MCQs Chapter 10 (Nursing)

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MCQs no 451 t- 500

  1. Which of the following statements best describes a wellness nursing diagnosis for an individual, family, or community?
    1. clinical judgment of transition to a higher level of wellness
    2. nursing judgment that in some area no pathology exists
    3. a judgment that in some area there is more wellness than illness
    4. statement of an area of family strength to use in interventions
  2. When reading the nursing-care plan of a newly assigned client prior to caring for this client, the LPN/LVN will notice that potential problems are stated using how many parts in the statement?
    1. One
    2. Two
    3. Three
    4. Four
  3. The physician writes an order for “progressive ambulation, as tolerated.” The RN writes an order for “Dangle for 5 min. 12 h post op and stand at bedside 24 h post op.” The LVN assigned to care for this client should do which of the following?
    1. Call the physician for clarification of the ambulation orders.
    2. Check with the State Board of Nursing for an opinion.
    3. Check client’s vital signs before dangling or standing client.
    4. Dangle or stand client only if they are agreeable to this.
  4. When does the nurse chart an intervention that involves administering medication to a client?
    1. before the end of shift
    2. before the next dose of medication or treatment is due
    3. within one hour
    4. Immediately
  5. When writing goals/outcomes for clients, the nurse should do which of the following?
    1. Combine related diagnoses and write a goal or goals for this set.
    2. Write goals that the treatment team believes are important.
    3. Involve the client in determining the goals/desired outcomes.
    4. Combine no more than two nursing diagnoses per goal.
  6. The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?
    1. chest pain related to cough secondary to pneumonia
    2. self-care deficit related to activity intolerance secondary to sleep-pattern disturbance
    3. risk for altered family processes secondary to hospitalization
    4. self-esteem deficit situational
  7. Which of the following activities on the part of the nurse most demonstrates individualization of the nursing-care plan for a client?
    1. A. Include client’s preferred times of care and methods used.
    2. Write the care plan instead of taking it off the computer.
    3. Use a care plan from a book but add some things to it.
    4. Select nursing diagnoses that match the client’s problems
  8. You are doing the evaluation step of the nursing process and find that two of the goals for the client have not been met. Which of the following actions would be best on your part?
    1. Stop working on these goals, as evaluation is the last step.
    2. Assess client’s motivation for complying with the care plan.
    3. Reassess problem and then review care plan and revise as needed.
    4. Determine if the client has a knowledge deficit causing nonattainment.
  9. When you discover an electrical fire and decide you need a fire extinguisher, you will need to find a fire extinguisher that is rated for which class of fire?
    1. Class A
    2. Class B
    3. Class C
    4. Class E
  10. Which of the following statements is an OBRA regulation that the nurse must keep in mind when considering applying a restraint to a client?
    1. Apply physical restraints as a first-choice intervention in fall prevention.
    2. The physician’s order for restraints must be time limited.
    3. Verbal or telephone orders for restraints must be signed within 72 hours.
    4. Restraints cannot be applied if a family member objects.
  11. When restraining a client in bed with a sleeveless jacket (vest) with straps, you will do which of the following things?
    1. Tie the straps to the side rails.
    2. Tie the straps to the movable part of the bed frame.
    3. Tie the straps with a square knot.
    4. Tie the straps with a quick-release knot.
  12. When you encounter the victim of an electrical-current injury who is still holding an electrical appliance, you would do which of the following things first?
    1. Move the client to a safe place immediately.
    2. Unplug the electrical cord before moving client.
    3. Shut off the electrical current.
    4. Check for a carotid pulse and for respirations.
  13. When instructing the family of a client who has diabetes with neuropathy causing impaired skin sensitivity, you would stress the importance of which one of the following things in regard to showering or bathing?
    1. cleaning the tub or shower with full-strength peroxide
    2. drying well after the shower or bath
    3. applying lotion after the shower or bath
    4. a method for assuring the water temperature is not hot
  14. The nurse finds that an assigned client is restless, agitated, and confused and is thinking of restraining the client. Which of the following questions is most important for the nurse to ask?
    1. “Which restraint is most appropriate?”
    2. “Will I be able to get an order for a restraint?”
    3. “What is the underlying cause of the restless, agitated, confused behavior?”
    4. “Could I try some medication to relax the client prior to using restraints?”
  15. The nurse giving discharge instructions advises the client to get out of bed slowly and to get up in stages from lying to sitting to standing. The client understands that the reason for doing this is:
    1. to prevent falls.
    2. to improve circulation.
    3. as a warm-up exercise.
    4. to increase oxygenation.
  16. Which of the following interventions on the part of the nurse would most help a confused ambulatory client find their room?
    1. having large room numbers on the door
    2. placing a picture on the door
    3. giving hourly reorientation to the correct room
    4. pinning the client’s room number on their attire
  17. When assessing the noise level that clients are exposed to, the nurse is aware that levels below which of the following number of decibels is usually safe in terms of hearing?
