NURS101 Proctored Exam: Questions With Solutions
A nurse is caring for a client who ingested a poison and is now experiencing a
seizure. Which of the following is the priority action the nurse should take?
a. Check the patency of the client's airway
b. Determine the poison that was ingested
c. Identify the amount of poison that was ingested
d. Position the client side-lying. Right Ans - a. Check the patency of the
client's airway
The priority action the nurse should take when using the airway, breathing,
circulation (ABC) approach to client care is checking the patency of the client's
airway.
A nurse is admitting a client who reports anorexia and is experiencing
malnutrition. Which of the following laboratory findings should the nurse
expect to be altered?
a. Creatine kinase
b. Troponin
c. Total bilirubin
d. Albumin Right Ans - D. Albumin
A low albumin is a measure of plasma proteins which reflects the nutritional
condition of a client experiencing anorexia and malnutrition over an extended
period of time
A nurse is planning care for an older adult client who is at risk for developing
pressure ulcers. Which of the following interventions should the nurse use
help maintain the integrity of the client's skin?
a. Use a transfer device to lift the client up in bed.
b. Apply cornstarch to keep sensitive skin areas dry
c. Massage the skin over the client's bony prominences
d. Elevate the head of the bed no more than 45 degrees Right Ans - a. Use a
transfer device to life the client up in bed
Using a lifting device prevents dragging the client's skin across the bed linens,
which can cause abrasions.
,A nurse is orienting a new assistive personnel (AP) to the unit. For which of
the following actions should the nurse intervene?
a. Wears a gown when entering the room of a client who requires contact
precautions
b. Dons gloves to empty a urinary drainage device
c. Washes and rinses her hands for 10 seconds
d. Wears a respirator mask when entering the room of a client who requires
airborne precautions Right Ans - c. Washes and rinses her hands for 10
seconds
The nurse should intervene because the AP should wash her hands for a least
20 seconds.
A nurse is assessing a client's bowel sounds. At which of the following points
in the assessment should the nurse auscultate the client's abdomen?
a. After palpating the abdomen
b. Prior to percussing the abdomen
c. After assessing for kidney tenderness
d. Prior to inspecting the abdomen Right Ans - b. Prior to percussing the
abdomen
According to evidence-based practice, the nurse should auscultate the
abdomen prior to percussing it to prevent altering the bowel sounds. Both
percussing and palpation can stimulate the intestines, increase their motility,
and intensify the bowel sounds
A nurse is filling out an incident report after finding a client lying on the floor.
Which of the following information should the nurse include?
a. " The client attempted to climb over the side rails and fell"
b. "The client was lying on the floor next to his bed."
c. "the client was restless and trying to get out of bed all evening."
d. "The presence of a bed alarm could have prevented the client from falling."
Right Ans - B. "The client was lying on the floor next to his bed."
In an incident report, the nurse should only document what she actually
witnessed, along with the date, time, place, and any other actual facts about
the incident.
,A nurse is caring for a client who has a prescription for a stool test for guaiac.
The nurse understands the purpose of the test is to check the stool for which
of the following substances?
a. Steatorrhea
b. Blood
c. Bacteria
d. Parasites Right Ans - b. Blood
A guaiac test detects the presence of occult or hidden blood in the stool. The
guaiac test is an extremely useful diagnostic screening test for the presence of
colon cancer and gastrointestinal ulcers.
A charge nurse is anticipating the admission of four clients and planning their
room assignments. Which of the following clients should the nurses assign to
the room closest to the nurses station?
a. A client who sustained a head injury and is having periods of confusion
b. A client who reports a severe migraine headache
c. A client who has a suspected diagnosis of Tuberculosis (TB)
d. A client who has a history of atrial fibrillation and is on continuous ECG
monitoring Right Ans - a. A client who sustained a head injury and is
having periods of confusion
A client who sustained a head injury and is confused is at risk for seizures. The
nurse should place this client in a room near the nurses' station so that he can
be closely monitored to prevent injury if a seizure occurs.
