fundamentals practice questions

A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A) Assessment B) Diagnosis C) Planning D) Implementation E) Evaluation

A

A confused patient is restless and continues to try to remove his oxygen and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? A. Risk for injury: Prevent harm to patient, use restraints if alternatives fail B. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter C. Disturbed body image: Encourage patient to express concerns about body D. Caregiver role strain: Identify resources to assist with care.

A

A nurse is administering oxygen to a patient with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the patient's anxiety level? A. Cannula B. Catheter C. Venturi mask D. Rebreather mask

A

A nurse is assigned to care for the patients. In planning patient rounds, which of the following patients should the nurse assess first? A. A patient receiving oxygen via nasal cannula B. A postoperative patient preparing for discharge C. A patient scheduled for a chest radiography (x-ray) D. A patient requiring daily dressing changes.

A

A nurse is caring for a dying patient. When is the best time for the nurse to discuss end-of-life care? A) During assessment. B) During planning C) During implementation. D) During evaluation

A

A nurse is providing care to a patient with an indwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)? A) Drapes the urinary drainage tubing with no dependent loops B) Washes the drainage tube toward the meatus with soap and water C) Places the urinary drainage bag gently on the floor below the patient D) Allows the drainage bag spigot to touch the container used to collect the urine when emptying the drainage bag

A

A patient has bladder overactivity. What does the nurse expect to be the most likely cause? A) Spinal cord injury B) Anesthetic agents C) Prostatic enlargement D) Chronic pain syndromes

A

A patient is brought to the emergency department by the EMTs after having seriously lacerated both wrists. The nurse should perform which action first? A. Check and treat the wound sites B. Collect data on psychosocial aspects C. Contact the crisis intervention team D. Encourage the patient to talk about their feelings

A

A patient with emphysema becomes restless and confused. What step should the nurse take next? A. Encourage the patient to perform pursed lip breathing B. Check the patient's temperature C. Assess the patient's potassium level. Does not help the patient D. Increase the patient's oxygen flow rate to 5 L/min

A

After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do FIRST? A. Apply warm blankets & continue oxygen as prescribed B. Take the patient's rectal temperature C. Page the doctor for further orders D. Adjust the thermostat in the room

A

An elderly patient is admitted to the nursing home setting. The patient is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate? A. Ask the woman's family to provide personal items such as photos or mementos B. Select a room with a bed by the door so the woman can look down the hall this does not help with the patient's confusion and unsteady gait C. Suggest the woman eat her meals in the room with her roommate. Does not help with her confusion D. Encourage the woman to ambulate in the halls twice a day

A

By rolling contaminated gloves inside-out, the nurse is interrupting which link in the chain of infection? A. Mode of transmission B. Portal of entry C. Reservoir D. Portal of exit

A

During report, the previous nurse emphasized that one of the newly admitted patients is on seizure precautions. The incoming nurse is correct when she performs which of the following actions to the client? A. Maintain the patient's bed in the lowest position B. Move the patient to a room closer to the nurse's station C. Serve the patient's food in paper and plastic containers D. Ensure that the soft limb restraints are appropriately secured to the side rail

A

Equipment-related accidents are risks in the health care agency. The nurse assesses for this risk when using: A. Sequential compression devices. B. A measuring device that measures urine. C. Computer-based documentation. D. A manual medication-dispensing device

A

How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes? A. Palpate around the tube insertion sites for crepitus B. Auscultate the breath sounds for crackles and rhonchi C. Observe the patient for the presence of a barrel shaped chest D. Compare the length of inspiration with the length at expiration

A

In a light-skinned patient how would the skin appear when assessing for pallor? A) Pale without underlying tones of pink B) Patchy redness C) Ashen gray or yellow D) Slightly bluish in color

A

The nurse assists the nurse practitioner with the removal of a chest tube. Before the nurse practitioner removes the chest tube, which instruction should the nurse give to the patient? A. "Exhale and bear down." B. "Hold your breath for five seconds." C. "Inhale and exhale rapidly." D. "Cough as hard as you can."

A

The nurse cares for a patient with a possible bowel obstruction. A nasogastric tube is to be inserted. Before inserting the tube, the nurse explains its purpose to the patient. Which of the following explanations, if made by the nurse, is most accurate. A. "It empties the stomach of fluids and gas." B. "It prevents spasms of the sphincter of Oddi." C. "It prevents air from forming in the small and large intestine." Also not in the stomach D. "It removes bile from the gallbladder."

A

The nurse is caring for a man who was involved in an auto accident the previous day. The patient has a double-lumen tracheostomy tube with a cuff. Which of the following actions should the nurse perform? A. Change the tracheostomy dressing every eight hours and PRN B. Change the tracheostomy ties every 48 hours C. Keep the inner cannula of the tracheostomy in place at all times D. Push the outer cannula back in if it accidentally "blows out"

A

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first? A. Provide analgesic medications as ordered B. Avoid accidentally removing the drain C. Don sterile gloves D. Gather supplies

A

The nurse is planning to administer a tuberculin test with a 27-gauge, ⅝-inch needle. At which angle will the nurse insert the needle? A) 15 degree. B) 30 degree C) 45 degree. D) 90 degree.

A

The nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation? A) Discard the supplies and prepare a new sterile field with another person holding the patient's hand B) Remove the instrument that was touched by the patient and continue setting up the sterile field. C) Ask another nurse to hold the hand of the patient and continue setting up the field D) No action is necessary since the patient has touched his or her own sterile field.

