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30. A nurse is collecting data from a client during a routine physical exam. Which of the following locations should the nurse identify as the point of maximum impulse? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer) B, C, A

 32. A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following statements by the client indicates an understanding of the teaching? a. I should take an antacid while taking this medication b. I might experience blurred vision as an expected side effect of the medication c. I should weigh myself every other day d. I will have my potassium level checked periodically

 33. A nurse is caring for a client who has closed head injury. In which of the following positions should the nurse place the client? a. Modified Trendelenburg b. Sims c. Prone d. Semi-Fowler’s

 34. A nurse is reinforcing teaching about foot care for a client who has diabetes. Which of the following client statements indicates an understanding of the teaching? a. I can wear open-toe shoes b. I should round the corners of my toenails when trimming them c. I can apply lotion between my toes after showering d. I should wear cotton socks

 36. A nurse enters a client’s room and sees smoke coming from the trash can next to the client’s bed. Which of the following actions should the nurse take first? a. Close the door to the client’ room b. Pull the fire alarm panel c. Remove the client from the room d. Obtain a fire extinguisher 

37. A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection? a. Diminished relexes b. Temperature 37.3* C (99.1* F) c. Changed mental status d. WBC count 9,000/mm 

38. A nurse is caring for a client who is 8 hr postoperative following a left hip arthroplasty. Which of the following laboratory values indicates the nurse should notify the provider? a. Hemoglobin 8.6 g/dl b. Potassium 3.6 mEq/l c. BUN 18 mg/dl d. Blood glucose 98 mg/dl

 39. A nurse is caring for a client who is receiving treatment for cancer and is experiencing stomatitis. Which of the following actions should the nurse take to help manage the condition? a. Minimize the use of gravies and sauces b. Discourage drinking with a straw c. Provide an alcohol-based mouthwash d. Recommend consumption of cold items

 40. A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema? a. Keep both hands below the level of the client’s heart b. Obtain blood pressure readings using the client’s right arm c. Limit range-of-motion exercise with the affected arm d. Use the client’s left arm to obtain blood samples

 44. A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider? a. Platelets 60, 000/mm b. Bilirubin 1.0 mg/dl c. Aspartate aminotransferase 34 units/L d. Ammonia 55 mcg/dl 

45. A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion? a. Polyuria b. Distended neck veins c. Vomiting d. Hypertension 

46. A nurse is reinforcing teaching with a client about breast self-examination. Which of the following statements by the client indicates an understanding of the teaching? a. I will perform breast exam every other month b. It is common for one breast to be larger than the other c. It is common for the skin on my breast to dimple d. I will perform breast exams the day my period begins 
47. A nurse is reinforcing teaching with a client regarding application of antiembolic stockings. Which of the following statements for the client indicates an understanding of the teaching? a. I should flex my toes when applying the stockings b. The thigh-high stockings should reach just above the gluteal folds c. I should reapply the stockings before I get out of bed d. Knee-high stockings can be rolled down slightly to provide comfort 

49. A nurse is assisting with the plan of care for a client who has osteoarthritis. The client reports knee stiffness upon ambulation. Which of the following interventions should the nurse include in the plan of care? a. Apply moist heat prior to ambulation b. Use a continuous passive motion machine c. Rest in a soft chair d. Delay ambulation until the next day 

50. A nurse is contributing to the plan of care for a client who has developed an infectious would with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care? a. Place the client in a private room with a private bathroom b. Discard soiled wound care supplies in a trash receptacle outside the client’s roomc. Instruct visitors to perform hand hygiene for 5 seconds after leaving the client’s room d. Administer antibiotic therapy before culturing the client’s wound 

