N400 Exam 3

Front 1

Your client has a Braden scale score of 17. Which is the appropriate nursing action?
1. Assess the client again in 24 hours; the score is within normal limits.
2. Implement a turning schedule; the client is at increased risk of skin breakdown.
3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk of skin breakdown.
4. Request an order for a special low-air-loss bed; the client is at very high risk of skin breakdown.

Back 1

2. Implement a turning schedule; the client is at increased risk of skin breakdown.

Rationale: A score ranging from 15-18 is considered at risk and a turning schedule is appropriate.

Front 2

Proper technique for performing a wound culture includes which of the following?
1. Cleansing the wound prior to obtaining the specimen.
2. Swabbing for the specimen in the area with the largest collection of drainage.
3. Removing crusts or scabs with sterile forceps and then culturing the site beneath.
4. Waiting 8 hours following a dose of antibiotic to obtain the specimen.

Back 2

1. Cleansing the wound prior to obtaining the specimen.

Rationale: Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for the infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client the discomfort of debriding. The nurse does not generally debride the wound to obtain a specimen. Once systemic antibiotics have been begun, the interval following a dose will not significantly affect the concentration of wound organisms.

Front 3

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing?
1. Alginate
2. Dry Gauze
3. Hydrocolloid
4. No dressing is indicated

Back 3

3. Hydrocolloid

Rationale: Hydrocolloid dressing protect shallow ulcers and maintain an appropriate healing environment. Alginates are used for wounds with significant drainage; dry gauze will stick to new granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance healing.

Front 4

Thirty minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains to the client that:
1. Heat application for longer than 30 min can actually cause the opposite effect (constriction) of the one desired (dilation)
2. It will be acceptable to leave the pad in place if the temperature is reduced.
3. It will be acceptable to leave the pad in place for another 30 min if the site appears satisfactory when assessed.
4. It will be acceptable to leave the pad in place as long as it is moist heat.

Back 4

1. Heat application for longer than 30 min can actually cause the opposite effect (constriction) of the one desired (dilation)

Front 5

Which statement, if made by the client or family member would indicate the need for further teaching?
1. If a skin area gets red but then the red goes away after turning, I should report it to the nurse.
2. Putting foam pads under the heels or other bony areas can help decrease pressure.
3. If a person cannot turn himself or herself in bed, someone should help the person change position every 4 hours.
4. The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.

Back 5

3. If a person cannot turn himself or herself in bed, someone should help the person change position every 4 hours.

Rationale: Patient should be turned every 2 hours.

Front 6

An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is
1. Risk for impaired skin integrity.
2. Impaired skin integrity
3. Impaired tissue integrity
4. Risk for infection

Back 6

2. Impaired skin integrity

Rationale: This client has an actual impairment of the integrity of the skin due to the rash and the scratching so is no longer "at risk"

Front 7

Which of the following are primary risk factors for pressure ulcers? Select all that apply.
1. Low-protein diet
2. Insomnia
3. Lengthy surgical procedures
4. Fever
5. Sleeping on a waterbed.

Back 7

1,3,4

Front 8

Which of the following items are used to perform wound irrigation? Select all that apply.
1. Clean gloves
2. Sterile gloves
3. Refrigerated irrigating solution
4. 60-mL syringe

Back 8

1,2,4

Front 9

Which of the following indicates proper use of a triangle arm sling?
1. The elbow is kept flexed at 90 degrees or more.
2. The knot is placed on either side of the vertebrae of the neck.
3. The sling extends to just proximal of the hand.
4. Remove the sling every 2 hours to check for circulation and skin integrity.

Back 9

2. The knot is placed on either side of the vertebrae of the neck.

Rationale: the knot must be kept off the spinal cord because this would be uncomfortable and put unnecessary pressure on the vertebrae.

Front 10

To increase stability during client transfer, the nurse increases the base of support by performing which action?
1. Leaning slightly backward
2. Spacing the feet farther apart
3. Tensing the abdominal muscles
4. Bending the knees

Back 10

2. Spacing the feet farther apart.

Front 11

Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply.
1. Increase muscle tone and improve circulation.
2. Increase BP
3. Increase muscle mass and strength.
4. Decrease heart rate and cardiac output
5. Maintain joint range of motion.

