Nursing Info

We will be discussing so many nursing exam questions for nurses who are already in School. These questions will help them broaden their knowledge:

1. When caring for a client in hemorrhagic shock, how should the nurse position the client?

1. Flat in bed with legs elevated
2. Flat in bed
3. Trendelenburg position 4. Semi-sitting position
4. Semi-sitting position

An adult woman has been in an automobile accident. She sustained numerous lacerations, a fractured tibia set by closed reduction, and a mild concussion. She has no apparent renal injuries and is conscious. An indwelling catheter is inserted for which of the following purposes?

1. To measure urine flow as an indicator of shock
2. To prevent contamination of her cast
3. For her comfort
4. To prevent renal complications

An adult is admitted with chronic renal failure. Strict intake and output is ordered. The client
is sometimes incontinent, so it is impossible to obtain an accurate record of output. How can the nurse best assess the client’s fluid status?

1. Estimate the amount voided each time.
2. Observe her skin turgor.
3. Weigh the client daily.
4. Record the number of voidings.

A client has Crohn’s disease with chronic diarrhea. Which nursing diagnosis is most likely to be appropriate for this client?

1. Risk for electrolyte imbalance (metabolic
   acidosis) related to loss of intestinal fluids
2. Risk for electrolyte imbalance (hyperkalemia)
   related to renal potassium retention with
   bicarbonate
3. Risk for electrolyte imbalance (metabolic
   alkalosis) related to excessive chloride losses in
   diarrhea
4. Risk for electrolyte imbalance (hypercalcemia) related to loss of phosphorus in diarrhea

The nurse is assessing a woman upon admission. Which data should be recorded as subjective data?

1. Her weight is 142 pounds.
2. She has a red rash covering the backs of her
   hands.
3. She states, “My hands itch so bad, I can hardly
   stand it.”
4. Her temperature is 99.8°F.

The LPN/LVN working in a long-term care facility is supervising a certified nursing assistant (CNA). Which observation indicates that the CNA needs further instruction in performing hygienic care?

1. The CNA washes the client’s face before
   washing the rest of the body.
2. The CNA puts one foot at a time into the basin
   of warm water when bathing the client’s feet.
3. The CNA applies lotion and powder liberally after bathing the client.
4. The bath water contains only a small amount of soap

The nurse is taking vital signs on a very obese individual and uses an extra-wide cuff. What is the primary reason for using an extra-wide cuff?

1. A regular-size cuff is not going to be long
   enough to go around the client’s arm.
2. Blood pressure taken with a cuff that is too
   narrow gives an artificially high reading.
3. A regular cuff is too tight and causes discomfort
   to the client.
4. A narrow cuff causes the client’s pulse to be
   elevated.

The LPN/LVN notes that an apical-radial pulse is ordered for a client. Which is the correct way to obtain this reading?

1. Have another nurse take the radial pulse while
   the LPN takes the apical pulse.
2. Take the apical pulse and immediately take the
   radial pulse.
3. The LPN should listen to the apical pulse and
   ask the client to take the radial pulse.
4. Take the radial pulse and then take the apical
   pulse.

Which behavior by a CNA in a long-term care facility indicates a need for further instruction?

1. Placing bed linens at the bedside prior to giving
   morning care.
2. Using the same wash basin for both residents in
   the semi-private room.
3. Washing hands after caring for one resident and
   before starting care for the next.
4. Wearing unsterile gloves to clean a resident who is solid with feces.

There is blood on the floor. How should the nurse clean up the spill?

1. Wipe up the spill and then clean the area with
   alcohol.
2. Use a 1:10 solution of chlorine bleach to clean
   the spill.
3. Wipe up the spill and clean the area with
   water.
4. Use an iodine solution to clean up the spill.

The nurse is changing a dressing. Which behavior, if observed, would indicate a break in technique?

