NR 224 EXAM 3 LATEST VERSION ACTUAL EXAM 50
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+||CHAMBERLAINE
COLLEGE
A nurse is performing mouth care for a client who is unconscious. Which of the
following actions should the nurse take?
A. Turn the client's head to the side
B. Place two fingers in the client's mouth to open it
C. Brush the client's teeth once per day
D. Inject a mouth rinse into the center of the client's mouth - ANSWER: A
this reduces risk of aspiration
A nurse is instructing a client who has DM about foot care. Which of the following
guidelines should the nurse include? (Select all that apply)
A. Inspect the feet daily
B. Use moisturizing lotion on the feet
C. wash the feet with warm water and let them air dry
D. use OTC products to treat abrasions
E. wear cotton socks - ANSWER: A, B, E
Feet should be inspected daily esp for diabetics
Use lotion for smooth and supple skin but do not use b/t toes
Pt should wear clean cotton socks each day esp diabetics
A nurse is planning care for a client who develops dyspnea and feels tired after
completing morning care. Which of the following actions should the nurse include in
the client's plan of care?
A. schedule rest periods during morning care
B. discontinue morning care for 2 days
C. perform all care as quickly as possible
D. ask a family member to come in and bathe the client - ANSWER: A
planning for rest periods during morning care will help prevent fatigue and
continue to foster independence
A nurse is beginning a complete bed bath for a client. After removing the client's
gown and placing a bath blanket over the body, which of the following areas should
the nurse wash first?
A. face
B. feet
C. chest
D. arms - ANSWER: A
greatest risk to the client is the transmission of pathogens from one area of the
body to another--> begin with the cleanest area and then move to the dirtiest
,A nurse is preparing to perform denture care for a client. Which of the following
actions should the nurse plan to take?
A. pull down and out at the back of the upper denture to remove
B. brush the dentures with a toothbrush and denture cleaner
C. rinse the dentures with hot water after cleaning them
D. place the dentures in a clean, dry storage container after cleaning them -
ANSWER: B
brushing throughly with a toothbrush and denture cleaner removes the debris that
accumulates on and between the teeth
A nurse is caring for a client scheduled for abdominal surgery. The client reports
being worried. Which of the following actions should the nurse take?
A. offer information on a relaxation technique and ask the client if they are
interested in trying it.
B. request a social worker see the client to discuss meditation
C. attempt to use biofeedback techniques with the client
D. tell the client many people feel the same way before surgery - ANSWER: A
recommend a noninvasive technique to facilitate coping
A nurse is assessing a client as part of an admission history. The client reports
drinking an herbal tea every afternoon at work to relieve stress. Tea includes which if
the following ingredients?
A. chamomile
B. ginseng
C. ginger
D. echinacea - ANSWER: A
this produces a calming effect and reduces anxiety
A nurse is reviewing complementary and alternative therapies with a group of newly
licensed nurses. Which of the following interventions are mind-body therapies?
(Select all that apply)
A. art therapy
B. acupressure
C. yoga
D. therapeutic touch
E. biofeedback - ANSWER: A, C, E
art therapy allows the client to express unconscious emotions, yoga focuses on
achieving well-being through exercise, posture, breathing and meditation,
biofeedback increases mental awareness of the body's response to stress
A nurse is teaching a group of newly licensed nurses on complementary and
alternative therapies they can incorporate into their practice without the need for
specialized licensing or certification. Which of the following should the nurse
encourage them to use? (select all that apply)
A. guided imagery
B. massage therapy
C. meditation
,D. music therapy
E. therapeutic touch - ANSWER: A, C, D
nurses can use guided imagery, meditation and music therapy with clients
A nurse is planning to use healing intention with a client who is recovering from a
lengthy illness. Which of the following is the priority action to take before attempting
this particular mind-body intervention?
A. tell the client the goal of therapy is to promote healing
B. ask whether the client is comfortable with using prayer
C. encourage the client participate actively for best results
D. instruct the client to relax during the therapy - ANSWER: B
the first action to take during nursing process is assessment and the nurse must first
determine the client is comfortable with a therapy that involves prayer
A nurse is performing an admission assessment on a client who has hypovolemia due
to vomiting and diarrhea. The nurse should expect which of the following findings?
(Select all that apply)
A. distended neck veins
B. hyperthermia
C. tachycardia
D. syncope
E. decreased skin turgor - ANSWER: C, D, E
all these are expected findings for hypovolemia
A nurse is on a med surg unit caring for a group of clients. The nurse should identify
that which of the following clients is at risk for hypovolemia?