Back 11

1. Increase muscle tone and improve circulation.
3. Increase muscle mass and strength.
5. Maintain joint range of motion.

Front 12

Five minutes after the client's first postoperative exercise, the client's vital signs have not yet returned to baseline. Which is an appropriate nursing diagnosis?
1. Activity intolerance
2. Risk for activity intolerance
3. Impaired physical mobility
4. Risk for disuse syndrome

Back 12

1. Activity intolerance

Front 13

Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching?
1. "Going up, the strong leg goes first, then the weaker leg with both crutches."
2. "Going down, the weaker leg goes first with both crutches, then the strong leg."
3. "The weaker leg always goes first with both crutches."
4. "A cane or single crutch may be used instead of both crutches if held on the weaker side."

Back 13

3. "The weaker leg always goes first with both crutches."

Front 14

A nurse is teaching a client about active ROM. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following?
1. Exercises past the point of resistance.
2. Performs each exercise one time.
3. Performs each series of exercises once a day.
4. Uses the same sequence during each exercise session.

Back 14

4. Uses the same sequence during each exercise session.

Front 15

When assessing a client's gait, which does the nurse look for and encourage?
1. The spine rotates, initiating locomotion.
2. Gaze is slightly downward.
3. Toes strike the ground before the heel.
4. Arm on the same side as the swing-through foot moves forward at the same time.

Back 15

1. The spine rotates, initiating locomotion.

Front 16

Performance of ADL's and active ROM can be accomplished simultaneously as illustrated by which of the following? Select all that apply.
1. Elbow flexion with eating and bathing.
2. Elbow extension with shaving and eating
3. Wrist hyperextension with writing
4. Thumb ROM with eating and writing
5. Hip flexion with walking

Back 16

1. Elbow flexion with eating and bathing.
4. Thumb ROM with eating and writing
5. Hip flexion with walking

Front 17

A client weighs 250lbs and needs to be transferred from the bed to a chair. Which instruction by the nurse to the UAP is most appropriate?
1. "Using proper body mechanics will prevent you from injuring yourself."
2. "You are physically fit and at lesser risk for injury when transferring the client."
3. "Use the mechanical lift and another person to transfer the client from the bed to the chair."
4. "Use the back belt to avoid hurting your back."

Back 17

3. "Use the mechanical lift and another person to transfer the client from the bed to the chair."

Front 18

The client is ambulating for the first time after surgery. The client tells the nurse, "I feel faint." which is the best action by the nurse?
1. Find another nurse for help.
2. Return the client to her room as quickly as possible.
3. Tell the client to take rapid, shallow breaths.
4. Assist the client to a nearby chair.

Back 18

4. Assist the client to a nearby chair.

Front 19

The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action?
1. Heart rate 86
2. Reddened area on sacrum
3. Nonproductive cough
4. Urine output of 50mL/hour

Back 19

2. Reddened area on sacrum.

Rationale: It can lead to skin breakdown.

Front 20

A client has a history of sleep apnea. Which is the most appropriate question for the nurse to ask?
1. Do you have a history of cardiac irregularities?
2. Do you have a history of any kind of nasal obstruction?
3. Have you had chest pain with or without activity?
4. Do you have difficulty with daytime sleepiness?

Back 20

4. Do you have difficulty with daytime sleepiness?

Front 21

Because of significant concerns about financial problems a middle-aged client complains of difficulty sleeping. Which outcome would be the most appropriate for the nursing care plan? "By day 5, the client will:
1. Sleep 8-10 hours per day"
2. Report falling asleep within 20-30 min"
3. Have a plan to pay all the bills"
4. Decrease worrying about financial problems and will keep busy until bedtime."

Back 21

2. Report falling asleep within 20-30 minutes.

Front 22

A client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. Which statement is the most appropriate advice for the nurse to provide the client?
1. Take the last pill on a Friday night so disrupted sleep can be compensated on the weekend.
2. Continue to take the pills since sleeping without them after such a long time will be difficult and perhaps impossible.
3. Discontinue taking the pills.
4. Continue taking the pills and discuss tapering the dose with the primary care provider.

