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1. Upon assessment of a patient with myasthenia gravis, the nurse observes drooping of the upper
eyelids. The finding is known as:
A. Ptosis
B. Entropin
C. Ectropion
D. Miosis
2. The Nurse will obtain the greatest amount if information about the thyroid glad by using which
technique of assessment?
A. Percussion
B. Auscultation
C. Palpation
D. Inspection
3. Upon auscultation of a patient's lung fields, the nurse hears a continuous high-pitched sound on
expiration. These characteristics are most common with which of adventitious breath sounds?
A. Fine crackles
B. Wheezes
C. Pleural Friction Rub
D. Stertorous breathing
4. A nurse documents the presence of clubbing of the fingernails in a client with emphysema. The
Nurse should understand that the underlying cause if clubbing is:
5. One the assessment form in the section titles " Peripheral edema " the nurse has noted : 1+ pedal
edema bilaterally". The nurse should recognize that this means:
A. Edema that leaves a depression of approx 2mm deep when pressure is applied
B. Edema that leaves a depression of approx 4mm deep when pressure is applied
C. Edema that causes a 10% increase in circumference of an extremity
D. Edema that causes a 25% increase in circumference of an extremity
6. A new type of charting will require that a nurse document as a narrative note the significant findings
in a shorthand method using well-defined standards of practice, this type of charting is defined as:
A. Charting by exception
B. Focus charting
C. Problem, Intervention, Evaluation charting
C. Variance charting
7. Which documentation tool will the nurse use to record the patient's vital signs every 4 hours?
A. A graph sheet
B. Acuity charting forms
C. Medical record
D. 25-hour fluid balance record
8. The method of charting by exception can pose legal risks. True or False
9. After the nurse enters fall risk information into the computer chart, the computer will calculate the
risk level for that patient. True or False.
10. If a patient refuses to sign an AMA form, it is not necessary to have another nurse witness and
document. True or False
11. Hyperglycemia can cause the following: ( Choose all that apply )
A. Increased inflammation
B. Increased platelet aggregation
C. Low blood pressure
D. Polyuria
12. A physicians orders for a patient with hypo or hyperglycemia will include which of the following? (
Choose all that apply)
13. Polyuria is the body’s way of trying to dilute glucose levels. True or False
A Alcoholism
B. Violence
C. Falls
D. Motor Vehicle accidents
17. A nurse is preparing to file an incident report after a patient falls. The nurse is aware that which
statement below is correct regarding the filing of the report?
A. The nurse should include a note in the chart that mentions the incident report
B. The nurse should await results of the x-ray before filing the report
C. The report should record the the incident in the medical record
D. The nurse should make a copy of the incident report and place it in the medical record
18. An acronym RACE is commonly taught as a means for remembering priories for action during a
fire. The "A" in this acronym stands for:
A. Activate the fire code system and notify the appropriate person
B. Attempt to extinguish the fire
C. Alert the local fire department
D. Answer all telephone calls and call bells
19. Identify the order for a new patient with a history of falls:
20. " Client will have no injuries from falls during this hospitalization" this is an example of a valid
outcome for a diagnosis of Risk for injury related to fall. True or False
22. The correct order for preforming assessment techniques for the abdomen is:
23. Which of the following assessments should be considered abnormal finding during skin
assessment?
A. No clubbing noted
B. Brisk capillary refill
C. 3+ pitting in the feet bilaterally
D. Numerous light brown macules,<3 mm in size, located on the nose and cheeks.
24. A whisper test is preformed when the client occludes one ear and the nurse whispers in the other ear
from 30 cm away. True or False
A. listen to the top anterior chest and then the top posterior chest
B. compare side to side proceeding from top to bottom
C. listen only to the posterior chest
D. complete one side of the chest before proceeding to the other side
26. A nurse is teaching a patient with a new diagnosis of diabetes. Which example demonstrated
cognitive learning by the patient?
27. It is important for the nurse to distinguish a patient's readiness to learn and ability to learn. An
example of a patient's ability to learn includes:
A. Emotional health
B. Social and economic stability
C. Culture
D. Physical condition
28. A nurse is working with a client that believes all children should be toilet trained by the age of one.
Following an educational session by the nurse, the client now states that her earlier ideas have changed.
She is now willing to postpone toilet training until the child is older. Learning has occurred in which
domain?
A. Cognitive
B. Affective
C. Psychomotor
D. Coping
29. Upon responding to a patients call bell the nurse discovers a wound dehiscence. Initial nursing
management includes calling the physician and:
A. Covering the wound area with sterile towels moistened with sterile saline
B. Closing the wound area with Steri-Strips
C. Pouring hydrogen peroxide into the abdominal cavity and packing with gauze
D. Holding the wound together until the physician arrives
30. The wound care nurse has been consulted to evaluate a wound on the leg of a patient with diabetes.
The wound care nurse determines that damage has occurred to the subcutaneous tissue and she
documents this wound as a:
A. Stage one pressure ulcer
B. Stage two pressure ulcer
C. Stage three pressure ulcer
D. Stage four pressure ulcer
31. The physician has prescribed heat therapy for a patient's leg wound. The nurse is preparing the
patient for the heat therapy, and she informs the patient that he will have warmed compresses on the
wound for:
A. An hour
B. 20 to 30 minutes
C. 5 minutes each hour
D. 2 hours each morning and night