Would you be able to assist with

Would you be able to assist with answering these questions 1. A nurse is teaching a group of nursing assistants about infection-control measures. What is the priority information to include in this teaching? a. hand-washing techniques b. proper use of gloves c. administration of antibiotics d. assignment of private rooms 2. After the change-of-shift report, which patient will the nurse assess first? a. A 40 year old man with continuous eternal feedings who has developed pulmonary crackles b. A 30-year old man with 4+ generalized pitting edema and severe protein-calorie malnutrition c. A 40- year old woman whose parenteral nutrition infusion bag has 30 minutes of solution left d. A 30 year old woman who gastrostomy tube is clogged after crushed medications were administered. 3. Which of the following measures can reduce or prevent the incidence of atelectasis. a. use of an incentive spirometer b. chest physiotherapy c. mechanical ventilation d. reducing oxygen requirements. 4. The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1-inch x 1 inch (3cmx3cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record. a. stage 1 pressure ulcer b. stage 2 pressure ulcer c. stage 3 pressure ulcer d. stage 4 pressure ulcer 5.The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicated a good understanding? a. ‘An example of this type of exercise is walking’ b. An example of this type of exercise is kegels c. An example of this type of exercise is running. d. an example of this type of exercise is swimming. 6. A client is admitted to the preoperative clinic for a breast biopsy. Which information would the nurse enter into the medical record as objective data? a. The client states” I’m worried about the results” b. Blood pressure is 122/84, and the pulse is 100 beats/minute c. The client reports anxiety at 7 out of 10. d. the client reports the left breast is tender to touch. 7. The nurse notes documentation that a client is exhibiting Cheyne-Stokes Respirations. On the assessment of the client, the nurse should expect to note which finding? a. Irregular repirations with pauses at the end of inspiration and expiration b. Rhythmic respirations with periods of apnea. c. Totally irregular respirations in rhythm and depth d. regular rapid and deep, sustained respirations. 8. The student nurse is working with a preceptor to administer an enema to the client. Which action by the student nurse prompts intervention and redirection by the preceptor? a. The client positioned comfortably in the right side lying Sims position b The client bedpan is put at the bedside in preparation for use. c. The enema tubing is primed with a solution that has been warmed d. Water-soluble lubricant is applied to the end of the enema tubing. 9. The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Cardiac d. Respiratory 10. When defining characteristics are consistent with fluid volume deficit? a. bounding radial pulse, flat neck veins when supine b. dry mucous membranes, thready pulse, tachycardia. c. Engorged neck veins when upright, bradycardia d. a weight loss of 1 lb (0.5 kg) in 1 week, pale yellow urine. 11. Which action most effectively demonstrates that a new staff member Jana understands the role of scrub nurse? a. monitor change in patient condition b. takes the patient to the postanesthesia area c. documents all patient care accurately d. “I must don full surgical attire and sterile gloves” 12. What is the name of the interval when a patient manifests signs and symptoms specific to a type of infection. a. incubation period b. convalescence c prodromal stage d. illness stage 13. Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145mEq/L, Potassium 4.5 mEq/L, calcium 4.5 mg/DL? a. Decreased deep tendon reflexes b.Light-headedness when standing up c weak quadriceps muscles d. tingling of extremities with possible tetany. 14. The nurse is assessing a client with multiple traumas who is at risk for developing acute respiratory distress syndrome. The nurse should asses for which earliest sign of acute respiratory distress syndrome? a. Intercostals retractions b. increase respiratory rate c bilateral wheezing d inspiratory crackles. 15. What will the nurse do to test for Trousseau’s sign as a diagnostic test for hypocalcemia? a. hyperextending the clients neck b. Tapping the clients face lightly over the facial nerve. C. addressing vital signs d. inflating a blood pressure cuff on the upper arm. 16. A nurse conducting Weber’s test. Which action will the nurse take? a. Place a vibrating tuning fork on the patient’s mastoid process. b. Compare the number of seconds heard by bone versus air conduction. c. Compare the patient’s degree of joint movement to the normal level. d. Place a vibrating tuning fork in the middle of the patient’s forehead. 17.The nurse receives a handoff report on the four patients. What patient should the nurse assess first? a. The patient with the right leg pain rated an 8/10 asked for pain medication. b. The patient with a resp rate of 18 breaths/ min c. The patient with a blood pressure of 110/64 d. The patient with a pulse of 42 beats/ min 18. A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing. A. oranges b. milk c. bananas d. chicken 19. A client with acute renal failure has a serum potassium level of 6.5mEq/L (6.5 mmol/L). The nurse should monitor the client for which potential complication? a. Circulatory collapse b. cardiac arrest c. hemorrhage d. pulmonary edema. 