NUR 280 Exam Questions With Complete Solutions
37. The nurse is performing an abdominal assessment. Indicate
the correct sequence the nurse should use to perform this
assessment.
(a) percussion
(b) palpation
(c) auscultation
(d) inspection Correct Answers D, C, B, and A. Inspection is
done first. Auscultation is performed before palpation to
decrease the risk of stimulating the bowel which could result in
false positive findings. Health Promotion and Maintenance
A 45 year old client who was recently diagnosed with terminal
cancer says to the nurse "If God could only let me live long
enough to put my daughter through college, I wouldn't mind
dealing with this illness." The nurse caring for this client
recognizes this statement as reflective of which stage of
grieving?
(a) Denial
(b) Acceptance
(c) Bargaining
(d) Anger Correct Answers C. During the bargaining stage the
client attempts to negotiate to prolong their life. Kübler-Ross
identified the stages of death and dying as denial (disbelief),
anger (hostility), bargaining, depression (sadness) and
acceptance (coming to terms with death). Psychosocial Integrity
,A client with end stage renal disease (ESRD) is scheduled for
hemodialysis in one hour. The nurse should notify the primary
health care provider that the client has a
(a) BUN of 60 mg/dl
(b) Creatinine 3.5 mg/dl
(c) Sodium 145 mEq/L
(d) Potassium 6.8 mEq/L Correct Answers D. Hyperkalemia
can result in serious adverse effects to excitable tissues
especially the heart, causing altered cardiac function; the BUN
and creatinine are elevated prior to dialysis due to increased
circulating wasted in the blood stream; a sodium level of 145
mEq/L is within the normal range of 135-145 mEq/L.
Physiological Integrity; Reduction of Risk Potential
A client with left-sided weakness following a cerebral vascular
accident (CVA) is learning to ambulate with a cane. The nurse
should teach the client to
(a) hold the cane on the left side and move the cane with the
right leg
(b) hold the cane on the right side and move the cane with the
left leg
(c) hold the cane on the left side and move the cane with the left
leg
(d) hold the cane on the right side and move the cane with the
right leg Correct Answers B. The proper technique to be used
when teaching a client to ambulate with a cane is to hold the
cane in the hand opposite the affected leg. Physiological
Integrity; Basic Care and Comfort
,A nurse is admitting a client with suspected pulmonary
tuberculosis (TB). Which of the following actions should the
nurse take?
(a) wear a gown when taking the client's health history
(b) place the client on droplet precautions
(c) keep the door to the client's room closed
(d) use disposable gloves when taking the client's blood pressure
Correct Answers C. The client with Tuberculosis (TB) is placed
no airborne precautions which include placement in a negative
pressure room with the door closed and use of a particulate
respirator mask; a gown and gloves are not needed when talking
with the client or taking the blood pressure; droplet precautions
are used for meningitis, HIB (haemophilus influenzae type b),
mumps, rubella, pertussis and epiglottitis. Physiological
Integrity; Physiological Adaptation
A nurse is caring for a two-month-old infant being evaluated for
congenital
hypothyroidism. The nurse should recognize which of the
following findings as
being consistent with congenital hypothyroidism?
(a) The infant sleeps for 6 hours at a time
(b) The infant has a high-pitched cry
(c) The infant has been having frequent loose stools
(d) The infant has 3 + reflexes Correct Answers A. Statements
made by the mother of the infant sleeping for prolonged periods
support the diagnosis. Follow up is needed for diagnostic
workup to confirm this disorder. Signs of congenital
hypothyroidism include lethargy, poor feeding, constipation and
, bradycardia; high pitched cry is not suggestive of
hypothyroidism; frequent loose stools and brisk reflexes may be
indicators of hyperthyroidism. Physiological Integrity;
Physiological Adaptation
A nurse is observing a newly-hired nurse provide care for
assigned clients. The
nurse should follow up if the newly-hired nurse is observed
(a) wearing gloves when taking the blood pressure of a client
with disseminated varicella zoster
(b) cleansing the wound from the outer surface to the inner
surface for a client whose wound is infected with a multi-drug
resistant organism
(c) washing the hands with the fingertips pointed downward
before providing care for a client on protective precautions
(d) removing the gloves before removing the gown when
leaving a room of a client who is on contact precautions Correct
Answers B. Cleansing of the wound from the outer surface to
the inner surface is incorrect technique. Wounds should be
cleansed in an outward direction to avoid transferring organisms
from the surrounding skin into the wound. Choices A, C, and D
follow the principles of infection control, follow up is not
required. Safe Effective Care Environment; Safety and Infection
Control
A student nurse is administering magnesium
hydroxide/aluminum hydrate (Maalox) prescribed as an antacid
to a client. The nursing instructor should intervene if the student
plans to administer the antacid
(a) two hours after the client has eaten a meal
37. The nurse is performing an abdominal assessment. Indicate
the correct sequence the nurse should use to perform this
assessment.