    1. 85
    2. 95
    3. 110
    4. 120
  18. One of your assigned clients who is scheduled for radiation therapy asks you to stay with her during radiation because she is scared. Your best response to this request would be which of the following responses?
    1. “Let’s think of how to reduce your fear, as I must stay a distance away.”
    2. “I will be right there with you, and I will hold your hand so you won’t be afraid.”
    3. “It is not necessary to be afraid, as nothing bad will happen to you.”
    4. “I will see if I can get permission from your doctor and the X-ray department.”
  19. A true pathogen will cause disease or infection:
    1. in a healthy person.
    2. only in an immuno-compromised person.
    3. in persons with allergy to the pathogen.
    4. in very few people.
  20. A client asks you to explain viruses. Which of the following statements would be true and therefore best to include in your answer?
    1. “Viruses are the most common agent causing infection.”
    2. “Viruses are commonly found in the intestinal tract.”
    3. “Viruses must enter into living cells to reproduce.”
    4. Candida is one of the most common viruses.”
  21. The nursing supervisor has asked the staff to reduce the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing iatrogenic infections?
    1. teaching correct hand washing to assigned clients
    2. using correct procedures in starting and caring for an intravenous infusion
    3. properly bagging soiled linens and disposed items used for a client in isolation
    4. isolating a client who has just been diagnosed as having tuberculosis
  22. Your assigned client has encephalitis, and there are other cases in the community. In a team meeting regarding your client and prevention of other cases of encephalitis, the nurse supervisor talks about breaking the chain of infection at the second link: the reservoir. You realize the nurse supervisor is talking about which of the following things?
    1. an area for the storage and filtering of water
    2. a place where the microorganism enters the body
    3. the place where the microorganism naturally lives
    4. the microorganism itself
  23. On a home visit, you notice some dust on a vent in your client’s room and on the windowsill. Which of the following methods would you teach the family to use for removing dust?
    1. Use a damp cloth to remove the dust.
    2. Use a feather duster to remove dust.
    3. Vacuum up the dust.
    4. Use a broom covered with a cloth.
  24. A client asks you how to best prevent vaginal infections. Your best answer would include which of the following statements?
    1. “I would suggest a vinegar douche.”
    2. “The pH of the vaginal secretions stops many disease-producing bacteria.”
    3. “Drinking cranberry juice will prevent most all of the vaginal infections.”
    4. “Your doctor can prescribe a medication that will prevent vaginal
    5. E. infections.”
  25. You would refer to the early phase of scar tissue formation as which of the following kinds of tissue?
    1. Keloid
    2. Cicatrix
    3. granulation
    4. Fibrous
  26. 58 . Which of the following situations represents the best example of passive immunity?
    1. A. a child receiving a vaccination for measles
    2. B. an infant receiving breast milk from the mother
    3. C. production of antibodies by a person with infection
    4. D. a person receiving antibiotics for an infection
  27. You are working with a client who has cancer and is undergoing treatment. The client complains of a loss of appetite. You will most need to make certain that your client eats which one of the following foods?
    1. fresh fruits
    2. raw vegetables
    3. carbohydrates
    4. Protein
  28. Your assigned client has a leg ulcer that has a dressing on it. During your assessment, you find that the dressing is wet. The client admits to spilling water on the dressing. What action would be best on your part?
    1. Reinforce the dressing with a dry dressing.
    2. Remove wet dressing and apply new dressing.
    3. Dry the dressing with a hair dryer.
    4. Let the room air dry the dressing.
  29. A fellow nurse who is working on another unit asks to read the chart of your assigned client. Which one of the following criteria would enable the nurse to have access to the chart?
    1. Be unrelated to the client.
    2. Have a current nursing license.
    3. Have client’s verbal permission.
    4. Be directly involved in client’s care.
  30. When charting in the client’s record or chart, the nurse most needs to do which one of the following things?
    1. Date and sign each entry.
    2. Chart every two hours.
    3. Use ballpoint pen and not pencil.
    4. Cross out errors so others can’t read them.
  31. While giving a shift report on your assigned client, you realize that you forgot to record a nursing procedure done on your client. Which of the following methods of documentation would be best on your part?
    1. Write the procedure between the two lines of your shift documentation closest to the occurrence.
    2. Find a blank space in your earlier charting, and chart the procedure in that space.
    3. Tell the oncoming nurse to chart the procedure for you and to cite the time it was done.
    4. Chart the current date and time and “Late entry,” indicating when and what was done.
  32. One of your assigned clients gets up to go to the bathroom without calling you. The client falls to the floor and calls for help. You answer the call and alert your supervisor. After assuring that the vital signs are normal and there does not appear to be any injuries, you are told to fill out an incident report. In addition to noting that the client was found on the floor, which of the following statements would you most need to record in the nursing notes for the client?
