” 43) The nurse is teaching a client about ways to control orthostatic (postural) hypotension. Which of the following statements by the client indicates the correct way to manage this illness? a. “I will need to sleep with my head flat to avoid headaches.” b. “I will need to avoid chewing on ice to avoid that head rush feeling.” c. “I need to sit on the side of the bed and let my feet dangle before standing up.” d. “I will need to drink more water at night to avoid a low morning blood pressure.” 44) The nurse is caring for a client who is in respiratory distress. It requires immediate intervention if the nurse observes a. clubbed fingers. b. a pulse of 92. c. substernal retractions. d. respirations of 22.45) The nurse is caring for a client who has pneumonia and has been prescribed 4 L of oxygen and is breathing mostly through the mouth. Which of the following oxygen delivery systems should the nurse use for this client? a. Nasal cannula. b. Simple face mask. c. Bag valve mask (Ambu bag). d. non-rebreather mask. 46) The nurse has attended a continuing education conference about the use of sequential compression devices (SCDs). It indicates a correct understanding if the nurse states that SCDs are used to a. actively exercises the muscles of the legs until the client can walk. b. enhances venous return to the heart for clients with limited mobility. c. prevents third-spacing of fluid into the lower extremities. d. improve vasoconstriction in the lower extremities. 47) The nurse is caring for a client who is being treated for hypertension. It indicates a potential complication from the disease process if the client’s a. morning headaches have decreased in frequency and severity. b. peripheral pulses are bounding and client reports feeling dizzy. c. blood pressure averages drop following weight loss. d. blood pressure increases when measuring orthostatic vital signs. 48) The nurse is caring for a client who has been diagnosed with a terminal illness. Which of the following nursing interventions assists the client with coping? a. Maximize family involvement in care so they can develop coping strategies for the client. b. Provide the client with information on reasonable options only, to decrease a false sense of hope. c. Have the client discuss any concerns with the primary health care provider (PHCP). d. Provide all information to the client about the diagnosis and plan of care. 49) The nurse is preparing a teaching session for a group of clients regarding a healthy heart diet. The nurse should include in the teaching to eat foods that are a. low in natural sugars. b. high in carbohydrates. c. high in unsaturated fats.d. low in saturated fats 50) The nurse notices that a co-worker is exhibiting a pattern of behavior suggestive of drug abuse. Which of the following actions should the nurse take? a. Discuss the suspicions with the charge nurse and let them handle it from there. b. Confront the co-worker to see if there is an easily explained reason for the behavior. c. Get proof of the drug abuse prior to reporting it. d. Leave a message on the compliance office anonymous hotline.