A

The nurse is reviewing the surgical consent with the patient during preoperative education and finds the patient does not understand what procedure will be completed. What is the nurse's best next step? A. Notify the health care provider about the patient's question B. Explain the procedure that will be completed C. Continue with preoperative education D. Ask the patient to sign the form

A

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development? A. Decreased level of consciousness B. Adequate dietary intake C. Shortness of breath D. Muscular pain

A

The patient has been diagnosed with a respiratory illness and complains of shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. What is the usual comfort range for most patients? A. 65° F to 75° F B. 60° F to 75° F C. 15° C to 17° C D. 25° C to 28° C

A

To best evaluate an ambulating patient's balance, the nurse should assess the patient's: A. Posture B. Strength C. Respiratory status D. Energy level

A

What is the correct order of wound measurements? A) Length X Width X Depth B) Length X Depth X Width C) Width X Length X Depth D) Width X Depth X Length

A

What is the correct order the stages of sexual response cycle. A) excitement => plateau => orgasm => resolution B) plateau => excitement => orgasm => resolution C) excitement => orgasm => plateau => resolution D) excitement => orgasm => resolution => plateau

A

When educating a patient about wound healing the nurse should include what in the teaching? A. inadequate nutrition delays wound healing and increases risk of infection. B. chronic wounds heal better in a dry, open environment so leave them open to air. C. fat tissue heals more rapidly because there is less vascularization. D. long term steroid use diminishes the inflammatory response and speeds up wound healing

A

Which desired outcome written by the nurse is correctly written and measurable? A) The client will lose 4 lbs. within next 2 weeks B) The client will breathe better after resting for 10 minutes C) The nurse will provide skin care at least 3 times each day D) Client will have a normal bowel pattern by April 2

A

Which is the primary reason why immobilized people develop contractures? A. Muscles that flex, adduct, and internally rotate are stronger than weaker opposing muscles B. Muscle mass and strength decline at a rate of 5-10% per week C. Muscular contractures occur because of the excessive muscle flaccidity D. Muscle catabolism exceeds muscle anabolism

A

Which method of asepsis requires hand to be held downwards while rinsing? A. medical asepsis B. surgical asepsis C. All asepsis methods regardless of types D. None of the above

A

Which nursing observation will indicate the patient is at risk for pressure ulcer formation? A. The patient has fecal incontinence B. The patient ate two thirds of breakfast C. The patient has a raised red rash on the right shin D. The patient's capillary refill is less than 2 seconds

A

Which of the following factors must be evaluated when assessing a client's safety risk? A. Age and developmental level B. Time of day C. Sensory enhancements D. Family willingness to help with care while the client is hospitalized

A

Which conditions may increase the risk for impaired skin integrity? Select all that apply. A. Vomiting B. Diarrhea C. Fever D. Headache E. Cataract

A, B

Which structures are involved in physical coordination? Select all that apply. A. Basal ganglia B. Cerebellum C. Cerebral cortex D. Frontal lobe E. Spinal cord

A, B, C

The nurse is caring for a patient who sustained a spinal cord injury. The patient has urinary incontinence. Which aspects of care should the nurse include when teaching the patient to perform self-catheterization? Select all that apply. A) The structures of the urinary tract B) The technique of catheterization C) The importance of adequate fluid intake D) The frequency of self-catheterization E) The technique of applying a condom catheter

A, B, C, D

. A nurse is preparing a list of instructions for a patient who had a creation of an colostomy and will be caring for the stoma at home. Which of the following should the nurse include in the instructions? (Select all that apply.) A. Inspect the skin surrounding the stoma. B. Inspect the stoma for color, moisture, and protrusion. C. Contact the health care provider if the stoma color changes from pink to purple. D. Cut an opening in the faceplate (the wafer) of the appliance that is slightly smaller than the stoma. - should be slightly bigger, not smaller E. Cleanse the skin around the stoma by using mild soap and water and then rinse and dry it well. - soap used is not necessary, but if patient uses soap it has to be mild F. Limit fluids to minimize appliance odor from fecal breakdown

A, B, C, E

A nurse is explaining the benefits of hospice services to a client with end-stage chronic obstructive pulmonary disease. Which statements best explain hospice? Select All That Apply. A) Quality of life is more important than length of life B) Clients have the right to die with dignity C) Clients should be surrounded by family when they are dying D) Emergency medical treatment can be provided for hospice clients E) Hospice services are provided for clients with six months or less life expectancy

A, B, C, E

During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. A. Perineal skin irritation B. Fluid intake of less than 1,500 mL/day C. History of antihistamine intake D. History of frequent urinary tract infections E. A fecal impaction

A, B, C, E

What are the roles of the nurse when caring for a patient with urinary diversions? Select all that apply. A) Refer the patient to an ostomy nurse B) Train the patient on management of urinary diversions C) Refer the patient to ostomy associations for further support D) Check the patency of the nephrostomy tube by trying to pull it out E) Refer the patient to the United Ostomy Associations of America

A, B, C, E

Which action(s) are appropriate for the nurse to implement when a patient experiences orthostatic hypotension? (Select all that apply.) A) Call for assistance. B) Allow patient to sit down. C) Take patient's blood pressure and pulse. D) Continue to ambulate patient to build endurance. E) If patient begins to faint, allow him to slide against the nurse's leg to the floor.

