Fun 1
Which of the following examples are steps of nursing assessment? 1. Collection of information from patient's family members 2. Recognition that further observations are needed to clarify information 3. comparison of data with another source to determine data accuracy 4. Complete documentation of observational information 5. Determining which medications to administer based on a patients assessment data
1, 2, 3
A nurse gathers the following assessment data. Which of the following cues together form a pattern suggesting a problem? (Select all that apply.) 1. The skin around the wound is tender to touch. 2. Fluid intake for 8 hours is 800 mL. 3. Patient has a heart rate of 78 beats/min and regular. 4. Patient has drainage from surgical wound. 5. Body temperature is at 101 degrees Fahrenheit.
1, 4, 5
Which patient is at highest risk for tachycardia? 1. A healthy basketball player during warm-up exercises 2. A patient admitted with hypothermia 3. A patient with a fever of 39.4 C (103 F) 4. A 90-year-old male taking beta blockers
3
1) The nurse is teaching a client about a new prescribed medication, atenolol (Tenormin). The nurse should instruct the client to: A) Avoid sudden discontinuation of the drug B) Monitor the blood pressure annually C) Check blood glucose before taking the medication D) Discontinue the medication if severe headaches develop
A
A charge nurse is admitting four clients. Which of the following clients should the nurse assign to the room closest to the nurses station? A. A client who has delirium because of a febrile illness. B. A client who reports a severe migraine headache. C. A client who has clinical manifestations of tuberculosis. D. A client who has a history of atrial fibrillation and requires continuous ECG monitoring.
A
A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? a. Encourage use of an overhead trapeze for positioning and transfer. b. Frequent family visits c. Assisting the patient to a wheelchair once per day d. Ensuring that there is an order for physical therapy
A
A nurse is providing teaching to an elderly client about how to prevent falls in the home. Which information should the nurse include? A. Keep nightlights on in the hallways and stairwells B. Remove soap buildup in the sink on a regular basis C. Avoid cleaning hardwood floors to reduce slippery surfaces D. Handrails are necessary for outdoor stairwells but not necessarily indoor stairs
A
A nurse is teaching a client who has a new prescription for daily aspirin. Which of the following statements should the nurse make? A - "Aspirin reduces the formation of blood clots that could cause a heart attack." B - "Aspirin relieves pain during a myocardial infarction." C - "Aspirin dissolves clots that are forming in your coronary arteries." D - "Aspirin can lower total cholesterol."
A
A nurse wants to avoid overstimulating her 88-year-old client who has limited mobility, yet still provide enough engagement to make his activities enjoyable. Which action of the nurse is most appropriate? A. Provide books and materials that have large print. B. Keep the client in an isolated environment to reduce distractions. C. Open the windows in the client's room. D. Allow the client to sit in a chair next to the nurse's station.
A
When caring for a patient diagnosed with viral hepatitis, the healthcare provider experiences a needlestick with a contaminated needle. Which of the following actions should the healthcare provider do first? a) wash the area thoroughly with soap and water b) report to the emergency department c) make an appointment with the infection control department d) put the needle into a biohazard bag for testing.
A
When making room assignments for 4 clients admitted to the med-surg unit, which of the following clients should the nurse place together? A. A client s/p ileostomy who is 1-day postop and a client who was admitted today with an asthma exacerbation B. A client with sickle cell anemia and vaso-occlusive crisis and a client with diabetes who is admitted for debridement of a draining wound C. A client s/p right total hip arthroplasty yesterday and a client with seasonal influenza D A client with chemotherapy induced nausea and a client with a urinary tract infection.
A
The nurse is providing information to the public at a community health event about screening for cancer. Which of the following lab tests are used as screening tests for cancer? (Select all that apply.) A.) PSA (Prostate Specific Antigen) B.) PAP test C.) Lactic dehydrogenase D.) Thiamine E.) Bilirubin
A, B
A nurse is planning a teaching session for a client who has type 2 diabetes mellitus. Which of the following topics should the nurse incorporate in the teaching plan? (Select all that apply.) A. Weight Management B. Lipid profile monitoring C. Blood pressure assessments D. Decreasing physical activity E. Food preferences
A, B, C, E
A nurse is providing education to a group of adolescents about suicide prevention. Which of the following findings should the nurse identify as risk factors for suicide? (Select all that apply.) A) Substance use disorder B) Chronic physical illness C) Male gender D) Currently married E) Bipolar disorder
A, B, C, E
A nurse is providing nutrition teaching to a group of clients who are at risk for developing type 2 diabetes mellitus. Which of the following statements should the nurse make? (Select all that apply.) A "Eat less red meat and processed foods." B. "Decrease your intake of saturated fats." C. "Increase your daily fiber intake." D. "Limit carbohydrates to 25% of your daily caloric intake." E. "Include foods that are high in omega-3 fatty acids in your diet."
