Custom NUR105 Midpoint Assessment

Question 2 of 25

Custom NUR105 Midpoint Assessment. A nurse is assessing a client’s cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

• Testing visual acuity
• Eliciting the gag reflex
• Checking the pupillary response to light
• Observing for facial symmetry

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Question 3 of 25

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?

• Stridor
• Wheezes
• Crackles
• Rhonchi

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Question 4 of 25

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client’s skin?

• Apply cornstarch to keep sensitive skin areas dry.
• Elevate the head of the bed no more than 45°.
• Use a transfer device to lift the client up in bed.
• Massage the skin over the client’s bony prominences.

Question 6 of 25

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?

• Standard
• Droplet
• Airborne
• Contact

Question 7 of 25

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

• Holds gauze packages 15 cm (6 in) above the sterile field.
• Wears sterile gloves when moving sterile items on the sterile field.
• Holds a bottle of solution with the label away from the palm of the hand.
• Positions the wrapped package on the bedside table so the outer flap is away from her.

Question 8 of 25

A nurse is providing nail care for a client. Which of the following actions should the nurse take?

• Push the cuticles back with a metal nail file.
• Trim the nails at the lateral corners.
• File the nails in a rounded shape.
• Clean under the nail with an orange stick

Question 9 of 25

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse maintain the integrity of the client’s skin?

• Massage bony prominences to promote circulation.
• Apply cornstarch to keep the skin dry.
• Reposition the client every 3 hr.
• Provide the client with a diet high in protein.

Question 11 of 25

A nurse is teaching a client’s partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?

• Wraps the blood pressure cuff snugly around the client’s arm
• Checks the instrument gauge to ensure the reading starts at zero
• Centers the cuff bladder over the client’s brachial artery
• Places the client’s arm above the level of the client’s heart Custom NUR105 Midpoint Assessment.

Question 12 of 25

A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

• Motor impairment
• Pain
• Hearing loss
• The client’s culture

Question 13 of 25

A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include?

• Use a passive voice to explain the information.
• Emphasize four important points at each session.
• Refer to the client in the third person during the session.
• Have short teaching sessions.

Question 14 of 25

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds?

• Abrasion
• Contusion
• Laceration
• Puncture

Question 15 of 25

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

• Turn the client on his side before starting oral care.
• Use the thumb and index finger to keep the client’s mouth open.
• Use a stiff toothbrush to clean the client’s teeth.
• Apply petroleum jelly to the client’s lips after oral care.

Question 16 of 25

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? Custom NUR105 Midpoint Assessment.

• Pinnae of the ears
• Dorsal surface of the foot
• Dorsal surface of the hand
• Conjunctivae

Question 17 of 25

A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

• Wear a gown when providing care to the client.
• Ensure the client’s room has HEPA filtration.
• Wear a mask when providing care to the client.
• Place the client in a room with negative airflow.

Question 19 of 25

A nurse is preparing to collect health history data during a client’s admission. Which of the following questions should the nurse use to promote this discussion?

• “Would it help to discuss your feelings about this hospitalization?”
• “Do you want to talk about your health concerns?”
• “What brought you to the hospital?”
• “Would you tell me about all of your medical issues?”

Question 20 of 25

A nurse is measuring a client’s oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

• Provide the client a sip of warm water, wait 5 min, and measure the temperature.
• Document that the nurse was unable to measure the client’s temperature.
• Proceed to measure the oral temperature.
• Wait 30 min and return to measure the oral temperature.

Question 21 of 25

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?

• Bilateral bowel sounds in lower quadrants
• Symmetrical convex sphere shape
• Concave umbilicus
• Ecchymosis

Question 22 of 25

A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include?

• Thickened vertebral disks
• Increased force of isometric contraction
• Decreased muscle mass
• Reduced chest width

Question 23 of 25

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

• Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle.
• Discard the dressing in the bedside trash receptacle.
• Dispose of the dressing in a biohazardous waste container.
• Double-bag the dressing in clear bags and label it “biohazard”.

Question 24 of 25

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client’s meal tray?

• Goggles
• Gown
• Gloves
• Mask

Question 25 of 25

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

• Contact
• Droplet
• Airborne
• Protective