A nurse is caring for a client who requires droplet precautions. Which of the
following personal protective equipment should the nurse wear when setting
up the client's meal tray?
a. Gloves
b. Goggles
c. Gown
d. Mask Right Ans - D. Mask
A nurse should follow droplet precautions for clients who have infections that
spread by droplets larger than 5 microns. The nurse should wear a mask
whenever she is within 1m (3ft) of the client.
, A nurse is caring for an older adult client who was alert and oriented at
admission but now seems increasingly restless and intermittently confused.
Which of the following actions should the nurse take to address the client's
safety needs?
a. Call the family and ask them to stay with the client
b. Move the client to a room closer to the nurse's station
c. Apply wrist and leg restraints to the client
d. Administer medication to sedate the client. Right Ans - b. Move the client
to a room closer to the nurse's station
This will make it easier for the staff to observe the client, should the client
behave in an unsafe manner.
A nurse is preparing to administer an ophthalmic solution to a client. Which of
the following actions should the nurse take?
a. Instill the drops into the inner canthus
b. Approach the client's eye from below it
c. Hold the ophthalmic solution 2cm (3/4 in) above the lower conjunctival sac.
d. Ask the client to look down when instilling the solution Right Ans - c.
Hold the Ophthalmic solution 2cm (3/4in) above the lower conjunctival sac.
A niurse is providing preoperative teaching for a client who will undergo
surgery. The nurse explains that the client will wear antiembolism stockings
during and after the surgery. When the client asks what the stockings do.
Which of the following responses should the nurse make?
a. "They protect your legs and heels from skin breakdown"
b. "They help keep you warm after your surgery"
c. "They improve your circulation to keep blood from pooling in your legs"
d. "They make it easier for you to do leg exercises after your surgery" Right
Ans - c. "They improve your circulation to keep blood from pooling in your
legs"
Antiembolism stockings promote venous return from the legs, thus helping to
prevent venous thrombosis, also known as clot formation and peripheral
edema.
An assistive personnel reports a client's vital signs as tympanic temperature
37.1, pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of
the following vital signs should the nurse re-assess?
A nurse is caring for a client who ingested a poison and is now experiencing a
seizure. Which of the following is the priority action the nurse should take?
a. Check the patency of the client's airway
b. Determine the poison that was ingested
c. Identify the amount of poison that was ingested
d. Position the client side-lying. Right Ans - a. Check the patency of the
client's airway
The priority action the nurse should take when using the airway, breathing,
circulation (ABC) approach to client care is checking the patency of the client's
airway.
A nurse is admitting a client who reports anorexia and is experiencing
malnutrition. Which of the following laboratory findings should the nurse
expect to be altered?
a. Creatine kinase
b. Troponin
c. Total bilirubin
d. Albumin Right Ans - D. Albumin
A low albumin is a measure of plasma proteins which reflects the nutritional
condition of a client experiencing anorexia and malnutrition over an extended
period of time
A nurse is planning care for an older adult client who is at risk for developing
pressure ulcers. Which of the following interventions should the nurse use
help maintain the integrity of the client's skin?
a. Use a transfer device to lift the client up in bed.
b. Apply cornstarch to keep sensitive skin areas dry
c. Massage the skin over the client's bony prominences
d. Elevate the head of the bed no more than 45 degrees Right Ans - a. Use a
transfer device to life the client up in bed
Using a lifting device prevents dragging the client's skin across the bed linens,
which can cause abrasions.
,A nurse is orienting a new assistive personnel (AP) to the unit. For which of
the following actions should the nurse intervene?
a. Wears a gown when entering the room of a client who requires contact
precautions
b. Dons gloves to empty a urinary drainage device
c. Washes and rinses her hands for 10 seconds
d. Wears a respirator mask when entering the room of a client who requires
airborne precautions Right Ans - c. Washes and rinses her hands for 10
seconds
The nurse should intervene because the AP should wash her hands for a least
20 seconds.
