1. A nurse is teaching a group of older adults about expected changes of aging.

Which of the following statements by a group member indicates that the teaching

has been effective?

"I should expect my heart rate to take longer to return to normal after

excessive as I get older."

2. A nurse is caring for a client who is postoperative and has paralytic ileum. Which

of the following abdominal assessments should the nurse expect?

Absent bowel sounds with distention

3. A nurse is planning care for a client who reports abdominal pain. An assessment

by the nurse reveals the client has a temperature of 39.2 degrees C (102

degrees F), heart rate of 105/min, a soft contender abdomen, and census

overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature

4. A nurse is caring for a child who is postoperative following a tonsillectomy. Which

of the following actions should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day

and night.

5. A nurse is assessing the heart sounds of a client who has developed chest pain

that becomes worse wth inspiration. the nurse auscultates a high-pitched

scratching sound during both systole and diastole with diaphragm of the

stethoscope positioned at the left sternal border. Which of the following heart

sounds should the nurse document?

Pericardial friction rub

6. A nurse is teaching an assistive personnel (AP) about proper hand hygiene.

Which of the following statements by the AP indicates an understanding of the

teaching?

"There are times I should use soap and water rather than alcohol based hand

rub to clean my hands."

7. A nurse is caring for a client who is unstable and has vital signs measured every

15 minutes by an electronic blood pressure machine. The nurse notices the

machine begins to measure the blood pressure at varied intervals and the

readings are inconsistent. Which of the following actions should the nurse take?

Discontinue the machine, and measure the blood pressure manually every 15

min.

8. A nurse is providing teaching to a client who has heart failure about how to

reduce his daily intake of sodium. Which of the following factors is the most

important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change

9. A nurse is planning to obtain the vital signs of a 2-year-old child who is

experiencing diarrhea and who might have a right ear infection. Which of the

following routes should the nurse use to obtain the temperature?

Temporal

10.A nurse is witnessing a client sign an informed consent form for surgery. Which

of the following describes what the nurse is affirming by this action?