A, B, C, E

Which of the following are accurate principles of sterile technique? Select all that apply. A. The edge of a sterile field and 1 inch inward is unsterile. B. If a package is not labeled sterile, it should be considered an unsterile item C. Sterile objects that come in contact with unsterile objects are considered contaminated D. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched E. When a sterile field becomes wet, it remains sterile as long as the items on the field are not contaminated F. Items in a sterile package must be used immediately once the package has been opened; otherwise it is considered contaminated

A, B, C, F

When a patient is standing, what can be used to prevent orthostatic hypotension problems? Select All That Apply. A. Medications B. Abdominal binders C. Walkers D. Antiembolism stockings E. Crutches

A, B, D

A nurse is teaching a parenting class for families with adolescents. Which health concerns will the nurse include in the teaching sessions. Select all that apply. A. Suicide B. Eating disorders C. Violence/homicide D. Sexually transmitted infections E. Gondatropic hormone stimulation

A, B, D, E

What factors should be assessed in a patient for self-care abilities? Select all that apply. A) Complete independence B) Requires a device or special equipment C) If the walking space is uncluttered D) Requires help, supervision, or teaching from another person E) Is totally dependent

A, B, D, E

What are the effects of immobility on the GI system? Select all that apply. A. Nausea B. Heartburn C. Diarrhea D. Ulcers E. Constipation

A, B, E

A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. A) The nurse removes all jewelry B) The nurse washes hands to one inch above the wrists C) The nurse uses approximately two teaspoons of liquid soap D) The nurse keeps hands higher than elbows when placing under faucet E) The nurse uses friction motion when washing for at least 15 seconds F) The nurse rinses thoroughly with water flowing toward fingertips

A, B, E, F

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. A) A patient diagnosed with rubella B) A patient diagnosed with diptheria C) A patient diagnosed with varicella D) A patient diagnosed with tuberculosis E) A patient diagnosed with MRSA F) An infant diagnosed with adenovirus infection

A, B, F

Which of the following may indicate internal hemorrhage? (select all that apply) A. distention or swelling of the affected body part. B. elevated WBC C. decrease in blood pressure and increase in pulse D. change in the type and amount of drainage

A, C

Which of the following are functions of dressings? (select all that apply) A. promote hemostasis B. keep wound bed dry C. wound debridement D. prevent contaminationE. increase circulation

A, C, D

For patient's who are at 'Risk for impaired skin integrity' what skin conditions should be monitored? Select all that apply. A) Nutritional status B) Wound healing C) Inadequate circulation D) Dehydration E) Dampness

A, C, D, E

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. A) The nurse is providing a bed bath for a patient B) The nurse has visibly soiled hands after changing the bedding of a patient C) The nurse removes gloves when patient care is completed D) The nurse is inserting a urinary catheter for a female patient E) The nurse is assisting with a surgical placement of a cardiac stent F) The nurse removes old magazines from a patient's table.

A, C, D, F

What strategies should be included in pressure ulcer prevention (select all that apply) A. use moisture barrier ointment with incontinence B. reposition immobile patients every 4 hours C. when patient in side lying position ensure HOB @ 30 degrees D. place patient on pressure reducing support surface E. maintain bed at 45 degree angle F. massage reddened bony prominences G. oral nutrition supplement should be used when undernourished

A, C, D, G

Which of the following patients would be expected to benefit from a moist to dry dressing (mechanical debridement)? Select all that apply. A. 24 year old with an open infected wound from a spider bite B. 7 year old with an abrasion on bilateral knees C. 50 year old with a post operative knee replacement incision D. 30 year old who had a large cyst removed and now has some necrotic tissue present in the crater type wound

A, D

Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. A) Admitting not knowing how to do a procedure and requesting help B) Using clever and persuasive remarks to support an opinion or position C) Accepting without question the values acquired in nursing school D) Finding a quick and logical answer, even to complex questions E) Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs.

A, E

. The nurse is giving an IM injection. Upon aspiration, the nurse notices blood return in the syringe. What should the nurse do? A) Administer the injection at a slower rate B) Withdraw the needle and prepare the injection again C) Pull the needle back slightly and inject the medication D) Give the injection and hold pressure over the site for 3 minutes

B

A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F blood pressure 100/56 apical pulse 56 respiratory rate 12 Which of the vital signs should be addressed immediately? A. Respiratory rate B. Temperature C. Apical pulse D. Blood pressure

B

A nurse caring for a male patient observes the nursing assistive personnel (NAP) performing perineal care. Which of the following observed actions indicates a need for further teaching for the NAP? The NAP: A. Used clean gloves. B. Did not retract the foreskin before cleansing. C. Used the clean portion of washcloth for each cleansing wipe. D. Used a circular motion to cleanse from urinary meatus outward.

B

A nurse in the post anesthesia care unit observes that after an abdominal cholecystectomy a patient has serosanguineous drainage on the abdominal dressing. What is the next nursing action? A. Change the dressing B. Reinforce the dressing C. Replace the tape with Montgomery ties D. Support the incision with an abdominal binder

B

A nurse is caring for a patient receiving an IV infusion. What should the nurse do first if the IV infusion infiltrates? A. Elevate the IV site B. Discontinue the infusion. C. Attempt to flush the tubing D. Apply a warm, moist compress

B

A nurse is caring for a patient who had a total hip replacement. What is the priority assessment when monitoring the patient for hemorrhage? A. Checking vital signs every four hours B. Examining the bedding under the patient C. Measuring the circumference of the thigh D. Observing for ecchymosis at the operative site

B

A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing? A. Muscular strength assessment B. Pulse oximetry assessment C. Sensation assessment. Is not related to wound healing D. Sleep assessment

B

A nurse is performing nasopharyngeal suctioning of a patient and suddenly notes the presence of bloody secretions. What action should the nurse take first? A. Continue suctioning to remove the blood B. Check the amount of suction pressure being applied C. Remove the suction catheter from the nose and begin vigorous suctioning through the mouth D. Encourage the patient to cough out the bloody secretions

B

A nurse receives the written lab results that show a positive pregnancy test for a client scheduled for an emergency appendectomy. What should the nurse do first? A) call the lab to verify the result B) call the surgeon to report the finding C) inform the client of the positive test result D) notify the client's primary care physician

B

A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needle stick injury when administering the patient's medications. What would be the priority action of the nurse following the exposure? A. Report the incident to the appropriate person and file an incident report. B. Wash the exposed area with warm water and soap. C. Consent to post exposure prophylaxis at appropriate time. D. Set up counseling sessions regarding safe practice to protect self.

