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Accuracy 100%
37. The nurse is performing an abdominal assessment. Indicate the correct sequence the nurse should
use to perform this assessment.
(a) percussion
(b) palpation
(c) auscultation
(d) inspection - Answer D, C, B, and A. Inspection is done first. Auscultation is performed before
palpation to decrease the risk of stimulating the bowel which could result in false positive findings.
Health Promotion and Maintenance
A 45 year old client who was recently diagnosed with terminal cancer says to the nurse "If God could
only let me live long enough to put my daughter through college, I wouldn't mind dealing with this
illness." The nurse caring for this client recognizes this statement as reflective of which stage of grieving?
(a) Denial
(b) Acceptance
(c) Bargaining
(d) Anger - Answer C. During the bargaining stage the client attempts to negotiate to prolong
their life. Kübler-Ross identified the stages of death and dying as denial (disbelief), anger (hostility),
bargaining, depression (sadness) and acceptance (coming to terms with death). Psychosocial Integrity
A client with end stage renal disease (ESRD) is scheduled for hemodialysis in one hour. The nurse should
notify the primary health care provider that the client has a
(a) BUN of 60 mg/dl
(b) Creatinine 3.5 mg/dl
(c) Sodium 145 mEq/L
(d) Potassium 6.8 mEq/L - Answer D. Hyperkalemia can result in serious adverse effects to
excitable tissues especially the heart, causing altered cardiac function; the BUN and creatinine are
elevated prior to dialysis due to increased circulating wasted in the blood stream; a sodium level of 145
mEq/L is within the normal range of 135-145 mEq/L. Physiological Integrity; Reduction of Risk Potential
,A client with left-sided weakness following a cerebral vascular accident (CVA) is learning to ambulate
with a cane. The nurse should teach the client to
(a) hold the cane on the left side and move the cane with the right leg
(b) hold the cane on the right side and move the cane with the left leg
(c) hold the cane on the left side and move the cane with the left leg
(d) hold the cane on the right side and move the cane with the right leg - Answer B. The proper
technique to be used when teaching a client to ambulate with a cane is to hold the cane in the hand
opposite the affected leg. Physiological Integrity; Basic Care and Comfort
A nurse is admitting a client with suspected pulmonary tuberculosis (TB). Which of the following actions
should the nurse take?
(a) wear a gown when taking the client's health history
(b) place the client on droplet precautions
(c) keep the door to the client's room closed
(d) use disposable gloves when taking the client's blood pressure - Answer C. The client with
Tuberculosis (TB) is placed no airborne precautions which include placement in a negative pressure room
with the door closed and use of a particulate respirator mask; a gown and gloves are not needed when
talking with the client or taking the blood pressure; droplet precautions are used for meningitis, HIB
(haemophilus influenzae type b), mumps, rubella, pertussis and epiglottitis. Physiological Integrity;
Physiological Adaptation
A nurse is caring for a two-month-old infant being evaluated for congenital
hypothyroidism. The nurse should recognize which of the following findings as
being consistent with congenital hypothyroidism?