20. A nurse is caring for a caring who just experienced a generalized seizure. Which of the following action should the nurse perform first? a. Provide client hygiene b. keep the client in a side-lying position c. Reorient the client to the environment d. Document the duration of the seizure. 21. The nurse is caring for a postoperative client who has not voided since before surgery. What is the nurse’s most appropriate action? A. Palpate for the bladder above the symphysis pubis b. Request an order to insert Foley catheter c. Initiate hourly intake and output measurements d. Force fluids to encourage voiding. 22. A community nurse is assessing a young child who has had a colostomy stoma for several years. The nurse notices that the stoma is pink and moist. What is the best response to the child’s parents about the appearance of the stoma? a. the stoma is irriated: change the appliance more frequently. B.” The stoma looks infected: you need an antibiotic cream c. The stoma looks healthy: continue your present care d. ” The stoma is too moist; we must try to prevent skin breakdown” 23. A high school nurse notes that girls on the cross-county team eat together each day. She notes that one of the girls only consumes an apple each day at lunch and has experienced a decline in her athletic performance, which condition the nurse suspect in this girl. a. anorexia nervosa b. Pheylketonuria (PKU) c. Crohn disease d. Bulimia nervosa 24. The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement? a. Place the tips of the two fingers over the groove along the little finger side of the patients wrist. b. Place the thumb over the groove along the little finger side of the patients wrist. c. Place the thumb over the groove along the thumb side of the patients wrist. d. Place the tips of the first two fingers over the groove along the thumb side of the patients wrist. 25. A nurse is assessing the skin of an immobilized patient. What will the nurse do? a. Use a standardized tool such as the Braden Scale b. Assess the skin every 4 hours. c. Limit the amount of fluid intake. d. Have special times for inspection so as to not interrupt routine care. 26. A patient is dehydrated and needs an infusion of isotonic fluids to correct dehydration. Which intravenous fluid is appropriate for this patient? a. Dextrose 10% in water (D10W) B. Dextroe 5% in water (D5W) C. Dextrose 5% in 0.9% sodium chloride( D 5NS; D 0.9% NaCl) d. Dextrose 5 % in lactated Ringers ( D 5 LR) 27. An infection control nurse has identified a problem related to infection control procedures on a medical unit that has a high census of clients diagnosed with tuberculosis. The nurse has decided to conduct an in-service education program for the staff about the required transmission- based precautions. The nurse determines that the program was successful based on which statement by the staff? a. It is okay to leave the client’s room door open to allow for interaction with the staff. b. “If the client needs to be transported, transport personnel needs to wear a mask” c. “The client needs to be placed in a private, negative air pressure room.” d.” When wearing a respirator, it needs to be removed before leaving the clients room” 28. A client has a potassium level of 6.1 mEq/L, which medication would the nurse anticipate giving? a. Potassium supplements b. Sodium Tablets c Kayexalate d. Calcium gluonate. 29. Which nutrients are considered macronutrients? Select all that apply a. minerals b. carbohydrates c. fats d. vitamins e. proteins 30.Which element is part of the chain of infection? Select all that apply. One, some, or all response may be correct. A . a vaccine schedule b. a susceptible host c. reservoir d. an infectious agent e. a clean surrounding 31.When auscultating a clients chest, a nurse assesses a second heart sound (S2). What would the nurse determine is the cause of this sound. a. closing of the aortic and pulmonic valves b. closing of the mitral and tricuspid valves c. opening of the mitral and tricuspid valves d. opening of the aortic and pulmonic valves. 32. The nurse is teaching hypertension management to a patient who is taking antihypertensive drugs. Which statement made by the patient indicates a need for further clarification? a. When my blood pressure becomes normal, I no longer need to take medication. b.” When I get out of bed in the morning, I should first sit for a few moments and then stand.” c.” Keeping my blood pressure under control reduces my risk for a heart attack” d. “Losing weight can reduce my need for blood pressure medication.” 