Question

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?

Answer 1

Correct Answers:

Have short teaching sessions.

Rationale :

♦Clients with low literacy levels benefit most from brief, focused educational encounters.

♦Short sessions help prevent cognitive overload, promote better comprehension and retention, and encourage engagement.

♦Teaching should be simple, interactive, and repeated if necessary.

♦The nurse should also use visual aids, teach-back methods, and avoid complex medical terminology.

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Answer 2

Correct Answers:

Ecchymosis

Rationale :

▶Ecchymosis (bruising) on the abdomen is an abnormal finding that may suggest internal bleeding, trauma, or coagulopathy and warrants immediate investigation.

▶While mild abdominal shape variation is common, bruising indicates vascular compromise or underlying pathology, such as a retroperitoneal hemorrhage or pancreatitis.

▶Early recognition is vital for patient safety.

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Answer 3

Correct Answers:

Wait 30 min and return to measure the oral temperature

Rationale :

⏺Recent consumption of cold substances, like ice chips, affects the accuracy of oral temperature readings by artificially lowering the result.

⏺Waiting 30 minutes allows the oral mucosa to return to baseline temperature, ensuring a more reliable and valid reading.

⏺Accurate assessment is essential for detecting fever or hypothermia.

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Answer 4

Correct Answers:

Wheezes

Rationale :

✅Wheezes are high-pitched, continuous musical sounds heard predominantly during expiration, often in clients with asthma, bronchospasm, or airway narrowing.

✅They are produced by air passing through constricted bronchioles.

✅Documenting wheezes supports respiratory assessment and treatment planning, such as the need for bronchodilators.

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Answer 5

Correct Answers:

Conjunctivae

Rationale :

📌In clients with dark skin, assessing central mucous membranes such as the conjunctivae, oral mucosa, or lips is more accurate for detecting cyanosis, since these areas are less affected by pigmentation.

📌Cyanosis reflects hypoxemia, and early detection can prompt life-saving interventions like oxygen therapy.

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Answer 6

Correct Answers:

Checking the pupillary response to light

Rationale :

🟡Cranial Nerve III (Oculomotor) is responsible for pupil constriction, lens shape regulation, and most eye movements.

🟡To assess its function, the nurse evaluates the client’s pupillary reaction to light, using a penlight to observe for direct and consensual constriction.

🟡A normal response—equal, round, and reactive pupils (PERRLA)—indicates intact cranial nerve function.

🟡Abnormal findings may indicate neurological impairment, brain herniation, or increased intracranial pressure, requiring urgent medical evaluation.

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Answer 7

Correct Answers:

Wears sterile gloves when moving sterile items on the sterile field

Rationale :

⚫During the preparation of a sterile field, the nurse must use clean, ungloved hands to open sterile packages and arrange sterile items using outer wrappers or sterile transfer methods.

⚫Wearing sterile gloves too early increases the risk of contamination, especially if hands touch non-sterile surfaces during setup.

⚫Sterile gloves are only worn after the sterile field is fully established, and just before direct contact with sterile items.

⚫Proper sequencing ensures aseptic integrity of the field and protects the client from healthcare-associated infections.

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Answer 8

Correct Answers:

"What brought you to the hospital?"

Rationale :

💎This open-ended question allows the client to provide a detailed narrative of their current condition, concerns, and experiences in their own words.

💎 It promotes therapeutic communication, encourages rapport building, and allows the nurse to gather rich subjective data.

💎Starting with open-ended inquiries aligns with effective assessment techniques and lays the groundwork for a patient-centered health history.

💎This approach respects the client's autonomy and encourages active participation in their care.

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Answer 9

Correct Answers:

Airborne

Rationale :

♦Tuberculosis (TB) is a highly contagious disease caused by Mycobacterium tuberculosis and transmitted via airborne particles.

♦Airborne precautions require that the client be placed in a negative-pressure isolation room, and healthcare providers must use a fit-tested N95 respirator when entering.

♦TB bacteria can remain suspended in air for long periods, especially during coughing or aerosol-generating procedures.

♦These precautions are essential to prevent nosocomial transmission, safeguard staff, and protect immunocompromised patients.

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Answer 10

Correct Answers:

Clean under the nail with an orange stick.

Rationale :

👉Proper nail care involves using a clean orange stick, a blunt and safe tool designed to gently remove debris from beneath the nails without damaging the nail bed or cuticles.

👉This method helps maintain hand hygiene, reduces bacterial buildup, and prevents infection, particularly important for clients with diabetes, circulatory disorders, or immunosuppression, who are at higher risk for complications.

👉The use of sharp instruments or improper technique can cause microtears or trauma, increasing the risk of infection.

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RN Nurs 104 Fundamentals Quiz

No.

1 : 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?

2 : 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?

3 : 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?

4 : 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?

5 : 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?

6 : 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 Ill?

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

8 : 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?

9 : 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?

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

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