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NUR 104 Practice Test Assessment Exam/91 Q’s and A’s
NUR 104 Practice Test Assessment Exam/91 Q’s and A’s
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NUR 104 Practice TestAssessment Exam/91 Q’s and A’s
The daughter of an older woman who became depressed following the death
of her husband asks, "My mother was always well adjusted until my father
died. Will she tend to be sick from now on?"Which response is best for the
nurse to provide? - -"It's highly likely that she will recover and return to her
pre-illness state."
-The home health, nurse visits and elderly, female client who had a stroke
three months ago, and is now able to ambulate with assistance of a quad
cane. Which assessment finding has the greatest implications for the clients
care? - -The nurse notes that there are numerous scatter rugs throughout
the house.
-What intervention should the nurse include in the plan of care for the client
who is being treated with an Unna's paste boot for leg ulcers due to chronic
venous insufficiency? - -Check, capillary refill of tools on lower extremity
with Unna's paste boot
-What client statement indicates to the nurse that the client requires
assistance with bathing? - -"I don't understand why I'm so weak and tired."
-A middle-aged woman who enjoys being a teacher and mentor, feels that
she should pass down her legacy of knowledge and skills to the younger
generation. According to Erikson, she is involved in what developmental
stage? - -Generativity.
-Which statement best describes, durable, power of attorney for healthcare?
- -The client sign the document that designates another person to make
legally binding healthcare decisions if the client is unable to do so
-Which statement is an example of a correctly written nursing diagnosis
statement? - -Ineffective coping related to response to positive biopsy test
results
-A client who has been on bed rest for several days now has a prescription
to progress activity as tolerated. When the nurse assist the client out of bed
for the first time, the client becomes dizzy. What action should the nurse
implement? - -Advise the client to sit on the side of the bed for a few
minutes before standing again
-A client is admitted with a stage four pressure ulcer that has a black,
hardened surface with a light pink warm bed with the malodorous green
, drainage. Which dressing is best for the nurse to use first? - -Wet to moist
dressing
-The charge nurse observes an unlicensed assistive personnel (UAP),
bending at the ways to live a 20 pound box of medical supplies of the
treatment room floor. What instruction should the charge nurse provide the
UAP? - -Bend at the knees when lifting heavy objects
-A female client who has breast cancer with metastasis to the liver and
spine is admitted with constant, severe pain despite around-the-clock use of
oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home.
During the admission assessment, which information is most important for
the nurse to obtain? - -Sensory pattern, area, intensity, and nature of the
pain.
-A male client arrives at the outpatient surgery center for a scheduled
needle aspiration of the knee. He tells the nurse that he has already given
verbal consent for the procedure to the healthcare provider. What action
should the nurse implement? - -Witness the client's signature on the consent
form.
-A client is demonstrating a positive Chvostek's sign. What action should the
nurse take? - -Ask the client about numbness or tingling in the hands.
-The nurse is preparing a male client who has an indwelling catheter and an
IV infusion to ambulate from the bed to the chair for the first time following
abdominal surgery. What action should the nurse implement prior to assist in
the client to the chair? (Select all that apply.) - -Pre-medicate the client with
an analgesic
Inform the client of the plan for moving to the chair
Ask the client to push the IV pole to the chair
Assess the clients blood pressure
-The nurse notes that a client consistently coughs while eating and drinking.
Which nursing diagnosis is most important for the nurse to include in the
client's plan of care? - -Risk for aspiration
-Amil, client with acquired immunodeficiency syndrome (AIDS) develops
cryptococcal meningitis, and tells the nurse that he does not want to be
resuscitated if his breathing stops. What action should the nurse implement?
- -Ask the client if this decision has been discussed with his healthcare
provider
-Well, the nurse is administering a bowl is feeding to a client via nasogastric
tube, the client begins to vomit. What action should the nurse implement
first? - -Discontinue the administration of the bolus feeding
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