Nursing 101 Exam 2: UPDATED ACTUAL Questions and
CORRECT Answers
The nurse auscultates a client with soft, high-pitched crackles
popping breath sounds on inspiration. The nurse
documents the breath sounds heard as:
Which medication is administered in the home or the corticosteroids
hospital to relieve inflammation in the lung tissue?
When a nurse observes that an older client's skin is dry poor tissue perfusion
and shiny and his nails are thickened, the nurse
determines that the client is most likely experiencing
The nurse is caring for a client who has a compromised arterial blood gas
cardiopulmonary system and needs to assess the client's
tissue oxygenation. The nurse would use which
appropriate method to assess this client's oxygenation?
The nurse is caring for a client with metabolic acidosis pH less than 7.35; HCO3 low; PaCO2 low
whose breathing rate is 28 breaths per minute. Which
arterial blood gas data does the nurse anticipate finding?
The plan of care for a client exhibiting signs of sensory providing a backrub with morning and evening care
deprivation includes incorporating tactile stimulation.
Which nursing intervention will provide tactile
stimulation?
During the nurse's morning assessment of a client with a Reorient the client to place and time.
diagnosis of dementia, the client states that the year is
1949 and she believes she is in a hotel. How should the
nurse best respond to this client's disorientation?
The physician tells the nurse that the elderly client has Decrease background noises, as much as possible, before speaking
presbycusis. Which of the following interventions will the
nurse place in the client's care plan?
The nurse assesses that her client has olfactory Eliminating disturbing odors with adequate ventilation
disturbances. Which of the following health topics would
be important to teach the client?
The community health nurse wants to identify clients who Do you work around loud noises at work?"
have lifestyle factors that may place them at risk for
sensory disturbances. Which of the following questions
should she ask?
Which example indicates the use of an internal sensory spitting out of hot coffee
receptor?
, A client reports to a health care facility with reporting client himself
abdominal pain and vomiting. The client's wife informs the
nurse that the client had gone out for dinner the previous
night. Which of the following would be the primary
source of assessment data?
During morning report, the night nurse tells the day nurse The nurse should determine the reason for the client's refusal.
that the client refused to allow the technician to draw
blood for laboratory testing. What step would be
essential for the day nurse to complete before selecting
a nursing diagnosis to address this issue?
The client, who is 8 weeks pregnant as the result of a Decisional Conflict related to conflict with moral beliefs as evidenced by the
rape, tells the nurse, "I do not want to have this baby, but client's statement
I have always believed that abortion is a sin. I don't know
what to do." What nursing diagnosis would be most
appropriate for the nurse to formulate?
A 50-year-old female client is admitted to a hospital unit Consult nursing and medical literature.
with the diagnosis of scleroderma. The nurse is unfamiliar
with this condition. What is the nurse's best source of
information?
A nurse has a two-way video communication with the Telemedicine and mobile technology
specialist involved in the care of a client in a long-term
care facility. This is an example of what nursing
informatics technology?
HIPAA allows incidental disclosures of client health A visitor hears a confidential conversation between two nurses in surroundings
information as long as it cannot reasonably be prevented, that are appropriate and with voices that are kept low.
is limited in nature, and occurs as a byproduct of an The nurse uses x-ray light boards that can be seen by passersby; however, client
otherwise permitted use or disclosure of client health x-rays are not left unattended on them.
information. What are examples of this type of client The nurse calls out names in the waiting room, but does not disclose the reason
health information disclosure? Select all that apply. for the client visit.
The nurse is caring for a client whose spouse wishes to "Only authorized persons are allowed to access client records."
see the electronic health record. What is the appropriate
nursing response?
which of the following is a s/sx of late hypoxia? cyanosis
which of the following would lead to an increase in o2 fever
demand?
a. fever
b. sleep
c. taking a narcotic
d. postural drainage
the primary purpose of an oral airway is? to prevent obstruction of the trachea by displacement of the tongue into the
oropharynx
CORRECT Answers
The nurse auscultates a client with soft, high-pitched crackles
popping breath sounds on inspiration. The nurse
documents the breath sounds heard as:
Which medication is administered in the home or the corticosteroids
hospital to relieve inflammation in the lung tissue?
