Davis Review Questions - Exam 1

The nurse is preparing to take a patient's routine 1000 vital signs. Upon entering the room, the nurse notices the patient drinking a cup of coffee. Which action should the nurse take? A- Take the blood pressure at 1030 B- Take the oral temperature C- Take the vital signs in 5 minutes D- Take the routine vital signs as planned

A- Take the blood pressure at 1030

The nurse in an adult clinic is assessing a patient who is being admitted. Which assessment of the patient's general appearance indicates physical distress? A- Facial expression with wide eyes B- Breathing through the mouth C- Unkempt physical appearance D- Slow response to verbal stimuli

B- Breathing through the mouth

The nurse is reassessing a patient and begins assessing the patient's head and neck. Which action does the nurse perform first? A- Observes the patient's pupil reaction B- Checks the patient's skin color C- Inspects the patient's oral membranes D- Evaluates the patient's swallowing

B- Checks the patient's skin color

The nurse is explaining to a coworker how a pressure injury occurs. The nurse should describe the process in which order? A- Tissues and capillaries are compressed B- Cells eventually necrose C- Tissues receive inadequate oxygen and nutrients D- External pressure is prolonged E- Reduced blood flow to the area occurs

D- External pressure is prolonged A- Tissues and capillaries are compressed E- Reduced blood flow to the area occurs C- Tissues receive inadequate oxygen and nutrients B- Cells eventually necrose

The nurse is observing an unlicensed assistive personnel (UAP) move a patient in bed. Which action by the UAP would the nurse praise? A- Slides the patient across the bed B- Pulls the patient across the bed C- Drags the patient across the bed D- Lifts the patient across the bed

D- Lifts the patient across the bed

The nurse needs to obtain a wound culture from a patient's draining wound. Which action should the nurse take? A- Swab the outer edges of the wound B-Swab the dark black area of the wound C-Swab the area of the drainage in the wound D- Swab the pinkish, red area of the wound

D- Swab the pinkish, red area of the wound

The nurse is performing a focused assessment at the beginning of the shift on a patient diagnosed with pneumonia. Which patient assessment is least informative for the nurse? A-Oxygen saturation level. B-Level of consciousness. C-Bilateral breath sounds. D-Skin color and warmth.

D-Skin color and warmth.

The nurse provides care for a postoperative patient who states, "Something just popped." The nurse assesses the wound and finds abdominal organs exposed. Which action would the nurse implement? Select all that apply. 1- Cover the area with sterile dressing soaked in normal saline 2- Take patients vital signs at least every 15 minutes 3- Place the patient in a supine position 4- Offer the patient cool water to drink 5- Gently replace the organs with gloves hands

1- Cover the area with sterile dressing soaked in normal saline 2- Take patients vital signs at least every 15 minutes

What are the steps in the development of a fever?

1. Bacteria enters the body 2. Phagocytes secrete pyrogens 3. Secretion of prostaglandin hormone 4. Hypothalamus raises the set point 5. Surface vasoconstriction occurs

The nurse has to apple a hydrocolloid dressing. What are the five steps the nurse should take.

1.- Perform hand hygiene and don gloves 2.- Clean the wound if ordered 3.- Cut the corners of the dressing so they are rounded 4.-Peel the paper backing from the hydrocolloid dressing 5.- Place the dressing over the wound and smooth gently

The new graduate nurse states, "I am always fearful that I will forget part of the physical assessment process." Which is the best response by the experienced nurse? A- "Start at the top and move downward to the toes, then do the arms and legs." B- "I begin with the part of the body associated with the symptoms shared by the patient." C- "Everyone has their own technique so just find an order that makes sense to you." D- "Write everything down and go back if you need to find missing information."

A- "Start at the top and move downward to the toes, then do the arms and legs."

Which responses by the nurse would facilitate communication? Select all that apply. A- "What is causing you the greatest concern at this time?" B- "Tell me more about this pain you are having." C- "Why did you do that?" D- "I don't think you should divorce your spouse." E- "It will be OK; my father had this surgery and did fine."

A- "What is causing you the greatest concern at this time?" B- "Tell me more about this pain you are having."

Which interventions should the nurse include in the pressure injury prevention plan of care? Select all that apply. A- Apply lotion to dry skin .B- Reassess pressure points daily. C- Use incontinence pads and assess for moisture every hour. D- Avoid the use of a draw sheet when lifting. E- Use specialty beds and devices. F- Keep linens free from wrinkles. G-Turn and reposition every 4 hours. H- Keep skin clean and dry. I- Apply heel and elbow protectors. J- Encourage oral fluids and nutrition.