1. The nurse opens a package of 4 × 4s away from
   the sterile field and then drops them onto the
   sterile field.
2. The sterile field is at waist height.
3. The nurse opens the first flap of a sterile
   package away from his or her body.
4. While pouring sterile saline into a sterile basin on the sterile field, the saline splatters onto the cloth backing.

The nurse is caring for a woman who had a CVA and has right-sided hemiplegia. Which action is least appropriate?

1. Performing ROM exercises when bathing the
   client
2. Changing the client’s position every two hours
3. Positioning the client supine and pulling the
   bed sheets tightly across her feet
4. Placing the client in the prone position for one
   hour three times a day.

The nurse is caring for an adult who had abdominal surgery this morning. Which action will do the most to prevent vascular complications?

1. Turn the client every two hours.
2. Encourage deep breathing and coughing every
   two hours.
3. Have the client move her legs and make circles
   with her toes every two hours.
4. Dangle the client as soon as she is awake and
   alert.

The nurse observes that an elderly man who is bedridden has a reddened area on his coccyx. The skin is not broken. The nurse most correctly interprets this pressure ulcer to be which stage?

1. Pre-ulcer
2. Stage I
3. Stage II
4. Stage III

An older adult who has a stage I pressure ulcer asks the nurse why a clear dressing has been put over the site when the skin is not broken. What should the nurse include when replying?

1. This dressing is a preventive measure to protect the skin from injury.
2. Covering it so the area is moist makes it heal faster.
3. Covering the area makes it more comfortable for you.
4. The clear dressing is designed to let light through and promote healing.

An adult is now alert and oriented following abdominal surgery. What position is most appropriate for the client?

1. Semi-sitting
2. Prone
3. Supine
4. Sims’

The LPN has delegated the task of taking vital signs to an unlicensed assistive personnel (UAP). Which instruction is most appropriate?

1. Take all the vital signs at 10:00 A.M.
2. Report any abnormalities to me.
3. Tell me if any blood pressure readings are over
   140/90 or under 100/70.
4. I am available if you have any problems

The LPN/LVN delegates the task of performing hygienic care of a bedridden client to a UAP. What responsibility does the LPN/LVN have regarding the performance of the care?

1. The LPN/LVN should check to be sure the task is performed correctly.
2. The UAP is solely responsible for his or her own actions.
3. The LPN/LVN should observe all of the care.
4. The UAP has the responsibility to ask for assistance if needed.

Following a craniotomy, the nurse positions a client in a semi-reclining position for which reason?

1. To promote comfort
2. To promote drainage from the operative area
3. To promote thoracic expansion
4. To prevent circulatory overload

The nurse is to help a client who has had a
CVA and has right-sided hemiplegia get up into
a wheelchair. How should the nurse place the wheelchair?

1. On the left side of the bed facing the foot of the
   bed
2. On the right side of the bed facing the head of the bed
3. Perpendicular to the bed on the right side
4. Facing the bed on the left side of the bed

The nurse is observing two UAPs log roll a
client who had a laminectomy yesterday. Which observation indicates that the procedure is being incorrectly performed?

1. One person moves the head and shoulders, and the second person moves the hips and legs at the same time.
2. The UAPs use a turning sheet to help turn the client.
3. One person keeps the client from falling out of bed, while the other person moves first the head and shoulders and then the hips and legs.
4. The UAPs place the bed in the highest position prior to turning the client.

An elderly adult has a nasogastric (NG) tube and an intravenous (IV) line. The client is confused and attempts to remove both the NG tube and the IV. How should the nurse ensure the client’s safety?

1. Apply four-point restraints.
2. Ask the physician for an order for wrist
   restraints.
3. Request a sitter to stay with the client.
4. Suggest that the family stay with the client at
   all times.

The client has just returned to the nursing care unit following a hemorrhoidectomy. What order should the nurse expect?

1. A sitz bath stat and qid
2. Warm compresses to the surgical area PRN
3. A hot water bottle to the surgical area PRN
4. An ice pack to the surgical area

Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?