A, B, C, E
In which of the following examples is a nurse applying critical thinking skills? (Check all that apply). A) The nurse asks the pain level on a range from 1-10, 1 being hardly any pain, 10 being unbearable. B) The nurse looks back to a personal experience before administering a medication subcutaneously. C) The nurse explains to the patient care technician that the patient cannot have anything to eat for 24 hours. D)The nurse goes over all the options after thoroughly assessing the patient. E) The nurse offers support to a colleague who just witnessed their patient pass away.
A, B, D
The nurse is putting together a care plan for their patient who was just prescribed fall risk precautions.Which of the following interventions should be included in the plan? (Select all that apply). A. Teach balance and strengthening exercises. B. Raise side rails on the bed while the patient is sleeping. C. Add throw rugs to prevent falls. D. Provide information on home safety checks. E. Lock beds and wheelchairs when not providing care.
A, B, D
A nurse is collecting data from a client who has peripheral arterial disease and is scheduled for a right lower extremity amputation. Which of the following findings should the nurse expect in the affected extremity? (Select all that apply.) A) Skin cool to touch from mid-calf to the toes B) Color of lower leg turns dusky to grey when in dependent position. C) Palpable pounding pedal pulse D) Excess hair growth on lower leg E) Blackened areas on several toes
A, B, E
A nurse is providing teaching about food allergies to a group of new parents. The nurse should include that infants who have an allergic reaction to which of the following of the foods typically outgrow the sensitivity? (Select all that apply) A. Soy B. Peanuts C. Cow's milk D. Eggs E. Fish
A, C, D
When conducting a patient-centered interview which of the following techniques should a nurse use? Select all that apply A. Back channeling B. Making assumptions based on what the patient tells you C. Open-ended questions D. Closed-ended questions
A, C, D
A nurse is caring for a client who has just passed away. Which of the following steps are part of the initial physical assessment process of post-mortem care? (select all that apply) A) Verifying that respirations have ceased and there is no pulse B) Bathing a client and providing a clean gown C) Notifying the family of the client's passing D) Checking the pupils for reaction to light E) Removing all lines
A, D
A nurse is examining a client with an obvious deformity of the forearm. Which of the following should the nurse include in the focused assessment? Select all that apply. A. Positive radial pulses B. Alert and oriented x4 C. Breath sounds clear D. Capillary refill less than 3 seconds. E. Skin is pink, warm, dry.
A, D, E
A nurse is assisting a patient who has limited hand movement with eating. Which of the following actions should the nurse take? A. Place the patient in a supine position. B. Provide an adaptive feeding device for the patient. C. Initiate a liquid diet for the patient. D. Arrange the food groups clockwise on the patients plate.
B
A nurse is teaching a client who has a new prescription for timolol ophthalmic drops. The client asks why she should press on the nasolacrimal duct when administering the drops. Which of the following responses should the nurse make? A. "Pressing on the duct will prevent the medication from burning or stinging." B. "Pressing on the duct will prevent the medication from being absorbed into the body." C. "Pressing on the duct will prevent infection." D. "Pressing on the duct will prevent dry eye."
B
A nurse is teaching a group of parents about fractures. Which of the following statements by a parent indicates an understanding of the teaching? A. "Children need a longer time to heal from a fracture than adults." B. "A fracture to an arm can cause it to be shorter than the non-injured arm. C. "A greenstick fracture is a complete break in the bone." D. "Bones are unable to bend, so they break."
B
A nurse smells smoke when entering a client's room and finds a fire is burning in the bathroom. What is the most appropriate response? A. Find other staff members to assist B. Take the client out of the room C. Check the bathroom to find out if anything is broken D. Find the closest fire extinguisher
B
A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation precaution is more appropriate for this patient? A. Reverse isolation B. Droplet precautions C. Standard precautions D. Contact precautions
B
How often should a nurse perform a respiratory assessment on a patient that has restricted activity? A. Once a day B. Once every 2 hours C. It is not necessary to perform this assessment D. Whenever the patient complains of difficulty breathing
B
Mrs. H is a 78-year-old woman with a history of Parkinson's disease. She has been admitted to the hospital for a bloodstream infection after having minor surgery. Mrs. H has motor weakness and uses a walker for mobility. One of the diagnoses the nurse has given Mrs. H is impaired physical mobility. Which of the following nursing interventions is most appropriate when working with Mrs. H? A. Call the physical therapist to help whenever Mrs. H needs out of bed. B. Use at least 1 person for assistance with a gait belt and the walker when Mrs. H ambulates. C. Teach Mrs. H to keep items close by and to be careful if she needs to reach very far. D. Avoiding making Mrs. H get up; bring her meals in bed and utilize a bed pan when necessary.