A- Apply lotion to dry skin C- Use incontinence pads and assess for moisture every hour. E- Use specialty beds and devices. F- Keep linens free from wrinkles. H- Keep skin clean and dry. I- Apply heel and elbow protectors.

The LPN/LVN tells the unlicensed assistive personnel to have a patient's complete bed bath done by 0900 and to report any skin problems. Which types of communication did the nurse use? Select all that apply. A- Downward B- Upward C- Job instructions D- Aggressive E- Job rationale

A- Downward C- Job instructions

The nurse is collecting data about a patient's wound. Which findings indicate the wound is infected? Select all that apply. A- Erythemic wound edges and surrounding area B- Thick yellow-ish drainage C- No odor from wound or drainage D- Warmer skin temperature around wound E- Edema 2 inches around wound

A- Erythemic wound edges and surrounding area B- Thick yellow-ish drainage D- Warmer skin temperature around wound E- Edema 2 inches around wound

Which information should the nurse include in a change-of-shift report? Select all that apply. A- Lungs clear bilaterally with no cough. B- Oh, I forgot, the blood pressure is continuing to rise. C- You should see what the patient's mother is wearing. D- Chest x-ray indicates tuberculosis. E- Patient uses a walker.

A- Lungs clear bilaterally with no cough. B- Oh, I forgot, the blood pressure is continuing to rise. D- Chest x-ray indicates tuberculosis. E- Patient uses a walker.

The nurse is interviewing a patient and states, "I will be asking you questions about the nausea and vomiting you have been having." This represents which stage of the interview process? A- Opening B- Closing C- Body D- Structure

A- Opening

The nurse enters a patient's room and discovers the patient sitting on the side of the bed and leaning forward over the bedside table. Which condition does the nurse suspect? A- Orthopnea. B- Lethargy. C- Dysphagia. D- Hypoxia.

A- Orthopnea.

The nurse is checking the vital signs sheet. Which findings would the nurse determine are normal for adult patients? Select all that apply. A- P - 88, R - 14, BP - 118/64, T - 97°F (36.1°C) B- P - 110, R - 26, BP - 88/40, T - 98F (36.7C) C- P - 65, R - 18, BP - 110/70, T - 99.6°F (37.5°C) D- P - 52, R - 10, BP - 145/95, T - 102°F (38.9°C) E- P - 76, R - 20, BP - 112/74, T - 98.6°F (37°C)

A- P - 88, R - 14, BP - 118/64, T - 97°F (36.1°C) C- P - 65, R - 18, BP - 110/70, T - 99.6°F (37.5°C) E- P - 76, R - 20, BP - 112/74, T - 98.6°F (37°C)

The nurse at a pediatric clinic is preparing to weigh an infant. Which action by the nurse will interfere with acquiring an accurate weight? A- Placing a cover on the scale after the scale is calibrated B- Undressing the infant following facility policy about the diaper C- Putting the infant supine on the cradle of the scale D- Holding a protective hand one to two inches above the infant

A- Placing a cover on the scale after the scale is calibrated

A patient's blood pressure drops when changing positions. Which information would the nurse share with the patient? A- Rise slowly to a standing position B- Use the modified Trendelenburg position C- Reduce dietary intake of salt D- Walk immediately upon standing

A- Rise slowly to a standing position

The nurse is collecting data on a patient's wound drainage. The drainage is reddish in color. How would the nurse document this finding? A- Sanguineous drainage present B- Serosanguineous drainage present C- Serous drainage present C- Purulent drainage present

A- Sanguineous drainage present

The nurse is making patient care assignments. The nurse would assign the assistive personnel (AP) to take vital signs for which patient? A- A patient with a change in mental status B- A patient who is 2 days postoperative. C- A patient who has an actively bleeding wound D- A patient who reported they cannot catch their breath

B- A patient who is 2 days postoperative.

The nurse provides care for multiple patients in an acute care setting. Which patient is likely to require a daily weight assessment? Select all that apply. A- A patient with a suppressed appetite from medication B- A patient who is being treated for generalized edema C- A patient with a history of heart disease D- A patient who is on fluid restrictions for kidney disease E- A bedfast patient with sacral pressure injuries

B- A patient who is being treated for generalized edema C- A patient with a history of heart disease D- A patient who is on fluid restrictions for kidney disease

Which technique can the nurse use to facilitate communication with a patient on a ventilator? A- Place the patient in a side-lying position. B- Ask "Are you in pain?" C- Speak softly into the good ear. D- Stand in front of the patient.

B- Ask "Are you in pain?"

