MDC Final Exam 2023/2024 PDF

lOMoARcPSD|43964769 MDC Final EXAM - 2023/2024 Multidimensional Care 1 (Rasmussen University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Bruce Lee ([email protected]) ...

lOMoARcPSD|43964769 MDC Final EXAM - 2023/2024 Multidimensional Care 1 (Rasmussen University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% 1. What is the best goal for pain control in a client with rheumatoid arthritis? A. The client will have no pain throughout the entire day. B. The client will have pain less than 3/10 throughout the day. C. The client will eat three healthy meals today and stay hydrated. D. The client will have pain less than 3/10 for most of the day. 2. A client is in skeletal traction. With the nurse’s assessment, it is noticed that the pins appear red, and swollen, and there is purulent drainage. What action does the nurse take first? A. Cleanse the skin around the pins. B. Collect a culture of the purulent fluid. C. Administer an antibiotic o Instruct the client to D. Complete exercises of the affected extremity. 3. What nursing intervention is best to improve communication with a hearing-impaired client? A. Write down the message B. Talk loudly in the impaired ear C. Speak slowly and clearly while D. facing the client o E. Talk in a regular voce in the good ear 4. A client just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy? A. "Tomorrow will be better.” B. "This must be hard news to hear. Tell me about it.” C. "What is your biggest fear about this diagnosis D. “I believe you can overcome this because I’ve seen how strong you are.” 5. The nurse notices a new area of skin breakdown near the site of a dressing. This would be an example of which phase of the nursing process. A. Diagnosis B. Assessment C. Implementation D. Evaluation 6. A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action? A. Call a chaplain B. Maintain the client’s blood pressure C. Provide the spouse with a chair Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% D. Ask the client’s spouse to explain what happened 7. During a skin inspection at the outpatient clinic the nurse notices patches of thick, red skin with silvery scales on the client’s elbows and knees. What skin abnormality does the nurse suspect? A. Psoriasis B. Rosacea C. Scables D. Stasis dermatitis 8. A client with lupus may experience Raynaud's phenomenon. What should the nurse include when providing client education about this? A. “In order to avoid flare-ups of Raynaud’s, ensure to keep cool.” B. In order to avoid flare-ups of Raynaud's, ensure you wear sunscreen.” C. “In order to avoid flare-ups of Raynaud’s, ensure you wear gloves in winter.” D. In order to avoid flare-ups of Raynaud s erasure you brush your teeth for two minutes.” 9. A nurse caring for an intubated and sedated geriatric client What intervention is most appropriate for reducing the risk for friction and shear injury? A. Postpone daily bed bath B. Elevate the client’s head of the bed to 45 degrees C. Caregiver independently slides the client up in bed D. Use a mechanical lift to reposition the client every 2 hours 10. The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has? A. Corneal dystrophy B. Conjunctivitis C. Diabetic retinopathy D. Cataracts 11.The Client with rheumatoid arthritis complains of intensely dry eyes. What does the nurse suspect? A. Chron's disease B. Discoid lupus C. Systemic sclerosis D. Sjogren’s syndrome Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% 12. The nurse assesses the client’s pain prior to completing a dressing change. The client says his current pain is 5/10, but he has a pain of 10/10 when his dressing is changed. What is the priority intervention for this client? A. Remove the old dressing with clean gloves B. Check medication administration record (MAR) for as-needed orders (PRN) C. Teach the client about nonpharmacological pain control methods D. Offer the client protein with meals to promote healing 12.The nurse is caring for four clients. Which of these clients will the nurse see first? A. A client with sudden and increasing pain in his fractured arm B. A client with a fractured ankle who would like a glass of water C. A client with rheumatoid arthritis and a scheduled pain medication D. A client being discharged in two hours and needs to be taught how to use his crutches 14. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding? A. Purulent B.exudate C.Creamy pus D.Serous o E.Serosanguineou 15. What are some of the expected outcomes when medications are given for rheumatoid arthritis? (Select all that apply) A. Reduced inflammation B. Increased range of motion C. Cure the disease D. Decreased pain E. Increased quality of life 16. What is a priority nursing intervention for a client with lupus who is receiving steroids for a flare-up? A. The nurse washes their hands before entering the room. B. Assist with the enhancement of soda well-being by providing activities. C. Assess the client's support system. D. Ensure privacy by keeping the door always closed. Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% 17. The nurse is providing medication education for a client with osteoarthritis. What teaching should the nurse include in the education? A. The main side effect of acetaminophen is gastrointestinal (GI) bleeding. B. You should not take more than 4000 mg of acetaminophen a day. C. Nonsteroidal anti-inflammatory drugs (NSAIDs) are very safe and are known to have no side effects. D. The most common adverse effect of nonsteroidal anti-inflammatory drugs (NSAIDs) are liver failure and tinnitus. 