B
The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? A. Side-lying on the operative side B. On the nonoperative side with the legs abducted C. Side-lying with the affected leg internally rotated D. Side-lying with the affected leg externally rotated
B
The nurse notices in their patient's family history, there were three instances where three family members were diagnosed with breast cancer. How can the nurse make sure the patient stays alert of any signs of breast cancer on their own? A) Have them come back monthly for a breast exam B) Ask the patient if they know how to conduct a self breast examination and teach the steps if they do not know. C) Have them document with pictures of self assessments and have them bring all the information into their next check-up D) Go through everyone in the family to make sure no one with breast cancer was missed.
B
While auscultating the adult patient's lungs, the nurse hears loud, bubbly sounds during inspiration that did not disappear after the patient coughed. Which finding should the nurse document from the lung assessment? a. Rhonchi b. Coarse crackles c. Sibilant wheeze d. Pleural friction rub
B
A nurse is caring for a client who has narcolepsy. When assessing a client, which of the following findings should the nurse expect? (Select all that apply.) A.) A lack of rapid eye movement (REM) sleep B.) sudden attacks of sleep C.) Sudden muscular weakness at emotional times D.) Sleep apnea E.) The urge to move the legs when trying to sleep
B, C
A charge nurse notices that a nursing assistant is lifting a client from the bed to the chair, in an erect position with straight stiffened knees. Which of the following is an appropriate response by the nurse? A. Positively reinforce the proper body mechanics with praise B. Negatively reinforce the improper body mechanics with a reprimand C. Use this observation to re-educate the staff member about the center of gravity D. Use this observation to re-educate the staff member about the line of gravity
C
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? A. Stridor B. Crackles C. Wheezes D. Diminished
C
A nurse is caring for a client admitted a day earlier after repair of a femur fracture who is agitated and short of breath. Physical examination reveals petechiae on the chest and abdomen. Which of the following is most likely the cause of these symptoms? A. Deep vein thrombus B. Myocardial infarction C. Fat embolism D. Ruptured aortic aneurysm
C
A nurse is caring for a client with a fractured wrist that is 36 weeks pregnant. Which of the following assessment items should the nurse prioritize? A) Client reports 3 contractions in the past hour B) The client has a hemoglobin of 12 g/dL C) The fetal heart rate is 210/min D) The fetus kicked 6 times in the past hour
C
A nurse is providing teaching to a client who has a new prescription for methadone to assist with abstinence from opioids. The nurse should instruct the client to monitor for which of the following adverse effects? A. Increased appetite B. Hypertension C. Sedation D. Tinnitus
C
A patient tells you he was diagnosed with congestive heart failure. What might you see in the patient's extremities? A. Pallor B. Erythema C. Cyanosis D. Jaundice
C
Nurse observes an unlicensed assistive personnel (UAP) handling a client roughly, grabbing the client's arm to pull the client out of her room for a scheduled bath. The client stated that she did not want a bath. Which of following is the most appropriate intervention by the nurse? A. Encourage the client to go for her scheduled bath B. Ignore the situation as the aide clearly has the situation under control C. Report the aide's rough handling of the client to your immediate supervisor D. Call the client's physician E. Attempt to talk to the aide privately and tell her that you will report her should you observe her mistreating a client again.
C
Nurses and other healthcare workers are considered high-risk for infection by blood-borne pathogens. Which of the following vaccines is mandated by the Occupational Safety and Health Administration (OSHA) for healthcare workers? A. Influenza B. Tuberculosis C. Hepatitis B D. Hepatitis C
C
Question 2: A nurse is documenting the assessment findings of a client who is in the ICU. Which of the following information should the nurse identify as subjective data? A. Blood Pressure; B. Level of consciousness; C. Nausea; D. Petechiae
C
The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? A. Out-of-bed activities as desired B. Bed rest with the affected extremity kept flat C. Bed rest with elevation of the affected extremity D. Bed rest with the affected extremity in a dependent position
C
The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which of the following is the most effective way to ensure that essential information about the client is reported? A. Give the report face-to-face with both nurses in a quiet room. B. Audiotape the report for future reference and documentation. C. Use a printed checklist with information individualized for the client. D. Document essential transfer information in the client's electronic health record.
