Exam 1 Past Paper QA1version PDF

A client with acquired immune deficiency syndrome (AIDS) has Pneumocystis carinii (PCP). What is the nurse's priority assessment for this client? a. Lung sounds b. Skin Turgor c. Radial pulses d. Capillary refill How many ml is one teaspoon? (Record answer as a whole number. Type answer as...

A client with acquired immune deficiency syndrome (AIDS) has Pneumocystis carinii (PCP). What is the nurse's priority assessment for this client? a. Lung sounds b. Skin Turgor c. Radial pulses d. Capillary refill How many ml is one teaspoon? (Record answer as a whole number. Type answer as numeric only.) 5 3. The client with rheumatoid arthritis is having her rheumatoid factor (RF) drawn while she is having a flare-up of the disease. Which result is seen in clients with rheumatoid arthritis? a. A positive rheumatoid factor b. Factor does not change c. A negative rheumatoid factor d. decreased level of rheumatoid factor 4. A nurse is providing education for a client who has glaucoma which of the following statements should the nurse include in the teaching? e. "Use of eye drops will improve vision overtime." f. "Without treatment, glaucoma can cause blindness." g. "Double vision is a common symptom of glaucoma." h. "Glaucoma is caused by inadequate production of fluid within the eye." 5. A nurse is caring for an immobile client. What is the priority assessment in this client? i. Assessment of skin turgor j. Auscultation of bowel sounds k. Auscultation of lung sounds l. Assessment for the presence of peripheral edema 6. A client with a diagnosis of human immunodeficiency virus (HIV) develops pneumonia. What type of infection is this? m. A nosocomial infection n. A pathogenic infection o. An opportunistic infection p. A root cause infection 7. What level of Maslow\'s hierarchy does shelter belong to? q. Esteem r. Love and belonging s. Safety and security t. Physiological 8. A client states that he has been experiencing oozing from his wound. What is the nurse\'s priority? u. Inspect the wound and assess the drainage v. Call the provider to initiate antibiotics w. Apply topical ointment to the wound x. Culture the wound 9. What is not a potential complication of rheumatoid arthritis? y. Joint deformity z. Fibromyalgia a. Paresthesia b. Dry eye 10. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention? c. Perform neurovascular assessment per protocol d. Use aseptic techniques for wound care and emptying of drains e. Observe client for changes in mental status f. Keep the client's heels off the bed 11. The nurse is providing medication education for a client with osteoarthritis. What teaching should the nurse include in the education? g. Nonsteroidal anti-inflammatory drugs (NSAIDs) are very safe and are known to have no side effects h. The main side effect of acetaminophen is gastrointestinal (GI) bleeding i. You should not take more than 4000mg of acetaminophen a day j. The most common adverse effect of nonsteroidal anti-inflammatory drugs (NSAIDs) 12. The mother of a newborn baby is concerned that the baby will develop illnesses from being around people from outside of their family. What is the nurse's best response? k. "I did that, and my kids turned out just fine" l. "Why do you think that it is a bad idea?" m. "You should never go around people after your baby is born" n. "Tell me more about that" 13. The nurse is preparing to administer medication to a client with osteoarthritis. What is the goal of medication therapy? o. Eradicate the disease p. Manage weight loss q. Reduce pain and inflammation r. Turn off the immune system 14. The nurse has documented the following wound assessment: "Shallow open, reddened ulcer with no slough on the anterior region of the right heel." What stage is the wound? s. Stage 3 t. Stage 2 u. Stage 4 v. Stage 1 15. By providing measures to prevent skin breakdown, how does the nurse break the chain of infection? w. Creating a reservoir to decrease the risk of infection x. Maintaining the integrity of a portal of entry y. Sterilizing the area to reduce the reservoir risk z. Creating a susceptible host 16. What is not an appropriate nursing intervention for psoriasis? a. Apply rubbing alcohol to plaques b. Apply corticosteroids as ordered c. Urge the client to consider participating in support groups d. Teach