18. A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? A. “Without treatment, glaucoma can cause blindness." B. Double vision is a common symptom of glaucoma." C. "Glaucoma is caused by inadequate production of fluid within the eye." D. "Use of eye drops will improve vision over time." 19. What is not appropriate client education on me preventing the spread of methicillin- resistant Staphylococcus aureus (MRSA)? A. Avoid contact sports until the Infection has cleared. B. Use an antibacterial soap when showering. C. Use a bath sponge to cleanse the skin. D. Wash hands with soap and water before and after touching the infected area. 20. A nurse is teaching a client about adequate nutrition and hydration for the client with acquired immunodeficiency syndrome (AIDS). What is important to teach the client? (Select all that apply.) A. Include many fresh fruits and vegetables in your diet. B. Drink at least 2 to 3 L of fluids per day C. Eat high-calorie foods D. Lower your caloric intake E. Choose foods high in protein 21. A client has cellulitis on his left arm. What statement by the client indicates a correct understanding of symptom management? A. “l can use tight bandages on my arm." B. “I should not apply heat to my arm” Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% C. “l can use a warm, moist towel on my arm.” D. “I should use a cold, dry source on my arm.” 22. What are opportunistic infections associated with acquired immunodeficiency syndrome (AIDS)? (Select all that apply) A. Candidiasis B. Hodgkin's lymphoma C. Pneumocystis jiroveci pneumonia D. Clostridium difficile E. Non-Hodgkin’s lymphoma 23. What is not an expected assessment finding in a client with inflammation? (Select all that apply.) A. Polyuria B. Edema C. Heat D. Erythema Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o Pain 24. What are the risk factors for osteoarthritis? (Select all that apply.) A. Female gender B. Older age C. Obesity D. Sports injuries E. Vegan diet 25. A client has suffered a femur fracture. What is the nurse’s priority assessment? A. Pain B. Medication history C. Socio-economic status D. Pedal pulses 26. A client sustains an injury to his heel while the unlicensed assistive personnel and the nurse are moving him up in bed. What force caused the injury? A. Shearing or friction B. Pressure or gravity C. Chemical or pressure D. Twisting and bending 27. A nurse is teaching a client how to follow a low-purine diet as prescribed by the provider for the management of gout. What statement by the client indicates a correct understanding of the teaching? A. “I will need to limit the number of fruit servings each day.” B. “I should avoid eating liver and other organ meats.” C. “I can drink only white wine.” D. “I should choose red meat instead of poultry.” 28. The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include? A. “There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you." B. “My grandfather always had problems with his arthritis, and he would tell me that it’s better to be more stoic and not let pain interrupt your life." Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% C. “Placethrow rugs throughout your home. You'll enjoy how pretty they are. and you can use them to cover up power cords, so you don't trip on them.” D.“Lack of home safety may be an issue of compliance. Are you being compliant with your medications?" 29. The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound? A. Blanching B. Cellulitis C. Tunneling D. Eschar 30. What link in the chain of infection is broken when contact precautions are in place? A. Reservoir B. Mode of transmission C. Portal of entry D. Initiation phase 31. A client has been suffering from arthritis for many years and is experiencing an exacerbation. The client states he has a lot of stress from his position as an admirative assistant, and his job is not getting better. What is the most appropriate response from the nurse? A. “I feel stressed by my job. and I take a walk every day. You should do that.” B. "You shouldn’t worry about your job. There is nothing to worry about.” C. "You are stating that this job is not getting better. Tell me more about that.” D. “Most people with this kind of stress have to quit their jobs or retire.” 32. What is not a potential complication of rheumatoid arthritis? A. Paresthesia B. Joint deformity C. Dry eyes D. Fibromyalgia 33. How many mg is 3000 mcg? (Record as a whole number. Type the answer as numeric only.) 3 Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o 34. What are the causes of a pressure ulcer? (Select all that apply) A. Ischemia B. Immobility C. Poor nutrition D. Moisture E. Adequate perfusion 35. A nurse is assessing a client’s vital signs. The oxygen saturation is 85%. What intervention should the nurse perform first? A. Call the provider B. Place the client in the lithotomy position C. Raise the head of the bed D. Obtain pain medication 36. A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse? A. The client is in a private room. B. The client has a dedicated vital signs machine. C. The client has a vase of fresh flowers on the table. D. There is hand sanitizer by the door. 37. What is a classic symptom assessed in clients with lupus? A. Heberden's nodes B. Chvostek's sign C. Ovide's sign D. Butterfly rash 38. A nurse assesses an audible grating sound (crepitus) when a client with osteoarthritis moves his knees, what is the cause of this sound? A. Popping bursae from standing B. A herniated area disk diseases joint C. Pieces of bone and cartilage floating D. Years of an autoimmune process 39.Dry skin (xerosis) can lead to itching (pruritis). What statement by the client indicates a need for further teaching about preventing dry skin? A. I will use a humidifier during the winter months.” B. I will shower every day in hot water.” Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% C. “I will avoid tight belts.” D. “I will drink at least 3000 mL of water daily.” 40. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. The nurse observes the bone and tendon at the base of the wound. How would the nurse document this wound? A. A Stage II pressure injury B. Stage pressure injury C. Stage IV pressure injury D. A non-staging pressure injury 41. A client arrives speaking only Spanish. What is the priority nursing intervention? A. Call the chaplain for support B. Verify the reason for admission C. Request a medical interpreter D. Give the client a tall of the unit 42. A client recently had an above-the-knee amputation and complains of pain distal to the amputation. What type of pain is the client experiencing? A. Nociceptive B. Neuropathic C. Cutaneous D. Visceral 43. A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation? A. Once the tissue has necrosed from high pressure, it does not regenerate. B. Glaucoma always leads to permanent blindness C. Once retinal detachment occurs, it does not return to its normal state. D. Once the bacterial infection has caused damage, the tissue does not regenerate. 44. Which practice is recommended to prevent human immune deficiency virus (HIV) transmission by healthcare workers? A. Using standard precautions B. Double gloving C. Applying hand sanitizer to gloves during care D. Wearing a mask within three feet of the client 45. A nurse is teaching a client who has gout about dietary recommendations. The nurse should teach the client which of the following beverage can trigger an attack Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o A. Alcohol B. Fruit juice C. Milk D. Coffee 46. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client pulse. What persona protective equipment (PPE) should the nurse don? A. Gown and gloves B. Sterile gloves C. PAPR mask Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o Surgical mask 46. What steps are included in preparing a sterile field? (Select all that apply.) A. Obtain a PAPR mask B. Do not turn away from the sterile field C. Add items to the sterile field by dropping them gently D. Cover the sterile field once it is set up E. Prepare the client before setting up the sterile field 48. Which organizations publish the National Patient Safety Goals? A. Medicare B. The American Nurses Association C. The Joint Commission D. The Institute of Medicine 49. A nurse is providing teaching to an older adult client who has osteoarthritis that is affecting the knees. What statement by the client indicates a correct understanding of the teaching? A. “I can use either heat or ice to help relieve the discomfort.” B. “The purpose of drug therapy is to stop the disease progression.” C. “I should avoid physical activity to prevent further injury.” D. “I will start a daily running program to get more exercise.” 50. What can the nurse teach the client with acquired immunodeficiency syndrome (AIDS) to reduce the risk of infection? (Select all that apply) A. Wash your hands thoroughly. B. Avoid cleaning your toothbrush with bleach C. Avoid raw fruits and vegetables. D. Avoid crowds E. Share toothpaste with family members 51. A client is admitted for treatment of a wound. What is true about wound healing and nutrition? A. Extra sugar is important in the diet of a client with a healing wound. Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o B. The client’s food intake will likely be decreased because of the illness. C. Wound healing is negatively impacted by poor nutrition. D. The wound will not heal if the client has eaten protein. 52. The nurse is performing psychosocial assessment on a client with severe rheumatoid arthritis. What would be the most appropriate statement by the nurse? A. "Tell me about what medications you are taking." B. What physical limitations are you experiencing?". C. “How does this impact your role in your family?" D. “What therapies are you using to reduce swelling?" 