NP1 Exam 1 Review (TCC)

Which statements are appropriate for the nurse to make to a patient who is about to receive pain medication by intravenous push? Select all that apply. "The medication is being injected into your bloodstream." "You will feel effects quickly." "Let me know if your arm hurts or swells." "It may take awhile for the medication to kick in." "The medication is being injected into your muscle."

"The medication is being injected into your bloodstream." "You will feel effects quickly." "Let me know if your arm hurts or swells."

A pt who has been placed on Contact Precautions for C dif asks you to explain what he should know about this organism. Which statements made by the patient show an understanding of patient teaching? Select all that apply. "C. dif dies quickly once outside the body." "The organism is usually transmitted through the fecal-oral route." "Hands should always be cleaned with soap and water rather than the alcohol-based hand sanitizer." "While I am in Contact Precautions, I cannot leave the room." "Everyone coming into the room must wear a gown and gloves."

"The organism is usually transmitted through the fecal-oral route." "Hands should always be cleaned with soap and water rather than the alcohol-based hand sanitizer." "Everyone coming into the room must wear a gown and gloves."

The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective? This is conducted on admission in a primary care or long-term care setting." "This is mostly used in a walk-in clinic or emergency department." "This is focused on disease detection and conducted in a health care provider's office." "This is conducted as a follow-up examination by a health care provider."

"This is mostly used in a walk-in clinic or emergency department."

The primary care provider prescription reads levothyroxin 150mcg orally daily. The med label reads 0.1mg per tablet. The nurse would plan to administer how many tablets to the client?

1.5 tablets

The primary health care provider's prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg per tablet. The nurse would plan to administer how many tablet(s) to the client?

1.5 tablets

Which of the following is a independent nursing intervention? Select all that apply. 1.Educating a patient on adequate nutrition and fluid intake. 2.Administering O2 via nasal cannula 3.Administering medication. 4.Performing oral care. 5.Helping reposition the patient for comfort.

1.Educating a patient on adequate nutrition and fluid intake. 4.Performing oral care. 5.Helping reposition the patient for comfort.

A primary health care provider prescription reads phenytoin 0.2g orally twice a day. The medication label states that each capsule is 100mg. The nurse prepares how many capsules to administer per dose?

2 capsules

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 lack of normal sense of position when the client is unable to return extended fingers to a point of reference A dorsiflexion of the ankle and great toe with fanning of the other toes A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed An involuntary rhythmic, rapid twitching of the eyeballs

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

The nurse is preparing to measure the apical pulse. The nurse places the diaphragm of the stethoscope over which cardiac site? A.Mitral artery B.Right atrium C.Right ventricle D.Pulmonary vein

A. Mitral artery

Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? A."Validation involves comparing data with other sources for accuracy." B."Data interpretation occurs before data validation." C."Validation involves looking for patterns in professional standards." D."Data interpretation involves discovering patterns in professional standards."

A."Validation involves comparing data with other sources for accuracy."

A postoperative client has been tolerating a full liquid diet and the nurse plans to advance the diet to solid food as prescribed. Which assessment is most important for the nurse to make before advancing the diet to solid? A.Ability to chew B.Food preferences C.Cultural preferences D.Presence of bowel sounds

A.Ability to chew

A patient has COPD, which intervention for airway management should you delegate to a nursing assistant? A.Assisting the pt to sit up on the side of the bed B.Instructing the pt to cough effectively C.Teaching the pt to use incentive spirometer D.Auscultation of breath sounds every four hours (q4h)

A.Assisting the pt to sit up on the side of the bed

The nurse is providing instructions to a client with kidney disease about a low protein diet. The client demonstrates understanding of the dietary instructions by stating the need to limit which food from their diet? A.Chicken B.Whole Milk C.Swiss Cheese D.Peanut butter

A.Chicken

A client who is mouth breathing is receiving oxygen by face mask. The assistive personnel (AP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose? A.Humidifies the oxygen that is bypassing the client's nose. B.Prevents the client from getting a nosebleed. C.Gives the client added fluid via the respiratory tree. D.Prevents fluid loss from the lungs during mouth bre

A.Humidifies the oxygen that is bypassing the client's nose.