A. client who has a nasogastric suctioning
B. client who has chronic constipation
C. client who has syndrome of inappropriate antidiuretic hormone
D. client who took a toxic dose of sodium bicarbonate antacids - ANSWER: A
from the Ng tube and excessive GI loses
A nurse is reviewing the lab test results for a client who has an elevated
temperature. The nurse should identify which of the following findings as a
manifestation of dehydration?(select all that apply)
A. Hct 55%
B. blood osmolarity 260 mOsm/kg
C. blood sodium 150 mEq/L
D. urine specific gravity 1.035
E. blood creatinine 0.6 mg/dL - ANSWER: A, C, D
Hct is greater than expected reference range and is an indication of dehydration due
to hemoconcentration, blood sodium level is greater than expected and so is urine
specific gravity
A nurse on the med surg unit is caring for a group of clients. For which of the
following clients should the nurse expect a prescription for fluid restriction?
A. a client who has a new diagnosis of adrenal insufficiency
, B. a client who has heart failure
C. a client who is receiving treatment for diabetic ketoacidosis
D. a client who has abdominal ascites - ANSWER: B
a client with HF has to require fluid and sodium restriction to reduce the workload
on the heart
A nurse is planning care for a client who has dehydration. Which of the following
actions should the nurse include?
A. administer antihypertensive on schedule
B. check the client's weight each morning
C. notify the provider of a urine output greater than 30 ml/hr
D. encourage independent ambulation four times a day - ANSWER: B
include obtaining the client's weight each day at the same time so the nurse can
evaluate the client's response to treatment
A nurse is planning care for a client who has hypernatremia. Which of the following
actions should the nurse include in the plan of care?
A. infuse hypotonic IV fluids
B. implement a fluid restriction
C. increase sodium intake
D. administer sodium polystyrene sulfonate - ANSWER: A
indicated for the treatment of hypernatremia expand the ECF volume and rehydrate
the cells
A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse
should identify which of the following findings as a risk factor for the development of
this electrolyte imbalance?
A. Crohn's disease
B. post -op following appendectomy
C. history of bone cancer
D. hyperthyroidism - ANSWER: A
client with crohn's disease is at risk for hypocalcemia due to inadequate calcium
absorption
A nurse receives a lab report for a client indicating a potassium level of 5.2 mEq/L.
When notifying the provider, the nurse should expect which of the following
actions?
A. starting an IV infusion of 0.9% sodium chloride
B. consulting w/ dietitian to increase intake of potassium
C. initiating continuous cardiac monitoring
D. preparing the client for gastric lavage - ANSWER: C
need cardiac monitoring b/c K+ deals with heart rhythm
A nurse is collecting data from a client who has hypercalcemia as a result of long-
term use of glucocorticoids. Which of the following findings should the nurse expect?
(select all that apply)
A. hyperreflexia
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+||CHAMBERLAINE
COLLEGE
A nurse is performing mouth care for a client who is unconscious. Which of the
following actions should the nurse take?
A. Turn the client's head to the side
B. Place two fingers in the client's mouth to open it
C. Brush the client's teeth once per day
D. Inject a mouth rinse into the center of the client's mouth - ANSWER: A
this reduces risk of aspiration
A nurse is instructing a client who has DM about foot care. Which of the following
guidelines should the nurse include? (Select all that apply)
A. Inspect the feet daily
B. Use moisturizing lotion on the feet
C. wash the feet with warm water and let them air dry
D. use OTC products to treat abrasions
E. wear cotton socks - ANSWER: A, B, E
Feet should be inspected daily esp for diabetics
Use lotion for smooth and supple skin but do not use b/t toes
Pt should wear clean cotton socks each day esp diabetics
A nurse is planning care for a client who develops dyspnea and feels tired after
completing morning care. Which of the following actions should the nurse include in
the client's plan of care?
A. schedule rest periods during morning care
B. discontinue morning care for 2 days
C. perform all care as quickly as possible
D. ask a family member to come in and bathe the client - ANSWER: A
planning for rest periods during morning care will help prevent fatigue and
continue to foster independence
A nurse is beginning a complete bed bath for a client. After removing the client's
gown and placing a bath blanket over the body, which of the following areas should
the nurse wash first?
A. face
B. feet
C. chest
D. arms - ANSWER: A
greatest risk to the client is the transmission of pathogens from one area of the
body to another--> begin with the cleanest area and then move to the dirtiest
,A nurse is preparing to perform denture care for a client. Which of the following
actions should the nurse plan to take?
A. pull down and out at the back of the upper denture to remove
B. brush the dentures with a toothbrush and denture cleaner
C. rinse the dentures with hot water after cleaning them
D. place the dentures in a clean, dry storage container after cleaning them -
ANSWER: B
brushing throughly with a toothbrush and denture cleaner removes the debris that
accumulates on and between the teeth
A nurse is caring for a client scheduled for abdominal surgery. The client reports
being worried. Which of the following actions should the nurse take?
A. offer information on a relaxation technique and ask the client if they are
interested in trying it.
B. request a social worker see the client to discuss meditation
C. attempt to use biofeedback techniques with the client
D. tell the client many people feel the same way before surgery - ANSWER: A
recommend a noninvasive technique to facilitate coping
A nurse is assessing a client as part of an admission history. The client reports
drinking an herbal tea every afternoon at work to relieve stress. Tea includes which if
the following ingredients?