(a) The infant sleeps for 6 hours at a time
(b) The infant has a high-pitched cry
(c) The infant has been having frequent loose stools
(d) The infant has 3 + reflexes - Answer A. Statements made by the mother of the infant sleeping
for prolonged periods support the diagnosis. Follow up is needed for diagnostic workup to confirm this
disorder. Signs of congenital hypothyroidism include lethargy, poor feeding, constipation and
bradycardia; high pitched cry is not suggestive of hypothyroidism; frequent loose stools and brisk
reflexes may be indicators of hyperthyroidism. Physiological Integrity; Physiological Adaptation
,A nurse is observing a newly-hired nurse provide care for assigned clients. The
nurse should follow up if the newly-hired nurse is observed
(a) wearing gloves when taking the blood pressure of a client with disseminated varicella zoster
(b) cleansing the wound from the outer surface to the inner surface for a client whose wound is infected
with a multi-drug resistant organism
(c) washing the hands with the fingertips pointed downward before providing care for a client on
protective precautions
(d) removing the gloves before removing the gown when leaving a room of a client who is on contact
precautions - Answer B. Cleansing of the wound from the outer surface to the inner surface is
incorrect technique. Wounds should be cleansed in an outward direction to avoid transferring organisms
from the surrounding skin into the wound. Choices A, C, and D follow the principles of infection control,
follow up is not required. Safe Effective Care Environment; Safety and Infection Control
A student nurse is administering magnesium hydroxide/aluminum hydrate (Maalox) prescribed as an
antacid to a client. The nursing instructor should intervene if the student plans to administer the antacid
(a) two hours after the client has eaten a meal
(b) at the same time as a prescribed iron preparation
(c) after briskly shaking the bottle of Maalox
(d) when assessing the client for the presence of gastric pain - Answer B. Antacids should not be
administered at the same time with iron preparations because absorption is inhibited; to enhance the
antacid effect Maalox (aluminum hydroxide/magnesium hydroxide) is administered 1-3 hours after meals
and at bedtime; shaking the medication and assessing for the presence of gastric pain is applicable.
Physiological Integrity; Pharmacological and Parenteral Therapies
Four clients recently returned to the unit following invasive diagnostic testing.
The nurse should immediately intervene if one of the clients:
(a) reports blood tinged sputum following a bronchoscopy
(b) has decreased abdominal girth following paracentesis
(c) reports a headache following a lumbar puncture
(d) is observed flexing and extending the legs two hours after cardiac catheterization - Answer D.
Following cardiac catheterization of the femoral artery, the client remains on bedrest for 2 to 6 hours
with the affected leg straight and the head of the bed elevated to 30 degrees; blood tinged sputum is an
expected finding after bronchoscopy; removal of fluid from the peritoneal cavity as in paracentesis will
result in decreased abdominal girth; post lumbar puncture headache ranging from mild to severe may
appear a few hours to days following the procedure. Safe Effective Care Environment; Management of
Care
, It would be appropriate to assign which of these tasks to the CNA?
(a) Feeding a client who is experiencing dysphagia
(b) One-on-one client observation for safety
(c) Removal of an indwelling catheter
(d) Performing a simple dressing change - Answer B. The Certified Nursing Assistant may be
assigned to a client that requires one- to-one observation for safety; the other choices require skilled
nursing intervention by a LPN (Licensed Practical Nurse) or RN (Registered Nurse).
The charge nurse is observing a Licensed Practical Nurse (LPN) performing
care for assigned clients. Follow up will be required if the LPN:
(a) assesses a client's apical pulse before administering Digoxin (lanoxin)
(b) elevates the client's stump on a pillow eight hours after amputation
(c) dons a clean glove on the dominant hand before tracheal suctioning
(d) positions a client on the operative side following a pneumonectomy - Answer C. A sterile
glove, not clean, should be used on the dominant hand during tracheal suctioning to prevent infection;
the apical pulse should be assessed for one full minute prior to the administration of Digoxin (Lanoxin);
elevation of the stump following amputation is performed for the first 24 hours only to prevent hip or
knee flexion contracture; clients should be positioned on the operative side to promote lung expansion
of the unaffected lung. Safe Effective Care Environment; Management of Care
The charge nurse of a medical-surgical unit notices a nurse walking with an unsteady gait, slurred speech
and a faint smell of alcohol on the breath immediately following a lunch break. The charge nurse's
priority action would be to
(a) notify the nursing supervisor
(b) asking the nurse about recent alcohol consumption
(c) complete an incident report
(d) relieve the nurse of assigned clients - Answer D. The priority in this situation is client safety.
The nurse should be relieved of their assigned clients since these behaviors suggest that the nurse may
be impaired; the charge nurse should not confront the other nurse. Instead, a clear factual description of
the situation should be documented then reported to the nursing supervisor. Safe Effective Care
Environment; Safety and Infection Control
The community health nurse is caring for the following clients. It would be a
priority for the nurse to initiate a multidisciplinary conference for the client who
is
Accuracy 100%
37. The nurse is performing an abdominal assessment. Indicate the correct sequence the nurse should
use to perform this assessment.