53. The nurse assesses a wound with exudate. What should be included when documenting the exudate? (Select all that apply.) A. Color B. Odor C. Heat D. Consistency E. Amount 54. What is a symptom of the expected disease pattern of rheumatoid arthritis? A. Unilateral joint pain B. Bilateral joint pain C. Contralateral joint pain D. Obtuse variety joint pain 55. A client with a diagnosis of the human immunodeficiency virus (HIV) develops pneumonia. What type of infection is this? A. A pathogenic infection B. An opportunistic infection C. A nosocomial infection D. A root cause infection Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o 56. What are the early signs and symptoms of rheumatoid arthritis? (Select all that apply.) A. Inflammation in the joints B. Bilateral, symmetric symptoms C. Anorexia and weight loss D. Normal erythrocyte sedimentation rate (ESR) E. Fever 57. What phase of wound healing occurs at the time of injury and lasts about 3-5 days? A. Inflammatory B. Proliferative C. Maturation D. Intentional 58. The nurse is preparing to administer medications to a client with osteoarthritis. What is the goal of medication therapy? A. Eradicate the disease B. Turn on the immune system C. Reduce pain and inflammation D. Manage weight loss 59. What is the nurse’s priority action for a client with compromised immunity? A. Determine whether it is temporary or permanent B. Take the client’s vital signs every four hours C. Teach the family members to receive the flu shot annually W D. Wash hands before entering the client's room 60. The nurse is most concerned about which of these findings in a client with systemic lupus erythematosus? A. The client has a butterfly rash B. Blood pressure of 126/85 mm Hg C. The client reports chronic fatigue D. Urine output of 20 mL/hour 61. A nurse is caring for a 25-year-old male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility? Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o A. Provide an active range of motion (ROM) B. Provide passive range of motion (ROM) C. Turn the client every 2 hours D. Administer glucosamine supplements 62. A client with systemic sclerosis (scleroderma) has been in bed for two weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red, and painful. What does the nurse suspect? A. Amputation B. Deep vein thrombosis C. Internal bleeding D. Kidney failure 63. A client has an open wound with creamy thick yellow drainage. How would the nurse document this finding? A. Serous B. Purulent C. Serosanguinous D. Sanguineous 64. When providing a routine bed bath, what action does the nurse complete first? A. Cleanse the client's hands B. Cleanse the client's feet C. Cleanse the client’s perineal area D. Cleanse the client's face C. Which of the following statements made by a client diagnosed with human immunodeficiency virus (HIV) would require further teaching? A. “l will take all prescribed medications." B. “I will only need to take HIV medications for 6 months, and I will be cured." C. “I will have to take medications for the rest of my life." D. “I will have to be careful and avoid crowds." 65. Which of the following clients should be placed in isolation for airborne precautions? A. A client with an unknown skin infection B. A client that recently traveled and developed a fever with a cough Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o C. A high school wrestling champion with a rash D. A client with heart palpitations 67. The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse? A. Ice packs can be used to reduce swelling but should be removed after 20 minutes.” B. “Apply ice packs, it is generally okay to keep them on for up to one hour at a time.” C. “Heat always makes the swelling go down. You don’t need any other interventions.” D. “Try a high-impact exercise like running to loosen up your joints and reduce pain.” 68. What level of Maslow’s Hierarchy of Needs does shelter belong to? A. Love and belonging B. Safety and security C. Physiological D. Esteem 69. A client on bedrest complains of pain and burning in the right calf area. What is the nurse’s next action? A. Deeply palpate the area for rebound tenderness B. Percuss over the area for a change in tone C. Compare the circumference to the left calf D. Medicate the client for pain and reassess in 60 minutes 70. By providing measures to reduce skin breakdown, how does the nurse break the chain of infection? A. Creating a susceptible host B. Maintaining the integrity of a portal of entry C. Creating a reservoir to decrease the risk of infection D. Sterilizing the area to reduce the reservoir risk 71. What is not an appropriate nursing intervention for psoriasis? A. Apply corticosteroids as ordered B. Teach the client how to utilize UV radiation Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o C. Urge the client to consider participating in support groups D. Apply rubbing alcohol to plaques 72. What statement by the client indicates a correct understanding of the timing of the progression human immunodeficiency virus (HIV) to acquired immunodeficiency syndrome (AIDS)? A. “If I am re-exposed to HIV, progression to AIDS may be faster.” B. “My diet does not influence the progression of HIV to AIDS." C. “If I practice meditation, I may develop AIDS faster.” D. “Sexually transmitted infections will not make AIDS faster.” 73. A nurse is teaching a newly hired group of unlicensed assistive personnel (UAP) about infection-control measures on the unit. What is the most effective way to prevent the spread of pathogens during client care? A. Properly dispose of contaminated equipment B. Discard used syringes into appropriate containers C. Change soiled linens D. Perform hand hygiene 74. The client states “Why am I getting protein supplements while in healing from a bed sore?" What is the best response by the nurse? A. Because it is easy to digest." B. If you don’t like it. you don't have to take it.” C. "These supplements have nothing to do with your wound. D. Protein has amino acids that promote wound healing.” 