33. A male client 30 years of age is postoperative day 2 following a nephrectomy ( kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse’s best intervention in this clients care? a. Show the client the expected outcomes on his clinical pathway that relate to mobilization. b. Respect the client’s wished to remain in his bed and ask him when he would like to begin mobilizing. c. Educate the client about the benefits of earlt mobilization and offer to assist him. D Document the clients noncompliance and reiterate the consequences of delaying mobilization. 34. Which of the following needles would the nurse choose for an SQ injection? a. 22 gauge, 1 inch b. 19 gauge, 1 inch c. 23 gauge, 1 1⁄2 inch d .25 gauge, 5/8 inches 35.The nurse is caring for a patient who is receiving vancomycin to treat a severe infection. The next Vancomycin dose is due to be administered at 10: 00 AM. What time will the nurse draw the vancomycin serum trough level? a. 7:30 am b. 9:30 am c. 1:30 pm d 11:30 am 36. A febrile preschool-aged child presents to the after-hours clinic. Varicella( chickenpox) is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. Which type of skin lesion will the nurse report? a. pustules b, papules c. wheals d. vesicles 37. The nurse is caring for a 48- year old client with hyperkalemia. Which of the following interventions would the nurse provide for the client? Select all that apply. a. administer insulin and D50 as per MD orders b. monitor cardiac status and ECG C. Hold Potassium Supplements d. Administer IV potassium chloride via IV push e. Administer IV potassium chloride slowly as per MD orders 38. A client has an impairment of cranial nerve II. To maintain safety in the home, the nurse should teach the spouse to implement which measure? a. Keep traveled paths in home free of clutter b. Lower the temperature setting of the hot water heater. C. Speak to the client in a loud voice. d. Serve food that is not too hot or too cold. 39. Which of the following is a sign and symptom of hyperkalemia? a. constipation b. muscle strength c. hypoactive bowl sounds d. diarrhea 40. Which of the following terms is used to describe the inability to breath easily except in an upright position. a. hemoptysis b. orthopnea c. dyspnea d. hypoxemia 41. A small-bore tube is placed. Which technique will the nurse use to best verify tube placement? A. X-RAY B. aspirations of contents c. auscultation d. pH testing. 42. A patient in the emergency department is reporting left lower abdominal pain. Which proper order will the nurse follow to perform the comprehensive abdominal examination? a. inspection, palpation, auscultation b. inspection, auscultation, palpation c, percussion, palpation, auscultation d. percussion, auscultation, palpation. 43. Which areas are at risk for development of pressure ulcers in immobile patients? Select all that apply. a. elbows c. coccyx c. heels d. chest e. buttocks 44. The edges of a patients incision are approximated, and no drainage is noted. Which type of healing does this signify? a. granulation b. secondary intention c. tertiary intention d. primary intention 45. The nurse is caring for a patient who is receiving an IV antibiotic. The patient reports new signs and symptoms, including a rash and pruritus. The nurse understands that this is which kind of response from medication? a. idiosyncratic reaction b. allergic reaction c. side effect d. toxic effect 46. A client must receive a blood transfusion of packed red blood cells (RBC’S) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product? a. Dextrose 5% in water as this is considered an isotonic solution. b. Current guidelines suggest that no priming is needed since blood products must be infused alone. c. The normal saline solution as this is considered an isotonic solution d. Lactated Ringer’s solution as this is considered an isotonic solution. 47. The nurse administers medication to a patient. Shortly afterward, the patient develops an itchy rash all over his body and reports feeling very unwell. What is the priority action of the nurse? a. Determine if the patient is having an difficulty breathing b. Document the reaction in the patients chart. c. Obtain and order for hydrocortisone cream to relieve the itching. d. Leave the patient to notify the physician and the pharmacist. 48. The nurse is assessing skin lesions. Which would the nurse recognize as the priority for referral for a skin biopsy? a. asymmetrical, tan with a s defined border, 3 mm b. symmetrical; dark brown with regular border; 7mm c. symmetrical; brown with regular borders d. asymmetrical; brown with a black; irregular bored; 6.5 mm 49. A nurse has completed discharge teaching for a client , which involves instructions for changing a leg dressing. Which statement would indicate that the teaching has been effective? a. the dressing should be changed next time I have an appointment with my healthcare provider b. I will report any signs of redness or drainage when I change the dressing. c. I don’t need to worry about this dressing because the home health nurse will change it. d. I should change this dressing once a week when it starts to hurt. 50. On admission of a client to the post anesthesia care unit( PACU), the blood pressure is 126/82. Thirty minutes after admission, the blood pressure falls to 114/72 with pulse of 74 and warm, dry skin. Which action by the nurse is the most appropriate? a. Increase the IV fluid rate b. continue to take vitals every 15 minutes c. administer oxygen therapy at 100% per mask d. notify the anesthesia care provider immediately. 