When a nurse observes that an older client's skin is dry poor tissue perfusion
and shiny and his nails are thickened, the nurse
determines that the client is most likely experiencing
The nurse is caring for a client who has a compromised arterial blood gas
cardiopulmonary system and needs to assess the client's
tissue oxygenation. The nurse would use which
appropriate method to assess this client's oxygenation?
The nurse is caring for a client with metabolic acidosis pH less than 7.35; HCO3 low; PaCO2 low
whose breathing rate is 28 breaths per minute. Which
arterial blood gas data does the nurse anticipate finding?
The plan of care for a client exhibiting signs of sensory providing a backrub with morning and evening care
deprivation includes incorporating tactile stimulation.
Which nursing intervention will provide tactile
stimulation?
During the nurse's morning assessment of a client with a Reorient the client to place and time.
diagnosis of dementia, the client states that the year is
1949 and she believes she is in a hotel. How should the
nurse best respond to this client's disorientation?
The physician tells the nurse that the elderly client has Decrease background noises, as much as possible, before speaking
presbycusis. Which of the following interventions will the
nurse place in the client's care plan?
The nurse assesses that her client has olfactory Eliminating disturbing odors with adequate ventilation
disturbances. Which of the following health topics would
be important to teach the client?
The community health nurse wants to identify clients who Do you work around loud noises at work?"
have lifestyle factors that may place them at risk for
sensory disturbances. Which of the following questions
should she ask?
Which example indicates the use of an internal sensory spitting out of hot coffee
receptor?
, A client reports to a health care facility with reporting client himself
abdominal pain and vomiting. The client's wife informs the
nurse that the client had gone out for dinner the previous
night. Which of the following would be the primary
source of assessment data?
During morning report, the night nurse tells the day nurse The nurse should determine the reason for the client's refusal.
that the client refused to allow the technician to draw
blood for laboratory testing. What step would be
essential for the day nurse to complete before selecting
a nursing diagnosis to address this issue?
The client, who is 8 weeks pregnant as the result of a Decisional Conflict related to conflict with moral beliefs as evidenced by the
rape, tells the nurse, "I do not want to have this baby, but client's statement
I have always believed that abortion is a sin. I don't know
what to do." What nursing diagnosis would be most
appropriate for the nurse to formulate?
A 50-year-old female client is admitted to a hospital unit Consult nursing and medical literature.
with the diagnosis of scleroderma. The nurse is unfamiliar
with this condition. What is the nurse's best source of
information?
A nurse has a two-way video communication with the Telemedicine and mobile technology
specialist involved in the care of a client in a long-term
care facility. This is an example of what nursing
informatics technology?
HIPAA allows incidental disclosures of client health A visitor hears a confidential conversation between two nurses in surroundings
information as long as it cannot reasonably be prevented, that are appropriate and with voices that are kept low.
is limited in nature, and occurs as a byproduct of an The nurse uses x-ray light boards that can be seen by passersby; however, client
otherwise permitted use or disclosure of client health x-rays are not left unattended on them.
information. What are examples of this type of client The nurse calls out names in the waiting room, but does not disclose the reason
health information disclosure? Select all that apply. for the client visit.
The nurse is caring for a client whose spouse wishes to "Only authorized persons are allowed to access client records."
see the electronic health record. What is the appropriate
nursing response?
which of the following is a s/sx of late hypoxia? cyanosis
which of the following would lead to an increase in o2 fever
demand?
a. fever
b. sleep
c. taking a narcotic
d. postural drainage
the primary purpose of an oral airway is? to prevent obstruction of the trachea by displacement of the tongue into the
oropharynx