B

A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy. As the nurse you would? A. Continue to monitor the patient B. Notify the MD C. Obtain an EKG D. Check the patient's blood glucose

B

A patient on bed rest for several days attempts to walk with assistance. He becomes dizzy and nauseated. His pulse rate jumps from 85 to 110 beats/min. These are most likely symptoms of which of the following? A) Rebound hypertension B) Orthostatic hypotension C) Dysfunctional proprioception. D) Central nervous system rebound hypotension

B

A patient with an intravenous infusion requests a new gown after bathing. Which of the following actions is most appropriate? A. Disconnect the intravenous tubing, thread the end through the sleeve of the old gown and through the sleeve of the new gown, and reconnect B. Thread the intravenous bag and tubing through the sleeve of the old gown and through the sleeve of the new gown without disconnecting C. Inform the patient that a new gown is not an option while receiving an intravenous infusion in the hospital D. Call the charge nurse for assistance because linen use is monitored and this is not a common procedure

B

A student nurse and an UAP are caring for a client with right-sided paralysis. Which action by the UAP requires the RN to intervene? A. The UAP places a gait belt around the client's waist prior to ambulating B. The UAP places their hand under the patient's right axilla to help them move up in the bed C. The UAP places the patient on their side with pillow support D. The UAP praises the patient for attempting to perform ADLs independently

B

An elderly patient has been admitted to the ED, what information from the patient makes the nurse suspect elder neglect? A) Bruises on the torso B) Being left at a grocery store C) The patient's hair is infested with fleas D) A hip fracture

B

An older confused patient sits and slumps in her chair most of the day. She is most likely to develop a pressure ulcer because of what factor? A. Malnutrition B. Shearing forces C. Edema D. A chronic disease

B

How long should the nurse auscultate each quadrant prior to documenting the absence of bowel sounds? A) 30 seconds B) 3 minutes C) 2 minutes D) 1 minutes

B

The RN instructs the student nurse to provide a complete bed bath to a client who has an IV line. Which action made by the student nurse needs to be corrected by the RN? A. Applying deodorant to the client B. Disconnecting the IV tubing during the bath C. Folding the washcloth around the nurse's hand to make a mitt, tucking in loose corners D. Using a different corner of the washcloth to wipe each eyelid

B

The nurse cares for a patient with end stage AIDS who has an acquired pneumonia. Which of the following precautions levels is appropriate for this patient? A) Contact precautions B) Standard precautions C) Droplet precautions D) Airborne precautions

B

The nurse has been called to a hospital room where a patient is using a hair dryer from home. The patient has received an electrical shock from the dryer. The patient is unconscious and is not breathing. What is the best next step? A. Ask the family to leave the room. B. Check for a pulse. C. Begin compressions. D. Defibrillate the patient.

B

The nurse identifies that a patient has received Mylanta (simethicone) instead of the prescribed Pepto-Bismol (bismuth subsalicylate) for the problem of indigestion. The nurse's next intervention is to: A. Do nothing, no harm has occurred. B. Assess and monitor the patient. C. Notify the physician, treat and document. D. Complete an incident report.

B

The nurse is concerned about pulmonary aspiration when providing the patient with an intermittent tube feeding. Which action is the priority? A) Observe the color of gastric contents B) Verify tube placement before feeding C) Add blue food coloring to the enteral formula D) Run the formula over 12 hours to decrease overload

B

The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Which priority goal is the nurse trying to achieve? A. Manage pain B. Prevent atelectasis C. Reduce healing time D. Decrease thrombus formation

B

The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A) The client reports abdominal pain B) The client's urine output was 450 mL C) The client states, "I didn't see any stones in my urine." D) The client states, "I feel like I have passed a stone."

B

The nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? A) Place the bottle cap on the table with the edges down. B) Pour the solution from a height of 4 to 6 inches (10 to 15 cm) C) Hold the bottle with the label side opposite the palm of the hand D) Hold the bottle inside the edge of the sterile field

B

The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan? A) Client will be able to turn self by day 3 B) Skin will remain intact and without redness during hospital stay C) Client will state pain relieved within 30 minutes after medication D) Pressure will be prevented by repositioning client every 2 hours

B

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which of the following nursing diagnoses will the nurse add to the patient's plan of care? A. Risk for poisoning B. Deficient knowledge C. Risk for imbalanced body temperature D. Risk for suffocation

B

The primary reason for aseptic procedures is to A. Protect patients B. Protect patients and health care providers C. Wipe out all bacteria in the office D. None of the above

B

What is the use of double-lumen catheters? A) Straight catheterization B) Urinary drainage and inflation of a balloon C) Continuous bladder irrigation D) Intermittent catheterization

B

When explaining the cause of frequent urinary tract infections related to immobility, the nurse understands that immobility may result in which of the following? A. Improved renal blood supply to the kidneys B. Urinary stasis C. Decreased urinary calcium D. Acidic urine formation

B

When should an alcohol-based hand rub be used? A. When hands are visibly soiled B. When the hands are not visibly soiled C. After using the restroom D. After an exposure to spore-producing bacteria is confirmed

