NursGuru
    Login/Signup
    Review ModeExam ModePractice Mode

    Exam Review

    1. A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?
      A)
      Iron
      B)
      Vitamin C
      C)
      Potassium
      D)
      Niacin
    2. A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?
      A)
      Massage reddened areas during dressing changes.
      B)
      Apply a heat lamp twice a day.
      C)
      Cleanse with 0.9% sodium chloride irrigation.
      D)
      Cleanse with povidone-iodine solution.
    3. A nurse is collecting data on a client. Which of the following findings increase the client's risk for developing a pressure injury?
      A)
      Adequate hydration
      B)
      Chronic diseases
      C)
      Elevated blood pressure
      D)
      Regular exercise routine
    4. A nurse is collecting data on client who has a heart rate of 56/min. Which of the following findings should the nurse expect?
      A)
      Temperature of 39° C (102.2° F).
      B)
      Hypoglycemia
      C)
      Report of dizziness
      D)
      History of cigarette smoking
    Page 1 of 10

    Exam Review

    1. A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?
      A)
      Reposition the client every 3 hr.
      B)
      Provide the client with a diet high in protein.
      C)
      Apply cornstarch to keep the skin dry.
      D)
      Massage bony prominences to promote circulation.
    2. A nurse is measuring an adult client's tympanic temperature. Which of the following actions should the nurse take?
      A)
      Use a cotton-tipped applicator to remove cerumen.
      B)
      Insert the probe snugly into the ear canal and press scan.
      C)
      Pull the pinna downward and backward.
      D)
      Hold the probe flat against the forehead and press scan.
    3. A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?
      A)
      Determine the client's blood pressure 1 min after each position change.
      B)
      Assist the client into a standing position.
      C)
      Check the blood pressure with the client in a supine position.
      D)
      Place the client in a sitting position.
    4. A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown?
      A)
      Clean the skin and perineum with hot water after each episode of incontinence.
      B)
      Apply a moisture barrier ointment to the skin.
      C)
      Check the client's skin every 8 hr for signs of breakdown.
      D)
      Request a prescription for the insertion of an indwelling urinary catheter.
    Page 2 of 10

    Exam Review

    1. (Highlight — findings requiring follow-up are marked)

      Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

      Exhibits

      Wound bed is red.

      Redness noted at wound borders, skin surrounding wound is warm to touch

      purulent drainage noted

      Temp 38.9° C (102° F)

      Hct 37% (37% to 47%)

      WBC 13,500/mm3 (5000 to 10,000 mm3)
       

    2. A nurse is collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?
      A)
      Partial-thickness skin loss with red tissue in wound bed
      B)
      Intact skin with localized erythema
      C)
      Full thickness skin loss with visible adipose tissue.
      D)
      Full thickness skin loss with visible bone
    3. A nurse is collecting data on a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?
      A)
      Granulation tissue forming at the bottom of the wound bed.
      B)
      Healing of the wound is prolonged.
      C)
      Wound is contaminated at the time of injury.
      D)
      Skin edges of the wound are sutured closed with edges that are well approximated.
    4. A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
      A)
      Full thickness skin loss with visible bone
      B)
      Full thickness skin loss with visible adipose tissue.
      C)
      Partial-thickness skin loss with red tissue in wound bed.
      D)
      Intact skin with localized erythema.
    Page 3 of 10

    Exam Review

    1. A nurse is contributing to the plan of care for a client who has a superficial skin tear with no exudate. Which of the following dressings should the nurse recommend to cover the wound?
      A)
      Hydrofiber dressing
      B)
      Transparent-film dressing
      C)
      Alginate dressing
      D)
      Foam dressing
    2. A nurse is preparing to measure a client's oral temperature. The client states that he has just had some ice chips in his mouth. Which of the following actions should the nurse take?
      A)
      Provide the client a sip of warm water and wait 5 min before measuring his oral temperature.
      B)
      Wait 30 min and return to measure the client's oral temperature.
      C)
      Proceed to measure the client's oral temperature.
      D)
      Document the inability to obtain an accurate reading of the client's oral temperature.
    3. A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?
      A)
      Rate, Rhythm, and Equality
      B)
      Rate and Rhythm
      C)
      Rate, Strength, and Symmetry
      D)
      Rhythm, Rate, and Depth
    4. A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take?
      A)
      Elevate the client's arm above the level of the heart.
      B)
      Align the artery indicator on the blood pressure cuff with the client's brachial artery.
      C)
      Place the blood pressure cuff 5 cm (2 in) above the client's antecubital space.
      D)
      Select a cuff that covers 50% of the client's upper arm.
    Page 4 of 10

    Exam Review

    1. A 45-year-old mother of 3 young children is at the doctor's office and her blood pressure is 152/92. This is the first time that has ever shown an elevated reading. She is concerned that she has hypertension. The nurse's best response would be:
      A)
      "Fortunately, hypertension isn't related to other diseases and is easily treated"
      B)
      "A single reading may not mean anything. We will take it again, 2 more times, within the next few weeks."
      C)
      "It looks like you have high blood pressure now. We'll check it again in 3 months"
      D)
      "You may have hypertension, but there is little else that can be done except medication."
    2. The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girl's temperature rectally and obtaining a reading of 100.4 F. The mother was concerned that her daughter might be ill. Which of the following is the best response?
      A)
      "When taking multiple temperature, the sites should be rotated."
      B)
      "Because of her age, it is probably a bacterial infection."
      C)
      "Children usually run lower rather than higher temperatures when ill."
      D)
      "Rectal temperature readings are higher than temperature obtained orally."
    3. A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
      A)
      Decreased serum calcium
      B)
      Increased muscle mass
      C)
      Decreased circulation
      D)
      Increased collagen
    4. A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?
      A)
      Place a gauze pad around the drain.
      B)
      Connect the drain to continuous low-pressure suction.
      C)
      Clean the skin near the drain in a circular motion from the outside to the inside.
      D)
      Empty the drainage device when it is half full.
    Page 5 of 10

    Exam Review

    1. A patient is obese. At the bedside is a standard-size blood pressure cuff. The nurse realizes that the use of this cuff will provide which of the following?
      A)
      A falsely high reading if the cuff is too small.
      B)
      A falsely low reading if the cuff is wrapped too loosely around the arm.
      C)
      Accurate readings as long as it is 20% of the circumference of the midpoint of the limb.
      D)
      Indistinct readings if the bladder encircles 80% of the adult's arm
    2. A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?
      A)
      Carotid
      B)
      Femoral
      C)
      Popliteal
      D)
      Brachial
    3. Which of the following interventions is important for preventing dehiscence of an abdominal incision?
      A)
      Restricting fluid intake
      B)
      Using a pillow to support the abdomen when coughing
      C)
      Encouraging early ambulation
      D)
      Administering high-dose corticosteroids
    4. A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device (wound vac) placed over it. Which of the following findings by the nurse, during a dressing change, indicates healing of the wound?
      A)
      Musty odor from the foam dressing upon removal
      B)
      Granulation tissue on the surface of the wound
      C)
      Peeling of the edges of the transparent dressing
      D)
      Sanguineous drainage in the suction device
    Page 6 of 10