75. What nursing interventions decrease the risk of pressure injuries? (Select all that apply) A. Padding hard surfaces B. Keep head of the bed (HOB) at or less than 30 degrees C. Keep the head of the bed (HOB) elevated75 degrees D. Have the client sit in a wheelchair as much as possible E. Place pillows between bony surfaces. Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o 76. What is the likely reason that a client with acquired immunodeficiency syndrome (AIDS) would succumb to pneumonia while a healthy person exposed to the same infection did not? A. The client with AIDS is a susceptible host. B. The client with AIDS was not as careful. C. The client with AIDS has more portals of entry. D. The client with AIDS has greater immune defenses. 77. What is an infectious disease that can be transmitted directly from one person to another? A. A susceptible host B. A communicable disease C. A portal of entry to a host D. A portal of exit from the reservoir 78. A nurse is teaching a client who has a new prescription for ibuprofen to treat rheumatoid arthritis. The nurse should teach the client to monitor for what adverse effect of this medication? A. Constipation B. Bleedin g C. Blurred vision D. Insomn ia 79. The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education? A. The client instills the prescribed number of eye drops into the conjunctival sac. B. The client washes her hands before instilling the eye drops. C. The client sets the cap to the eye drop container down in a manner that does not contaminate it. D.The client touches the administration dropper her to the eye. 80. A client is recovering from a fractured radius that occurred 7 weeks ago. Which stage of bone healing occurs at this time as the callus is resorbed and transformed into bone? O Stage 4 o Stage 3 Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o o Stage 5 o Stage 1 81. A client has an abdominal incision. The surgical wound was closed with 10 sutures. This surgical wound is healing by what process? A. Binary intention B. Secondary intention C. Tertiary intention D. Primary intention 82. What client is a susceptible host most at risk for infection? A. A client with leukemia B. A child who is immunized C. A 60-year-old client D. A hospitalized 35-year-old client 83. What is an example of a client’s primary defense to infection? A. Inflammation B. Fever C. Phagocytosis D. Intact skin 84. A goal for a client with impaired mobility is to prevent skin breakdown. What nursing intervention would best help the client meet this goal? A. Turn the client every 2 hours B. Offer a protein-rich diet C. Assist the client to orthopneic position D. Offer the client a bedpan for toileting 85. What is the priority intervention for the nurse to enhance meeting the psychosocial needs of a client on transmission-based precautions? A. Allow the client sleep to build up stamina B. Maintain a six-foot distance from the client C. Provide a timeframe for the isolation D. Provide the client with diversional activities 86. A client is diagnosed with narcolepsy. What is the nurse's priority intervention? Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% A. Encourage the client to stop drinking caffeine after 6 pm B. Inform the client to drink two cups of regular coffee C. Encourage the client to participate in normal activities D. Inform the client that driving would be dangerous 87. Which of the following lab tests may be used for diagnosing connective tissue diseases? (Select all that apply.) A. Erythrocyte sedimentation rate (ESR) B. C-reactive protein (CRP) C. Anti-nuclear antibody (ANA) D. Rheumatoid factor (RF) E. Thyroid stimulating hormone (TSH) 88. The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take? A. Deliver upward abdominal thrusts with a fisted hand. B. Complete five rapid back blows between the shoulder blades. C. Encourage the child to continue coughing. D. Perform a blind finger sweep of the child's mouth. 89. Where will the nurse collect the most reliable source of pain assessment? A. From the client B. From a medical-surgical book C. From the client’s chart D. From nurse-to-nurse bedside report 90. A client has acquired immunodeficiency syndrome (AIDS). Which of these assessment findings indicate possible infection? (Select all that apply.) A. Temperature: 101.3 degrees Fahrenheit B. Oxygen saturation: 97% on room air o Respirations: o o o Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o C. 22 breaths per minute Purulent drainage D. Client ambulates 20 feet 90. Which assessment is a nonverbal sign of pain? (Select all that apply.) A. Increased agitation B. Decreased attention span C. Grimacing o Reported pain of 5/10 D. Increase in heart rate 92. A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool, and swollen. What action does the nurse take next? A. Encourage range of motion B. Apply heat to the affected hand C. Remove the cast to decrease pressure D. Raise the arm above the level of the heart 93. What nursing intervention is appropriate for a client with-systemic lupus erythematosus (SLE)? A. Administer topical hydrocortisone B. Intense cold therapy to the extremities C. Administer antibiotics D. Encourage ultraviolet (UV) light exposure 101. A client has a new diagnosis of human immunodeficiency virus HIV. The client is distraught and does not know what to do. What intervention by the nurse is best? A. Assess the clients support system o o o Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% B. Call the hospital clergy to speak with the client C. Explain the legal requirement to tell sex partners D. Offer to tell the family for the client 102. The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take? A. Deliver upward abdominal thrusts with a fisted hand. B. Compete five rapid back blows between the shoulder blades. C. Encourage the child to continue coughing. C. Perform a blind finger sweep of the child's mouth. 