(a) percussion
(b) palpation
(c) auscultation
(d) inspection - Answer D, C, B, and A. Inspection is done first. Auscultation is performed before
palpation to decrease the risk of stimulating the bowel which could result in false positive findings.
Health Promotion and Maintenance
A 45 year old client who was recently diagnosed with terminal cancer says to the nurse "If God could
only let me live long enough to put my daughter through college, I wouldn't mind dealing with this
illness." The nurse caring for this client recognizes this statement as reflective of which stage of grieving?
(a) Denial
(b) Acceptance
(c) Bargaining
(d) Anger - Answer C. During the bargaining stage the client attempts to negotiate to prolong
their life. Kübler-Ross identified the stages of death and dying as denial (disbelief), anger (hostility),
bargaining, depression (sadness) and acceptance (coming to terms with death). Psychosocial Integrity
A client with end stage renal disease (ESRD) is scheduled for hemodialysis in one hour. The nurse should
notify the primary health care provider that the client has a
(a) BUN of 60 mg/dl
(b) Creatinine 3.5 mg/dl
(c) Sodium 145 mEq/L
(d) Potassium 6.8 mEq/L - Answer D. Hyperkalemia can result in serious adverse effects to
excitable tissues especially the heart, causing altered cardiac function; the BUN and creatinine are
elevated prior to dialysis due to increased circulating wasted in the blood stream; a sodium level of 145
mEq/L is within the normal range of 135-145 mEq/L. Physiological Integrity; Reduction of Risk Potential
,A client with left-sided weakness following a cerebral vascular accident (CVA) is learning to ambulate
with a cane. The nurse should teach the client to
(a) hold the cane on the left side and move the cane with the right leg
(b) hold the cane on the right side and move the cane with the left leg
(c) hold the cane on the left side and move the cane with the left leg
(d) hold the cane on the right side and move the cane with the right leg - Answer B. The proper
technique to be used when teaching a client to ambulate with a cane is to hold the cane in the hand
opposite the affected leg. Physiological Integrity; Basic Care and Comfort
A nurse is admitting a client with suspected pulmonary tuberculosis (TB). Which of the following actions
should the nurse take?
(a) wear a gown when taking the client's health history
(b) place the client on droplet precautions
(c) keep the door to the client's room closed
(d) use disposable gloves when taking the client's blood pressure - Answer C. The client with
Tuberculosis (TB) is placed no airborne precautions which include placement in a negative pressure room
with the door closed and use of a particulate respirator mask; a gown and gloves are not needed when
talking with the client or taking the blood pressure; droplet precautions are used for meningitis, HIB
(haemophilus influenzae type b), mumps, rubella, pertussis and epiglottitis. Physiological Integrity;
Physiological Adaptation
A nurse is caring for a two-month-old infant being evaluated for congenital
hypothyroidism. The nurse should recognize which of the following findings as
being consistent with congenital hypothyroidism?