1. Use sterile technique when applying the
   compresses.
2. Leave the compresses on continually, pouring
   warm solution on the area when it cools
   down.
3. Alternate warm compresses with cool
   compresses.
4. Apply a wet dressing to the wound and cover
   with a dry dressing.

An adult returned from the post anesthesia care unit (PACU) following abdominal surgery. At 2:00 P.M., he asks for pain medication. He has an order for meperidine (Demerol) 75 mg intramuscularly (IM) q 3 to 4 hours PRN for operative site pain. He was last medicated at 10:30 A.M. What is the best initial action for the nurse?

1. Administer 75 mg of meperidine.
2. Ask the client to state where he hurts.
3. Listen to the client’s bowel sounds and breath
   sounds before administering the meperidine.
4. Inform the client he has to wait a half-hour before receiving pain medication.

The family of an adult who is terminally ill with advanced metastatic cancer asks the nurse to “let him die in peace.” The client is alert and oriented and in severe pain. What response is appropriate for the nurse?

1. Ask the family member to sign a release form for a do not resuscitate (DNR) order.
2. Encourage the family to talk with the client and the physician.
3. Suggest that not doing all that is possible for the client is unethical.
4. Ask the doctor for a DNR order.

An adult who is terminally ill asks the nurse, “Am I going to die soon?” What is the best response for the nurse to make?

1. “No one can tell for sure when the end will
   come.”
2. “Are you afraid of dying?”
3. “You are concerned about when you will die?”
4. “Everyone has to die sometime.”

An adult has just died. How should the nurse prepare the body for transfer to the mortuary?

1. Leave the body as is; no preparation is
   necessary.
2. Bathe the body and put identification tags on it.
3. Remove dentures before bathing the body.
4. Position the body with its head down and arms folded on its chest.

A cooling blanket is ordered for an adult who has a temperature of 106°F (41.5°C). Which nursing action is appropriate?

1. Place a sheet over the cooling blanket before
   putting the client on the blanket.
2. Maintain the client in a supine position on the
   blanket.
3. Apply powder to the skin that is in contact
   with the blanket.
4. Turn the client every 10 minutes and assess for frostbite.

An adult is admitted to the hospital after several days of vomiting. Her breathing is now slow and shallow. What acid-base imbalance does the nurse suspect?

1. Respiratory acidosis with metabolic compensation
2. Respiratory alkalosis with little metabolic compensation
3. Metabolic alkalosis with respiratory compensation
4. Metabolic acidosis with little respiratory compensation.

Let’s see how many of you scored a good grade. Drop your scores in the comments section.