B

Which is the correct gait when a patient is ascending stairs on crutches? A. A modified two-point gait (The affected leg is advanced between the crutches to the stairs) B. A modified three-point gait (The unaffected leg is advanced between the crutches to the stairs) C. A swing-through gait D. A modified four-point gait. (Both legs advance between the crutches to the stairs)

B

Which of the following statements about surgical asepsis is true? A. In surgical asepsis, items are either sterile, clean or dirty B. Surgical asepsis keeps an area free of all microorganisms C. In surgical asepsis, the goal is to reduce the number of potentially infective agents D. Surgical asepsis is the state of infection that requires surgery for eradication of microbes

B

6.) A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the MD. What non-invasive nursing interventions can you perform without a MD order? A. Insert a nasogastric attached to intermittent suction B. Administer IV fluids C. Encourage ambulation, maintain NPO status, and monitor intake & output D. Encourage at least 3000 ml of fluids per day

C

A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A) Nurse explains to the client the purpose of each administered medication B) Nurse reviews the client's history on the medical record C) Nurse rapidly reset priorities for client care based on a change in the client's condition D) Nurse and client agree upon health care goals for the client

C

A nurse is developing a plan of care for a patient placed in Buck's traction (an orthopedic mechanism by which pull is exerted on the lower extremity with a series of ropes, weights, and pulleys - used to immobilize, align, and position the injured extremity) after a hip fracture. The nurse determines that the priority consideration in caring for the patient receiving this treatment is which of the following? A. Lack of divisional activity as a result of bed rest B. Difficulty with bathing and other self-care measures because of the need for traction C. Lack of mobility as a result of the traction device D. Difficulty with social interactions because of the need for traction

C

A nurse is instructing a patient who has decreased leg strength on the left side how to use a cane. Which action indicates proper cane use by the patient? A. The patient keeps the cane on the left side of the body B. The patient slightly leans to one side while walking C. The patient keeps two points of support on the floor at all times D. After the patient places the cane forward, he or she then moves the right leg forward to the cane

C

A patient is to have a gastric gavage. In which position should the nurse place the patient when the nasogastric tube is being inserted? A. Supine B. Mid-Fowler C. High-Fowler. D. Trendelenburg

C

A patient with a urinary catheter reports discomfort in the bladder and urethra. What should the nurse do first? A. Milk the tubing gently B. Notify the health care provider C. Check the patency of the catheter D. Irrigate the catheter with antibiotics

C

According to Standard Precautions, during patient care the use of an isolation gown is: A. Rarely indicated B. Indicated for all patient care C. Based on a patient's infection status D. Based on anticipated exposure to blood or body fluids

C

An older-adult patient needs an IM injection of antibiotic. Which site is best for the nurse to use? A) Deltoid B) Dorsal gluteal C) Ventrogluteal D) Vastus lateralis

C

Critical thinking and the nursing process have which of the following in common? Both: A. Are important to use in nursing practice B. Use an ordered series of steps C. Are patient specific processes D. Were developed specifically for nursing

C

If a patient walks into your clinic from a parking lot and communicates with you - that means that A - airway and B - breathing are ok- the patient has an open airway and is breathing - Concentrate on the C - Circulation - pulse A patient walks into the clinic from the parking lot and states "I am having chest pain." What should the nurse assess next? A) Check for an open airway B) Assess breath sounds C) Take pulse D) General appearance

C

In general, a patient has sufficient strength to walk if they can do which of the following? A. Lie prone for 1 hour B. Bathe themselves C. Raise the foot off the bed 1 inch D. Sit up in bed for 1 hour

C

In which stage of sleep would beta waves be present? A) When transitioning to deep sleep B) Earlier phrase of NREM C) In periods of wakefulness D) Drowsy stage

C

The nurse is assessing a patient admitted to the hospital with rectal bleeding. Which position should the nurse place the patient in when examining this patient's rectal area? A. Supine B. High Fowler's C. Sims D. Prone

C

The nurse is caring for a group of patients. Which patient will the nurse see first? A. A patient with a Stage IV pressure ulcer B. A patient with a Braden Scale score of 18 C. A patient with appendicitis using a heating pad. D. A patient with an incision that is approximated

C

The nurse is caring for a surgical patient, when the family member asks what perioperative nursing means. How should the nurse respond? A. Perioperative nursing occurs in preadmission testing. B. Perioperative nursing occurs primarily in the postanesthesia care unit. C. Perioperative nursing includes activities before, during, and after surgery D. Perioperative nursing includes activities only during the surgical procedure.

C

The nurse is discussing with a patient's physician the need for restraint. The nurse indicates that alternatives have been utilized. What behaviors would indicate that the alternatives are working? A. The patient continues to get up from the chair at the nurses' station B. The patient apologizes for being "such a bother." C. The patient folds three washcloths over and over D. The sitter leaves the patient alone to go to lunch

C

The nurse is preparing to administer an injection into the deltoid muscle of an adult patient. Which needle size and length will the nurse choose? A) 18 gauge × 1 1/2 inch B) 23 gauge × 1/2 inch C) 25 gauge × 1 inch. D) 27 gauge × 5/8 inch

C

The nurse is preparing to teach a client how to use crutches. Before initiating the lesson, the nurse performs an assessment on the client which includes the: A. The patient's feelings about the restricted mobility B. The patient's fear related to the use of crutches C. The patient's muscle strength and previous activity level D. The patient's understanding of the need for increased mobility

