QUESTIONS WITH SOLUTIONS GRADED A
PLUS COMPLETE REVIEW SET 200 ITEMS
◉ A nurse is collecting data from a client who was admitted with a
Glasgow Coma Scale of 3. Which
of the following findings should the nurse expect?
- Vacalizes sound
-Blinks eyes when asked
-Follows motor commands
-Nonresponsive Commands.
Answer: Nonresponsive Commands
A client who has a GCS of less than 8 has evidence of severe head
injury and is in a comatose state. The GCS is a standardized tool that
allows for the evaluation of a client's level of consciousness. The test
is divided into three sections that evaluate eye opening, motor
response, and verbal response. The GCS ranges from a high score of
15 (fully alert) to a low score of 3 (fully comatose).
◉ A nurse is monitoring a client who has a pneumothorax and a
chest tube in place with a closed chest drainage system connected to
,low suction. For which of the following findings should the nurse
notify the charge nurse
- Fluctation of the water level in the water seal chamber
-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber.
Answer: - Persistent bubbling in the water seal chamber
Excessive and persistent bubbling in the water-seal chamber
indicates an air leak in the drainage system. The nurse should notify
the charge nurse of this finding.
◉ A nurse is reinforcing teaching with a male client who has right
sided hemiparesis about
preforming ADL's. Which of the following instructions should the
nurse include in the teaching
-Comb your hair with the unaffected arm
-Dress your unaffected side first
choose clothing with buttons
-shave with your affected side.
Answer: Comb your hair with the unaffected arm
,The nurse should instruct the client to brush their hair with the
unaffected arm to reduce frustration and increase independence and
self-esteem.
◉ A nurse is collecting data from a client and auscultates
intermittent high-pitched sounds during inspiration over the lower
base of the lungs. The nurse should identify this finding as which of
the following lungs sounds
- Fine crackles
-stridor
-rhonchi
-friction.
Answer: - Fine crackles
Fine crackles are auscultated in the base of the lungs as air moves
through airway secretions. Fine crackles are intermittent, high-
pitched sounds heard more often during inspiration.
◉ A nurse is collecting data from a client who has coronary artery
disease. Which of the following
manifestations should the nurse identify as an indication that the
client has angina ( SatA)
- Chest Discomfort Radiated
, - Pain lasting less that 15mins
- Pain that is relieved with rest.
Answer: - Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with res
◉ A nurse is receiving change-of-shift report for a group of clients.
Which of the following clients
should the nurse plan to see first?
- A client who has diabetes mellitus with diaphoretic.
Answer: A client who has diabetes mellitus with diaphoretic
When using the urgent vs. nonurgent approach to client care, the
nurse should determine that the priority action is to attend to a
client who has diabetes mellitus and is diaphoretic. Diaphoresis is a
manifestation of hypoglycemia and can lead to decreased cerebral
function. The nurse should check the client's blood glucose and
administer a fast-acting glucose as prescribed.
◉ A nurse is reinforcing teaching with a young adult client about
testicular self-examination. Which
of the following instructions should the nurse include?
- Examine your testicles after a warm shower
- Press each testicle inwardly with your finger