Patient: "I don't want another pill; you can just forget about that!" Nurse: "This is your antibiotic. It's needed to treat your bladder infection. If you don't want it, that's fine." Which technique would IMPROVE the therapeutic communication? A- Establishing Trust B- Assertiveness C- Summarizing D- Seeking Clarification

B- Assertiveness

The nurse at a summer camp provides care for a camper who falls and is injured during a hike. The nurse has no medical equipment available. Which assessment process is the nurse likely to use? Select all that apply. A- Tactile skills to determine the presence of internal injuries B- Critical thinking to determine the safest way to monitor and care for the hiker C- Visual inspection to identify the location of physical injuries D- Auditory skills to receive and process the hiker's subjective input E- Visualization to observe any external, active bleeding

B- Critical thinking to determine the safest way to monitor and care for the hiker C- Visual inspection to identify the location of physical injuries D- Auditory skills to receive and process the hiker's subjective input E- Visualization to observe any external, active bleeding

A patient has a slightly elevated temperature. Which questions would the nurse ask to determine if there are factors that may have contributed to the elevated temperature? Select all that apply. A- Had the patient drunk a cold beverage? B- Had the patient ambulated before the temperature? C- Had the patient eaten a meal earlier? D- Was the patient shivering? E- Was the patient diaphoretic?

B- Had the patient ambulated before the temperature? C- Had the patient eaten a meal earlier? D- Was the patient shivering?

Which would the nurse consider to effectively communicate and provide culturally sensitive patient care? Select all that apply A- Emotion B- Language C- Body position D- Personal Space

B- Language D- Personal Space

The nurse is using the ISBARR to report a patient problem to the health-care provider. Which information should the nurse include for the B? A- Dr. Smith, this is Mary Jones, LPN, at Lakeview Hospital. B- Mr. Allan is having chest pain that is not relieved by medication. C- The patient's O2 sats are 86% and pulse is 54 and irregular. Skin is clammy. D- Would you like an ECG done and cardiac enzymes drawn?

B- Mr. Allan is having chest pain that is not relieved by medication.

The nurse is collecting data about a patient's wound and notices that the wound is getting smaller and filling with deep pink to light red tissue. The nurse determines the patient's wound is in which phase of healing? A- Maturation B- Reconstruction C- Remodeling D- Inflammatory

B- Reconstruction

The nurse is reassessing a patient admitted to the hospital. When inspecting the patient's mouth, the nurse notes that the patient has no teeth. The patient states, "I have dentures but they hurt my mouth so I didn't even bring them." What is the nurse's best response? A- Inspect the patient's mouth for sores. B- Seek an order for a mechanically soft diet. C- Ask if a family member can bring the dentures. D- Inquire if the patient has consulted a dentist.

B- Seek an order for a mechanically soft diet.

The nurse is providing care for a patient who suddenly develops abdominal pain at a level of 7 on a scale of 0 to 10. Which resource will the nurse use to assist in evaluating the patient's condition? A- The patient's health-care provider to ascertain if the development of pain is significant. B- The physical assessment notes acquired at the time of admission. C- The patient's significant other for information about previous pain. D- The patient's previous nurse to learn if the pain is reoccurring.

B- The physical assessment notes acquired at the time of admission.

The nurse is beginning care with a patient who was just admitted with stroke. What is essential for the nurse to develop in the nurse-patient relationship? A- Humor B- Trust C- Encouragement D- Intellect

B- Trust

The nurse is assisting with health screenings at a local health fair. Which factor would the nurse recognize as increasing the risk for hypertension? A- Is a nonsomker B- Works as an air traffic controller at a local airport C- Has normal weight for height D- Drinks wine occasionally

B- Works as an air traffic controller at a local airport

Which action should the nurse take to facilitate communication with a patient who wears a hearing aid? A- Use an interpreter. B- Speak loudly into the good ear. C- Turn off the television. D- Leave the door open.

C- Turn off the television.

The nurse is reviewing the instructions for a negative pressure wound therapy dressing for a patient's infected wound. Which statement by the nurse indicates a correct understanding of the instructions? A- "I will use clean technique for this procedure." B- "I will remove the old transparent dressing by pulling it away from the wound ." C- "I will make sure the dressing collapses after the pump is turned on." D- "I will cut the foam dressing to attach the suction device."

C- "I will make sure the dressing collapses after the pump is turned on."

A patient who has an abdominal incision reports that the pain is so bad "I can hardly stand it." Which response should the nurse make first? A- "Let me get the charge nurse." B- "I'll get you some pain medication right away." C- "Where is the pain?" D- "Let's take your vital signs."

