ASSESSMENT TEST WITH 150
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ACTUAL LATEST FINAL EXAM
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A nurse is teaching a newly licensed nurse about preventing a catheter-associated
urinary tract infection for a client who has an indwelling urinary catheter. Which of
the following instructions should the nurse include?
A. Ensure the urinary catheter tubing is not kinked
B. Rest the catheter bag on the floor when the client is sitting in a chair
,C. Clean the perineal area with an antiseptic solution
D. Empty the collection bag for the client every 12 hr - ANSWER- A
Kinks can cause blockage of urinary flow and result in a UTI
A nurse is planning wound management for a client who has a stage 3 pressure
injury. Which of the following interventions should the nurse include in the plan?
A. Measure the depth of the wound with a cotton-tipped applicator
B. Measure the wound using a reusable tape measure
C. Cover the wound bed with dry gauze dressings
D. Cleanse the wound with soap and water - ANSWER- A
Check wound for tunneling
A nurse is planning care for four clients following chase-of-shift report. Which of
the following clients is the nurse's priority?
A. A client who had a stroke and has expressive aphasia
B. A client who has a hemoglobin of 11g/dL and requires 1 unit of blood
C. A client who has asthma and a peak expiratory flow rate in the green zone
D. A client who has peptic ulcer disease and a rigid abdomen - ANSWER- D
The client is unstable and a rigid abdomen is a manifestation of a perforated peptic
ulcer and could lead to septicemia and shock.
A nurse is planning care for four clients following chase-of-shift report. Which of
the following clients should the nurse see first?
A. A client who is receiving propranolol and has a HR of 55/min
B. A client who is receiving warfarin and has an INR of 2.5
C. A client who has a pacemaker and has persistent hiccuping
D. A client who has cholecystitis and reports rebound tenderness - ANSWER- C
,Hiccuping is a manifestation of a dislocation of the pacemaker lead and could lead
to bradycardia and decreased CO
A nurse is reviewing the laboratory data of a client who is taking the herbal
supplement feverfew to reduce the frequency of migraine headaches. The nurse
should identify that which of the following findings indicates a potential
contraindication to taking this herbal supplement?
A. Potassium 3.5mEq/L
B. Platelet count 100,000/mm3
C.Cholesterol 250mg/dL
D. Urine bilirubin 0.2mg/dL - ANSWER- B
Feverfew can lead to platelet dysfunction by suppressing platelet aggregation. A
patient with a decreased platelet count should not take fever few because it can
increase the risk of bleeding. Monitor for bleeding and impaired coagulation while
taking feverfew
Ranges:
-Platelet 150,000-450,000/mm3
-Potassium 3.5-5mEq/L
-Cholesterol <200mg/dL
-Urine Bilirubin 0.0mg/dL
A nurse is caring for a client who is postoperative and has a history of heart failure.
The client reports slight dyspnea when ambulating. Which of the following
findings should the nurse expect when performing a skin assessment?
A. Petechiae over the client's chest and abdomen
B. Tenting of the skin on the client's arm
C. Shiny areas on the client's ankles and feet
D. Dry, flaky skin on the client's arms and hands - ANSWER- C
, Edema is an expected finding for HF with dyspnea with exertion. Edematous skin
appears taut and shiny, and can also look swollen and blanched.
A hospice nurse is planning end-of-life comfort care for a client. Which of the
following interventions should the nurse include in the plan?
A. Cover the client with an electric blanket if extremities become mottled
B. Provide frequent feedings during the day
C. Position the client on their side to improve breathing
D. Remove visitors from the room if the Clint becomes restless - ANSWER- C
Position laterally to improve breathing and promote comfort
A nurse is teaching a client who has a prescription for continuous ambulatory
peritoneal dialysis. Which of the following instructions should the nurse include?
A. Eat a low-fiber diet to maintain dialysate flow
B. Warm the dialysate in the microwave before instillation
C. Expect the dialysate outflow to appear cloudy
D. Allow the dialysate to dwell for 4 hr during each exchange - ANSWER- D
Allow to dwell for 4-8 hr during each exchange to filter and remove fluid and
waste products
A nurse is providing hydrotherapy for a client who has full-thickness turns on the
lower leg. Which of the following actions should the nurse take?
A. Perform the hydrotherapy three times per week
B. Wash the client's burns with mild soap
C. Rinse the client's burns with cold water
D. Immerse the client in a whirlpool tub - ANSWER- B
Mild soap and water to clean and decried the wounds, promote healing, and reduce
the risk for infection
A nurse is assessing a client who is receiving head and neck radiation therapy to