A. chamomile
B. ginseng
C. ginger
D. echinacea - ANSWER: A
this produces a calming effect and reduces anxiety
A nurse is reviewing complementary and alternative therapies with a group of newly
licensed nurses. Which of the following interventions are mind-body therapies?
(Select all that apply)
A. art therapy
B. acupressure
C. yoga
D. therapeutic touch
E. biofeedback - ANSWER: A, C, E
art therapy allows the client to express unconscious emotions, yoga focuses on
achieving well-being through exercise, posture, breathing and meditation,
biofeedback increases mental awareness of the body's response to stress
A nurse is teaching a group of newly licensed nurses on complementary and
alternative therapies they can incorporate into their practice without the need for
specialized licensing or certification. Which of the following should the nurse
encourage them to use? (select all that apply)
A. guided imagery
B. massage therapy
C. meditation
,D. music therapy
E. therapeutic touch - ANSWER: A, C, D
nurses can use guided imagery, meditation and music therapy with clients
A nurse is planning to use healing intention with a client who is recovering from a
lengthy illness. Which of the following is the priority action to take before attempting
this particular mind-body intervention?
A. tell the client the goal of therapy is to promote healing
B. ask whether the client is comfortable with using prayer
C. encourage the client participate actively for best results
D. instruct the client to relax during the therapy - ANSWER: B
the first action to take during nursing process is assessment and the nurse must first
determine the client is comfortable with a therapy that involves prayer
A nurse is performing an admission assessment on a client who has hypovolemia due
to vomiting and diarrhea. The nurse should expect which of the following findings?
(Select all that apply)
A. distended neck veins
B. hyperthermia
C. tachycardia
D. syncope
E. decreased skin turgor - ANSWER: C, D, E
all these are expected findings for hypovolemia
A nurse is on a med surg unit caring for a group of clients. The nurse should identify
that which of the following clients is at risk for hypovolemia?
A. client who has a nasogastric suctioning
B. client who has chronic constipation
C. client who has syndrome of inappropriate antidiuretic hormone
D. client who took a toxic dose of sodium bicarbonate antacids - ANSWER: A
from the Ng tube and excessive GI loses
A nurse is reviewing the lab test results for a client who has an elevated
temperature. The nurse should identify which of the following findings as a
manifestation of dehydration?(select all that apply)
A. Hct 55%
B. blood osmolarity 260 mOsm/kg
C. blood sodium 150 mEq/L
D. urine specific gravity 1.035
E. blood creatinine 0.6 mg/dL - ANSWER: A, C, D
Hct is greater than expected reference range and is an indication of dehydration due
to hemoconcentration, blood sodium level is greater than expected and so is urine
specific gravity
A nurse on the med surg unit is caring for a group of clients. For which of the
following clients should the nurse expect a prescription for fluid restriction?
A. a client who has a new diagnosis of adrenal insufficiency
, B. a client who has heart failure
C. a client who is receiving treatment for diabetic ketoacidosis
D. a client who has abdominal ascites - ANSWER: B
a client with HF has to require fluid and sodium restriction to reduce the workload
on the heart
A nurse is planning care for a client who has dehydration. Which of the following
actions should the nurse include?
A. administer antihypertensive on schedule
B. check the client's weight each morning
C. notify the provider of a urine output greater than 30 ml/hr
D. encourage independent ambulation four times a day - ANSWER: B
include obtaining the client's weight each day at the same time so the nurse can
evaluate the client's response to treatment
A nurse is planning care for a client who has hypernatremia. Which of the following
actions should the nurse include in the plan of care?
A. infuse hypotonic IV fluids
B. implement a fluid restriction
C. increase sodium intake
D. administer sodium polystyrene sulfonate - ANSWER: A
indicated for the treatment of hypernatremia expand the ECF volume and rehydrate
the cells
A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse
should identify which of the following findings as a risk factor for the development of
this electrolyte imbalance?
A. Crohn's disease
B. post -op following appendectomy
C. history of bone cancer
D. hyperthyroidism - ANSWER: A
client with crohn's disease is at risk for hypocalcemia due to inadequate calcium
absorption
A nurse receives a lab report for a client indicating a potassium level of 5.2 mEq/L.
When notifying the provider, the nurse should expect which of the following
actions?
A. starting an IV infusion of 0.9% sodium chloride
B. consulting w/ dietitian to increase intake of potassium
C. initiating continuous cardiac monitoring
D. preparing the client for gastric lavage - ANSWER: C
need cardiac monitoring b/c K+ deals with heart rhythm
A nurse is collecting data from a client who has hypercalcemia as a result of long-
term use of glucocorticoids. Which of the following findings should the nurse expect?
(select all that apply)
A. hyperreflexia
