353 Final Assessment Exam Questions with
Verified Correct Answers
A nurse is assisting with the admission of a client who has active tuberculosis. Which of the
following actions should the nurse plan to take?
A. Restrict the client's visitors to the immediate family.
B. Assign the client to a negative airflow pressure room.
C. Discard personal protective equipment outside the client's room.
D. Assign the client to a positive airflow room.
B. Assign the client to a negative airflow pressure room.
A nurse administers an oral medication to a client. The client reports itching 30 min later.
Which of the following represents appropriate documentation of this client finding?
A. Client is itching from medication.
B. Client states, "I am itching all over."
C. It appears that the client has a rash from the medication.
D. Rash from medication noted.
B. Client states, "I am itching all over."
A nurse is reinforcing teaching regarding palliative care with a client who has cancer. Which of
the following statements by the client indicates a need for further teaching?
A."My family will receive emotional support during this process."
B."My provider will still attempt to cure my illness."
C."I want to feel as comfortable as possible and enjoy the good times"
D."My family can set up appointments with a massage therapist for me."
B."My provider will still attempt to cure my illness."
A nurse offers pain meds to a client who is post-op prior to ambulation. The nurse
understands that this aspect of care delivery is an example of which of the following ethical
principles?
A) Fidelity
B) Autonomy
C) Justice
D) Beneficence
,D) Beneficence
A nurse is performing an integumentary assessment for a group of clients. Which of the
following findings should the nurse recognize as requiring immediate intervention?
A. Pallor
B. Cyanosis
C. Jaundice
D. Erythema
B. Cyanosis
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery
bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and
notes an elevation in blood pressure and heart rate. The nurse should recognize this response
as which part of the general adaptation syndrome (GAS)?
A. Exhaustion stage
B. Resistance stage
C. Alarm reaction
D. Recovery reaction
C. Alarm reaction
The nurse who works on the night shift enters the medication room and finds a co-worker
with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle,
attached to a syringe containing a clear liquid, into the antecubital area. Which is the most
appropriate action by the nurse?
- Call security
- Call the police
- Call the nursing supervisor
- Lock the co-worker in the medication room until help is obtained
- Call the nursing supervisor
Contact precautions are initiated for a client with a healthcare-associated (nosocomial)
infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to
provide colostomy care and should obtain which protective items to perform this procedure?
- Gloves and gown
- Gloves and goggles
- Gloves, gown, and shoe protectors
- Gloves, gown, goggles, and a mask or face shield
- Gloves, gown, goggles, and a mask or face shield
, The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The
nurse should tell the staff which child behavior is characteristic of the formal operations
stage?
- The child has the ability to think abstractly
- The child begins to understand the environment
- The child is able to classify, order, and sort facts
- The child learns to think in terms of past, present, and future
- The child has the ability to think abstractly
The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child
because the child seems to be more attentive to friends than anything else. Using Erikson's
psychosocial development theory, the nurse should make which response?
- "You need to be concerned"
- "You need to monitor the child's behavior closely"
- "At this age, the child is developing his own personality"
- "You need to provide more praise to the child to stop this behavior"
- "At this age, the child is developing his own personality"
The nurse is monitoring the status of a postoperative client in the immediate postoperative
period. The nurse would become most concerned with which sign that could indicate an
evolving complication?
- Increasing restlessness
- A pulse of 86 beats/minute
- Blood pressure of 110/70 mm Hg
- Hypoactive bowel sounds in all 4 quadrants
- Increasing restlessness
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an
NG tube. Which of the following actions should the nurse complete prior to administering the
tube feeding? (Select all that apply)
A. Auscultate bowel sounds.
B. Assist the client to an upright position.
C. Test the pH of gastric aspirate.
D. Warm the formula to body temperature.
E. Discard any residual gastric contents.
Verified Correct Answers
A nurse is assisting with the admission of a client who has active tuberculosis. Which of the
following actions should the nurse plan to take?
A. Restrict the client's visitors to the immediate family.
B. Assign the client to a negative airflow pressure room.
C. Discard personal protective equipment outside the client's room.
D. Assign the client to a positive airflow room.
B. Assign the client to a negative airflow pressure room.
A nurse administers an oral medication to a client. The client reports itching 30 min later.
Which of the following represents appropriate documentation of this client finding?
A. Client is itching from medication.
B. Client states, "I am itching all over."
C. It appears that the client has a rash from the medication.
D. Rash from medication noted.
B. Client states, "I am itching all over."
A nurse is reinforcing teaching regarding palliative care with a client who has cancer. Which of
the following statements by the client indicates a need for further teaching?
A."My family will receive emotional support during this process."
B."My provider will still attempt to cure my illness."
C."I want to feel as comfortable as possible and enjoy the good times"
D."My family can set up appointments with a massage therapist for me."
B."My provider will still attempt to cure my illness."
A nurse offers pain meds to a client who is post-op prior to ambulation. The nurse
understands that this aspect of care delivery is an example of which of the following ethical
principles?
A) Fidelity
B) Autonomy
C) Justice
D) Beneficence
,D) Beneficence
A nurse is performing an integumentary assessment for a group of clients. Which of the
following findings should the nurse recognize as requiring immediate intervention?
A. Pallor
B. Cyanosis
C. Jaundice
D. Erythema
B. Cyanosis
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery
bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and
notes an elevation in blood pressure and heart rate. The nurse should recognize this response
as which part of the general adaptation syndrome (GAS)?
A. Exhaustion stage
B. Resistance stage
C. Alarm reaction
D. Recovery reaction
C. Alarm reaction
The nurse who works on the night shift enters the medication room and finds a co-worker
with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle,
attached to a syringe containing a clear liquid, into the antecubital area. Which is the most
appropriate action by the nurse?
- Call security
- Call the police
- Call the nursing supervisor
- Lock the co-worker in the medication room until help is obtained
- Call the nursing supervisor
Contact precautions are initiated for a client with a healthcare-associated (nosocomial)
infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to
provide colostomy care and should obtain which protective items to perform this procedure?
- Gloves and gown
- Gloves and goggles
- Gloves, gown, and shoe protectors
- Gloves, gown, goggles, and a mask or face shield
- Gloves, gown, goggles, and a mask or face shield
, The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The
nurse should tell the staff which child behavior is characteristic of the formal operations
stage?
- The child has the ability to think abstractly
- The child begins to understand the environment
- The child is able to classify, order, and sort facts
- The child learns to think in terms of past, present, and future
- The child has the ability to think abstractly
The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child
because the child seems to be more attentive to friends than anything else. Using Erikson's
psychosocial development theory, the nurse should make which response?
- "You need to be concerned"
- "You need to monitor the child's behavior closely"
- "At this age, the child is developing his own personality"
- "You need to provide more praise to the child to stop this behavior"
- "At this age, the child is developing his own personality"
The nurse is monitoring the status of a postoperative client in the immediate postoperative
period. The nurse would become most concerned with which sign that could indicate an
evolving complication?
- Increasing restlessness
- A pulse of 86 beats/minute
- Blood pressure of 110/70 mm Hg
- Hypoactive bowel sounds in all 4 quadrants
- Increasing restlessness
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an
NG tube. Which of the following actions should the nurse complete prior to administering the
tube feeding? (Select all that apply)
A. Auscultate bowel sounds.
B. Assist the client to an upright position.
C. Test the pH of gastric aspirate.
D. Warm the formula to body temperature.
E. Discard any residual gastric contents.