C

The nurse knows that four categories of risk have been identified in the health care environment. Which of the following provides the best examples of those risks? A. Tile floors, cold food, scratchy linen, and noisy alarms B. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach C. Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not functioning properly D. Dirty floors, hallways blocked, medication room locked, and alarms set

C

The presence of which adaptation is most important to assess before administering passive ROM exercises? A. Weakness B. Flaccidity C. Pain D. Atrophy

C

Tracheostomy - if it comes out - don't cover the hole - the patient will become hypoxic and then stop breathing- don't put a new one in - the provider does that - yes, obturator was not in the choices - but you must keep the stoma open for the patient to breathe While changing the ties on a patient with a tracheostomy the tube suddenly dislodges from the patient's throat. What is the next immediate action the nurse should take? A) Attempt to put the tube back in B) Cover the hole with sterile gauze and call for help C) Notify the physician D) Keep the hole open with your fingers

C

What is the priority nursing intervention for a patient during the immediate postoperative period? A. Monitoring vital signs B. Observing for hemorrhage C. Maintaining a patent airway D. Recording the intake and output

C

What type of client would benefit the most from an elevated head of the bed position? A) Patient who had a hemorrhoidectomy B) Patient who had a liver biopsy C) Patient who had a laryngectomy D) Patient who had a lumbar puncture

C

When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A) Determine gaps in the vital signs in the client record B) Compare the reading with one taken in the opposite arm C) Compare this reading against defined standards D) Compare the current measurement with previous ones

C

When the nurse administers an IM corticosteroid injection, the nurse aspirates. What is the rationale for the nurse aspirating? A) Prevent the patient from choking B) Increase the force of the injection C) Ensure proper placement of the needle D) Reduce the discomfort of the injection

C

Which action describes the period when the concentration of medicine is highest in the blood? A) Onset of action B) Duration of action C) Peak action D) Therapeutic range

C

Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient's nose from a nasogastric tube? A) Instill Xylocaine into the nares once a shift B) Tape tube securely with light pressure on nare C) Lubricate the nares with water-soluble lubricant D) Apply a small ice bag to the nose for 5 minutes every 4 hours

C

Which hospitalized patient is most at risk for developing a helthcare-associated infection? A. A 60 year old patient who smokes two packs of cigarettes daily B. A 40 year old patient who has a white blood cell count of 6,000/mm3 C. A 65 year old patient who has indwelling urinary catheter in place D. A 60 year old patient who is a vegetarian and slightly underweight

C

Which of the following should the nurse do when assisting the patient to ambulate? A. Place a hand under the axilla to provide support B. Ensure the patient walks as far as possible for as long as possibly C. Use a gait belt to provide support D. Encourage the patient to watch their feet to ensure a steady gait

C

Which positioning device helps in preventing foot drop, but does not reduce heel pressure? A. Trapeze bar B. Trochanter rolls C. High-top sneakers D. Stryker frame bed

C

Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter? A. "I will keep the collecting bag below the level of the bladder at all times." B. "Intake of cranberry juice may help decrease the risk of infection." C. "Soaking in a warm tub bath may ease the irritation associated with the catheter." D. "I should use clean technique when emptying the collecting bag."

C

Which word is most closely associated with nursing care strategies to maintain functional alignment when patients are bedridden? A. Endurance B. Strength C. Support D. Balance

C

A nurse is following safety principles to reduce the risk of needlestick injury. Which actions will the nurse take? (Select all that apply.) A) Recap the needle after giving an injection B) Remove needle and dispose in sharps box C) Never force needles into the sharps disposal D) Use clearly marked sharps disposal containers. E) Use needleless devices whenever possible.

C, D, E

For a comatose patient what are the appropriate nursing interventions? Select all that apply. A) Eyes appear clean, no discharge or redness present B) Use warm water to cleanse eyes every 2-4 hours C) Use saline to lubricate eyes every 2-4 hours D) Instill eye ointment on lower lids as prescribed E) Use a protective eye shield to keep eyes closed

C, D, E

What are the environmental factors that can influence a person's ability to exercise? Select all that apply. A. Congenital disorders B. Medical diseases C. Financial strains D. Pollutants E. Weather

C, D, E

What interventions should the nurse implement in the care plan of a female client with urinary incontinence? Select all that apply. A. Use firm strokes for cleaning the perineal area B. Clean the perineal area with a washcloth in a circular motion C. Clean and dry the perineal area after each episode of incontinence D. Use no-rinse cleanser and soft wipes for cleaning E. Provide bladder retraining and scheduling to the client

C, D, E

What is normal developmental behavior for a toddler? Select all that apply. A) Understanding gender roles and identity B) Practicing getting married C) Touching their genitals D) Asking where babies come from E) Walking around nude

C, E

A patient who is cognitively impaired and has dementia requires hygiene care. The patient often displays aggressive behavior such as screaming and hitting during the bath. Which techniques make the bathing experience less stressful for both the nurse and the patient? (Select all that apply.) A) Start by washing the face B) Allow the patient to perform as much of the care as possible C) Try an alternative to traditional bathing such as the "bag bath" D) Use restraints to prevent the patient from injuring self or the nurse

B, C

The nurse is caring for a patient who is at risk for skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.) A) Vision B) Hyperemia C) Induration D) Blanching E) Temperature of skin

B, C, D, E

The nurse understands that urinary tract infections (UTIs) in women are eight times more common than in men. What are the reasons for this? Select all that apply. A) Urination is infrequent. B) The urethra is shorter than it is in males. C) The urethra lies closer to the anus than it does in males. D) Failure to wipe from front to back after voiding or defecating. E) Lack of antibacterial substances in vaginal secretions.