the client how to utilize UV radiation 17. How many milligrams is 3000 mcg? (Record as a whole number. Type answer as numeric only) 3 mg 18. A client has sustained an open fracture. How can the nurse best prevent osteomyelitis in this client? e. Delegate all client personal care to specific unlicensed assistive personnel (UAP) f. Place the client in contact precautions g. Use proper hand hygiene and strict infection control h. Administer pain medication 19. Where will the nurse collect the most reliable source of pain assessment? i. From a medical-surgical book j. From the client's chart k. From nurse-to-nurse bedside report l. From the client 20. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery? m. Client will increase mobility by the time of discharge from the hospital n. Client will remain free from falls throughout their hospital stay o. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay p. Client will increase activity tolerance by discharge from the hospital 21. Dry skin (xerosis) prevention statement requiring further teaching:\ A. "I will avoid tight belts"\ B. "I will shower every day in hot water"\ C. "I will use a humidifier during the winter months"\ D. "I will drink at least 3000ml of water daily" 22. Client most at risk for infection:\ A. A client with leukemia\ B. A hospitalized 35-year-old client\ C. A 60-year-old client\ D. A child who is immunized 23. PPE for MRSA:\ A. Surgical mask\ B. PAPR mask\ C. Sterile gloves\ D. Gown 24. Interventions to decrease risk of pressure injuries (Select all that apply):\ A. Keep the head of the bed (HOB) at or less than 30 degrees\ B. Padding hard surfaces\ C. Keep the head of the bed (HOB) elevated to 75 degrees\ D. Place pillows between bony surfaces 25. Nurse concern for client with lupus:\ A. The client has a butterfly rash\ B. Urine output of 20 mL/hour\ C. The client reports chronic fatigue\ D. Blood pressure of 126/85 mm Hg 26. Education for lupus client with Raynaud's phenomenon:\ A. "Ensure to keep cool"\ B. "Wear sunscreen"\ C. "Wear gloves in winter"\ D. "Brush your teeth for two minutes" 27. Home safety teaching for rheumatoid arthritis:\ A. "Better to be more stoic and not let pain interrupt your life"\ B. "Place throw rugs throughout your home"\ C. "Lack of home safety may be an issue of compliance"\ D. "There are many adaptive devices available that may help you" 28. Vision loss from glaucoma explanation:\ A. Bacterial infection caused the damage\ B. Necrosis from high-pressure does not regenerate\ C. Retinal detachment does not return to its normal state\ D. Glaucoma always leads to permanent blindness 29. Nonpharmacological methods for rheumatoid arthritis pain (Select all that apply):\ A. Adequate rest\ B. Heat for 20-30 minutes\ C. Frequent running\ D. Hot showers\ E. Ice for 2 hours at a time 30. Nutrition and wound healing:\ A. Wound will not heal if client has eaten protein\ B. Extra sugar is important\ C. Poor nutrition negatively impacts wound healing\ D. Food intake will likely be decreased 31. Nurse's first action for red, swollen, purulent pin site in skeletal traction:\ A. Collect a culture of the purulent fluid\ B. Administer an antibiotic\ C. Instruct the client to complete exercises\ D. Cleanse the skin around the pins 32. First action in routine bed bath:\ A. Cleanse the client's hands\ B. Cleanse the client's feet\ C. Cleanse the client's face\ D. Cleanse the client's perineal area 33. Symptom of rheumatoid arthritis:\ A. Bilateral joint pain\ B. Contralateral joint pain\ C. Unilateral joint pain\ D. Obtuse variety joint pain 34. Teaching to reduce infection risk for AIDS clients (Select all that apply):\ A. Avoid crowds\ B. Avoid raw fruits and vegetables\ C. Avoid cleaning your toothbrush with bleach\ D. Wash hands thoroughly 35. Priority intervention for oral hygiene for unconscious client:\ A. Gentle brushing and flossing for fragile mucosa\ B. Position the client on one side with the head turned toward you\ C. Have a suction apparatus ready at the bedside\ D. Handle dentures with care 36. Medication class that delays bone healing:\ A. NSAIDs\ B. Anticoagulants\ C. Opioids\ D. Narcotics 37. Braden Scale Assessment components (Select all that apply):\ A. Friction and shear\ B. Nutrition\ C. Mental state\ D. Age\ E. Sensory perception 38. Expected outcomes from rheumatoid