Answers And Rationale

1. The shock position is flat in bed with the legs elevated to increase venous return. The head
   can be placed on a pillow. The Trendelenburg position, with the head lower than the chest, is no longer the recommended position because
   the abdominal organs can put pressure on the diaphragm and interfere with breathing and heart function. The semi-sitting position would make the client worse by increasing venous return.
2. 1. Twenty-five percent of the cardiac output goes to the kidneys. If cardiac output goes down, as it will in shock, the kidneys will produce less urine. Most trauma victims will be catheterized to help determine if there is shock caused by possible internal bleeding. A urinary catheter does not prevent kidney damage; it merely measures urine output.
3. 3. Daily weights are the best way to assess fluid balance. Estimations of the amount voided are usually not accurate. Skin turgor can give some information about fluid status but is not the best way to assess it. Recording the number of voidings gives some indication of fluid status but does not indicate how much urine is in each voiding. When unable to measure output, the best assessment measure is daily weights.
4. 1. Loss of alkaline intestinal fluid causes metabolic acidosis. Hyperkalemia is unlikely because intestinal fluids are high in potassium. Sodium, not potassium, is resorbed with bicarbonate. Chloride is retained as bicarbonate is lost, contributing to metabolic acidosis. Calcium levels do increase as phosphorus is lost, but diarrhea does not cause a loss of large amounts of phosphorus.
5. 3. Subjective data are data from the client’s perspective, something that the client tells you. Weight and temperature are measured and are objective data. A rash is observed and is objective data.
6. 3. Powder tends to cake and dry the client’s skin. Powder applied following the application of lotion makes a sticky mess. The bath should start with the eyes and face first. Putting the feet into warm water when bathing the feet is a very good thing to do. It is comforting and soothing to the client and helps soften any tough skin on the feet. The bath water should contain only small amounts of soap; too much soap dries the skin.
7. 2. A cuff that is too narrow gives an artificially high reading. A cuff that is too wide will give
   a reading that is too low. The pulse will not be affected. It is not the length of the cuff that is the concern; rather, it is the width of the cuff.
8. 1. When an apical-radial pulse is taken, two nurses are needed. One nurse listens to the apical pulse, while the other nurse takes the radial pulse. The nurse should not ask the client to take his or her own radial pulse.
9. 2. All clients should have their own wash basin that is used exclusively for them. Bed linens can be placed at the bedside prior to morning care so that the needed materials are close at hand. Hands should be washed before and after all client contact. Feces are full of bacteria. Protective barriers should be working when
   the health care worker is at risk for exposure to body fluids. Gloves are appropriate when cleaning up feces.
10. 2. Blood should be cleaned with a solution of bleach at a 1:10 dilution. Alcohol and iodine are not appropriate because they do not kill human immunodeficiency virus (HIV), which might be in the blood. Sometimes soap and water are used, but just plain water does not kill microorganisms.
11. 4. Moisture carries organisms through a barrier. If moisture spills on a cloth or paper sterile field, the field is no longer sterile. Sterile packages should be opened away from the sterile field. Items below the waist on a sterile field are not considered sterile. The first flap of a sterile package should be opened away from the nurse so that the last flap will come toward the nurse. Reaching across a sterile field is not appropriate.
12. 3. The bed sheets should not be drawn tightly
    over the feet because this action might cause footdrop—especially with the client in the supine position. ROM exercises should be performed during the bath and at several other times during the day. The client’s position should be changed every two hours. Placing a person who has had a CVA in the prone position for one hour three times a day will help prevent hip flexion contractures. Note that the question asked which action is LEAST appropriate.
13. 3. Moving the legs and drawing circles with the toes promotes venous return and helps prevent venous stasis and thrombophlebitis. Turning
    the client every two hours will help prevent respiratory complications and skin breakdown. Deep breathing and coughing help to prevent respiratory complications. Dangling the client is not related to preventing vascular complications. In fact, it promotes venous stasis. Not enough information is given as to whether dangling the client as soon as she is alert is appropriate.
14. 2. Pressure areas that have color changes and changes in skin texture with no break in the skin are assessed as stage I pressure ulcers. Stage II ulcers have a break in the skin with involvement of the dermis. Stage III pressure ulcers involve the subcutaneous tissue. Pressure ulcers are not classed as pre-ulcers.
15. 2. Moist skin will heal better than skin that is dried out. There is some truth to the idea that covering the area helps to prevent further injury, but answer 2 is more correct. Comfort is not the primary reason for covering the area. The dressing is not primarily designed to let light in.