B, C, D, E

What are the benefits that a patient can experience from bathing? Select all that apply. A) The approach, method and time can be adapted to suit the patient's preferences B) It promotes well-being, self-image, relaxation and comfort C) It can be a time to strengthen the nurse-patient relationship D) It increases circulation through warmth and friction which dilates blood vessels E) Stimulates the depth of respirations and provides sensory input

B, C, D, E

Which of the following are common sites for development of pressure ulcers? (select all that apply) A. sternum B. heels C. sacrum D. ears E. lateral malleoli F. trochanters G. tip of great toe

B, C, D, E, F

What are the factors that influence how a person responds to a stimulus? Select All That Apply. A) Presence of specialized receptors B) Intensity C) Contrast D) Adaptation E) Numbers of receptors activated F) Previous experience

B, C, D, F

Which procedures necessitate the use of surgical asepsis techniques? Select all that apply. A) Intramuscular medication administration B) Central line intravenous medication administration C) Donning gloves in the operating room D) Neonatal bathing E) Foley catheter insertion F) Emptying a urinary drainage bag

B, C, E

A patient begins to experience a tonic-clonic seizure. The nurse should take which of the following action(s)? (Select all that apply.) A. Restrain the patient B. Turn the patient to the side C. Maintain the patient's airway D. Place a padded tongue blade into the patient's mouth E. Loosen any restrictive clothing that the patient is wearing F. Protect the patient from injury and guide the patient's movement G. Leave the room and call the health care provider

B, C, E, F

A decrease in cardiac tissue perfusion can occur with: (Select All That Apply) A) Oral contraceptives B) Substance abuse C) Hypovolemia D) Hyperlipidemia E) Pregnancy

B, D

A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply. A. Limit fluids to avoid the burning sensation on urination B. Review symptoms of UTI with the client C. Wipe the perineal area from back to front D. Wear cotton underclothes E. Take baths rather than showers

B, D

A patient with an indwelling catheter carries the collection bag at waist level when ambulating. The patient is at risk for what? Select all that apply. A) Retention B) Infection C) Stagnant urine D) Hypotension E) Reflux of urine

B, E

A registered nurse is a preceptor for a new nursing graduate and is observing the new nursing graduate organize the patient assignment and daily tasks. The registered nurse intervenes if the new nursing graduate does which of the following? A. Provides time for unexpected tasks B. Lists the supplies needed for a task C. Prioritizes patient needs and daily tasks D. Plans to document task completion at the end of the day

D

After providing care, a nurse charts in the patient's record. Which entry should the nurse document? A) Appears restless when sitting in the chair B) Drank adequate amounts of water C) Apparently is asleep with eyes closed D) Skin pale and cool

D

After surgery your patient is semicomatose with vital signs within normal limits. As the nurse, what position would be best for this patient? A. Semi-Fowlers B. Prone C. Low-Fowlers D. Side positioning preferably on the left side

D

An elderly patient who has dementia is suffering from cognitive deficit and an overactive bladder. Which type of urinary incontinence is this patient likely to suffer? A) Stress incontinence B) Functional incontinence C) Low risk of incontinence D) Urge incontinence

D

The chain of infection requires a means/mode of transmission. Which of the following is NOT a means/mode of transmission? A. Dirty hands B. Air C. Contaminated food D. Sneezing

D

The client reports nausea and constipation. Which of the following would be the priority nursing action? A) Collect a stool sample B) Notify the physician C) Administer an anti-nausea medication D) Complete an abdominal assessment

D

The medical/surgical nurse cares for a middle-aged patient with a wound infected with MRSA (Methicillin-resistant Staphylococcus aureus). Which of the following protective safety items, if worn by the nurse, would be considered appropriate? A) Mask, gown, gloves B) Gloves only C) Shoe covers, a gown, and gloves D) A gown and gloves

D

The nurse discussed threats to adult safety with a college group. Which of the following statements would indicate understanding of the topic? A. "Our campus is safe; we leave our dorms unlocked all the time." B. "As long as I have only two drinks, I can still be the designated driver." C. "I am young, so I can work nights and go to school with 2 hours' sleep." D. "I guess smoking even at parties is not good for my body."

D

The nurse encourages a patient with type 2 diabetes to engage in a regular exercise program primarily to improve the patient's: A. Gastric motility, thereby facilitating glucose digestion B. Respiratory effort, thereby decreasing activity intolerance C. Overall cardiac output, thereby resuming resting heart rate D. Use of glucose and fatty acids, thereby decreasing blood glucose level

D

The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to complete the goal? A) Client behavior B) Conditions or modifiers C) Performance criteria D) Target time

D

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must: A) Keep splashes on the sterile field to a minimum. B) Cover the nose and mouth with gloved hands if a sneeze is imminent. C) Use forceps soaked in a disinfectant. D) Consider the outer 1 inch of the sterile field as contaminated

D

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan? A. Partial-thickness repair B. Secondary intention C. Tertiary intention D. Primary intention

D

The nurse is caring for a patient with Clostridium difficile. Which nursing actions will have the greatest impact in preventing the spread of the bacteria? A) Appropriate disposal of contaminated items in biohazard bags B) Monthly in-services about contact precautions C) Mandatory cultures on all patients D) Proper hand hygiene techniques

D

The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube? A) From the tip of the nose to the earlobe B) From the tip of the earlobe to the xiphoid process C) From the tip of the earlobe to the nose to the xiphoid process D) From the tip of the nose to the earlobe to the xiphoid process

D

The nurse is removing an old dressing on a surgical wound. The nurse notes a large pool of pus on the dressing and in the central portion of the wound. This exudate would most appropriately be called: A. Serous B. Sanguineous C. Purosanguineous D. Purulent

D

The nurse knows that children in late infancy and toddlerhood are at risk for injury owing to A. Learning to walk. B. Trying to pull up on furniture. C. Being dropped by a caregiver. D. Growing ability to explore and oral activity.