Which aspect of cardiovascular function does the nurse assess when inspecting the skin and lower extremities? A.Peripheral perfusion B.Apical pulse C.Peripheral pulses D.Heart rhythm

A.Peripheral perfusion

A client with pneumonia is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? A.Plan short sessions with the client to obtain data. B.Focus only on the physical examination. C.Obtain all information from family members. D.Use primary health care provider's medical history.

A.Plan short sessions with the client to obtain data.

Which item would the nurse select to test the function of cranial nerve II? A.Snellen chart B.Flashlight C.Reflex hammer D.Opthalmoscope

A.Snellen chart

The nurse is preparing to perform an abdominal examination on a client. The nurse would place the client in which position for this examination? A.Supine with the head raised slightly and the knees slightly flexed B.Left lateral position C.Supine with the head and feet flat D.Semi-Fowler's position with the head raised 45 degrees and the knees flat

A.Supine with the head raised slightly and the knees slightly flexed

Diphenhydramine hydrochloride 25mg orally q6 hrs is prescribed to a child with an allergic reaction. The child weighs 25kg. The safe dosage is 5mg/kg/day. The nurse would determine which concerning the dose prescribed? A.The dose prescribed is safe B.The dose prescribed is too low C.The dose prescribed is too high D.There is not enough information to determine the safe dose

A.The dose prescribed is safe

The home care nurse is performing an environmental assessment in the home of an older client. Which observation by the nurse requires intervention? A.Unsecured scattered rugs B.Clear exit passageways C.An operable smoke detector D.A prefilled medication cassette

A.Unsecured scattered rugs

The nurse is providing instructions to an assistive personnel who is assigned to care for a client who had a seizure & is experiencing hemiparesis of the right arm & leg. Where would you instruct the AP to place personal articles for morning care? A.Within the clients reach on the left side B.Within the clients reach on the right side C.Just out of clients reach on the left side D.Just out of clients reach on the right side

A.Within the clients reach on the left side

Which patient situation would the nurse assess first? Hypertension Absence of breathing Hypotension Orthostatic hypotension

Absence of breathing

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye. Turn the flashlight on directly in front of the eye and watch for a response. Ask the client to follow the flashlight through the six cardinal positions of gaze. Check pupil size, and then ask the client to alternate looking at the flashlight and the examiner's finger.

Ask the client to follow the flashlight through the six cardinal positions of gaze.

Which actions would the nurse implement during auscultation of the cardiovascular system? Select all that apply. Feel for quality of pulses Listen to all 3 valves Evaluate for symmetry Assess rate and rhythm Use both sides of stethoscope

Assess rate and rhythm Use both sides of stethoscope

Place the steps of the nursing process in order 1 Evaluation 2 Assessment 3 Diagnosis 4 Planning 5 Implementation

Assessment, Diagnosis, Planning, Implementation, & Evaluation

The nursing instructor is observing a student nurse donning a pair of sterile gloves & preparing a sterile field. Which observation made by the instructor indicates the need for further teaching? A.The student puts on the right glove & then the left glove B. The student dons the sterile gloves without washing their hands C.The student uses the inner wrapper of the gloves as a sterile field D. The student touches a glove on the overbed table, removes both & replaces them

B. The student dons the sterile gloves without washing their hands

The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse would ask the client to take which action? A.Focus on a close object. B.Focus on a distant object. C.Close 1 eye and read letters on a chart. D.Raise 1 finger when the sounds is heard.

B.Focus on a distant object.

The nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which intervention would the nurse implement to determine the effectiveness of the tube feeding? A.Use a calorie counter B.Obtain a daily weight C.Evaluate input & output D.Monitor serum protein lvl

B.Obtain a daily weight

Which cue would alert the nurse that a patient may be experiencing orthostatic hypotension? A.Patient experiences paralysis in legs B.Patient feels faint upon position change C.Blood pressure increases when patient stands D.Blood pressur remains constant during transfers

B.Patient feels faint upon position change

A pt was receiving enteral feedings at the hospital & has been started on a regular diet & is preparing for discharge. The pt will be self administering supplemental tube feedings for a short time. The pt expresses concern about performing the procedure at home. What is the RN's best response? A.Maybe a friend will do the feedings for you B.Tell me more about your concerns going home C.Do you want to stay in the hospital a few more days? D.Have you discussed your feelings with your family &dr

B.Tell me more about your concerns going home

The RN is attempting to prompt the patient to elaborate on reports of daytime fatigue. Which question should the RN ask? A."What are your normal work hours?" B."Is there anything that you are stressed about right now that I should know?" C."What reasons do you think are contributing to your fatigue?" D."Are you sleeping 8 hours a night?"

C."What reasons do you think are contributing to your fatigue?"

The nurse performs a physical assessment on a client & gathers both subjective & objective data. Which would the nurse document as subjective data? A.Pedal pulses are present B.Temp: 99.6 C.Client reports difficulty sleeping at night D. Apical pulse rate of 56bpm

C.Client reports difficulty sleeping at night

Which action would the nurse recognize as a breach in surgical asepsis that contaminated the sterile field? A.Masked assistant talked over the sterile field B.Health care provider touched sterile field one-half inch from edge C.Health care provider reached over sterile field to pick up a towel D.Sterile packages opened facing away from the body

C.Health care provider reached over sterile field to pick up a towel

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site? A.Right atrium B.Right ventricle C.Mitral area D.Pulmonic valve

C.Mitral area

Which concept is the major focus of nursing interventions designed to promote safe medication administration in the home? A.Patient independence and autonomy B.Patient comfort C.Patient education D.Patient relationships with

C.Patient education

Which phrase describes medical asepsis? A.Requires use of sterile gloves B.Absence of all infectious agents C.Procedure known as clean technique D.Prevents microbial entry into body

C.Procedure known as clean technique

The nurse assesses the following data from a patient with diabetes mellitus who is 2 days postop for repair of an abdominal aortic aneuryism (AAA). Which assessment finding is of greatest concern? A.Blood glucose of 164 mg/dl B.Incision pain rating of 6 out of 10 C.Temperature 38.5 C (101.4 F) D.Vesicular breath sounds in the lung bases

C.Temperature 38.5 C (101.4 F)

The nurse is caring for an older adult with dysphagia who is at risk for aspiration. When preparing the client for meals the nurse would place them in which position to minimize the risk for aspiration? A.Low-Fowler's B.On the left side C.Upright in a chair D.On the right side

C.Upright in a chair

A nurse is using the problem-specific approach to data collection. Which action will the nurse take first? A.Conducting an observational overview B.Completing the questions in chronological order C.Making accurate interpretations of the data D.Focusing on the patient's presenting situation

D. Focusing on the patients presenting situation

The baseline vital signs for a pt with pneumonia are as follows: T98.8 HR:74BPM 18 breaths/min & BP 124/76. The clients temp suddenly spikes to 103. Which corresponding respiratory rate would the nurse anticipate? A. RR of 12 B. RR of 16 C. RR of 18 D. RR of 22

D. RR of 22

After a change of shift, you are assigned to care for the following patients. Which patient should you assess first? A.A 70 y.o. with pneumonia who needs to be started on IV antibiotics. B.A 60 y.o. pt on a ventilator for whom a sterile sputum specimen must be sent to the lab. C.A 55 y.o. with COPD and pulse oximetry reading from the previous shift of 90%. D.A 50 y.o. with asthma who complains of shortness of breath after using a bronchodilator.

D.A 50 y.o. with asthma who complains of shortness of breath after using a bronchodilator.

Which outcome would the nurse develop for a patient with hypotension? A.Pt will return to previous level of functioning. B.Patient's low blood pressure resolves. C.Vital signs will remain within expected ranges. D.Blood pressure will return to expected ranges 2 hours after treatment.

D.Blood pressure will return to expected ranges 2 hours after treatment.