16. 1. The semi-sitting position is the position of choice following abdominal surgery. This position allows for greater thoracic expansion and puts less pressure on the suture line. Supine puts pressure on the suture line and is very uncomfortable for persons who have had abdominal surgery. Prone is contraindicated for someone who has abdominal surgery. The Sims’ position is a semi-lateral, semi- prone position and would put too much pressure on the suture line.
17. 3. The nurse should give specific instruction to the UAP. This answer choice is the most specific of the instructions. The other choices are all very vague. The UAP might not know the norms.
18. 1. The LPN/LVN can delegate tasks that are delegatable to the UAP. The responsibility for making sure that the task is correctly performed, however, rests with the LPN/LVN. The UAP
    has responsibility, but the delegator also retains responsibility for the care given by those to whom it has been delegated. It is not necessary to directly observe all care given by the UAP. Although the UAP should ask for help if needed, it is the responsibility of the delegator to be sure that assistance is not needed.
19. 2. The semi-reclining position will promote drainage from the operative area and prevent cerebral edema without putting undue pressure on the cerebral structures. The major goal after craniotomy is to prevent cerebral edema and increased intracranial pressure. The position might or might not promote comfort. That is not the major reason for placing the client in the semi- reclining position, however. A semi-reclining position allows for moderate thoracic expansion (not as much as semi-Fowler’s), but that is not
    the reason for using a semi-reclining position in a client who had a craniotomy. A semi-reclining position will help a little in preventing circulatory overload (not as much as semi-sitting), but that is not the reason for using semi-reclining in a client who has had a craniotomy.
20. 1. The wheelchair should be placed on the unaffected side of the bed, facing the foot of the bed. The client can then stand on the unaffected leg and pivot and sit in the chair.
21. 3. Log rolling is used when the spine must be kept straight. The head and shoulders and hips and legs should be moved as a unit at the same time. Log rolling can be correctly performed by using a turning sheet. The bed should be placed in the highest position before turning the client to protect the backs of the personnel.
22. 2. The client is at risk for injuring himself or herself, so restraints are indicated. The nurse should ask the physician for an order for wrist restraints. The least restraint possible should be used. Four-point restraints are not indicated by the data in the question. A sitter does not appear to be necessary in this situation. There is no data to support that need. The nurse and the staff should be able to ensure the client’s safety without requiring the family to be present at ALL times.
23. 4. The client will have an ice pack applied to the surgical area on the day of surgery. Sitz baths will probably be ordered for the following day. The rule is cold for the first 24 hours to prevent edema followed by warmth to promote healing. The day after surgery, the client will start taking sitz baths.
24. 1. The nurse should use sterile technique when applying compresses to an open wound. Warm compresses are not left in place continually. Moist heat is left on for 15 to 25 minutes at a time. Alternating warm compresses and cool compresses is not what is ordered for the client. Answer 4 describes a wet to dry dressing.
25. 2. The question states that the client asks for pain medication. There is no indication of where the pain is. The nurse cannot assume that the pain is in the operative area. The time frame is adequate, so if the client’s pain is in the operative area, the nurse should administer the medication. Listening to bowel and breath sounds is not a criterion for administering pain medication.
26. 2. Because the client is alert, he should be involved in making the decision. This matter should be discussed with the client and with the physician who will need to write any orders. Suggesting that such a request is unethical is not appropriate. Clients have the right to refuse treatment and shape advance directives. The alert client should be involved in the process.
27. 3. This response is the most therapeutic. It focuses on what the client asked and opens the lines of communication. The first answer might be true but does not encourage the client to discuss his concerns. The second choice is not appropriate because it focuses on fear, which is not in the client’s question. The third response is much better than answer 2. Answer 4 closes communication and is not appropriate.
28. 2. The body should be bathed, a clean gown should be put on, and the body should have identification tags placed on it. Dentures, if normally used by the client, should be placed
    in the mouth. The body should be flat with extremities straight. If the head is down, the blood will go to the head and discolor the skin, making viewing difficult.
29. 1. There should always be a sheet between the client and the cooling blanket to protect from frostbite. The position of the client should be changed every two hours. Powder is not applied to the skin; it will cause the skin to be dry. If necessary, oil can be applied to the skin. The client should be checked for frostbite and should be turned every two hours, not every 10 minutes.
30. 3. A client who is vomiting is losing acid and will go into metabolic alkalosis. The slow, shallow breathing is evidence of trying to hold on to CO2, which is acid, thus compensating for the alkalosis.