D

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? A. The bladder distends and its capacity increases. B. Older adults ignore the need to void. C. Urine becomes more concentrated. D. The amount of urine retained after voiding increases.

D

What should the nurse teach an elderly client's caregiver about skin care? A. Provide the client with hot water for bathing B. Rub the skin thoroughly after bath to remove all water C. Massage moisturizing lotion over bony prominences D. Keep linens soft, clean, dry and free from wrinkles

D

Which is a true statement about glove us by healthcare workers? A. The CDC does not recommend the use of gloves with patient contact B. Use gloves only when providing care to patients with open wounds C. The use of gloves precludes the need for hand hygiene D. Use gloves when contact with mucous membranes is anticipated

D

Which of the following is the priority action before initiating an intermittent enteral feeding? A. Checking intake and output records B. Weighing the patient C. Checking the patient's vital signs D. Determining tube placement

D

Which type of asepsis eliminates all microorganisms? A. medical asepsis B. surgical asepsis C. All asepsis regardless of type D. None of the above

D

While doing range-of-motion exercises with a patient who is bedridden, the nurse is aware of which of the following considerations? A. Neck hyperextension should be encouraged, particularly in older people B. Exercises should be continued until the patient is fatigued C. Exercises should be done frequently to lessen pain for the patient D. Each joint is exercised to the point of resistance but not pain

D

You are helping a female patient bathe. As you are about to perform perineal care, the patient says, "I can finish my bath." The patient has discomfort and burning in the perineal area. What action do you need to take initially? A) Ask the patient if a family member can complete the care instead B) Insist that you are supposed to complete the care C) Honor the patient's request to complete her own perineal care to avoid any embarrassment D) Explain to the patient that, because of her symptoms, you need to observe the perineal area

D

You witnessed a female patient sustain a fall from the bed and suspect that the leg may be broken. The nurse takes which priority action? A. Takes a set of vital signs B. Call the radiology department for an x-ray C. Reassure the patient that everything will be alright d. Immobilize the leg before moving the patient.

D

Which patients should the nurse anticipate to require the use of a short- or long-term urinary catheter? Select all that apply. A) A patient who has chronic urinary retention B) A patient who has reflex urinary incontinence C) A patient who has stress urinary incontinence D) A patient who needs accurate monitoring of urine output after a gynecologic procedure E) A patient who is unable to completely empty the bladder due to a neurological condition

D, E

A patient tells the nurse she feels faint while walking in the corridor with the nurse. What should the nurse do? A. Instruct the patient to quicken her pace so they can return to her room B. Leave her momentarily to find another nurse to help C. Advise her to look down at her feet to help maintain her balance D. Guide her to a nearby chair, easing her onto it to rest

D

A patient returns from the post anesthesia care unit after an abdominal surgical procedure. The initial nursing action is to assess which of the following? A. The abdominal dressing. B. Urinary output in the Foley bag. C. Intravenous solution for accurate flow rate. D. Vital signs.

D

A 2 year-old is being admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action? A. Order a stat admission CBC B. Place a urine collection bag and specimen cup at the bedside C. Place a cooling mattress on his bed D. Pad the side rails of his bed

D

A nurse has developed a plan of care for a patient diagnosed with a stroke. The nurse would be concerned with which of the following aspects of care for this patient when the patient begins to ambulate? A. Hydration B. Hygiene C. Elimination D. Safety

D

A nurse is caring for a postoperative patient who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? A. Postural drainage B. Cupping the chest C. Nasotracheal suctioning D. Frequent changes of position

D

A nurse is checking the patient's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. The nurse interprets this observation as indicating which of the following? A. The system is intact B. A patient's pneumothorax is resolving C. The suction to the system is shut off D. There is an air leak somewhere in the system

D

A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention? A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated B. Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awake C. Encourage early ambulation and patient to eat meals in beside chair D. Repositioning every 3-4 hours

D

A nurse is preparing to administer a medication from a vial. In which order will the nurse perform the steps, starting with the first step? 1. Invert the vial. 2. Fill the syringe with medication. 3. Inject air into the airspace of the vial. 4. Clean with alcohol swab and allow to dry. 5. Pull back on the plunger the amount to be drawn up. 6. Tap the side of the syringe barrel to remove air bubbles. A) 1, 2, 3, 5, 4, 6 B) 1, 2, 6, 4, 5, 3 C) 4, 5, 1, 2, 3, 6 D) 4, 5, 3, 1, 2, 6

D

A nurse is providing tracheal suctioning to a patient in a step down unit. The patient becomes restless and tachycardic. What should the nurse do? A. Hyperoxygenate and hyperventilate the patient with the AMBU bag B. Notify the physician as soon as possible C. Contact the respiratory department to suction the patient D. Check the vital signs and discontinue attempts at suctioning until the patient is stabilized

D

A nurse teaching a family member caregiver how to bathe the patient explains the importance of using long strokes on the patient's extremities, moving from distal to proximal. Which explanation does the nurse include? Long strokes moving from distal to proximal are used to: A. Decrease the chance of infection B. Help remove dry, flaky skin C. Prevent skin trauma. D. Stimulate venous return

D

In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem? A) Assessment B) Diagnosis C) Planning D) Implementation E) Evaluation

E

In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem? A. Assessment B. Diagnosis C. Planning D. Implementation E. Evaluation

E