C
The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? A. An involuntary rhythmic, rapid, twitching of the eyeballs B. A dorsiflexion of the ankle and great toe with fanning of the other toes C. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed D. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference
C
Two nurses are attempting to transfer a morbidly obese client to his bed from the chair. Which principle of body mechanics should the nurses take advantage of to avoid injury? A. keep their backs and necks aligned and turn at the waist B. use their back muscles more than the arms and legs C. use more help if needed, including a mechanical lift D. tell the client to sit still and let the staff do most of the work
C
Which of the following are physiological outcomes of immobility? A. Increased metabolism B. Reduced cardiac workload C. Decreased lung expansion D. Decreased oxygen demand
C
Which patient has the highest risk of falling? a) a 63-year old patient with chronic chest pain due to coronary heart disease. b) a 3-6 year old female with a fractured tibia c) a 75 year old female with episodes of syncope d) a 33 year old male with 3 fractured ribs and right arm in a cast
C
You're performing a head-to-toe assessment on a patient admitted with abdominal pain. During inspection of the abdomen, you note the abdominal contour to be round and distended with no masses or lesions present. The patient reports that their last bowel movement was one hour ago, and the stool was loose. In addition, the patient states that the abdominal pain is located below the umbilicus and is sharp in quality. After inspection of the abdomen, you will: A. Perform light palpation on the abdomen, followed by deep palpation. B. Percuss the abdomen. C. Auscultate for bowel sounds by starting in the right lower quadrant. D. Palpate for bruits and rebound tenderness.
C
A nurse is providing information to a 45 year old client about risk factors for coronary artery disease. Which of the following is a modifiable risk factor that the nurse should discuss( select all that apply) A. Age B. Family history of heart heart disease C. Smoking D. Hypertension E. High HDL cholesterol
C, D
A nurse in the ICU is caring for a client who has been sedated and on a mechanical ventilator for ten days. Which of the following is a hazard associated with immobility? A) Extension contractures B) Positive nitrogen balance C) Hypocalcemia D) Muscular atrophy
D
A nurse is assessing a client who has COPD and limited mobility. For which of the following physiological responses to prolonged immobility should the nurse assess the client? a. increased insulin production b. decreased RBC production c. Decreased nitrogen excretion d. increased calcium absorption
D
A nurse is planning care for a client with a nursing diagnosis of impaired physical mobility related to prolonged bed rest. Which is the most appropriate nursing intervention for this diagnosis? A.keep lower side rails down and the bed in an elevated position B. Avoid turning the patient prone while in bed C. encourage liquid intake of 1000mL per day, unless contraindicated D. turn and reposition every 2 hours, or more often as needed
D
A nurse on the psychiatric unit is caring for a client who has been relatively calm all day until another client started staring at him. The nurse's client immediately become agitated and threatens to punch the other client. What is the priority action by the nurse? A) Establish a behavior management plan to prevent this behavior in the future B) Call the provider for a medication that can help prevent this disturbed behavior C) Initiate restraint or seclusion in order to prevent danger to others D) Eliminate the trigger using nursing measures and interventions
D
A nursing diagnosis is best described as: A. a determination of the etiology of disease. B. a pattern of coping. C. an individual's perception of health. D. a concise statement of actual or potential health concerns or level of wellness.
D
A nursing supervisor is providing a presentation to discuss the practice of hand hygiene, discussing collaborative efforts on the unit to improve hand hygiene and reduce transmission of disease. Which of the following statements is correct regarding hand hygiene and methods to reduce reinfection rates in the healthcare setting? A) Multifaceted facility-wide initiatives improve hand hygiene and reduce infection while the program is ongoing, but there is no sustained improvement after the program ends. B) Physicians have the highest hand hygiene compliance rates in ICUs compared to other staff members in the unit. C) Alcohol-based hand sanitizer delivery systems (including foam, gel, and wipes) are ineffective in reducing contamination by influenza A (H1N1) virus on hands. D) Working in the AM shift in the ICU has been associated with noncompliance with hand hygiene.
D
What position would be best for a patient that is at risk for developing pressure ulcers? A. Sim's position B. Prone position C. Fowlers position D. 30-degree lateral position
D
Where might nurse expect to hear a bruit best in a client with sharp back pain and a history of abdominal aortic aneurysm? A - Flank B - Right Upper Quadrant C - Suprapubic Region D - Epigastrium
D
Which of the following clients arriving at the same time to the emergency department should the nurse prioritize for assessment and intervention? A) A 30-year-old with urinary frequency and burning, nausea, vomiting, and temperature of 101°F B) An 8-month-old with a temperature of 101°F who is crying and pulling at her ears C) A 65-year-old with atrial fibrillation taking warfarin who fell and hit his head but had no loss of consciousness or mental status changes D) A 23-year-old with a history of depression who ingested a bottle of nortriptyline, a tricyclic antidepressant
D