51. A nurse in an urgent care facility is collecting data from a client who was stung by a wasp. Which of the following findings indicates the client is experiencing anaphylaxis? a. Petechial rash on the abdomen b. Hypertension c. Bilateral tinnitus d. Difficulty swallowing 52. A nurse is reinforcing teaching with an assistive personnel (AP) about a client who has pertussis. Which of the following instructions should the nurse include in the teaching? a. Wear a gown when caring for the client b. Place the client in a negative air pressure room c. Wear an N95 mask when in the client’s room d. Wera a single face mask when caring for the client 53. A nurse is reinforcing skin care teaching with a client who has systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching? (Select all that applies) a. I will gently pat my skin dry after bathing b. I will limit time on tanning bed to 10 minutes c. I should cleanse reddened area of my face with an astringent d. I should apply lotion to my skin twice daily e. I will apply an SPF 30 sunblock before gardening 54. A nurse is assisting with care of a client who received a tuberculin skin test 72 hr ago. When collecting data from the test site, which of the following findings indicates a need for further testing? a. Palpable area of induration, greater than 10 mm (0.4 in) in diameter b. Area of ecchymosis, greater than 12 mm(0.5 in) in diameter c. Tenderness at the injection site d. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter 55. A nurse is providing care to a client who has sustained deep partial-thickness burns to the back of both legs. Which of the following actions should the nurse anticipate taking? a. Change sterile gloves between caring for weapons on different areas of the body b. Restrict the client’s calorie intake to no more than 2,000 calories per day c. Administer a diuretic if the client’s urine output falls below 30 ml/hr d. Limit movement or bending of the client’s affected extremities 56. A nurse is reinforcing discharge teaching with the partner of a client who requires tracheal suctioning. Which of the following statements by the partner indicates an understanding of the teaching? a. I will suction the mouth before inserting the suction catheter into the tracheostomyb. I will wrap the suction catheters in a clean towel to be used again at a later time c. I will suction for less than 15 seconds while inserting the suction catheter d. I will set the suction pressure dial between 80 and 120 57. A nurse is reinforcing teaching with a client who has a new prescription for alendronate for the treatment of osteoporosis. Which of the following instructions should the nurse include? a. Take the medication right before eating breakfast b. Sti upright for 30 to 60 min after taking the medication c. Drink milk with the medication d. Chew the tablets thoroughly 58. A nurse is caring for an older adult client who has heart failure. Which of the following findings should the nurse report to the provider? a. Urinary output of 1,000 ml in 12 hr b. Potassium level 4.5 mE q/l c. PaCO2 55 mm hg d. Chest X-ray showing cardiomegaly 59. A nurse is collecting data from a female client during an initial health assessment. Which of the following findings should the nurse identify as a risk for osteoporosis? a. Applies an estrogen vaginal cream daily b. Uses a beclomethasone inhaler c. Walks 30 min per day d. Include canned sardine in her diet 61. A nurse is caring for a client who has a peripheral IV infusion and notes that the client’s arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect? a. Infiltration b. Phlebitis c. Nerve damage d. Infection 62. A nurse in a clinic is reinforcing teaching about breast health with a client who has a family history of breast cancer. Which of the following instructions should the nurse include? a. Include meats grilled over high heat in the dirt b. Expect clear discharge from the nipples c. Complete breast self-examinations 1 week prior to my instruction d. Consume a diet high in antioxidants 64. A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take? a. Use safety pins to secure the pad in place b. Apply the pad for 45 min at a time c. Fill the pad with sterile water d. Cover the pad prior to use 65. A nurse is reinforcing teaching about a transcutaneous electrical nerve stimulation (TENS) unit for a client who has a herniated intervertebral disk. Which of the following statements by the client indicated an understanding of the teaching? a. The TENS unit administers a continuous dose of pain medication b. I will need to charge the TENS unit for 2 hours each day c. The TENS unit should be applied at least 6 inches from the actual site of my paind. I should adjust the TENS unit until I feel a tingling sensation 67. A nurse in a provider’s office is collecting data from a client 1 month following surgery for a new colostomy. Which of the following statements indicates the client is in the acceptance stage of grieving? a. I have purchased a stoma cap I can use when needed b. I have my partner empty my pouch for me every morning c. I miss going to my church meetings like I used to do d. I am embarrassed by the odor that comes from my colostomy 68. A nurse is collecting data from a client who is postoperative and has a deep-vein thrombosis of the right calf. Which of the following actions should the nurse take? a. Decrease the client’s fluid intake b. Apply cool compresses to the right calf c. Maintain the client on bed rest d. Place the right leg in a dependent position 69. A nurse is reinforcing health promotion education at a community health fair. Which of the following statements by attendees indicates understanding of the teaching? a. I will examine my breasts a week after each menstrual period b. The flu shot I receive last year will last for 2 years c. I do my testicular self-exam every 6 months without fail d. I should get a hepatitis B vaccine on a yearly basis. 70. A nurse is caring for a client in hospice care who is dying. The client’s partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse? a. Encourage your partner to wake up to interact with family members b. I can ask the provider to prescribe a medication that will minimize drowsiness c. Sitting quietly near the bedside can provide comfort and support d. I will call the provider to discuss your concerns 72. A nurse is monitoring a client following a coronary angiograph. Which of the following findings should the nurse report to the provider? a. Sinus rhythm 95/min on a cardiac monitor b. BUN 30 mg/dL c. Respiratory rate 12/min d. aPTT 25 seconds 73. A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take in preparation for the procedure? a. Ensure the signed consent is in the medical record b. Administer a cleansing enema c. Shave the client from axillae to groin d. Have the client drink contrast medium

 75. A nurse is reinforcing teaching about meal planning with a client who has hypertension. Which of the following statements by the client indicates an understanding of the teaching? a. I can season food with ketchup b. I can have canned soup c. I can have a bologna sandwich d. I can season food with vinegar 

76. A nurse is collecting dada from a client who has iron-deficiency anemia. Which of the following locations should the nurse monitor for the clinical manifestation of chellosis? (you will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer) A, C, B. 

