A nurse is performing a focused assessment on a client who has a history of COPD and
is experiencing dyspnea. Which of the following findings should the nurse expect?)
a) Pulse oximetry reading of 95 %
b) Decreased depth of respirations
c) Flaring of the nostrils
d) Respiratory rate of 16/min - answers c. flaring of the nostrils
a nurse is assessing the pain level of a client who has dementia and difficulty
communicating, which pain assessment technique should the nurse use?
a) Numerical pain scale
b) Verbal description
c) Faces pain scale
d) Behavioral indicators - answers behavioral indicators (increased agitation,
restlessness)
PAINAD
A nurse is discussing immunity with a client who has received an immunization. The
nurse should identify that an immunization functions as a part of the which of the
following types of immunity?
a) Passive immunity
b) Active immunity
c) Cellular immunity
d) Acquired immunity - answers d. acquired immunity (artificial/acquired immunity
occurs when antigens from toxoids or immunizations are ADMINISTERED to a client,
once in the body, the stimulate the production of antibodies)
A nurse is preparing to perform a sterile dressing change for a client who has surgical
wound.
Which of the following actions should the nurse take to prevent contamination during the
dressing change?
a) Remove a piece of the new dressing that falls 5cm(2in) from the edge of the sterile
field
during the dressing change.
b) Begin the dressing change by applying sterile gloves and removing the existing
dressing
c) Restart the procedure if the sterile solution splashes onto the sterile flied when
pouring
the solution into the dressing tray
d) Place the existing dressing on the outermost portion of the sterile field and discard it
when the dressing change is finished. - answers c. restart the procedure if the sterile
solution splashes onto the sterile field when pouring the solution into the dressing tray
, (if liquid comes in contact with the sterile field at any point it is considered contaminated
and unsterile)
a nurse is providing discharge teaching to a client who has a prescription for home O2,
which info should the nurse teach? - answers wear cotton socks when the O2 is in use
(other fabrics cause static)
A nurse is teaching a client about the correct use of a cane. Which of the following
instruction should the nurse include in the teaching? (Selected all that apply)
a) Ensure the cane has a rubber cap.
b) Hold the cane on the weaker side.
c) Flex the elbow slightly when using the cane.
d) Move the cane and stronger leg forward simultaneously
e) Use a quad cane for increased support - answers a. ensure the cane has a rubber
cap
c. flex the elbow slightly when using the cane
e. use a quad cane for increased support
A nurse is planning to administer several medications to a client through a nasogastric
(NG)
tube. Which of the following actions should the nurse take?
a) Mix the medications together and administer through the NG tube .
b) Crush the sublingual medication into powder form
c) Dissolve crushed tablet medications in sterile water.
d) Flush the tube with 5 ml saline between each medication - answers c. dissolve
crushed tablet meds in sterile water
(in 15-30mL sterile water)
a nurse is in an ED monitoring the hydration status of a client receiving oral rehydration,
what should the intervene for? - answers heart rate 120/min
(initiate IV fluid replacement)
a nurse is documenting client care, which of the following entries should the nurse
identify as an example of implementation of client care?
"Contacted the provider to report client findings."
"Reports stomach pain as 3 on a pain scale of 0 to 10."
"Vomited 120 mL of clear, yellow emesis."
"Denies further nausea or vomiting since antiemetic administration." - answers
contacted the provider to report client findings
a nurse is caring for a client who has prescription for terazosin, the nurse should identify
that this medication is indicated for which of the following disorders? - answers
hypertension, BPH