PN 4006 MIDTERM G2 Q BASED QUESTIONS AND
ANSWERS
The nurse is preparing to perform a physical examination on a client who has
cardiopulmonary disease. Knowing this about the client, the nurse is alert for the
presence of which of the following when checking the client's nails?
Select one:
a. Clubbing
b. Bands in nailbeds
c. Yellow discoloration
d. Splinter hemorrhages - Answers :A- clubbing
The nurse is auscultating the client's lungs and notes normal vesicular sounds as being
which of the following?
Select one:
a. Medium-pitched blowing sounds with inspiration equalling expiration
b. Loud, high-pitched, hollow sounds with expiration longer than inspiration
c. Soft, breezy, low-pitched sounds with longer inspiration
d. Sounds created by air moving through small airways - Answers :c. Soft, breezy, low-
pitched sounds with longer inspiration
During the physical examination, the nurse should use which part of the hand to assess
characteristics such as consistency, contour, and texture in the client's glands?
Select one:
a. Dorsum of the hand
b. Pads of the fingers
c. Palmar surface of the hand
d. Fingertip grasp of the tissue - Answers :b. Pads of the fingers
If a low-pitched murmur is suspected with prior assessment, which of the following is the
best position for the client when the nurse auscultates the apical site?
Select one:
a. Sitting up
b. Standing
c. Lying on the left side
d. Dorsal recumbent - Answers :c. Lying on the left side
Which of the following positions maximizes the nurse's ability to assess the client's
upper body for symmetry?
Select one:
a. Sitting
b. Supine
c. Prone
d. Dorsal recumbent - Answers :a. Sitting
,The nurse is observing a new staff member work with the client. Of the following
activities, which one has the greatest possibility of contributing to a nosocomial infection
and requires correction?
Select one:
a. Washing hands before applying a dressing
b. Taping a plastic bag to the bed rail for tissue disposal
c. Placing a Foley catheter bag on the bed when transferring a client
d. Using alcohol to cleanse the skin before starting an intravenous line - Answers :c.
Placing a Foley catheter bag on the bed when transferring a client
Which one of the following indicates that the nurse is using surgical aseptic technique?
Select one:
a. Inserting an intravenous catheter
b. Placing soiled linen in moisture-resistant bags
c. Disposing of syringes in puncture-proof containers
d. Washing hands before changing a dressing - Answers :a. Inserting an intravenous
catheter
The client requires a sterile dressing change. Which of the following is an appropriate
intervention for the nurse to implement in maintaining sterile asepsis?
Select one:
a. Put sterile gloves on before opening sterile packages.
b. Check integrity of sterile packages prior to use.
c. Place the cap of the sterile solution well within the sterile field.
d. Place sterile items on the very edge of the sterile drape. - Answers :b. Check integrity
of sterile packages prior to use.
The nurse suspects that an older adult client may have pneumonia. Older adult clients
may react differently to infectious processes, so the nurse is alert to atypical signs and
symptoms, such as which one of the following?
Select one:
a. Hypotension
b. Confusion
c. Erythema
d. Chills - Answers :b. Confusion
The nurse recognizes the appropriate procedures for sterile asepsis. Of the following,
which action is consistent with sterile asepsis?
Select one:
a. Clean forceps may be used to move items on the sterile field.
b. Sterile fields may be prepared well in advance of the procedures.
c. The first small amount of sterile solution should be poured and discarded.
d. Wrapped sterile packages should be opened starting with the flap closest to the
nurse. - Answers :c. The first small amount of sterile solution should be poured and
discarded.
, The client has a 15-cm laceration on his right forearm and an infection develops. Which
of the following is a sign of an acute inflammatory process?
Select one:
a. A blanching of the skin
b. A decrease in temperature at the site
c. A decrease in the number of white blood cells (WBCs)
d. A release of histamine that adds to the pain response - Answers :d. A release of
histamine that adds to the pain response
The nurse works in a small rural hospital with a wide variety of clients. Of the clients
admitted this afternoon, the nurse recognizes that the individual with which of the
following conditions is most susceptible to infection?
Select one:
a. Burns
b. Diabetes
c. Pulmonary emphysema
d. Peripheral vascular disease - Answers :a. Burns
The client has a large, deep abdominal incision that requires a dressing. The incision is
packed with sterile 1.75-cm packing and covered with a dry, 10 × 10-cm gauze. When
changing the dressing, the nurse accidentally drops the packing onto the client's
abdomen. Which of the following actions should the nurse take?
Select one:
a. Add alcohol to the packing and insert it into the incision.
b. Throw the packing away, and prepare a new one.
c. Pick up the packing with sterile forceps, and gently place it into the incision.
d. Rinse the packing with sterile water, and put the packing into the incision with sterile
gloves. - Answers :b. Throw the packing away, and prepare a new one.
The nurse uses the Braden Scale in the extended care facility to determine the client's
risk for pressure ulcer development. Which score, based on this scale, places the client
at the highest level of risk?
Select one:
a. 9 or below
b. 10 to 12
c. 13 to 14
d. 15 to 16 - Answers :a. 9 or below
Which of the following statements is true for wounds that heal by primary intention?
Select one:
a. They will likely have minimal scarring.
b. They will likely contain infected tissue.
c. They will likely present with ragged edges.
d. They will likely have portions of missing tissue. - Answers :a. They will likely have
minimal scarring.
