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Nursing School original latest material

90 questions · Original · Latest version

Question 1

A nurse is planning care for a client who is at risk for pressure injuries. Which action is most appropriate to reduce the client's risk?

  1. A. Reposition the client at least every 2 hours
  2. B. Massage reddened bony prominences
  3. C. Keep the head of the bed elevated to 90 degrees
  4. D. Use a donut-shaped cushion under the sacrum

ANS: Answer: A

Correct: Repositioning at least every 2 hours reduces prolonged pressure over bony prominences and helps maintain tissue perfusion. Incorrect: Massaging reddened bony prominences can damage fragile tissue and worsen injury; the head of the bed at 90 degrees increases shear and pressure on the sacrum; donut-shaped cushions can concentrate pressure at the edges and impair circulation.

Question 2

A nurse is assessing a client with a history of chronic obstructive pulmonary disease. Which finding requires follow-up?

  1. A. Respiratory rate 18/min
  2. B. Mild barrel-shaped chest
  3. C. Use of accessory muscles during quiet breathing
  4. D. Slightly diminished breath sounds at the bases

ANS: Answer: C

Correct: Use of accessory muscles during quiet breathing indicates increased work of breathing and possible respiratory distress, so it requires follow-up. Incorrect: A respiratory rate of 18/min is within expected adult range; a barrel-shaped chest can be a chronic finding in clients with COPD; slightly diminished breath sounds at the bases may be expected and should be interpreted in context, but it is less urgent than accessory muscle use.

Question 3

Which structure is primarily responsible for the exchange of oxygen and carbon dioxide between the air in the lungs and the blood?

  1. A. Bronchioles
  2. B. Alveoli
  3. C. Pleura
  4. D. Diaphragm

ANS: Answer: B

Correct: Alveoli are the tiny air sacs where gas exchange occurs across the alveolar-capillary membrane. Incorrect: Bronchioles conduct air but are not the primary site of gas exchange; the pleura is the membrane surrounding the lungs; the diaphragm is the main muscle of respiration, not the gas-exchange surface.

Question 4

A nurse is reviewing infection-control practices with newly hired staff. Which actions help prevent the spread of microorganisms? Select all that apply.

  1. A. Perform hand hygiene before and after client contact
  2. B. Use alcohol-based hand rub when hands are not visibly soiled
  3. C. Wear the same gloves for multiple tasks on the same client
  4. D. Clean shared equipment between clients
  5. E. Place a client with suspected influenza on droplet precautions

Question 5

A client with heart failure reports dyspnea, and the nurse notes: \n\nVital signs\n BP 168/94 mm Hg\n HR 112/min\n RR 28/min\n SpO2 90% on room air\n\nPhysical assessment\n Crackles in both lower lobes\n 2+ pitting edema in the ankles\n Jugular venous distention\n\nClick to highlight the findings that require follow-up.

  1. A. BP 168/94 mm Hg
  2. B. HR 112/min
  3. C. RR 28/min
  4. D. SpO2 90% on room air
  5. E. Crackles in both lower lobes
  6. F. 2+ pitting edema in the ankles
  7. G. Jugular venous distention

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