    1. “Incident report completed.”
    2. the reason the client was unattended
    3. the vital signs and assessment of the client
    4. location of the incident report
  33. When the physician telephones to order a therapy such as a medication for the client of a student nurse, who is the best person to take this telephone order?
    1. whoever is authorized by hospital policy
    2. the student nurse giving the client’s care
    3. the student nurse’s instructor
    4. any licensed nurse on duty
  34. The nurse is sending some lab results to the primary physician’s office. The nurse most needs to do which of the following things?
    1. Make a note that the fax was sent and what time it was sent in the nurses’ notes.
    2. Document a follow-up telephone call verifying the receipt of information and who received it.
    3. Leave a note to the physician in the client’s record saying what information was faxed and when.
    4. Check with the laboratory to see if they have already provided the physician with the results.
  35. In the Problem Oriented Medical Record documentation system (POMR), which of the following answers best represents the person or persons who may contribute to the problem list representing the client’s physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs?
    1. the primary nurse
    2. the assigned social worker
    3. registered nurses and the physician
    4. all caregivers
  36. When working in a facility that uses focus charting, the nurse will use which of the following as a focus of care?
    1. problems identified in the initial assessment
    2. maximum level of functioning
    3. client identified goals and objectives
    4. client concerns and strengths
  37. When the nurse’s assigned client is being discharged to another institution or a home setting where a visit by the community health nurse is required, which of the following information is most likely to be included in the discharge and referral summaries?
    1. unresolved health-care problems and continuing care needs
    2. an assessment of the family’s financial assets and deficits
    3. a copy of the discharge order signed by the physician
    4. a new plan of care for the client and the family
  38. Which of the following words represents the basic unit of all life and is the simplest structure that possesses all the characteristics of life: organization, metabolism, responsiveness, homeostasis, growth, and reproduction?
    1. the cell
    2. a gene
    3. a chromosome
    4. the organelles
  39. Which of the following cells of the body are in almost constant mitosis?
    1. nerve cells
    2. stomach cells
    3. muscle cells
    4. renal cells
  40. Where is ribosomal RNA used in protein synthesis produced?
    1. organelles
    2. mitochondria
    3. Golgi apparatus
    4. Centrioles
  41. Tissue in the urinary bladder called transitional epithelium is best described in which of the following ways?
    1. changes from cuboidal to columnar
    2. are single layer and not stratified
    3. ontain a special elastic substance to aid in expansion
    4. change shape depending on the bladder’s fullness
  42. When teaching someone about endocrine glands, which of the following statements could you use?
    1. “The endocrine glands include sweat and sebaceous glands.”
    2. “Endocrine glands all have at least one duct.”
    3. “Hormones are carried away from the endocrine gland by the blood.”
    4. “There is no epithelial tissue in endocrine glands.”
  43. The vocal cords have and function with which of the following kinds of tissue?
    1. liquid connective tissue
    2. hard connective tissue
    3. fibrous connective tissue
    4. Soft connective tissue
  44. The thoracic and abdominopelvic cavities are divided by which of the following body structures?
    1. rib cage
    2. diaphragm
    3. sternum
    4. Stomach
  45. The body’s biggest organ is which of the following components of the body?
    1. large intestine
    2. the skin
    3. small intestine
    4. Kidneys
  46. The skeletal system acts as a storehouse for calcium, which is a very important component in muscle contractions, as well as which of the following activities in the body?
    1. producing testosterone
    2. preventing seizures
    3. making lymph
    4. blood clotting
  47. When reading an autopsy report, the nurse encounters the term “mid-sagittal plane.” This nurse understands that this means the body was viewed using a plane that matched which of the following descriptions?
    1. This plane cuts the body horizontally.
    2. This plane divides the body into front and back portions.
    3. The body is separated into left and right equal portions.
    4. The body is divided using an X across the chest.
  48. The nurse receives a report at the beginning of the shift and learns that the client scores 7 on the Glasgow Coma Scale. The nurse realizes that this client is at which of the following levels of consciousness?
    1. comatose
    2. moderate disability
    3. severe disability
    4. fully alert
  49. You partially darken a room and ask the client to look straight ahead. You use a penlight and, approaching from the side you shine the light, it constricts. You remove the light and then shine it on the same pupil again. You also observe the response of the other pupil. You would normally find the other pupil doing which of the following things?
    1. not make any change in size
    2. dilate in an oppositional response to the light
    3. first constrict, then dilate larger than the other pupil
    4. constrict in consensual response
  50. The nurse is preparing to do a focused assessment of the abdomen on an assigned client. Which of the following is most important for the nurse to do prior to the examination?
    1. Have client empty their bladder.
    2. Gather equipment.
    3. Place client in semi-Fowler’s position.
    4. Remove any dressings from abdomen.

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