arthritis medications (Select all that apply):\ A. Increased quality of life\ B. Decreased pain\ C. Cure the disease\ D. Increased range of motion\ E. Reduced inflammation 39. Injury risk for client in high Fowler's position:\ A. Shearing injury\ B. Friction injury\ C. Traumatic injury\ D. Pressure injury 40. MRSA prevention client education (Incorrect statement):\ A. Use a bath sponge to cleanse the skin\ B. Wash hands with soap and water\ C. Avoid contact spots until infection clears\ D. Use antibacterial soap when showering 41. Blanching documentation term for erythema:\ A. Redness\ B. Warmth\ C. Blanching\ D. Non-blanching 42. Intervention to promote joint mobility in quadriplegic client:\ A. Provide active range of motion (ROM)\ B. Turn the client every 2 hours\ C. Provide passive range of motion (ROM)\ D. Administer glucosamine supplements 43. Osteoarthritis risk factors (Select all that apply):\ A. Older age\ B. Sports injuries\ C. Obesity\ D. Female gender\ E. Vegan diet 44. Nurse's next action for sudden blood-tinged liquid draining from post-op incision:\ A. Assess the wound for signs of dehiscence\ B. Prepare to culture the wound\ C. Call the provider 45. HIV client statement requiring further teaching (Select all that apply):\ A. "I can still have unprotected intercourse with my partner"\ B. "I can spread this through contact with surfaces"\ C. "I need to place my needles in a proper disposal container"\ D. "Because I have HIV, I am an AIDS patient"\ E. "I will monitor my nutrition and fluid status" 46. Reason AIDS client is more susceptible to pneumonia:\ A. The client with AIDS has greater immune defenses\ B. The client with AIDS is a susceptible host\ C. The client with AIDS has more portals of entry 47. Nurse's best response for protein supplements for bed sore:\ A. "If you don't like it, you don't have to take it"\ B. "These supplements have nothing to do with your wound"\ C. "Protein has amino acids that promote wound healing" 48. Client requiring airborne precautions:\ A. A client with heart palpitations\ B. A client with fever and cough after travel\ C. High school wrestling champion with a rash\ D. A client with an unknown skin infection 49. Homeless client arrives in the ER. Nurse's priority action:\ A. Inspect the client's skin\ B. Call a social worker\ C. Provide a towel and show the client to the shower\ D. Ask if the client has been to a homeless shelter recently 50. Narcolepsy priority intervention:\ A. Encourage the client to stop drinking caffeine after 6 pm\ B. Inform the client to drink two cups of regular coffee\ C. Inform the client that driving would be dangerous\ D. Encourage the client to participate in normal activities 51. Osteoarthritis understanding by client:\ A. "I will start a daily running program to get more exercise"\ B. "The purpose of drug therapy is to stop the disease progression"\ C. "I can use either heat or ice to help relieve the discomfort"\ D. "I should avoid physical activity to prevent further injury" 52. Compartment syndrome cause explanation:\ A. "A bone fragment has injured the nerve supply in the area"\ B. "The fascia expands with injury, causing pressure on nerves and muscles"\ C. "Bleeding and swelling cause increased pressure in an area that cannot expand"\ D. "An injured artery causes impaired arterial perfusion through the compartment" 53. Nurse's report to the physician for eviscerated incision site:\ A. The client's incision site has lacerated\ B. The client's incisional site has dehisced\ C. The client's incisional site is approximated\ D. The client's incisional site has eviscerated 54. Understanding of HIV progression to AIDS:\ A. "If I practice meditation, I may develop AIDS faster"\ B. "If I am re-exposed to HIV, the progression to AIDS may be faster"\ C. "My diet does not influence the progression of HIV to AIDS"\ D. "Sexually transmitted infections will not make AIDS develop faster" 55. Evaluation of neurovascular status after ORIF of femur (Select all that apply):\ A. Skin integrity\ B. Sensation\ C. Temperature\ D. Ecchymosis\ E. Color 56. Numbness, tingling, pale fingers after new arm cast---nurse's next action:\ A. Encourage range of motion\ B. Apply heat to the affected hand\ C. Raise the arm above the level of the heart 57. Nurse's action when client has just had ice chips and