103. A nurse is preparing a community presentation about repetitive motion injuries. Which of the following occupations should the nurse identify as increasing a client's risk for carpal tunnel syndrome? A. Truck driver o Nursing assistant o Elementary school teacher o Assembly line worker 104. Which client is at the greatest risk for pressure injury development? A. 44-year-old prescribed antibiotics for pneumonia B. A 26-year-old bedridden client with a fractured leg C. A 65-year-old with hemiparesis and incontinence D. A 78-year-old requiring assistance to ambulate with a walker 105. What complication of wound healing is an abnormal passage that connects two body cavities or a cavity and the skin? A. Fistula B. Hemorrhage C. Infection D. Evisceration o o o Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o 106. A client has sustained an open fracture. How can the nurse best prevent osteomyelitis in this client? A. Place the client in contact precautions. B. Use proper hand hygiene and strict infection control. C. Administer pain medication. D. Delegate all client personal care to specific unlicensed assistive personnel (UAP). 107. A homeless client arrives in the emergency room. The client verbalizes an inability to bathe for at least one month. What is the nurse's priority? A. Inspect the client's skin B. Provide a towel and show the client to the shower C. Ask if the client has been to a homeless shelter' recently D. Call a social worker 108. Which of the following statements by a client with human immunodeficiency virus (HIV) requires further teaching? (Select all that apply) A. "I will monitor my nutrition and fluid status." B. “Because I have HIV, that means I’m an AIDS patient." C. "I can still have unprotected intercourse with my partner since he doesn’t have HIV." D. "I need to ensure that I place my needles in a proper needle disposal container.” E. "I can spread this through contact with surfaces, so I need to wear gloves in public.” 109. The client is at risk for impaired skin integrity related to the need for several weeks of bed rest. The nurse evaluates the client after one week and finds the skin integrity is not impaired. In evaluating the plan of care. What is the nurse’s best action? A. Remove the nursing diagnosis in the plan of care since it has not occurred. B. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present. C. Modify the nursing diagnosis in plan of care to impaired skin integrity. o o o Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% D.Changed the nursing diagnosis in plan of care to impaired mobility. 110. Which client is at the highest risk of compromised immunity? A. A client who has just had surgery B. A client with extreme anxiety C. A client who is awaiting surgery D. A client who just delivered a baby 111. A nurse is admitting a client who has tuberculosis. What transmission-based precautions should the nurse initiate? A. Airborne B. Contact C. Droplet D. Protective 112. A client with acquired immunodeficiency syndrome (AIDS) has Pneumocystis carinii (PCP). What is the nurse’s priority assessment for this client? A. Capillary refill B. Radial pulses C. Lung sounds D. Skin turgor 113. The nurse is preparing communication for a provider. The client is experiencing acute pain greater than the severity of the fracture. Distal to the injury, he is experiencing a “pins and needles” sensation. The pulse is weak and thready but is bounding on all unaffected extremities. What emergent condition does the nurse suspect? A. Pulmonary embolism B. Ischial tuberosity D. Compartment syndrome E. Broken arm syndrome 114. A client is bedridden and appears to be frail and malnourished. Which nursing interventions will decrease the risk of pressure injury? (Select all that apply.) A. Cleansing the skin routinely after soiling occurs. o o o Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o B. Applying moisturizer to dry areas of skin. C. Using a Hoyer lift for all transfers. D. Massaging the client’s reddened shoulders and heels. E. Reposition client once per shift. 115. What is a sign of inadequate perfusion? A. Bounding pulses B. Pink fingers C. Pallor in toes D. Intact sensation o o o Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% 116. The nurse will be using the Braden Scale with each admission to the long-term care center. Which of these will be utilized in a Braden Scale Assessment? (Select all that apply.) A. Sensory perception B. Age C. Friction and shear D.Nutrition E. Mental State 117. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. What is the best response by the nurse? A. “A bone fragment has injured the nerve supply in the area " B. “An injured artery causes impaired arterial perfusion through the compartment. C. "Bleeding and swelling cause increased pressure in an area that cannot expand.” D. “The fascia expands with injury, causing pressure on underlying nerves and muscles.” 118. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse the physician about the event? A. The client’s incisional site has dehisced. B. The client’s incisional site has eviscerated. C. The client’s incisional site has lacerated. D. The client’s incisional site is approximately. 119. The nurse is caring for a client who is develops compartment syndrome from a severely fractured arm. The client asks the client asks the nurse how this can happen. What is the best response by the nurse? A. “A bone fragment has injured the nerve supply in the area.” B. “An injured artery causes impaired arterial perfusion through the compartment.” C. “Bleeding and swelling cause increased pressure in an area that cannot expand.” D. “The fascia expands with injury, causing pressure on underlying nerves and muscles.” o o Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o 120. When assessing the skin in the elderly, what age-related change should the nurse consider? A. Loss of elasticity of the dermal layer B. Increased activity of the sebaceous glands C. Increased regeneration of healthy skin D. Loss of vernix caseosa 121. A nurse is obtaining a client’s oral temperature. The client informs the nurse that he has just had some ice chips. What is the most appropriate action by the nurse? A. Proceed to take the oral temperature B. Document the temperature was unable to be obtained C. Proceed to take the oral temperature D. Wait 30 minutes to take an oral temperature 122. A nurse assesses an area of skin over a bony prominence. What finding would be most concerning? A. Blanching B. Warmth C. Redness D. Non-blanching 123. Most adults with human immunodeficiency virus will exhibit which of the following laboratory values? A. Higher-than-normal number of CD4+ T-cells and CD8+ T-cells are normal B. Lower-than-normal number of CD4+ T-cells and CD8+ T-cells are normal C. Lower-than-normal number of CD4+ T-cells and higher than normal CD8+ T-cells D. Higher-than-normal number of CD4+ T-cells and CD8+ T-cells are low 124. The nurse is caring for a 65-year-old client and notes a temperature of 101F. How does the nurse interpret this finding? A. Hypothermia B. Hyperthermia C. Normal D. A cold environment 125. Convert 60 ml to ounces. (Record as a whole number. Type answer as numeric only.) 2 Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o 126. A client is diagnosed with systemic sclerosis (scleroderma). What symptom is the first to occur? A. Joint pain B. Intense wrinkles C. Raynaud's phenomenon D. Tachycardia 127. A man has been admitted to the hospital unit with a medical diagnosis of chronic obstructive pulmonary disease (COPD). He is receiving supplemental oxygen at 2 L/min via cannula. Which positioning technique will best assist him with his breathing? A. Fowler’s position B. Sim’s position C. Prone position D. Lateral position 128. 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? A. Client will remain free from falls throughout their hospital stay. B. Client will increase activity tolerance by discharge from the hospital. C. Client will demonstrate effect breathing pattern when ambulating throughout hospital stay. D. Client will increase mobility by the time of discharge from hospital. 129. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately A. The client reports intermittent flatus and minor abdominal discomfort B. The client reports a minor headache and states she takes an over-the-counter pain pill at home. C. The client refused her pain medication this morning and is doing physical therapy. D. The client has paresthesia in her fingers and intense increasing pain in her shoulder. 130. The quality and risk nurse in the local hospital is performing a hospital survey on sentinel events. Which statement would the nurse use to best describe a sentinel event? A. An event that can cause serious injury to a client that should never happen in a hospital B. Specific events that enable a hospital to maximize reimbursement C. An unexpected event involving death or serious physical or psychological Injury D. Operating room event involving the use of unsafe equipment Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o 131. How many ml is one teaspoon? (Record answer as a whole number. Type answer as numeric only.) 5 132. What is true about antiretroviral drugs used to treat human immunodeficiency virus (HIV)? A. These drugs kill the virus B. Only certain licensed drugs are effective C. A few missed doses per month are OK D. These drugs inhibit viral replication 133. What should the nurse do first if they are stuck by a needle? A. Flush the exposed skin with water B. Report the exposure C. Seek medical attention D. Complete an incident report 134. Antibodies are passed from mother to fetus through the placenta. What is this type of immunity called? A. Natural active B. Artificial active C. Natural passive D. Artificial passive 135. The client had surgery one day ago. What assessment most likely related to pain? A. Heart rate 60 beats/minute B. Blood pressure of 175/90 mm C. Oxygen saturation of 97% D. Respirations of 10 breaths per minute 136. A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at highest risk for skin breakdown? A. An adolescent who has a patella fracture and is in an immobilizer. B. A young adult who has a femur fracture and is going to surgery in two hours. Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o C. A middle-aged adult who has fractured his radius and has a cast. D. An older adult who has a hip fracture and is immobile. 137. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention? A. Use gentle brushing and flossing techniques for clients with fragile mucos B. Handle dentures with care C. Position the client on one side with the head turned towards you D. Have a suction apparatus ready at the bedside 138. 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. Decreased level of rheumatoid factor B. A negative rheumatoid factor C. A positive rheumatoid factor D. Factor does not change. 139. A nurse is caring for a client who has acute osteomyelitis Which of the following interventions is the nurse's priority? A. Provide the client with anti-pyretic therapy. B. Administer antibiotics to the client. C. Increase the client’s protein intake. D. Teach relaxation breathing to reduce the client’s pain 140. A nurse is teaching a client who has fibromyalgia about strategics that might help reduce her symptoms What should the nurse include in the client education? A. Establish a regular sleep pattern B. Avoid exercise during flare-ups C. Do high-impact exercises like running D. Increase calcium and caffeine intake 141. An area of erythema on the child’s skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What term does the nurse document for this finding? Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o A. Blanching B. Warmth C. Redness D. Non-blanching 142. Client complains of fatigue and joint pain and reports that they are unable to walk due to pain in the knees. What is the most appropriate statement by the nurse? A. “You should avoid walking. This might ho osteoporosis.” B. “You just have arthritis and should take some ibuprofen.” C. “Please tell me more about when your pain started.” D. "You need to lose weight or the pain won’t go away.” 143. The nurse is caring for four clients. What client should the nurse see first? A. A client with chronic rheumatic pain. B. A client with lupus asking for dinner. C. A client on Methotrexate with a fever. D. A client with multiple children siting. 144. How many ml is two tablespoons? (Record answer as whole number. Type answer as numeric only.) 30 145. What does CREST syndrome sand for? A. Calcinosis, Raynaud’s, Esophageal dysmotility, Sclerodactyly and Telangiectasia B. Calcinosis, Reverse isolation, Esophageal dysmotility, Sclerodactyly, and Telangectasia C. Calcinosis, Raynaud’s, Everted colon. Sclerodactyly and Telangectasia D. Calcinosis, Raynaud’s, Esophageal dysmotility, Sclerodactyly, and Telekinesis 146. The client with systemic sclerosis (scleroderma) is experiencing Raynaud's phenomenon. What assessment finding does the nurse anticipate? A. Excessive heartburn B. Excess wrinkled skin C. Cyanosis of the lips D. Cold and purple nailbeds Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% o o 147. What medication class can decrease tissue inflammation but delays bone healing? A. Opioids B. Anticoagulants C. Nonsteroidal anti-inflammatory drugs (NSAIDs) D. Narcotics 148. The nurse has documented the following wound assessment: “Shallow, open, reddened ulcer with slough on the anterior region of the right heel?” What stage is the wound? o Stage 1 o Stage 2 o Stage 3 o Stage 4 Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% 148. What lifestyle habits negatively affect skin integrity? (Select all that apply.) A. Tanning B. Regular exercise C. Smoking D. Nutritious diet E. Tattoos 150. A client with systemic lupus erythematosus complains of flank pain. Which laboratory test does the nurse anticipate will be ordered? A. Hemoglobin B. Creatinine C. Platelets D. Skin biopsy 151. A nurse is caring for an immobile client. What is the priority assessment in this client? A. Assessment for the presence of peripheral edema B. Auscultation of lungs sounds C. Auscultation of bowel sounds D. Assessment of skin turgor 152. A client is post-operative day 1 and reports a sudden increase in blood-tingles liquid draining from his incision after feeling a popping sensation, what is the nurse’s next action? A. Send the client back to surgery B. Call the provider immediately C. Assess the wound for signs of dehiscence D. Prepare to culture the wound 153. A nurse is caring for a client who is post-operative following an open reduction internal fixation (ORIF) of a femur fracture. What is the included in the evaluation of the neurovascular status of the client’s affected extremity? (Select all that apply.) A. Color B. Temperature C. Ecchymosis D. Skin integrity E. Sensation Downloaded by Bruce Lee ([email protected])  lOMoARcPSD|43964769 Multidimensional 1. Final Exam 100% 154. The mother of a newborn baby is concerned that the baby will develop illness from being around people from outside of their family. What is the nurse’s best response? A. “You should never go around people after your baby is born.” B. “Tell me more about that that.” C. “I did that, and my kids turned out just fine.” D. “Why do you think that is a bad idea?” 155. Which of the following nonpharmacological methods can be used to manage the chronic pain of a client with rheumatoid arthritis? (Select all that apply.) A. Adequate Rest B. Frequent running C. Hot showers D. Heat for 20-30 minutes E. Ice for 2 hours at a time 156. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action? A. Put on non-sterile gloves B. Gently remove the soiled dressings C. Irrigate the wound D. Label the specimen tube Downloaded by Bruce Lee ([email protected])