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PRACTICE TEST QUESTIONS

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Q & A Random -17

Question Number 1 of 13
After the death of a client, the family approaches the nurse and
requests that a family member be allowed to perform a ritual bath on
the deceased prior to moving the body. The appropriate response by
the nurse is
".
A) I will have to check on hospital regulations and policies.
B) These procedures have to be carried out by our staff.
C) Is there anything you need from me to perform the ritual bath?
D) A ritual bath will have to wait until after post-mortem care
Your response was "A".

The correct answer is C: Is there anything you need from me to


perform the ritual bath?

Rationale: In some religious traditions, a ritual bath is performed by a


family member or a ritual burial society. Nurses should inquire about
rituals or observances following death and respect these. Options 1, 2
and 4 are inappropriate and insensitive.

Question Number 2 of 13
An elderly client with tuberculosis has difficulty coughing up secretions
for a sputum specimen. Which nursing action is appropriate?

A) Spray the oropharynx with saline


B) Ask the client to drink a warm liquid
C) Force fluids for the next 8 hours
D) Raise the head of the bed to at least 45 degrees
Your response was "A".

The correct answer is D: Raise the head of the bed to at least 45


degrees

Placing the client in semi or high fowler’s position will promote lung
expansion and effective coughing. While drinking liquids helps to
loosen secretions over time, they should not be given when collecting
a specimen. Spraying the throat with saline may cause irritation and
coughing and reduce oxygenation.

Question Number 3 of 13
A client has just returned from the Post-Anesthesia Care Unit (PACU)
to the surgical unit after a cholecystectomy. When initial vital signs are
taken the nurse notes a temperature of 94.8 degrees Fahrenheit.
Which first nursing action is appropriate?

A) Continue to monitor the vital signs as indicated


B) Apply a warm blanket and check the temperature in 10 minutes
C) Ask the PACU nurse more details of what happened in PACU
Call the health care provider and obtain further orders for
D)
warming
Your response was "A". The correct answer is B: Apply a warm blanket
and check the temperature in ten minutes

A client’s post-operative temperature should be at least 95 degrees. If


the temperature does not increase, the nurse should call the provider
for orders for an electric warming blanket or other measures. It is not
sufficient to continue monitoring without taking action.

Question Number 4 of 13
The client with amyotrophic lateral sclerosis is scheduled for 160 ml of
enteral feeding as a bolus every 4 hours. Before flushing with water
the nurse aspirates the feeding tube contents and gets back 180 ml of
feeding. What is the next appropriate nursing action?

A) Administer the feeding as ordered


B) Hold the next feeding
C) Flush with sterile water
D) Discard the undigested feeding
Your response was "A". The correct answer is B: Hold the next feeding

If residual is greater than 150 ml, then the next feeding should be
held. Administering water or the next feeding does not help with the
digestion of this feeding. Discarding the feeding that was aspirated
depletes the body of enzymes and electrolytes that have been mixed
with the feeding

Question Number 5 of 13
The nurse is removing a fecal impaction on a 75 year-old client. It is
most important that the nurse remember that
A) the procedure be done prior to the bath
B) family members should be taught the procedure
C) cardiac dysrhythmias can result during the process
D) increased dietary fiber can minimize such problems
Your response was "A". The correct answer is C: cardiac dysrhythmias
can result during the process

Cardiac dysrhythmias such as severe bradycardia can result from


vagal nerve stimulation during fecal impaction removal in the elderly
or in cardiac patients. Options 1, 2 and 4 are appropriate though are
not the most important considerations.

Question Number 6 of 13
A client is being discharged home today, and will be taking K-dur
20mEq per day by mouth. The nurse should reinforce that potassium
levels will be decreased by

A) foods seasoned with salt substitute


B) frequent daily snacks of black licorice
C) prescribed potassium-sparing diuretics
occasional use of a nonsteroidal anti-inflammatory drug
D)
(NSAID)
Your response was "A". The correct answer is B: frequent daily snacks
of black licorice

Excessive intake of black licorice can lead to decreased K+ levels due


to the effect of glyceric acid (aldosterone effect). The excessive intake
of salt substitutes, K+ sparing diuretics and NSAIDs all have the
potential for raising the K+ level.

Question Number 7 of 13
When taking the client’s blood pressure (BP), the nurse cannot hear
the sounds through the stethoscope. Which action should the nurse
take first?

