questions and answers
During a routine vital sign assessment, the nurse notes the client's blood pressure is 212/110.
Why is this finding particularly significant? - ANSWER>>It deviates from normal and is
significant.
The normal adult temperature obtained through the oral route ranges from: -
ANSWER>>97.6°F to 99.6°F (36.4°C to 37.6°C).
To assess the client's pulse, the nurse knows the normal range for pulse rate of a healthy
adult is: - ANSWER>>60 to 100 beats per minute.
Infants and children's pulses vary most with: - ANSWER>>Respirations
An ultrasonic Doppler is used for: - ANSWER>>Auscultating a pulse that is difficult to palpate.
An adult pulse greater than 100 beats per minute is: - ANSWER>>Tachycardia
A client has smoked most of his life and has labored respirations. He is experiencing: -
ANSWER>>Dyspnea
Which outcome best reflects achievement of the goal, "The client will demonstrate correct
steps in taking his own pulse rate"? - ANSWER>>Palpation of the radial pulse on the thumb
side of the inner aspect of the wrist.
What is the most common reason people contact healthcare providers? -
ANSWER>>infectious disease
The nurse performs hand hygiene with soap and water before caring for a client. What is the
primary rationale for this action? - ANSWER>>To eliminate disease-producing organisms from
the nurse's skin
A nursing student presents to the university health center reporting a sore throat, malaise,
and loss of appetite. The nurse assesses the student and determines he or she has large,
,white-yellow exudates in the back of the throat and a fever. The student is presenting with: -
ANSWER>>An infectious disease
When a nurse picks up a client's contaminated tissue without gloves and fails to wash the
hands sufficiently, the nurse provides for the client's organisms to be spread by which type of
transmission? - ANSWER>>Contact
What is the most common client site for development of healthcare-associated infections
(HAl)? - ANSWER>>UTI
When the client who has been diagnosed with hepatitis B has been hospitalized, the type of
isolation the nursing staff should observe is: - ANSWER>>Droplet precautions.
A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus
aureus (MRSA) infection at the surgical site. What is the most important factor to prevent this
infection? - ANSWER>>Surgical asepsis
The nurse explains to the client that the first line of defense against infection is: -
ANSWER>>Intact skin and mucous membranes.
When a female African American adolescent client asks the nurse how to care for her long
hair, which is braided into small braids, the nurse should instruct the client that: -
ANSWER>>Hair should be washed as often as necessary
A new mother has brought her infant into the pediatric clinic. The infant has an excoriation
on the buttocks. What should the nurse instruct the mother? - ANSWER>>Keep the diaper
and buttocks clean and dry and apply zinc oxide.
The nurse is caring for a woman who informs the nurse that she needs assistance to remove
and clean her glass eye. What actions by the nurse are most appropriate to accomplish the
task? - ANSWER>>Pull down on the lower lid and exert slight pressure below the lid.
A parent reports that their water is not fluoridated and questions the nurse whether her 9-
year-old child needs fluoride supplements. Which response by the nurse is most appropriate?
- ANSWER>>In the absence of fluoridated water supplies, supplementation is recommended
, What is the primary goal of the planning phase of the nursing process? - ANSWER>>The third
step of the nursing process; the nurse prioritizes diagnoses, formulates desired goals, and
selects nursing interventions.
A nurse is conducting an assessment of a client. Which information would the nurse identify
as a primary source? - ANSWER>>The client is the primary source of information
A nursing student is developing interpersonal skills. Which method would best facilitate this
type of learning? - ANSWER>>Participating in communication courses.
In order to implement the most effective care for clients what is the most appropriate action
for the student to take? - ANSWER>>Apply theoretical knowledge to present clinical
situations.
A client has been discharged from an acute care facility. The first task a home health nurse
must accomplish is: - ANSWER>>Coordinating future care for the client
The nurse observes the client while walking into the room. What information will this provide
the nurse? - ANSWER>>Information regarding the client's gait
Which cultural group may interpret touch by another as an invasion of privacy? -
ANSWER>>Chinese
The home care nurse is preparing to perform a nursing history on a newly assigned adult
client with a venous stasis ulcer. Which statement by the nurse is most accurate? -
ANSWER>>"I would like to schedule a time for me to perform a nursing history. It will take
around 30 to 60 minutes."
While performing the nursing history, the nurse notes that the client reports having very little
pain but is occasionally grimacing and rubbing one shoulder throughout the interview. The
nurse acknowledges this behavior, questions the client, and then proceeds with other phases
of the interview. This action takes place during which phase of the nursing interview? -
ANSWER>>Maintenance
When making an inference from the cues obtained during an assessment, it is important for
the nurse to keep what in mind? - ANSWER>>Validate inferences with the patient