fundamentals final practice (missed questions)

A nurse reviews the vital signs assessed on a group of patients. Which patient should have these signs remeasured within 4 hours? Select all that apply.

- Blood pressure (BP) 164/90, temperature (T) 98.4°F (36.89°C), pulse rate (P) 89 bounding and regular, respiration rate (R) 26 - BP 116/72, T 100.6°F (38.11°C), P 88 strong and regular, R 32 - BP 112/86, T 97.8°F (36.56°C), P 48 weak and irregular, R 24

A nurse is taking care of a patient who is in an isolation room with a clinical diagnosis of tuberculosis (TB). Which information should the nurse share with the patient to make sure that the patient understands why these precautions are needed? Select all that apply.

- prevents spread of infection to others - considered to be airborne

An LPN/LVN listens to the RN provide discharge teaching to a patient about newly prescribed nitroglycerine. Which action is within the LPN/LVN's scope of practice? Select all that apply.

- reinforces the patient teaching provided by the RN - listens to then patient tell a spouse how the medication is taken - tells the RN the patient does not know the purpose of the medication

A student nurse is learning how to take blood pressure readings using a manual blood pressure cuff. Which activities demonstrate that the student nurse understands about Korotkoff sounds? Select all that apply.

- they are heard during cuff deflation - they sound like a tapping sound

A patient asks about chiropractic medicine and whether it would be a good choice to help relieve body aches and pain. What is the bestnursing response?

- this speciality of medicine may prove to be helpful

A patient with degenerative osteoporosis has increased pain and wants to know if massage therapy would be helpful. What is the best nursing response?

- this type of therapy would be contraindicated based on diagnosis

A group of nursing students are reviewing nursing roles in the operative setting. Which statement indicates understanding of the function of a circulating nurse?

Circulating nurses record information during the surgical procedure.

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan take

Don sterile gloves before inserting the indwelling urinary catheter

A nursing staff educator observes a nurse who collects and prepares sterile supplies for a procedure. Which behavior indicates to the staff educator that additional teaching is needed?

The nurse rejects packs with dark hash marks on the sterilization tape.

A nurse is changing a wound dressing on an obese patient. Which device should the nurse consider to help maintain the dressing in place?

abdominal binder

A patient who is recovering from a myocardial infarction (MI) asks a nurse about following a heart-healthy diet. The patient states that she is primarily a visual learner. Which activity will best help the patient learn about a heart-healthy diet?

reading a chapter in a book about a heart-healthy diet

A fire breaks out on the nursing unit and the fire doors close. A family member tries to open the doors. What is the best response by the nurse based on the RACE protocol?

tell the family member not to try to open the doors

A nurse is caring for a patient diagnosed with bacterial meningitis. Which laboratory result indicates that the patient has a left shift in the differential?

the banded neutrophil count is higher than normal

A patient is diagnosed with congestive heart failure (CHF). For which reason will this patient have a decreased cardiac output?

weakened and damaged heart muscle

For which patient would the nurse likely use a butterfly or winged infusion set for venipuncture? Select all that apply.

- a 2-year old patient - a 70-year old patient - a patient with veins that roll

A nurse is providing care to a 23-year-old patient who sustained a muscular spasm during a sports activity. Which interventions would lead to decreased pain? Select all that apply.

- apply heat to the area - take a whirlpool bath - rest the extremity

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? Select All That Apply

- avoid twisting your spine and bending at the waist - request assistance when repositioning a client - use smooth movements when lifting and moving clients

A nurse is using personal protective equipment (PPE) to care for a patient who has been assigned to contact precautions. Which observation if noted by the nurse manager warrants immediate intervention? Select all that apply.

- extra space is noted in gloves beyond fingertips - hands are wet before gloving

A nurse applies wrist restraints to a patient. Which actions indicate appropriate technique? Select all that apply.

- mitt secured around wrist of patient - check area every 2 hours

A nurse has a multiple-patient assignment. Which actions would not be appropriate to delegate to unlicensed assistive personnel (UAP)? Select all that apply.

- patient teaching relative to starting a DASH diet - performing oral care - educating the patient about the need to maintain hydration

A nurse has just performed venipuncture and is preparing to dispose of equipment. The nurse used a prepackaged IV start kit. Which nursing actions are appropriate? Select all that apply.

- perform hand hygiene - place used catheter in sharps container

A nurse is preparing to perform a dermal puncture to obtain blood for a glucose reading. Which actions reflect best practice? Select all that apply.

- wear clean gloves - use alcohol prep to clean area and allow to dry

Which of the following are considered part of hand hygiene guidelines as proposed by the Centers for Disease Control and Prevention (CDC)? Select all that apply.

- when hands are visibly soiled, use soap and water first - maintain short and well-trimmed nails - alcohol-based preparations are recommended - use alcohol-based gels before and after patient care