oral temperature is needed:\ A. Proceed to take the oral temperature\ B. Document that temperature was unable to be obtained\ C. Proceed to take the oral temperature\ D. Wait 30 minutes to take an oral temperature 58. Surgical wound with sutures---wound healing process:\ A. Secondary intention\ B. Binary intention\ C. Primary intention\ D. Tertiary intention 59. Best intervention for distressed HIV client after diagnosis:\ A. Explain legal requirements\ B. Offer to tell the family for the client\ C. Assess the client's support system\ D. Call the hospital clergy to speak with client 60. Nurse's first intervention for client with oxygen level of 85%:\ A. Obtain pain medication\ B. Call the provider\ C. Raise the head of the bed\ D. Place the client in the lithotomy position 61. Practice recommended to prevent HIV transmission by healthcare workers:\ A. Wearing a mask within three feet of the client\ B. Using standard precautions\ C. Double gloving\ D. Applying hand sanitizer to gloves during care 62. Client with systemic sclerosis---leg hot, red, painful---nurse suspects:\ A. Deep vein thrombosis\ B. Internal bleeding\ C. Amputation\ D. Kidney failure 63. Teaching for ibuprofen prescription for rheumatoid arthritis---monitor for:\ A. Blurred vision\ B. Insomnia\ C. Constipation\ D. Bleeding 64. Nurse's priority action for a client with compromised immunity:\ A. Take the client's vital signs every four hours\ B. Wash hands before entering the client's room\ C. Determine whether it is temporary or permanent 65. Nutrition and hydration education for AIDS client (Select all that apply):\ A. Drink at least 2 to 3 liters of fluids per day\ B. Include many fresh fruits and vegetables in your diet\ C. Lower your caloric intake\ D. Choose foods high in protein\ E. Eat high-calorie foods 66. Communication for client with acute pain, \"pins and needles\" sensation, weak pulse:\ A. Compartment syndrome\ B. Ischial tuberosity\ C. Pulmonary embolism\ D. Broken arm syndrome 67. Convert two tablespoons to milliliters:\ A. 30 Ml 68. Organization publishing National Patient Goals:\ A. Medicare\ B. The Joint Commission\ C. The American Nurse Association\ D. The Institute of Medicine 69. Client on Methotrexate with a fever---what client to see first:\ A. A client with multiple children visiting\ B. A client on Methotrexate with a fever\ C. A client with lupus asking for dinner\ D. A client with chronic rheumatic pain 70. Nurse's role in nursing process when noticing new skin breakdown near dressing:\ A. Implementation\ B. Assessment\ C. Evaluation\ D. Diagnosis 71. Correct understanding of cellulitis symptom management by client:\ A. "I can use tight bandages on my arm"\ B. "I should not apply heat on my arm"\ C. "I can use a warm, moist towel"\ D. "I should use a cold, dry source on my arm" 72. Best response to client complaining of joint pain and fatigue:\ A. "You need to lose weight or the pain won't go away"\ B. "You should avoid walking. This might be osteoporosis"\ C. "You just have arthritis and should take some ibuprofen"\ D. "Please tell me more about when your pain started" 73. First action for wound culture of non-healing wound:\ A. Label the specimen tube\ B. Put on non-sterile gloves\ C. Irrigate the wound\ D. Gently remove the soiled dressing 74. Hospital sentinel events description:\ A. Specific events that enable a hospital to maximize reimbursement\ B. An event causing serious injury that should never happen in a hospital\ C. Operating room event involving the use of unsafe equipment\ D. An unexpected event involving death or serious physical or psychological injury 75. Nurse should call provider immediately for rheumatoid arthritis client after shoulder injury if:\ A. The client refused pain medication and is doing physical therapy\ B. The client has paresthesia in her fingers and increasing pain in her shoulder\ C. The client reports intermittent flatus and minor abdominal discomfort 76. Appropriate statement by nurse during psychosocial assessment for client with rheumatoid arthritis:\ A. \"What therapies are you using to reduce swelling?\"\ B. \"What physical limitations are you experiencing?\"\ C. \"How does this impact your role in your family?\"\ D. \"Tell me about what medications you are taking?