ANSWERS
The nurse is preparing to perform a physical examination on a client who has
cardiopulmonary disease. Knowing this about the client, the nurse is alert for the
presence of which of the following when checking the client's nails?
Select one:
a. Clubbing
b. Bands in nailbeds
c. Yellow discoloration
d. Splinter hemorrhages - Answers :A- clubbing
The nurse is auscultating the client's lungs and notes normal vesicular sounds as being
which of the following?
Select one:
a. Medium-pitched blowing sounds with inspiration equalling expiration
b. Loud, high-pitched, hollow sounds with expiration longer than inspiration
c. Soft, breezy, low-pitched sounds with longer inspiration
d. Sounds created by air moving through small airways - Answers :c. Soft, breezy, low-
pitched sounds with longer inspiration
During the physical examination, the nurse should use which part of the hand to assess
characteristics such as consistency, contour, and texture in the client's glands?
Select one:
a. Dorsum of the hand
b. Pads of the fingers
c. Palmar surface of the hand
d. Fingertip grasp of the tissue - Answers :b. Pads of the fingers
If a low-pitched murmur is suspected with prior assessment, which of the following is the
best position for the client when the nurse auscultates the apical site?
Select one:
a. Sitting up
b. Standing
c. Lying on the left side
d. Dorsal recumbent - Answers :c. Lying on the left side
Which of the following positions maximizes the nurse's ability to assess the client's
upper body for symmetry?
Select one:
a. Sitting
b. Supine
c. Prone
d. Dorsal recumbent - Answers :a. Sitting
,The nurse is observing a new staff member work with the client. Of the following
activities, which one has the greatest possibility of contributing to a nosocomial infection
and requires correction?
Select one:
a. Washing hands before applying a dressing
b. Taping a plastic bag to the bed rail for tissue disposal
c. Placing a Foley catheter bag on the bed when transferring a client
d. Using alcohol to cleanse the skin before starting an intravenous line - Answers :c.
Placing a Foley catheter bag on the bed when transferring a client
Which one of the following indicates that the nurse is using surgical aseptic technique?
Select one:
a. Inserting an intravenous catheter
b. Placing soiled linen in moisture-resistant bags
c. Disposing of syringes in puncture-proof containers
d. Washing hands before changing a dressing - Answers :a. Inserting an intravenous
catheter
The client requires a sterile dressing change. Which of the following is an appropriate
intervention for the nurse to implement in maintaining sterile asepsis?
Select one:
a. Put sterile gloves on before opening sterile packages.
b. Check integrity of sterile packages prior to use.
c. Place the cap of the sterile solution well within the sterile field.
d. Place sterile items on the very edge of the sterile drape. - Answers :b. Check integrity
of sterile packages prior to use.
The nurse suspects that an older adult client may have pneumonia. Older adult clients
may react differently to infectious processes, so the nurse is alert to atypical signs and
symptoms, such as which one of the following?
Select one:
a. Hypotension
b. Confusion
c. Erythema
d. Chills - Answers :b. Confusion
The nurse recognizes the appropriate procedures for sterile asepsis. Of the following,
which action is consistent with sterile asepsis?
Select one:
a. Clean forceps may be used to move items on the sterile field.
b. Sterile fields may be prepared well in advance of the procedures.
c. The first small amount of sterile solution should be poured and discarded.
d. Wrapped sterile packages should be opened starting with the flap closest to the
nurse. - Answers :c. The first small amount of sterile solution should be poured and
discarded.
, The client has a 15-cm laceration on his right forearm and an infection develops. Which
of the following is a sign of an acute inflammatory process?
Select one:
a. A blanching of the skin
b. A decrease in temperature at the site
c. A decrease in the number of white blood cells (WBCs)
d. A release of histamine that adds to the pain response - Answers :d. A release of
histamine that adds to the pain response
The nurse works in a small rural hospital with a wide variety of clients. Of the clients
admitted this afternoon, the nurse recognizes that the individual with which of the
following conditions is most susceptible to infection?
Select one:
a. Burns
b. Diabetes
c. Pulmonary emphysema
d. Peripheral vascular disease - Answers :a. Burns
The client has a large, deep abdominal incision that requires a dressing. The incision is
packed with sterile 1.75-cm packing and covered with a dry, 10 × 10-cm gauze. When
changing the dressing, the nurse accidentally drops the packing onto the client's
abdomen. Which of the following actions should the nurse take?
Select one:
a. Add alcohol to the packing and insert it into the incision.
b. Throw the packing away, and prepare a new one.
c. Pick up the packing with sterile forceps, and gently place it into the incision.
d. Rinse the packing with sterile water, and put the packing into the incision with sterile
gloves. - Answers :b. Throw the packing away, and prepare a new one.
The nurse uses the Braden Scale in the extended care facility to determine the client's
risk for pressure ulcer development. Which score, based on this scale, places the client
at the highest level of risk?
Select one:
a. 9 or below
b. 10 to 12
c. 13 to 14
d. 15 to 16 - Answers :a. 9 or below
Which of the following statements is true for wounds that heal by primary intention?
Select one:
a. They will likely have minimal scarring.
b. They will likely contain infected tissue.
c. They will likely present with ragged edges.
d. They will likely have portions of missing tissue. - Answers :a. They will likely have
minimal scarring.