(a) The infant sleeps for 6 hours at a time
(b) The infant has a high-pitched cry
(c) The infant has been having frequent loose stools
(d) The infant has 3 + reflexes - Answer A. Statements made by the mother of the infant sleeping
for prolonged periods support the diagnosis. Follow up is needed for diagnostic workup to confirm this
disorder. Signs of congenital hypothyroidism include lethargy, poor feeding, constipation and
bradycardia; high pitched cry is not suggestive of hypothyroidism; frequent loose stools and brisk
reflexes may be indicators of hyperthyroidism. Physiological Integrity; Physiological Adaptation
,A nurse is observing a newly-hired nurse provide care for assigned clients. The
nurse should follow up if the newly-hired nurse is observed
(a) wearing gloves when taking the blood pressure of a client with disseminated varicella zoster
(b) cleansing the wound from the outer surface to the inner surface for a client whose wound is infected
with a multi-drug resistant organism
(c) washing the hands with the fingertips pointed downward before providing care for a client on
protective precautions
(d) removing the gloves before removing the gown when leaving a room of a client who is on contact
precautions - Answer B. Cleansing of the wound from the outer surface to the inner surface is
incorrect technique. Wounds should be cleansed in an outward direction to avoid transferring organisms
from the surrounding skin into the wound. Choices A, C, and D follow the principles of infection control,
follow up is not required. Safe Effective Care Environment; Safety and Infection Control
A student nurse is administering magnesium hydroxide/aluminum hydrate (Maalox) prescribed as an
antacid to a client. The nursing instructor should intervene if the student plans to administer the antacid
(a) two hours after the client has eaten a meal
(b) at the same time as a prescribed iron preparation
(c) after briskly shaking the bottle of Maalox
(d) when assessing the client for the presence of gastric pain - Answer B. Antacids should not be
administered at the same time with iron preparations because absorption is inhibited; to enhance the
antacid effect Maalox (aluminum hydroxide/magnesium hydroxide) is administered 1-3 hours after meals
and at bedtime; shaking the medication and assessing for the presence of gastric pain is applicable.
Physiological Integrity; Pharmacological and Parenteral Therapies
Four clients recently returned to the unit following invasive diagnostic testing.
The nurse should immediately intervene if one of the clients:
(a) reports blood tinged sputum following a bronchoscopy
(b) has decreased abdominal girth following paracentesis
(c) reports a headache following a lumbar puncture
(d) is observed flexing and extending the legs two hours after cardiac catheterization - Answer D.
Following cardiac catheterization of the femoral artery, the client remains on bedrest for 2 to 6 hours
with the affected leg straight and the head of the bed elevated to 30 degrees; blood tinged sputum is an
expected finding after bronchoscopy; removal of fluid from the peritoneal cavity as in paracentesis will
result in decreased abdominal girth; post lumbar puncture headache ranging from mild to severe may
appear a few hours to days following the procedure. Safe Effective Care Environment; Management of
Care
, It would be appropriate to assign which of these tasks to the CNA?
(a) Feeding a client who is experiencing dysphagia
(b) One-on-one client observation for safety
(c) Removal of an indwelling catheter
(d) Performing a simple dressing change - Answer B. The Certified Nursing Assistant may be
assigned to a client that requires one- to-one observation for safety; the other choices require skilled
nursing intervention by a LPN (Licensed Practical Nurse) or RN (Registered Nurse).
The charge nurse is observing a Licensed Practical Nurse (LPN) performing
care for assigned clients. Follow up will be required if the LPN:
(a) assesses a client's apical pulse before administering Digoxin (lanoxin)
(b) elevates the client's stump on a pillow eight hours after amputation
(c) dons a clean glove on the dominant hand before tracheal suctioning
(d) positions a client on the operative side following a pneumonectomy - Answer C. A sterile
glove, not clean, should be used on the dominant hand during tracheal suctioning to prevent infection;
the apical pulse should be assessed for one full minute prior to the administration of Digoxin (Lanoxin);
elevation of the stump following amputation is performed for the first 24 hours only to prevent hip or
knee flexion contracture; clients should be positioned on the operative side to promote lung expansion
of the unaffected lung. Safe Effective Care Environment; Management of Care
The charge nurse of a medical-surgical unit notices a nurse walking with an unsteady gait, slurred speech
and a faint smell of alcohol on the breath immediately following a lunch break. The charge nurse's
priority action would be to
(a) notify the nursing supervisor
(b) asking the nurse about recent alcohol consumption
(c) complete an incident report
(d) relieve the nurse of assigned clients - Answer D. The priority in this situation is client safety.
The nurse should be relieved of their assigned clients since these behaviors suggest that the nurse may
be impaired; the charge nurse should not confront the other nurse. Instead, a clear factual description of
the situation should be documented then reported to the nursing supervisor. Safe Effective Care
Environment; Safety and Infection Control
The community health nurse is caring for the following clients. It would be a
priority for the nurse to initiate a multidisciplinary conference for the client who
is