A nurse is assessing a client's bowel sounds. At which of the following points
in the assessment should the nurse auscultate the client's abdomen?
a. After palpating the abdomen
b. Prior to percussing the abdomen
c. After assessing for kidney tenderness
d. Prior to inspecting the abdomen Right Ans - b. Prior to percussing the
abdomen
According to evidence-based practice, the nurse should auscultate the
abdomen prior to percussing it to prevent altering the bowel sounds. Both
percussing and palpation can stimulate the intestines, increase their motility,
and intensify the bowel sounds
A nurse is filling out an incident report after finding a client lying on the floor.
Which of the following information should the nurse include?
a. " The client attempted to climb over the side rails and fell"
b. "The client was lying on the floor next to his bed."
c. "the client was restless and trying to get out of bed all evening."
d. "The presence of a bed alarm could have prevented the client from falling."
Right Ans - B. "The client was lying on the floor next to his bed."
In an incident report, the nurse should only document what she actually
witnessed, along with the date, time, place, and any other actual facts about
the incident.
,A nurse is caring for a client who has a prescription for a stool test for guaiac.
The nurse understands the purpose of the test is to check the stool for which
of the following substances?
a. Steatorrhea
b. Blood
c. Bacteria
d. Parasites Right Ans - b. Blood
A guaiac test detects the presence of occult or hidden blood in the stool. The
guaiac test is an extremely useful diagnostic screening test for the presence of
colon cancer and gastrointestinal ulcers.
A charge nurse is anticipating the admission of four clients and planning their
room assignments. Which of the following clients should the nurses assign to
the room closest to the nurses station?
a. A client who sustained a head injury and is having periods of confusion
b. A client who reports a severe migraine headache
c. A client who has a suspected diagnosis of Tuberculosis (TB)
d. A client who has a history of atrial fibrillation and is on continuous ECG
monitoring Right Ans - a. A client who sustained a head injury and is
having periods of confusion
A client who sustained a head injury and is confused is at risk for seizures. The
nurse should place this client in a room near the nurses' station so that he can
be closely monitored to prevent injury if a seizure occurs.
A nurse is caring for a client who requires droplet precautions. Which of the
following personal protective equipment should the nurse wear when setting
up the client's meal tray?
a. Gloves
b. Goggles
c. Gown
d. Mask Right Ans - D. Mask
A nurse should follow droplet precautions for clients who have infections that
spread by droplets larger than 5 microns. The nurse should wear a mask
whenever she is within 1m (3ft) of the client.
, A nurse is caring for an older adult client who was alert and oriented at
admission but now seems increasingly restless and intermittently confused.
Which of the following actions should the nurse take to address the client's
safety needs?
a. Call the family and ask them to stay with the client
b. Move the client to a room closer to the nurse's station
c. Apply wrist and leg restraints to the client
d. Administer medication to sedate the client. Right Ans - b. Move the client
to a room closer to the nurse's station
This will make it easier for the staff to observe the client, should the client
behave in an unsafe manner.
A nurse is preparing to administer an ophthalmic solution to a client. Which of
the following actions should the nurse take?
a. Instill the drops into the inner canthus
b. Approach the client's eye from below it
c. Hold the ophthalmic solution 2cm (3/4 in) above the lower conjunctival sac.
d. Ask the client to look down when instilling the solution Right Ans - c.
Hold the Ophthalmic solution 2cm (3/4in) above the lower conjunctival sac.
A niurse is providing preoperative teaching for a client who will undergo
surgery. The nurse explains that the client will wear antiembolism stockings
during and after the surgery. When the client asks what the stockings do.
Which of the following responses should the nurse make?
a. "They protect your legs and heels from skin breakdown"
b. "They help keep you warm after your surgery"
c. "They improve your circulation to keep blood from pooling in your legs"
d. "They make it easier for you to do leg exercises after your surgery" Right
Ans - c. "They improve your circulation to keep blood from pooling in your
legs"
Antiembolism stockings promote venous return from the legs, thus helping to
prevent venous thrombosis, also known as clot formation and peripheral
edema.
An assistive personnel reports a client's vital signs as tympanic temperature
37.1, pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of
the following vital signs should the nurse re-assess?
