NURS 337 FINAL QUESTIONS WITH VERIFIED
ANSWERS
During a mental status examination, a hospitalized client states that she cannot
remember if she is married or if she has children.
The nurse would document this as an example of what aspect of the mental status
examination?
Decreased judgment
Decreased level of knowledge
Poor insight
Poor remote memory - Answers - poor remote memory
Which of the following are examples of subjective assessment data? (Select all that
apply)
Client states he has "no reason to live."
Client's speech is slow and soft.
Client has jaundiced skin color.
Client can recall three numbers.
Client "meditates for relaxation." - Answers - Client states he has "no reason to live"
Client "meditates for relaxation"
While performing a mental status examination on a client, the nurse notices that the
client has a slouched posture.
This information should be documented as part of the client's ______________?
Appearance
Behavior
Thought Process
Judgment - Answers - appearance
Why is it important to label the dressing covering the site of an intravenous access
device with the date, time, and nurse's initials?
Reminds the nurse when to change the infusion tubing.
Informs the nurse and other staff when the next dressing change is due.
Reminds the nurse to document the insertion of the device.
Proves that the access site was assessed. - Answers - Informs the nurse and other staff
when the next dressing change is due
The nurse is performing an IV insertion procedure on a client.
Which of the following actions puts the client at risk?
Select All That Apply.
Verify client's name and birthdate.
,Place tape for anchoring the IV on the hospital bed railing or tray table so that it is
handy
Touch the open hub of the IV catheter after removing the needle
Touch the area that has already been cleansed / prepared for the IV insertion
Perform hand hygiene - Answers - Place tape for anchoring the IV on the hospital bed
railing or tray table so that it is handy
Touch the open hub of the IV catheter after removing the needle
Touch the area that has already been cleansed / prepared for the IV insertion
Which action would the nurse take first if an intravenous (IV) insertion site appeared
red, warm, and swollen?
Apply a heat pack.
Elevate the extremity the IV site is on.
Change the dressing.
Discontinue the infusion. - Answers - Discontinue the infusion.
What is the primary - and potentially most serious - danger related to a broken IV
catheter tip?
Pain
Phlebitis
Embolus
Infection - Answers - Embolus
What would the nurse do to assess a patient's risk for embolus when removing a
venous access device?
Ask the patient to rate any pain at the site.
Palpate the site for possible edema.
Visualize the tip of the IV catheter.
Inspect for redness. - Answers - Visualize the tip of the catheter
When should the tourniquet be released a second time during the procedure for
insertion of a peripheral intravenous device?
After flushing the newly-placed IV with sterile saline to verify patency.
Immediately after observing a "flashback" of blood in the catheter.
After a "flashback" of blood is observed and the catheter has been advanced off the
stylet.
Immediately after the catheter punctures the skin. - Answers - After a "flashback" of
blood is observed and the catheter has been advanced off the stylet.
A client states, "The voices keep telling me that my hands are dirty." What is the best
response by the nurse?
"I don't hear anything; you must be imagining it."
"Maybe you should wash your hands."
"I believe you are hearing the voices but I think it is a part of your illness because I
cannot hear them."
, "Yes, I hear that, too. Don't worry, the voices say that to all of us." - Answers - "I believe
you are hearing the voices but I think it is a part of your illness because I cannot hear
them."
A client states that she hears voices constantly and that they interfere with her ability to
sleep.
Which intervention suggested by the nurse would be appropriate and potentially
therapeutic for the client?
Drink herbal tea before bedtime.
Take an over-the-counter sleep medication regularly.
Listen to soothing music with headphones while you are trying to fall asleep.
Contact a nearby psychiatric hospital immediately. - Answers - Listen to soothing music
with headphones while you are trying to fall asleep.
What can nurses do to provide therapeutic, compassionate care to clients who hear
voices?
Ask questions in a calm, patient manner.
Complete your assessments as quickly as possible.
Reassure the client that everyone hears the voices.
Discourage discussion of imaginary voices or visions - Answers - Ask questions in a
calm, patient manner.
The APGAR score is typically performed on the newborn at minute ____ and ____
minutes after birth. - Answers - 1 and 5
Which of the following ranges represents a normal heart rate for a newborn?
80 - 160 bpm
80 - 120 bpm
160 - 200 bpm
120 - 160 bpm - Answers - 120 - 160 bpm
New parents observe that their 1-hour old newborn has blue hands and feet. The rest of
the newborn's body is pink and the baby is breathing and crying. The parents express
concern about the blue hands and feet and ask the nurse if it is normal.
What is the best reply by the nurse?
"It is normal for a newborn to have blue and hands and feet for the first few hours as
circulation is established; this is called acrocyanosis."
"Thank you for pointing that out; I will contact the physician to report this finding."
"That is discoloration related to bruising from the birth process."
"It is normal for a newborn to have blue and hands and feet for the first few hours as
circulation is established; this is called extremity hypoxia." - Answers - "It is normal for a
newborn to have blue and hands and feet for the first few hours as circulation is
established; this is called acrocyanosis."
A patient who has chronic heart failure tells the nurse, "I don't pass much urine during
the day but, once I lay down to go to sleep, I feel like I have to pee every hour!"