51. The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg(30 mmol/L) and HCO3- of 20 mEq/L. The nurse analyzes these results as indicating which condition? A. metabolic acidosis, compensated b. respiratory alkalosis, compensated c. metabolic alkalosis, uncompensated d. respiratory acidosis, uncompensated. 52. The nurse is caring for a client with Clostridium difficile infection. Prior to entering the room, which step would the nurse take? a. apply a face mask b. apply foot protection c. put on goggles d. put on a gown 53. The nurse is caring for a client who needs a hypertonic IV solution. What solutions are hypotonic? Select all that apply? a. 10% dextrose in water b. 5%NS C. 0.45% sodium chloride d. 0.33 NS E. 0.9 sodium chloride. 54. The nurse receives a handoff report on four patients. Which patient should the nurse assess first? a. The patient with right leg pain rated 8/10 asked for pain medication b. the patient with resp rate 18 breaths/ min c the patient with blood pressure of 110/64 d. the patient with a pulse of 42 beats/ min 55. Fifteen minutes after beginning of a blood transfusion the patient complains of having a headache and chills. The patient also has an elevated temperature. The nurse should first? a. Stop the transfusion and run separate NS line. b. Recheck the blood with a second nurse and take the vital signs every ten minutes. c. Take the vital signs and slow down transfusion d. Call the doctor and document. 56. The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH= 7.53, Pao2= 72 mm, and HCO3= 28 mEq/L. Which conclusion about the client should the nurse make? a. the client is probably hyperventilating b. the client is probably overreacting c. the client is fluid volume overload d. the client has acidotic blood. 57. Several laboratory test are prescribed for a client, and the nurse reviews the results of the test. Which laboratory test results should the nurse report? Select all that apply. A. potassium 5.0 mEq/L B. Calcium level 9.5 c. Sodium 150 mEq/L D. Magnesium level 1.9 e. White blood cells, 3000 mm3 58. The nurse is preparing to witness the client signing the operative consent form when the patient says, ‘ I do not really understand what the doctor said.” Which action is best for the nurse to take? a. Notify the operating room staff that the surgeon need to give a complete explanation of the procedure b. administer the prescribed preoperative antibiotics and withhold any order sedative medications c. Provide an explanation of the planned surgical procedure. d. Notify the surgeon that the informed consent process is not complete. 59. A nurse is preparing to administer a blood transfusion. Which assessment finding would the nurse report immediately? a. poor skin turgor and pallor b. heart rate 110 beats per minute c. blood pressure 90/50 d. temperature 100.9 60. The nursing assistive personnel (NAP) is taking vital signs and reports that the patient’s blood pressure is abnormally low. What should the nurse do next? a. Ask the NAP to retake the blood pressure b. Instruct the NAP to assess the patients other vital signs c. Retake the blood pressure personally and asses the patient’s condition. d. Disregard the report and have it rechecked at the next schedule time. 61. Which is a description best fits that of serous drainage from a wound? a. Beige to brown foul smelling b. clear, watery plasma c. fresh bleeding d. thick and yellow 62.A patients is admitted to the emergency unit with headache and stage 2 hypertension. Which prescription order would be primary health care provider use in this situation? a. standing order b.now order c. PRN order d. STAT order. 63. A 7 year old is admitted to the emergency department with a tentative diagnosis of asthma. Which observation requires a priority intervention by the nurse? a. expiratory wheezing b. stridor c. snoring sound on inspiration d. intercostals retractions 64. During a routine examination of a 70 year old patient, a blowing sound is auscultated over the carotid artery. Which assessment finding will the nurse report to the health care provider? a. right sided heart failure b. phlebitis c. thrill d. bruit 65.Which type of infection may the patient contract after undergoing a bronchoscopy? a. suprainfection b. Iatrogenic infection c. Exogenous infection d. Endogenous infection. 66. A male patient 86 years of age with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer, but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. Additionally, he repeatedly withdraws his head when the nurse attempts to use the tympanic thermometer. How should the nurse proceed with this assessment? a. Assess the clients skin tone and the presence or absence of sweating to determine whether the client is febrile b. Take the temperature rectally c. use a disposable mercury thermometer to take the clients temperature. d. assess the clients temperature by axilla. SCIENCE HEALTH SCIENCE NURSING NURS 420

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