Back 22

4. Continue taking the pills and discuss tapering the dose with the primary care provider.

Front 23

During a well-child visit, a mother tells the nurse that her 4 year old daughter typically goes to bed at 10:30pm and awakens each morning at 7am. She does not take a nap in the afternoon. Which is the best response by the nurse?
1. Encourage the mother to consider putting her daughter to bed between 8 and 9pm.
2. Reassure the mother that it is normal for 4 year olds to resist napping, but encourage her to insist that she rest quietly each afternoon.
3. Recommend that her daughter be allowed to sleep later in the morning.
4. Reassure her that her daughter's sleep pattern is normal and that she has outgrown her need for an afternoon nap.

Back 23

1. Encourage the mother to consider putting her daughter to bed between 8 and 9pm.

Rationale: A preschooler needs at least 10-12 hours of sleep.

Front 24

A college student was referred to the campus health service because of difficulty staying awake in class. What should be included in the nurse's assessment? Select all that apply.
1. Amount of sleep he usually obtains during the week and weekends.
2. How much alcohol he usually consumes.
3. Onset and duration of symptoms
4. Whether or not his classes are boring.
5. What medications, including herbal remedies, he is taking.

Back 24

1. Amount of sleep he usually obtains during the week and weekends.
3. Onset and duration of symptoms
5. What medications, including herbal remedies, he is taking.

Front 25

During a yearly physical, a 52 year old male client mentions that his wife frequently complains about is snoring. During the physical exam, the nurse notes that his neck size is 18 inches, his soft palate and uvula are reddened and swollen, and he is overweight. What is the most appropriate nursing intervention for the nurse to recommend to this client?
1. Recommend that he and his wife sleep in separate bedrooms so that his snoring does not disturb his wife.
2. Refer him to a dietitian for a weight loss program.
3. Caution him not to drink or take sleeping pill since they may make his snoring worse.
4. Refer him to a sleep disorders center for evaluation and treatment of his symptoms.

Back 25

4. Refer him to a sleep disorders center for evaluation and treatment of his symptoms.

Front 26

A new nursing graduate's first job requires 12 hour night shifts. Which strategy will make it easier for the graduate to sleep during the day and remain awake at night?
1. Wear dark wrap-around sunglasses when driving home in the morning, and sleep in a darkened bedroom.
2. Exercise on the way home to avoid having to stand around waiting for equipment at the gym.
3. Drink several cups of strong coffee or 16oz of caffeinated soda when beginning the shift.
4. Try to stay in a brightly lit area when working at night.

Back 26

1. Wear dark wrap-around sunglasses when driving home in the morning, and sleep in a darkened bedroom.

Front 27

The nurse is answering questions after a presentation on sleep at a local senior citizens center. A woman in her late 70s asks for an opinion about the advisability of allowing her husband to nap for 15-20 min each afternoon. Which is the nurse's best response?
1. "Taking an afternoon nap will interfere with his being able to sleep at night. If he's tired in the afternoon, see if you can interest him in some type of stimulating activity to keep him awake."
2. "He shouldn't need to take an afternoon nap if he's getting enough sleep at night."
3. "Unless your husband has trouble falling asleep at night, a brief afternoon nap is fine."
4. "Encourage him to consume coffee or some other caffeinated beverage at lunch to prevent drowsiness in the afternoon."

Back 27

3. "Unless your husband has trouble falling asleep at night, a brief afternoon nap is fine."

Rationale: If a person has difficulty sleeping at night, a 15-20 min nap is okay.

Front 28

During admission to a hospital unit, the client tells the nurse that her sleep tends to be very light and that it is difficult for her to get back to sleep if she's awakened at night. Which interventions should the nurse implement? Select all that apply.
1. Remind colleagues to keep their conversation to a minimum at night.
2. Encourage the client to ask family members to bring in a fan to provide white noise.
3. Increase the temperature in the room.
4. Encourage the client's family members to bring in a radio to play soft music at night.
5. Deliver necessary meds and procedures at 1.5-3 hour intervals between 11pm and 6am

Back 28

1. Remind colleagues to keep their conversation to a minimum at night.
2. Encourage the client to ask family members to bring in a fan to provide white noise.
3. Increase the temperature in the room.