\" 77. Convert 60 mL to ounces:\ A. 2 78. Transmission-based precautions for tuberculosis:\ A. Protective\ B. Contact\ C. Droplet\ D. Airborne 79. Disease transmitted directly from one person to another:\ A. A portal of entry to a host\ B. A communicable disease\ C. A portal of exit from the reservoir\ D. A susceptible host 80. Nurse\'s strategy to reduce fibromyalgia symptoms:\ A. Avoid exercise during flare-ups\ B. Do high-impact exercises like running\ C. Establish a regular sleep pattern\ D. Increase calcium and caffeine intake 81. Client prioritization by nurse---who to see first:\ A. A client with a fractured ankle who wants a glass of water\ B. A client being discharged in two hours who needs crutch teaching\ C. A client with rheumatoid arthritis and a scheduled pain medication\ D. A client with sudden and increasing pain in his fractured arm 82. Possible infection signs in client with AIDS (Select all that apply):\ A. Temperature: 101.3°F\ B. Oxygen saturation: 97% on room air\ C. Purulent drainage\ D. Respirations: 22 breaths per minute\ E. Client ambulates 20 feet 83. Deep wound covered with black necrotic tissue documentation:\ A. Blanching\ B. Tunneling\ C. Eschar\ D. Cellulitis 84. Causes of pressure ulcers (Select all that apply):\ A. Ischemia\ B. Adequate perfusion\ C. Immobility\ D. Poor nutrition\ E. Moisture 85. Priority assessment for client with femur fracture:\ A. Socio-economic status\ B. Pedal pulses\ C. Pain\ D. Medication history 86. Nurse\'s next action for client on bedrest with pain and burning in calf:\ A. Medicate the client for pain and reassess in 60 minutes\ B. Compare the circumference to the left calf\ C. Percuss over the area for a change in tone\ D. Deeply palpate the area for rebound tenderness 87. Most concerning finding over bony prominence:\ A. Warmth\ B. Non-blanching\ C. Blanching\ D. Redness 88. Blurred vision in older male client thinking glasses need cleaning---eye disorder suspected:\ A. Diabetic retinopathy\ B. Conjunctivitis\ C. Cataracts\ D. Corneal dystrophy 89. Blood-tinged liquid dripping from surgical wound documentation:\ A. Creamy pus\ B. Serosanguineous\ C. Serous\ D. Purulent 90. Priority intervention for client who only speaks Spanish:\ A. Give the client a tour of the unit\ B. Verify the reason for admission\ C. Call the chaplain for support\ D. Request a medical interpreter 91. Pain-unlikely related assessment after surgery one day ago:\ A. Respirations of 10 breaths per minute\ B. Heart rate 60 beats/minute\ C. Oxygen saturation of 97%\ D. Blood pressure of 175/90 mmHg 92. Priority intervention for client with acute osteomyelitis:\ A. Teach relaxation breathing to reduce pain\ B. Provide antipyretic therapy\ C. Increase protein intake\ D. Administer antibiotics 93. First symptom of systemic sclerosis (scleroderma):\ A. Raynaud's phenomenon\ B. Intense wrinkles\ C. Tachycardia\ D. Joint pain 94. HIV client's lab values typically show:\ A. Higher-than-normal CD4+ T-cells and low CD8+ T-cells\ B. Lower-than-normal CD4+ T-cells and normal CD8+ T-cells\ C. Higher-than-normal CD4+ T-cells and normal CD8+ T-cells\ D. Lower-than-normal CD4+ T-cells and higher-than-normal CD8+ T-cells 95. Intensely dry eyes in client with rheumatoid arthritis---suspected condition:\ A. Systemic sclerosis\ B. Crohn's disease\ C. Sjogren's syndrome\ D. Discoid lupus 96. Nonverbal signs of pain (Select all that apply):\ A. Reported pain of 5/10\ B. Increased heart rate\ C. Decreased attention span\ D. Grimacing\ E. Increased agitation 97. Lab tests for diagnosing connective tissue disease (Select all that apply):\ A. Rheumatoid Factor (RF)\ B. C-reactive protein (CRP)\ C. Anti-nuclear antibody (ANA)\ D. Erythrocyte sedimentation rate (ESR)\ E. Thyroid stimulating hormones (TSH) 98. Nurse's response to stressed client with arthritis and administrative job:\ A. "You are stating that this job is not getting better. Tell me more about that."\ B. "I feel stressed by my job, and I take a walk every day. You should do that."\ C. "Most people with this kind of stress have to quit their jobs or retire." 99. Best positioning technique for client with COPD:\ A. Lateral position\ B. Sim's position\ C. Fowler's position\ D. Prone position 100. Nurse's first action after being stuck by a needle:\ A. Report the exposure\ B. Seek medical attention\ C. Wash exposed skin with water\ D. Complete an incident report