C- "Where is the pain?"

The nurse counts the respirations for 15 seconds and gets 4. How many respirations per minute should the nurse chart on the vital signs sheet? A- 8 B- 12 C- 16 D- 20

C- 16

Patient: "I'm so terrified about this diagnosis. I'm afraid I'll never see my children grow up." Nurse, while checking the IV pump. "Oh? How old are your children?" Which technique would IMPROVE the therapeutic communication? A- Using Silence B- Giving Information C- Active Listening D- Using Restatement

C- Active Listening

A patient says to the nurse, "I was hurting so bad that I called my husband at work. He works at a school as a teacher, so it was hard to get a hold of him. The pain is just so overwhelming." The nurse responds by saying, "Are you saying the pain is unbearable?" Which therapeutic technique did the nurse use? A- Summarizing B- Reflecting C- Clarifying D- Using open-ended question

C- Clarifying

Which term would the nurse use in report to describe a patient's bruise? A- Open wound B- Abrasion C- Contusion D- Laceration

C- Contusion

The nurse is caring for a dark-skinned patient. The nurse suspects the patient has a stage 1 pressure injury. Which finding will help confirm the nurse's conclusion? A- Red area B- Purple area C- Darkened area D- Maroon area

C- Darkened area

The nurse is describing the inflammatory process. In which order should the nurse explain the process? A- Pain occurs B- There is increased blood flow to the site C- Injury occurs D- Damaged cells release histamine E- Capillaries dilate F- Edema develops

C- Injury occurs D- Damaged cells release histamine E- Capillaries dilate B- There is increased blood flow to the site F- Edema develops A- Pain occurs

The nurse is preparing to interview an older adult patient. Which assessment is most important for the nurse to perform before the interview? A- Vital sign readings. B- Visual acuity. C- Level of consciousness. D- Ability to hear.

C- Level of consciousness.

The nurse is giving report about a transgender patient. On the chart, the patient's legal name is shown as Shawn, but the patient prefers the name Lisa. Which information should the nurse share in report to the oncoming shift? A- He was admitted with chest pain.. B- Shawn does not like orange juice. C- She has stable vital signs. D- His mother is in the room.

C- She has stable vital signs.

While observing the skin of a patient, the nurse discovers a pressure injury that extends into the subcutaneous tissue with undermining and tunneling. The nurse would report the patient has which stage of pressure injury? A- Stage 1 B- Stage 2 C- Stage 3 D- Stage 4

C- Stage 3

The nurse is caring for an adult patient with hypertension. Which action should the nurse take when taking a blood pressure? A- Close the screw valve by turning it counterclockwise B- Place the cuff ½ inch above the antecubital space C- Support the patient's arm at the level of the heart D- Position the diaphragm lightly against the skin

C- Support the patient's arm at the level of the heart

The nurse is preparing to reassess a patient's neurological status. Which reason is why the nurse verbally explains the assessment process to a patient who is comatose? A- It helps the nurse to remain organized. B- Family members will repeat the behavior. C- The sense of hearing may still be present. D- It demonstrates respect for the patient.

C- The sense of hearing may still be present.

The nurse is caring for a patient who had eye surgery and has patches over both eyes. Which action should the nurse take? A- Avoid body language. B- Speak in a loud voice. C- Quietly slip out the door. D- Announce when entering the room.

D- Announce when entering the room.

Nurse (while standing at the door with arms crossed, looking at the family and not the patient)"We've made arrangements to transfer you to hospice." The patient thinks, "That nurse doesn't care about me." Which technique would IMPROVE the therapeutic communication? A- Establishing Trust B- Offering self C- Giving Information D- Body language

D- Body language

During the reassessment of a patient's lungs, the patient states, "I have been coughing up stuff that is kind of foamy and pink in color." Which patient diagnosis does the nurse anticipate? A- Bacterial pneumonia. B- Tuberculosis. C- Chronic pulmonary disease. D- Congestive heart failure.

D- Congestive heart failure.

The nurse is observing an unlicensed assistive personnel (UAP) who is caring for a comatose patient. Which action by the UAP would require the nurse to intervene? A- Talking to the patient about the weather B- Telling the patient that laboratory personnel is here to draw blood C- Informing the visitors in the room that they can talk to the patient D- Explaining the care plan for a family member who is in the hospital to the patient

D- Explaining the care plan for a family member who is in the hospital to the patient

The assessment of the open but shallow injury with a reddish pink wound bed on the upper side indicates a ___________ pressure injury

Stage 2

The boggy area with visible bone and tendon indicates a ________ pressure injury

Stage 4