Front 29

To prevent postoperative complications, the nurse assists the client with coughing and deep-breathing exercises. This is best accomplished by implementing which of the following?
1. Coughing exercises 1 hour before meals and deep breathing 1 hour after meals.
2. Forceful coughing as many times as tolerated.
3. Huff coughing every 2 hours or as needed.
4. Diaphragmatic and pursed lip breathing 5-10 times, 4 times a day.

Back 29

2. Huff coughing every 2 hours or as needed.

Rationale: helps keep the airways open and secretions mobilized.

Front 30

The nurse is preparing to perform tracheostomy care. Prior to beginning the procedure the nurse performs which action?
1. Tells the client to raise two fingers to indicate pain or distress
2. Changes the twill tape holding the tracheostomy in place.
3. Cleans the incision site.
4. Checks the tightness of the ties and knot.

Back 30

1. Tells the client to raise two fingers to indicate pain or distress

Front 31

Which action by the nurse represent proper nasopharyngeal/nasotracheal suction technique?
1. Lubricate the suction catheter with petroleum jelly before and between insertions.
2. Apply suction intermittently while inserting the suction catheter.
3. Rotate the catheter while applying suction.
4. Hyperoxygenate with 100% Oxygen for 30 min before and after suctioning.

Back 31

3. Rotate the catheter while applying suction.

Front 32

Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective?
1. "I should breathe out as fast and hard as possible into the device."
2. "I should inhale slowly and steadily to keep the balls up."
3. "I should use the device three times a day, after meals."
4. "The entire device should be washed thoroughly in sudsy water once a week."

Back 32

2. I should inhale slowly and steadily to keep the balls up.

Front 33

While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by the nurse is most appropriate?
1. Assist the client to ambulate back to bed.
2. Reconnect the tube to the water seal.
3. Assess the client's lung sounds with a stethoscope.
4. Have the client cough forcibly several times.

Back 33

2. Reconnect the tube to the water seal.

Front 34

The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has
1. Anemia
2. An infection
3. A fractured rib
4. A tumor of the medulla

Back 34

1. Anemia

Hemoglobin transports oxygen.

Front 35

A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. the nurse responds by saying that the corticosteroids will do which of the following?
1. Promote bronchodilation
2. Help the client to cough
3. Prevent respiratory infection
4. Decrease inflammation in the airways.

Back 35

4. Decrease inflammation in the airways.

Front 36

The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the client's care?
1. Percussion and postural drainage should be done before lunch.
2. The order should be coughing, percussion, positioning, and then suctioning.
3. A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested.
4. Percussion and postural drainage should always be preceded by 3 minutes of 100% oxygen.

Back 36

1. Percussion and postural drainage should be done before lunch.

Front 37

The home health nurse has developed a teaching guide for a client with cardiovascular risk factors that focuses on the importance of regular physical activity with gradually increasing activity levels. This teaching guide specifically promotes which topic?
1. Cardiac output and tissue perfusion.
2. Renal perfusion and formation of urine.
3. Oxygen-carrying capacity of WBC
4. Effective breathing and airway clearance.

Back 37

1. Cardiac output and tissue perfusion

Front 38

Which would most likely be included in the evaluation of the client goal of "Demonstrate adequate tissue perfusion"?
1. symmetrical chest expansion
2. use of pursed-lip breathing
3. brisk capillary refill
4. activity intolerance

Back 38

3. Brisk capillary refill

Front 39

Which client is most likely to experience poor cardiac output?
1. A client who has recently completed exercising and is talking easily with an exercise partner.
2. A client who has a stroke volume of 70ml/beat and a HR of 70beats/min
3. A client with a sustained HR of 150beats/min
4. A client who receives a positive inotropic medication.

Back 39

3. A client with a sustained HR of 150beats/min

Front 40

Which set of assessment data best validates that the nurse should initiate cardiopulmonary resuscitation on a comatose patient?
1. Cool, pale skin; unconsciousness, absence of radial pulse
2. Cyanosis, slow pulse, dilated pupils.
3. Absent pulses, flushed skin, pinpoint pupils
4. Apnea, absence of carotid or femoral pulses, dilated pupils.

Back 40

4. Apnea, absence of carotid or femoral pulses, dilated pupils.