(a) percussion
(b) palpation
(c) auscultation
(d) inspection Correct Answers D, C, B, and A. Inspection is
done first. Auscultation is performed before palpation to
decrease the risk of stimulating the bowel which could result in
false positive findings. Health Promotion and Maintenance
A 45 year old client who was recently diagnosed with terminal
cancer says to the nurse "If God could only let me live long
enough to put my daughter through college, I wouldn't mind
dealing with this illness." The nurse caring for this client
recognizes this statement as reflective of which stage of
grieving?
(a) Denial
(b) Acceptance
(c) Bargaining
(d) Anger Correct Answers C. During the bargaining stage the
client attempts to negotiate to prolong their life. Kübler-Ross
identified the stages of death and dying as denial (disbelief),
anger (hostility), bargaining, depression (sadness) and
acceptance (coming to terms with death). Psychosocial Integrity
,A client with end stage renal disease (ESRD) is scheduled for
hemodialysis in one hour. The nurse should notify the primary
health care provider that the client has a
(a) BUN of 60 mg/dl
(b) Creatinine 3.5 mg/dl
(c) Sodium 145 mEq/L
(d) Potassium 6.8 mEq/L Correct Answers D. Hyperkalemia
can result in serious adverse effects to excitable tissues
especially the heart, causing altered cardiac function; the BUN
and creatinine are elevated prior to dialysis due to increased
circulating wasted in the blood stream; a sodium level of 145
mEq/L is within the normal range of 135-145 mEq/L.
Physiological Integrity; Reduction of Risk Potential
A client with left-sided weakness following a cerebral vascular
accident (CVA) is learning to ambulate with a cane. The nurse
should teach the client to
(a) hold the cane on the left side and move the cane with the
right leg
(b) hold the cane on the right side and move the cane with the
left leg
(c) hold the cane on the left side and move the cane with the left
leg
(d) hold the cane on the right side and move the cane with the
right leg Correct Answers B. The proper technique to be used
when teaching a client to ambulate with a cane is to hold the
cane in the hand opposite the affected leg. Physiological
Integrity; Basic Care and Comfort
,A nurse is admitting a client with suspected pulmonary
tuberculosis (TB). Which of the following actions should the
nurse take?
(a) wear a gown when taking the client's health history
(b) place the client on droplet precautions
(c) keep the door to the client's room closed
(d) use disposable gloves when taking the client's blood pressure
Correct Answers C. The client with Tuberculosis (TB) is placed
no airborne precautions which include placement in a negative
pressure room with the door closed and use of a particulate
respirator mask; a gown and gloves are not needed when talking
with the client or taking the blood pressure; droplet precautions
are used for meningitis, HIB (haemophilus influenzae type b),
mumps, rubella, pertussis and epiglottitis. Physiological
Integrity; Physiological Adaptation
A nurse is caring for a two-month-old infant being evaluated for
congenital
hypothyroidism. The nurse should recognize which of the
following findings as
being consistent with congenital hypothyroidism?
(a) The infant sleeps for 6 hours at a time
(b) The infant has a high-pitched cry
(c) The infant has been having frequent loose stools
(d) The infant has 3 + reflexes Correct Answers A. Statements
made by the mother of the infant sleeping for prolonged periods
support the diagnosis. Follow up is needed for diagnostic
workup to confirm this disorder. Signs of congenital
hypothyroidism include lethargy, poor feeding, constipation and
, bradycardia; high pitched cry is not suggestive of
hypothyroidism; frequent loose stools and brisk reflexes may be
indicators of hyperthyroidism. Physiological Integrity;
Physiological Adaptation
A nurse is observing a newly-hired nurse provide care for
assigned clients. The
nurse should follow up if the newly-hired nurse is observed
(a) wearing gloves when taking the blood pressure of a client
with disseminated varicella zoster
(b) cleansing the wound from the outer surface to the inner
surface for a client whose wound is infected with a multi-drug
resistant organism
(c) washing the hands with the fingertips pointed downward
before providing care for a client on protective precautions
(d) removing the gloves before removing the gown when
leaving a room of a client who is on contact precautions Correct
Answers B. Cleansing of the wound from the outer surface to
the inner surface is incorrect technique. Wounds should be
cleansed in an outward direction to avoid transferring organisms
from the surrounding skin into the wound. Choices A, C, and D
follow the principles of infection control, follow up is not
required. Safe Effective Care Environment; Safety and Infection
Control
A student nurse is administering magnesium
hydroxide/aluminum hydrate (Maalox) prescribed as an antacid
to a client. The nursing instructor should intervene if the student
plans to administer the antacid
(a) two hours after the client has eaten a meal