The nurse will document this assessment finding as:
ANSWERS
During a mental status examination, a hospitalized client states that she cannot
remember if she is married or if she has children.
The nurse would document this as an example of what aspect of the mental status
examination?
Decreased judgment
Decreased level of knowledge
Poor insight
Poor remote memory - Answers - poor remote memory
Which of the following are examples of subjective assessment data? (Select all that
apply)
Client states he has "no reason to live."
Client's speech is slow and soft.
Client has jaundiced skin color.
Client can recall three numbers.
Client "meditates for relaxation." - Answers - Client states he has "no reason to live"
Client "meditates for relaxation"
While performing a mental status examination on a client, the nurse notices that the
client has a slouched posture.
This information should be documented as part of the client's ______________?
Appearance
Behavior
Thought Process
Judgment - Answers - appearance
Why is it important to label the dressing covering the site of an intravenous access
device with the date, time, and nurse's initials?
Reminds the nurse when to change the infusion tubing.
Informs the nurse and other staff when the next dressing change is due.
Reminds the nurse to document the insertion of the device.
Proves that the access site was assessed. - Answers - Informs the nurse and other staff
when the next dressing change is due
The nurse is performing an IV insertion procedure on a client.
Which of the following actions puts the client at risk?
Select All That Apply.
Verify client's name and birthdate.
,Place tape for anchoring the IV on the hospital bed railing or tray table so that it is
handy
Touch the open hub of the IV catheter after removing the needle
Touch the area that has already been cleansed / prepared for the IV insertion
Perform hand hygiene - Answers - Place tape for anchoring the IV on the hospital bed
railing or tray table so that it is handy
Touch the open hub of the IV catheter after removing the needle
Touch the area that has already been cleansed / prepared for the IV insertion
Which action would the nurse take first if an intravenous (IV) insertion site appeared
red, warm, and swollen?
Apply a heat pack.
Elevate the extremity the IV site is on.
Change the dressing.
Discontinue the infusion. - Answers - Discontinue the infusion.
What is the primary - and potentially most serious - danger related to a broken IV
catheter tip?
Pain
Phlebitis
Embolus
Infection - Answers - Embolus
What would the nurse do to assess a patient's risk for embolus when removing a
venous access device?
Ask the patient to rate any pain at the site.
Palpate the site for possible edema.
Visualize the tip of the IV catheter.
Inspect for redness. - Answers - Visualize the tip of the catheter
When should the tourniquet be released a second time during the procedure for
insertion of a peripheral intravenous device?
After flushing the newly-placed IV with sterile saline to verify patency.
Immediately after observing a "flashback" of blood in the catheter.
After a "flashback" of blood is observed and the catheter has been advanced off the
stylet.
Immediately after the catheter punctures the skin. - Answers - After a "flashback" of
blood is observed and the catheter has been advanced off the stylet.
A client states, "The voices keep telling me that my hands are dirty." What is the best
response by the nurse?
"I don't hear anything; you must be imagining it."
"Maybe you should wash your hands."
"I believe you are hearing the voices but I think it is a part of your illness because I
cannot hear them."
, "Yes, I hear that, too. Don't worry, the voices say that to all of us." - Answers - "I believe
you are hearing the voices but I think it is a part of your illness because I cannot hear
them."
A client states that she hears voices constantly and that they interfere with her ability to
sleep.
Which intervention suggested by the nurse would be appropriate and potentially
therapeutic for the client?
Drink herbal tea before bedtime.
Take an over-the-counter sleep medication regularly.
Listen to soothing music with headphones while you are trying to fall asleep.
Contact a nearby psychiatric hospital immediately. - Answers - Listen to soothing music
with headphones while you are trying to fall asleep.
What can nurses do to provide therapeutic, compassionate care to clients who hear
voices?
Ask questions in a calm, patient manner.
Complete your assessments as quickly as possible.
Reassure the client that everyone hears the voices.
Discourage discussion of imaginary voices or visions - Answers - Ask questions in a
calm, patient manner.
The APGAR score is typically performed on the newborn at minute ____ and ____
minutes after birth. - Answers - 1 and 5
Which of the following ranges represents a normal heart rate for a newborn?
80 - 160 bpm
80 - 120 bpm
160 - 200 bpm
120 - 160 bpm - Answers - 120 - 160 bpm
New parents observe that their 1-hour old newborn has blue hands and feet. The rest of
the newborn's body is pink and the baby is breathing and crying. The parents express
concern about the blue hands and feet and ask the nurse if it is normal.
What is the best reply by the nurse?
"It is normal for a newborn to have blue and hands and feet for the first few hours as
circulation is established; this is called acrocyanosis."
"Thank you for pointing that out; I will contact the physician to report this finding."
"That is discoloration related to bruising from the birth process."
"It is normal for a newborn to have blue and hands and feet for the first few hours as
circulation is established; this is called extremity hypoxia." - Answers - "It is normal for a
newborn to have blue and hands and feet for the first few hours as circulation is
established; this is called acrocyanosis."
A patient who has chronic heart failure tells the nurse, "I don't pass much urine during
the day but, once I lay down to go to sleep, I feel like I have to pee every hour!"
The nurse will document this assessment finding as:
