Exam 1 N112
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1. A nurse receives a shift report and is preparing to care for clients assigned on
a medicalsurgical unit. Which client should the nurse plan to assess first?
A) The client who needs assistance with activities of daily living
B) The client who needs help ambulating to the bathroom
C) The client with a pain rating of 3/10
D) The client experiencing shortness of breath: D
2. 2) A client with congestive heart failure (CHF) is having difficulty breathing.
Before leaving the room, the nurse ensures the client has an overbed table
to lean on when awake if needed to ease breathing. Which technique did the
nurse use to make this decision? A) Delegating a task
B) Priority setting
C) Conflict resolution
D) Critical thinking: D
3. 3) A postoperative client prescribed pain medication every 4 to 6 hours is
requesting medication every 6 hours. At 4 hours the client's pain level is 8 on
a rating scale of 1 to 10. The nurse decides to give the pain medication now.
What does this nurse's action exemplify?
A) Meeting a client goal
B) Time management skills
C) Prioritizing the client's care
D) Responding to a change in the client's condition: D
4. 4) The nurse is assigned two clients. One client needs postoperative teaching
in preparation for discharge, and the other client with pneumonia has a PaCO2
of 85. Why does the nurse decide to see the client with pneumonia first?
A) The nurse can delegate postoperative teaching to unlicensed assistive per-
sonnel (UAP).
B) The client with pneumonia needs more care than the client needing postop-
erative teaching.
C) The client with pneumonia may be experiencing respiratory distress.
D) The room of the client with pneumonia is closer than that of the client
needing postoperative teaching: C
, Exam 1 N112
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5. 5) The urgent care clinic nurse is treating a client who is experiencing abdom-
inal pain. The client states, "I think I ate tainted food last night." What should
the nurse do after the client states that the food was tainted?
A) Ask the client open-ended questions to further assess the situation.
B) Tell the client the healthcare provider does not need to assess the client.
C) Call an ambulance before assessing the client any further.
D) Advise the client to take an antacid.: A
6. 6) A client with aspiration pneumonia is diaphoretic, pale, and taking gasping
breaths. Which is the priority nursing action?
A) Notify the healthcare provider.
B) Complete a thorough cardiopulmonary assessment.
C) Administer 10 L of oxygen per face mask.
D) Reposition the client to help with breathing.: B
7. 7) The home health nurse is visiting a client who is 2 weeks postoperative from
a coronary artery bypass surgery. The client has lost 10 pounds, is continuing
to experience pain, and is not eating. What should be the nurse's next action?
A) Examine the current interventions for pain relief.
B) Refer the client to social services.
C) Contact Meals on Wheels so that the client will eat.
D) Revise the goals in the current plan of care.: A
8. 8) The nurse is caring for an older adult client with decreased energy who
needs to get up to prevent the development of pressure ulcers. The client is
unable to ambulate and wants to be alone. What should the nurse do?
A) Notify the healthcare provider of the client's noncompliance.
B) Leave the client alone until ready to get out of bed.
C) Gain knowledge about the client from family to gain compliance. D) Proceed
to get help to get the client out of bed.: C
9. 9) The nurse is caring for an older school-age client who is sleeping when the
menu choices for dinner are brought to the room. Which intervention should
the nurse use to meet the dietary needs of this client?
A) Wake the child to choose a meal for dinner.
B) Order chicken nuggets because most children like this meal.
, Exam 1 N112
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C) Ask the dietary worker to come back later.
D) Ask the parents to bring dinner from home for the client.: C
10. 10) A client asks the student nurse to explain the pathophysiology of dia-
betes. The student nurse does not know the answer to this question. What
should the student respond to the client? A) "I do not know, but I will find out."
B) "You'll have to ask the doctor that question." C) "Why do you need to know
that?" D) "I do not know.": A
11. 11) A novice nurse is planning care for an older adult client with a wound
infection and systemic blood infection. The nurse completes the plan of care
and decides to complete which action to enhance the skill of critical thinking?
A) Discuss the plan with the physician.
B) Request that the client review the plan.
C) Request a review of the plan with the nurse's preceptor.
D) Place the plan on the client's chart.: C
12. 12) The nurse is taking the time to reflect on a care situation in which a client
sustained a cardiac arrest and died. On which areas should the nurse focus
when performing this reflection? Select all that apply.
A) Things that could have been done differently
B) Gut reactions to the situation
C) Things that were done well
D) Resources that were used at the time
E) Resources that were needed but not available: A, C, D, E
13. 13) A client begins to vomit blood. The nurse immediately measures the
blood pressure and prepares to insert a nasogastric tube while directing others
to notify the healthcare provider and prepare to perform iced saline lavage.
Which features of the Tanner Clinical Judgment Model did this nurse demon-
strate? Select all that apply.
A) Presencing
B) Noticing
C) Reflecting
D) Interpreting
E) Responding: B, D, E
, Exam 1 N112
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14. 14) The nurse who uses clinical decision making to start CPR on a client is
concerned about what other nursing concept?
A) Cognition
B) Perfusion
C) Thermoregulation
D) Acid-base balance: B
15. 1) During a health history, a client becomes upset because the nurse is
asking many questions. Which response by the nurse is the most appropriate
in this situation?
A) "I use the answers to determine your current health needs."
B) "I am sorry the questions disturb you."
C) "I will skip the questions that bother you."
D) "I cannot help you if you do not answer me.": A
16. 2) The nurse is conducting a class for a group of expectant mothers regard-
ing basic infant care techniques. What goal will allow the nurse to best evaluate
the mothers' learning?
A) The mothers will be able to set goals for the next class session.
B) The mothers will be able to pass a written test on how to bathe a newborn
infant.
C) The mothers will be able to review the major points of the class. D) The
mothers will be able to provide a return demonstration of a bath on a newborn
doll.: D
17. 3) A goal of care for a client with congestive heart failure (CHF) is for serum
sodium levels to be within normal limits. Which information documented in the
medical record would indicate that the client is not meeting this goal?
A) The client is experiencing dependent edema.
B) The client experiences joint pain.
C) The client is constipated.
D) The client is experiencing wheezing respirations.: A
18. 4) The nurse is collecting data about a client's current health status. Which
statement would assist in gathering subjective data about the client?
A) "Your eyelid is red and swollen."
Study online at https://quizlet.com/_hrwy9k
1. A nurse receives a shift report and is preparing to care for clients assigned on
a medicalsurgical unit. Which client should the nurse plan to assess first?
A) The client who needs assistance with activities of daily living
B) The client who needs help ambulating to the bathroom
C) The client with a pain rating of 3/10
D) The client experiencing shortness of breath: D
2. 2) A client with congestive heart failure (CHF) is having difficulty breathing.
Before leaving the room, the nurse ensures the client has an overbed table
to lean on when awake if needed to ease breathing. Which technique did the
nurse use to make this decision? A) Delegating a task
B) Priority setting
C) Conflict resolution
D) Critical thinking: D
3. 3) A postoperative client prescribed pain medication every 4 to 6 hours is
requesting medication every 6 hours. At 4 hours the client's pain level is 8 on
a rating scale of 1 to 10. The nurse decides to give the pain medication now.
What does this nurse's action exemplify?
A) Meeting a client goal
B) Time management skills
C) Prioritizing the client's care
D) Responding to a change in the client's condition: D
4. 4) The nurse is assigned two clients. One client needs postoperative teaching
in preparation for discharge, and the other client with pneumonia has a PaCO2
of 85. Why does the nurse decide to see the client with pneumonia first?
A) The nurse can delegate postoperative teaching to unlicensed assistive per-
sonnel (UAP).
B) The client with pneumonia needs more care than the client needing postop-
erative teaching.
C) The client with pneumonia may be experiencing respiratory distress.
D) The room of the client with pneumonia is closer than that of the client
needing postoperative teaching: C
, Exam 1 N112
Study online at https://quizlet.com/_hrwy9k
5. 5) The urgent care clinic nurse is treating a client who is experiencing abdom-
inal pain. The client states, "I think I ate tainted food last night." What should
the nurse do after the client states that the food was tainted?
A) Ask the client open-ended questions to further assess the situation.
B) Tell the client the healthcare provider does not need to assess the client.
C) Call an ambulance before assessing the client any further.
D) Advise the client to take an antacid.: A
6. 6) A client with aspiration pneumonia is diaphoretic, pale, and taking gasping
breaths. Which is the priority nursing action?
A) Notify the healthcare provider.
B) Complete a thorough cardiopulmonary assessment.
C) Administer 10 L of oxygen per face mask.
D) Reposition the client to help with breathing.: B
7. 7) The home health nurse is visiting a client who is 2 weeks postoperative from
a coronary artery bypass surgery. The client has lost 10 pounds, is continuing
to experience pain, and is not eating. What should be the nurse's next action?
A) Examine the current interventions for pain relief.
B) Refer the client to social services.
C) Contact Meals on Wheels so that the client will eat.
D) Revise the goals in the current plan of care.: A
8. 8) The nurse is caring for an older adult client with decreased energy who
needs to get up to prevent the development of pressure ulcers. The client is
unable to ambulate and wants to be alone. What should the nurse do?
A) Notify the healthcare provider of the client's noncompliance.
B) Leave the client alone until ready to get out of bed.
C) Gain knowledge about the client from family to gain compliance. D) Proceed
to get help to get the client out of bed.: C
9. 9) The nurse is caring for an older school-age client who is sleeping when the
menu choices for dinner are brought to the room. Which intervention should
the nurse use to meet the dietary needs of this client?
A) Wake the child to choose a meal for dinner.
B) Order chicken nuggets because most children like this meal.
, Exam 1 N112
Study online at https://quizlet.com/_hrwy9k
C) Ask the dietary worker to come back later.
D) Ask the parents to bring dinner from home for the client.: C
10. 10) A client asks the student nurse to explain the pathophysiology of dia-
betes. The student nurse does not know the answer to this question. What
should the student respond to the client? A) "I do not know, but I will find out."
B) "You'll have to ask the doctor that question." C) "Why do you need to know
that?" D) "I do not know.": A
11. 11) A novice nurse is planning care for an older adult client with a wound
infection and systemic blood infection. The nurse completes the plan of care
and decides to complete which action to enhance the skill of critical thinking?
A) Discuss the plan with the physician.
B) Request that the client review the plan.
C) Request a review of the plan with the nurse's preceptor.
D) Place the plan on the client's chart.: C
12. 12) The nurse is taking the time to reflect on a care situation in which a client
sustained a cardiac arrest and died. On which areas should the nurse focus
when performing this reflection? Select all that apply.
A) Things that could have been done differently
B) Gut reactions to the situation
C) Things that were done well
D) Resources that were used at the time
E) Resources that were needed but not available: A, C, D, E
13. 13) A client begins to vomit blood. The nurse immediately measures the
blood pressure and prepares to insert a nasogastric tube while directing others
to notify the healthcare provider and prepare to perform iced saline lavage.
Which features of the Tanner Clinical Judgment Model did this nurse demon-
strate? Select all that apply.
A) Presencing
B) Noticing
C) Reflecting
D) Interpreting
E) Responding: B, D, E
, Exam 1 N112
Study online at https://quizlet.com/_hrwy9k
14. 14) The nurse who uses clinical decision making to start CPR on a client is
concerned about what other nursing concept?
A) Cognition
B) Perfusion
C) Thermoregulation
D) Acid-base balance: B
15. 1) During a health history, a client becomes upset because the nurse is
asking many questions. Which response by the nurse is the most appropriate
in this situation?
A) "I use the answers to determine your current health needs."
B) "I am sorry the questions disturb you."
C) "I will skip the questions that bother you."
D) "I cannot help you if you do not answer me.": A
16. 2) The nurse is conducting a class for a group of expectant mothers regard-
ing basic infant care techniques. What goal will allow the nurse to best evaluate
the mothers' learning?
A) The mothers will be able to set goals for the next class session.
B) The mothers will be able to pass a written test on how to bathe a newborn
infant.
C) The mothers will be able to review the major points of the class. D) The
mothers will be able to provide a return demonstration of a bath on a newborn
doll.: D
17. 3) A goal of care for a client with congestive heart failure (CHF) is for serum
sodium levels to be within normal limits. Which information documented in the
medical record would indicate that the client is not meeting this goal?
A) The client is experiencing dependent edema.
B) The client experiences joint pain.
C) The client is constipated.
D) The client is experiencing wheezing respirations.: A
18. 4) The nurse is collecting data about a client's current health status. Which
statement would assist in gathering subjective data about the client?
A) "Your eyelid is red and swollen."