The nurse is assessing for correct placement of a NG tube. The nurse aspirates the stomach contents, checks gastric PH, & notes PH of 7.35. Which action would the nurse take next? A.Retest the PH using another strip B.Document the NG tube is in the correct place C.Check for placement by auscultating for air injected into the tube D.Call the Dr & request an order for a chest X-ray

D.Call the Dr & request an order for a chest X-ray

The nurse performs a physical assessment on a client and gathers both subjective and objective data. Which would the nurse document as subjective data? A.Client has an apical pulse rate of 56 beats/min. B.Pedal pulses are present. C.Temperature is 99.6 F (37.6 C) D.Client reports difficulty sleeping at night.

D.Client reports difficulty sleeping at night.

Which assessment would the nurse perform during the patients initial visit to a new health care provider? A.Brief B.Focused C.Emergency D.Comprehensive

D.Comprehensive

Which transmission-based precaution would the nurse take for a seriously ill patient being admitted for influenza? A.Obtain an N95 disposable respirator mask. B.Avoid admitting through the reception area. C.Admit to an airborne infection isolation room. D.Provide a mask for the pt if leaving the room.

D.Provide a mask for the pt if leaving the room.

A client with hypotension has been prescribed a low sodium diet. The nurse teaching the client about foods that are allowed would plan to include which food in a list provided to the client? A.Tomato soup B.Boiled shrimp C.French fries D.Summer squash

D.Summer squash

A client is admitted to a long term facility with the diagnosis of weight loss secondary to anorexia. The PCP prescribes an enteral tube feeding. A nursing student is assigned to care for the pt. Which statement made by the student indicates an understanding of the dietary treatment? Enteral tube feeding frequently causes sepsis Enteral feedings need to be refrigerated until just before use Enteral feedings are typically used for long term nutrition Enteral feedings require normal digestive fn

Enteral feeding require normal digestive fn (capabilities of the GI tract)

Which types of medication cannot be administered to patients who have difficulty swallowing and require medications to be crushed? Select all that apply. Enteric-coated tablets Capsules Scored tablets Sublingual tablets Time-release tablets

Enteric-coated tablets Time-release tablets

Which type of infection would a nurse suspect when caring for a patient who has a prescription for a Clostridium difficile test? Gastrointestinal Respiratory Urinary Cellulitis

Gastrointestinal

Which type of PPE should the nurse wear when caring for a pediatric patient who is placed on Airborne Precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) Gloves N95 respirator mask Disposable gown Disposable mask Face shield or goggles

Gloves N95 respirator mask Disposable gown

Which step is first in the sequence for donning personal protective equipment (PPE)? Gown Hand hygeine Head cover Mask

Hand hygiene

Which techniques would the nurse use when assessing a patient's head, eyes, ears, nose, and throat? Select all that apply. Inspection Percussion Palpation Evaluation Auscultation

Inspection, palpation, & ausculation

Where is the apical pulse measured?

Left side of chest over the apex of the heart

Which potential findings would the nurse assess during the palpation phase of the musculoskeletal examination? Select all that apply. Deep tendon reflexes Masses Crepitus Tenderness Postural abnormalities

Masses Crepitus Tenderness

Which signs would the nurse associate with arterial insufficiency? Select all that apply. Paralysis Pallor Edema Numbness Pulselessness

Paralysis, pallor, numbness, & pulselessness

Which part of the nose would the nurse palpate to assess for swelling, drainage, and tenderness? Septum Nostrils Mucosa Sinuses

Sinuses

The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a whisper test by taking which action? Whisper a statement with the examiner's back to the client. Whisper a statement while the client blocks both ears. Quietly whisper a statement and test both ears at the same time. Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block one external ear canal.

Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block one external ear canal.

What type of precautions should the nurse use for a patient diagnosed with HIV? Standard Airborne Droplet Body-substance isolation

Standard

At which times does the nurse check for the "right drug"? Select all that apply. On completion of documentation that the medication was given. When preparing the medication When removing drug from dispensing unit Just before entering the pt's room At the bedside immediately before administration

When preparing the medication When removing drug from dispensing unit At the bedside immediately before administration