When auscultating the client’s lungs, a nurse notes normal vesicular sounds as: 1. Medium-pitched blowing sounds with inspirations that equal expirations 2. Loud, high-pitched, hollow sounds with expiration longer than inspiration 3. Soft, breezy, low-pitched sounds with longer inspiration 4. Sounds created by air moving through small airways ANSWER ANS: 3 Normal vesicular sounds […]
The nurse initiates a blood transfusion for a client. What action should the nurse take next? 1. Stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. 2. Assign the UAP to sit with the client for 15 minutes. 3. Advise the client to notify the nurse […]
A client has several dark, thick scars on body locations from previous surgeries and injuries. The nurse realizes this occurs during which phase of wound healing? 1. Exudative 2. Proliferative 3. Inflammatory 4. Maturation ANSWER Correct Answer: 4 Rationale 1: Exudative is not a phase of wound healing. Rationale 2: Keloid formation does not […]
A client with a terminal illness without an advance directive stops breathing, and does not have a heartbeat. What should the nurse do? 1. Call a “slow code.” 2. Call a partial code. 3. Call the physician. 4. Call a code. ANSWER Correct Answer: 4 Rationale 1: Both legally and ethically, there is no […]
When obtaining vital signs, a nursing assistive personnel is concerned that the heart rate of 56 is too low for a 23-year-old client who has been training for a marathon. The nurse explains that: 1. A low heart rate is normal in well-conditioned athletes 2. The health care provider needs to be notified immediately 3. […]
A 9-year-old client asks the nurse, “Why do I need to sleep?” The nurse’s most age-appropriate, informative response is: 1. “Everyone needs to sleep to feel rested.” 2. “It gives your body a chance to really rest.” 3. “You’ll be able to do so much better in school if you’re rested.” 4. “Your body needs […]
The female client on the surgical unit is being prepared for abdominal surgery with general anes-thesia. In preparing this client for surgery, the nurse should: 1. Leave all of her jewelry intact 2. Provide her with sips of water for a dry mouth 3. Remove her makeup and nail polish 4. Remove her hearing aid […]
In the postoperative period, the nurse recognizes that an early sign of malignant hyperthermia is: 1. Fever 2. Tachycardia 3. Muscle relaxation 4. Skin pallor ANSWER ANS: 2 Malignant hyperthermia should be suspected when there is unexpected tachycardia and tachyp-nea; jaw muscle rigidity; body rigidity of limbs, abdomen, and chest; or hyperkalemia. Tempera-ture elevation […]
Following an assessment of the client, the nurse identifies the nursing diagnosis activity intoler-ance related to increased weight gain and inactivity. An outcome identified by the nurse should be: 1. Resting heart rate will be 90 to 100 beats/minute 2. Blood pressure will be maintained between 140/80 and 160/90 mm Hg 3. Exercise will be […]
The nurse knows that studies of sexuality in older adults have shown: 1. To be inconsistent in their overall findings 2. That this population is reluctant to discuss their sexual practices 3. That there is a decline of sexual interest and behavior among older adults 4. That older adults retain an interest in sexual function […]
