N142 Test 2 Questions With Complete Solutions
A charge nurse is observing a newly licensed nurse perform an
anterior chest auscultation on a client. For which of the
following actions should the charge nurse intervene?
A) The nurse asks the client to cough before beginning the
auscultation.
B) The nurse is auscultating through the client's gown.
C) The nurse places, the stethoscope on the intercostal spaces.
D) The nurse moves down the chest in a ladder sequence.
Correct Answers B
A charge nurse is teaching a newly licensed nurse, how to
recognize manifestations of decreased oxygenation in a client.
Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching.
A) "A client using thoracic breathing is experiencing a lack of
oxygen."
B) "A pulse oximeter reading of less than 95% indicates
respiratory distress"
C) "Clubbing of the ends of the fingers indicates a chronic state
of impaired perfusion"
D) " a pinkish hue on the cheeks of a client who is light-skinned
indicates they are struggling to breathe" Correct Answers C
A nurse is admitting a client who has a new diagnosis of COPD.
Which of the following documentation information from the
nurse is subjective data? (Select all that apply)
A) Pulse oximeter reading is 89% on O2 L/min via nasal
cannula
,B) Report from client says they sleep while propped on two
pillows at night
C) Client says they quit smoking 2 years ago
D) Respiratory rate increases to 28/min when client ambulates to
restroom
E) Client states, "Being short of breath all the time is making me
depressed." Correct Answers B,C,E
A nurse is assessing a client who is dark-skinned in which of the
following areas of client's body should you assess for adequate
oxygenation? (Select all that apply)
A) Cheeks
B) Nail beds
C) Oral mucosa
D) Sclarea
E) Lips Correct Answers B,C,E
A nurse is assessing a client's head and neck. Which of the
following findings should the nurse report to the provider?
A) C-7 is the most prominent vertebrae
B) Clicking is noted in the temporomandibular joint
C) The muscles of the neck are firm
D) There is locking of the jaw joint Correct Answers D
A nurse is caring for a client who has a history of migraines. The
client tells the nurse, "I have not been sleeping well. My
migraine headaches have returned after not having one for over
a year." The nurse should identify that which of the following
are potential contributing factors to the clients migraines? (select
all that apply.)
A) Sleep-wake homeostasis
, B) Sensory overload
C) Sleep deprivation
D) Increased melatonin
E) Decreased hypocretin levels Correct Answers B,C
A nurse is caring for a client who has narcolepsy with cataplexy.
The nurse should identify that this condition is caused by a lack
of which of the following hormones?
A) Hypocretin
B) Melatonin
C) Estrogen
D) Insulin Correct Answers A
A nurse is caring for a client who is having difficulty breathing.
Which of following actions should the nurse take first?
A) Instruct the client to deep breathe and cough
B) Provide the client with an incentive spirometer
C) Elevate the head of the client's bed
D) Reassess by auscultating the client's lungs Correct Answers
C
A nurse is caring for a client who is having difficulty falling
asleep. Which of the following interventions should the nurse
implement to promote sleep for the client?
A) Offer the client a caffeinated drink three hours before their
bedtime
B) Turn on the clients television before they go to bed
C) Warm the temperature of the clients room before they go to
bed
D) Dim the lights in the clients room at bedtime Correct
Answers D
A charge nurse is observing a newly licensed nurse perform an
anterior chest auscultation on a client. For which of the
following actions should the charge nurse intervene?
A) The nurse asks the client to cough before beginning the
auscultation.
B) The nurse is auscultating through the client's gown.
C) The nurse places, the stethoscope on the intercostal spaces.
D) The nurse moves down the chest in a ladder sequence.
Correct Answers B
A charge nurse is teaching a newly licensed nurse, how to
recognize manifestations of decreased oxygenation in a client.
Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching.
A) "A client using thoracic breathing is experiencing a lack of
oxygen."
B) "A pulse oximeter reading of less than 95% indicates
respiratory distress"
C) "Clubbing of the ends of the fingers indicates a chronic state
of impaired perfusion"
D) " a pinkish hue on the cheeks of a client who is light-skinned
indicates they are struggling to breathe" Correct Answers C
A nurse is admitting a client who has a new diagnosis of COPD.
Which of the following documentation information from the
nurse is subjective data? (Select all that apply)
A) Pulse oximeter reading is 89% on O2 L/min via nasal
cannula
,B) Report from client says they sleep while propped on two
pillows at night
C) Client says they quit smoking 2 years ago
D) Respiratory rate increases to 28/min when client ambulates to
restroom
E) Client states, "Being short of breath all the time is making me
depressed." Correct Answers B,C,E
A nurse is assessing a client who is dark-skinned in which of the
following areas of client's body should you assess for adequate
oxygenation? (Select all that apply)
A) Cheeks
B) Nail beds
C) Oral mucosa
D) Sclarea
E) Lips Correct Answers B,C,E
A nurse is assessing a client's head and neck. Which of the
following findings should the nurse report to the provider?
A) C-7 is the most prominent vertebrae
B) Clicking is noted in the temporomandibular joint
C) The muscles of the neck are firm
D) There is locking of the jaw joint Correct Answers D
A nurse is caring for a client who has a history of migraines. The
client tells the nurse, "I have not been sleeping well. My
migraine headaches have returned after not having one for over
a year." The nurse should identify that which of the following
are potential contributing factors to the clients migraines? (select
all that apply.)
A) Sleep-wake homeostasis
, B) Sensory overload
C) Sleep deprivation
D) Increased melatonin
E) Decreased hypocretin levels Correct Answers B,C
A nurse is caring for a client who has narcolepsy with cataplexy.
The nurse should identify that this condition is caused by a lack
of which of the following hormones?
A) Hypocretin
B) Melatonin
C) Estrogen
D) Insulin Correct Answers A
A nurse is caring for a client who is having difficulty breathing.
Which of following actions should the nurse take first?
A) Instruct the client to deep breathe and cough
B) Provide the client with an incentive spirometer
C) Elevate the head of the client's bed
D) Reassess by auscultating the client's lungs Correct Answers
C
A nurse is caring for a client who is having difficulty falling
asleep. Which of the following interventions should the nurse
implement to promote sleep for the client?
A) Offer the client a caffeinated drink three hours before their
bedtime
B) Turn on the clients television before they go to bed
C) Warm the temperature of the clients room before they go to
bed
D) Dim the lights in the clients room at bedtime Correct
Answers D