77. A nurse is assisting with the preparation of a client who is scheduled for a thoracentesis. In which of the following positions should the nurse place the client during the procedure? a. Knees elevated b. Prone c. Lithotomy d. Leading forward

 

 78. A nurse is caring for a client who is postoperative following the placement of a colostomy. Which of the following findings indicates the colostomy is functioning properly? a. Stoma is pinkish red b. Absent bowel sounds c. Passing of flatus d. Tolerating a clear liquid diet 

 

79. A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take? a. Insert a tongue blade into the client’s mouth b. Apply restraints to the client c. Place the client in the prone position d. Administer an IV bolus of lorazepam 

80. A nurse is reviewing the AGB value of a client who has pneumonia. Which of the following findings indicate the client is developing respiratory acidosis? a. pH 7.47 b. PaCO2 55 mm Hg c. Pa O2 85 mm Hg d. HCO3″ 25 mEq/L 83. A nurse is checking the skin of a client who has chronic venous insufficiency. Which of the following images should the nurse identify as a venous stasis ulcer? 84. A nurse has just received morning change-of-shift report for four clients. Which of the following clients has the highest priority need? a. A client who returned 1 hr ago from lithotripsy and is reporting nausea b. A client who has a serum potassium level of 5 mEq/l and is scheduled for dialysis in the afternoon c. A client who has an indwelling urinary catheter and has a total urine output of 80 ml over the past 8 hr d. A client who had a total abdominal hysterectomy 2 days ago and is reporting a pain level of 3 on a scale of ) to 10 85. A nurse is assisting in the care of a client who is to receive a transfusion of packed RBCs. Which of the following solutions should the nurse obtain? a. Lactated Ringer’s b. Dextrose 3% in 0.45% sodium chloride c. Dextrose 5% in water d. 0.9% sodium chloride 

86. A nurse is reinforcing teaching with a client who is taking oxybutynin. The nurse should tell the client that the medication will have which of the following effects? a. Increases venous return to the heart b. Relaxes the muscles of the colon c. Relaxes the muscles of the bladder d. Increases tissue perfusion in the lungs

 89. A nurse is reviewing the medical records of a client who reports his urine is red-orange. The nurse should identify that which of the following medications can course this adverse effect? a. Rifampin b. Metoprolol c. Furosemide d. Isoniazid 

 

92. A nurse is reviewing the results of a client’s fecal occult blood screening test. Which of the following findings from the client’s history should the nurse identify as potentially causing a false-position result? a. The client takes ibuprofen for headaches b. The client has a history of breast cancer c. The client consumed citrus juice 3 days before the test d. The client had a hemorrhoidectomy 1 year ago. 

 

93. A charge nurse a observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factor for falls? a. Attaches the call light to the side rail of the client’s bed b. Positions the bedside table close to the client c. Keeps the client’ bed in the low position d. Instructs the client to wear their own socks to the bathroom 

 

94. A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads” Apply to the left foot for 20 min.” Which of the following actions should the nurse take? a. Complete Semmes-Weinstein monofilament testing following treatment b. Clarify the prescription with the provider c. Observe the skin 10 min after the start of treatment d. Apply the heating pad as prescribed by the pastor 95.

 A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hyposis. Which of the following actions should the nurse plan to take? a. Maintain the client in a supine position b. Implement contact precautions c. Apply petroleum jelly to the client’s naves d. Initiate fall precautions 96. A nurse is preparing to perform a sterile dressing for a client who has stage III pressure ulcer. Which of the following actions should the nurse plan to take? a. Disinfect the wound bed with alcohol before applying tape b. Don sterile gloves before removing the dressing c. Prepare the sterile dressing supplies 30 min before the dressing change d. Offer the client pain medication before the procedure

 97. A nurse is caring for a client who is visually impaired. When delivering the client’s meal tray, which of the following actions should the nurse take? a. Discourage conversations during the client’s mealtime b. Provide the client with small-handled adaptive utensils c. Describe the food placement as though the plate were a clock d. Arrange for an assistive personnel to feed the client 

98. A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first? a. Place the client in high-Flower’s position b. Encourage the client to cough and deeper breathe c. Administer heparin to the client d. Obtain the client’s vital signs 

99. A nurse is planning care for a client who is receiving radiation therapy to treat throat cancer and reports a change in the taste of food. Which of the following interventions should the nurse include in the plan of care? a. Provide three large meals daily b. Add honey to sweeten fruit smoothies c. Heat food before serving d. Offer artificial saliva frequently

 100. A nurse in a long-term care facility is reinforcing teaching about pain control with a client who has terminal cancer. Which of the following information should the nurse include? a. Pain patches are applied each morning and removed at bedtime b. We will use intramuscular medications to control your pain c. Analgesia should be used around the clock to promote pain control d. A medication dose must be decreased if you develop tolerance

SCIENCE
HEALTH SCIENCE
NURSING
NUR 211

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