A) take the BP again in 2 minutes in the same arm


B) retake the BP again immediately in the same arm
C) use an electronic BP cuff on the other arm
D) check to see if the stethoscope is plugged
Your response was "A". The correct answer is A: take the BP again in 2
minutes in the same arm
It is best to wait 2 minutes between readings of a BP in the same arm
to allow the vessels to recover from being squeezed. The electronic
cuff would also require a 2 minute wait and may not read a very low
pressure

Question Number 8 of 13
On admission to the ambulatory surgery unit, the nurse notices the
client's painted finger nails. On reviewing the pre-op orders, the nurse
notes that pulse oximetry has been ordered. Which statement by the
nurse is appropriate?

"In order to measure your oxygen level, please remove the


A)
polish from at least 2 nails."
"If you do not remove all your polish, I will request a
B)
needlestick to test oxygen levels."
C) "I am sorry. All your nail polish must go off."
D) "I will ask your provider if we must ruin those beautiful nails."
Your response was "A". The correct answer is A: "In order to measure
your oxygen level, please remove the polish from at least 2 nails."

In order to effectively measure pulse oximetry, there can be no nail


polish on the finger with the reading device. The client should be
approached using therapeutic communication skills. The other options
are not appropriate

Question Number 9 of 13
The client with multiple sclerosis has an order to change the
nasogastric tube. To promote safety when removing the tube, the
nurse should

A) ask the client to hold a breath


B) offer sips of water
C) bring the code cart to the bedside
D) empty the tube of all drainage
Your response was "A". The correct answer is A: ask the client to hold
a breath

Holding the breath closes the epiglottis to help prevent aspiration.


Occasionally passing a NG tube is easier if the client swallows during
the process. Emptying the tube does not prevent aspiration. There
should be no need for the code cart.

Question Number 10 of 13
The client referred for a mammography questions the nurses about the
cancer risks from radiation exposure. What is the appropriate response
by the nurse?

The radiation from a mammography is equivalent to 1 hour of


A)
sun exposure.
You have nothing to worry about; it is less than tanning in the
B)
nude.
C) A chest x-ray gives you more radiation exposure.
D) Exposure to mammography every 2 years is not dangerous.

Your response was "A". The correct answer is A: The radiation from a
mammography is equivalent to one hour of sun exposure. The
exposure of radiation from a mammography is equivalent to 1 hour of
sun exposure; a client would have to have several in a year’s time to
be at risk for cancer. This answer is concise and gives the client a
point of reference. Option 2 is judgmental and non-therapeutic. Option
3 is not accurate and can cause further concern about radiation
exposure. Option 4 does not clearly address the client’s question.

Question Number 11 of 13
A client experiences intense anxiety after the home was destroyed by
a fire. The client escaped from the fire with only minor injuries. The
nurse knows that the most important initial intervention would be to:

A) Suggest the client rent an apartment with a sprinkler system


B) Provide a brochure on methods to promote relaxation.
C) Determine available community and personal resources
D) Explore the feelings of grief associated with the loss
Your response was "A".

The correct answer is C: Determine available community and personal


resources

The client has experienced a sudden event that has resulted in


disequilibrium. The most important initial intervention focuses on
identifying resources and obtaining assistance for housing and other
immediate needs. Information on home safety, relaxation exercises,
and grief counseling are of value after meeting initial needs for shelter.
Question Number 12 of 13
The nurse is inserting a Foley catheter into the bladder of a female
adult client. The nurse slips the catheter into an opening for four-5
inches and no urine is obtained. The most probable reason for this is
that

A) there is no urine present in the bladder


B) the catheter is in the vagina
C) the catheter is not inserted in far enough
D) the bladder is over distended
Your response was "A". The correct answer is B: the catheter is in the
vagina

The urinary catheter is inserted about 2 to 3 inches in the urinary


meatus until the urine flow is visualized. If urine does not flow, the
catheter is rotated gently and carefully inserted another inch farther. A
catheter inserted 4 to 5 inches with no urine return is probably in the
vagina

Question Number 13 of 13
The nurse is caring for a 16 year-old client with femur fracture14
hours after surgery. Assessment findings include tachycardia,
increased shortness of breath, a temperature of 100.2 degrees
Fahrenheit, complaints of feeling anxious, and oxygen saturation level
of 88%. In immediately notifying the provider of these findings, the
nurse recognizes the client is at risk for

A) compartment syndrome
B) atelectasis
C) myocardial infarction
D) fatty embolism
Your response was "A".

The correct answer is D: fatty embolism

The findings are cardinal signs of a fatty embolism. Compartment


syndrome does not cause increased shortness of breath or feelings of
anxiousness. Atelectasis occurs when ventilation is decreased and
secretions accumulate. Myocardial infarction is characterized with
chest pain and generally does not occur in 16 year olds unless there is
a cardiac history

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