Nursing 101 Exam 2: practice UPDATED ACTUAL
Questions and CORRECT Answers
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the
breath sounds heard as: - CORRECT ANSWER -crackles
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue? - CORRECT
ANSWER -corticosteroids
When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the
client is most likely experiencing - CORRECT ANSWER -poor tissue perfusion
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue
oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? - CORRECT
ANSWER -arterial blood gas
The nurse is caring for a client with metabolic acidosis whose breathing rate is 28 breaths per minute. Which arterial
blood gas data does the nurse anticipate finding? - CORRECT ANSWER -pH less than 7.35; HCO3 low; PaCO2
low
The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which
nursing intervention will provide tactile stimulation? - CORRECT ANSWER -providing a backrub with morning
and evening care
During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and
she believes she is in a hotel. How should the nurse best respond to this client's disorientation? - CORRECT
ANSWER -Reorient the client to place and time.
The physician tells the nurse that the elderly client has presbycusis. Which of the following interventions will the nurse
place in the client's care plan? - CORRECT ANSWER -Decrease background noises, as much as possible, before
speaking
The nurse assesses that her client has olfactory disturbances. Which of the following health topics would be important to
teach the client? - CORRECT ANSWER -Eliminating disturbing odors with adequate ventilation
The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory
disturbances. Which of the following questions should she ask? - CORRECT ANSWER -Do you work around loud
noises at work?"
Which example indicates the use of an internal sensory receptor? - CORRECT ANSWER -spitting out of hot coffee
A client reports to a health care facility with reporting abdominal pain and vomiting. The client's wife informs the nurse
that the client had gone out for dinner the previous night. Which of the following would be the primary source of
assessment data? - CORRECT ANSWER -client himself
During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for
laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to
address this issue? - CORRECT ANSWER -The nurse should determine the reason for the client's refusal.
The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have
always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the
nurse to formulate? - CORRECT ANSWER -Decisional Conflict related to conflict with moral beliefs as evidenced
by the client's statement
A 50-year-old female client is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with
this condition. What is the nurse's best source of information? - CORRECT ANSWER -Consult nursing and
medical literature.
Questions and CORRECT Answers
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the
breath sounds heard as: - CORRECT ANSWER -crackles
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue? - CORRECT
ANSWER -corticosteroids
When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the
client is most likely experiencing - CORRECT ANSWER -poor tissue perfusion
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue
oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? - CORRECT
ANSWER -arterial blood gas
The nurse is caring for a client with metabolic acidosis whose breathing rate is 28 breaths per minute. Which arterial
blood gas data does the nurse anticipate finding? - CORRECT ANSWER -pH less than 7.35; HCO3 low; PaCO2
low
The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which
nursing intervention will provide tactile stimulation? - CORRECT ANSWER -providing a backrub with morning
and evening care
During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and
she believes she is in a hotel. How should the nurse best respond to this client's disorientation? - CORRECT
ANSWER -Reorient the client to place and time.
The physician tells the nurse that the elderly client has presbycusis. Which of the following interventions will the nurse
place in the client's care plan? - CORRECT ANSWER -Decrease background noises, as much as possible, before
speaking
The nurse assesses that her client has olfactory disturbances. Which of the following health topics would be important to
teach the client? - CORRECT ANSWER -Eliminating disturbing odors with adequate ventilation
The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory
disturbances. Which of the following questions should she ask? - CORRECT ANSWER -Do you work around loud
noises at work?"
Which example indicates the use of an internal sensory receptor? - CORRECT ANSWER -spitting out of hot coffee
A client reports to a health care facility with reporting abdominal pain and vomiting. The client's wife informs the nurse
that the client had gone out for dinner the previous night. Which of the following would be the primary source of
assessment data? - CORRECT ANSWER -client himself
During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for
laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to
address this issue? - CORRECT ANSWER -The nurse should determine the reason for the client's refusal.
The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have
always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the
nurse to formulate? - CORRECT ANSWER -Decisional Conflict related to conflict with moral beliefs as evidenced
by the client's statement
A 50-year-old female client is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with
this condition. What is the nurse's best source of information? - CORRECT ANSWER -Consult nursing and
medical literature.
